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The Need for

Perioperative
Screening in Sleep
Apnea Patients
Marietta Bellamy Bibbs, BA,
RPSGT
Morton Plant Mease Healthcare
Clearwater, FL

Discuss the importance of recognizing


undiagnosed obstructive sleep apnea (OSA)
Review the patients at risk for OSA
Describe the consequences of untreated
OSA in the surgery patient
Review screening tools to identify at risk
patients
Discuss preventative measures to decrease
perioperative risk in OSA patients

Presentation Content
Undiagnosed
OSA Statistics

Consequences
of Untreated
OSA

Identifying
the At-Risk
Patient

The Surgical
Patient
Postoperative
catastrophes

Screening
Tools and
Preventive
Measures

Untreated Obstructive
Sleep Apnea

Men with Moderate OSA


Obese Men

Women with Moderate OSA


Obese Women

The Risk Factors


Risks of Untreated OSA

Risk of Dying
Population Percentage
Percent Undiagnosed

Predisposing
Characteristics
Clinical Signs and
Symptoms

BMI
BMI 35
35 kg/m2
kg/m2
Pediatric
patients
95
percentile
Pediatric patients 95 percentile for
for age
age and
and gender
gender

Hypertension
Hypertension (difficult
(difficult to
to
manage
and
manage and treat)
treat)

th
th

Large
(>17 inches
Large Neck
Neck (>17
inches in
in men
men and
and >16
>16
inches
inches in
in women
women

Tonsils
Tonsils nearly
nearly touching
touching or
or
touching
touching in
in the
the midline
midline

Craniofacial
Craniofacial abnormalities
abnormalities

History of Airway Obstruction


During Sleep

Anatomical
Frequent
Anatomical Nasal
Nasal Obstruction
Obstruction
Frequent and
and Loud
Loud Snoring
Snoring
Awakens
Awakens with
with choking
choking sensation
sensation
from
from sleep
sleep

Frequent
Frequent arousals
arousals
from
from sleep
sleep

Excessive
Excessive
Sleepiness
Excessive sleepiness
sleepiness or
or fatigue
fatigue despite
despite
adequate
adequate sleep
sleep

Pauses
Pauses in
in breathing
breathing during
during sleep
sleep

Restless
Restless sleep,
sleep, difficulty
difficulty breathing
breathing
or
increased
respiratory
or increased respiratory effort
effort
during
during sleep
sleep

Falls
Falls asleep
asleep easily
easily in
in sedentary
sedentary (non(nonstimulating)
situations
stimulating) situations

Parent
Parent or
or teacher
teacher notes
notes child
child is
is sleepy
sleepy during
during day,
day, easily
easily distracted
distracted and
and overly
overly
aggressive
and
difficulty
concentrating
aggressive and difficulty concentrating
Child
Child is
is difficult
difficult to
to arouse
arouse at
at usual
usual awakening
awakening
time
time

Why Perioperative Screening


In the undiagnosed Obstructive Sleep Apnea
(OSA) patient population..
Minimize the number of undiagnosed patients presenting
for surgery.
Provide appropriate monitoring and access to postoperative evaluation.
Provide longitudinal care if indicated.
Continue post-operative PAP therapy since treatment
requirements may increase.

OSA and The Surgical


Risk

It is estimated that 82% of men and


92% of women with moderate-severe
OSA have not been diagnosed
40% of obese men and 50% of obese
women have been identified as having
OSA
Estimated life span of untreated OSA
is 58 years (normal men 78 yrs.,
women 83 years)
John Hopkins study found severe OSA
increased risk of dying by 46%

Prevalence of OSA
18 -20 million adults suffer from
symptomatic OSA or severe asymptomatic
OSA
It is estimated that 90% of those suffering
from OSA are still undiagnosed and
untreated
4% of the US population affected
Frequently goes unrecognized and
undiagnosed in the medical community
Affects all aspects of life
OSA patients have a higher risk of postoperative complications

Healthcare Utilization
and OSA

Associated with increased sick days


and loss of productivity at work
Prescription costs:
OSA patients with hypertension receive
more anti-hypertensive prescriptions and
other drug therapies that are higher in
cost
Highest diagnosis-specific expenditures
related to hypertension and
cardiovascular disease

