This document discusses the perioperative management of patients with asthma or COPD undergoing surgery. It covers preoperative evaluation including spirometry and optimization. Spirometry can help assess surgical risk and optimize treatment. Optimization includes smoking cessation, treating infections, using bronchodilators, and stabilizing cardiac conditions. Proper preoperative evaluation and optimization can reduce postoperative pulmonary complications in these high-risk patients undergoing surgery.

1. ASTHMA AND COPD
DR NARENDRA JAVADEKAR DR BHASKAR
SHENOLIKAR
PERIOPERATIVE MANAGEMENT OF
HIGH RISK PATIENTS

3. • O R EVALUATION
• PREMEDICATION
• ANASTHESIA TECHNIQUES
• INDUCTION
• AIRWAY MANAGEMENT
• INTRAOP MONITORING
• INTRAOP COMPLICATIONS
• RECOVERY ROOM
• POSTOP COMPLICATIONS
• DEFINITIONS
• DIAGNOSIS
• SAFETY OF SURGERY
• PREOPERATIVE EVALUATION
• CLINICAL EXAMINATION
• INVESTIGATIONS
• RISK ASSESSMENT
• OPTIMISATION
ASTHMA AND COPD
PERIOPERATIVE MANAGEMENT
DR NARENDRA JAVADEKAR DR BHASKAR SHENOLIKAR

4. PERIOPERATIVE PULMONARY
COMPLICATIONS
PULMONARY COMPLICATIONS
MORE COMMON THAN CARDIAC COMPLICATIONS
CAUSE SIGNIFICANTLY LONGER HOSPITAL STAYS
LAWRENCE, VA, HILSENBECK, SG, ET AL. J GEN INTERN MED 1995;
10:671
MOST COSTLY COMPLICATIONS
DIMICK, JB, CHEN, SL, ET AL. J AM COLL SURG 2004; 199:531
PULMONARY COMPLICATIONS 6.8% ACROSS ALL TYPES SURGERIES
ATELECTASIS, PULMONARY INFECTION,
PROLONGED MECHANICAL VENTILATION, RESPIRATORY FAILURE,
CHRONIC LUNG DISEASE EXACERBATION, BRONCHOSPASM
SMETANA, GW, LAWRENCE, GA, ET AL, ANN INTERN MED 2006; 144:581

5. • 6% PREVALENCE
• PROGRESSIVE DYSPNEA
• SPUTUM PRODUCTION
• EXPOSURE TO RISK
FACTORS
• OLDER AGE GROUP
• FAMILY HISTORY +/-
• NOT FULLY REVERSIBLE
• FEV1/FVC< 70% AFTER
BRONCHODILATOR THERAPY
• 7% PREVALENCE
• INTERMITTANT DYSPNEA
• EXACERBATIONS AND
REMISSIONS
• RESPONSE TO SPECIFIC
ALLERGENS
• YOUNGER AGE GROUP
• FAMILY HISTORY
• RAISED IGE/EOSINOPHILLIA
• COMPLETELY REVERSIBLE
DIFFERENTIAL DIAGNOSIS
ASTHMA COPD

6. DIAGNOSTIC ASSESSMENT
• SPIROMETRY-AIRWAY RESISTANCE
• BODY PLETHYSMOGRAPHY(LUNG VOLUMES)-
COMPLIANCE OF CHEST WALL AND LUNGS
• DLCO-PULMONARY GAS EXCHANGE

7. Total
lung
capacity
Tidal volume
Inspiratory reserve
volume
Expiratory reserve
volume
Residual volume
Inspiratory
capacity
Vital
capacity
Lung Volume Terminology

8. ASTHMA MANAGEMENT
• PATIENT EDUCATION
• IDENTIFICATION OF RISK FACTORS –REDUCE EXPOSURE
• STEPWISE TREATMENT
• MANAGE ACUTE EXACERBATIONS

9. ASTHMA MANAGEMENT
• BETA 2 AGONIST
• SABA-SALBUTAMOL/TERBUTALINE
• LABA-FORMOTEROL/SALMETEROL
• METHYLXANTHINES
• THEOPHYLLINE/AMINOPHYLLINE
• DOXOPHYLLIN
• ANTICHOLINERGICS
• IPRATROPIUM
• CORTICOSTEROIDS
• PREDNISOLONE/DEXAMETHASONE
HYDROCORTISONE/
METHYLPREDNISOLONE
• BECLOMETHASONE/BUDESONIDE
• FLUTICASONE/CICLESONIDE
• MAST CELL STABILISERS
• SODIUM
CHROMOGLYCATE,KETOTIFEN
• ANTI IGE ANTIBODY
• OMALIZUMAB
• LEUKOTRIENE MODIFIERS
• MONTELUKAST
• ZIFERLUKAST
• ZILEUTON

