Risks of general anaesthesia in people with obstructive sleep apnoea
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《英国医生杂志》
1 Department of Otolaryngology/Head and Neck Surgery, St Lucas Andreas Hospital, Jan Tooropstraat 164, 1006 AE, Amsterdam, Netherlands, 2 Department of Anaesthesiology, St Lucas Andreas Hospital, 3 Department of Anaesthesiology and Operative Intensive Care Medicine, University Hospital Mannheim, University of Heidelberg Theodor-Kutzer-Ufer, D-68167, Mannheim, Germany
Correspondence to: C den Herder c.denherder@slaz.nl
Introduction
To write this review, we consulted the Cochrane Library and did a thorough Medline search. We read the full text of relevant papers found by using the keywords "obstructive sleep apnoea," "airway management," and "general anaesthesia."
Summary points
Patients with obstructive sleep apnoea are at high risk of developing complications when having surgery or other invasive interventions under general anaesthesia, whether or not the surgery is related to obstructive sleep apnoea
Surgeons of all specialties, and especially anaesthetists, should be aware that undiagnosed obstructive sleep apnoea is common
They should be alert to patients who are at risk of having obstructive sleep apnoea and be aware of the potential preoperative and postoperative complications in such patients
Management options include alternative methods of pain relief, use of nasal continuous airway pressure before and after surgery, and surveillance in an intensive care unit, especially after nasal surgery in which packs are used
An algorithm for management of difficult airways should be established
Preoperative aspects
Premedication
Preoperative sedation with benzodiazepines 45 minutes before the induction of general anaesthesia has anticonvulsive and muscle relaxing effects on the upper airway musculature, causing an appreciable reduction of the pharyngeal space. Consequently, a higher risk of preoperative phases of hypopnoea and consecutive hypoxia and hypercapnia arises after administration, and oxygen saturation needs to be monitored adequately.15 w12 An effective anxiolytic agent will reduce the dose of anaesthetic needed to induce general anaesthesia, which may otherwise lead to an increased likelihood of cardiovascular complications. If needed, oxygen can be given by an insufflation mask preoperatively, and application of nasal continuous positive airway pressure might be necessary postoperatively.w2
Intubation technique
The main goal in all patients is to avoid inadequate ventilation and oxygenation resulting in hypoxaemia or hypercapnia and any associated haemodynamic changes (such as tachycardia, arrhythmia, and hypertension) leading to increased morbidity and mortality. Death, brain injury, cardiopulmonary arrest, airway trauma, and damage to teeth are among the adverse events associated with difficult airway management. A difficult airway is defined as the clinical situation in which a conventionally trained anaesthetist experiences difficulties with ventilation of the upper airway by facemask, difficulty with tracheal intubation, or both. The purpose of the American Society of Anesthesiologists' guidelines is to reduce the likelihood of adverse outcomes by providing basic recommendations.w13 Components of the preoperative physical examination of the airway are shown in the table.
Components of preoperative physical examination of airway that may indicate difficult intubationw13
The equipment for management of a difficult airway should be in place before induction of general anaesthesia. Orotracheal tubes in various sizes, as well as a McCoy laryngoscope and a fastrach laryngeal mask, are necessary. Fibreoptic devices may be helpful but have no impact in acute emergency situations. A strategy or algorithm for establishing a secure airway should be defined (fig 2).
Fig 2 Algorithm for management of difficult airways
Oxygen must be administered for three or more minutes before intubation and, whenever possible, during the process of establishing a secure airway and also after extubation. Endoscopically guided intubation with use of a "laryngeal airway mask" is an alternative, as is the use of a rigid ventilation-bronchoscope or an oesophageal-tracheal combitube. Patients with extreme anatomical anomalies should be intubated in alert condition with optimal local anaesthesia.w14 In the case of a ventilation emergency, surgical tracheostomy or needle cricothyrotomy should be considered early.16 Close cooperation with the ear, nose, and throat surgeon can be of value not only in these critical incidents but also in the preoperative and perioperative management of all patients with obstructive sleep apnoea.
