Updates in Surgical and

Anesthetic Management of

Obstructive Sleep Apnea

Samuel A. Schechtman, MD

Clinical Assistant Professor of Anesthesiology

Director of Head and Neck Anesthesiology & Airway

Management

Disclosure Statement

$$$$$$$$

TruBlu Dentistry

http://www.trubludentistry.com

http://shanahq.com/

@SamSchechtman

@shanasociety

Learning Objectives• Case presentation

• Background

• Surgical & Anesthetic Management

– Role of Drug-Induced Sleep Endoscopy

(DISE)

– Upper Airway Stimulator (Inspire ® device)

– Transoral Robotic Surgery (TORS)

– Postoperative considerations

• Team communication

One day in the alternatives to

CPAP clinic…

• 67 yo ASA 3 male - severe OSA

–Intolerant of CPAP

–Daytime sleepiness, snoring

–BMI 31

• Interested in surgery

Patient MD

• Apnea-Hypoapnea Index

(AHI) 32.6

• O2 minimum 78%

• Tolerates CPAP ~ 2 hours

per night

Exam

• Septal deviation

• Tonsils absent

• Friedman TP 3

• Mallampati 4

• Class I occlusion

• Medialized palatopharyngeal

muscles, uvula 1 cm

• Flexible nasal endoscopy:

Minimal lingual tonsillar tissue

Defining OSA & Anesthetic

Considerations

Forms of Sleep Apnea

Obstructive

Continued thoracoabdominal effort in the setting of partial or

complete airflow cessation

Central

The lack of thoracoabdominal effort in the setting of partial or complete

airflow cessation

Mixed

A respiratory event with both obstructive and central features, with

mixed events generally beginning as central events and ending with

thoracoabdominal effort without airflow

Wakefield TL et al. 2010. Cummings Otolaryngology. Chapter 18, 5th Edition

Obstructive Sleep Apnea (OSA)

• Common sleep-related breathing

disorder

• Prevalence ranges from 3% to 7%

• Several factors that increase

vulnerability

Respiratory Events During SleepApnea Cessation of airflow for at least 10 seconds

HypopneaA reduction in airflow (≥30%) at least 10 seconds with ≥4%

oxyhemoglobin desaturation

OR

A reduction in airflow (≥50%) at least 10 seconds with ≥3%

oxyhemoglobin desaturation or an electroencephalogram

(EEG) arousal

Respiratory

effort–related

arousal

(RERA)

Sequence of breaths for at least 10 seconds with increasing

respiratory effort or flattening of the nasal pressure waveform,

leading to an arousal from sleep when the sequence of

breaths does not meet the criteria for an apnea or a hypopnea

• Apnea-Hypopnea Index (AHI) = Apneas + Hypopneas per hour of sleep

• Respiratory Disturbance Index (RDI) = A+H+RERA per hour of sleep

Wakefield TL et al. 2010. Cummings Otolaryngology. Chapter 18, 5th Edition

Sleep-related Breathing

Disorders

• Primary snoring

• Upper Airway Resistance Syndrome

(UARS)

• Obstructive Sleep Apnea (OSA)

Syndrome

• Obesity - Hypoventilation Syndrome

Wakefield TL et al. Cummings Otolaryngology. 2010. Chapter 18, 5th Edition

OSA Severity

• Data from the Wisconsin Sleep Cohort Study

• Severe sleep-disordered breathing (AHI≥15):

• 10% among 30-49 year-old men

• 17% among 50-70 year-old men

• 3% among 30-49 year-old women

• 9% among 50-70 year-old womenPeppard et al. 2013.

STOP-BANG Screening Questions

Joshi et al. 2012.

< 3 questions

positive

– Low risk of

OSA

≥ 3 positive

– High risk of

OSA

≥ 5 positive

– High risk of

moderate to

severe OSA

Polysomnography & Diagnosis

• Overnight sleep lab PSG =

gold standard

• Home sleep studies widely

used

Medical Comorbidities

• Cardiovascular disease

• GERD

• Alcoholism and tobacco use

• Stroke

• HTN (does not improve during sleep)

• Arrhythmias (atrial fibrillation)

• Pulmonary HTN

• Diabetes

• Memory loss - Kumar R et al. 2008.

Yaggi et al. 2005.