10. ASTHMA COMORBIDITIES
• COPD MAY COEXIST
• ADVERSE EFFECTS OF STEROIDS –
APD,OSTEOPOROSIS,DIABETES,IMMUNOSUPRESSION,OR
AL THRUSH,SUPRESSION OF ADRENOCORTICAL AXIS
• BRONCHODILATORS-
• HYPOKALEMIA/TACHYARRHYTHMIAS/TREMORS

11. COPD SEVERITY BY GOLD STAGES
• STAGE 0-FEV1 N FEV1/FVC N
• STAGE 1-FEV1>= 80% FEV1/FVC<0.7
• STAGE 2-FEV1< 80% FEV1/FVC<0.7
• STAGE 3-FEV1< 50% FEV1/FVC<0.7
• STAGE 4-FEV1<30% FEV1/FVC<0.7

12. COPD MANAGEMENT
• SMOKING CESSATION
• OXYGEN THERAPY
• LUNG VOLUME REDUCTION
SURGERY
• INHALED CORTICOSTEROIDS
• SABA
/ANTICHOLINERGICS/THEOPHYLLI
NE
• PULMONARY REHABILITATION
• NON INVASIVE VENTILLATION
• VACCINES –
PNEUMOCOCCAL/INFLUENZA
• LUNG TRANSPLANTATION

13. COPD COMORBIDITIES
• HYPERTENSION
• ATHEROSCLEROTIC
VASCULAR DISEASE
• ISCHEMIC HEART DISEASE
• ARRHYTHMIAS –ATRIAL
FIBRILLATION
• HEART FAILURE
• DIABETES
• MUSCULOSKELETAL
WEAKNESS/OSTEOPOROSIS
• ANXIETY/DEPRESSION

14. COPD AND ASTHMA-IS SURGERY SAFE?
• NUMBER OF COPD/ASTHMA CASES COMING FOR SURGERY IS ON
RISE DUE TO
• ADVANCING AGE
• INCREASE IN LIFE EXPECTANCY
• INCREASED PREVALENCE OF COPD/ASTHMA
• INCREASED FREQUENCY OF DIAGNOSTIC AND THERAPEUTIC
PROCEDURES

15. COPD/ASTHMA AND
ANASTHESIA
• SURGERY IS SAFE
• COMPLICATION RATE IS EQUAL TO
CARDIAC EVENT RATE (1-3%)
• MODERN ANASTHESIA TECHNIQUES AND
PERIOPERATIVE MANAGEMENT
IMPROVES OUTCOMES

16. • RESPIRATORY DEPRESSION
• REDUCED RESPONSE TO
HYPERCAPNIA AND HYPOXIA
• REDUCED FRC
• REDUCED LUNG VOLUME
• ATELECTASIS IN DEPENDANT
LUNG
• V/Q MISMATCH-HYPOXIA
• REDUCE SYMPATHETIC
TONE
• SYSTEMIC VASODILATION
• MYOCARDIAL DEPRESSION
• DECREASED CARDIAC
OUTPUT
• DECREASE BLOOD
PRESSURE
• VARIABLE EFFECT ON HEART
RATE
EFFECTS OF ANASTHETIC AGENTS
CARDIVASCULAR SYSTEM RESPIRATORY SYSTEM

17. TYPE OF ANASTHESIA
• NEUROAXIAL SAFER THAN GENERAL FOR PREVENTION
OF PULMONARY COMPLICATIONS THOUGH CARDIAC
EVENTS ARE SAME.
• COMBINATION OF BOTH TO REDUCE GA REQUIREMENTS
IS USEFUL.
• EPIDURAL ANALGESIA FOR PAIN RELIEF REDUCES
POSTOP COMPLICATION RATE.
• (INTERSCALENE BRACHIAL PLEXUS BLOCK CAUSES
IPSILATERAL PHRENIC NERVE PALSY)

