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Indian Journal of Anaesthesia 2008; 52 (2): 140-147 Indian Journal of Anaesthesia, April
Special 2008
Article
1. Professor, 2. Senior Instructor, Department of Anaesthesiology, Aga Khan University, Correspondence to: Fauzia A Khan, Department of
Anaesthesiology, Aga Khan University,Stadium Road, PO Box 3500, Karachi 74800, Pakistan,
Email: fauzia.khan@aku.edu Accepted for publication on: 10.2.08
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7.5%12. A preliminary study from Karachi, Pakistan re- risks have been proposed but not validated6. In case of
ports the incidence in one centre to be the same as in diagnosed sleep apnoea the severity of apnoea, treat-
the west, in patients studied in a sleep lab13. ment received and patient's compliance with the treat-
ment and complications of OSA should be reviewed.
Brief pathophysiology
If the patient is suspected to have OSA and sleep
A narrow and floppy upper airway is the basis of studies are not available or the surgery is emergency,
OSA. Sleep specially rapid eye movement sleep makes patients should be treated as though they have moderate
the airway more floppier and narrower due to muscle sleep apnoea6.
relaxation, resulting in partial or complete obstruction14.
Each cycle is followed by arousal, and in severe cases Anaesthetic management should be carefully
this scenario is repeated hundreds of times every night. planned in consultation with the surgeon.
These repeated cycles of hypoxemia and hypercarbia Preoperative preparation
may result in several potential sequelae like pulmonary
The recommendation of the American Society of
hypertension15, systemic hypertension, ischemic heart
Anesthesiologists state that preoperative continuous posi-
disease, right heart failure16, gastro-oesophageal reflux,
tive airway pressure (CPAP) should be considered in
intra-cranial hypertension17, polycythemia and right heart
severe OSA and in patients who do not respond to CPAP,
failure, all of which are of potential anaesthetic signifi-
non invasive positive pressure ventilation (NIPPV) is of
cance.
benefit6.
Pre-operative screening for OSAS Patients who have had prior corrective surgery e.g.
Early identification of OSAS is important in the uvulopalatopharyngoplasty should still be assumed at
surgical patient population. A recent publication by Kaw higher risk until a normal sleep study pattern has been
et al recommends that heavy snoring, sudden awaken- obtained. Weight loss should be considered when fea-
ing from sleep with a choking sensation and witnessed sible.
apnoea by a bed partner should be a routine component
Premedication
of the pre-operative visit4. ASA guidelines6 recommend
history of snoring, headaches, and day time somnolence Preoperative sedation with benzodiazepines for
in addition to above. Physical examination may reveal anxiolysis may cause considerable relaxation of the up-
associated features like nasal obstruction, tonsillar hy- per airway musculature. It causes an appreciable re-
pertrophy, retrognathia and obesity. These features may duction of the pharyngeal space which may lead to a
not be a reliable predictor of the severity. In addition to higher risk of preoperative phases of hypopnoea and
airway assessment physical examination should include consecutive hypoxia and hypercapnia20,21. Oxygen satu-
neck circumference and tongue volume. ration needs to be monitored during preoperative period
and patient should be kept in a monitored area. In pa-
Polysomnography still remains the gold standard
tients on CPAP there is no real contraindication to pre-
for diagnosing the disorder if feasible in a given clinical
medication as their CPAP may be applied if they get
situation. Alternative screening tools like overnight oxim-
sleepy and oxygen can be added if necessary22.
etry have been explored by some authors18. Nocturnal
oximetry only identified one third of those who experi- Many patients with OSA are morbidly obese. This
enced post operative complications18. A study by Fidan places them at increased risk for aspiration of acidic
et al recommends polysomnography in all surgical pa- gastric fluid at the time of induction of anaesthesia. These
tients who have two or more major symptoms of OSA patients should receive medications to suppress gastric
present19. Nasopharyngoscopy is sometimes performed acid production, neutralize the acid, or to stimulate emp-
to assess the benefits of surgery14. tying of the stomach20.
If sleep studies are available, the results of the sleep Perioperative management
lab assessment in terms of mild, moderate or severe
The anaesthetic care of patients with OSA is chal-
disease should be used to determine the anaesthetic man-
lenging because anaesthetic drugs profoundly influence
agement6. Scoring systems to estimate peri-operative
control of an already dysfunctional respiratory system,
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and presence of significant co-morbidities. Hyperten- If tracheal intubation is to be done while the pa-
sion and cardiovascular diseases is more common often tient is awake using flexible fiberscope, it is essential
than other patients23. that the patient be properly prepared by topical and nerve
No evidence exists regarding perioperative risk in block anaesthesia of the upper airway.
