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Preop Assessment Periop Management


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Preop Assessment Periop Management

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