Noninvasive positive pressure ventilation versus no noninvasive positive pressure ventilation CPAP, oxygen, or room air. Extended stay in postanesthesia care unit versus no extended stay in postanesthesia care unit. Anesthesiology ; 2 We have emailed you at with instructions on how to set up a new password. If you do not receive an email in the next 24 hours, or if you misplace your new password, please contact:. To get started with Anesthesiology, we'll need to send you an email.
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We'll send you your username identified by your email account. Login Log in to access full content You must be logged in to access this feature. Join today! Forgot password? Forgot username? View Access Options. Advanced Search. View Full Size. Summary of Recommendations Appendix 2. Methods and Analyses References. Supplemental Digital Content is available for this article. Submitted for publication October 16, Accepted for publication October 16, Gross, M.
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Supplemental Digital Content is available in the text. What other guideline statements are available on this topic? How does this statement differ from existing guidelines? The updated ASA practice guidelines differ from those published by other organizations in that: They include critical analysis of data from a large-scale survey of practicing anesthesiologists rather than a consensus opinion of a few individuals. They apply to both inpatients and outpatients.
They apply to both pediatric and adult patients. Why does this statement differ from existing guidelines? PRACTICE guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints, and are not intended to replace local institutional policies. In addition, practice guidelines developed by the American Society of Anesthesiologists ASA are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome.
Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open-forum commentary, and clinical feasibility data.
Obstructive sleep apnea OSA is a syndrome characterized by periodic, partial, or complete obstruction in the upper airway during sleep. This, in turn, causes repetitive arousal from sleep to restore airway patency, which may result in daytime hypersomnolence or other daytime manifestations of disrupted sleep such as aggressive or distractible behavior in children.
The airway obstruction may also cause episodic sleep-associated oxygen desaturation, episodic hypercarbia, and cardiovascular dysfunction. In the perioperative period, both pediatric and adult patients with OSA, even if asymptomatic, present special challenges that must be addressed to minimize the risk of perioperative morbidity or mortality. Because procedures differ among laboratories, it is not possible to use specific values of indices such as the apnea—hypopnea index to define the severity of sleep apnea.
Therefore, for the purposes of these Guidelines, patients will be stratified using the terms mild , moderate , and severe as defined by the laboratory where the sleep study was performed. The purposes of these Guidelines are to improve the perioperative care and reduce the risk of adverse outcomes in patients with confirmed or suspected OSA who receive sedation, analgesia, or anesthesia for diagnostic or therapeutic procedures under the care of an anesthesiologist. These Guidelines focus on the perioperative management of patients with confirmed or suspected OSA who may be at increased risk of perioperative morbidity and mortality because of potential difficulty in maintaining a patent airway.
This population includes but is not limited to patients who have sleep apnea resulting from obesity, pregnancy, and other skeletal, cartilaginous, or soft tissue abnormalities causing upper airway obstruction. These Guidelines do not focus on patients with the following conditions: 1 pure central sleep apnea, 2 abnormalities of the upper or lower airway not associated with sleep apnea e.
These Guidelines apply to both inpatient and outpatient settings and to procedures performed in an operating room as well as in other locations where sedation or anesthesia is administered. They are directly applicable to care administered by anesthesiologists and individuals who deliver care under the medical direction or supervision of an anesthesiologist.
They are also intended to serve as a resource for other physicians and patient care personnel who are involved in the care of these patients. In addition, these Guidelines may serve as a resource to provide an environment for safe patient care. The original Guidelines were developed by an ASA-appointed Task Force of 12 members, consisting of anesthesiologists in both private and academic practices from various geographic areas of the United States, a bariatric surgeon, an otolaryngologist, and two methodologists from the ASA Committee on Standards and Practice Parameters.
The original Task Force developed the Guidelines by means of a six-step process. First, they reached consensus on the criteria for evidence of effective perioperative management of patients with OSA. Second, original published research studies from peer-reviewed journals relevant to the perioperative management of patients with OSA were evaluated.
Third, the panel of expert consultants was asked to 1 participate in opinion surveys on the effectiveness of various perioperative management strategies for patients with OSA and 2 review and comment on a draft of the Guidelines developed by the Task Force. Fourth, the Task Force held open forums at two major national meetings to solicit input on its draft recommendations. National organizations representing most of the specialties whose members typically care for patients with OSA were invited to participate in the open forums.
Fifth, the consultants were surveyed to assess their opinions on the feasibility and financial implications of implementing the Guidelines. Sixth, all available information was used to build consensus within the Task Force to finalize the Guidelines. This update consists of an evaluation of literature published since completion of the original Guidelines and an evaluation of new survey findings of expert consultants and ASA members.
A summary of recommendations is found in appendix 1. Preparation of these updated Guidelines followed a rigorous methodological process. Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence appendix 2.
Oral appliance treatment for obstructive sleep apnea. A CPAP device fitted to provide positive pressure to nasal and oral cavities during sleep. On the other hand, it is obvious that DISE can allow to observe the dynamic airway activity in real time. More statistics for editors and authors Login to your personal dashboard for more detailed statistics on your publications. Women were more likely to present with atypical complaints namely insomnia, depression, fatigue, and lack of energy, less likely to have apnea. We'll send you your username identified by your email account. The original Task Force developed the Guidelines by means of a six-step process.
