Obstructive Sleep

ApneadImplications
for Procedural Sedation
j Celestine O. Okwuone, MD; Wilson Po, MD; John T. Swick II, MD; and Piotr K. Janicki, MD, PhD

ABSTRACT: Obstructive sleep apnea (OSA) represents a significant problem, especially in the growing popula-
tion of obese patients having radiological, medical and surgical procedures requiring sedation. Due to the
increased risk of loss of airway and difficulty in securing an adequate airway in OSA patients, particularly
during emergency situations, it is very important to understand the condition of OSA, the associated anatomic
and physiologic variations, the potential problems, as well as the effective management strategies. (J Radiol
Nurs 2006;25:2-6.)

O
bstructive sleep apnea (OSA) is one of the
worst sleep disorders, with a prevalence esti-
mated to be 20e30 million people (National
Commission on Sleep Disorders Research, 1993); 6 mil-
lion of whom have severe enough symptoms to benefit
from immediate medical intervention. OSA affects
1e4% of the middle-aged population in the United
States (Benumof, 2001). Approximately 24% of adult
men and 9% of adult women are affected (Meoli
et al., 2003). Presently, however, only about 500,000
patients are undergoing treatment for OSA (Young,
Evans, Finn, & Palta, 1997). Significant risk factors
for OSA include snoring with increased age and obe-
sity, which may explain the increasing rate of OSA in
the United States (Strohl & Redline, 1996).
Patients with OSA are at higher risk for periopera-
tive complications due to upper airway obstruction
Celestine O. Okwuone is an assistant professor of Anesthesiology from
the Department of Anesthesiology at Penn State Milton S. Hershey
Medical Center, Hershey.
Wilson Po is an instructor of Anesthesiology from the Department of
Anesthesiology at Penn State Milton S. Hershey Medical Center,
Hershey.
John T. Swick II is a resident of Anesthesiology from the Department of
Anesthesiology at Penn State Milton S. Hershey Medical Center,
Hershey.
Piotr K. Janicki is a professor of Anesthesiology from the Department
of Anesthesiology at Penn State Milton S. Hershey Medical Center,
Hershey.
Address reprint requests to Piotr K. Janicki, Department of
Anesthesiology, H187, Penn State Milton S. Hershey Medical
Center, 500 University Drive, Hershey, PA 17033. E-mail:
pjanicki@psu.edu
1546-0843/$32.00
Copyright Ó 2006 by the American Radiological Nurses Association.
doi: 10.1016/j.jradnu.2005.11.001
during sleep, sedation, or anesthesia. OSA is defined
as a cessation of airflow despite continuing respiratory
effort, exceeding 10 s in duration and occurring 5 or
more times per hour of sleep. It is also accompanied
by oxygen desaturation of more than 4%. A severe
form of OSA is called obstructive sleep hypopnea,
and is defined as a reduction in airflow of more than
50% for more than 10 s, 15 or more times per hour
of sleep, and again accompanied by desaturation of
4% (Benumof, 2001). Apneas can be obstructive, char-
acterized by persistent ventilatory effort without air-
flow, central when ventilatory effort is absent, and
mixed when it is a combination of both. The term
OSA syndrome is applied when episodes of sleep apnea
are accompanied by daytime sequelae such as excessive
daytime sleepiness (Loadsman & Hillman, 2001).
A significant percentage of patients with OSA are
overweight, obese, or morbidly obese. Obesity is ex-
pressed quantitatively as body mass index (BMI)1 of
greater than 30. Ninety percent of OSA patients may
have a BMI greater than 28 kg/m2. OSA with concur-
rent obesity increases the risks of cardiovascular and
pulmonary complications in most individuals, espe-
cially during sedation.
DIAGNOSIS OF OSA
The definitive diagnosis of OSA can be made from
a sleep study. The gold standard is a full overnight
polysomnography, which can be done in a sleep lab
or at home. Interestingly though, patients preferred
1
BMI Z mass/height2 Z kg/m2; normal Z 19.0e24.9, overweight Z
25.0e29.9, obesity Z 30.0e34.9, and morbid obesity R35.0. SI unit is
kg/m2.