• 1022 enrolled patients

• 68 percent with OSA mean AHI 35

• OSA & stroke or death

- Hazard ratio = 2.24

• After adjustment for cofounders: OSA with

stroke or death

- Hazard ratio = 1.97

2018 – Anesthesia & Analgesia

Summary Recommendations• Risk of difficult airway management

• Anesthetics & analgesics drugs

Perioperative risk

• NMBAs increase risk

• Propofol sedation Hypoxia

• Benzodiazepines Airway obstruction

• Desflurane and sevoflurane Increase safety

• Ketamine and alpha-2-agonists ? Increase

safety

• Regional anesthesia may decrease risk

Perioperative Complications with OSA

From Joshi et al. (2012). In Anesthesia and Analgesia.

Memtsoudis et al. 2011.

• 2,610,441 orthopedic surgeries 2.5 %

OSA

• 3,441,262 general surgeries 1.4 % OSA

• With OSA more pulmonary complications• Aspiration pneumonia

• ARDS

• Intubation/mechanical ventilation

• PE after orthopedic procedures

OSA & Airway Assessment

• Difficult intubation: 8 times higher

• Preoperative otolaryngology

evaluation

– Direct visual examination

– Flexible endoscopic

nasopharyngoscopy

• Muller maneuver

– CT/MRI

ASA Recommended Guidelines for

Perioperative OSA Management

2014. Anesthesiology

Recommendations & Criteria

• Preoperative evaluation

• Determination of inpatient vs

outpatient

• Preoperative preparation

• Intraoperative management

• Discharge to unmonitored

settings

Surgical Evaluation and

Treatment of OSA

Surgical TreatmentsAnatomical

Location

Surgical Procedure Anesthetic Technique

Nasal Septoplasty, functional

rhinoplasty, turbinate

reduction, nasal polypectomy

Local +/- sedation or general

anesthesia with supraglottic

airway or endotracheal tube

Oral/oropharyngeal/

nasophargyneal

UPPP, UPF,

Tonsillectomy/adenoidectomy

GA with ETT

Hypopharyngeal GA, tongue reduction surgery GA with ETT

Laryngeal Epiglottoplasty, hyoid

suspension

GA with ETT

Global Airway MMA, Maxillomandibular

expansion

GA with nasal ETT

Trachea Tracheostomy Local +/- sedation or general

anesthesia with supraglottic

airway or endotracheal tube

Abdelmalak and Doyle. 2013.

Assessment and Diagnosis• History

• Polysomnogram data

• Epworth Sleepiness Scale

• BMI and neck circumference

• Physical exam

– Mallampati classification

– Friedman tongue position

• Awake nasal flexible laryngoscopy

Epworth Sleepiness Scale

• Scores 0-9 ”normal” range

• 10-24 excessive daytime sleepinessJohns MW. 1991.

Friedman Tongue Position

Friedman M et al. Diagnostic value of the Friedman tongue position and

Mallampati classification for OSA: a meta-analysis. Otolaryngol Head

Neck Surg. 2013 Apr;148(4):540-7.

Relative Indications for

Surgery• Moderate or severe OSA (AHI > 15)

• Minimum O2 < 90%

• UARS or mild OSA

- Excessive daytime sleepiness

- Poor QOL

• Cardiac arrhythmias

• CPAP intolerance or patient preference

• Medically optimizedWakefield TL et al. Cummings Otolaryngology. Chapter 18, 5th Edition.

• AHI > 15

• Epworth sleepiness scale (ESS) > 12

• < 50% use at 1 & 3 months after

initiation

Rosen et al. 2012.

Chase Dental Sleepcare

https://www.chasedentalsleepcare.com

Surgical Options?

Surgical selection

• Most have multilevel obstruction

consider multilevel surgery

– Nasal airway

– Palate or pharyngeal surgery

– Hypopharyngeal expansion

Measuring Outcomes

• Variable success few achieve cure

• Surgical success:

– AHI < 20

and

– AHI reduced by > 50%

• Surgical cure: AHI < 5 per hour

Patient MD

• Several options discussed

–Multilevel surgery

or…

–Drug induced sleep endoscopy

(DISE) evaluate for Upper

Airway Stimulation

Sleep Endoscopy

• Drug-Induced Sleep Endoscopy

(DISE)

– Approximates natural sleep state

– Endoscopic evaluation of upper airway

• Identify and stratify level of

obstruction

• Risks of anesthesia & airway

compromise

Charakorn N. 2016.