Healthcare Utilization
A Canadian study on a targeted group
of OSA patients revealed that they:
used 25-50% more medical resources in
the 5 years prior to diagnosis
had more physician office visits
spent more nights in the hospital
Had higher physician costs than matched
controls

Risk Factors
Obesity
Enlarged adenoids, tonsils, and soft
palate tissues including large uvula,
low lying soft palate and excessive
pharyngeal tissue
Jaw malformations
Large tongue

Common Symptoms
Snoring
Waking up from
snoring
Witnessed apnea
Frequent nocturnal
awakenings
Sleep maintenance
insomnia
Waking unrefreshed
in the mornings or
following naps

Commonly
Recognized
Symptoms
Waking up choking,
short of breath or
gasping for breath
Excessive daytime
sleepiness
Chronic
fatigue/tiredness
Falling asleep or
nodding off at
inappropriate times

Unrecogniz
ed
Symptoms
Nighttime
sweating
Nighttime GE
reflux
Automatic
behaviors
Sleep
drunkenness

Other Indications of OSA


These symptoms are often not thought
of or recognized as being associated
with OSA in the medical community:
Change in personality or mood
Weight gain
Nocturia
Morning headaches
Morning dry mouth
Loss of libido or impotency
Poor concentration
Decreased memory, especially short term

What this means..


Studies have documented that 80% of
men and 90% of women have
obstructive sleep apnea and have
never been diagnosed.
Undiagnosed OSA presents special
challenges for patients and healthcare
workers, particularly in surgical
patients
OSA patients are at high risk for
surgical complications

OSA Complications
Hypertension
Untreated OSA is
associated with
hypertension in 40 % of
patients
30 % of patients with
idiopathic hypertension
have OSAS

Cardiac arrhythmias during


sleep
Sinus arrhythmia, sinus

OSA Complications
Heart attacks
Stroke
Type 2 Diabetes Mellitus

OSA Surgical Patients


High Risk
Related to comorbities

Congestive Heart Failure


Myocardial Infarction
Arrhythmias
Sudden Cardiac

Event-related sleep disturbance


Decreased arousal threshold related to
sleep fragmentation
Decreased arousal delay due to narcotics

The Importance of
Screening for
Obstructive Sleep
Apnea Prior to
Surgery

Patient Safety
OSA patients have a higher rate of
Difficult Intubation
Difficult Extubation
Hypercapnia
Oxygen desaturations
Cardiac insults

Anesthesiologists know
the Dangers
American Society
of Anesthesiology
published
guidelines
recommending
that patients
should be
screened for OSA
before surgery.

Goal:

Identify patients
undiagnosed OSA
patients prior to surgery.
Diagnose and treat prior
to surgery when
possible.
If unable to diagnose
prior to surgery, treat
patients as if they have
documented OSA in
order to avoid

Starting a Perioperative
Program

Questions for
Anesthesiologists

How do you screen patients pre-operatively?

What do you do with patients who screen positive?

How are these patients monitored?

How and when are patients treated that screen positive?

What happens after discharge?

Perioperative Program
GoalFocused
Patient
Approach

Emphasis on communication about effects of


untreated OSA
A smooth, streamlined experience for patients
Consistent, respectful care and improved surgical
outcomes
Education about OSA during the initial
preoperative process
Increased level of patient safety and trust in our
services
Focused monitoring, preparedness and
intervention

Goal in Identifying OSA


Surgical Patients
Eliminate or markedly reduce the
unrecognized OSA patient
presenting for surgery
Create heightened awareness of
which patients may be at
increased postoperative risk
Provide opportunity to identify and
intervene with patients who are
non-compliant or inadequately
treated

The Presenting OSA


Surgical Patient

OSA patients will present for surgery


in one of three categories:
1. Known OSA and compliant with therapy
2. Known OSA :
Mild OSA and therapy not recommended
Refused therapy or non-compliant
Other therapy, e.g., weight loss, surgical
intervention, dental appliances

3. Status unknown

The Presenting OSA


Surgical Patient

Patients with known OSA and on no active


therapy:
May be asymptomatic or minimally
symptomatic
May become symptomatic post-op

Patients who are non-compliant and


unrecognized:

Surgical Risk Factors


Screening tools assist with identifying
patients at highest risk for OSA using
established risk factors.
Obesity and increasing age are
strong risk factors for OSA.
Common signs and symptoms include
loud snoring, observed apnea, daytime
hypersomnolence, urinary frequency
at night and morning headaches.