patients with sleep apnoea whether it depends on the If intubation is to be done with the patient asleep,
type of anaesthetic technique employed24. It is gener- the patient should be fully preoxygenated because an
ally believed that regional anaesthesia (RA) is prefer- obese patient with a relatively small functional residual
able over general anaesthesia (GA) whenever possible. capacity (FRC) and high oxygen consumption desaturates
Regional anaesthesia minimally affects respiratory drive much more rapidly during obstructive apnoea than does
and can reduce the effect of anaesthetic agents on sub- a normal patient26. Effective preoxgygenation is achieved
sequent sleep patterns as well as maintain arousal re- by delivering FIO2 = 1.0 for more than three minutes
sponses during apnoeic episodes. Regional anaesthesia duration with a properly sealed face mask27. Oxygen
may obviate the need for sedative and opioid drugs both insufflation into the pharynx via a small nasopharyngeal
intraoperatively and postoperatively25. One should be catheter during laryngoscopy of the obese patient may
ready for airway management because the regional tech- further delay the onset of arterial oxygen desaturation28.
nique may result in unconsciousness or respiratory pa- Patient should be in sniffing position before induc-
ralysis unintentionally14. Landmarks may be difficult to tion of GA. Use of optimal external laryngeal manipula-
identify if the patient is obese. tion during laryngoscopy may improve the laryngeal
If general anaesthesia is the only option, controlled view29. Mask ventilation may require two anaesthesia
ventilation with tracheal intubation should be the choice. providers. The airway pressure relief valve and mask
There is compelling evidence in the literature that obese seal should be set in a way to deliver CPAP (5-15 cm
OSA patients are, in general, more difficult to intubate H2O) 25.
than normal controls. Obesity, short thick neck and ex- In the context of difficult airway one should be
cess pharyngeal tissue deposits in the lateral pharyngeal ready for "cannot ventilate, cannot intubate" situation.
walls are causative factors for difficult intubation. Equipment (cricothyrotomy set, jet ventilator) and per-
Benumof recommends that all patients who have a tra- sonnel (ENT surgeon) to deal with this situation should
chea that is difficult to intubate should be regarded as be readily available.
having OSA until excluded by clinical features and, where
doubt exists, sleep studies25. Rapid sequence induction in sleep aponea
In a recent review article, Freid concluded that rapid
Intubation tchnique
sequence induction remains important in obese and sleep
The equipment for management of a difficult air- apnoea syndrome patients with symptomatic gastroe-
way should be in place before induction of general ana- sophageal reflux or other predisposing condition such as
esthesia. Orotracheal tubes in various sizes, gum elastic diabetes mellitus, pregnancy, emergency surgery, and
bougie as well as a McCoy laryngoscope and a laryn- gastrointestinal conditions. In the case of elective sur-
geal mask airway are necessary. Fibreoptic devices may gery in a fasted patient with no risk factors other than
be helpful but have no impact in acute emergency situa- obesity or sleep apnoea syndrome, the requirement for
tions. A strategy or algorithm for establishing a secure rapid sequence induction is debatable. Cricoid pressure
airway should be defined. With the increased index of is probably efficacious but has not been proven in a ran-
suspicion of difficult intubation in patients with OSA, the domized, controlled trial to prevent gastric aspiration. The
decision to do tracheal intubation with the patient awake clinician should be aware of the possibility that cricoid
or under general anaesthesia must be individualized on pressure will worsen mask ventilation and laryngoscopy
the basis of a complete preoperative airway evaluation. and be prepared to loosen or release the pressure if mask
If difficulty with either mask ventilation or tracheal intu- ventilation or intubation is compromised30.
bation is expected, then, according to the ASA Difficult
Airway Algorithm, intubation and extubation should be The effect of anaesthetic drugs
performed while the patient is awake25. There is evidence that many anaesthetic agents
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supervision while they are sedated and not familiar with gesia may exacerbate symptoms of sleep apnoea re-
its use, until they are capable, unaided, of applying their sulting in respiratory depression and respiratory arrest
therapy correctly. It may need high dependency unit even if given intramuscularly, epidurally or via patient
admission for few days14. controlled analgesia37. There are no adequately pow-
ered studies to guide analgesic therapy of these patients.
Location of patient If narcotics are required for pain control then patient
It is important that the patient with OSA is nursed controlled analgesia with no basal rate and restricted
in the appropriate postoperative environment. This is- dosing may help to limit dosing4.
sue is closely related to the patient's analgesic require- The use of nonsteroidal anti inflammatory drugs,
ments. local anaesthetics for incision infiltration, epidural anal-
Factors to be considered for decision about loca- gesia and peripheral nerve blocks, when appropriate,
tion of postoperative care are the body mass index can minimize the necessity for the administration of large
(BMI) of the patient, the severity of the OSA, the de- doses of narcotic drugs to achieve adequate analge-
gree of associated cardiopulmonary disease, intraop- sia 24,25.
