Dr. Shais S. Jallu
Dr M.J. Mador
Obstructive sleep apnea:
 Cardinal features include:
 Perturbations of a regular respiratory pattern during
sleep including obstructive apneas, hypopneas or
respiratory effort related arousals.
 Daytime symptoms attributable to disrupted sleep
including: fatigue, sleepiness or poor concentration.
 Signs of disturbed sleep including snoring or
restlessness.
Obstructive sleep apnea:
 Risk factors include obesity, craniofacial or upper
airway soft tissue abnormalities, nasal congestion and
current smokers.
 Prevalence
 Elevetated AHI -27-35%in men and 9-12% in women
 OSA - 3-7% in men and 2-5% in women
 Age
 African-Americans
Obstructive sleep apnea:
Polysomnogram is the gold-standard diagnostic
test:
 Apneas — Apnea is airflow less than 20 percent of baseline for at




least ten seconds in adults
Hypopneas —decrease (>50 percent) in the amplitude of breathing
during sleep which lasts at least ten seconds,
Apnea-Hypopnea Index
RERAs
RDI
 OSA categories:



Mild- AHI 5-15
Moderate-15.1-30
Severe->30
Obstructive sleep apnea:
 Treatment:
 Conservative measures-weight reduction,
avoidance of alcohol, BZDs or opioids
 CPAP
 Oral appliances
 Surgery-UPPP, genioglossus advancement
 Drug therapy-Modafinil
 Use of CPAP can reduce the rate of complications in OSA
patients:
 Improves upper airway patency and ventilation
 Reduces myocardial ischemia and cardiac
arrhythmias, stabilizes fluctuations in BP
Sedation & OSA:
 Patients with OSA suffer from anatomical abnormalities
including short, thick neck, excessive tissue on pharyngeal
wall, craniofacial abnormalities.
 Sedatives and opioids:
 Decrease pharyngeal tone & increase
resistancepharyngeal collapse
 CNS depressantsdepression of RAS
 Respiratory depression
 Patients with OSA appear to be more sensitive to sedation
than others
Introduction:
 No established guidelines for sleep apnea patients
receiving conscious sedation in the endoscopy suite.
 Several studies have suggested increased risk for
perioperative cardiorespiratory complications in OSA
patients.
 Can these results be extrapolated to the endoscopy suite
where moderate sedation and no postoperative
analgesia is used?
Study Design:
 Retrospective; chart review type.
 Performed at VAMC, buffalo.
 VAMC records and any scanned non-VA records.
 VAMC patients who had any type of endoscopic procedure
were linked with patients who had sleep study.
 Data collected about:
 Baseline Characteristics
 Sleep study results
 Endoscopy procedure
 Minor and major complications during the procedure
Inclusion Criteria:
 Patients who had any type of endoscopic procedure
including:



Colonoscopy
EGD
Combined procedure (including EUS)
 performed in the GI suite.
 under conscious sedation.
 from 2002 to 2008.
 Linked with patients who had sleep studies:
 from 2001 to 2008.
 In the VAMC sleep lab or outside VAMC if report was
scanned.
Exclusion Criteria:
 PEG tube placement procedures
 Bronchoscopy procedures
 Sigmoidoscopy procedures
 Patient who had procedure-related complications.
 Patients who had the procedure done in the ICU
 Patient with missing data regarding the procedure
report, sleep study report or both
 Complicated endoscopic procedures where more
intense anesthesia was used
Baseline Characteristics:
 Age
 Sex
 Race
 BMI (body mass index)
 Smoking history
 PFTs
 LVEF%
 Charlson co-morbidity index
Charlson co-morbidity index:
Sleep study results:
 patients were divided into two main groups:
 negative sleep study (apnea hypopnea index AHI <
5/hr)
 positive sleep study (apnea hypopnea index AHI >
5/hr)
 positive group was also divided into 3 subgroups:



mild OSA (AHI 5-15/hr)
moderate OSA (AHI 15.1-30/hr)
severe OSA (AHI > 30/hr)
Endoscopy procedure:
 Type
 Indication
 Amount of sedation
 Inpatient vs Outpatient
 Baseline vital signs right before the procedure
 Presence or absence of home oxygen
 CPAP usage before or during the procedure
 Minor and major complications were identified
Minor complications:
Defined based on two definitions:
1) Patients who had vital signs within normal range
before the procedure :
 hypertension (SBP >160)
 hypotension (SBP<90)
 bradycardia (HR<55)
 tachycardia (>100)
 desaturation (< 90%)
 hypoventilation (RR < 8)
with no associated pain.
2) Patients who had abnormal vital signs:

25% change or above from the baseline vital signs.
Major complications:
 Chest pain/MI.
 Arrhythmias (like 3rd degree heart block)
 Hypotension requiring fluid resuscitation
 Respiratory distress
 Cardio- respiratory arrest
 Any minor complication that required intervention including:
 IV fluids
 atropine
 epinephrine
 reversal agent
 up-titration of oxygen
 use of CPAP machine
 intubation
 transfer to ICU
 prolonged observation after the procedure
 unplanned admission
Results:
 818 patients had both endoscopic procedures and
sleep studies.
 179 were excluded.
 130 patients had documented negative sleep study in
the last 5 years, while 509 had positive ones.
 135 had mild OSA, 125 had moderate OSA and 249 had
severe sleep apnea.
Results…
 Majority of procedures were done in the outpatient setting (96%).
 Type of Procedure:
 438 colonoscopy procedures (68.5%),
 12 9 EGD procedures (20.1 %)
 72 combined procedures (including EUS, combined EGD and Colonoscopy)
(11.4%).
 38% of the procedures were done for screening purposes while the rest were
diagnostic.




