“What specific precautions will be taken during anesthesia?”
I have a history of sleep apnea. What specific precautions will be taken during anesthesia to manage my airway and breathing?
2 Answers
AnesthesiologistAnesthesiologist
The Degree of your obstructive sleep apnea affects how much management is needed for you during anesthesia. The type of anesthesia is also a factor. Most general anesthesia techniques include some sort of airway device such as a breathing tube(ET endotracheal tube) or an LMA(laryngeal mask airway). Sometimes we can do general anesthesia without either of those using just a mask with you breathing on your own. In those cases if you are obstructing we may place an OPA(oral pharyngeal airway) or NPA(nasal pharyngeal airway) to alleviate the obstruction. both of these create like a tunnel from the back of your throat to the outside of your body so your tongue or tissue does not block the air going in and out. With sedation cases we may use an OPA or NPA but often we just move your head or jaw so that it opens up your natural airway and alleviates the obstruction. The main take away is we are watching you and your vital signs the entire time to ensure you are moving air past any potential obstruction.
Hi there,
Great question! Your anesthesiologist will be well trained and familiar with how to monitor and manage your airway and breathing during anesthesia. Obstructive sleep apnea is a commonly encountered medical condition and affects up to 25% of all adult men. There are various ways an anesthetic can be safely performed in patients with sleep apnea, and I will break it down into the preoperative, intraoperative, and postoperative periods.
In the preoperative period, your anesthesiologist will take a history and physical exam. In the history, he/she will ask about the severity of your sleep apnea if known, whether or not you wear a CPAP at night, and the duration of your sleep apnea. He/she will also assess for any other commonly associated medical conditions that may be present (i.e., high blood pressure, obesity, high cholesterol, diabetes, and pulmonary hypertension). In general, patients with sleep apnea that are compliant with wearing their CPAP at night and are well controlled are less likely to suffer severe airway obstruction during and/or after their procedure. Your anesthesiologist will then discuss the options for anesthesia with you based on the type of surgery being performed and the severity of your sleep apnea. If the type of surgery allows for regional anesthesia (nerve block and/or spinal anesthesia), this may be preferable to a general anesthetic because airway manipulation with a breathing tube can often be avoided, and usually patients do not need as much opioid medications during and after the procedure. This is preferable in patients with sleep apnea because they are more sensitive to sedation and are more likely to obstruct when high doses of opioid medications. When the surgery only allows for general anesthesia, typically your anesthesiologist will be conservative when giving opioids and also use short acting, shorter duration opioids in order to prevent over sedation and severe obstruction. Keep in mind, that despite these goals, we still try to provide optimal pain relief for the patient. It doesn’t mean we do not treat pain adequately, just that we are more careful in our titration of these drugs and, if possible, opt for shorter acting opioids. Some commonly used anesthetics may be specifically selected or avoided to achieve a safer outcome based on severity of sleep apnea as well.
During the intraoperative period, your anesthesiologist will be monitoring your breathing carefully with pulse oximetry (oxygenation), capnography (adequacy of ventilation), and visual observation. If general anesthesia with a breathing tube is required for the surgery, then the anesthesiologist will prepare for a potentially difficult intubation, as often patients with sleep apnea have redundancy in tissue in mouth, palate, and tongue, all of which can make intubation more difficult. However, we have various tools for laryngoscopy that make the majority of airways manageable, even in patients with sleep apnea. If you are spontaneously breathing during your procedure, whether under general anesthesia or conscious sedation, your anesthesiologist will be observing your breathing pattern along with the monitors to make sure you are moving air to your lungs adequately. In the event of moderate to severe obstruction, the anesthesiologist can either lighten the anesthetic and/or place a noninvasive oral or nasal airway (in through the mouth or nostril) that stents open the airway or provides a conduit for air to flow to the lungs more adequately during the anesthetic and procedure. Regarding analgesia, as mentioned earlier, opioids and other respiratory depressants will be given cautiously or even avoided if appropriate. Also, multimodal analgesia is especially important, which means we give a number of other non opioid analgesics like acetaminophen, NSAIDS, gabapentin, and/or nerve blocks (if appropriate) in order to lessen the amount of opioid required to achieve optimal pain control. In addition, in surgeries that require muscle relaxation, it is imperative that the anesthesiologist fully reverse the muscle relaxation using a nerve stimulater to make sure there isn’t muscle weakness in recovery room that might lead to greater airway obstruction and pulmonary complications later on (aspiration, pneumonia, desaturation or decrease in oxygenation, and possibly the need for re-intubation).
In the postoperative period, you will be monitored carefully by your anesthesiologist and recovery room nurse who will be monitoring the same vitals mentioned above and observing your breathing pattern. It is sometimes necessary to place the oral and/or nasal airways initially if the patient is still relaxed/sedated and showing signs of airway obstruction. Usually, these devices only need to remain in place until the patient becomes awake enough to be bothered by them. At that point, they are quickly removed, and the patient is more awake, coachable for taking deep breaths, and has more airway tone. In severe cases, we will use CPAP/BiPAP to help patient ventilate during their recovery period. Once the patient is awake, breathing well, and maintaining oxygenation for typically an hour to an hour and a half on room air, they are considered safe for discharge or transfer to hospital room. Also, if you had surgery at an outpatient center and wear a CPAP regularly at night, it is especially important to wear it the night following your surgery as the anesthesia clears your system over time.