Postoperative aspects
Patients with obstructive sleep apnoea are at high risk of developing postoperative complications when having surgery or other invasive interventions under general anaesthesia. This holds true for both surgery related to obstructive sleep apnoea and unrelated surgery. Surgeons of all specialties, as well as anaesthetists, should be aware of the fact that undiagnosed obstructive sleep apnoea is common. They should be alert to patients who are at risk of having obstructive sleep apnoea and should be aware of the potential preoperative and postoperative complications in such patients having surgery. In the case of a medical history suggestive of obstructive sleep apnoea, particularly in obese patients with a short bulky neck and a large tongue, full night polysomnography should ideally be done before surgery takes place. Options that should be considered include alternative methods of pain relief, use of nasal continuous positive airway pressure before and after surgery, and surveillance in an intensive care unit, especially after nasal surgery in which packs are used. An elaborated algorithm for management of difficult airways should be established.
Information for patients
Respironics (www.sleepapnea.com)—gives useful information about symptoms of obstructive sleep apnoea
Anesthesia and the apnea patient (www.healthyresources.com/sleep/apnea/contrib/anesthes.html)—explains some important considerations for patients with obstructive sleep apnoea having surgical or medical procedures involving anaesthesia
eMedicine (www.emedicine.com/ent/topic370.htm)—an article about snoring, obstructive sleep apnoea, and surgery
Extra references are on bmj.com
Contributors: NdV and CdH were responsible for the idea and design of the study. CdH had overall responsibility for the data collection and drafted the manuscript. All authors contributed to interpretation of the data and revising the paper.
Funding: None.
Competing interests: None declared.
References
Strohl KP, Cherniack NS, Gothe B. Physiologic basis of therapy for sleep apnea. Am Rev Respir Dis 1986;134: 791-802.
Gleadhill IC, Schwartz AR, Schubert N, Wise RA, Permutt S, Smith PL. Upper airway collapsibility in snorers and in patients with obstructive hypopnea and apnea. Am Rev Respir Dis 1991;143: 1300-3.
Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep disordered breathing among middle-aged adults. N Engl J Med 1993;328: 1230-5.
Young T, Evans L, Finn L, Palta M. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep 1997;20: 705-6.
Loadsman JA, Hillman DR. Anaesthesia and sleep apnoea. Br J Anaesth 2001;86: 254-66.
Gupta RM, Parvizi J, Hanssen AD, Gay PC. Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: a case-control study. Mayo Clin Proc 2001;76: 897-905.
Chung F, Imarengiaye C. Management of sleep apnea in adults. Can J Anaesth 2002;49: R1-6.
Chung F, Crago RR. Sleep apnea syndrome and anaesthesia. Can Anaest Soc J 1982;29: 439-45.
Reimer MA, Flemons WW. Quality of life in sleep disorders. Sleep Med Rev 2003;7: 335-49.
Barthel SW, Strome M. Snoring, obstructive sleep apnea and surgery. Med Clin North Am 1999;83: 85-96.
Shahar E, Witney CW, Redline S, Lee ET, Newman AB, Javier Nieto F, et al. Sleep-disordered breathing and cardiovascular disease. Am J Respir Crit Care Med 2001;163: 19-25.
Verin E, Tardif C, Buffet X, Marie JP, Lacoume Y, Andrieu-Guitrancourt J, et al. Comparison between anatomy and resistance of upper airway in normal subjects, snorers and OSAS patients. Respir Physiol 2002;129: 335-43.
Hoekema A, Hovinga B, Stegenga B, De Bont LG. Craniofacial morphology and obstructive sleep apnea: a cephalometric analysis. J Oral Rehabil 2003;30: 690-6.
Mallampati SR, Gatt SP, Gugino LD, Desai SP, Waraksa B, Freiberger D, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 1985;32: 429-34.
