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Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
Preop Assessment Periop Management
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Preop Assessment Periop Management

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  • The preoperative assessment and planning is probably the most important part in the surgical treatment of OSA patients. You can have the best surgical technique in the world but if you chose the wrong patient or use the wrong procedure on the patient, you will not get a good surgical outcome.
  • Transcript

    • 1. Preoperative Assessment & Perioperative Management Ho-Sheng Lin, MD Associate Professor Department of Otolaryngology/ Head and Neck Surgery SCS Educational Day 11/27/07
    • 2. Introduction
      • OSA is a multi-level upper airway disease
      • Positive Airway Pressure effective in relieving obstruction at all levels
      • Surgical Treatments (UPPP and BOT procedures)
        • Address only specific segment of the upper airway
        • Effective only if precise localization of the site of airway obstruction can be identified
    • 3. Introduction
      • Failure to recognize the multi-level nature of airway obstruction may account for the poor surgical outcome following UPPP alone
      • Sher et al. (1996)
        • Meta-analysis (n = 337 pts) - UPPP alone
        • No selection for level of airway obstruction (Types I - III)
          • Response rate = 40.7%
      • UPPP
        • Discredited by many in the field of sleep medicine
        • May not be a bad procedure
        • Poor result due to misuse by Surgeons
      • Attempt to identify site(s) of obstruction and tailor surgical approach to address this obstruction resulted in improved outcome following surgery
    • 4.
      • Riley and Powell (1986)
        • Genioglossus advancement and hyoid myotomy (GAHM) - BOT
        • Stanford Powell Riley Protocol (Response rate = 76. 5 % , n=306)
          • Phase I: Select surgical procedures based on site of airway obstruction
            • Response rate = 60%
          • Phase II: Bimaxillary Advancement
            • Response rate = 95%
        • Basis of modern surgical management of OSA
      Powell Riley 2-Phase Surgical Protocol 66% GAHM BOT only Type III 60% UPPP and GAHM Palatal and BOT Type II 80% UPPP Palatal only Type I Response Rate Type of Surgical Procedure(s) Site of Obstruction Fujita Classification
    • 5. Powell Riley 2-Phase Surgical Protocol
    • 6. Powell Riley 2-Phase Surgical Protocol
      • Overall success = 76.5% (234/306)
        • Phase I surgery = 61% cure rate (145/239)
        • Phase II surgery = 97% cure rate (89/91)
      • Cure rate = 95% for pts who completed protocol
      N=306 Phase I Surgery N=239 Failed prior UPPP N=60 Responder N=145 Nonresponder N=94 Skeletal deformity N=7 Refused further surg N=70 Proceed to phase II N=24 Phase II Surgery N=91 Responder N=89 Nonresponder N=2
    • 7. Powell-Riley Phase I – Soft Tissue
      • Riley and Powell reported “Cure” rate of 61%
      • Other investigators reported “Cure” rate ranging from 24 - 84%
      • Average of 56%
      Sleep 2007; 30:461-7
    • 8. Powell-Riley Phase I – Soft Tissue
      • Good Phase I surgical result depend on precise localization of site of obstruction
      • Problem: Current Modalities to Identify Exact Sites of Airway Obstruction is Imprecise and Subjective
        • Wide variation in surgical success rate ( 24 - 84%)
        • Less than perfect results following phase I surgery (56%)
    • 9. Diagnostic Modalities
      • Current diagnostic modalities are inadequate
      • Limited by lack of accuracy, high cost, invasiveness
        • General Head & Neck Exam
          • Assess size of tongue, tonsil, soft palate, OP airway
          • Modified Muller’s Maneuver
        • Lateral Cephalometric Analysis
        • Fluoroscopy
        • Pharyngeal Pressure Measure
        • Sine-CT Scan and MRI
        • Sleep Endoscopy
    • 10.
