Sleep Labs Are Obsolete for Peri-operative Assessment of...

SleepLabsAreObsoleteforPeri-operativeAssessmentof

SleepDisorderedBreathing- CONSocietyofAnesthesiaandSleepMedicine

2017AnnualMeetingOctober19th,2017

SusheelPatil,MD,PhDJohnsHopkinsSchoolofMedicine

ClinicalDirector,JohnsHopkinsSleepMedicine

Conflictsofinterest

• Consultant– MedicalAdvisoryBoardforSomnomed,Inc (endedinearly2017)

SleepLabs CentersAreObsoleteforPeri-operativeAssessmentofSleep

DisorderedBreathing- CONSocietyofAnesthesiaandSleepMedicine

2017AnnualMeetingOctober19th,2017

SusheelPatil,MD,PhDJohnsHopkinsSchoolofMedicine

ClinicalDirector,JohnsHopkinsSleepMedicine

Currentguidelinesforsleeptesting

• PatientsathighriskformoderatetosevereOSAshouldbeconsideredforHSAT

• Patientswithsignificantcardiopulmonarycomorbidities,neuromusculardisorders,orothersleepdisordersshouldbeconsideredforin-labsleeptesting

• FailedornegativeHSATinapatientwithhighpre-testprobabilityshouldhavein-labsleeptestingtoruleoutOSA.

KapurV,etal.JCSM2017:13:479– 504.

ConsequencesofOSAonpost-operativeoutcomes

KawR,etal.BrJAnaesth;2012;109:897-906.

Dx ofOSAbasedonquestionnaire,oximetry,orPSG.ICD-9onlybaseddxexcluded.

PotentialeffectsofCPAPonpost-operativeoutcomes

LOS

Post-OpAdverseEvents

Nagappa etal.Anesth Analg 2015;120:1013–23.

Uniqueaspectsofperi-operativeassessmentofOSA

• Timesensitivity– donotwanttodelaysurgeriesunnecessarily

• Planningofresourceutilization• Isthepatientathighriskforanadverseoutcomeafterplannedsurgery?

• Canthisbesamedaysurgeryorisaninpatientadmissionneeded?

• Ifaninpatientadmissionneeded– isanICUbed,monitoredbed,orfloorbedneeded?

Emergentsurgeries

• ThereislittlethataSleepCentercanofferwhenemergentsurgeriesmustbedone

• Managingriskofpost-opcomplicationsinhighriskOSApatients:

• Inpatientpulmonary/anesthesiapre-opconsultations• AvailabilityofmonitoredbedwithoximetryandCO2monitoring

• ProtocolsformanagingpatientsrecognizedathighriskforOSA

EmergentsurgeriesSASM2016Guidelines:• WeakFor:ThereisinsufficientevidencetosupportcancelingordelayingsurgerytoperformmoreadvancedscreeningtechniquesorsleeptestingtodiagnoseOSAinthosepatientsidentifiedasbeingathighriskofOSApreoperatively,unless thereisevidenceofanassociatedsignificantoruncontrolledsystemicdiseaseoradditionalproblemswithventilationorgasexchange(LevelofEvidence:Low)

ASA2014Guidelines:• IfanycharacteristicsnotedduringthepreoperativeevaluationsuggestthatthepatienthasOSA,theanesthesiologistandsurgeonshouldjointlydecidewhetherto(1)managethepatientperioperatively basedonclinicalcriteriaalone or(2)obtainsleepstudies,conductamoreextensiveairwayexamination,andinitiateOSAtreatmentinadvanceofsurgery

• Ifthepreoperativeevaluationdoesnotoccuruntilthedayofsurgery,thesurgeonandanesthesiologisttogethermayelectforpresumptivemanagement basedonclinicalcriteriaoralast-minutedelayofsurgery.

ChungFetal.Anesth Analg 2016;123:452-473.ASAGuidelines.Anesthesiology2014;120:1-19.

Whyaresleepcentersevenneededforperi-operativeassessments?ItOnlyTakesOne...

P.Gay.JClin SleepMed2010;6:473-474

Acasetoconsider...

• 52yearoldmalewithHTNandT2DMandplansforelectiveAAArepair.

• BMI21kg/m2,neckcircumference14cm• Snoresperhiswife• Hassomefatigue• PCPhadsenthimforasleepstudy

Acasetoconsider...

• Sleepstudyreport• TST345minutes;TIB412minutes;SE84%• N1– 21%;N2– 53%,N3– 8%;R– 18%

• AHI– 8/h• RDI– 11/h

• Interpretation:Thepatient’ssleepisconsistentwithmildsleepapnea.

