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Perioperative Management of Obstructive Sleep Apnea And AMERICAN THORACIC SOCIETY DOCUMENTS Knowledge Gaps in the Perioperative Management of Adults with Obstructive Sleep Apnea and Obesity Hypoventilation Syndrome An Official American Thoracic Society Workshop Report Najib T. Ayas, Cheryl R. Laratta, John M. Coleman, Anthony G. Doufas, Matthias Eikermann, Peter C. Gay, Daniel J. Gottlieb, Indira Gurubhagavatula, David R. Hillman, Roop Kaw, Atul Malhotra, Babak Mokhlesi, Timothy I. Morgenthaler, Sairam Parthasarathy, Satya Krishna Ramachandran, Kingman P. Strohl, Patrick J. Strollo, Michael J. Twery, Phyllis C. Zee, and Frances F. Chung; on behalf of the ATS Assembly on Sleep and Respiratory Neurobiology THIS OFFICIAL WORKSHOP REPORT OF THE AMERICAN THORACIC SOCIETY WAS APPROVED OCTOBER 2017. This official American Thoracic Society Workshop Report was endorsed by the Canadian Sleep Society November 2017 and by the Canadian Thoracic Society December 2017. Abstract OHS in the perioperative setting to achieve these objectives. Patients who are at greatest risk of respiratory or cardiac complications related The purpose of this workshop was to identify knowledge gaps in the to OSA and OHS are not well defined, and the effectiveness of perioperative management of obstructive sleep apnea (OSA) and monitoring and other interventions remains to be determined. obesity hypoventilation syndrome (OHS). A single-day meeting was Centers involved in sleep research need to develop collaborative held at the American Thoracic Society Conference in May, 2016, with networks to allow multicenter studies to address the knowledge gaps representation from many specialties, including anesthesiology, identified below. perioperative medicine, sleep, and respiratory medicine. Further research is urgently needed as we look to improve health outcomes for Keywords: obstructive sleep apnea; perioperative care; obesity these patients and reduce health care costs. There is currently hypoventilation syndrome; risk assessment; postoperative insufficient evidence to guide screening and optimization of OSA and complications Ann Am Thorac Soc Vol 15, No 2, pp 117–126, Feb 2018 Copyright © 2018 by the American Thoracic Society DOI: 10.1513/AnnalsATS.201711-888WS Internet address: www.atsjournals.org Contents Methods of Obstructive Sleep Apnea Committee Composition and Obesity Hypoventilation Overview Workshop Structure and Syndrome Key Knowledge Gap Literature Review Perioperative Use of Positive 1. How can we identify patients Document Development Airway Pressure with obstructive sleep apnea or Perioperative Outcomes of Obesity Hypoventilation obesity hypoventilation Patients with Sleep- Syndrome in the syndrome at highest risk of disordered Breathing Perioperative postoperative cardiopulmonary Screening for Obstructive Sleep Period complications? Apnea in Surgical Patients Opioids and the Surgical Patient 2. How do we prevent Obstructive Sleep Apnea with Obstructive Sleep Apnea postoperative cardiopulmonary Endotypes and Potential The Use of Administrative complications in patients with Relevance in the Databases and Patient obstructive sleep apnea or Perioperative Registries obesity hypoventilation Period Patient Safety and Healthcare syndrome? Role of Algorithms in the Management Considerations Introduction Perioperative Management Conclusions American Thoracic Society Documents 117 AMERICAN THORACIC SOCIETY DOCUMENTS Overview postoperative cardiopulmonary iv. Are there nonopioid analgesic complications? strategies (e.g., nonsteroidal A. Can we risk stratify patients for antiinflammatories, peripheral/ Perioperative management of sleep- perioperative complications related to epidural use of local anesthetics) disordered breathing, such as obstructive or novel strategies (e.g., respiratory sleep apnea (OSA) and obesity OSA or OHS? stimulants) that can be employed hypoventilation syndrome (OHS), is an area B. Is there any safe threshold of in patients with OSA or OHS to of patient care that requires improvement opioid therapy in patients fi mitigate risk? due to the risk of morbidity and mortality identi ed as high risk of having v. Are there patient (or family) from sleep-disordered breathing in the OSA or OHS? educational tools and interventions perioperative period (1). Adverse C. What clinical or physiologic markers that can be employed to improve perioperative outcomes of patients with (serum bicarbonate, troponin levels, fl patient outcomes? OSA or OHS include anoxic brain injury preoperative in ammatory markers, B. Key questions related to monitoring in or death in rare circumstances (2), and may etc.) predict opioid sensitivity or the perioperative setting include: be preventable. During the development postoperative cardiopulmonary i. How do we risk stratify patients of