erative complications and the postoperative opioid re-
quirement. When all of these factors are mild, then the Sleep apnoea syndrome in children
patient may go to a relatively unmonitored environment. Preoperative assessment
When any of these factors are severe, the patient should
go to an intensive care unit (ICU). The large gray zone The symptoms, polysomnographic findings, patho-
in between these extremes requires careful judgment. physiology and treatment of Obstructive Sleep Apnoea
The most suitable postoperative environment is also de- (OSA) in children are significantly different from those
termined by the particular conditions within each hospi- seen in adults. It is most commonly associated with
tal25,35. adenotonsillar hypertrophy21. Preanaesthesia screening
should routinely include a detailed birth and medical his-
Role of nasal obstruction tory, growth assessment, review of systems for recent
Presence of nasogastric tubes and nasal packing respiratory infection, behavioral issues, and school per-
after nasal surgery may pose an extra risk. The pres- formance. Troublesome behavior often can be addressed
ence of a nasogastric tube does not preclude the appli- by the relief of SA38.
cation of CPAP as the nasal mask can be applied over Premedication
the tube, which runs under the mask cushion, but leak-
age and comfort may be a problem. After nasal sur- Cultrara and colleagues after a retrospective study
gery a nasopharyngeal airway may be passed and the suggested that preoperative sedation might be safely
surgeon may pack the nose around it, although it may administered to children with mild or moderate sleep-
have limited calibre. In such cases full face continuous disordered breathing, and possibly to children with se-
positive airway pressure is needed to prevent danger- vere obstructive sleep apnoea (OSA), if children are
ous apnoeas25, 36. If serious compromise of upper air- closely observed prior to surgery. They recommended
way patency is anticipated after upper airway surgery further prospective studies to confirm their results39.
then undue reliance on CPAP is inappropriate. The pa- Francis et. al in a recent study of 70 children, premedi-
tient may require prolonged tracheal intubation or, where cated with midazolam (0.5 mg.Kg -1 ) planned for
several days or more of airway compromise is antici- adenotonsillectomy for treatment of sleep-disordered
pated, tracheostomy should be considered14. breathing concluded that many of these children may
safely be pre- medicated40.
Postoperative analgesia Antireflux medications and antisialagogue drugs
The provision of adequate postoperative analge- are important adjuncts to be considered for the preven-
sia is an integral part of the anaesthetic plan. Multimodal tion of aspiration and laryngospasm41.
analgesia is preferable wherever possible. Obese OSA
patients have an increased risk of opioid induced upper Perioperative management
airway obstruction. Sedation and narcotic-based anal- Both inhaled and intravenous anaesthesia should
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be carefully titrated to the effect, particularly when used and adenoidectomy in children with severe OSA48.
in combination. Children with OSA show an exaggera- Children who have a history of pulmonary hyper-
tion of the blunted respiratory drive in response to opioid tension and cor pulmonale also may be at risk for circu-
and benzodiazepine administration42. latory failure.
Hullett et al compared tramadol with morphine in Children with severe OSA or cardiovascular dis-
adenotonsillectomy for OSA in children. They found that ease should be monitored after surgery in the pediatric
children in tramadol group had fewer episodes of intensive care unit. Most children with mild to moderate
desaturation (<94%) in postoperative period therefore OSA, however, do not require postoperative monitoring
they recommended the use of tramadol for this proce- in an intensive care unit41.
dure in children with OSA43.
Luscre et al recently described a case series of Recent reviews and guidelines
three children with OSA given monitored anaesthesia There are some published reviews on the anaes-
care with a combination of ketamine and thetic management of OSA in recent literature (2005
dexmedetomidine during magnetic resonance imaging. onwards). Passannante et al24 reviewed the general
This combination provided effective sedation with no anaesthetic management of OSA patients in adults and
clinically significant haemodynamic or respiratory ef- Bandla et al41 in children. Bell et al35 reviewed the post
fects44. Difficult airway may also be anticipated in chil- operative complication in these OSA patients. All these
dren with OSA because of craniofacial or known ana- reviews were published in the Anesthesiology Clinics of
tomical airway abnormalities. Skilled clinicians and the North America.
equipment for managing a difficult airway, such as a Kaw et al4 reviewed the perioperative implications
fiber-optic laryngoscope as well as a laryngeal mask for the sleep apnoea surgical patient in the journal, Chest
airway, also should be readily available. Jaw thrust to and Mickelson et al49 reviewed the pre and post opera-
treat airway obstruction in these patients is the most tive management of OSA patients in Otolaryngologeal
useful and is superior to the chin lift45. Clinics of North America (2007).
The greatest concern when extubating a child from The only available consensus guidelines are by the
deep anaesthesia is laryngospasm. When possible, chil- American Society of Anesthesiology Task force on the
dren with OSA are extubated when they are fully perioperative management of OSA patients which was
awake 41. published in 2006 in Anesthesiology6.
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Pramila Bajaj
Editor, IJA
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