Obstructive sleep apnea: preoperative assessment

Modified STOP-Bang for predicting perioperative adverse events in the Thai population

Background

Undiagnosed obstructive sleep apnea (OSA) is associated with adverse perioperative outcomes. The STOP-Bang questionnaire is a validated screening tool for OSA. However, its precision may vary among different populations. This study determined the association between high-risk OSA based on the modified STOP-Bang questionnaire and perioperative adverse events.

Methods

This cross-sectional study included patients undergoing elective surgery from December 2018 to February 2019. The modified STOP-Bang questionnaire includes a history of Snoring, daytime Tiredness, Observed apnea, high blood Pressure, Body mass index > 30 kg/m², Age > 50, Neck circumference > 40 cm, and male Gender. High risk for OSA was considered as a score ≥ 3.

Results

Overall, 400 patients were included, and 18.3% of patients experienced perioperative adverse events. On the basis of modified STOP-Bang, the incidence of perioperative adverse events was 23.2 and 13.8% in patients with high risk and low risk (P-value 0.016) (Original STOP-Bang: high risk 22.5% vs. low risk 14.7%, P-value 0.043). Neither modified nor original STOP-Bang was associated with perioperative adverse events (adjusted OR 1.91 (95% CI 0.99–3.66), P-value 0.055) vs. 1.69 (95%CI, 0.89–3.21), P-value 0.106). Modified STOP-Bang ≥3 could predict the incidence of difficult ventilation, laryngoscopic view ≥3, need for oxygen therapy during discharge from postanesthetic care unit and ICU admission.

Conclusions

Neither modified nor original STOP-Bang was significantly associated with perioperative adverse events. However, a modified STOP-Bang ≥3 can help identify patients at risk of difficult airway, need for oxygen therapy, and ICU admission.

Trial registrations

This study was registered on Thai Clinical Trials Registry, identifier TCTR20181129001, registered 23 November 2018 (Prospectively registered).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01347-0.

Analysis and Temporal Evolution of Extubation Parameters for Patients Undergoing Single-Stage Circumferential Cervical Spine Surgery

Objective

Airway obstruction after postoperative extubation is a dreaded but uncommon complication in patients undergoing circumferential cervical spine surgery (CCSS). The cuff leak test (CLT) has been utilized to assess air leak around the endotracheal tube which may reflect airway swelling. In this prospective observational study, we analyze the temporal evolution of CLT and perioperative factors that may influence it.

Methods

Twenty patients undergoing single-stage CCSS were managed according to our extubation protocol. Patients were maintained intubated overnight following surgery. They were extubated if a CLT > 200 mL and both intensive care unit (ICU) and Neurosurgery teams agreed that it was safe. Patients extubated in the first postoperative day (8 of 20) comprised the early group, and the remaining patients (12 of 20) the delayed group. Patient and operative data were analyzed as a single group and comparing both groups.

Results

The main indication for surgery was cervical deformity. Median number of levels fused was 5 anteriorly (range, 1–6) and 6 (range, 1–13) posteriorly. Patients were kept intubated for an average of 73.6 hours (range, 26–222 hours) and stayed in the ICU for 119.1 hours (range, 36–360 hours). There were 4 failed extubations and 3 patients (15%) required a tracheostomy. Patient profiles between both groups were very similar across most patient variables but differed significantly regarding infraglottic luminal area (p < 0.05). Patients with larger preoperative cuff leak values tended to have a shorter intubation period (p=0.053).

Conclusion

This study objectively demonstrates the difficulties in airway management following CCSS and provides useful insight for preoperative planning and counseling. Local anatomic factors influence airway outcome more than operative factors. The study format does not allow for testing of interventions but we suggest that patients with favorable anatomy (larger infraglottic luminal area) may benefit from a less strict airway management protocol.

