This document summarizes a patient visit and evaluation for obstructive sleep apnea. The 32-year-old male patient presented with snoring, throat pain, and disturbed sleep. Examination found obesity, enlarged tonsils, and other risk factors. Polysomnography was not performed but the patient's symptoms and characteristics were consistent with severe obstructive sleep apnea. The patient underwent uvulopalatopharyngoplasty surgery, which had complications requiring extended operating time. Post-operatively, the patient required oxygen and CPAP support. Risk factors, diagnosis, treatment options and postoperative care for obstructive sleep apnea were discussed.

1. Dr Bikash Subedi
Moderator: Prof. Dr Baburaja Shrestha
19th Aug,2014

2. O Mr Ghimire,32/m

3. Presenting complaints
O Snoring x 3 years
O Recurrent Throat pain/foreign body
sensation x 2 yrs
O ?Disturbed sleep x 2 yrs

4. HOPI
O Off and on throat pain and tonsillar
enlargement
O Unaware of sleeping difficulty (snoring,
obstructed breathing)
O Somnolence,fatigue, headache in the
morning

5. O No significant past medical except for
taking painkillers & antibiotics off and on
for throat pain
O No h/o surgical oR anesthetic exposure

6. Personal history
O Smoker- 5-6 cigarettes/day for the last 6 yrs
?left since last 1.5 mnths
O Occasional drinker
O Normal bowel/bladder habits

7. Physical examination

8. General examination
O General condition – fair
O Wt.-108 kgs, Ht.- 165 cms
O BMI – 39.66 kg/M2
O PILLCCOD – NIL
BMI- < 18.5= underweight. 18.5-25= normal wt. 25-30= overweight. 30-35= class
1 obesity. 35-40= class II. > 40= class III obesity

9. Airway
O Normal Dentition/ Patent nares
O Mouth opening – 3 fingers breadth
O TMD – >6 cm
O TMJ – free/mobile
O Neck mobility –
slightly restricted due to surascapular hump
O MP – II grade, tonsillar enlargement +Ve (?Grade IV)
O Thick neck
O Suprascapular hump

10. Systemic examination
OCVS Examination :
O Pulse: 80,regular
O BP: 130/80 mm Hg (left sitting)
O S1 + S2 + M0
ORespiratory Examination:
O RR: 16/min
O Air entry B/L on bases, otherwise NVB

11. OAbdomen
distended, fatty
no organomegaly,

12. Investigations
O Hb:13.2 gm%
O TC: 10,300/mm3
O P72, L22, E06
O PT: 15 secs
O INR: 1.1
O Platelets: 2,25,000/mm3
O Blood group: 0 +ve
O Na: 146 meq/l
O K: 4.7 meq/l
O Urea: 26 mg/dl
O Creatinine: 0.9
mg/dl
O RBS: 134 mg/dl
O ABG: N/A
O Trop I – Neg
O CK MB- 17 U/L

13. O Normal echocardiographic findings
LVEF-65%
O Normal Thyroid function tests
T3= 2.63 pg/L
T4= 11.49 pg/L
TSH= 1.10 mIU/L

15. RAD

16. Preoperative preparation
O NPO/Premedication PPI,Prokinetic
O IV access/ 16 G cannula
O Equipments for Difficult airway made
ready
O Ramping done
O Preoxygenation & RSI

17. OPIOID-LESS SURGERY!!
O INDUCTION
inj Propofol 250 mg
inj Sux 150 mg
1.5 gms of PCM
150 mg of Diclofenac sodium
O 6.5 mm ID RAE tube. uneventful

18. O MAINTENANCE
Vecuronium,Ketamine
(intermittent/analgesia)
O2 (100%), Isoflurane
O REVERSAL
DOS = 1 hr 45 mins
Neostigmine, Glycopyrrolate

19. Intraoperative

20. NOT so smooth emergence!!
O Bucking on the tube
O Oral bleeding noticed >> re-induced with
Propofol
O Another 40 mins of cautery!
O Awake intubation planned >> violent pt.
>> nasopharyngeal airway sutured! >>
suctioned/extubated >> another 25 mins
of airway support maneuvers

21. O Shifted to ICU for monitoring/ CPAP
PCM/ NSAIDS for pain
O O2 Sats dropped to 65% during sleep
O CPAP not tolerated well >> O2 face mask
>> sats above 90 %

22. DISCUSSION

23. Obstructive Sleep Apnea
O Sleep apnea-hypopnea syndrome
O Cessation or significant decrease in
airflow in the presence of breathing effort
O Recurrent episodes of upper airway
collapse during sleep
O Recurrent desaturations and arousals

24. O OSA a/w excessive daytime sleepiness
OSA syndrome

25. Signs & Symptoms

26. Night symptoms
O Snoring, usu loud & bothersome
O Witnessed apneas (interrupt snoring &
end with snort)
O May have Gasping/choking that arouse
O Restless sleep (toss & turn)
O nocturia

27. Daytime symptoms
O Sleepiness,fatigue
O Headache, dry/sore throat
O ↓vigilance, confusion
O Personality/mood changes
(depression,anxiety)
O ↓libido, GERD
O Paradoxical “good sleepers”

