Evolution of Changes in Upper Airway Collapsibility during Slow Induction of Anesthesia with Propofol

Hillman, David R.; Walsh, Jennifer H.; Maddison, Kathleen J.; Platt, Peter; Kirkness, Jason P.; Noffsinger, William; Eastwood, Peter R.

doi:10.1097/aln.0b013e3181a7ec68

Cited by 196 publications

(143 citation statements)

References 30 publications

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“…[21][22][23] In 12 healthy subjects undergoing minor surgery, increasing depth of propofol anesthesia was associated with a progressive increase in critical airway pressure and upper airway collapsibility. 23,24 This increased upper airway collapsibility was found to be secondary to progressive decrease in the genioglossus muscle activity. Upper airway collapsibility may cause worsening of the sleep apnea and increase the risk of hypoxemia, cardiac arrhythmias, and postoperative complications.…”

Section: Impact Of Sedation Anesthesia and Opioidsmentioning

confidence: 99%

Obstructive Sleep Apnea Syndrome and Perioperative Complications: A Systematic Review of the Literature

Vasu

Grewal

Doghramji

2012

Journal of Clinical Sleep Medicine

217

147

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Obstructive sleep apnea syndrome (OSAS) is a common sleep related breathing disorder. Its prevalence is estimated to be between 2% and 25% in the general population. However, the prevalence of sleep apnea is much higher in patients undergoing elective surgery. Sedation and anesthesia have been shown to increase the upper airway collapsibility and therefore increasing the risk of having postoperative complications in these patients. Furthermore, the majority of patients with sleep apnea are undiagnosed and therefore are at risk during the perioperative period. It is important to identify these patients so that appropriate actions can be taken in a timely fashion. In this review article, we will discuss the epidemiology of sleep apnea in the surgical population. We will also discuss why these patients are at a higher risk of having postoperative complications, with the special emphasis on the role of anesthesia, opioids, sedation, and the phenomenon of REM sleep rebound. We will also review how to identify these patients preoperatively and the steps that can be taken for their perioperative management. OSAS has been shown to be associated with various healthrelated consequences, including increased rate of motor vehicle accidents, hypertension, diabetes mellitus, congestive heart failure, stroke, and all-cause mortality. [1][2][3][4][5][6][7][8][9] Recently, numerous studies have demonstrated that surgical patients with sleep apnea are at increased risk of having perioperative complications, including hypoxemia, pneumonia, diffi cult intubation, myocardial infarction, pulmonary embolism, atelectasis, cardiac arrhythmias, and unanticipated admission to the ICU. The majority of patients with OSA are undiagnosed upon admission and are at risk during the perioperative period, presumably due to their underlying sleep apnea. Therefore, it is very important to identify these patients preoperatively so that one can initiate appropriate perioperative measures. EpidemiologyOSAS is an extremely common sleep related breathing disorder, and its prevalence has been increasing throughout the world because of obesity and increasing age of the general population. Its prevalence is between 2% and 25% in the general population, depending upon how sleep apnea is defi ned. In an epidemiological study, Young et al. noted that the prevalence of sleep apnea, defi ned as apnea-hypopnea index (AHI) ≥ 5/h was 9% for women and 24% for men. 10 However, the prevalence of OSAS (defi ned as AHI ≥ 5/h and daytime sleepiness) was 2% in women and 4% in men. 10 The National Sleep Foundation (NSF) Sleep in America 2005Poll found that 1 in 4 Americans are at high risk of having sleep apnea based on the Berlin Questionnaire. 11 The prevalence of sleep apnea is much higher in surgical patients and depends on the type of surgery. In the bariatric surgery population, the prevalence of sleep apnea has been found to be > 70%. 12,13 It is the standard of care for these patients to get a formal sleep evaluation prior to undergoing the bariatric surgery. Howev...

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Section: Impact Of Sedation Anesthesia and Opioidsmentioning

confidence: 99%

Obstructive Sleep Apnea Syndrome and Perioperative Complications: A Systematic Review of the Literature

Vasu

Grewal

Doghramji

2012

Journal of Clinical Sleep Medicine

217

147

View full text Add to dashboard Cite

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“…31 However, when light sedation using midazolam is used to induce a sleeplike state, upper airway collapsibility is similar to natural sleep. 32 This finding is consistent with the current study in which upper airway collapsibility and sleep parameters were similar before versus after trazodone.…”

mentioning

confidence: 99%

Trazodone Increases the Respiratory Arousal Threshold in Patients with Obstructive Sleep Apnea and a Low Arousal Threshold