Prevalence of Sleep Apnea in Patients with Carotid Artery Stenosis

Obstructive sleep apnea (OSA) is a common disease affecting about 13% of men and 6% of women, usually having severe cardiovascular sequalae. OSA is responsible for the systemic inflammatory response and oxidative stress and results in endothelial injury being a risk factor for atherosclerosis. The aim of this study was to estimate the prevalence of OSA among patients with severe carotid artery stenosis. Fifty-five patients (F/M-24/31, mean age 70 ± 7 years, body mass index 28.3 ± 6.3 kg/m²) were enrolled into the study. The patients were qualified for elective surgical treatment of carotid artery stenosis. Polysomnography was performed in all patients the night before surgery. Thirty-six patients underwent surgical endarterectomy and nineteen patients underwent carotid artery stenting. Sleep apnea was diagnosed in 44 (80%) of all patients. The mean apnea-hypopnea index (AHI) was 14.5 ± 12.9. The OSA severity distribution was as follows: 22 mild, 16 moderate, and 6 severe cases. We found that the percentage of carotid endarterectomies was the greatest in mild and moderate OSA. It was approximately twofold greater than that in non-OSA patients. Carotid artery stenting was performed in nearly half of the patients in each of these groups. We conclude that OSA is highly prevalent in patients with carotid artery stenosis scheduled for carotid surgery. Nonetheless, the exact pathogenetic mechanisms underlying mutual interaction between OSA and vascular wall damage remain elusive. OSA is not routinely diagnosed among patients with advanced atherosclerosis. The study results might be an argument for performing polysomnography in patients with carotid artery stenosis.

Perioperative considerations and anesthesia management in patients with obstructive sleep apnea undergoing ophthalmic surgery

Obstructive sleep apnea (OSA) is a disorder characterized by breathing cessation caused by obstruction of the upper airway during sleep. It is associated with multiorgan comorbidities such as obesity, hypertension, heart failure, arrhythmias, diabetes mellitus, and stroke. Patients with OSA have an increased prevalence of ophthalmic disorders such as cataract, glaucoma, central serous retinopathy (detachment of retina, macular hole), eyelid laxity, keratoconus, and nonarteritic anterior ischemic optic neuropathy; and some might require surgery. Given that OSA is associated with a high incidence of perioperative complications and more than 80% of surgical patients with OSA are unrecognized, all surgical patients should be screened for OSA (eg, STOP-Bang questionnaire) with comorbidities identified. Patients suspected or diagnosed with OSA scheduled for ophthalmic surgery should have their comorbid conditions optimized. This article includes a review of the literature and highlights best perioperative anesthesia practices in the management of ophthalmic surgical patients with OSA.

Don't Ignore My Snore: Reducing Perioperative Complications of Obstructive Sleep Apnea

PURPOSE

Obstructive sleep apnea (OSA), a condition associated with decreased muscle tone in the airway, has been linked to postoperative complications. The purpose of the initiative was to develop and implement a guideline for patients identified as high-risk for OSA to reduce complications related to OSA.

DESIGN

A multidisciplinary team developed the guideline utilizing the Iowa Model of Evidence-Based Practice to Promote Quality Care.

METHODS

PubMed literature search from 2006-2013 and critique of over 40 articles were completed. A nursing care plan was created from the guideline to facilitate communication of care for this population.

FINDINGS

Postoperative cardiopulmonary complications related to OSA decreased from 27% to 14.6% after guideline implementation.

CONCLUSIONS

Guideline and nursing care plan specific to OSA in the perioperative setting improved patient outcomes.

Manejo perioperatorio del paciente con síndrome de apnea-hipopnea obstructiva del sueño (SAHOS)

Los pacientes con diagnóstico de síndrome de apnea-hipopnea obstructiva del sueño (SAHOS) pueden ser llevados de forma segura a cualquier procedimiento quirúrgico, incluso de manera ambulatoria si tienen control adecuado de sus otras comorbilidades. El tratamiento con presión positiva continúa en vía aérea (CPAP) en pacientes con diagnóstico confirmado disminuye el riesgo de presentar complicaciones cardiovasculares a largo plazo. La sedación debe ser hecha por un anestesiólogo, quien, además, debe vigilar al paciente y disponer del equipo adecuado para atender complicaciones respiratorias emergentes. Se sugiere que, en estos pacientes, los procedimientos sean hechos en el ámbito hospitalario, donde se tenga disponibilidad en la unidad de cuidados post-anestésicos y personal para monitoreo por al menos una hora tras finalizar el procedimiento. El tratamiento con CPAP debe continuar según sea ordenado por el médico tratante. Es importante que desde la valoración preanestésica se identifique a los pacientes con riesgo de SAHOS para lograr trazar un plan anestésico que disminuya las complicaciones a nivel respiratorio y del manejo de la vía área.