Scientific evidence used in the development of these Guidelines is based on findings from literature published in peer-reviewed journals. Literature citations are obtained from PubMed and other healthcare databases, direct internet searches, task force members, liaisons with other organizations, and from hand searches of references located in reviewed articles. Findings from the aggregated literature are reported in the text of the Guidelines by evidence category, level, and direction.
Evidence categories refer specifically to the strength and quality of the research design of the studies. Category A evidence represents results obtained from randomized controlled trials RCTs , and Category B evidence represents observational results obtained from nonrandomized study designs or RCTs without pertinent controls. When available, Category A evidence is given precedence over Category B evidence in the reporting of results. These evidence categories are further divided into evidence levels. Evidence levels refer specifically to the strength and quality of the summarized study findings i.
For this document, only the highest level of evidence is included in the summary report for each intervention, including a directional designation of benefit, harm, or equivocality for each outcome. Randomized controlled trials report comparative findings between clinical interventions for specified outcomes. Level 2: The literature contains multiple RCTs, but the number of RCTs is not sufficient to conduct a viable meta-analysis for the purpose of these Guidelines.
Findings from these RCTs are reported as evidence. Level 3: The literature contains a single RCT, and findings from this study are reported as evidence. Observational studies or RCTs without pertinent comparison groups may permit inference of beneficial or harmful relationships among clinical interventions and outcomes.
Inferred findings are given a directional designation of beneficial B , harmful H , or equivocal E. For studies that report statistical findings, the threshold for significance is P value less than 0.
Obstructive sleep apnoea (OSA) is a common disorder characterized by repetitive episodes of nocturnal breathing cessation due to upper airway collapse . OSA. Ann Intern Med. Oct 1;(7) Management of obstructive sleep apnea in adults: A clinical practice guideline from the American College of.
Level 1: The literature contains observational comparisons e. Level 2: The literature contains observational studies with associative statistics e. Level 3: The literature contains noncomparative observational studies with descriptive statistics e. Level 4: The literature contains case reports. The lack of sufficient scientific evidence in the literature may occur when the evidence is either unavailable i.
Inadequate literature cannot be used to assess relationships among clinical interventions and outcomes, because such literature does not permit a clear interpretation of findings due to methodological concerns e. All opinion-based evidence e. However, only the findings obtained from formal surveys are reported. Opinion surveys were developed for this update by the Task Force to address each clinical intervention identified in the document. Identical surveys were distributed to expert consultants and a random sample of ASA members.
Survey responses from Task Force—appointed expert consultants are reported in summary form in the text, with a complete listing of consultant survey responses reported in appendix 2. There seems to be insufficient evidence to support increased OSA in schizophrenia or in bipolar disorder; 29 however, individuals with these conditions are known to be at an increased risk for metabolic syndrome and obesity, which are also important risk factors for OSA.
OSA is often overlooked in the context of schizophrenia, because its hallmark symptom, daytime sleepiness, is so easily attributable to antipsychotic medications. Various types of antidepressants have been investigated for the treatment of OSA, and, as depression has been linked with OSA, treatment with a tricyclic antidepressant TCA , selective serotonin receptor inhibitor SSRI , or another form of serotonergic agent may provide benefits for both of these diseases.
Three crossover studies published in the s comparing protriptyline to placebo demonstrated a nonsignificant improvement in objective apnea parameters or symptoms. It has been reported that the levels of serotonin are reduced in patients with depression and in certain sleep states that can cause augmentation of OSA symptoms.
On the basis of these findings that endogenous serotonin release in the brainstem promotes upper airway dilation during the awake state while peripheral serotonin release at 5-HT 3 receptors promotes REM-related apnea, Prasad et al tested if using an SSRI fluoxetine in combination with a medication that inhibits 5-HT 3 receptors ondansetron would be advantageous. Marshall et al further researched the use of mirtazapine in OSA by reporting on two separate randomized, double-blind, placebo-controlled trials.
Additionally, there was a significant increase in weight in patients taking mirtazapine across all treatment groups in both studies, which may worsen OSA. Benzodiazepines and other sedatives or hypnotics may be used for insomnia or anxiety in patients with diverse psychiatric conditions. The use of benzodiazepines in patients with OSA has been limited because of their known risk of causing reduced upper airway muscle tone and decreased ventilatory response to hypoxia, thus potentially increasing the AHI and prolonging apnea events.
The more sedated the patient is, the more difficult it is to rouse and consequently the longer it takes to reopen the airway. Nonbenzodiazepine agents, such as zopiclone, zolpidem, and eszopiclone, have hypnotic and sedative effects similar to those of benzodiazepines, but some have fewer muscle-relaxant effects; thus, they may be preferable to use in the short-term management of insomnia in OSA. Psychostimulant medications are associated not only with disrupted or disturbed sleep, but also, paradoxically, calm some patients with ADHD to sleep by alleviating their symptoms.