I hope all of this gives you a better understanding of how sleep apnea is managed and approached during the perioperative period, and gives you comfort in knowing that many patient with this condition get through anesthesia and surgery safely.
Great question! Your anesthesiologist will be well trained and familiar with how to monitor and manage your airway and breathing during anesthesia. Obstructive sleep apnea is a commonly encountered medical condition and affects up to 25% of all adult men. There are various ways an anesthetic can be safely performed in patients with sleep apnea, and I will break it down into the preoperative, intraoperative, and postoperative periods.
In the preoperative period, your anesthesiologist will take a history and physical exam. In the history, he/she will ask about the severity of your sleep apnea if known, whether or not you wear a CPAP at night, and the duration of your sleep apnea. He/she will also assess for any other commonly associated medical conditions that may be present (i.e., high blood pressure, obesity, high cholesterol, diabetes, and pulmonary hypertension). In general, patients with sleep apnea that are compliant with wearing their CPAP at night and are well controlled are less likely to suffer severe airway obstruction during and/or after their procedure. Your anesthesiologist will then discuss the options for anesthesia with you based on the type of surgery being performed and the severity of your sleep apnea. If the type of surgery allows for regional anesthesia (nerve block and/or spinal anesthesia), this may be preferable to a general anesthetic because airway manipulation with a breathing tube can often be avoided, and usually patients do not need as much opioid medications during and after the procedure. This is preferable in patients with sleep apnea because they are more sensitive to sedation and are more likely to obstruct when high doses of opioid medications. When the surgery only allows for general anesthesia, typically your anesthesiologist will be conservative when giving opioids and also use short acting, shorter duration opioids in order to prevent over sedation and severe obstruction. Keep in mind, that despite these goals, we still try to provide optimal pain relief for the patient. It doesn’t mean we do not treat pain adequately, just that we are more careful in our titration of these drugs and, if possible, opt for shorter acting opioids. Some commonly used anesthetics may be specifically selected or avoided to achieve a safer outcome based on severity of sleep apnea as well.
During the intraoperative period, your anesthesiologist will be monitoring your breathing carefully with pulse oximetry (oxygenation), capnography (adequacy of ventilation), and visual observation. If general anesthesia with a breathing tube is required for the surgery, then the anesthesiologist will prepare for a potentially difficult intubation, as often patients with sleep apnea have redundancy in tissue in mouth, palate, and tongue, all of which can make intubation more difficult. However, we have various tools for laryngoscopy that make the majority of airways manageable, even in patients with sleep apnea. If you are spontaneously breathing during your procedure, whether under general anesthesia or conscious sedation, your anesthesiologist will be observing your breathing pattern along with the monitors to make sure you are moving air to your lungs adequately. In the event of moderate to severe obstruction, the anesthesiologist can either lighten the anesthetic and/or place a noninvasive oral or nasal airway (in through the mouth or nostril) that stents open the airway or provides a conduit for air to flow to the lungs more adequately during the anesthetic and procedure. Regarding analgesia, as mentioned earlier, opioids and other respiratory depressants will be given cautiously or even avoided if appropriate. Also, multimodal analgesia is especially important, which means we give a number of other non opioid analgesics like acetaminophen, NSAIDS, gabapentin, and/or nerve blocks (if appropriate) in order to lessen the amount of opioid required to achieve optimal pain control. In addition, in surgeries that require muscle relaxation, it is imperative that the anesthesiologist fully reverse the muscle relaxation using a nerve stimulater to make sure there isn’t muscle weakness in recovery room that might lead to greater airway obstruction and pulmonary complications later on (aspiration, pneumonia, desaturation or decrease in oxygenation, and possibly the need for re-intubation).
In the postoperative period, you will be monitored carefully by your anesthesiologist and recovery room nurse who will be monitoring the same vitals mentioned above and observing your breathing pattern. It is sometimes necessary to place the oral and/or nasal airways initially if the patient is still relaxed/sedated and showing signs of airway obstruction. Usually, these devices only need to remain in place until the patient becomes awake enough to be bothered by them. At that point, they are quickly removed, and the patient is more awake, coachable for taking deep breaths, and has more airway tone. In severe cases, we will use CPAP/BiPAP to help patient ventilate during their recovery period. Once the patient is awake, breathing well, and maintaining oxygenation for typically an hour to an hour and a half on room air, they are considered safe for discharge or transfer to hospital room. Also, if you had surgery at an outpatient center and wear a CPAP regularly at night, it is especially important to wear it the night following your surgery as the anesthesia clears your system over time.
I hope all of this gives you a better understanding of how sleep apnea is managed and approached during the perioperative period, and gives you comfort in knowing that many patient with this condition get through anesthesia and surgery safely.
