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can prevent desaturation (Patel and Nouraei 2015; Ramachandran et al. 2010). An
array of airway tools should be readily available to manipulate the airway if masking
or intubating proves to be challenging. The use of two-hand ventilation with oral or
nasal airway adjuncts may be useful. Supraglottic airway devices can help bridge
difficult ventilation or facilitate intubation. Videolaryngoscopic devices have made
intubation more successful with morbidly obese patients. In suspected or know n
difficult masking or intubation, awake intubati
on is more prudent.
58 V. Nguyen et al.
During the maintenance phase,
ventilation strategies with low tidal volume, low
plateau pressure, low driving pressure, and a moderate PEEP level are key to
maintaining protective ventilation (Guldner et al.
2015). Atelectasis in these obese
patients is common, and alveolar recruitment maneuvers can improve intraoperative
oxygenation and compliance (Aldenkortt et al. 2012). OSA management principle,
that is,careful titration of sedatives, hypnotics and NMBA, should be applied to OHS
or MOHS populations. Extubation is a critical period, especially in the obese
population with OHS or MOHS. They are at high risk for postoperative respiratory
failure. Therefore, applying a positive airway pressure device may limit the amount
of respiratory failure post-extubation. If possible, regional anesthesia can offer an
advantage over general anesthesia. Less airway manipulation and avoidance or
limited amount of respiratory depressed drugs have led to fewer airway
complications.
MOHS anesthesia management is like OHS, but the syndrome has a multi-organ
dysfunction component. It is vital to know what organ system MOHS has affected
and tailored the intraoperative anesthetic based on the patient comorbidities. Most
MOHS patients are diagnosed with nonalcoholic steatohepatitis. Focal segmental
glomerulopathy is linked to morbidly obese patients, and the incidence of pulmonary
hypertension can be as high as 50% of MOHS (Marik and Desai 2013; Serra et al.
2008). Each diseased organ’s physiology must be considered to minimize organ
failure and judicious anesthetic drug selection.
Overlap syndrome refers to the coexistence of OSA and COPD. These patients
may have increased dead space ventilation with flattening diaphragm due to COPD.
They tend to have more severe nocturnal desaturation due to the synergistic effect of
both conditions as well, as pulmonary hypertension. Intraoperative anesthetic care
should be like any OSA patient but with a focus on not aggravating COPD.
Ventilation strategies include increasing expiratory time (to prevent air trapping)
and limiting hyperoxia. Pulmonary hypertension physiology should be monitored so
to prevent any exacerbations that may lead to right heart failure.
4.2.5 Pediatric Sleep Disorder
Sleep disordered breathing has become more prevalent in the pediatric population
and thus bringing unique airway challenges to the anesthesiologists. These pediatric
populations are at higher risk for significant oxygen desaturations due to airway
obstruction, opioid intolerance, and laryngospasm. These disorders encompass
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mostly upper airway abnormalities leading to obstructive sleep apnea, central sleep
apnea, and hypovent ilation. Intraoperative management of these patients includes an
adequate assessment of the severity of the patient sleep disorder. A PSG can help
facilitate intraoperative considerations. Not all children can tolerate PSG; thus, the
STBUR sleep questionnaire can help delineate which child is at an increased risk of
opioid-related adverse events.
4 Perioperative Assessment and Management of Patients with Sleep Disorders 59
The
pediat
ric
a
irway anatomy is different than the typical adult airway. In
general, their tongue is larger than the oral cavity. The occiput is more prominent,
leading to a more flexed position when lying supine. This causes a more natural
tendency to obstruct the airway. Their thyromental distance is short; thus, the tongue
is closer to the soft palate leading to a propensity for airway obstru ction. Given all
these structural changes, enlarged pharyngeal tissues will cause a significant risk of
airway collapse. It is essential to relieve obstructions using airway adjuncts durin g
the induction phase. Two distinctive devices are fundamental to alleviate obstruc-
tion, an oropharyngeal and/or nasopharyngeal adjunct. Patients with SDB may have
intermittent hypoxia. Studies show that hypoxia increases activation of opioid
receptors in the brain. Therefore, in these populations, less opioids are needed for
pain control. As a result, the usual weight-based opioid dosing can lead to
overdosing in these children. It is good practice to reduce opioids by half for patients
with obstructive sleep apnea during surgery. This has been adopted by the current
American Society of Anesthesiologists practice guideline (ASA taskforce
2014). A
multimodal approach is effective in the treatment of pain for children with SDB.