Indications Contraindications

OSA Allergy to sedative agents

Failed CPAP Pregnancy

Considering alternatives to CPAP Significant medical comorbidities

Relative:

Obesity or markedly severe OSA

DISE

Procedural Steps & Considerations

• Prior PSG & awake nasal endoscopy

• Outpatient procedure in procedure suit or

OR

– Standard anesthetic equipment

– Anesthesia staffing required

• Equipment:

- Local anesthetic +/- nasal decongestant

- Flexible endoscope

- BIS Monitor

- Surgical and anesthesia team

DISE – Michigan Medicine Protocol

• Pre-operative management–No anxiolytic–Supine awake endoscopy performed

• Intraoperative Management–Backup emergency airway plan–BIS monitor–Propofol started at 150 mcg/kg/min and

titrated with constant infusion to attain BIS level 50 – 65

–Supplemental oxygen safe

DISE

2016

2016

2017

Why BIS Level 50 – 65

• Bispectral index monitoring (BIS)

correlates with sleep stages

– Light sleep EEG patterns at BIS 75-90

– Slow wave sleep at 20-70

• BIS 50-65 induces snoring & sleep-like

state

– 30 patients undergoing DISE

– Compared with controls - natural sleep PSG

Sleigh JW et al. 1999.

Babar-Craig H et al. 2012.

DISE Scoring and Classification

–DeVito et al. 2014.

• No consensus on structures/levels classification

• Severity

– VOTE System with 3 degrees (none, partial, complete)

– Quantitative system (0-25%, 25-50%, 50-75%, 75-100%)

• Configuration

– Severity

– Site

– Pattern obstruction: anteroposterior, lateral, concentric

Classification Systems

Sleep Endoscopy - Assessment

• VOTE classification

– Scoring 0-2, A-P vs lateral vs concentric

• None, without vibration (<50% airway

narrowing)

• Partial (50-75%)

• Complete (>75%)

Velum Oropharynx Tongue Epiglottis

Charakorn N. Drug-Induced Sleep Endoscopy. Otolaryngol Clin North Am. 2016 Dec.

2018

• 275 patients at 14 centers

• Moderate interrater reliability

• Lower surgical response

- Oropharyngeal lateral wall

obstruction

- Complete tongue-relate

obstruction

• Tonsil size and BMI inversely related

• Velum and epiglottic obstruction not

predictive

Patient MD – Sleep Endoscopy

• VOTE scoring system (0-2):

– Velum: 2 A-P

– Oropharynx: 1 lateral

– Tongue base/ lingual tonsils: 1 A-P

– Epiglottis: 0

• Septoplasty and turbinate reduction

performed

• NOT a candidate for lingual

tonsillectomy

Upper Airway Stimulation Criteria

• Non-concentric collapse at

velum

• Partial obstruction at tongue

base

• BMI < 32

• AHI between 20 - 65

Upper Airway Stimulation

The Distal Hypoglossal Nerve

Hypoglossal

Nerve (CN XII)

Genioglossus

Muscle

Geniohyoid

Muscle

Styloglossus

Muscle

Hyoglossus

Muscle

Gentle stimulation

Hypoglossal Nerve Stimulation EffectNo Stimulation Gentle Stimulation

Base of Tongue Base of TonguePalate Palate

Inspire ® Upper Airway

Stimulator

Inspire Upper Airway Stimulation. Accessed On-Line January 16, 2019: https://www.inspiresleep.com/what-is-inspire-therapy/how-inspire-therapy-

works/

Stimulation

delivered during

inspiration

Timing

Resp

ira

tory

Cycle

Inspire Upper Airway

Stimulator

Inspire Upper Airway Stimulation. Accessed On-Line January 16, 2019: https://www.inspiresleep.com/what-is-inspire-therapy/how-inspire-therapy-

works/

Inspire® Upper Airway

Stimulation - Hypoglossal

Nerve Stimulator

Stimulation Therapy for Apnea

Reduction (STAR) Trial – 2014 NEJM

• Multicenter, prospective, cohort

(N=126)

• Primary: AHI & O2 desaturation index

• Secondary:

– Epworth Sleepiness Scale

– Functional Outcomes of Sleep

Questionnaire (FOSQ)

– % of sleep time with SpO2 <90%Strollo PJ Jr et al. 2014.

Upper Airway Stimulation for

OSA

• AHI 20 - 50

• Difficulty with CPAP

• BMI < 32

• Exclusions

– Significant comorbidities

– Other sleep disorders

– Unfavorable anatomy

Strollo PJ Jr et al. 2014.

Results

• PSG at 12 months

– Median AHI decreased 68% (29.3 9.0)

– Median ODI decreased 70% (25.4 7.4)

• 66% had at least 50% reduction in AHI

• Secondary outcome measures

– Improved responses on sleep surveys

– Median sleep time at SpO2 < 90% decreased

from 5.4% 0.9%

Strollo PJ Jr et al. Upper-airway stimulation for obstructive sleep apnea. N Engl J Med.