MildObstructiveSleepApnea

Sowouldthisbeareasontobeconcernedforgreatermonitoringpost-op?

NREMSleeponhissideNREMRDI7/h

REMSleeponhisbackREMRDI58/h

Acasetoconsider...

• Wouldhestillbeconsideredlowerrisk?• Wouldprecautionsmightbetakenknowingthisinformation?

• Presumepost-ophehastolaysupine?• MightbeatriskforREM-sleepreboundafterreceivinggeneralanesthesiaandpossibleopiatesforpaincontrol?

• Ifnotontherapyathome,shouldPAPbestartedinhouse?

Whyaresleepcentersevenneededforperi-operativeassessments?• Questionnairesareimperfect• Pre-treatmentofOSAmaybeassociatedwithbetteroutcomesthanin-hospitalinitiation.

• Optimizeadherencepriortosurgery• ComplexPatients- Assistindeterminingcausesofunexplainedhypoxemiaorhypercarbia.

• CPAPcanbeasurrogateforcompliancewithpost-opcare(e.g.post-bariatricsurgerydiet)

• Toensureappropriatepost-surgeryevaluationandcare

Questionnairesareimperfect

• Falsepositiveratescanrangefrom44– 68%• Falsenegativeratecanrangefrom7– 32%• Willvarybasedonsensitivity/specificitythresholdschosenforaparticularOSA

threshold• Implications

• Moreresourceuseandcostsdependingonthresholdchosen• Costsassociatedwithpotentialmisseddiagnosisandsubsequentcomplications

ChungF,etal.Anesth Analg 2016;123:452-473..





SamedayassessmentofOSAmayhaveworseoutcomesthandiagnosedOSA

• Setting:AcademicCenterand2communitypractices• Retrospective,dataextractionfromEMR• PreviouslydiagnosedOSA(D-OSA)– pre-existinginmedicalrecordorselfreportbypatientondateofsurgery

• Pre-operativesuspectedOSA(S-OSA)- ifclassifiedbyanesthesiaprovidersandhadSTOP-Bang>3.

• STOP-Bangmissingdataon“STO”– considerednegative:• Snoring(44%)• Tiredness(83%)• Observedapneas(82%)

• 57%ofthosewithreportedOSAself-identifiedasbeingcompliantwithCPAP.

Fernandez-Bustamente.Anesth Analg 2017;125:593-602.





Post-opdesaturationeventsarecommoninthefirst48h

Sun,etal.Anesth Analg 2015;121:709-715.

• 66%receivedsupplementaloxygen• 4-5%receivedPAPtherapy• Only5%hadasingledesaturation<90%

documented

37%

11%3%

CouldhomeinstitutionofCPAPreduceadverseoutcomes?

GuptaR,etal.MayoClin Proceed2001;76:897.

• Lessthan½ofpatientswithhomeCPAPreceivedroutineCPAPtherapyinthehospital- ?carryoverprotectionforthe1st post-opday

Reducedpost-opcomplications:PAPusecomparedtountreatedOSA

• 10%of26,842pre-oppatientswithdiagnosedorsuspectedOSA

• 55%Untreated

N=2646

Abdelsattar etal,SLEEP2015;38(8):1205–1210.

aOR=1.8

aOR=2.5

aOR=2.6

InitiatingPAPinhospitalisnotalwayseasy...

• HighriskgroupidentifiedwithSACS>=15• Randomizedtostandardcare(n=43)vs.standardcare+APAP(n=43)

• MedianAPAPusewas184.5min(IQR:64– 451min)

• 64%usedAPAP100%ofpost-opnights• 36%reportedAPAPtobetoouncomfortable• 14/38withanAHI<10/hperAPAPcard• NoreductioninLOSinAPAPvsnoAPAPgroups

GormanS,etal.Chest2013;144:72-78.

PotentialreasonswhypriorCPAPusemayimproveoutcomes

• Possiblecarryovereffectresultingin:• Decreasedupperairwayinflmamtion• Decreasedupperairwayedema• Increasedupperairwaystability

• ThosewhousePAPathomemaybemorelikelytouseinthehospital

Abdelsattar etal,SLEEP2015;38(8):1205–1210.





