Obesity and Obstructive Sleep

Apnoea
Anaesthesiology

Dr M Pienaar
17 September 2019
Content
• Introduction
• Definitions
• Epidemiology
• Multisystem involvement
• Anaesthetic concerns
• Conclusion
• References
Introduction
• Obesity is a global health problem. Approximately 7% of the adult
population is obese worldwide; 30% of patients presenting for
surgery. There is also a recent trend of increasing prevalence of
obesity in adolescents and children
• Obesity is a multiorgan disease especially affecting the
cardiorespiratory system
• A high BMI (body mass index) is associated with anaesthetic
complications, especially if symptoms of OSA (obstructive sleep
apnoea) are present
 BMI (kg/m2)

Obesity <25
25-30
Normal
Overweight
30-35 Obese
>35 Morbidly obese

• Obesity is defined by calculating the body mass index (BMI)

• Regional distribution of excess fat is more predictive of morbidity and
mortality than BMI
• Central obesity is predictive of type 2 Diabetes Mellitus, dyslipidaemia
and cardiovascular disease, therefore waist circumference is used to
determine if a patient is at increased risk
Increased Substantially Increased
Men ≥94cm ≥102cm
Women ≥80cm ≥88cm
General anaesthetic concerns in
obesity
• Placement of an intravenous line to deliver anaesthetic agents
• Determining the right dose of medications
• Placement of an endotracheal tube
• Ensuring adequate oxygen and airflow, especially in patients with
OSA
• Increased time of awakening post-surgery
• Increasing the risk of respiratory depression with narcotics and
other analgesics
Obesity is a multiorgan disease
Airway
Physiological changes
• Short, fat neck makes both mask ventilation and direct
laryngoscopy technically more challenging
• Obese women are likely to have large breasts, which can interfere
with easy placement of the laryngoscope
• Increased bulk of soft tissues in the upper airway make them prone
to partial obstruction with the loss of consciousness
• Increased risk of aspiration and difficult intubation
Airway
Anaesthetic implications
• Prepare for a difficult airway, having different size laryngoscopes
and entotracheal tubes available
• Aim for a degree of head-up tilt if patient has large breasts or ask
assistant to pull breasts away from the airway
• A rapid sequence induction can be considered
• If a fibrescope is available, consider awake intubation but be wary
of using any additional sedation
OSA
• Obstructive Sleep Apnoea (OSA) is a sleep-related breathing
disorder characterized by repeated episodes of apnoea and
hypopnoea during sleep
• Apnoea = complete cessation of airflow for more than 10 seconds
• Hypopnoea = airflow reduction more than 50% for more than 10
seconds
• Oxygen desaturation and arousal from sleep often occurs due to
the repetitive upper airway obstruction
• OSA often results in excessive daytime sleepiness, unrefreshing
sleep, poor concentration, fatigue and morning headaches
 OSA
Risk factors
• Obesity
• The prevalence of overt OSA is • age >50 years
approximately 4% in men and 2% in • male gender
women, but up to 80% of patients are • neck circumference >40cm
undiagnosed preoperatively • nasal/pharyngeal/laryngeal
obstruction
• OSA is strongly correlated with obesity, • craniofacial abnormalities
in particular morbid obesity (BMI >40) • neuromuscular disorders
• It is found in 40% of obese females and • use of alcohol, sedatives and
50% of obese males cigarettes
 Pathophysiology
• Apnoea occurs when the pharyngeal airways
collapse. The body is in its most relaxed state
during rapid eye movement sleep (REM), which is
when the pharyngeal dilator muscles
(genioglossus and geniohyoid) are hypotonic
• In obese patients, increased adipose tissue in the
neck and pharyngeal tissues narrows the airway
further, predisposing to airway closure during
sleep
• In non-obese patients, tonsillar hypertrophy or
craniofacial skeletal abnormalities may lead to
airway narrowing and sleep apnoea
Pathophysiology
• Airway obstruction leads to an increase in inspiratory efforts, leading
to a partial arousal from sleep and a sudden opening of the airway
• A short period of hyperventilation follows, until sleep deepens and
airway obstruction recurs, repeating the cycle
• The result is blood gas oscillation and sleep fragmentation
• Physiological changes arising from repetitive airway obstruction
include arterial hypoxaemia, arterial hypercarbia, polycythaemia,
systemic hypertension, pulmonary hypertension, cardiac rhythm
disturbances and right ventricular failure
• There is an increased incidence of heart disease, cerebrovascular
events and sudden death
 OSA and anaesthesia
• OSA is associated with increased peri-operative morbidity and mortality
• High risk of developing a range of complications when they receive sedation, analgesia
or anaesthesia including difficult intubation, postoperative respiratory depression and
airway obstruction
• The most serious of these risks being the potential loss of the airway
• The American Society of Anesthesiologists (ASA) recommends that patients should be
screened for risk of OSA prior to surgery
Pre-operative Management
• The gold standard for the diagnosis of OSA is a sleep study (polysomnography)
• The gold standard of treatment for OSA is the nocturnal use of nasal continuous
positive airway pressure (nCPAP) delivery devices
• Preoperative weight loss can also be recommended
• Elective surgery should be postponed until the patient has been fully investigated
and treated
• Review of previous anaesthetic notes grading ease of direct laryngoscopy and
intubation should be sought
• A thorough history and examination is required, with particular attention to
assessment of the airway
• Patients using nasal CPAP are required to bring their device to hospital
Intra-operative Management
Premedication - sedative premedications should be avoided as they cause relaxation of the
upper airway muscles

Choice of anaesthetic technique - central depressant drugs diminish pharyngeal tone

predisposing to upper airway collapse. Local or regional anaesthesia should therefore be the
preferred technique whenever possible