Furthermore, nonsteroidal anti-inflammatory drugs (NSAIDs) reduce the require-
ment of opioids. However, NSAIDs inhibit platelet aggregation and prolong bleed-
ing. Although some physicians are concerned about postoperative bleeding with
NSAIDs administration, the Cochrane database has not shown an increased risk of
bleeding postoperatively (Lewis et al. 2013).
Congenital central hypoventilation syndrome (CCHS) is characterized by a
diminished drive to breathe during sleep despite progressive hypoxia or hypercapnia.
CCHS can be linked to genetic condition, hypoxic brain injury, or seizure.
Intraoperative ventilation management for these patients is challenging. It is a
progressive disease where a perioperative patient is mechanically ventilated via
tracheostomy. In contrast, another patient may present with a noninvasive ventilator,
such as bilevel pressure ventilation or even a diaphragmatic pacemaker. Patients
with diaphragmatic pacem akers should be evaluated for electrosurgical unit inter-
ference. A safe option would be to turn off the transmitter and disconnect itself from
the electrodes during proximity cauterization (Venkatraghavan et al.
2009). Once the
procedure is done, reconnecting the diaphragm pacemaker can facilitate extubation.
There is no evidence that one anesthetic is superior to the other. It is judicious to
avoid steroid NMBAs, but, if necessary, then vigilant neuromuscular monitoring and
reversal with sugammadex should be performed. Using short-acting sedative-
inhaled agents or drugs and restricting narcotic use would be ideal. Thus, total
intravenous anesthesia with propofol and remifentanil have shown positive result
while avoiding NMBAs (Niazi et al. 2011). There should be a low threshold to
include a bridging post-extubation noninvasive ventilation with bilevel PAP before
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arriving in the recovery room. Anesthesia providers need to be knowledgeable of
this condition, limit long-acting depressants, and monitor for postoperative apnea.
60 V. Nguyen et al.
4.3 Postoperative Concerns
4.3.1 Obstructive Sleep Apnea
Postoperative complications are most likely to occur in OSA patients during the first
24 h following emergence from anesthesia. Obstructive sleep apnea renders patients
at very high risk for postoperative respiratory depression. The specific problems
which can occur in the post-anesthesia care unit include hypoxemia, apnea/respira-
tory arrest, acute respiratory failure, urgent reintubation, negative-pressure pulmo-
nary edema, and overall worsening of upper airway obstruction (Kaw et al.
2012).
Due to the loss of airway patency, OSA patients carry a more significant risk for
inadequate oxygenation and ventilation. The administration of continuous supple-
mental oxygen is routine immediately after emergence from anesthesia. Oxygen
delivered at low flow rates should be carefully titrated to pulse oximetry with a goal
to achieve at least 90% oxygen saturation. The rate should not be too high so as to
miss detecting acute hypercapnia secondary to hypoventilation. Oxygen therapy
may be lowered once the patient can maintain baseline oxygen saturation on room
air. Compared to patients without OSA, monitoring of oxygenation via pulse
oximetry should continue at least an extra hour once meeting discharge criteria
from the post-anesthesia care unit (Gali et al.
2009).
Monitoring of ventilation is equally as critical as oxygenation for patients with
known or suspected OSA in the immediate postoperative period (Lee and Weinger
2012). There are several methods to detect hypoventilation: clinical observation and
evaluation, capnography (end-tidal carbon dioxide monitoring), and quantitative
measurements of arterial blood gases. The presence of hypercapnia can help deter-
mine whether the OSA needs a lower rate of supplemental oxygen, non-invasive
positive pressure ventilation, or urgent re-intubation and mechanical ventilation.
Hypoventilation and airway obstruction in the postoperative period can be treated
with non-invasive positive pressure ventilation (NIPPV) strategies such as continu-
ous positive airway pressure (CPAP) or biphasic positive airway pressure (BiPAP)
devices. In fact, unless contraindicated by the surgical procedure, these therapies
should be used routinely for all patients with OSA who are compliant with NIPPV
prior to surgery (ASA 2014). NIPPV not only treats respiratory insufficiency but
prevents arterial desaturation and the risk of postoperative negative pressure pulmo-
nary edema secondary to airway obstruction. NIPPV therapy should start in the
PACU and continue through the rest of recovery. To improve compliance, OSA
patients should bring their own equipment to the hospital.
