High-Flow Nasal Oxygen in Patient With Obstructive

Sleep Apnea Undergoing Awake Craniotomy: A Case

Report
Jaclyn W. M. Wong, MBChB,* Amy H. S. Kong, MBChB,* Sau Yee Lam, MBChB,*
and Peter Y. M. Woo, FRCS†

Patients with obstructive sleep apnea are frequently considered unsuitable candidates for
awake craniotomy due to anticipated problems with oxygenation, ventilation, and a potentially
difficult airway. At present, only a handful of such accounts exist in the literature. Our report
describes the novel use of high-flow nasal oxygen therapy for a patient with moderate obstruc-
tive sleep apnea who underwent an awake craniotomy under deep sedation. The intraoperative
application of high-flow nasal oxygen therapy achieved satisfactory oxygenation, maintained the
partial carbon dioxide pressure within a reasonable range even during periods of deep sedation,
permitted responsive patient monitoring during mapping, and provided excellent patient and
surgeon satisfaction.  (A&A Case Reports. 2017;XXX:00–00.)

I
n an awake craniotomy, the anesthetist is presented with
significant challenges to provide patient comfort, physi-
ological stability, and optimal operative conditions for
the surgeon.1 Many prefer general endotracheal anesthe-
sia with controlled ventilation in patients with obstructive
sleep apnea (OSA) because of the respiratory depressant
effect of sedative agents that may lead to hypoventilation
and intracranial hypertension and potentially disastrous
airway management difficulties.
OSA is a condition characterized by limitation of airflow
despite respiratory effort during sleep. An overnight sleep
study is required for diagnosis by measuring the apnea-
hypopnea index, which is the number of apnea and hypop-
nea events per hour (adults ≥5, children ≥1).
Few accounts in the literature describe successful awake
craniotomies in patients with OSA. One early report described
a patient with mild OSA who underwent the sleep-awake-
sleep technique, with the use of a nasal mask and pressure-
controlled ventilation in periods of apnea and proportional
assist ventilation during spontaneous breathing.2 Another
reported an obese OSA patient where the airway was main-
tained using i-gel in the asleep phase, a nasal RAE (Ring,
Adair and Elwyn) tube just above the laryngeal opening to
provide continuous positive airway pressure (CPAP) during
the awake phase, and a nasal airway in the transition phase.3
Intraoperative continuation of nasal CPAP has also been
reported for a morbidly obese OSA patient with significant
cardiorespiratory comorbidities that require nocturnal CPAP.4
In this report, we present the novel use of a high-flow
nasal oxygen (HFNO) delivery system in a patient with
From the Departments of *Anaesthesiology and Operating Theatre Services,
and †Department of Neurosurgery, Kwong Wah Hospital, Yau Ma Tei, Hong
Kong.
Accepted for publication June 14, 2017
Funding: None.
The authors declare no conflicts of interest.
Address correspondence to Jaclyn W. M. Wong, MBChB, Department of
Anaesthesiology and Operating Theatre Services, Kwong Wah Hospital,
25 Waterloo Rd, Yau Ma Tei, Hong Kong. Address e-mail to jaclynwg03@
yahoo.ca.
Copyright © 2017 International Anesthesia Research Society
DOI: 10.1213/XAA.0000000000000615
moderate OSA who underwent awake craniotomy under
deep sedation. Written consent was obtained from the
patient to write this case report.
CASE DESCRIPTION
A 43-year-old man was scheduled for an awake craniotomy
for the excision of a right frontal lobe low-grade glioma. He
was diagnosed to have moderate OSA when a sleep study
revealed an apnea-hypopnea index—the number of apnea
and hypopnea events per hour—of 17.4 with a trough oxy-
gen saturation of 81%. Airway assessment revealed a thyro-
mental distance of 6 cm, Mallampati score of 2, good mouth
opening, and a normal neck circumference. Physical exami-
nation revealed a body mass index of 22.1 kg/m2 and nor-
mal cardiovascular and respiratory system functions.
Because CPAP was not a viable option due to intoler-
ance by the patient and obstruction to the surgical field by
facemask strapping, high-flow nasal cannula (HFNC) was
chosen as a reasonable option. Other contingency plans
included the use of a nasal airway, laryngeal mask, and
video laryngoscopy.
Our anesthetic technique is outlined in the Table.
Presedation baseline arterial blood gas (ABG) analysis was
pH 7.37, Pco2 5.8 kPa (44 mm Hg), Pao2 10.8 kPa (81 mm
Hg), and Sao2 95%. To reduce procedural discomfort, a
dexmedetomidine infusion and target-controlled infusion
of propofol were used. The target-controlled infusion sys-
tem is a computerized syringe pump, which uses real-time
pharmacokinetic models to calculate the bolus and infusion
rates required to achieve target blood or effect site concentra-
tions predefined by the anesthetist. We started with a target
effect site concentration propofol infusion of 1 μg/mL with
the level slowly titrated upward to 2.5 μg/mL according
to the patient’s response to stimulation during scalp block.
Simultaneously, dexmedetomidine was started with an ini-
tial 1 μg/kg bolus over 10 minutes followed by a 0.2 μg/
kg/h infusion and titrated up to a maximum of 0.7 μg/kg/h.
HFNO was commenced immediately after the start
of sedation. The system we used was AIRVO 2 (Fisher &
Paykel, Auckland, New Zealand), which delivers a humidi-
fied air-oxygen mixture at a flow rate of up to 60 L/min. The