Intubation technique - Equipment necessary to handle a difficult airway should be readily

available prior to induction, and attention to adequate preoxygenation is important. Consider
an awake fibreoptic intubation if an airway problem is suspected

Extubation – Patient should be conscious, communicative, and breathing spontaneously with

an adequate tidal volume and oxygenation. Antihypertensive drugs can be used prior to
extubation to avoid excessive hypertension, especially in patients with cardiovascular disease
 Post-operative Management
• Respiratory depression and repetitive apnoeas are common immediately
following extubation in patients with OSA. Careful cardiorespiratory monitoring
in the postanaesthesia care unit (PACU) is needed with supplemental oxygen
• Preoperative and postoperative nCPAP reduce the risk of developing
complications
• Analgesic requirements are high during the first few days post-surgery - an
associated risk of respiratory depression
• Reestablishment of sleep patterns occurs three to four days postoperatively,
with the potential for a “REM rebound”– patients are still considered high risk 7
days post-surgery
• Early postoperative mobilisation is vital in OSA and obese patients
Ventilation
Physiological changes
• Increased body mass and metabolically active adipose tissue leads to
increased oxygen consumption and carbon dioxide production. Minute
ventilation is thus increased to achieve normocapnia
• Reduced chest wall compliance (of up to 30%) due to the heavy chest
wall, increased pulmonary blood volume and splinted diaphragm. This
results in an increased work of breathing
• Functional residual capacity (FRC) declines with increasing BMI.
Anaesthesia, a supine position and the abnormally high elevation of the
diaphragm (due to increased visceral and abdominal wall fat) all cause
ventilation-perfusion mismatch, right-to-left shunting and arterial
hypoxaemia
Ventilation
Anaesthesic implications
• Pre-oxygenation in essential - obese patients desaturate rapidly once
apnoeic as their FRC are reduced and oxygen utilisation increased
• Higher inflation pressures are required for ventilation
• Hypoventilation will often occur when breathing spontaneously via an
LMA/facemask and thus these techniques are not recommended
• Application of PEEP via an endotracheal tube is particularly useful in
improving oxygenation by reducing small airways collapse
• Extubation is usually best performed with the patient in the sitting
position as awake as possible to allow maximal diaphragmatic
excursion
Cardiovascular System
Physiological changes
• Cardiac risk factors such as hypertension, ischaemic heart disease,
cardiomyopathies, cardiac failure, arrhythmias, sudden cardiac death and
dyslipidaemias are common
• Hypertension causes an increased absolute blood volume and increased
cardiac output. Left ventricular stroke work is increased and left ventricular
hypertrophy can result. Left and right cardiac failure can both occur
• Venous return is reduced. The abdomen compresses venous return from
the legs (also doubling the risk of deep vein thrombosis (DVT) and
pulmonary embolism).
• Once ventilated, higher inflation pressures and application of PEEP further
reduces venous return, which may result in a fall in cardiac output
Cardiovascular System
Anaesthetic implications
• Preoperative assessment looking for evidence of IHD and cardiac failure on
history, examination and ECG
• Chest x-ray and echocardiography
• Measure non-invasive BP with the correct sized cuff. In the morbidly
obese, invasive BP monitoring is advisable
• Continue cardiac drugs throughout the perioperative period. Heparin
prophylaxis, stockings and early mobilisation are some measures to reduce
the incidence of DVT
• Postoperative oxygen may particularly reduce nocturnal ischaemic events
Gastrointestinal and Endocrine System
Physiological changes
• Increased incidence of hiatus hernia in the obese. The volume and
acidity of gastric contents is often increased, increasing aspiration risk
• Non-insulin dependent diabetes mellitus (and its associated
microvascular and macrovascular changes) is much more common in
the obese caused by insulin resistance and inadequate insulin
production
• Hypercholesterolaemia, hypothyroidism, gout, osteoarthritis, back
pain, hepatic impairment, gallstones, abdominal hernia, breast and
endometrial malignancies are all more common in the obese
Gastrointestinal and Endocrine System
Anaesthetic implications
• Prescribe oral H2 receptor antagonists (e.g. ranitidine 150mg) or PPI
(e.g. omeprazole 20-40mg) routinely 1-2 hours preoperatively
• Consider performing rapid sequence induction with cricoid pressure
at induction and extubate when fully awake
• Perform a random HGT on all obese patients. Ensure good
perioperative sugar control to reduce infection and risk of
myocardial events
• Continue statins perioperatively as they might improve coronary
plaque stability
Pharmacological Implications
• Volumes of distribution, binding and elimination of drugs are
unpredictable. Therefore, use clinical end points of drug action rather than
dose of ideal, lean or actual body weight
• Reduction in total body water, higher fat mass, relatively higher lean
mass, higher GFR, increased renal clearance and normal hepatic clearance
• The apparent volume of distribution for a fat-soluble drug is increased
because of the lipophilic nature. Therefore, the dose should be increased
but a raised volume of distribution also results in reduced elimination
resulting in prolonged effects
• Slow emergence after use of fat-soluble volatile agents may be due to
central sensitivity as much as due to delayed release from adipose stores
Regional Anaesthesia
• Good regional anaesthesia may reduce opioid and inhalational
requirements
• Technically difficult because of the loss of landmarks, increased
movement of the skin and the need for long needles. Initial failure
rate is higher in the obese
• Due to the engorged extradural veins and extra fat constricting the
potential space, less local anaesthetic is needed for epidurals (75-
80% of the normal dose)
Conclusion

Significant cardio
Calculate a BMI for all Obesity is a multi
respiratory disease is
patients organ disease
particularly common

Pre-operative
Perioperative assessment,
mortality and Screen obese patients intraoperative care
morbidity increases for OSA and postoperative
with BMI monitoring is
essential
References
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