Additional Surgical
Risk Factors

Male sex, excessive alcohol intake,


and female menopause.
Craniofacial abnormalities, such as
retrognathia and macroglossia.
Wide neck circumference (17 inches
for men and 16 inches for women), are
also considered as risk factors for OSA.

Why Surgical Screening


for OSA
Surgeons/anesthesiologists may not
be informed of sleep study results
(clinical diagnosis of OSA noted by
record review).
One study indicated:
86% of patients were not identified by
surgeons.
47% of OSA patients were not identified
by Anesthesiologists.

Why Perioperative
OSA Safety?
OSA is a major risk factor for perioperative adverse
events; however, no screening tool for OSA has
been validated specifically in surgical patients.
If you think someone might have sleep apnea, you
might not be correct. You cannot always pick out
OSA patients by looking at them.
The American Society of Anesthesiologists
screening guidelines recommend that OSA
screening should be done on every patient.

Perioperative Complications
Factors in OSA that could increase
perioperative complications:
Anatomical imbalance
Lung volume reduction (decreased FRC
and ERV)
Sympathetic nervous system activation
Ventilatory instability

Sedatives and the


OSA
ImpactPatient
of sedatives, anesthetics and

analgesics on respiratory function:


Dose dependent depression of upper
airway muscles.
Depression of central respiratory output
and upper airway reflexes (increased
collapsibility of the upper airway).
Increased collapsibility of the upper
airway.
Direct action (peripheral) on hypoglossal
and phrenic nerves (phrenic nerve
depression leads to decrease in lung

Present
a
Sample
Case

Needs Assessment
Case #1:
A 40-year old male with history of mobid obesity
and prior laparoscopic cholecystectomy and
nephrolithiasis presented to the hospital for an
incisional hernia repair. He was noted to have a
difficult airway preoperatively, but was intubated
with a glide scope without difficulty and was
ventilated fairly easily through surgery.
Postoperatively the patient was extubated and it
was noted that he would drop his oxygen saturation
down into the 40% or less range, even with nasal
and high-flow mask O2. His baseline oxygen range
was 80% or less when awake. The patient was
reportedly aware of a diagnosis of obstructive sleep

Case 1 (Continued)
The Anesthesiologist became
concerned about releasing the patient
home with witnessed severe O2
desats.
This resulted in the patient being
admitted to the ICU with plans to
titrate him on the Vision BiPAP.
Pulmonary consult was ordered with
resulting impression that the patient
had severe obstructive sleep apnea

Case 1 (continued)
Patient was immediately placed on empirical
BiPAP settings in the ICU at pressures of
12/4 cmH2O (IPAP/EPAP). The consulting
Pulmonologist scheduled an emergency
sleep study on the patient which was
performed the next day as a split-night
procedure.
The diagnostic portion of the sleep study
confirmed sleep apnea with AHI of 115
events per hour, SpO2 nadir of 51% and
average SpO2 of 69% in absence of REM or
slow wave sleep.

Results
The patient failed CPAP and was changed to

BPAP with significant improvement but


not significant resolution of his sleep
apnea.
Best response at pressures of 24/18
cmH2O.
Patient was sent home on Auto BPAP
with 6 l/minute of O2 bleed-in with
overnight oximetry and a follow-up
download of his BPAP machine to

Screening Tools

The Sleep
The STOP and
Apnea Clinical STOP-BANG
Score (SACS) Questionnaire

The ASA
Checklist

The Berlin
Questionnaire
33% -High
Risk

27% high
28% high
risk
risk
No significant difference in the questionnaires
ability to identify
patients with OSA)

The Berlin Questionnaire


The Berlin Questionnaire was initially
used and validated for outpatient
screening of OSA in primary care
clinics but has also been validated
as a screening tool in the surgical
population.