Outpatient Anesthetic Safety Considerations for Obstructive Sleep Apnea

Most patients with obstructive sleep apnea (OSA) are not diagnosed preoperatively. The STOP-Bang questionnaire may identify patients at risk of OSA, especially those with severe OSA. Patients with mild to moderate OSA, with optimized comorbidities, can usually safely undergo outpatient surgery. Patients with severe OSA, who are not optimized medically, should avoid outpatient surgery.

The prevalence of perioperative complications in patients with and without obstructive sleep apnoea: a prospective cohort study

BACKGROUND AND AIMS

Patients with obstructive sleep apnoea (OSA) have a high risk of postoperative complications. The purpose of the study was to record the spectrum and frequency of postoperative complications in patients with OSA versus (vs.) without OSA depending on the type of surgery and type of anaesthesia in a large cohort of patients.

METHODS

We conducted a prospective, descriptive study (n = 400). Ethics Committee approval was obtained and written informed consent was signed. The Berlin screening questionnaire was used for OSA screening (77.2% - OSA [+]). Adverse events and complications were recorded postoperatively (AOS [+] vs. AOS [-]). Statistics: Chi square test.

RESULTS

The highest rate of complications was found in patients who had underwent surgery in the abdominal cavity under general anaesthesia, AOS [+] vs. AOS [-]: cardiovascular [56.4%] vs. [7.5%], respiratory [17.6%] vs. [3.5%], stroke [0.7%] vs. [0.0% ], prolonged awakening from anaesthesia [2.5%] vs. [0.0%], postoperative fever [1.4%] vs. [0.3%], difficult orotracheal intubation [3.5%] vs. [0.3% ], unscheduled transfer to the intensive care unit [5.7%] vs. [0.0%].

CONCLUSIONS

OSA [+] patients who underwent abdominal surgery under general anaesthesia had a higher rate of complications compared to OSA [-] patients, and also compared to patients who had undergone peripheral limb surgery. Surgery on the musculoskeletal system is much better tolerated by patients with OSA, suffering a lower number and range of events and postoperative complications. Loco-regional anaesthesia should be considered a priority in patients with OSA.

A Quality Improvement Project: Using the STOP-BANG Tool in a Military Population to Improve Equity in Preoperative Screening

BACKGROUND

The lack of a preoperative screening tool to detect obstructive sleep apnea (OSA) may lead to an increase in postoperative complications.

AIM

The aim of the study was to implement a prescreening tool to identify diagnosed or undiagnosed OSA before a surgical procedure.

SETTING

The study was conducted in the surgical admission center and postanesthesia care unit at a military treatment facility in Hawaii.

PARTICIPANTS

Participants of the study included military personnel, military family members, veterans, and veteran beneficiaries.

METHODS

The STOP-BANG (snore/tired/obstruction/pressure-body mass index/age/neck/gender) tool was used between April and June 2013 to identify and stratify 1,625 patients into low-risk, intermediate-risk, high-risk, and known OSA categories.

RESULTS

The STOP-BANG tool confirmed the diagnosed OSA rate to be 13.48%, and increased at-risk OSA detection by 24.69%. Hawaiians/Pacific Islanders were more frequently found to be at risk with known OSA, likely to have complications, and be transferred to PACU 23-hour extended stay compared to other races and intermediate-risk and high-risk categories.

CONCLUSION

The STOP-BANG tool identified and stratified surgical patients at risk for OSA and standardized OSA assessments.

Utility of screening questionnaire, obesity, neck circumference, and sleep polysomnography to predict sleep-disordered breathing in children and adolescents

BACKGROUND

Polysomnography (PSG) remains the gold standard for diagnosing obstructive sleep apnea (OSA) and sleep-disordered breathing in children. Yet, simple screening tools are needed as it is not feasible to perform PSG in all patients with possible OSA.