Sedation:
Both Versed and Fentanyl were used in almost all the procedures.
the median amount of versed and fentanyl was 4 mg, 87.5 mg respectively.
The amount of sedation was distributed equally with no significant difference
among the groups.
 20 % of patients had minor complications, while 7.3 % had major
complications.
 Only one case that had severe sleep apnea, had respiratory arrest that required
transfer to ICU.
Discussion:
 Studies have shown that benzodiazepines and opioids
have detrimental effect on sleep apnea
 Various studies have documented increased
perioperative risk of cardiopulmonary complications in
sleep apnea patients receiving general anesthesia
 Mechanisms include:
 Effect on ventilatory control and upper airway tone
 Depression of RAS
 Sleep deprivation and fragmentation postoperatively
causing rebound increase in REM sleep
 Postoperative analgesia
Discussion:
 Gupta et al (2001) assessed risk of post-op
complications in patients with OSA undergoing hip or
knee replacement and found that sleep apnea patients
had higher rate of adverse postoperative outcome.
 Hwang et al (2008) recorded home nocturnal oximetry
on patients with clinical features of OSA and found
that ODI 4% > 5 was associated with increased rate of
postoperative complications.
Discussion:
 conscious sedation is different from general anesthesia
in terms of:
 Short acting agents
 No postoperative analgesia
 Short procedures
 No mechanical ventilation
 Literature concerning sleep apnea patients receiving
conscious sedation in the endoscopy suite is
inadequate.
Discussion:
 Sharma et al (2003) conducted a prospective study
which concluded that OSA was detected in a majority
of previously undiagnosed patients undergoing
outpatient procedures (bronchoscopy and colonoscopy)
under conscious sedation.
 Khiani et al (2008) conducted a prospective study on
233 patients stratifying them into low & high risk for
OSA (using Berlin Questionnaire):
 Patients underwent either EGD or colonoscopy under
conscious sedation
 Sedation related transient hypoxia was compared between
the 2 groups with no resultant difference.
Discussion:
 Our data was analyzed in two different ways :
 comparing patients with positive and negative sleep study.
 merging normal and mild sleep apnea into a single
category

Both showed same conclusions
 Chung et al (2008) compared postoperative
complications in sleep apnea patients and concluded
 patients with positive sleep studies had increased risk as
compared to negative ones
 however no increased risk with mild OSA group
Discussion:
 In our retrospective analysis, sleep apnea patients
undergoing endoscopy procedures (colonoscopy, EGD,EUS
or combination of those) under conscious sedation are at
no increased risk of cardiopulmonary complications as
compared to those without sleep apnea.
 Patients with sleep apnea can undergo procedures under
conscious sedation using standard monitoring practices.
 Use of CPAP during the procedure may not be required.
Limitations:
 Problems with documentation:
 Retrospective design
 Baseline co-morbidities
 Minor complications
 Missing data
 Sample bias:
 Elderly patients
 Majority are males, Caucasians
 Multiple co-morbidities
 preselected for sleep study
Conclusion
 Sleep apnea does not appear to predispose to a
significantly increased rate of cardiopulmonary
complications during endoscopy procedures under
conscious sedation.
 In terms of clinical implication, it appears that sleep
apnea patients can undergo such procedures safely
using present monitoring practices.
References:
Frances Chung, F.R.C.P.C.,* Balaji Yegneswaran, M.B.B.S et al ,Validation of the Berlin Questionnaire and American
Society of Anesthesiologists Checklist as Screening Tools for Obstructive Sleep Apnea in Surgical Patients
anesthesiology 2008
Blacke, Chia et al, Preoperative assessment for OSA and the prediction of postoperative respiratory obstruction
and hypoxemia anesthesia intensive care 2008
Shireen, Alexander et al, Postoperative Hypoxemia in Morbidly Obese Patients with and Without Obstructive
Sleep Apnea Undergoing Laparoscopic Bariatric Surgery anesthesia analog 2008
Daniel D. Moos, CRNA, MS Obstructive Sleep Apnea and Sedation in the Endoscopy Suite Gastroenterology
Nursing 2006
Vijay S. Khiani, Santo Maimone et al, Safety of Conscious Sedation During Routine Endoscopy for Patients At
Risk for Obstructive Sleep Apnea Gastrointestinal endoscopy 2008
Roop Kaw, ; Franklin Michota et al, Unrecognized Sleep Apnea in the Surgical Patient* Implications for the
Perioperative Setting Chest 2006
Hwang, Shakir et al, association of sleep-disordered breathing with postoperative complications. Chest 2008
Gupta, Parvizi et al. Postoperative complications in patients with OSA undergoing hip or knee replacement: a
case control study. Mayo Clin Proc 2001
Sharma, Haber et al. unexpected risk during administration of conscious sedation: previously undiagnosed OSA.
Ann Intern Med 2003
Moote, Skinner. Morphine disrupts nocturnal sleep in a dose-dependent fashion.Anesth Analog 1989
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