The Berlin Questionnaire


10 questions
5 on snoring
3 on EDS
One on witnessed apnea
One on hypertension

Includes age, gender, weight, height,


neck circumference

The Berlin Questionnaire


Category 1
6 questions on snoring and
apnea
Category positive if score 2
or more points

Category 2
3 questions on tiredness and
fatigue
Category positive if score two
or more points

Category 3
positive if HTN or BMI > 30
kg/m2

Question 9 has second


part on frequency of
nodding off or falling

High Risk
2 or more categories
positive

Low Risk
0-1 categories
positive

Sensitivity 0.89
Specificity 0.71
Netzer NC et al. Ann Internal Med 1999;
131:485-491

The ASA Checklist


In 2006, the American Society of
Anesthesiologists published obstructive
sleep apnea guidelines for
anesthesiologists.
The ASA recommends that anesthesiologists
screen for obstructive sleep apnea utilizing
the ASA checklist of 14 questions (12 for
adults and 14 for children).
The ASA OSA scoring checklist combines the
severity of OSA, invasiveness of surgery and
anesthesia, and postoperative opioid
requirements to estimate overall

The ASA Checklist


Sensitivity
5-14/hr AHI 72.1
15-30/hr AHI 78.6
>30/hr AHI 87.2

Chung F, et al. Anesthesiology 2008; 108:


822-830

The STOP Questionnaire


The STOP
questionnaire is
a concise and
easy-to-use more
practical
screening tool for
OSA. It has been
developed and
validated in
surgical patients
at preoperative
clinics.

Four questions
combined with body
mass index, age, neck
size, and gender.
A high sensitivity,
especially for patients
with moderate to
severe OSA.
Two positive
questions on the STOP
indicates that the
patient may be at high

The STOP Questionnaire


Snoring
Tiredness
Observed apnea
High blood pressure

High risk is yes to 2


or more
Low risk is yes to <
2
Sensitivity
5-14/hr AHI 65.6
15-30/hr AHI 74.3
>30/hr 79.3

Chung F, et al. Anesthesiology 2008; 108:


822-830

The STOP BANG


Questionnaire
S=Snoring. Do you snore loudly (louder than
talking or loud
enough to be heard through closed doors)?
T=Tiredness. Do you often feel tired, fatigued, or
sleepy during
daytime?
O=Observed apnea. Has anyone observed you
stop breathing
during your sleep?
P=Pressure. Do you have or are you being treated
for high BP?
B=BMI >35 kg/m2
A=Age >50 y
N=Neck circumference >40 cm

The STOP BANG


Questionnaire

High risk greater or equal to 3


Sensitivity
5-14/hr AHI 83.6
15-30/hr AHI 92.9
>30/hr AHI - 100

Chung F, et al. Anesthesiology 2008; 108: 822-830

Discharge
(longitudinal
evaluation
and care)

Monitoring
(keeping the
patient safe)

Perioperative
Screening
(Identification
)

Clinical Management
Strategy

Clinical Management
Protocol
OSA
OSA focused
focused
history
history and
and
physical
physical
examination
examination

Perioperative
Perioperative
Screening
Screening
tool
tool (STOP(STOPBANG,
BANG, Berlin
Berlin
or
or ASA)
ASA)

Low
Low Risk
Risk for
for
OSA
OSA

Proceed
Proceed with
with
surgery
surgery
utilizing
utilizing usual
usual
perioperative
perioperative
care
care

High
High Risk
Risk for
for
OSA
OSA

Identify
Identify
Patient
Patient with
with
wrist
wrist alert
alert
band
band

Patient with
diagnosed
OSA

Intraoperative
Management in the
OSA Patient
Consider using regional anesthetic or peripheral nerve block with
minimal sedation

Be prepared for difficult


airway management

Consider PAP therapy and


inclined head position to
improve FRC

Use short-acting anesthetic, opioid or


sedative medications

Consider invasive monitoring for respiratory


management

Extubate trachea after patient is


completely awake

Ensure Neuromuscular blocking agents are


reversed

Postoperative Anesthesia
Recovery Management of
the OSA Patient
Focused attention to oxygen saturation and
hemodynamics in recovery