AIM

The study adapted questions from the Pediatric Sleep Questionnaire-Sleep-Related Breathing Disorder (SRBD) Questionnaire to develop a predictive scale for OSA identified on PSG. We also tested whether adding anthropometric measurements (body mass index and neck circumference) improved prediction of OSA.

METHODS

After IRB approval, OSA questionnaires and anthropometric measurements were collected on 948 consecutive patients scheduled for PSG, aged 4 months to 24.5 years (median = 8.5 years). The sample was reduced to 636 patients in the age range (6-18 years old) where normative values for neck circumference are defined. OSA was characterized using the obstructive apnea-hypopnea index (AHI). After identifying questions related to OSA in univariate logistic regression, multivariable models were fitted to select questions for a short scale, and points for exceeding body mass or neck circumference cutoffs were added to assess improvement in predictive value.

RESULTS

A long scale of 16 questionnaire items was constructed using univariate models, while six items were selected for the short scale by multivariable regression. The short scale was associated with greater odds of moderate/severe OSA (OR = 1.964; 95% CI = 1.620, 2.381; P < 0.001) and attained good predictive value (area under receiver operating characteristics curve [AUC] = 0.74), which was not significantly improved by addition of BMI and neck circumference data (AUC = 0.75).

CONCLUSIONS

We developed a six-question scale with good predictive utility for OSA. These findings may contribute to developing a preoperative clinical tool to help clinicians identify children with OSA for determining risk stratification and postoperative disposition.

Prevalence of and treatment outcomes for patients with obstructive sleep apnoea identified by preoperative screening compared with clinician referrals

Obstructive sleep apnoea (OSA) has implications perioperatively. We compared the prevalence of OSA and outcome with continuous positive airway pressure (CPAP) in patients diagnosed through preoperative screening and following referrals from other clinicians.Among 1412 patients (62% males) the prevalence of OSA, Epworth Sleepiness Score (ESS), the number referred for CPAP, and short and longer term use of CPAP were compared between the two groups.The prevalence of OSA was similar (62% versus 58%). There were differences in mean±sd age (61±16 versus 55±13 years; p<0.0001), ESS (11±6 versus 8±5; p<0.0001) and oxygen desaturation index (22±20 versus 19±17; p=0.039). Clinician-referred patients were more likely to be offered CPAP (p<0.0001; OR 2.84). Pre-assessment patients with mild OSA were less likely to continue CPAP long term (p=0.002; OR 6.8). No difference was seen between moderate and severe OSA patients.The prevalence of OSA was similar in both groups but pre-assessment patients were younger and less symptomatic. Preoperative screening of patients is worthwhile, independent of any effect of CPAP upon surgical outcomes; younger and less symptomatic patients are identified earlier. Pre-assessment patients with mild OSA were less likely to use CPAP; this should be considered when offering CPAP to these patients prior to surgery.

Prediction of obstructive sleep apnea using visual photographic analysis

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) has been historically underdiagnosed and may be associated with grave perioperative complications. The ASA and American Academy of Sleep Medicine recommend OSA screening prior to surgery; however, only a minority of patients are screened. The objective of this study was to determine the proficiency of anesthesiologists, otolaryngologists, and internists at predicting the presence of OSA by visual photographic analysis without the use of a computer program to assist, and determine if prediction accuracy varies by provider type.

DESIGN

Prospective case series

SETTING

Tertiary care hospital-based academic center

PATIENTS

Fifty-six consecutive patients presenting to the sleep laboratory undergoing polysomnography had frontal and lateral photographs of the face and torso taken.

INTERVENTIONS

Not applicable.

MEASUREMENTS

Polysomnography outcomes and physician ratings. An obstructive apnea hypopnea index (oAHI) ≥15 was considered "positive." Twenty anesthesiologists, 10 otolaryngologists, and 11 internists viewed patient photographs and scored them as OSA "positive" or "negative" before and after being informed of patient comorbidities.