Studies using modafinil, a nonamphetamine stimulant medication used in the treatment of ADHD, have shown significant reduction of excessive daytime sleepiness associated with OSA in both objective and subjective measures with this medication. Despite the aforementioned benefits of modafinil as adjunct therapy, its use is associated with some risks, including cardiovascular complications, dependency, and abuse potential. Heitmann et al studied blood pressure effects of modafinil in patients with OSA. Because of the greater risk of dependency and abuse with stimulant medications, they are not recommended for the treatment of OSA at this time.
As rates of smoking are at least two times higher among patients with psychiatric disorders, 63 the value of nicotine replacement products for patients with both psychiatric disorders and OSA was also researched. Nicotine may improve OSA by stimulating respiration and oropharyngeal muscles. Of particular importance is the avoidance, or reduction, of alcohol intake.
Ingestion of alcohol before sleep has been shown to increase upper airway collapsibility, therefore, precipitating obstructive apneas and hypopneas during sleep. No controlled studies have exclusively focused on the use of CPAP in patients with severe mental illness; however, there are case reports describing improvement in both OSA and psychiatric symptoms with the use of CPAP in patients with schizophrenia. El-Sherbini et al found a significant reduction in depressive symptoms as determined by the Hamilton Depression Rating Scale and improvement in ESS scores Krakow et al examined the effect of CPAP, oral appliances, or surgery on sleep measures in patients with chronic insomnia and episodes of sleep apnea who completed a cognitive behavior therapy program.
The current literature review also revealed only a few case reports of CPAP-induced psychiatric relapse, one in a previously stable chronic schizophrenic as well as emergent manic episodes in patients with bipolar disorder. OSA is particularly prevalent in patients with psychiatric disorders. The medical care that patients with these comorbidities require can be challenging as some of the psychiatric medications used by these patients may worsen or exacerbate OSA symptoms.
Although pharmacotherapy for the management of OSA is available, evidence on their efficacy is not robust. As such, CPAP continues to be the first-line treatment, even in patients with psychiatric comorbidity. However, more controlled studies are required, particularly to determine CPAP compliance in patients with mental illness, the impact of treating OSA on psychiatric symptoms, and the impact of the use of psychotropic medications on OSA symptoms. Updates on definition, consequences, and management of obstructive sleep apnea: concise review for clinicians. Mayo Clin Proc.
Sleep-disordered breathing, hypoxia, and risk of mild cognitive impairment and dementia in older women. Obstructive sleep apnea and risk of motor vehicle crash: systematic review and meta-analysis. J Clin Sleep Med. Hypertension and obstructive sleep apnea. Nat Sci Sleep. Sleep apnea and cardiovascular disease. Obstructive sleep apnea and cardiovascular risk: meta-analysis of prospective cohort studies. Type 2 diabetes and pre-diabetes are associated with obstructive sleep apnea in extremely obese subjects: a cross-sectional study.
Cardiovasc Diabetol. The comorbidity of sleep apnea and mood, anxiety, and substance use disorders among obese military veterans within the veterans health administration. Association of psychiatric disorders and sleep apnea in a large cohort. Associations between the use of common medications and sleep architecture in patients with untreated obstructive sleep apnea.
Medications that can exacerbate sleep apnea.
Risk factors for obstructive sleep apnea in adults. Gender differences in obstructive sleep apnea syndrome: a clinical study of 1, patients. Resp Med. Adult obstructive sleep apnoea. Sex differences in obstructive sleep apnoea in an elderly French population. Eur Respir J. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Canadian Thoracic Society guideline update: diagnosis and treatment of sleep disordered breathing.
Can Respir J. Diagnosis of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. Canadian Thoracic Society guidelines: diagnosis and treatment of sleep disordered breathing in adults. Management of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians.
Continuous positive airways pressure for obstructive sleep apnoea in adults.
Cochrane Database Syst Rev. Non-CPAP therapies in obstructive sleep apnoea. Adherence to continuous positive airway pressure therapy. The challenge to effective therapy. Proc Am Thorac Soc. Practice parameters for the medical therapy of obstructive sleep apnea. Those with a backward collapse of the tongue, diagnosed via a nasal endoscopy, can also be treated using an Inspire hypoglossal nerve stimulator. This consists of a breathing sensor and a stimulation lead powered by a small battery. It delivers mild stimulation to key airway muscles and gently moves the tongue and other soft tissues out of the airway to enable breathing during sleep.
Patients with shortened upper or lower jawbones may benefit from MMA surgery maxillomandibular advancement , in which the upper jaw maxilla and the lower jaw mandible are lengthened and moved forward. This surgery is reserved for patients with moderate to severe OSA. This option requires a combination of orthodontic appliances and surgery to expand the jawbones, with the goal of enlarging the airway and increasing the space available for the tongue. Weight gain can cause fat tissue to build up around the throat and at the base of the tongue. Medical weight loss or bariatric surgery may be indicated in certain cases.
Tongue reduction surgery may be helpful when the tongue is abnormally enlarged. Health Management.