the Society of Anesthesia and Sleep complications? with OSA to identify patients who Medicine (SASM) Guidelines on D. Do particular physiologic endotypes of may not require monitoring (low Preoperative Screening and Assessment of OSA predict opioid sensitivity or risk of postoperative Adult Patients with Obstructive Sleep postoperative cardiopulmonary complications)? Apnea, hereafter referred to as the SASM complications? ii. What duration and components of guidelines, it became clear that further E. Can assessments in postanesthesia care monitoring are critical to mitigate research was necessary to improve the unit (PACU) provide additional value risk? quality and strength of the clinical in reducing adverse outcomes upon iii. Once optimized detection and recommendations. Further research on discharge? alarm thresholds are determined, OSA and OHS in the perioperative F. Are polysomnography (PSG) or how do we train our workforce setting is urgently needed as we look to ambulatory studies useful in risk and use our electronic health improve health outcomes for these stratifying patients before surgery? That records to optimize outcomes and patients, and reduce health care costs that is, do these tests help to predict which resource utilization? arise from postoperative monitoring, patients may be at increased risk after cardiopulmonary complications, increased surgery and help to direct length of stay (LOS) in intensive care, and management? increased LOS in hospital. There is little 2. How do we prevent postoperative Introduction evidence to guide screening and treatment cardiopulmonary complications in patients of sleep-disordered breathing in the with obstructive sleep apnea or obesity TheprevalenceofOSAis10%–20% in adult perioperative setting to achieve these hypoventilation syndrome? surgical patients (3, 4) and up to 70% before objectives. Patients who are at greatest risk A. Key questions related to positive airway bariatric surgery (5). Postoperatively, there of respiratory or cardiac complications pressure therapy in the perioperative are physiologic changes in sleep architecture related to OSA or OHS are not well defined, setting include: and an increase in the apnea–hypopnea index and the effectiveness of monitoring and i. Does it confer benefits beyond (AHI) in both patients with and without OSA other interventions remains to be those of enhanced monitoring (6). The most severe arterial oxygen determined. Centers involved in sleep strategies? desaturations and highest AHI occur on research need to develop collaborative ii. When does continuous positive Night 3 postoperatively, and have been networks to allow multicenter studies to airway pressure (CPAP) attributed in part to a gradual increase in address the research questions identified administration reduce risks: is rapid eye movement sleep and a reduction in below. postoperative administration the use of supplemental oxygen after the sufficient, or is preoperative initial postoperative night (6). Numerous Key Knowledge Gaps initiation of CPAP needed, and, if variables influence sleep-disordered breathing so, for how long preoperatively? in the perioperative period, including the 1. How can we identify patients with iii. Which ventilatory strategies would be anesthetic, upper airway injury after obstructive sleep apnea or obesity most effective in treating intubation, fluid shifts, pain medications, and hypoventilation syndrome at highest risk of postoperative OSA? the administration of oxygen. ORCID IDs: 0000-0003-0259-7464 (N.T.A.); 0000-0002-7656-0173 (C.R.L.); 0000-0003-1268-0106 (M.E.); 0000-0002-9391-2011 (P.C.G.); 0000-0001-7712-7729 (R.K.); 0000-0001-9664-4182 (A.M.); 0000-0001-8135-5433 (B.M.); 0000-0002-2614-3793 (T.I.M.); 0000-0002-1128-3005 (S.P.); 0000-0002-7176-6375 (S.K.R.); 0000-0001-7740-9013 (K.P.S.); 0000-0002-2065-9641 (P.J.S.); 0000-0001-6296-6685 (P.C.Z.); 0000-0001-9576-3606 (F.F.C.). Correspondence and requests for reprints should be addressed to Najib T. Ayas, M.D., M.P.H., Leon Judah Blackmore Centre for Sleep Disorders UBC Hospital, Purdy Pavillion Room G34A, 2211 Wesbrook Mall Vancouver, BC, V6T 2B5 Canada. E-mail: [email protected]. 118 AnnalsATS Volume 15 Number 2| February 2018 AMERICAN THORACIC SOCIETY DOCUMENTS Moderate-quality evidence patients. During the planning of this discussion within each topic were performed predominantly from large cohort studies workshop, which was originally organized independently by each presenter. After a suggests that patients with OSA have a two- to discuss primarily OSA, it was identified short presentation, the presenter and Chairs to three-times increased risk of that a particularly high-risk group in the facilitated a discussion with all workshop cardiopulmonary complications after perioperative period are
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