MAIN RESULTS

Nineteen patients had an oAHI <15, 18 were ≥15 but <30, and 19 were ≥30. The mean oAHI was 28.7 ± 26.7 events/h (range, 0-125.7), and the mean body mass index was 34.1 ± 9.7 kg/m(2) (range, 17.4-63.7). Overall, providers predicted the correct answer with 61.8% accuracy without knowledge of comorbidities and 62.6% with knowledge (P < .0001). There was no difference between provider groups (P = .307). Prediction accuracy was unrelated to patient age (P = .067), gender (P = .306), or race (P = .087), but was related to body mass index (P = .0002).

CONCLUSION

The ability to predict OSA based on visual inspection of frontal and lateral photographs is marginally superior to chance and did not differ by provider type. Knowledge of comorbidities did not improve prediction accuracy.

High STOP-BANG questionnaire scores predict intraoperative and early postoperative adverse events

INTRODUCTION

Obstructive sleep apnoea (OSA) is the most common sleep-related breathing disorder associated with multisystemic organ involvement. The STOP-BANG questionnaire is a concise, validated questionnaire that is used to screen for OSA. This study aimed to establish the use of the STOP-BANG questionnaire for perioperative patient risk stratification.

METHODS

In this retrospective cohort study, we extracted the demographic, medical and perioperative outcome data of all patients who underwent elective surgery, excluding ophthalmic surgeries, from January to December 2011. Multivariate regression analysis was used to predict independent risk factors for intraoperative and early postoperative adverse events.

RESULTS

Of the 5,432 patients analysed, 7.4% had unexpected intraoperative and early postoperative adverse events. We found that the risk of unexpected intraoperative and early postoperative adverse events was greater in patients with STOP-BANG scores ≥ 3 compared to those with a STOP-BANG score of 0 (score 3: odds ratio [OR] 3.6, 95% confidence interval [CI] 2.1-6.3, p < 0.001; score 4: OR 3.4, 95% CI 1.8-6.5, p < 0.001; score 5: OR 6.4, 95% CI 2.7-15.0, p < 0.001; score ≥ 6: OR 5.6, 95% CI 2.1-15.4, p < 0.001). Patients with STOP-BANG scores ≥ 5 had a fivefold increased risk of unexpected intraoperative and early postoperative adverse events, while patients with STOP-BANG scores ≥ 3 had a 'one in four' chance of having an adverse event. Other independent predictors included older age (p < 0.001), American Society of Anesthesiologists class ≥ 2 (p < 0.003) and uncontrolled hypertension (p = 0.028).

CONCLUSION

STOP-BANG score may be used as a preoperative risk stratification tool to predict the risk of intraoperative and early postoperative adverse events.

Preoperative evaluation of the vascular surgery patient

Patients undergoing vascular surgery present a myriad of perioperative challenges due to the complex comorbidities affecting them in conjunction with high-risk surgical procedures. Additionally, advances in endovascular technology have enabled surgical procedures to be performed on patients who would not have been considered surgical candidates in the past. This combination of increasing patient morbidity and evolving surgical technique requires a well-planned preoperative assessment and close communication with surgical and perioperative colleagues. This article outlines an appropriate approach by first considering each organ system, followed by review of considerations unique to various surgical procedures, and then an overall assessment of risk.

Pediatric polysomnography for sleep-disordered breathing prior to tonsillectomy: a guideline review

Snoring and other signs of sleep-disordered breathing (SDB) represent a common management challenge for the pediatrician, pulmonologist, anesthesiologist, and otolaryngologist. In 2011, the American Academy of Otolaryngology-Head and Neck Surgery published a clinical practice guideline for the treatment of patients with SDB. This guideline provides indications for polysomnography use in patients with SDB. In this article, we discuss the management of SDB in pediatric patients, which relies on the accurate assessment of symptoms of SDB, identification of comorbidities known to increase the severity of SDB, and appropriate preoperative assessment of the patient.

Predicting postoperative pulmonary complications in high-risk populations

PURPOSE OF REVIEW

Our objective is to describe prediction models for surgical patients who have suspected obstructive sleep apnea (OSA) at risk for postoperative respiratory complications and for surgical patients at risk for postoperative acute respiratory distress syndrome (ARDS).