      • Overall
          • Body mass index (BMI)
          • Neck circumference
          • Retrognathia facial profile
      • Nose and Nasopharynx
      • Oropharynx
          • Tonsil (1-4+)
          • Soft palate
          • Lateral pharyngeal wall
          • BOT
          • Oropharyngeal opening
      • Friedman Staging System
          • Tonsil size, BOT position, BMI
      General Head & Neck Examination
    • 11. General Head & Neck Examination
      • Oropharynx
        • Tonsil (1-4+)
        • Soft palate
          • Long, wide,
          • bifid, etc
        • Lateral pharyngeal wall
        • Oropharyngeal opening
        • BOT (1-4+)
          • Mallampati
          • Friedman
    • 12. General Head & Neck Examination
      • Oropharynx
        • Performed with tongue inside mouth
        • BOT (1-4+)
          • Mallampati
          • Friedman
    • 13. Friedman Clinical Staging
      • Stage I
      < 40 < 40 3, 4 3, 4 I II BMI Tonsil Size Friedman Tongue Position
    • 14. Friedman Clinical Staging
      • Stage III
      < 40 < 40 0, 1, 2 0, 1, 2 III IV BMI Tonsil Size Friedman Tongue Position
    • 15. Friedman Clinical Staging
      • Stage II
      < 40 < 40 0, 1, 2 3, 4 I, II III, IV BMI Tonsil Size Friedman Tongue Position
    • 16. Friedman Clinical Staging
      • Stage IV
      All patients with significant craniofacial or other anatomic deformities  40 0, 1, 2, 3, or 4 1, 2, 3, or 4 BMI Tonsil Size Friedman Tongue Position
    • 17. Successful Treatment of OSAHS with UP3 % Successful Treatment Friedman et al. Otolaryngol Head Neck Surg 2003;129:611-21.
    • 18. Distribution of Patients with OSAHS by Stage Percentage of Patients Friedman et al. Otolaryngol Head Neck Surg 2003;129:611-21.
    • 19. Successful Treatment of OSAHS with UP3 vs. UP3 + TBRF % Successful Treatment * * * Different from UP3 only ( P < .001) Friedman et al. Otolaryngol Head Neck Surg 2003;129:611-21.
    • 20. Modified Muller Maneuver
      • Attempt to duplicate negative pressure during sleep
      • Inspiration against closed nose and mouth
      • Sitting and supine positions
      • Identify amount of pharyngeal collapse at soft palate and BOT level
      • Drawbacks:
        • Awake patient
        • Effort dependent
        • Interpretations may
        • be subjective
    • 21. Lateral Cephalometric Analysis SNB SNB < 72o Severe mandibular deficiency BOT obstruction PNS-P > 40 velopharyngeal obstruction PAS < 7 mm BOT obstruction MP-H > 20 BOT obstruction
      • Taken using standardized technique
        • Sitting natural head position
        • End-expiration phase
        • Distance of 5 feet
      • Drawbacks:
        • Awake patient
        • Upright rather than supine
        • 2-Dimensional
        • Adynamic
    • 22. Fluoroscopy and Somnofluoroscopy
      • Can be performed with PSG
      • Ingestion of barium contrast to coat lumen
      • Dynamic assessment of airway collapse
      • Visualization of propagation of obstruction
      • Drawbacks:
        • 2-D representation
        • Only a limited number of apnea events can be captured due to worry about excessive radiation exposure
    • 23. Pharyngeal Pressure Measurement
      • Performed at time of sleep study
      • 2.3 mm Catheter w/ microtip pressure sensors
        • Nasopharynx (above uvula)
        • Oropharynx (between uvula and BOT)
        • Hypopharynx (below BOT)
      • Level of airway collapse determined by changes in pressure patterns
      • If a portion of airway collapse, sensor proximal to the obstruction becomes silent
      • Drawbacks
        • May alter sleep architecture
        • Able to detect only the lowest site of airway obstruction
        • Stenting of airway by catheter
        • Precise localization of obstruction depends upon number of pressure sensors
    • 24. Cine CT Scan
      • Can be combined with PSG
      • Capable of scanning entire airway from nasopharynx to larynx (8 cm) in 0.24 seconds
      • Allow analysis of entire airway during inspiration, expiration, and apneic episodes
