The utility of perioperative polygraphy in the diagnosis of obstructive sleep apnea

Comparison of oxygen reserve index according to the remimazolam or dexmedetomidine for intraoperative sedation under regional anesthesia-A single-blind randomized controlled trial

Introduction

We aimed to evaluate the difference in intraoperative oxygen reserve index (ORi) between the sedatives remimazolam (RMMZ) and dexmedetomidine (DEX).

Methods

Seventy-eight adult patients scheduled for sedation under regional anesthesia were randomly assigned to either the DEX (n = 39) or RMMZ (n = 39) group. The primary outcome was the difference in perioperative ORi between the groups. The secondary outcomes included respiratory depression, hypo- or hypertension, heart rate (HR), blood pressure, respiratory rate and postoperative outcomes. Additionally, the number of patients who experienced a decrease in intraoperative ORi to < 50% and the associated factors were analyzed.

Results

The ORi was significantly higher in the RMMZ group at 15 min after sedation maintenance. There were no significant differences in respiratory depression between the two groups. The intraoperative HR was significantly higher in the RMMZ group after the induction of sedation, 15 min after sedation maintenance, and at the end of surgery. No other results were significantly different between the two groups. The incidence of a decrease in intraoperative ORi to < 50% was significantly higher in the DEX group. Factors associated with a decrease in the intraoperative ORi to < 50% were diabetes mellitus, low baseline peripheral oxygen saturation (SpO2), and DEX use. In the receiver operating characteristic curve analysis for a decrease in the intraoperative ORi to < 50%, the cutoff baseline SpO2 was 97%.

Conclusion

RMMZ is recommended as a sedative for patients with a low baseline SpO2 and intraoperative bradycardia. Further studies should be conducted to establish the criteria for a significant ORi reduction.

Perioperative management of obstructive sleep apnea in lower extremity orthopedic procedures: A review of evidence to inform the development of a clinical pathway

Obstructive sleep apnea (OSA) is unrecognized in as high as 80% of patients before surgery. When untreated, OSA increases a surgical patient's propensity for airway collapse and sleep deprivation lending to a higher risk for emergent re-intubation, prolonged recovery time, escalation of care, hospital readmission, and longer length of stay. We have reviewed the evidence regarding diagnostic performance of OSA screening methods and the impact of perioperative management strategies on postoperative complications among patients with diagnosed or suspected OSA who are undergoing orthopedic surgery. We then integrated the data and recommendations from professional society guidelines to develop an evidence-based clinical care pathway to optimize the perioperative management of this surgical population. Successful management of patients with diagnosed or suspected OSA encompass five facets of care: screening, education, airway management, medications, and monitoring. This narrative review revealed two gaps in the evidence to inform management of patients undergoing orthopedic surgery 1) during the perioperative setting to include evidence-based interventions that reduce postoperative complications and 2) after discharge to an unmonitored environment. The clinical care pathway as well as perspectives for future research are discussed.

The Automatic Algorithm of the Auto-CPAP Device as a Tool for the Assessment of the Treatment Efficacy of CPAP in Patients with Moderate and Severe Obstructive Sleep Apnea Syndrome

Obstructive sleep apnea syndrome (OSAS) is a common sleep-related breathing disorder where precise treatment assessment is of high importance. We aimed to validate an automatic algorithm of the auto-CPAP device and reveal polygraph usefulness in the OSAS diagnosis and treatment of outpatients. One hundred patients with moderate OSAS, severe OSAS, and excessive daytime sleepiness qualified for CPAP treatment were included. The study was conducted in three stages. The first stage included a minimum 6-hour polysomnographic examination to select moderate and severe OSAS. The second stage involved an auto-CPAP treatment lasting at least 4 h with simultaneous polygraph recording. The third stage was a titration of at least 4 h with auto-CPAP. The Apnea–Hypopnea Index (AHI) and oxygen desaturation index (ODI) were calculated under auto-CPAP treatment, simultaneously using polygraph (stage two), and as a result of treatment with auto-CPAP (stage three). The mean AHI was 40.0 ± 20.9 for OSAS. Auto-CPAP treatment was effective in 97.5%. The mean residual AHI was 8.6 ± 4.8; there was no significant difference between the AHI CPAP, and the AHI polygraph values were assessed with an accuracy of 3.94/h. The sensitivity and specificity of calculated cut point 8.2 event/hour were: 55% and 82%, respectively. The calculated AUC for the AHI CPAP parameter was 0.633. Presented data confirmed that the automatic algorithm of auto-CPAP is a good tool for the assessment of the treatment efficacy of CPAP in patients, i.e., home setting, with a moderate or severe stage OSAS-presented high sleepiness.