18. GRADES OF COMMON NON-CARDIAC
SURGICAL PROCEDURES
• HIGHER-
• EMERGENCY SURGERY,ESP ELDERLY
• AORTIC AND NONCAROTID MAJOR VASCULAR SURGERY
• PROLONGED SURGERY/LARGE FLUID SHIFT/BLOOD LOSS
• INTERMEDIATE-
• MAJOR THORACIC SURGERY
• MAJOR ABDOMINAL SURGERY
• CAROTID ENDARTERECTOMY
• HEAD /NECK SURGERY
• ORTHOPEDIC SURGERY
• PROSTATE SURGERY
• LOWER—
• EYE,SKIN,SUPERFICIAL SURGERY
• ENDOSCOPIC PROCEDURES

19. PRE-OPERATIVE ASSESSMENT GOALS
• NEED FOR SURGERY—IS IT URGENT?
• CONFIRM THE DIAGNOSIS
• ASSESS SEVERITY OF THE DISEASE
• ASSESS ONGOING TREATMENT-IS IT EFFECTIVE
• PREOPERATIVE OPTIMISATION
• PLAN ANASTHESIA MANAGEMENT

20. TOOLS FOR ASSESSMENT
• HISTORY
• SMOKING HISTORY, DURATION ,NO OF CIGARETTES/DAY
• EXERCISE TOLERANCE.
UNRELIABLE WHEN SELF-REPORTED
• ENQUIRE ABOUT THE MAXIMAL LEVEL OF EXERTION.
• THE FREQUENCY OF EXACERBATIONS.
• TIMING OF THE MOST RECENT COURSE OF ANTIBIOTICS OR
STEROIDS.
• HOSPITAL ADMISSIONS.
• PREVIOUS REQUIREMENTS FOR INVASIVE AND NON-INVASIVE
VENTILATION.
• ANY CO-MORBID CONDITIONS IDENTIFIED. SIGNS OF CHF, COR
PULMONALE.

21. PRE-OP EVALUATION (CONTD)
• ROUTINE PRE-OPERATIVE BLOOD TESTS.
• ECG (LOOK FOR ANY EVIDENCE OF RIGHT-SIDED HEART DISEASE OR
CONCOMITANT ISCHEMIC HEART DISEASE).
• XRC IS NOT MANDATORY AND MAY ADD LITTLE VALUE
• ( CONSIDERED IF THERE IS CURRENT INFECTION OR RECENT
DETERIORATION IN SYMPTOMS.)
• SPIROMETRY IS USEFUL TO CONFIRM THE DIAGNOSIS AND TO
ASSESS THE SEVERITY OF COPD .
• ASSESS THE FUNCTIONAL STATUS OF PATIENTS, SIMPLE AND SAFE
TESTS SUCH AS STAIR CLIMBING AND THE 6-MIN WALK TEST
CORRELATING WELL WITH MORE FORMAL EXERCISE TESTING.
• ABG- MEASUREMENT MAY BE USEFUL IN PREDICTING HIGH-RISK
PATIENTS.
• 2DECHO-IF SUSPECTED COR PULMONALE OR CHF.

22. WHAT IS SPIROMETRY?
SPIROMETRY IS A METHOD
OF ASSESSING LUNG
FUNCTION BY MEASURING
THE VOLUME OF AIR THE
PATIENT CAN EXPEL FROM
THE LUNGS AFTER A
MAXIMAL EXPIRATION.

23. WHY PERFORM SPIROMETRY?
• Measure airflow obstruction to help make a definitive
diagnosis of COPD
• Confirm presence of airway obstruction
• Assess severity of airflow obstruction in COPD
• Detect airflow obstruction in smokers who may have
few or no symptoms
• Monitor disease progression in COPD
• Assess one aspect of response to therapy
• Assess prognosis (FEV1) in COPD
• Perform pre-operative assessment

24. FLOW MEASURING SPIROMETER

25. SMALL HAND-HELD SPIROMETERS

26. Total
lung
capacity
Tidal volume
Inspiratory reserve
volume
Expiratory reserve
volume
Residual volume
Inspiratory
capacity
Vital
capacity
Lung Volume Terminology