Connolly LA. Anaesthetic management of obstructive sleep apnea patients. J Clin Anesth 1991;3: 461-9.
Rafferty TD, Ruskins A, Sasaki C, Gee JB. Perioperative considerations in the management of tracheotomy for the obstructive sleep apnoea patient: three illustrative case reports. Br J Anaesth 1980;52: 619-22.
Sheppard LM, Werkhaven J, Mickelson S, Crissman JD, Peterson E, Jacobsen G. Effect of steroids or tissue pre-cooling on oedema and tissue thermal coagulation after CO2 laser impact. Laser Surg Med 1992;12: 137-46.
Ostermeier AM, Roizen MF, Hautkappe M, Klock PA, Klafta JM. et al. Three sudden postoperative respiratory arrests associated with epidural opioids in patients with sleep apnea. Anesth Analg 1997;85: 452-60.
Knill RL, Moote CA, Skinner MI, Rose EA. Anesthesia with abdominal surgery lead to intense REM sleep during the first postoperative week. Anesthesiology 1990;73: 52-61.
Burgess LP, Derderian SS, Morin GV, Gonzalez C, Zajtchuk JT. Postoperative risk following uvulopalatopharyngeoplasty for obstructive sleep apnea. Otolaryngol Head Neck Surg 1992;106: 81-6.
McColley SA, April MM, Carroll JL, Naclerio RM, Loughlin GM. Respiratory compromise after adenotonsillectomy in children with obstructive sleep apnea. Arch Otolaryngol Head Neck Surg 1992;118: 940-3.
Kravath RE, Pollak CP, Borowiecki B, Weitzman ED. Obstructive sleep apnea and death associated with surgical correction of velopharyngeal incompetence. J Pediatr 1980,96: 645-8.
Valnicek SM, Zuker RM, Halpern LM, Roy WL. Perioperative complications of superior pharyngeal flap surgery in children. Plast Reconstr Surg 1994;93: 954-8.
Nunn JF. The sleep apnea syndrome. In: Nunn's applied respiratory physiology. 4th ed. Oxford: Butterworth Heinemann, 1993: 333-7.
Verse T, Maurer JT, Pirsig W. Effect of nasal surgery on sleep-related breathing disorders. Laryngoscope 2002;112: 64-8.(Cindy den Herder, residen)
Correspondence to: C den Herder c.denherder@slaz.nl
Introduction
To write this review, we consulted the Cochrane Library and did a thorough Medline search. We read the full text of relevant papers found by using the keywords "obstructive sleep apnoea," "airway management," and "general anaesthesia."
Summary points
Patients with obstructive sleep apnoea are at high risk of developing complications when having surgery or other invasive interventions under general anaesthesia, whether or not the surgery is related to obstructive sleep apnoea
Surgeons of all specialties, and especially anaesthetists, should be aware that undiagnosed obstructive sleep apnoea is common
They should be alert to patients who are at risk of having obstructive sleep apnoea and be aware of the potential preoperative and postoperative complications in such patients
Management options include alternative methods of pain relief, use of nasal continuous airway pressure before and after surgery, and surveillance in an intensive care unit, especially after nasal surgery in which packs are used
An algorithm for management of difficult airways should be established
Preoperative aspects
Premedication
Preoperative sedation with benzodiazepines 45 minutes before the induction of general anaesthesia has anticonvulsive and muscle relaxing effects on the upper airway musculature, causing an appreciable reduction of the pharyngeal space. Consequently, a higher risk of preoperative phases of hypopnoea and consecutive hypoxia and hypercapnia arises after administration, and oxygen saturation needs to be monitored adequately.15 w12 An effective anxiolytic agent will reduce the dose of anaesthetic needed to induce general anaesthesia, which may otherwise lead to an increased likelihood of cardiovascular complications. If needed, oxygen can be given by an insufflation mask preoperatively, and application of nasal continuous positive airway pressure might be necessary postoperatively.w2
Intubation technique
The main goal in all patients is to avoid inadequate ventilation and oxygenation resulting in hypoxaemia or hypercapnia and any associated haemodynamic changes (such as tachycardia, arrhythmia, and hypertension) leading to increased morbidity and mortality. Death, brain injury, cardiopulmonary arrest, airway trauma, and damage to teeth are among the adverse events associated with difficult airway management. A difficult airway is defined as the clinical situation in which a conventionally trained anaesthetist experiences difficulties with ventilation of the upper airway by facemask, difficulty with tracheal intubation, or both. The purpose of the American Society of Anesthesiologists' guidelines is to reduce the likelihood of adverse outcomes by providing basic recommendations.w13 Components of the preoperative physical examination of the airway are shown in the table.