XXX 2017 • Volume XXX • Number XXX cases-anesthesia-analgesia.org

1
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 gas mixture, ranging from Fio2 0.21 to 1.0, passed through

monitoring at end of operation

an active heated humidifier before reaching our patient

slowly tailed down near the

end to wake patient up for
Sedation titrated to BIS and
via a wide-bore nasal cannula. The respiratory circuit was
equipped with heated wires to minimize condensation.
End of Testing
Up to End of
Operation
Supplemental oxygen was initiated at 10 L/min. With an

0.5–1.5

0.2–0.5

60
6
initial air flow rate at 30 L/min, oxygen saturation stayed
above 97% except for a sudden drop to 89% 20 minutes
into sedation when stimulation from needling temporarily
ceased. This desaturation was quickly remedied by increas-
ing air flow rate to 60 L/min without changing the oxygen
flow rate. Infusion rates were unchanged as the block was
still ongoing. After completing the scalp block, sedation was
Sedation titrated to BIS to aim Low-dose sedation continued stopped to confirm adequate pain control and to ensure
for waking patient before dura as patient was anxious
and Intermittent
Dura Opening

patient comfort after positioning.

0.2–0.7
Testing

The patient was sedated again before the dura was

0–1

60
6

during testing
opened, and bispectral index monitoring (target bispectral
index 60–70) was used to avoid excessive sedation and facil-
itate rapid awakening of the patient for brain mapping. A
second ABG obtained during deep sedation was: pH 7.30,
Paco2 6.93 kPa (52 mm Hg), Pao2 24.3 kPa (182 mm Hg), and
Sao2 99%. Both cortical and subcortical mapping were per-
formed for motor function using low-frequency (60 Hz) con-
tinuous biphasic square-wave pulse stimulation delivered
Begin Up to Dura
From Operation

by a bipolar probe. The entire mapping procedure lasted for

Opening
1.5–2

2 hours, and positive sites for speech articulation (at the ven-
0.7

60
6

tral premotor cortex) and hand and thigh motor power (at
the precentral gyrus) were identified. Postoperative visual
opening

analog scale (0–10) pain assessment during various phases

of the operation was as follows: during head-pin fixation
1/10; skin incision 0/10; mapping 0/10; and during tumor
Operation and Checking

resection 0/10. The patient was satisfied with the level of

Patient Comfort

pain control, and the assessors of speech articulation could

Positioning for
Table. Sedation and HFNC Regimen in Relation to Intraoperative Events

clearly hear his verbal responses.

10
60

The patient was resedated for wound closure. A final

0

Abbreviations: BIS, bispectral index; HFNC, high-flow nasal cannula; TCI, target-controlled infusion.

ABG taken when the patient was fully aroused at the con-
clusion of the operation was pH 7.34, Paco2 5.98 kPa (45 mm
Hg), Pao2 18.2 kPa (136 mm Hg), and Sao2 99%. Throughout
the 6-hour operation, the patient remained hemodynami-
despite desaturation as
sedation level was not

cally stable with an oxygen saturation of 97% to 98% all

Sedation not decreased
Desaturation During

deepened before the

along with continuously applied HFNC set at a constant

Scalp Block

flow rate of 60 L/min to deliver a gas mixture of 35°C and

1–2.5

0.7

10
60

Fio2 0.4 to 0.5.

episode

DISCUSSION
HFNC first gained popularity in neonatal medicine to treat
respiratory distress syndrome and is considered a safe and
Dexmedetomidine 1 μg/kg loading over 10 min

well-tolerated mode of oxygen delivery to infants and older

movement in response to
Sedation titrated to patient

pain during scalp block

children with respiratory disorders. In adults, its appli-

and Scalp Block
Line Insertion

cations include chronic obstructive pulmonary disease

then 0.7 μg/kg/h
1–2.5

patients with hypercapnic respiratory failure,5 mild-to-

10
30

moderate acute hypoxemic respiratory failure,6 cardiac sur-

gery patients,7 and an alternative to CPAP in the treatment
of OSA. Its effectiveness is affirmed by improved polysom-
nography results in both adults and children.8
Currently, intraoperative use of HFNC is uncommon.
Oxygen flow (L/min)

