Case presentation obstructive sleep apnea (osa)

obstructive sleep apnea

1. D r Bikash Subedi Moderator: Prof. Dr Baburaja Shrestha 19th Aug,2014 C ase Presentation

2. M r Ghimire,32/m

3. P resenting complaints S noring x 3 years R ecurrent T hroat pain/foreign body sensation x 2 yrs ? D isturbed sleep x 2 yrs

4. HOPI O ff and on throat pain and tonsillar enlargement U naware of sleeping difficulty (snoring, obstructed breathing) S omnolence,fatigue, headache in the morning

5. N o significant past medical except for taking painkillers & antibiotics off and on for throat pain N o h/o surgical oR anesthetic exposure

6. P ersonal history S moker- 5-6 cigarettes/day for the last 6 yrs ?left since last 1.5 mnths O ccasional drinker N ormal bowel/bladder habits

7. P hysical examination

8. G eneral examination G eneral condition – fair W t.-108 kgs, Ht.- 165 cms BMI – 39.66 kg/M 2 PILLCCOD – NIL BMI- < 18.5= underweight. 18.5-25= normal wt. 25-30= overweight. 30-35= class 1 obesity. 35-40= class II. > 40= class III obesity

9. Airway N ormal Dentition/ Patent nares Mouth opening – 3 finger s breadth TMD – > 6 cm TMJ – free/mobile Neck mobility – slightly restricted due to surascapular hump MP – II grade , tonsillar enlargement +Ve (?Grade IV) T hick neck S uprascapular hump

10. Systemic examination CVS Examination : Pulse: 80,regular BP: 130/80 mm Hg (left sitting) S 1 + S 2 + M Respiratory Examination: RR: 16/min A ir entry B/L on bases, otherwise NVB

11. Abdomen distended, fatty no organomegaly,

12. Investigations Hb : 13 . 2 gm% TC: 10,300 /mm3 P 72 , L 22 , E 06 PT: 15 secs INR: 1.1 Platelets: 2 ,25,000 /mm3 Blood group: + ve Na: 146 meq /l K: 4.7 meq /l Urea: 26 mg/dl Creatinine: 0.9 mg/dl RBS: 134 m g / dl ABG: N/A Trop I – N e g CK MB- 17 U/L

13. Normal echocardiographic findings LVEF-65% Normal Thyroid function tests T3= 2.63 pg/L T4= 11.49 pg/L TSH= 1.10 mIU/L

14. RAD

15. P reoperative preparation NPO/ P remedication PPI,Prokinetic IV access/ 16 G cannula Equipments for Difficult airway made ready Ramping done P reoxygenation & RSI

16. OPIOID-LESS SURGERY!! INDUCTION inj Propofol 250 mg inj Sux 150 mg 1.5 gms of PCM 150 mg of Diclofenac sodium 6 .5 mm ID RAE tube. uneventful

17. MAINTENANCE Vecuronium,Ketamine (intermittent/analgesia) O2 (100 %), Isoflurane REVERSAL DOS = 1 hr 45 mins Neostigmine, Glycopyrrolate

18. I ntraoperative

19. NOT so smooth emergence!! B ucking on the tube O ral bleeding noticed >> re-induced with Propofol A nother 40 mins of cautery! Awake intubation planned >> violent pt. >> nasopharyngeal airway sutured! >> suctioned/extubated >> another 25 mins of airway support maneuvers

20. S hifted to ICU for monitoring/ CPAP PCM/ NSAIDS for pain O2 Sats dropped to 65% during sleep CPAP not tolerated well >> O2 face mask >> sats above 90 %

21. DISCUSSION

22. O bstructive Sleep Apnea S leep apnea-hypopnea syndrome C essation or significant decrease in airflow in the presence of breathing effort R ecurrent episodes of upper airway collapse during sleep R ecurrent desaturations and arousals

23. OSA a/w excessive daytime sleepiness OSA syndrome

24. S igns & Symptoms

25. N ight symptoms S noring, usu loud & bothersome W itnessed apneas (interrupt snoring & end with snort) May have G asping/choking that arouse R estless sleep (toss & turn) nocturia

26. D aytime symptoms S leepiness,fatigue H eadache, dry/sore throat ↓vigilance, confusion P ersonality/mood changes (depression,anxiety) ↓libido, GERD P aradoxical “good sleepers”

27. STOP! S : "Do you snore loudly, loud enough to be heard through a closed door?" T : "Do you feel tired or fatigued during the daytime almost every day?" O : "Has anyone observed that you stop breathing during sleep?" P : "Do you have a history of high blood pressure with or without treatment ?“ >>2 OUT OF 4 >> The STOP-Bang Questionnaire (SBQ) has a high sensitivity and specificity to identify OSA. A SBQ of < 2 predicts a very low likelihood of OSA. A SBQ of 5-8 indicates a high probability of moderate-severe OSA.Other screening questionnaires include the Berlin Questionnaire the American Society of Anesthesiologists Checklist,

28. PATHOPHYSIOLOGY the cross-sectional area of the airway in patients with OSA is smaller than that of people without OSA; this difference is due to the volume of the soft tissue, including the tongue, lateral pharyngeal walls, soft palate, and parapharyngeal fat pads.