Components of preoperative physical examination of airway that may indicate difficult intubationw13
The equipment for management of a difficult airway should be in place before induction of general anaesthesia. Orotracheal tubes in various sizes, as well as a McCoy laryngoscope and a fastrach laryngeal mask, are necessary. Fibreoptic devices may be helpful but have no impact in acute emergency situations. A strategy or algorithm for establishing a secure airway should be defined (fig 2).
Fig 2 Algorithm for management of difficult airways
Oxygen must be administered for three or more minutes before intubation and, whenever possible, during the process of establishing a secure airway and also after extubation. Endoscopically guided intubation with use of a "laryngeal airway mask" is an alternative, as is the use of a rigid ventilation-bronchoscope or an oesophageal-tracheal combitube. Patients with extreme anatomical anomalies should be intubated in alert condition with optimal local anaesthesia.w14 In the case of a ventilation emergency, surgical tracheostomy or needle cricothyrotomy should be considered early.16 Close cooperation with the ear, nose, and throat surgeon can be of value not only in these critical incidents but also in the preoperative and perioperative management of all patients with obstructive sleep apnoea.
Postoperative aspects
Patients with obstructive sleep apnoea are at high risk of developing postoperative complications when having surgery or other invasive interventions under general anaesthesia. This holds true for both surgery related to obstructive sleep apnoea and unrelated surgery. Surgeons of all specialties, as well as anaesthetists, should be aware of the fact that undiagnosed obstructive sleep apnoea is common. They should be alert to patients who are at risk of having obstructive sleep apnoea and should be aware of the potential preoperative and postoperative complications in such patients having surgery. In the case of a medical history suggestive of obstructive sleep apnoea, particularly in obese patients with a short bulky neck and a large tongue, full night polysomnography should ideally be done before surgery takes place. Options that should be considered include alternative methods of pain relief, use of nasal continuous positive airway pressure before and after surgery, and surveillance in an intensive care unit, especially after nasal surgery in which packs are used. An elaborated algorithm for management of difficult airways should be established.
Information for patients
Respironics (www.sleepapnea.com)—gives useful information about symptoms of obstructive sleep apnoea
Anesthesia and the apnea patient (www.healthyresources.com/sleep/apnea/contrib/anesthes.html)—explains some important considerations for patients with obstructive sleep apnoea having surgical or medical procedures involving anaesthesia
eMedicine (www.emedicine.com/ent/topic370.htm)—an article about snoring, obstructive sleep apnoea, and surgery
Extra references are on bmj.com
Contributors: NdV and CdH were responsible for the idea and design of the study. CdH had overall responsibility for the data collection and drafted the manuscript. All authors contributed to interpretation of the data and revising the paper.
Funding: None.
Competing interests: None declared.
References
Strohl KP, Cherniack NS, Gothe B. Physiologic basis of therapy for sleep apnea. Am Rev Respir Dis 1986;134: 791-802.
Gleadhill IC, Schwartz AR, Schubert N, Wise RA, Permutt S, Smith PL. Upper airway collapsibility in snorers and in patients with obstructive hypopnea and apnea. Am Rev Respir Dis 1991;143: 1300-3.
Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep disordered breathing among middle-aged adults. N Engl J Med 1993;328: 1230-5.