Periprocedural Management during Therapeutic Cardiac Catheterization in Patients with Sleep Apnea Syndrome: Report of Three Cases and Review of Literature

Most of the patients with sleep apnea syndrome (SAS) also known as sleep disordered breathing are not diagnosed before undergoing any cardiac interventional procedure. Many of them can safely undergo outpatient procedure under sedation or anesthesia. Few of them with moderate to severe grade of SAS, who are not optimized medically, may create problem and need special consideration. We managed three such cases in cardiac catheterization laboratory; two of them were not diagnosed before. The periprocedural problems we faced in these patients are narrated in this article along with review of literature. Some suggestions for management of such patients undergoing therapeutic cardiac catheterization are also highlighted.

Comparison of Jaw Elevation Device vs. Conventional Airway Assist during Sedation in Chronic Kidney Diseases Undergoing Arteriovenous Fistula Surgery: A Randomized Controlled Trial

Patients with chronic renal failure (CRF) are likely to have obstructive sleep apnea (OSA) underdiagnosed, and maintaining airway patency is important during sedation. This study compared Jaw elevation device (JED) with conventional airway interventions (head lateral rotation, neck extension, oral or nasal airway insertion, and jaw thrust maneuver) during sedation and hypothesized that JED may be effective to open the airway. A total of 73 patients were allocated to a conventional group (n = 39) and a JED group (n = 34). The number of additional airway interventions was the primary outcome. Percentage of patients with no need of additional interventions and apnea-hypopnea index (AHI) were secondary outcomes. The number of additional interventions was significantly less in the JED group compared to the conventional group (0 (0–0) vs. 1 (0–2); p = 0.002). The percentage of patients with no requirement for additional interventions was significantly higher in the JED group compared to the conventional group (76.5% vs. 43.6%; p = 0.004). AHI was significantly lower in the JED group compared to the conventional group (4.5 (1.5–11.9) vs. 9.3 (3.8–21.9), p = 0.015). In conclusion, JED seems to be effective in opening the airway patency during sedation in CRF patients.

Dexmedetomidine-induced polysomnography as a diagnostic method in obstructive sleep apnea: a reliable alternative method?

BACKGROUND

Under-diagnosis of obstructive sleep apnea (OSA) is common because of the demanding and time-consuming nature of polysomnography (PSG). Herein, we assessed the utility of a short daytime dexmedetomidine-induced PSG for diagnosis of OSA in adults.

METHODS

This was a single-center, prospective, diagnostic trial. We evaluated 86 patients using a full overnight PSG and a short diurnal drug-induced PSG (DIPSG). DIPSG was induced by continuous intravenous dexmedetomidine infusion. Sedation depth was monitored and maintained using the Narcotrend index (50-70). Diagnostic performance for DIPSG with different apnea-hypopnea index (AHI) cut-off values were calculated. Bland-Altman plots used for analysis. Sleep architecture and position were compared.

RESULTS

We studied 47 OSA patients and 39 healthy volunteers. Sensitivity and specificity for detection of OSA by DIPSG were 92% and 79%, respectively, for an AHI cut-off value of 5, 90% and 77%, respectively, for an AHI cut-off value of 15, and 95% and 85%, respectively, for an AHI cut-off value of 30. The DIPSG bias was -5 (-25; 15) for AHI and -3 (-13; 7) for minimal oxygen saturation. N2 sleep was increased (32.9% vs. 50.75%, respectively; p < 0.01) and REM sleep was decreased (21.35% vs. 1.24%, respectively; p < 0.01) during DIPSG. Twenty-eight (33%) participants had postural shifts during DIPSG. No significant adverse events were observed during DIPSG.

CONCLUSIONS

Dexmedetomidine-induced PSG had a good sensitivity and specificity, and can be used as a screening tool for diagnosis of OSA in adults.

CHINESE CLINICAL TRIAL REGISTRATION

ChiCTR1900024044.