28. STOP!
O S: "Do you snore loudly, loud enough to
be heard through a closed door?"
O T: "Do you feel tired or fatigued during the
daytime almost every day?"
O O: "Has anyone observed that you stop
breathing during sleep?"
O P: "Do you have a history of high blood
pressure with or without treatment?“
O >>2 OUT OF 4 >>

29. PATHOPHYSIOLOGY
STATIC
FACTORS
• Anatomic
factors
• ↓pharyngeal
diameter
• Gravity/posture
DYNAMIC
FACTORS
• Airway
resistance
• Bernoulli’s
effect
• Dynamic
adherence

30. Nonstructural risk factors
O Obesity
O Central fat distribution
O Male sex (M:F=2:3.1
O Age (inc with inc age)
O Postmenopausal state
O Alcohol use
O Sedative use
O Smoking
O Supine sleep position
O Hypothyroidism, Acromegaly
O Rapid eye movement (REM) sleep

31. PATHOPHYSIOLOGY
ue
a
is
to

32. Examination may reveal
O Obesity (BMI usu > 30)
O Enlarged neck circumference
men > 43 cm. Women >37 cm
O High MP scores, enlarged tonsils (grade
3/4)
O Retro/micrognathia, overjet
O High arched palate
BANG! – BMI, AGE > 50 ,Neck circum Gender M

33. O Systemic arterial HTN (upto 50% OSA
cases)
O Pulm. HTN, CHF
O Type II DM, Metabolic syndrome

34. DIAGNOSIS

35. The Apnea Hypopnea Index
(AHI)O defined as the average number of abnormal
breathing events per hour of sleep
O APNEA refers to cessation of airflow for 10s,
O Hypopnea -reduced airflow with desaturation
≥4%.
O The American Academy of Sleep Medicine
(AASM) diagnostic criteria either an AHI ≥15, or
AHI ≥5 with symptoms, such as daytime
sleepiness, loud snoring, or observed
obstruction during sleep.
O OSA severity is
O mild for AHI ≥5 to15, moderate for AHI 15 to
30, and severe for AHI >30.

36. Overnight sleep study
Polysomnography
SLEEP STAGES
EEG,electro-
oculogram,chin
electromyogram
BREATHING
Flow
Apnea,hypoapnea
HEART RHYTHM
via ECG
LEG MOVEMENT
Tibialis anterior
electromyogram

37. Apnea,Hypoapnea & RERA

38. Derivation and validation of a simple
perioperative sleep apnea prediction
score. Ramachandran et al Anesth Analg. al.2010 Apr 1l
O Abstract/BACKGROUND:….
O METHODS:
O A retrospective, observational study was designed to identify patients with a known
diagnosis of OSA. Independent predictors of a diagnosis of OSA were derived by
logistic regression, based on which prediction tool (P-SAP score) was developed.
The P-SAP score was then validated in patients undergoing overnight
polysomnography.
O RESULTS:
O The P-SAP score was derived from 43,576 adult cases undergoing anesthesia. Of
these, 3884 patients (7.17%) had a documented diagnosis of OSA. 3 demographic
variables: age > 43 years, male gender, and obesity; 3 history variables: history
of snoring, diabetes mellitus Type 2, and hypertension; and 3 airway measures:
thick neck, modified Mallampati class 3 or 4, and reduced thyromental distance
were identified as independent predictors of a diagnosis of OSA. A diagnostic
threshold P-SAP score > or = 2 showed excellent sensitivity (0.939) but poor
specificity (0.323), whereas for a P-SAP score > or = 6, sensitivity was poor (0.239)
with excellent specificity (0.911). Validation of this P-SAP score was performed in
512 patients with similar accuracy.
O CONCLUSION: The P-SAP score predicts diagnosis of OSA with dependable
accuracy across mild to severe disease. The elements of the P-SAP score are
derived from a typical university hospital surgical population

39. Conservative therapy &
prevention
O Sleep position (NOT supine)
O Upright position for markedly obese
O Smoking cessation
O Alcohol/ sedatives avoidance
O Avoidance of sleep deprivation

40. Baseline Risk Reduction
Strategies
O Preoperative CPAP
O Opioid sparing techniques
O Regional anesthesia/analgesia
O Non-opioid adjuncts
O Minimal access surgery
O Continuous pulse oximetry monitoring
O Postoperative CPAP

41. Mechanical means
O CPAP
O Bilevel positive airway pressure
O Oral appliance therapy ??

42. Surgical options
O Underlying cause= tonsillectomy,
adenoidectomy
O Uvulopalatopharyngoplasty
O Craniofacial reconstruction
O Tracheostomy

43. O Implantable neurostimulator for OSA

45. O http://emedicine.medscape.com/article/295807-
clinical#aw2aab6b3b2
O http://journal.frontiersin.org/Journal/10.3389/fneur.
2012.00095/full
O http://www.stopbang.ca/pdf/pub10.pdf
O http://www.michiganrc.org/sites/michiganrc.org/file
s/u1258/SKR%20Boston%20IARS%20-
%20Ramachandran.pdf
O http://www.sasmhq.org/wp-
content/uploads/2014/05/SASM14_Educational_v3
.pdf
O http://www.sign.ac.uk/pdf/qrg73.pdf