Young T, Evans L, Finn L, Palta M. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep 1997;20: 705-6.
Loadsman JA, Hillman DR. Anaesthesia and sleep apnoea. Br J Anaesth 2001;86: 254-66.
Gupta RM, Parvizi J, Hanssen AD, Gay PC. Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: a case-control study. Mayo Clin Proc 2001;76: 897-905.
Chung F, Imarengiaye C. Management of sleep apnea in adults. Can J Anaesth 2002;49: R1-6.
Chung F, Crago RR. Sleep apnea syndrome and anaesthesia. Can Anaest Soc J 1982;29: 439-45.
Reimer MA, Flemons WW. Quality of life in sleep disorders. Sleep Med Rev 2003;7: 335-49.
Barthel SW, Strome M. Snoring, obstructive sleep apnea and surgery. Med Clin North Am 1999;83: 85-96.
Shahar E, Witney CW, Redline S, Lee ET, Newman AB, Javier Nieto F, et al. Sleep-disordered breathing and cardiovascular disease. Am J Respir Crit Care Med 2001;163: 19-25.
Verin E, Tardif C, Buffet X, Marie JP, Lacoume Y, Andrieu-Guitrancourt J, et al. Comparison between anatomy and resistance of upper airway in normal subjects, snorers and OSAS patients. Respir Physiol 2002;129: 335-43.
Hoekema A, Hovinga B, Stegenga B, De Bont LG. Craniofacial morphology and obstructive sleep apnea: a cephalometric analysis. J Oral Rehabil 2003;30: 690-6.
Mallampati SR, Gatt SP, Gugino LD, Desai SP, Waraksa B, Freiberger D, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 1985;32: 429-34.
Connolly LA. Anaesthetic management of obstructive sleep apnea patients. J Clin Anesth 1991;3: 461-9.
Rafferty TD, Ruskins A, Sasaki C, Gee JB. Perioperative considerations in the management of tracheotomy for the obstructive sleep apnoea patient: three illustrative case reports. Br J Anaesth 1980;52: 619-22.
Sheppard LM, Werkhaven J, Mickelson S, Crissman JD, Peterson E, Jacobsen G. Effect of steroids or tissue pre-cooling on oedema and tissue thermal coagulation after CO2 laser impact. Laser Surg Med 1992;12: 137-46.
Ostermeier AM, Roizen MF, Hautkappe M, Klock PA, Klafta JM. et al. Three sudden postoperative respiratory arrests associated with epidural opioids in patients with sleep apnea. Anesth Analg 1997;85: 452-60.
Knill RL, Moote CA, Skinner MI, Rose EA. Anesthesia with abdominal surgery lead to intense REM sleep during the first postoperative week. Anesthesiology 1990;73: 52-61.
Burgess LP, Derderian SS, Morin GV, Gonzalez C, Zajtchuk JT. Postoperative risk following uvulopalatopharyngeoplasty for obstructive sleep apnea. Otolaryngol Head Neck Surg 1992;106: 81-6.
McColley SA, April MM, Carroll JL, Naclerio RM, Loughlin GM. Respiratory compromise after adenotonsillectomy in children with obstructive sleep apnea. Arch Otolaryngol Head Neck Surg 1992;118: 940-3.
Kravath RE, Pollak CP, Borowiecki B, Weitzman ED. Obstructive sleep apnea and death associated with surgical correction of velopharyngeal incompetence. J Pediatr 1980,96: 645-8.
Valnicek SM, Zuker RM, Halpern LM, Roy WL. Perioperative complications of superior pharyngeal flap surgery in children. Plast Reconstr Surg 1994;93: 954-8.
Nunn JF. The sleep apnea syndrome. In: Nunn's applied respiratory physiology. 4th ed. Oxford: Butterworth Heinemann, 1993: 333-7.
Verse T, Maurer JT, Pirsig W. Effect of nasal surgery on sleep-related breathing disorders. Laryngoscope 2002;112: 64-8.(Cindy den Herder, residen)