Eckert

Malhotra

Wellman

et al. 2014

Sleep

123

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Study Objectives: The effect of common sedatives on upper airway physiology and breathing during sleep in obstructive sleep apnea (OSA) has been minimally studied. Conceptually, certain sedatives may worsen OSA in some patients. However, sleep and breathing could improve with certain sedatives in patients with OSA with a low respiratory arousal threshold. This study aimed to test the hypothesis that trazodone increases the respiratory arousal threshold in patients with OSA and a low arousal threshold. Secondary aims were to examine the effects of trazodone on upper airway dilator muscle activity, upper airway collapsibility, and breathing during sleep. Design: Patients were studied on 4 separate nights according to a within-subjects cross-over design. Setting: Sleep physiology laboratory. Patients: Seven patients with OSA and a low respiratory arousal threshold. Interventions: In-laboratory polysomnograms were obtained at baseline and after 100 mg of trazodone was administered, followed by detailed overnight physiology experiments under the same conditions. During physiology studies, continuous positive airway pressure was transiently lowered to measure arousal threshold (negative epiglottic pressure prior to arousal), dilator muscle activity (genioglossus and tensor palatini), and upper airway collapsibility (Pcrit). Measurements and Results:Trazodone increased the respiratory arousal threshold by 32 ± 6% (-11.5 ± 1.4 versus -15.3 ± 2.2 cmH 2 O, P < 0.01) but did not alter the apnea-hypopnea index (39 ± 12 versus 39 ± 11 events/h sleep, P = 0.94). Dilator muscle activity and Pcrit also did not systematically change with trazodone. Conclusions: Trazodone increases the respiratory arousal threshold in patients with obstructive sleep apnea and a low arousal threshold without major impairment in dilator muscle activity or upper airway collapsibility. However, the magnitude of change in arousal threshold was insufficient to overcome the compromised upper airway anatomy in these patients. Keywords: Arousal, lung, muscles, respiratory physiology, sedative, sleep-disordered breathing, upper airway Citation: Eckert DJ; Malhotra A; Wellman A; White DP. Trazodone increases the respiratory arousal threshold in patients with obstructive sleep apnea and a low arousal threshold. SLEEP 2014;37(4):811-819.

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“…However, patients may lose consciousness at variable effect site concentrations (Ce), with a higher Ce being associated with higher upper airway critical closing pressure. 6,7 Most DISE procedures are started shortly after the patients lose consciousness. O bstructive sleep apnea (OSA) involves multiple segments of the upper airway.…”

mentioning

confidence: 99%

Bispectral Index in Evaluating Effects of Sedation Depth on Drug-Induced Sleep Endoscopy

Wang

et al. 2015

Journal of Clinical Sleep Medicine

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achieve a target effect site (brain) concentration of propofol. However, patients may lose consciousness at variable effect site concentrations (Ce), with a higher Ce being associated with higher upper airway critical closing pressure.6,7 Most DISE procedures are started shortly after the patients lose consciousness. Objective:To evaluate the effect of sedation depth on druginduced sleep endoscopy (DISE). Methods: Ninety patients with obstructive sleep apnea (OSA) and 18 snorers underwent polysomnography and DISE under bispectral index (BIS)-guided propofol infusion at two different sedation levels: BIS 65-75 (light sedation) and 50-60 (deep sedation). Results: For the patients with OSA, the percentages of velopharynx, oropharynx, hypopharynx, and larynx obstructions under light sedation were 77.8%, 63.3%, 30%, and 33.3%, respectively. Sedation depth was associated with the severity of velopharynx and oropharynx obstruction, oropharynx obstruction pattern, tongue base obstruction, epiglottis anteroposterior prolapse and folding, and arytenoid prolapse. In comparison, OSA severity was associated with the severity of velopharynx obstruction, severity of oropharynx obstruction, and arytenoid prolapse (odds ratio (95% confi dence interval); 14.3 (4.7-43.4), 11.7 (4.2-32.9), and 13.2 (2.8-62.3), respectively). A good agreement was noted between similar DISE fi ndings at different times and different observers (kappa value 0.6 to 1, respectively 1 Drug-induced sleep endoscopy (DISE) has been used for decades to directly examine the upper airways in sedative-induced sleep and improve treatment outcomes by acting as an adjuvant tool to assess surgical or nonsurgical treatment options. 2-4Various sedation methods have been used to allow for the performance of DISE. Roblin introduced target-controlled infusion (TCI) of propofol to DISE to allow for better control of the sedation level.5 TCI of propofol uses computer-based pharmacokinetic and pharmacodynamic models to predict and Bispectral Index in Evaluating Effects of Sedation Depth on Drug-Induced Sleep EndoscopyYu-Lun Lo, MD BRIEF SUMMARYCurrent Knowledge/Study Rationale: Drug-induced sleep endoscopy (DISE) were performed under different sedative conditions and might affect upper airway obstructions. We aimed to evaluate the affects of sedation depth and obstructive sleep apnea severity on different upper airway obstruction patterns. Study Impact: Under DISE, sedation depth affected velopharynx and oropharynx obstruction severity, oropharynx obstruction pattern, tongue base obstruction, epiglottis anteroposterior prolapse and folding, and arytenoid prolapse; however, OSA severity was associated with velopharynx and oropharynx obstruction severity as well as arytenoid prolapse. Bispectral index guided DISE offers an objective and reproducible method to evaluate upper airway collapsibility.

show abstract

Evolution of Changes in Upper Airway Collapsibility during Slow Induction of Anesthesia with Propofol

Cited by 196 publications

References 30 publications

Obstructive Sleep Apnea Syndrome and Perioperative Complications: A Systematic Review of the Literature

Obstructive Sleep Apnea Syndrome and Perioperative Complications: A Systematic Review of the Literature

Trazodone Increases the Respiratory Arousal Threshold in Patients with Obstructive Sleep Apnea and a Low Arousal Threshold

Bispectral Index in Evaluating Effects of Sedation Depth on Drug-Induced Sleep Endoscopy

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