Obstructive Sleep Apnea & UPPP Overview

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Questions and Answers

What is the primary characteristic of obstructive sleep apnea (OSA)?

Chronic upper airway obstruction during sleep (correct)

Increased appetite during the night

Intermittent coughing episodes while awake

Frequent daytime sleepiness

Which population has a higher rate of undiagnosed obstructive sleep apnea?

Children and adolescents

Elderly women

Women with moderate to severe OSA (correct)

Men with mild OSA

Which of the following factors contributes to increased perioperative risk in patients with obstructive sleep apnea?

Presence of a difficult airway only

Patient age over 65 years only

Severity of OSA and invasiveness of surgery (correct)

Type of anesthesia technique used

When managing anesthetic considerations in uvulopalatopharyngoplasty (UPPP), what must be closely monitored?

Airway obstruction and bleeding (A) Signup and view all the answers

What is a significant health risk associated with untreated obstructive sleep apnea?

Increased cardiovascular risk (C) Signup and view all the answers

Based on the presented information, identify the most relevant factor associated with increased perioperative risk in patients undergoing Uvulopalatopharyngoplasty (UPPP).

The severity of chronic hypoxia and hypercarbia (C) Signup and view all the answers

Which of the following statements accurately reflects the relationship between undiagnosed OSA and the reported prevalence rates?

The undiagnosed rate implies that the actual prevalence of OSA is significantly higher than the reported statistics. (C) Signup and view all the answers

If the given prevalence rates for OSA are accurate, what is the approximate ratio of men to women at risk for OSA?

3:1 (B) Signup and view all the answers

Which of the following is NOT a factor contributing to the pathophysiology of OSA?

Increased production of respiratory secretions (D) Signup and view all the answers

Which of these muscles is NOT directly responsible for maintaining the patency of the upper airway during wakefulness?

Trapezius (B) Signup and view all the answers

Which of these is NOT a characteristic of OSA?

Increased levels of luteinizing hormone (D) Signup and view all the answers

Which of the following segments of the upper airway is MOST prone to collapse during sleep due to its lack of bony support?

Hypopharynx (A) Signup and view all the answers

A patient presents with loud snoring, a BMI of 35 kg/m2, neck circumference of 17 inches, and is male. Based on these characteristics, which diagnostic test is MOST appropriate to confirm a diagnosis of OSA?

Polysomnography (C) Signup and view all the answers

Which of the following coexisting diseases associated with OSA can directly contribute to left ventricular failure due to systemic vasoconstriction?

Essential hypertension (D) Signup and view all the answers

A patient with OSA undergoing UPPP has a history of difficult intubation during previous anesthetic experiences. Which component of the preoperative evaluation would be MOST helpful in assessing this patient's current risk for difficult intubation?

Airway examination and laryngoscopy (B) Signup and view all the answers

Which of the following BEST explains why patients with OSA require a thorough preoperative evaluation prior to UPPP?

To identify and minimize potential perioperative complications (C) Signup and view all the answers

Which of the following OSA-related complications is NOT a direct consequence of hypoxemia and hypercapnia during sleep?

Cerebrovascular disease (CVD) (B) Signup and view all the answers

Which anesthetic agent is associated with a dose-dependent decrease in the genioglossal muscle and increased airway collapsibility?

Propofol (B) Signup and view all the answers

Following UPPP, what sleep stage rebounds after the third postoperative day, increasing the risk of life-threatening deep sleep-induced apnea in patients with OSA?

REM sleep (A) Signup and view all the answers

Which of the following BEST describes the effect of postoperative pain on sleep patterns in patients with OSA undergoing UPPP?

Postoperative pain can exacerbate OSA symptoms, increasing the risk of life-threatening apnea. (A) Signup and view all the answers

Which of the following postoperative complications, after UPPP, is MOST likely to occur within the first few days after surgery?

Hemorrhage (B) Signup and view all the answers

A patient with severe OSA undergoing UPPP is experiencing significant postoperative pain. Which of the following interventions would be MOST appropriate to manage their pain while minimizing the risk of opioid-induced airway obstruction?

Using nonsteroidal antiinflammatory agents (A) Signup and view all the answers

Which of the following is the LEAST likely reason for a patient with severe OSA to be admitted to the intensive care setting for up to 24 hours after UPPP?

To minimize the patient's discomfort and improve their sleep quality (B) Signup and view all the answers

Which of the following post-UPPP complications is NOT characteristic of a biphasic pattern of occurrence, meaning it may occur both immediately after surgery and several days later?

