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Child with OSA Anesthetic considerations


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Child with OSA Anesthetic considerations

  1. 1. Child with “OSA” Anesthetic Considerations BY Eid Ali Gumaa Assist. Professor of Anesthesia Faculty of Medicine Zagazig University 2013
  2. 2. Milestones 1837: Charles Dickens, in the Posthumous Papers of the Pickwick Club, described an obese boy named Joe with excessive daytime somnolence. Joe has become the prototype of the obesity- hypoventilation syndrome, and probably suffered from obstructive sleep apnea. 1918: Sir William Osler, was subsequently coined the word „Pickwickian‟ to describe such obese, hypersomnolent patients. 1928: Berger, Human EEG alpha waves. 1937: Loomis, EEG Sleep stages described.
  3. 3. Milestones 1965: Gastaut et al. documented the presence of repetitive obstructive apneas during polysomnographic recording of an obese Pickwickian patient. The link between obesity, hypoventilation, daytime somnolence, and upper airway obstruction was now established. 1972: Guilleminault – coined the term OSA. 1990: International Classification of Sleep Disorders.
  4. 4. What is Sleep? “a reversible behavioral state of perceptual disengagement from and unresponsiveness to the environment” 75% in Non-REM sleep 25% REM sleep –muscle atonia, autonomic activation
  5. 5. NREM sleep: Normal muscle tone Regular respiration Four stages of NREM sleep based on EEG Stage 1-small amplitude high frequency waves resembling awake state Stage 4-large amplitude and lowest frequency waves approaching REM
  6. 6. REM sleep: Rapid eye movements. Generalized hypotonia of muscles. Irregular rate and depth of respiration. Marked suppression of hypothalamic regulation of homeostasis.
  7. 7. Sleep Disordered Breathing: Sleep-Disordered Breathing (SDB): Obstructive Sleep Apnea Syndrome (OSAS) –Obstructive Sleep Hypopnea Syndrome (OSHS) –Upper Airway Resistance Syndrome (UARS) Heavy Snorers Disease (HSD):
  8. 8. Definitions: OSAS: describe a person with specific symptoms and signs (daytime sleepiness, cognitive dysfunction, snoring, hypertension, and a narrow upper airway), and a polysomnogram showing upper airway obstruction. associated symptoms have frequently been described, including gastro-esophageal reflux, nocturnal or unusually enuresis, abnormal motor activity, and sweating during sleep.
  9. 9. Definitions (Continue): Apnea is cessation of airflow >10 sec, ends in arousal OSA- apnea with continued respiratory efforts Hypopnea –reduction in airflow of 50% with 4% desaturation, ends in arousal Apnea / Hypopnea Index (AHI)
  10. 10. Syndromes: OSAS: AHI >5/ h. on polysomnography. UARS: AHI <5/ h., excessive daytime somnolence, elevated intra-thoracic pressure Primary Snoring: no polysomnogram abnormalities
  11. 11. OSAS: AHI SaO2 (%) Mild 5–20 >85 Moderate 21–40 65–84 Severe >40 <65
  12. 12. OSA severity scoring Severe OSAModerate OSAMild OSA Mouth breathing, markedly increased respiratory effort, loud snoring and „snorting‟, disrupted sleep Mouth breathing with moderate increase in respiratory effort, +/- snoring or „snorting‟, restless sleep Mouth breathing, slight increased respiratory effort, +/- snoring, sleeps quietly at night Clinical signs Frequent prolonged episodes of paradoxical breathing, frequent prolonged desaturation Normal baseline SpO2, repeated desaturation to mid 80s SpO2 in normal limits, +/- minor dips Sleep study correlate
  13. 13. Control of Airway Patency:
  14. 14. Pathophysiology Anatomy -Obesity –Nasal Obstruction –Pharyngeal Obstruction Jaw Tongue Palate Physiology –Failure of dilator muscles –Excessive intra-thoracic pressure
  15. 15. Consequences of OSAS: Hypertension Ischemic heart disease Myocardial dysfunction & arrhythmias Cerebro-vascular disease Mood, neurocognitive, behavioral –Increased industrial/traffic accidents Increased mortality.
  16. 16. Consequences of OSAS:
  17. 17. Consequences of OSAS:
  18. 18. Upper airway resistance syndrome: A group of children with: Symptoms of (OSAS) excessive daytime somnolence but Without polygraphic apnea and hypopneas. Rather repeated central nervous system arousals, during sleep However, these children were found to have increased respiratory efforts during sleep. Using esophageal manometry as a measure of respiratory effort, it was noted that such arousals were preceded by increased respiratory effort.
