STARTING BLOCK Regional anesthesia avoids airway trouble by letting patients breathe on their own.

In 2013, some colleagues and I published a study (osmag.net/JSK9cx) that called into question the prevailing attitude that patients with obstructive sleep apnea are never good candidates for ambulatory surgery. We looked at 404 OSA patients who'd had outpatient procedures over a 2-year period, and found that there hadn't been a single catastrophic complication. That doesn't mean you should throw your doors open to every sleep apnea patient, but it does show that these patients can be managed safely as long as you keep these important factors in mind.

1. Many people don't know they have it. Sleep apnea is clearly under-recognized and the undiagnosed patient is the one you need to worry about most — the big, heavy-set guy with a short neck and retrognathic jaw. He's never been told he has sleep apnea, but all the signs are there.

The "STOPBANG" test (see "The STOPBANG Obstructive Sleep Apnea Questionnaire") requires only a couple of minutes and is a good place to start when assessing a patient's potential sleep apnea risk. But don't wait until the day of surgery. If the patient's sick — and sleep apnea should be considered a serious condition — you want to leave time to discuss it with your team. Assessing a patient's OSA status several days in advance of surgery lets you assess if he's a candidate for outpatient surgery and plan appropriately.

According to practice guidelines issued in February 2014 by the American Society of Anesthesiologists, you should weigh several factors when determining if patients are suitable for the ambulatory setting. What is their sleep apnea status? How old are they? Do they have anatomical and physiological abnormalities? What about coexisting diseases? What procedures are they scheduled to undergo and what type of anesthesia is required? Will opioids be needed to control their pain? Is there a caregiver at home who can monitor their recovery? An honest assessment of all these factors and the capabilities of your care team will help guide your decision.

2. Teamwork and communication are crucial. The anesthesiologist who suspects sleep apnea needs to tell the surgeon, I'm unable to ascertain the severity, but you should be aware. He also knows how adept the operative team is in emergency airway interventions. That should be part of the discussion. Recovery room nurses need to provide reliable feedback: How well did the patient recover from anesthesia? How did he respond to narcotics?

If surgeons and anesthesiologists disagree about the efficacy of a given case, the best approach is to go ahead when things are optimized. That may mean postponing surgery until you have additional information from a sleep apnea evaluation or a formal sleep study, but you want to have a plan. You want to say patients can go home once they meet certain criteria.

PATIENT SCREENING
The STOPBANG Obstructive Sleep Apnea Questionnaire

• Do you SNORE loudly?
• Do you often feel TIRED during the day?
• Has anyone OBSERVED you stopping breathing while you sleep?
• Do you have high blood PRESSURE?
• Is your BMI more than 35?
• Is you AGE over 50?
• Is your NECK circumference greater than 16 inches?
• Is your GENDER Male?

5 to 8 yes answers: High risk
3 or 4: Intermediate risk
0 to 2: Low risk

3. Regional is preferred. All narcotics have the potential to suppress respiration and increase risk. The more narcotics patients receive, the more likely it is they'll have airway trouble. Employing local blocks whenever possible can minimize a patient's reliance on opioids to manage post-op pain.

For patients with severe sleep apnea, sedation and pain meds can turn a bad airway into no airway. If you can't establish an airway, you shouldn't do the procedure in an ASC. It's a mistake to say, this patient is a difficult intubation, so we're going to use regional. If something goes wrong, you may have to intubate. If the patient's bad airway was the reason you chose regional, you've put yourself behind the eight ball.

According to the ASA's practice guidelines, local anesthesia or peripheral nerve blocks with or without moderate sedation should be considered for superficial procedures. Regional anesthesia is preferable for mild sleep apnea patients, because the more the patient breathes on his own, the safer the airway.

Another concern would be an extremity procedure with a regional block on a patient with unrecognized sleep apnea. If the head is in a dependent position and the procedure lasts longer than expected, passive swelling of the oropharynx may cause mild sleep apnea to progress to significant obstructive sleep apnea.

When moderate sedation is employed, the use of capnography is an effective way to determine if ventilation is adequate. Additionally, a patient's CPAP machine can be used during administration of sedation to improve breathing. If general anesthesia is needed, make sure your providers have the tools and techniques to secure the airway. Finally, unless a contraindication exists, OSA patients should be extubated while fully awake.

4. Stay vigilant in recovery. Whenever possible, say the ASA guidelines, the patient should be in the lateral or semi-upright position during extubation and recovery. Administer supplemental O2 until patients are able to maintain baseline oxygen saturation levels while breathing on their own. Continue use of CPAP in post-op if the patient uses the device pre-operatively.

If patients have sleep apnea equipment at home, by all means have them bring it with them on the day of surgery. Familiarity can only help. And since they'll use the same equipment at home, you'll know that if they can't be safely managed in recovery, they're not going to tolerate it at home, either. Patients should not be discharged to home until they're no longer at risk of experiencing respiratory depression or airway obstruction. Making that crucial decision may require a longer stay in PACU for extended monitoring.

5. Err on the side of caution. Judgment and communication are the essential elements of safe perioperative care. The diagnosis that a sleep apnea patient is a candidate for surgery needs to be followed by appropriate intraoperative monitoring and post-op care. And everybody needs to agree that discharging the OSA patient is safe.