RECENT FINDINGS

Because of the increased rate of severe perioperative respiratory complications in patients with OSA, the American Society of Anesthesiologists issued practice guidelines for perioperative management. When OSA is diagnosed preoperatively, the rate of postoperative pulmonary complications is low and not associated with OSA severity. However, OSA continues to be an important risk because a substantial proportion of patients in the contemporary surgical population have undiagnosed OSA. Strategies based on preoperative and immediate postoperative clinical signs and symptoms can help identify patients with a high likelihood of OSA, postoperative desaturations, and pulmonary complications. ARDS is another serious postoperative complication associated with high mortality rate and limited treatment options, and its prevention is critical. Practice changes have led to a dramatic reduction in ARDS incidence. A recently developed prediction model can help identify high-risk patients.

SUMMARY

Evidence is emerging that early identification of modifiable risk factors and implementation of 'protective' management strategies may lead to reduction of severe postoperative pulmonary complications.

The association of pre-operative STOP-BANG scores with postoperative critical care admission

The STOP-BANG questionnaire screens for obstructive sleep apnoea. We retrospectively analysed the independent association of pre-operative variables with postoperative critical care admission using multivariable logistic regression for patients undergoing elective surgery from January to December 2011. Of 5432 patients, 338 (6.2%) were admitted postoperatively to the critical care unit. In multivariate analysis, the odds ratios (95% CI) for critical care admission were: 2.2 (1.1-4.6), p = 0.037; 3.2 (1.2-8.1), p = 0.017; and 5.1 (1.8-14.9), p = 0.002, for STOP-BANG scores of 4, 5 and ≥ 6, respectively. The odds ratio was also independently increased for: each year of age, 1.015 (1.004-1.026), p = 0.019; asthma, 1.6 (1.1-2.4), p = 0.016; obstructive sleep apnoea, 3.2 (1.9-5.6), p < 0.001; and for ASA physical status 2, 3 and ≥ 4, 2.1 (1.4-3.3), 6.5 (3.9-11.0), 6.3 (2.9-13.8), respectively, p < 0.001 for all.

Management Plan to Reduce Risks in Perioperative Care of Patients with Obstructive Sleep Apnoea Averts the Need for Presurgical Polysomnography

Introduction: Obstructive sleep apnoea (OSA) is associated with increased perioperative morbidity and mortality. Patients at risk of OSA as determined by pre-anaesthesia screening based on the American Society of Anesthesiologists checklist were divided into 2 groups for comparison: (i) those who proceeded to elective surgery under a risk management protocol without undergoing formal polysomnography preoperatively and; (ii) those who underwent polysomnography and any subsequent OSA treatment as required before elective surgery. We hypothesised that it is clinically safe and acceptable for patients identified on screening as OSA at-risk to proceed for elective surgery without delay for polysomnography, with no increase in postoperative complications if managed on a perioperative risk reduction protocol. Materials and Methods: A retrospective review of patients presenting to the pre anaesthesia clinic over an 18-month period and identified to be OSA at-risk on screening checklist was conducted (n = 463). The incidence of postoperative complications for each category of OSA severity (mild-moderate and severe) in the 2 study groups was compared. Results: There was no statistically significant difference in the incidence of cardiac (3.3% vs 2.3%), respiratory (14.3% vs 12.5%), and neurologic complications (0.6% vs 0%) between the screening-only and polysomnography-confirmed OSA groups respectively (P >0.05). There was good agreement of the OSA risk that is identified by screening checklist with OSA severity as determined on formal polysomnography (kappa coefficient = 0.953). Conclusion: Previously undiagnosed OSA is common in the presurgical population. In our study, there was no significant increase in postoperative complications in patients managed on the OSA risk management protocol. With this protocol, it is clinically safe to proceed with elective surgery without delay for formal polysomnography confirmation. Key words: Postoperative complications, Preoperative screening, Risk management, Undiagnosed OSA

Caring for the patient with obstructive sleep apnea: implications for health care providers in postanesthesia care