Laryngospasm (C) Signup and view all the answers

Which of the following techniques of airway topicalization can be used for nasal intubation?

2% lidocaine jelly in a 10-mL syringe injected into the nose (A), Neo-Synephrine spray and 4% lidocaine in a syringe or atomizer (D) Signup and view all the answers

Which of the following airway devices is NOT explicitly mentioned as part of the 'difficult airway cart' for awake fiber-optic intubation in the provided text?

Gum elastic bougie (D) Signup and view all the answers

Based on the provided text, which of these statements accurately describes the purpose of a Williams or Ovassapian airway during awake fiber-optic intubation for Uvulopalatopharyngoplasty?

To facilitate placement of the fiber-optic bronchoscope (A) Signup and view all the answers

According to the provided text, which of the following is NOT a critical step in preparing for awake fiber-optic intubation for Uvulopalatopharyngoplasty?

Ensuring the patient is adequately sedated before intubation (C) Signup and view all the answers

Which of the following techniques is described in the text as an alternative to injecting lidocaine onto the vocal cords via the side port of the fiber-optic scope during awake fiber-optic intubation for Uvulopalatopharyngoplasty?

Performing a transtracheal injection of local anesthetic (A) Signup and view all the answers

Study Notes

Obstructive Sleep Apnea (OSA)

OSA is recurrent upper airway obstruction during sleep, causing hypoxia and hypercarbia.
OSA increases risk of cardiovascular, neuropsychological, and endocrine problems, and reduced quality of life.
Significant underdiagnosis; up to 93% of women and 82% of men with moderate-severe OSA remain undiagnosed. Prevalence in the US is estimated at 2% for women and 4% for men. Surveys suggest a much higher potential risk, with 21% of women and 31% of men potentially at risk.
OSA increases perioperative risk due to difficult intubation, coexisting conditions, and life-threatening apnea. OSA patients are at increased risk of postoperative respiratory complications, including severe oxygen desaturation.
OSA is associated with significant morbidity, due to chronic, frequent upper airway obstruction during sleep leading to hypoxia and hypercarbia.
OSA is a syndrome with periodic, partial or complete upper airway obstruction during sleep, resulting in episodes of apnea-hypopnea, frequent arousals, oxygen desaturation, and daytime hypersomnolence.
Apnea is cessation of airflow for >10 seconds with effort to breathe. Hypopnea is abnormal respiration with at least 30% reduction in airflow or thoracoabdominal movement for ≥10 seconds and 4% oxygen desaturation.
Polysomnography diagnoses OSA, with severity based on the Apnea-Hypopnea Index (AHI). Higher arousal index, lower SaO2, and reduced slow-wave sleep are common in OSA patients.
Typical OSA patient profile: loud snorer, BMI ≥35 kg/m², age ~50, neck circumference ~17 inches, and male.
Pathophysiology is multifactorial, involving upper airway anatomy, motor control, ventilatory control, and arousal threshold.
Upper airway segments (nasopharynx, oropharynx, hypopharynx) vulnerable to collapse due to lack of bony support.
Pharyngeal dilator muscles (tensor palatini, genioglossus, hyoid) maintain airway patency during wakefulness. Muscle tone loss during sleep (NREM and REM) contributes to airway collapse.
Obesity contributes to OSA by increasing fat deposition (uvula, tonsils, tongue, etc.) obstructing the airway.
Poor upper airway motor control during sleep, muscle damage, further worsen obstruction.
Ventilation instability (increases/decreases in respiratory output) impacts pharyngeal dilator muscles and, alongside fat deposition, contributes to obstruction.
Apnea, hypoxemia, and hypercarbia trigger increased respiratory effort, neural stimulation, arousals, vocalization, extremity twitching, turning, gasping, or snorting.
Hyperventilation after obstruction can lower CO2, reducing respiratory drive and contributing to subsequent apnea.
Repeated obstruction-hypoxemia-hypercarbia cycles cause sleep fragmentation, sympathetic hyperactivity, inflammation (higher CRP and interleukin-6), endothelial dysfunction, and metabolic dysregulation, increasing cardiovascular, neuropsychological, and endocrine risks.
OSA affects cardiovascular (hypertension, left ventricular failure, arrhythmias, nocturnal angina, MI), cerebrovascular (CVD, stroke), pulmonary (pulmonary hypertension, right-sided heart failure), neuropsychological (daytime somnolence, impaired cognition, accidents, depression, anxiety), and endocrine (obesity, glucose intolerance, diabetes, decreased testosterone, growth hormone) systems.