29. Nonstructural risk factors Obesity Central fat distribution Male sex (M:F=2 : 3.1 Age (inc with inc age) Postmenopausal state Alcohol use Sedative use Smoking Supine sleep position H ypothyroidism, Acromegaly Rapid eye movement (REM) sleep

30. PATHOPHYSIOLOGY Transmural pressure is the difference between intraluminal pressure and the surrounding tissue pressure. If transmural pressure decreases, the cross-sectional area of the pharynx decreases. If this pressure passes a critical point, pharyngeal closing pressure is reached. Exceeding pharyngeal critical pressure ( Pcrit ) causes a juggernaut of tissues collapsing inward. The airway is obstructed. Until forces change transmural pressure to a net tissue force that is less than Pcrit , the airway remains obstructed. OSA duration is equal to the time that Pcrit is exceeded.

31. E xamination may reveal Obesity ( B MI usu > 30) E nlarged neck circumference men > 43 cm. W omen >37 cm H igh MP scores, enlarged tonsils (grade 3/4) R etro/micrognathia, overjet H igh arched palate BANG! – B MI, A GE > 50 , N eck circum G ender M

32. S ystemic arterial HTN (upto 50% OSA cases) P ulm. HTN, CHF T ype II DM, Metabolic syndrome

33. DIAGNOSIS

34. The Apnea Hypopnea Index (AHI) defined as the average number of abnormal breathing events per hour of sleep APNEA refers to cessation of airflow for 10s, H ypopnea - reduced airflow with desaturation ≥4 %. The American Academy of Sleep Medicine (AASM) diagnostic criteria either an AHI ≥15, or AHI ≥5 with symptoms, such as daytime sleepiness, loud snoring, or observed obstruction during sleep . OSA severity is mild for AHI ≥5 to15, moderate for AHI 15 to 30, and severe for AHI >30 .

35. O vernight sleep study Polysomnography Sleep stages are recorded via an electroencephalogram, electro- oculogram , and chin electromyogram Heart rhythm is monitored with a single-lead electrocardiogram Leg movements are recorded via an anterior tibialis electromyogram Breathing is monitored, including airflow at the nose and mouth (using both a thermal sensor and a nasal pressure transducer), effort (using inductance plethysmography ), and oxygen saturation The breathing pattern is analyzed for the presence of apneas and hypopneas (as per definitions standardized by the American Academy of Sleep Medicine)

36. A pnea,Hypoapnea & RERA

37. Derivation and validation of a simple perioperative sleep apnea prediction score . Ramachandran et al Anesth Analg .   al.2010 Apr 1l Abstract/ BACKGROUND:…. METHODS: A retrospective, observational study was designed to identify patients with a known diagnosis of OSA. Independent predictors of a diagnosis of OSA were derived by logistic regression, based on which prediction tool (P-SAP score) was developed. The P-SAP score was then validated in patients undergoing overnight polysomnography . RESULTS: The P-SAP score was derived from 43,576 adult cases undergoing anesthesia. Of these, 3884 patients (7.17%) had a documented diagnosis of OSA. 3 demographic variables : age > 43 years, male gender , and obesity ; 3 history variables : history of snoring , diabetes mellitus Type 2 , and hypertension ; and 3 airway measures: thick neck , modified Mallampati class 3 or 4, and reduced thyromental distance were identified as independent predictors of a diagnosis of OSA. A diagnostic threshold P-SAP score > or = 2 showed excellent sensitivity (0.939) but poor specificity (0.323), whereas for a P-SAP score > or = 6, sensitivity was poor (0.239) with excellent specificity (0.911). Validation of this P-SAP score was performed in 512 patients with similar accuracy. CONCLUSION: The P-SAP score predicts diagnosis of OSA with dependable accuracy across mild to severe disease. The elements of the P-SAP score are derived from a typical university hospital surgical population

38. C onservative therapy & prevention S leep position (NOT supine) U pright position for markedly obese S moking cessation A lcohol/ sedatives avoidance A voidance of sleep deprivation

39. Baseline Risk Reduction Strategies Preoperative CPAP Opioid sparing techniques Regional anesthesia/analgesia Non-opioid adjuncts Minimal access surgery Continuous pulse oximetry monitoring Postoperative CPAP

40. M echanical means CPAP Bilevel positive airway pressure O ral appliance therapy ??

41. S urgical options U nderlying cause= tonsillectomy, adenoidectomy U vulopalatopharyngoplasty C raniofacial reconstruction T racheostomy

42. I mplantable neurostimulator for OSA

43. Patients with OSA have been reported to be 2-7 times as to have a motor vehicle crash . M nemonic “STOP & BANG”

44. http:// emedicine.medscape.com/article/295807-clinical#aw2aab6b3b2 http:// journal.frontiersin.org/Journal/10.3389/fneur.2012.00095/full http:// www.stopbang.ca/pdf/pub10.pdf http://www.michiganrc.org/sites/michiganrc.org/files/u1258/SKR%20Boston%20IARS%20-% 20Ramachandran.pdf http:// www.sasmhq.org/wp-content/uploads/2014/05/SASM14_Educational_v3.pdf http://www.sign.ac.uk/pdf/qrg73.pdf