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PAP Therapy for OSA in the Perioperative Setting:

Is There a Best Approach?

Dennis Auckley MD Director, Center for Sleep Medicine

MetroHealth Medical Center Associate Professor of Medicine

Case Western Reserve University

Financial Disclosures

•  Research Funding: - Teva: Perioperative survey study

Medical inpatient PSG study

•  Research Equipment: - ResMed: Perioperative study

Perioperative PAP Therapy: Known OSA on Treatment

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Case # 1

•  52 y/o M with known OSA - PSG 18 months prior: AHI of 38.7 and CPAP 12 cm H2O

resulted in an optimal titration - Reports CPAP compliance, denies OSA symptoms, and has

gained 1.5 kg since his sleep study

•  PMHx: HTN, hyperlipidemia, current smoker

•  Planned right total knee replacement in 1 week

Case # 1

•  You: A.  Proceed with surgery, using his CPAP at current setting,

no special monitoring B.  Proceed with surgery, using his CPAP at current setting,

monitor postoperatively with oximetry C.  Repeat his PSG preoperatively to ensure CPAP is still

effective, delaying surgery if needed D.  Place on autoadjusting CPAP perioperatively E.  Other?

ASAA OSA Patient’s Rights and Responsibilities

•  To be adequately treated for OSA during all surgical procedures whether in-hospital or outpatient

•  To be adequately treated for OSA while hospitalized for surgery, other medical conditions, or having same day surgery

•  To use your own mask and headgear, and your own CPAP equipment set at your prescribed pressure… ASAA website

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CPAP in the Perioperative Management of Known OSA

•  2 pts with OSA had postop complications - Not initially treated with CPAP - 1 died

•  Next 14 pts with OSA received pre / postop CPAP •  Variety of operations (CABG, gastroplasty,

thyroidectomy, AAA repair)

•  No significant complications occurred in any of the patients on CPAP Rennotte et al, Chest 1995

CPAP in the Perioperative Management of Known OSA

“…N-CPAP…allows us… to freely use sedative, analgesic and anesthetic drugs without major complications.”

Rennotte et al, Chest 1995

Gupta et al, Mayo Clinic Proc 2001

%

IB, no hCPAP = 2/32 CPAP postOp IB, hCPAP = 12/33 CPAP postOp

* *

* * P < 0.05

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CPAP in the Perioperative Management of Known OSA  

•  Retrospective analysis of 284 pts with PSG confirmed OSA who underwent Roux-en-Y GBS: - 144 were using CPAP/BPAP preoperatively - 140 were not using CPAP/BPAP preoperatively - Postoperatively, pts were monitored with oximetry while on

supplemental O2 at 2-4 l/m to keep saturations >92% - None were treated with CPAP/BPAP postoperatively

•  Results: PAP No PAP Complication rate 0.7% 2.1% not SS

Jensen et al, Surg Obes Relat Dis 2008

Is CPAP Use Enough During the Postoperative Period?

•  CPAP at the usual home-setting may not prevent upper airway collapse postoperatively - Lowered threshold for upper airway collapse

- Increased time in supine position - REM rebound

•  Consequently may still have respiratory events and hypoxia

•  No data available looking at this

Example of Postoperative Hypoxia on CPAP

Pulse Oximetry Dx PSG

6/2006

CPAP 9 cm H20 6/2006

Ist PostOP night CPAP 9 cm H2O

9/2007

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Postoperative Oximetry Study of OSA Patients on CPAP: Methods

•  Observational cohort study (n=38)

•  Patients with known OSA well-controlled (not hypoxemic) on CPAP therapy

•  Elective surgery at our institution

•  Monitored with an overnight pulse-oximeter for approximately 8 hour period on the first night after surgery

Brar et al, J Sleep Dis and Therapeutics, in press

Postoperative Oximetry Study of OSA Patients on CPAP: Results

Brar et al, J Sleep Dis and Therapeutics, in press

Postoperative Oximetry Study of OSA Patients on CPAP: Conclusions

•  Significant hypoxia (n=7, 18%) was associated with: - baseline AHI and supine AHI - Average SpO2 on diagnostic PSG - Fluid balance - IV MEQ dose

•  The etiology of the hypoxia not always clear

•  It is uncertain if the hypoxia increases the risk of other complications

•  Monitoring would be required to detect the hypoxia Brar et al, J Sleep Dis and Therapeutics, in press

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OSA, Narcotics and CPAP

Home

OSA, Narcotics and CPAP

Admitted, IV dilaudid x 2

Perioperative PAP Therapy: Known OSA on Treatment

•  We need better data! -  Is PAP assessment prior to surgery needed? -  Is there a role for ACPAP in this setting? -  Should postOp monitoring be recommended for OSA pts

on PAP therapy?

•  In the meantime, my thoughts: -  PreOp assessment with history +/- machine download +/-

oximetry -  Consider repeat titration or ACPAP before surgery* -  Monitor (oximetry) those at high-risk for problems

-  Severe OSA, high narcotic requirement, co-morbidities

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Case # 2

•  52 y/o F with known OSA - PSG 4 weeks prior: AHI of 45.2 with REM worsening and

REM desaturations -  Just now being seen in clinic and has not been evaluated for

PAP therapy yet -  HCO3- is normal

•  PMHx: HTN, DM, morbid obesity

•  Planned right total hip replacement in 1 week

Case # 2

•  You: A.  Do nothing preoperatively, proceed with surgery, no

special postoperative monitoring B.  Do nothing preoperatively, proceed with surgery, monitor

postoperatively with oximetry C.  Place on autoadjusting CPAP perioperatively, proceed

with surgery, no special postoperative monitoring D.  Place on autoadjusting CPAP perioperatively, proceed

with surgery, monitor postoperatively with oximetry E.  Arrange for urgent PAP titration study, delaying surgery if

needed F.  Other?