Complexpatients

SASM2016Guidelines(similarstatementsforthoseathighriskforOSAorpoorlyadherentorrefusetherapyforOSA):• WeakFor:Wesuggestthatadditionalevaluationforpre-operativecardiopulmonaryoptimizationbeconsideredinpatientswhohaveaknowndiagnosisofOSAandnon-adherentorpoorlyadherenttoPAPtherapyandwherethereisindicationofuncontrolledsystemicconditionsoradditionalproblemswithventilationorgasexchange.Theseconditionsincludebutarenotlimitedto:i)hypoventilationsyndromes,ii)severepulmonaryhypertension,iii)restinghypoxemianotattributabletoothercardiopulmonarydisease(LevelofEvidence:Low)

• WeakFor:WesuggestthatuntreatedOSApatientswithoptimizedcomorbidconditionsmay proceedtosurgeryprovidedstrategiesformitigationofpostoperativecomplicationsareimplemented.Therisksandbenefitsofthedecisionshouldincludeconsultationanddiscussionwiththesurgeonandpatient(LevelofEvidence:Low)

ChungFetal.Anesth Analg 2016;123:452-473.

Considerations

• Suchpatientsaremorelikelytodeveloppost-opcomplications

• Thesecomorbiditiesoftenco-existwithformsofsleepdisorderedbreathing

Considerations

• Sleepcentersaffiliatedwithhospitalscansupporttheperi-operativeteamthroughurgentinpatientrespiratorypolygraphytesting

• Sleepcenterproviderscanprovideneededconsultationsupporttooptimizecardiopulmonarystatuspriortoaftertesting

• Caninvestigatereasonsfortreatmentrefusalornon-compliance

PamidiS,etal.Chest2012;141:51-57.

Sleepmedicinetrainedprovidershadhigheradherencewithpatientsthannon-sleepmedicineproviders





CPAPasasurrogateforcompliancewithothertherapies

• 330veteransonlipidloweringmedicationsandnewlyprescribedCPAP.

• Thoseadherenttoanti-hyperlipidemic medicationsaremoreadherenttoCPAP

• 40.1%probabilityofCPAPadherenceinthosewith<80%adherencetomedicationscomparedto55.2%CPAPadherenceinthosewith≥80%medicationadherence

PlattABetal.Chest2010;137:102-108

CPAPadherencepredictedweightlosstrajectory

• Studyof24subjectthatunderwentgastricbanding

• Age:48.5± 9.4years;73%werefemale;

• Pre:• BMI:51.1± 10.9kg/m2• MeanAHI:48.2/h± 32.8/h

• Post:• Weightloss:121.1± 50.2lb;BMI:-18.6kg/m2.

• MeanAHI:24.5± 18.8events/h

• n=8wereusingCPAP





• WeakFor:SASM2016Guideline:PatientsshouldbeadvisedtonotifytheirprimarymedicalproviderthattheywerefoundtohaveahighprobabilityofhavingOSA,thusallowingforappropriatereferralforfurtherevaluation(LevelofEvidence:Low)

• 80%ofpatientswithOSAareundiagnosedanduntreated

• Pre-operativeevaluationcanbeatimetoincreasepatientawarenessofpotentialimportanceofaddressingsleepissues

ValueaddedofSleepCenters?

• SleepCentersprovideexpertisetocomplementpre-operativeevaluations

• Sleeptesting• Implicationsofsleeptestingresults• Consultationstounderstandcomplexbreathingissue• Optimizationoftreatmentpriortooperativecare

Missing Periods of Hypoxemia

• 8 patients – every one had at least on event not detected by routine monitoring

• T90 was 165 +/- 49 minutes

• Mean total number of events with SpO2<90% for > 30s: 62 +/- 16 events

• No patient experienced cardiopulmonary arrest/instability.

Gallagher et al JOURNAL OF SURGICAL RESEARCH: VOL. 159, NO. 2, APRIL 2010

• In this study post op gastric bypass patients were monitored with pulse oximetry.• Even the use of CPAP therapy did not completely resolve desaturation events• However, timing of PAP use was not known

Why would PAP therapy fail?Why would PAP therapy fail?

OSA and post-operative complications in orthopaedic procedures

• 101 OSA and 101 controls matched on age, sex, operation type, side, surgeon, year, anesthesia.

• Group 1A: surgery 3 years prior to diagnosis of OSA• Group 1B: confirmed OSA at time of surgery• Complication or intervention

• Complication - Reintubation, acute hypercapnia, episodic desaturations, acute cardiac ischemia or arrhythmia, delirium

• Serious complication – ICU transfer, acute cardiac ischemia or arrhythmia, or urgent need for respiratory support.

• Intervention - performed in response to the historically reported complication was defined as administration of a new treatment (such as supplemental oxygen) or implementation of additional monitoring (such as pulse oximetry).

GuptaR,etal.MayoClin Proceed2001;76:897.

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