      • Accurately localize the level of obstruction during apneic episodes
      • Drawbacks
        • High cost
        • Weight limitations
        • Ionizing radiation
        • Limited to axial plane
    • 25. MRI
      • Excellent soft tissue anatomy
      • Multiple planes
      • No ionizing radiation
      • Drawbacks
        • High Cost
        • Weight limitations
        • Noisy and may require sedation
        • Claustrophobia
        • Can not be combined w/ PSG
    • 26. Sleep Endoscopy
      • Can be performed for surgical planning before or at the same time as the definitive procedure
      • Determine the site of airway obstruction / collapse during simulated natural sleep state (induced w/ low dose propofol)
      • Drawbacks
        • Use of sedation may not completely simulate natural sleep
        • Expensive and time consuming (if performed as part of surgical planning separately from surgical Tx)
        • Stenting of airway by endoscope
    • 27. Palatal Level: Posterior Collapse of Soft Palate
    • 28. Palatal Level: Circumferential Narrowing
    • 29. Oropharyngeal Level : Posterior Collapse of BOT
    • 30. Oropharyngeal Level : Collapse of Lateral OP Wall
    • 31. Oropharyngeal Level: Circumferential Narrowing
    • 32. Supraglottic Level: Collapse of Epiglottis
    • 33. Summary
      • Precise localization of the site(s) of airway obstruction is crucial for surgical success
      • Current diagnostic modalities are inadequate
        • May account for the less than perfect results following phase I surgery (54%)
        • Validate our current existing diagnostic modalities
        • Identify new and better diagnostic modalities for localization of upper airway obstruction
        • Standardization of diagnostic modalities in order to evaluate and assess effectiveness of surgical procedures
    • 34. Preoperative Considerations: Selection of Surgical Candidates
      • Reason for surgical consideration
          • Failed Tx w/ PAP
          • Noncompliant w/ PAP
          • Desire surgical Tx despite good result using PAP
      • Weigh carefully the benefit to risk ratio
        • Chance of “surgical cure” depends on:
          • Severity of OSA (Inferior result if RDI > 60)
          • Body mass index (Inferior result if BMI > 35)
          • Site of airway obstruction (Inferior result if large BOT)
        • Comorbidities and surgical risks
    • 35. Preoperative Considerations
      • Antibiotics
        • Ancef 1 g and Flagyl 500 mg x 1
        • If PCN allergic, Clinda 600 mg iv
      • Do not sedate patients preop
      • Decadron 10-16 mg iv prior to surgery
      • Discuss w/ anesthesia about difficult intubation
    • 36. Intraoperative Considerations
      • Plan for difficult intubation
      • Toradol 30 mg IV (if < 65 yo) or 15 mg IV (if > 65 yo or weight < 110 lbs.)
        • Given over 30 sec x 1
        • Cautious use in pts w/ h/o CAD, COPD, Asthma, peptic ulcers, bleeding tendency
      • Decadron 10-16 mg iv at end of surgery
      • Extubate only when patient is completely awake
    • 37. Postoperative Considerations
      • Obstruction may get worse after surgery due to
        • Postop edema/swelling
        • Residual anesthetics
        • Use of postop pain medication
      • Low threshold to admit to ICU
      • Diet-clear to soft
      • Respiratory
        • Patient must use CPAP/BiPAP when sleeping
        • Call HO if patient refuse to wear CPAP
      • Keep SBP < 140 and diastolic BP < 90
    • 38.
      • Pain meds
        • Toradol 30 mg IV Q6 hours or 15 mg IV (if >65 yo or wt < 110lbs) given over 30 sec (standing order) x 3 days
        • Tylenol with codeine elixir (120mg/12mg/5cc) 20-40 cc Q 4hrs prn
        • 2% Viscuous lidocaine 15 cc gargle and spit Q4 hrs prn
        • Morphine sulfate 2-4 mg iv Q 2hrs prn
      • Antibiotics
      • Decadron 10-18 mg iv Q6 hour
      • Peridex oral rinse 15 cc swish and spit Q6 hrs prn
      • Zantac 50mg iv Q6 hours
      Postoperative Considerations

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