ACPAP initiation for the Perioperative Management of Known OSA  

•  Case-control study of 45 pts with severe OSA undergoing upper airway surgery (uvula sparing): - 21 pts started on CPAP at least 7 days preOp, then placed on

ACPAP for 3 nights postOp - 24 pts not treated with PAP therapy - All had a PSG on night 2 following their surgery

•  Results (Cases): Dx study PAP titration PostOp

AHI 61.1 2.2 3.6 Low O2 Sat 65.0% 94.5% 93.7%

Lin et al, Zhonghua Er Bi Yan Hou Ke Za Zhi 2003

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CPAP Adherence in the Perioperative Management of Known OSA  

•  Retrospective observational study of 138 pts who underwent preOp PSG, found to have an AHI > 15 and started on PAP therapy preOp: - PSGs were split nights - ACPAP started (max +3 cm H2O, min – 2 H2O best PSG

CPAP pressure) on average 4 days preOp -  All had RT instruction, mask fitting and MD phone contact

•  Results - at 30 days after starting ACPAP - Average use = 2.5 hrs / night - Use > 4 hrs / night = 33%

Guralnick et al, J Clin Sleep Med 2012

Perioperative PAP Therapy: Known OSA not on Treatment

•  We need better data! -  Should ACPAP (or other PAP) be started preOp / postOp? -  What can be done to improve compliance with therapy? -  Should postOp monitoring be recommended for OSA pts

initiated on PAP therapy perioperatively?

•  In the meantime, my thoughts: -  PreOp assessment with history, exam and review of PSG -  Consider ACPAP before surgery if can ensure quality

instruction -  Monitor (oximetry) those at high-risk for problems

-  Severe OSA, high narcotic requirement, co-morbidities

Case # 3

•  58 y/o M screens positive for OSA during preOp assessment (STOP-Bang score is 4) - You are called by the presurgical clinic regarding how to

proceed

•  PMHx: HTN, TIA, obesity

•  Planned for lower abdominal surgery in 1 week

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Case # 3

•  You: A.  Do nothing preoperatively, proceed with surgery, no

special postoperative monitoring B.  Do nothing preoperatively, proceed with surgery, monitor

postoperatively with oximetry C.  Place on autoadjusting CPAP perioperatively, proceed

with surgery, no special postoperative monitoring D.  Place on autoadjusting CPAP perioperatively, proceed

with surgery, monitor postoperatively with oximetry E.  Arrange for urgent PSG, delaying surgery if needed F.  Other?

PostOp ACPAP initiation for the Management of Suspected OSA

•  86 pts at-risk for OSA (positive SACs questionnaire) undergoing TKR or THR randomized to ACPAP + UC vs UC alone -  Those randomized to ACPAP all had video/verbal

instruction, mask fitting and 15-30 minute practice preOp -  ACPAP was initiated postOp, preferrably in the PACU -  ACPAP were set at 5-15 cm H2O -  Primary outcome was LOS with a secondary outcome of

complication rates

Gorman et al, Chest 2013

PostOp ACPAP initiation for the Management of Suspected OSA

•  Results: -  No difference in LOS (primary)

-  1 day longer LOS in those with AHI > 15 placed on ACPAP

-  No difference in postoperative complications (secondary) -  CPAP compliance: 6 hrs night 1, 3 hrs for LOS

•  Issues: •  Screened 2075 to enroll 138 •  Study ended up being underpowered •  Median AHI was 13.5 on ACPAP •  ACPAP initiated postOp

Gorman et al, Chest 2013

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Perioperative PAP Therapy: Suspected OSA not on Treatment

•  We need more data! -  Should these pts get a preOp PSG or PM? -  Should ACPAP (or other PAP) be started preOp vs

postOp or at all? -  Should postOp monitoring be recommended for suspected

OSA pts with or without PAP therapy?

•  In the meantime, my thoughts: -  There may be a role for PM/ preOp ACPAP -  ACPAP initiation would require quality instruction -  Monitor (oximetry) those at high-risk for problems

-  Severe OSA, high narcotic requirement, co-morbidities

PAP Therapy for OSA in the Perioperative Setting: Is There a Best Approach?

•  Known OSA pts already on PAP therapy should be clinically reassessed preOp: -  Consider need for repeat testing -  Consider need for postOp monitoring

•  Known OSA pts not on PAP therapy should be clinically assessed preOp: -  Consider PAP titration vs ACPAP trial -  Consider the need for postOp monitoring

•  Suspected OSA pts should be placed in the clinical context

PAP Therapy for OSA in the Perioperative Setting: Lots of Questions

•  Who is considered highest risk for complications? •  Who should be monitored postOp? And how?

- oximetry? - CO2 monitoring? - other? •  Is there a role for autoadjusting Bilevel PS?

•  Data, Data, Data, Data, Data, Data, Data, Data

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Thank You!