Postoperative pain control can be challenging for patients with obstructive sleep
apnea in the first 24 h after surgery. Opioids increase the risk of airway obstruction,
hypoventilation, hypoxemia, and other respiratory complications. Patients with OSA
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often have lower pain thresholds leading to higher analgesic requirements as well as
greater sensitivity to the respiratory depressant effects of opioids (Cozowicz et al.
2019). To minimize respiratory depression, multimodal analgesia with opioid-
sparing techniques has been shown to be effective and is the preferred approach
(Cozowicz et al.
2019
). Non-opioid analgesics such as non-steroidal anti-inflamma-
tory drugs, acetaminophen, gabapentin, cyclo-oxygenase-2 inhibitors, and ketamine
should be considered. Regional anesthesia provided by epidural catheters or periph-
eral nerve block provides prolonged analgesia while reducing systemic opioid
requirements. Regardless of the specific medications administered, vigilance for
respiratory depression should be maintained throughout the patient’s
postoperative
recovery period for respiratory depression. After leaving a closely monitored envi-
ronment (e.g., PACU or intensive care unit), continuous infusions of opioids should
be avoided when prescribing patient-contro lled analgesia. Patients who received
epidural or intrathecal bolus doses of hydrophilic opioids (morphine,
hydromorphine) should be monitored for delayed respiratory depression for 24 h
after the dose (ASA
2016).
4 Perioperative Assessment and Management of Patients with Sleep Disorders 61
In addition to the
usual PACU discharge criteria, additional factors will determine
the timing and disposition of the patient with OSA following surgery. These factors
include the severity of the patient’s obstructive disease, the nature of the surgery,
preoperative use of CPAP, and postoperative analgesic requirements. Patients with
mild OSA and low opioid requirements have a lower risk for respiratory depression
and may be considered for discharge to an unmonitored setting (e.g., home or
hospital ward). These patients should be able to maintain baseline oxygen saturation
levels while breathing room air in an unstimulated setting such as sleeping (also
known as the “room air challenge test”). In contrast, patients with higher risk for
postoperative respiratory complications should be admitted to the hospital for at least
24 h of continuous pulse oximetry. The following factors typically necessitate
additional monitoring: high pain scores and analge sic needs, frequent desaturation
and apneic events in the PACU, moderate to severe OSA , major surgery particularly
that involving the airway, significant medical comorbidities, and preoperative
noncompliance with NIPPV (Hillman and Chung 2017).
4.3.2 Patients with Narcolepsy
Much is unknown regarding the postoperative outcomes of narcolepsy patients. In
the immediate recovery period, theoretical adverse events include both cardiovas-
cular (autonomic dysfunction leading to hemodynamic instability, dysrhythmias) or
respiratory (depression, apnea) perturbations. Patients with narcolepsy demonstrate
increased sensitivity to anesthetics which could lead to delayed emergence and
hypersomnolence. One case report described a narcolepsy patient who required up
to 12 h to emerge from general anesthesia after three operations (Mesa et al. 2000).
However, the limited data document few postoperative complications. A retrospec-
tive review of 37 narcolepsy patients found no difference in emergence time, length
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of recovery, morbidity, or mortality in those patients who received their preoperative
narcolepsy therapy (Burrow et al. 2005). A retrospective study of 76 patients found
no difference in episodes of respiratory depression, time in recovery, or ICU trans-
fers in patients with narcolepsy (Cavalcante et al.
2017). Increased postoperative risk
may still exist since this study also found a higher frequency of emergency response
team activation on the hospital wards primarily for the management of hemody-
namic instability.
62 V. Nguyen et al.
After discharge from
the post-anesthesia care unit, long- and short-term postop-
erative concerns include an exacerbation of pre-procedure narcolepsy symptoms
with worsening daytime sleepiness and increased sleep paralysis or hallucination
episodes. The literature consists of mainly case reports and series and lacks pro-
spective clinical trials. A recent systematic review described 49 cases of patients
with narcolepsy undergoing surgery (Hu et al.