27. STANDARD SPIROMETRIC INDICES
• FEV1 - FORCED EXPIRATORY VOLUME IN ONE SECOND:
THE VOLUME OF AIR EXPIRED IN THE FIRST SECOND OF
THE BLOW
• FVC - FORCED VITAL CAPACITY:
THE TOTAL VOLUME OF AIR THAT CAN BE FORCIBLY
EXHALED IN ONE BREATH
• FEV1/FVC RATIO:
THE FRACTION OF AIR EXHALED IN THE FIRST SECOND
RELATIVE TO THE TOTAL VOLUME EXHALED
• VC - VITAL CAPACITY:
A VOLUME OF A FULL BREATH EXHALED IN THE PATIENT’S
OWN TIME AND NOT FORCED. OFTEN SLIGHTLY GREATER
THAN THE FVC, PARTICULARLY IN COPD

28. SPIROMETRIC CRITERIA
FEV1< 1L ,NORMAL PaO2 AND PaCO2—
LOW RISK
FEV1< 1L ,LOW PaO2 AND NORMAL PaCO2---
WILL NEED O2
FEV1<1L,LOW PaO2 AND HIGH PaCO2---
MAY NEED MECHANICAL VENTILLATION

29. SPIROMETRY
FEV1 LESS THAN 50% OF PREDICTED WAS A CONTRAINDICATION
TO SURGERY.
1992 STUDY BY KROENKE ET AL, THAT EVALUATED 107 GENERAL
SURGICAL PROCEDURES (SOME HIGH-RISK)
IN 89 PATIENTS WITH SEVERE COPD (IE, FEV1 < 50% OF PREDICTED).
 MORTALITY WAS 6% OVERALL AND WAS CLUSTERED IN THE SUBSET
OF PATIENTS UNDERGOING CORONARY ARTERY BYPASS GRAFT
(CABG) SURGERY (5 OF 10 PATIENTS; 50%);
MORTALITY WAS 1% FOLLOWING THE 92 NON CARDIAC OPERATIONS.
PULMONARY COMPLICATIONS OCCURRED FOLLOWING 29% OF
OPERATIONS;
MAJOR PULMONARY COMPLICATIONS OCCURRED AFTER 7%.
HOWEVER FOR CABG SURGERY FEV1<60% IS INDICATIVE OF HIGH RISK

30. SPIROMETRY
• FOR CABG FEV1 <60% IS
PREDICTIVE OF HIGH RISK
• SPIROMETRY IS MUST FOR
PREOPERATIVE EVALUATION
OF LUNG RESECTION
PATIENTS

31. BEDSIDE PFTS
• THE COUGH TEST-
• ASKING THE PATIENT TO TAKE A DEEP INSPIRATION AND COUGH
ONCE.
TEST IS POSITIVE IF FIRST COUGH LEADS TO RECURRENT
BOUTS
OF COUGHING
• THE WHEEZE TEST-
• FIVE DEEP INSPIRATIONS AND EXPIRATIONS, AUSCULTATE
BETWEEN THE SHOULDER BLADES POSTERIORLY WHEEZE?
INDICATES POSITIVE TEST.
• MAXIMUM LARYNGEAL HEIGHT-
• DISTANCE BETWEEN THE TOP OF THYROID CARTILAGE AND
SUPRASTERNAL NOTCH -- <4 CMS IS ABNORMAL.

32. BEDSIDE PFTS
• FORCED EXPIRATORY TIME-BELL OF STETHOSCOPE ON TRACHEA
IN SUPRASTERNAL NOTCH, STOPWATCH TO ZERO. DEEP
INSPIRATION AND BLOW IT OUT AS FAST AS POSSIBLE, TIME TO NO
AUDIBLE EXPIRATION IS MEASURED. FET >6 SEC
INDICATES SEVERE EXP AIRFLOW OBSTRUCTION.FEV1<50%
• AVERAGE WITH THREE RESULTS
• SABRASEZ BHT-DEEP BREATH HOLDING FOR AS LONG AS
POSSIBLE PLACE STETHOSCOPE ON TRACHEA TO KNOW EARLY
EXPIRATION
• >40 SEC- NORMAL ,20-30 SEC CPMPROMISED CP RESERVE, <20
SEC VERY POOR CP RESERVE
• PEAK EXPIRATORY FLOW RATE – IN ASTHMA

33. OPTIMISATION
PREOPERATIVELY

34. OPTIMISE THE PATIENT
1) CESSATION OF SMOKING
>8 WEEKS BEST RESULTS( IMPROVEMENT IN MUCOCILIARY
FUNCTION INCREASED SPUTUM CLEARANCE, REDUCED AIRWAY
HYPER REACTIVITY AND DECREASED SPUTUM PRODUCTION)
<8 WEEKS MAX 57 % COMPLICATIONS
WITHIN 12 HRS OF CESSATION OF SMOKING THE CARBOXY HB
LEVELS DROP
RISK OF PATIENTS WHO QUIT FOR MORE THAN 6 MONTHS IS SAME
AS THOSE WHO NEVER SMOKED