  19. 19. The typical presentation of UARS patients: Daytime somnolence, Not obese, May or may not snore, But typically has a narrowed upper airway anatomy. particularlyhypotension,Of interest, postural hypotension, seems to be a common finding in such patients, in contrast to OSAS where hypertension is the usual finding.
  20. 20. Clinical assessment: Diagnosis may be wrong in 50 % cases Loud snoring + witnessed apneas identified OSAHS with sensitivity 78% and specificity 67% Neck circumference <37cm , >48 cm are associated with low and high risk of OSA Obesity (BMI>30) independent risk factor but ~ 50% cases are not obese
  21. 21. Polysomnography: EEG EOG EMG ECG Oronasal airflow Pulse oximetry Respiratory efforts Snoring Position Leg movements
  22. 22. Normal Sleep Study:
  23. 23. Obstructive apnea: Complete cessation of airflow despite efforts to breathe Desaturation Obstructive apnea Respiratory paradox Snore
  24. 24. Hypopnea:Reduction in airflow compared to baseline, associated with desaturation: Desaturation Hypopnea Progressively increasing respiratory effort
  25. 25. Pediatric OSAS: 2% of children Boys = Girls Peak at age 2:5 years Peak OSA =Peak ATH
  26. 26. Pediatric OSAS: Snoring- severity not predictive Many are mouth breathers (Adenoid facies 15% have OSA) Excessive daytime sleepiness Obesity Vs. Fatty Increased respiratory effort
  27. 27. Pediatric OSAS: Impaired growth * Possible impairment of release or end- organ response to GH * Increased caloric effort with respiration * Difficulty with eating Cor pulmonal Associated with GERD
  28. 28. Clinical features of OSA in children and adults ObesityAdenotonsillar hypertrophy Craniofacial disorders Chromosomal abnormalities Hypotonia Causes ObeseFailure to thriveWeight CommonUncommonDaytime sleepiness Cognitive impairment Poor vigilance Hyperactive Poor school performance Secondary enuresis Neurobehavioural Adults and Children Type II OSA Children Type I OSA Clinical features Middle age2-6 yearsPeak age Male>>femaleMale=femaleGender
  29. 29. Anesthesia Considerations: High rate of comorbidity (COPD, CAD, etc) Pre-op. CPAP/BiPAP Short, obese neck / retrognathia – setup for disaster unless prepared Post-op. HTN Post-obstructive pulmonary edema
  30. 30. Anesthesia Considerations: Identification of children at high risk for complications after adenotonsillectomy Age < 3 years or Weight < 15 Kg. Severe OSA Failure to thrive Cardiac complications Obesity Prematurity Recent URTI Craniofacial abnormalities
  31. 31. Anesthesia Considerations: Children with OSA with a cold should be postponed for 4 weeks. Children with signs and symptoms suggestive of severe OSA with cardiac involvement need to be assessed by a cardiologist prior to surgery The improvement is not immediate, but children are dramatically improved in the weeks after surgery.
  32. 32. Premedication: Sedative premedication should be avoided for children with OSA. Parents to accompany the child to the anaesthetic room to reduce the child‟s anxiety.
  33. 33. Induction: May be gaseous or intravenous, depending on the child and the preference of the anesthetist. Immediately after induction” with the loss of pharyngeal tone “ airway almost obstruct & may be relieved by jaw thrust and the application of CPAP. As soon as the child is deep enough an oral airway should be inserted and effectively relieves the obstruction.
  34. 34. Induction (Continue): Children with severe micrognathia (expected will not be easy to intubate) a cautious gas induction is sensible in this situation. Intubation and electively ventilation of children with severe OSA, usually using a short acting non-depolarising NMBDs. Intubation under deep anesthesia without muscle relaxant is unwise in this situation. Suxamethonium should be used if non depolarising agents are not available.
  35. 35. Maintenance& Recovery: Children with severe OSA have been estimated to require 50% less opioid than normal children due to increased opioid sensitivity. Analgesia should be carefully titrated to effect, Simple analgesics should be used. Awake Extubation at the end of surgery. Opioid analgesia should be kept to a minimum in the postoperative period. Insertion of a nasopharyngeal prong airway (NP airway) for these children at the end of surgery
  36. 36. Postoperative: Airway obstruction is not relieved immediately after surgery in children undergoing adenotonsillectomy for severe OSA. This is mainly due to edema and swelling at the operation site, which improves in the first 24- 48 hours after surgery. The child is nursed on the high dependency area (HAD) with the NP airway in position for the first night at least – it is very important to regularly do suction the airway with soft suction catheter. Careful overnight observation, using saturation monitoring as part of routine monitoring on the ward / HAD , but do not administer oxygen to those with severe OSA unless required.
  37. 37. Thank you………….