In the THRIVE (Transnasal Humidified Rapid-Insufflation

infusion rate

Ventilatory Exchange) study, use of HFNC from the pre-

Air flow (L/min)
(μg/kg/h)
TCI propofol

oxygenation phase to the end of apneic phase was dem-

(μg/mL)

Comments

onstrated to significantly prolong safe apneic duration in

Event

difficult airway patients undergoing hypopharyngeal or

laryngotracheal surgery.9 For difficult airways requiring

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 awake fiberoptic intubation, HFNC provides uninterrupted
oxygen delivery to improve safety and helps in the atomi-
zation and spread of local anesthetics while the humidified
gas reduces mucosal friability to lessen bleeding.10 HFNC
has been used intraoperatively in sedated dental patients
and was found to improve arterial partial oxygen and car-
bon dioxide pressures with fewer intraoperative interrup-
tions when compared to low-flow nasal oxygen therapy.11
In our patient, we expected HFNC to confer the follow-
ing physiological advantages:
1. Carbon dioxide washout of anatomical dead space
and reduced work of breathing.
Compared to conventional facemask delivery,
patients receiving HFNO exhibited a lower respira-
tory rate.12 It can be inferred that HFNC reduces ana-
tomical dead space ventilation such that the minute
alveolar ventilation remains unchanged despite a
decrease in respiratory rate and hence further reduces
the work of breathing.
2. Generation of positive end-expiratory pressure
(PEEP) with improved oxygenation and ventilation.
PEEP is created when a sufficiently high flow of gas
resists against the pressure produced from the expi-
ratory flow. It was demonstrated that esophageal
pressure measured in HFNC patients was higher
compared to those on facemasks, especially during
mouth closure and when gas flow was increased with
a mean airway pressure of up to 7.1 cm H2O at 50 L/
min.12,13 The resultant PEEP translates to less airway
collapse and atelectasis and greater end-expiratory
lung volume.14 A small but significant increase in
Pao2/Fio2 ratio is found in respiratory failure patients
on HFNC compared to a nonrebreathing facemask.15
However, it is inferior to CPAP as the PEEP generated
from HFNO is influenced by factors like leakage, gen-
der differences (different upper airway dimensions),
and mouth closure.15
3. More reliable fraction of inspired oxygen (Fio2).
In a low-flow oxygen delivery device, Fio2 is affected
by oxygen flow rate and respiratory rate. This effect
is diminished by the high-flow effect of HFNO. A
minimal flow rate of 30 L/min can deliver a predeter-
mined Fio2 during normal nose breathing.13
4. Benefits of heat and humidification.
CPAP often causes naso-oral discomfort due to deliv-
ery of dry cold gas. It can trigger bronchoconstriction
and reduce respiratory compliance. Mucosal drying
also impairs mucociliary function and atelectasis. In
contrast, warm and humidified gas delivered through
HFNC is much better tolerated6 and improves pulmo-
nary compliance.13
The anticipated respiratory benefits from HFNO were con-
firmed by our sequential ABG analysis, with only a small
increase of Paco2 and well-maintained Pao2. The advan-
tages of HFNO in the setting of awake craniotomy are
improved patient comfort, ease of use, and smooth transi-
tions between sleep and awake phases compared to endo-
tracheal intubation or laryngeal mask airway insertion. The
nasal cannula is less bulky than the CPAP mask, thereby
avoiding interruption of the surgical field, and allows better
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Copyright © 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
assessment of speech and orofacial motor function during
mapping.
Potential drawbacks of HFNO include risk of operating
room fire and burn injuries, especially when diathermy is
used near high-flow oxygen, accumulation of condensate
in the breathing tube which may lead to nosocomial infec-
tion, displacement of the nasal prongs, and lack of a secured
airway in case of intraoperative seizures or respiratory
depression.
In summary, although not yet widely used in operating
rooms, HFNC is a promising modality of ventilatory sup-
port for OSA patients for intraoperative sedation, such as
that given for awake craniotomy. E
DISCLOSURES
Name: Jaclyn W. M. Wong, MBChB.
Contribution: This author helped review the background litera-
ture, and write, edit and revise the manuscript.
Name: Amy H. S. Kong, MBChB.
Contribution: This author helped conceive and design the study,
recruit the patient, acquire the data, and edit and revise the
manuscript.
Name: Sau Yee Lam, MBChB.
Contribution: This author helped conceive and design the study,
recruit the patient, acquire the data, and revise the manuscript.
Name: Peter Y. M. Woo, FRCS.
Contribution: This author helped recruit the patient, and edit and
revise the manuscript.
This manuscript was handled by: Raymond C. Roy, MD.
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