Maintain head up at 30-degree position for a minimum of


two hours
Maintain lateral position for a minimum of two hours

Use non-opioid analgesics, opioid adjuncts and regional


anesthesia
Utilize PAP therapy early to prevent desaturations

Managing the OSA


Patient on the
Hospital Floor

Ensure patient is monitored on an appropriate


medical-surgical floor

Continuous oxygen saturation monitoring is


recommended

Known diagnosis of OSA


OSA and
and compliant
compliant on
on PAP
PAP
Known
diagnosis
of
therapy pre-operatively
pre-operatively
therapy

Continue PAP therapy on the floor

High
High Risk
Risk of
of OSA
OSA or
or known
known OSA
OSA and
and non-compliant
non-compliant prepreoperatively
or
known
OSA
but
PAP
pressures
unknown
operatively or known OSA but PAP pressures unknown

Place patient on auto-PAP therapy

Managing the OSA Patient


after Discharge
Follow-up with sleep
specialist
Diagnostic PSG for definitive diagnosis
and treatment

PAP titration if indicated


PAP management and
compliance


Date:

Re: Patient: _____________________________

Dear Dr. ___________________:


As a part of pre-anesthesia assessment prior to surgery, your
patient was screened for obstructive sleep apnea using the StopBang Questionnaire*. The results identified your patient as at-risk
for obstructive sleep apnea. Patients identified as at-risk may
require further evaluation and follow up for sleep apnea.
Sincerely yours,

____________, MD, DABSM


Medical Director
Sleep Disorders Center

*Frances Chung, F.R.C.P.C., Balaji Yegneswaran, M.B.B.S., Pu Liao, M.D., Sharon A. Chung, Ph.D, Santhira
Vairavanathan, M.B.B.S, Sazzadul Islam, M.Sc., Ali Khajehdehi, M.D., Colin M. Shapiro, F.R.C.P.C.,
Adapted from: STOP Questionnaire -- A Tool to Screen Patients for Obstructive Sleep Apnea.
Anesthesiology 2008; 108:81221 Copyright 2008, the American Society of Anesthesiologists, Inc.
Lippincott Williams & Wilkins, Inc. 1

Make it Easy
PAT Scripting for Nurses:

The Questionnaire you completed is part of a


program to screen for patients who may have
undiagnosed obstructive sleep apnea. The
results indicated that you have a likelihood of
having obstructive sleep apnea. Because of
these results, we would like to include you in
the program for follow-up with your primary
care physician for further evaluation. This
means that your physician will be sent a letter
indicating the results, and we will include your
name in the pilot program for evaluation and
follow-up. Would you like for us to include you
in the pilot program for obstructive sleep apnea
follow-up?

Ensure Follow-up
Date:

Re: Patient: _____________________________


Dear Dr. ___________________:
During pre-anesthesia assessment, your patient was identified
as at-risk for obstructive sleep apnea. The validated
assessment tool (The STOPBang1 questionnaire1) revealed a
score of ____, indicating a ____fold risk of obstructive sleep
apnea. Patients identified as at-risk indicate the need to be
further evaluated for sleep apnea.
Sincerely yours,

Frances Chung, F.R.C.P.C., Balaji Yegneswaran, M.B.B.S., Pu Liao, M.D., Sharon A. Chung, Ph.D,
Santhira Vairavanathan, M.B.B.S, Sazzadul Islam, M.Sc., Ali Khajehdehi, M.D., Colin M. Shapiro,
F.R.C.P.C., Adapted from: STOP Questionnaire -- A Tool to Screen Patients for Obstructive Sleep Apnea.
Anesthesiology 2008; 108:81221 Copyright 2008, the American Society of Anesthesiologists, Inc.
Lippincott Williams & Wilkins, Inc.1
1

Other Useful Tools


The Stop BangHow to Make It Work
Use Other Programs as examples
Use OSA Near Misses as a Teaching
Tool
Present SAMBA Patient Selection
Guidelines
Identify the Challenges in
Implementing a Perioperative Protocol
The Joint Commission Sentinel Event
Alert