Uvulopalatopharyngoplasty (UPPP)

Perioperative risk is determined by OSA severity, surgery invasiveness, and postoperative opioid needs.
Anesthetic management for UPPP involves identifying and managing potentially difficult airways.
Close monitoring is essential for airway obstruction and bleeding.
Careful titration of postoperative opioids is crucial.
Preoperative Period
- Preoperative evaluation is crucial, including history, physical exam (airway focus), STOP-BANG, review of systems for coexisting conditions, difficult intubation factors, prior anesthetic issues.
- Preoperative testing (ECG, stress test, chest X-ray, electrolytes, CBC, coagulation panel), sleep study review (or moderate OSA assumption if no study). CPAP settings and instructions. Inpatient/outpatient suitability, monitoring based on OSA severity, comorbidities, anesthetic type, opioid needs, age.
Perioperative Risk Prediction (using ASA Practice Guidelines for OSA)
- Severity of OSA (none = 0, mild = 1, moderate = 2, severe = 3; subtract 1 if CPAP pre/postop; add 11 if PaCO2 >50 mmHg)
- Invasiveness of surgery (superficial = 0, moderate sedation/general = 1, peripheral spinal/epidural =1, airway/major general = 2, 3)
- Postoperative opioid needs (none = 0, low dose oral = 1, high dose = 3)
- A + B + C = Overall risk score (0-6). Score of 4 = potentially increased risk; 5 or 6 = significantly increased risk.
- Examples (as provided).

Postoperative Complications of UPPP

Respiratory (1.1% to 11%): laryngospasm, postobstructive pulmonary edema, airway obstruction and oxygen desaturation, emergent tracheotomy, reintubation, pneumonia.
Hemorrhage (0.3% to 14%): immediate or several days later.
Hypertension (2% to 70%).
Cardiovascular (0.3%): arrhythmias, cardiac arrest, angina, MI, cerebrovascular accident, pulmonary embolism.

Postoperative Management of Severe OSA after UPPP

Anesthetic considerations: decreasing postoperative pain, ensuring adequate oxygenation, observing for airway obstruction, positioning patient laterally or semi-recumbent, CPAP resumption.
Severe OSA Patients: High risk for opioid-induced airway obstruction, requiring close monitoring in a recovery room, and ideally in an intensive care unit for at least 24 hours.
Pain Management: Nonsteroidal antiinflammatory drugs (opioid-sparing effect) should be considered.
Oxygenation: Supplemental oxygen and continuous pulse oximetry. Maintain baseline or 90% O2 saturation.
Positioning: Lateral or semi-recumbent.
CPAP: Restart CPAP postoperatively

Awake Fiber-Optic Intubation Procedure

Discuss need for awake fiber-optic intubation with patient and surgical team.
Obtain IV access and administer 0.2 mg glycopyrrolate IV.
Prepare difficult airway cart with fiber-optic bronchoscope, atomizer, nebulizer, nasal trumpets, viscous lidocaine/lubricant, Ovassapian and Williams airways, oxygen/suction, applicators, bag-valve mask, and additional intubation equipment.
Verify bronchoscope function, practice scope rotations.
Topicalize airway: 4% lidocaine atomizer/nebulizer, 5% lidocaine ointment, Neo-Synephrine spray/lidocaine for nasal intubation, and local anesthetic nerve blocks (glossopharyngeal and superior laryngeal).
Oral intubation with Williams/Ovassapian airway to keep scope midline, or pass ETT past the scope for nasal intubation.
Inject additional lidocaine onto vocal cords via scope side port or perform transtracheal injection to block recurrent laryngeal nerve.
Suction and oxygen as needed with scope.
Observe vocal cords (pull scope back if pink tissue seen). Jaw thrust or cricoid pressure for better visualization.
Pass scope through cords, advance avoiding carina. Slide ETT over scope; if resistance, rotate ETT 90° counterclockwise.
Confirm placement, induce general anesthesia.

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Description

This quiz covers the critical aspects of Obstructive Sleep Apnea (OSA) and the perioperative management of Uvulopalatopharyngoplasty (UPPP). It highlights the risks associated with OSA, including underdiagnosis rates and complications during surgery. Test your knowledge on the implications of OSA in surgical settings and the importance of anesthetic management.