35. OPTIMISATION
2)INFECTION-
TREAT INFECTION WITH APPROPRIATE ANTIBIOTICS
IN CASE OF URI IDEALLY WAIT FOR 2-3 WEEKS
3)BRONCHODILATORS-
BENEFITS THOSE WITH AND WITHOUT BRONCHOSPASM.
USE OF INHALED STEROIDS + SALBUTAMOL 3 DAYS PRE-OP
REDUCED THE INCIDENCE OF POST-OP BRONCHOSPASM
FROM 93% TO 6.3%
4)CARDIAC STABILISATION- CHF/COR PULMONALE SHOULD
BE TREATED WITH DIURETICS OR /AND DIGITALIS
.CARDIOSELECTIVE BETA BLOCKERS ARE SAFE.STATINS
REDUCE RISK.ACE INHIBITORS SHOULD BE STOPPED 24
HRS PRIOR.

36. OPTIMISATION
5)HYDRATION +MUCOLYTIC THERAPY,
-LOOSENS SECRETIONS AND CHEST PHYSIOTHERAPY CLEARS
THE CHEST OF SECRETIONS
6)INCENTIVE SPIROMETRY-AND DEEP BREATHING EXERCISES
HAVE BEEN SHOWN TO REDUCE POSTOPERATIVE PULMONARY
COMPLICATION RATE.
7)EXPLANATION TO PATIENT ABOUT POSTOPERATIVE O2/ NIV /
IPPV THERAPIES HELPS IN GETTING COOPERATION FOR SUCH
THERAPIES WITH POSITIVE RESULTS.
8)NIL BY MOUTH ORDER

37. PERIOPERATIVE LUNG
EXPANSION MANEUVERS
• A META-ANALYSIS EVALUATING: UPPER ABDOMINAL
SURGERY
• INCENTIVE SPIROMETRY (IS)
• DEEP BREATHING EXERCISE (DB)
• INTERMITTENT POSITIVE PRESSURE BREATHING
(IPPB)
• SIMILAR IN EFFICACY
• BETTER THAN NO RESPIRATORY THERAPY
• PREOPERATIVE- BETTER RESULTS
Thomas JA, et al. Physical Therapy 1994; 74:3-10.

38. OPTIMISATION
ORAL STEROIDS- METHYLPREDNISOLONE 40 MG/DAY FOR 5
DAYS PREOPERATIVELY
-ONGOING WHEEZE
-NEWLY DIAGNOSED PATIENT
-POORLY COMPLIANT PATIENT
- FOR MODERATE TO SEVERE
ASTHMA/COPD
MAST CELL STABILIZERS LIKE CROMOLYN AND
MONTELUKAST PREVENT REFLEX BRONCHOSPASM

39. PATIENTS ON PRE-OP STEROID
THERAPY
• WHO HAVE BEEN TREATED WITH STEROIDS FOR MORE
THAN 2 WEEKS IN LAST 6 MONTHS
• ASSUMED TO HAVE ADRENO-CORTICAL AXIS
SUPPRESSION
• TREAT FULLY WITH STEROIDS FOR MAJOR SURGERY
• 100 MG TDS I.-V.
• FOR 48 HRS
• ( STUDY-NO INCREASE IN THE INCIDENCE OF WOUND
INFECTIONS)

40. DRUGS PRECIPITATING ASTHMA
• ASPIRIN

41. NASOGASTRIC TUBE INSERTION
• PROPHYLACTIC NASOGASTRIC TUBE
INSERTION IN COPD /ASTHMA CASES HAS BEEN
SHOWN TO INCREASE THE RISK OF POST-
OPERATIVE PULMONARY COMPLICATIONS,
• HENCE SELECTIVE NASOGASTRIC TUBE
INSERTION ONLY WHEN THERE IS
POSTOPERATIVE NAUSEA ,VOMITTING OR
SYMPTOMATIC ABDOMINAL DISTENSION IS
ADVOCATED