2018). Narcolepsy symptoms wors-
ened in the postoperative period only for those patients for whom preoperative
therapy was discontinued or decreased or for whom no therapy was prescribed for
symptom control. Obstetric patients carried the highest risk. The review also noted
that patients undergoing neurosurgery around the hypothalamus, pineal gland, and
the third and fourth ventricles developed new-onset postoperative narcolepsy. This
finding is perhaps due to the loss of hypothalamic neurons which secrete the
neuropeptide hypocretin, a mediator within the arousal system.
4.3.3 Patients with Restless Leg Syndrome
Patients with restless leg syndrome carry a greater risk for disease exacerbation in the
immediate postoperative period regardless of anesthetic technique (general, regional,
or local/sedation). The exacerbation may be misdiagnosed as delirium or agitation.
Acute exacerbation of RLS may occur in postoperative setting due to the use of
neuroleptics and antihistamines, withdrawal of dopaminergic agents, and blood loss.
The two most significant inciting factors were found to be immobility during the case
and/or postoperative pain (Smith and White 2009). Postoperative management
should include aggressive pain control, early ambulation, and re-initiation of the
patient’s preoperative dopamine agonist therapy (pramipexole, ropinirole).
Antiemetic drugs that are dopaminergic antagonists, such as metoclopramide,
prochlorperazine, and droperidol, are contraindicated for these pati ents with RLS.
Selective serotonin reuptake inhibitors, tricyclic antidepressants, and some antihis-
tamines may also have antidopaminergic activity. Naloxone could also worsen RLS
symptoms. In one case of RLS exacerbation following bilateral sagittal split ramus
osteotomy, symptoms resolved after initiation of a continuous infusion of
dexmedotomidine, a central alpha-two receptor agonist (Ohshita et al.
2020).
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4 Perioperative Assessment and Management of Patients with Sleep Disorders 63
4.4 Conclusion
History and physical exam data remain imperfect at predicting sleep disordered
breathing. Surgeons and anesthesiologists should consider sleep disordered breath-
ing as a comorbidity in the surgical patient. Non-opioid alternatives should be
considered in the perioperative period. Postoperative monitoring is important in
surgical patients with sleep disordered breathing. Determining which patients benefit
from monitoring remains uncertain. Further research will help refine guidelines to
make treatment in patients with sleep disordered breathing safer in the perioperative
period.
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Chapter 5
Central Sleep Apnea: Advances in the Last
Decade
Ahmed S. BaHammam, Mahadevappa Hunasikatti,
and Seithikurippu R. Pandi-Perumal
Abstract Central sleep apnea (CSA) is characterized by recurrent apneic episodes
with absent respiratory effort. This is not a common clinical condition like obstruc-
tive sleep apnea. Central sleep apnea is diagnosed when more than 50% of the events
are central types.
Cheyne–Stokes respiration (CSR) is a breathing pattern characterized by cycles
of crescendo-decrescendo changes in tidal volume followed by central sleep apneas.
These changes are associated with fluctuations in hemodynamic, respiratory, neuro-
logic, and acid-base parameters. Historical and current theories of causation strongly
implicate an alteration of central respiratory control as the most key factor in the
genesis of periodic respiration. Tissue perfusion and metabolically determined
changes in acid-base balance have dominant roles in the production of CSR. At
least ten consecutive minutes of these cycles should be recorded before CSR can be
diagnosed. The ICSD-3 specifies that at least ten central apneas and hypopneas per
hour of sleep should occur, accompanied by arousals and derangement of sleep
structure.
Other types of central sleep apnea are also important and have been discussed in
this chapter by the authors. The management also differs from the underlying cause,
which is clearly emphasized. The controversy about ASV versus other forms of PAP
therapy in the management of CSA is delineated. This chapter discusses a range of
A. S. BaHammam
The University Sleep Disorders Center, Department of Medicine, College of Medicine, King
Saud University, Riyadh, Saudi Arabia
King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
M. Hunasikatti (
✉)
Division of Respiratory, Sleep and Anesthesiology (DSRA), OHT1, Food and Drug
Administration (FDA), Silver Spring, MD, USA
S. R. Pandi-Perumal
Somnogen Canada Inc., College Street, Toronto, ON, Canada
Saveetha Medical College and Hospitals, Saveetha Institute of Medical and Technical Sciences,
Saveetha University, Chennai, Tamil Nadu, India
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
A. S. BaHammam, M. Hunasikatti (eds.), Sleep Apnea Frontiers, Progress in Sleep
Research,
https://doi.org/10.1007/978-981-99-7901-1_5
67
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