Obstructive sleep apnea (OSA) is a sleep disorder affecting 18 million Americans. The prevalence of OSA is increasing due to an epidemic rise in obesity, which is a major contributing factor. The primary treatment for OSA is continuous positive airway pressure, designed to maintain a patent airway for unobstructed breathing. OSA patients may experience postoperative hypoventilation due to residual anesthetic, analgesic requirements, and other comorbidities. Postoperative health care providers must be prepared to assess for hypoventilation and intervene using evidence-based interventions to improve outcomes. It is incumbent that the PACU nurse be aware of and implement evidence-based clinical guidelines for patients with OSA. Therefore, the purpose of this manuscript is to (1) describe the physiology, comorbidities, diagnosis, and treatment of OSA; (2) identify the effects of anesthesia in persons with OSA; (3) discuss clinical guidelines; and (4) describe implications for care in an effort to improve health outcomes in persons with OSA during the perianesthesia period.

Utility of the pediatric sleep questionnaire and pulse oximetry as screening tools in pediatric patients with suspected obstructive sleep apnea syndrome

Objective. To assess the screening tools in snoring patients. Material and Methods. A retrospective review of data was conducted from children between 2 and 15 years old who were referred on suspicion of obstructive sleep apnea-hypopnea (OSAH) between June 2008 and June 2011. We excluded patients with significant comorbidities. Pediatric Sleep Questionnaire (PSQ), physical exam (PE), and pulse-oximetry data were collected and correlated with the results of the nightly polygraph at home. Results. We selected 98 patients. The 22-item version of the PSQ had sensitivity of 96% and specificity of 36.8%. The overall value of the clinic predictor of OSAH (PSQ and PE together) exhibited an increased specificity 57.6% with 94.6% of sensitivity. The nocturnal home oximetry method used alone was very specific, 92.1%, but had a lower sensitivity, 77.1%. The set of clinical assessment tools used together with pulse-oximetry screening provided excellent specificity 98.1% and a positive predictive value 94.1% globally. The performance of this screening tool is related with the severity of OSAH and accuracy is better in moderate and severe cases. Conclusion. The combination of clinical assessment and pulse-oximetry screening can provide a sufficient diagnostic approach for pediatric patients with suspected OSAH at least in moderate and severe cases.

Respiratory perioperative management of patients with obstructive sleep apnea

Obstructive sleep apnea (OSA) has become a major public health problem in the United State and Europe. However, perioperative strategies regarding diagnostic options and management of untreated OSA remain inadequate. Preoperative screening and identification of patients with undiagnosed OSA may lead to early perioperative interventions that may alter cardiopulmonary events associated with surgery and anesthesia.(1) Hence, clinicians need to become familiar with the preoperative screening and diagnosis of OSA. Perioperative management of a patient with OSA should be modified and may include regional anesthesia and alternative analgesic techniques such as nonsteroidal anti-inflammatory drugs that may reduce the need for systemic opioids. Additionally, supplemental oxygen and continuous pulse oximetry monitoring should be utilized to maintain baseline oxygen saturation. Postoperatively patients should remain in a semi-upright position and positive pressure therapy should be used in patients with high-risk OSA.

Perioperative care for the older outpatient undergoing ambulatory surgery

As the number of ambulatory surgery procedures continues to grow in an aging global society, the implementation of evidence-based perioperative care programs for the elderly will assume increased importance. Given the recent advances in anesthesia, surgery, and monitoring technology, the ambulatory setting offers potential advantages for elderly patients undergoing elective surgery. In this review article we summarize the physiologic and pharmacologic effects of aging and their influence on anesthetic drugs, the important considerations in the preoperative evaluation of elderly outpatients with coexisting diseases, the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and offer recommendations regarding the management of common postoperative side effects (including delirium and cognitive dysfunction, fatigue, dizziness, pain, and gastrointestinal dysfunction) after ambulatory surgery. We conclude with a discussion of future challenges related to the growth of ambulatory surgery practice in this segment of our surgical population. When information specifically for the elderly population was not available in the peer-reviewed literature, we drew from relevant information in other ambulatory surgery populations.