2014 Jan.

Results

• Therapy withdrawal for 7 days

(randomized)

– AHI increased from 7.6 25.8

• Complications

– 2 required reoperation to reposition

device

– 18% with temporary tongue weakness

Strollo PJ Jr et al. Upper-airway stimulation for obstructive sleep apnea. N

Engl J Med. 2014 Jan.

2018

STAR TRIAL 60 MONTH

• 97/126 completed protocol

• 71 consented to a voluntary PSG

• Improvement in Epworth Sleepiness Scale &

QOL

- AHI < 20 events/hour and > 50% reduction

75%

• Events related to lead/device adjustments

6%

Hypoglossal Nerve Stimulator,

Anesthetic Considerations

• Thorough pre-operative

evaluation

• General anesthesia + ETT–No long-acting paralytic

• Airway management discussion

with surgical and anesthesia

teams

Transoral Robotic Surgery

(TORS) for benign disease of

the upper airway

TORS Consideration

Alternative: multilevel surgery

– Lateral pharyngoplasty

– Lingual tonsillectomy, robotic transoral

approach

Friedman grading for lingual tonsillar hypertrophy

Friedman M et al.A standardized lingual tonsil grading system. Otolaryngol Head Neck Surg. 2015 Apr.

Grade I Grade II

Grade III Grade IV

TORS - History

• 2006: O’Malley et al. introduced TORS for base of tongue

neoplasms

• 2011: Vicini et al. TORS for treatment of OSA

• 2015: Hoff et al. reviewed 293 TORSs for benign indications

– 77 complications (59 patients) within 3 months

– 12 bleeding events

– 14 dehydration

– 15 dysphagia

– 2 reintubation

2011

• Successful - 76.6%

• 50% reduction of pre-operative AHI

• Overall AHI <20 events per hour

• Bleeding - 4.2%

• Transient dysphagia - 7.2%

2017

• Significant improvement in the following:

- AHI

- Epworth Sleepiness Scale

- Lowest O2 saturation

- Snoring visual analog scale

• Surgical success rate - 68.4%

• Cure rate (postoperative AHI < 5) - 23.8%

BMI predicts success- 121 patients with AHI > 15

• AHI 42.7 22.2

• 84% improved AHI

• 51% had success (AHI < 20 and 50%

reduction)

• 14% had cure (AHI < 5)

– BMI < 30 – 69.4% success (p=0.004)

– BMI > 30 – 41.7% successHoff PT et al. 2014.

Friedman stage &

surgical success

• 118 patients TORS LT +/- other procedures

• Stratified by Friedman stage (palate position +

tonsil size)

Spector et al. 2016.

Friedman stage predicts success

• Stage I – 75%

• Stage II – 70%

• Stage III – 66%

• Stage IV - 10%

• 70% vs 51% success

for BMI < 30 or > 30

(p=0.04)

• Nasal intubation– High risk of difficult airway

• General Anesthesia– ≤ 30% FiO2

– TIVA with paralysis

– Multimodal analgesia

• Eye shields

• Rotate bed 90 degrees

• Lower incisor guard

• Davis-Meyer mouth gag– McIver if edentulous

• Instruments– 30 degree scope

– Maryland dissector

– Monopolar (15J)

TORS: Pearls

Airway Management

• Intraoperative dexamethasone

• Extubation in the OR

- Consider airway exchange catheter

• Monitor overnight

- CPAP if able

• Prolonged intubation / tracheostomy -

Rare

So Which Surgery?!?

2018

Upper Airway Stimulation vs TORS

• Upper Airway Stimulation

• 50 men and 26 women

• Surgical success – 87%

• Postoperative AHI < 15 - 89%

• Postoperative AHI < 5 – 59 %

• No readmissions

Upper Airway Stimulation vs TORS

• TORS

• 20 men and 4 women

• Surgical success – 54%

• Postoperative AHI < 15 – 50%

• Postoperative AHI < 5 – 21%

• Mean stay - 1.33 days

• 4 readmitted

Summary

• OSA is frequently encountered

• Numerous criteria for diagnosis and severity

• DISE aids in diagnosis & surgical planning

• New modalities demonstrating significant

potential

• Upper Airway Stimulation Hypoglossal

nerve stimulator

• Transoral Robotic Surgery

THE TEAM!!

THANK YOU

???????

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