42.  SMOKING CESSATION FOR ≥8 WEEKS
 TREATMENT FOR PATIENTS WITH UNDERLYING ASTHMA /
COPD (PFT)
 DELAY ELECTIVE SURGERY AND TREAT WITH ANTIBIOTICS IF
RESPIRATORY INFECTION IS PRESENT
 PATIENT EDUCATION REGARDING LUNG EXPANSION
MANEUVERS
 STEROIDS WHEN INDICATED
 PREOPERATIVE AEROSOL NEBULISATION
 OBESE PATIENTS SHOULD BE MANAGED TO LOSE WEIGHT
 CHOOSE PROCEDURE LASTING < 4 HRS (IF
POSSIBLE)/REGIONAL ANASTHESIA PREFERED.
 SELECTIVE NASOGASTRIC TUBE INSERTION
SUMMARY

43. PREDICTORS OF PULMONARY
COMPLICATIONS
• Patient Related
Age > 50, 60, 70, 80
Chronic Lung Disease
Asthma
Smoking
Heart Failure
Albumin
BUN
Functional Dependence
ASA Class >= 2
• Odds Ratio of Complications
1.5, 2.28, 3.9, 5.63
2.36
Uncontrolled 3, Controlled 1
Current 5.5, 2 mo Cessation
1.26
2.93
2.53
2.29
Total 2.51 Partial 1.65
4.87

44. AROZULLAH RESPIRATORY
FAILURE RISK INDEX
• Type of Surgery
– AAA
– Thoracic
– Neurosurgery, Upper
Abdominal Peripheral
Vascular, Neck
• Emergency Surgery
• Albumin < 3.0 g/dL
• BUN > 30 mg/dL
• Partial/Full Dependence
• History of COPD
• Age > 70
• Age 60 - 69
• Point Value
27
21
14
11
9
8
7
6

45. AROZULLAH RESPIRATORY
FAILURE INDEX SCORING
Class Point Total % Respiratory
Failure
One <= 10 0.5
Two 11 – 19 1.8
Three 20 – 27 4.2
Four 28 – 40 10.1
Five > 40 26.6
Arozullah, AM, Daley, J, et al, Ann Surg 2000; 232:242

46. INDICATORS OF POSTOPERATIVE
PULMONARY COMPLICATIONS
• Age  60
• H/o smoking for 40 pack years or more . risk 6 times more.
• +cough test
• +wheeze test
• Forced expiratory time 9sec
• Wheeze, cough,dyspnoea,excessive sputum production chest pain
• Spirometry-FEV11 L/min, FVC1.5 L/min
• ABG-pCo245mm hg(61 times more risk) ,pO275 mm hg.
• Presence of CHF
• ASA grade 2 and above

47. Risk factors Point
> 70 years old 5
Myocardial infarction within the last 6 months 10
S3 gallop or jugular venous distension 11
Significant aortic stenosis 3
Premature atrial beats or arrhythmias 7
Premature ventricular contractions> 5 min 7
Intrathoracic, intraperitoneal, and aortic
surgery
3
Emergency operation 4
Impairment of general health status 3
Goldman cardiac risk index
Ebstein SK. Chest 1993; 104:694-700,

48. Variable Point
BMI>27 kg/m2 1
Cigarette (last 8 weeks) 1
Productive cough (last 5 days) 1
Wheezing (last 5 days) 1
FEV1/FVC < 70% 1
Pa CO2 > 45 mmHg 1
Pulmonary risk index:
Risk factors known to increase PPC
Ebstein SK. Chest 1993; 104

49. Goldman CRI
0 - 5 points : 1
6 -12 points : 2
13 - 25 points : 3
26 - 53 points : 4
Pulmonary risk index
Between 0 - 6
Cardiopulmonary risk index scor
( 1 ... 4 ) + ( 0... 6 ) = 10 ; total
If the CPRIS is higher than 4, prognosis is poor
Cardiopulmonary complication risk is more than 22 folds
Ebstein SK. Chest 1993; 104

50. STOP-BANG SCORE
• S Snoring Do you Snore Loudly? Louder than talking or loud enough to be heard through
a closed door?
• T Tiredness Do you often feel Tired?Do you sleep during the daytime?
• O Observed apnea Has anyone observed you stop breathing during sleep?
• P Pressure Do you have high blood pressure?
• B BMI > 35 kg m−2
• A Age Over 50 years
• N Neck Circumference >40 cm
• G Gender Male

52. THANK YOU
DR JAVADEKAR NARENDRA