A systematic review of the effects of sedatives and anesthetics in patients with obstructive sleep apnea

The objective of this review is to determine the effects of perioperative sedatives and anesthetics in surgical patients with obstructive sleep apnea (OSA) on respiratory events, medication requirements, hemodynamics, pain, emergence, and hospital stay. We searched The Cochrane CENTRAL Register of Controlled Trials, Medline, Embase, and Cochrane Database of Systematic Reviews from 1950 to June 2010 for relevant articles. All prospective and retrospective studies were eligible for inclusion if the effects of perioperative administration of sedation and anesthetics on medication requirements, pain, emergence, hemodynamics, respiratory events, and length of hospital stay in OSA patients were reported. The search strategy yielded 18 studies of 1467 patients. Of these, 456 patients were documented as having OSA. Few adverse respiratory effects were reported. Eight out of 700 (1.14%) patients undergoing middle ear surgery with midazolam and fentanyl had impaired upper airway patency and were retrospectively diagnosed as having OSA by polysomnography. Also, intraoperative snoring causing uvular edema in the postoperative period was described in an OSA patient undergoing upper limb surgery when propofol was administered with midazolam and fentanyl for sedation. A decrease in oxygen saturation in the postoperative period was described with propofol and isoflurane in 21 OSA patients undergoing uvulo-palato-pharyngoplasty and tonsillectomy surgery (P<0.05). Perioperative alpha 2 agonists were shown to decrease the use of anesthetics (P<0.05), analgesics (P=0.008) and anti-hypertensives (P<0.001) in OSA patients. Contradictory reports regarding emergence occurred with intraoperative dexmedetomidine. Intraoperative opioids decreased the analgesic consumption (P=0.03) and pain scores (P<0.05) in the postoperative period. There was limited data on the length of hospital stay. There were few adverse effects reported when patients with known OSA underwent elective surgery with the currently available sedatives and anesthetics. Adverse events were reported with midazolam. However, the quality and number of patients in the studies were limited. There is a need for further trials with large numbers and uniform reporting of outcomes.

Clinical practice guideline: Polysomnography for sleep-disordered breathing prior to tonsillectomy in children

OBJECTIVE

This guideline provides otolaryngologists with evidence-based recommendations for using polysomnography in assessing children, aged 2 to 18 years, with sleep-disordered breathing and are candidates for tonsillectomy, with or without adenoidectomy. Polysomnography is the electrographic recording of simultaneous physiologic variables during sleep and is currently considered the gold standard for objectively assessing sleep disorders.

PURPOSE

There is no current consensus or guideline on when children 2 to 18 years of age, who are candidates for tonsillectomy, are recommended to have polysomnography. The primary purpose of this guideline is to improve referral patterns for polysomnography among these patients. In creating this guideline, the American Academy of Otolaryngology--Head and Neck Surgery Foundation selected a panel representing the fields of anesthesiology, pulmonology medicine, otolaryngology-head and neck surgery, pediatrics, and sleep medicine.

RESULTS

The committee made the following recommendations: (1) before determining the need for tonsillectomy, the clinician should refer children with sleep-disordered breathing for polysomnography if they exhibit certain complex medical conditions such as obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (2) The clinician should advocate for polysomnography prior to tonsillectomy for sleep-disordered breathing in children without any of the comorbidities listed in statement 1 for whom the need for surgery is uncertain or when there is discordance between tonsillar size on physical examination and the reported severity of sleep-disordered breathing. (3) Clinicians should communicate polysomnography results to the anesthesiologist prior to the induction of anesthesia for tonsillectomy in a child with sleep-disordered breathing. (4) Clinicians should admit children with obstructive sleep apnea documented on polysomnography for inpatient, overnight monitoring after tonsillectomy if they are younger than age 3 or have severe obstructive sleep apnea (apnea-hypopnea index of 10 or more obstructive events/hour, oxygen saturation nadir less than 80%, or both). (5) In children for whom polysomnography is indicated to assess sleep-disordered breathing prior to tonsillectomy, clinicians should obtain laboratory-based polysomnography, when available.