2 www.radiologynursing.org MARCH 2006

Obstructive Sleep Apnea JOURNAL OF RADIOLOGY NURSING
laboratory testing rather than home testing (den
Herder, Schmeck, Appelboom, & de Vries, 2004). A
presumptive diagnosis of OSA is commonly made in
patients with clinical signs and symptoms of obesity,
snoring, apparent arousal at night, and daytime sleepi-
ness (Benumof, 2001). The Epoworth Sleepiness Scale
can also be used to screen for OSA, but it has a low
specificity and sensitivity (den Herder et al.).
Signs associated with OSA are edematous soft palate
or uvula, decreased oropharyngeal dimensions, maxil-
lary hypoplasia, and retrognathia. Some of the symp-
toms associated with OSA are heavy snoring,
excessive daytime sleepiness, and witnessed apneas usu-
ally by a partner. Predisposing factors include increas-
ing age, male gender, use of alcohol, obesity
(BMI O 30), large neck circumference (O44 cm), and
alterations in craniofacial morphology such as macro-
glossia, retrognathia, and narrow hypopharynx (den
Herder et al., 2004).
ANESTHESIA AND SEDATION
In the perioperative management of diagnosed and
undiagnosed OSA patients, the main goal is to avoid
inadequate ventilation and oxygenation because these
events increase morbidity and mortality, mostly sec-
ondary to hypoxemia and hypercapnea (Meoli et al.,
2003). Patients with OSA are generally not good candi-
dates for outpatient surgery or procedures requiring
general anesthesia, although some literature suggests
that they do not have an increased risk of unanticipated
admissions (Sabers, Plevak, Schroeder, & Warner,
2003). In general, there is a greater incidence of difficult
intubation in patients with OSA, should the need for
intubation arise; therefore, regional anesthesia with ei-
ther neuroaxial or individual nerve blocks is encour-
aged if the procedure can be tolerated with a regional
anesthetic. The use of short-acting anesthetic agents
(midazolam, fentanyl, propofol, ketamine, etc.) is also
favored.
Patients with OSA should be identified. They can
come either with a definitive diagnosis from a sleep
study or with symptoms of OSA suggesting that pa-
tients should undergo sleep studies before admission.
If this is not possible and the surgery or procedure
needs to proceed, then patients with symptoms of
OSA should be treated the same way as those with a de-
finitive diagnosis of OSA. Patients using continuous
positive airway pressure (CPAP) mask devices at
home should be encouraged to have them available be-
cause they may be useful during the perioperative pe-
riod (Hillman, Loadsman, Platt, & Eastwood, 2004).
Sedation should be supervised and monitored, a diffi-
cult airway cart with essential airway devices should
be in the room, and airway experts should be readily
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Okwuone et al
available. If endotracheal intubation is indicated, the
decision to do it asleep or awake depends on the ability
to mask ventilate the patient using the hand-bag tech-
nique. If intubation is planned when awake, it is very
important that the patient is fully prepared. Sedation
and analgesics should be given judiciously or even elim-
inated depending on the status of the patient. Nerve
blocks of the upper airway should be done, followed
by oral or nasal flexible fiberoptic scope intubation. If
the patient is to be intubated asleep, proper positioning
and adequate preoxygenation for at least 3 min should
be done (Benumof, 2001). Use of a short-acting muscle
relaxant like succinylcholine is well advised because of
its very short duration of action. Extubaton of patients
with OSA is associated with higher risk of airway ob-
struction. The decision to extubate in the operating
room, other alternative procedure sites, intensive care
units, or the postanesthesia care unit should be based
on the induction experience of providing mask ventila-
tion; the patient should be fully awake and able to fol-
low commands. Full reversal of the neuromuscular
agent should be documented, and emergency airway
devices and experts should also be readily available.
CARE FOR PATIENTS WITH OSA DURING
PROCEDURAL SEDATION
Monitoring
An important point to keep in mind is that sedation
is given for a reason. Commonly, this is to counteract
some type of unpleasant stimuli (e.g., auditory, visual,
tactile) or anxiety. In the immediate postprocedure pe-
riod, the patient has less stimulation but still has resid-
ual sedation. This situation can be even more
problematic in a patient with OSA.
When caring for the patient with OSA undergoing
sedation, careful monitoring after the procedure is
mandatory. At a minimum, pulse oximetry and blood
pressure monitoring should be used. A supplemental
oxygen delivery device should be nearby. Emergency
resuscitation equipment, including invasive airway de-
vices, electrocardiography with defibrillator, bag valve
mask, and emergency cardiac medications, should be
readily available.
Potential Problems
Poor oxygenation is the most common problem en-
countered in patients with OSA receiving sedation.
When encountering any problems with oxygenation,
two vital steps should be taken: open the airway and
provide supplemental oxygenation. Snoring respira-
tions are an indication of partial airway obstruction
and are commonly present in patients with OSA. Ab-
sence of snoring can be either no airway obstruction
or complete airway obstruction and must be evaluated
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Okwuone et al JOURNAL OF RADIOLOGY NURSING
immediately. Often, airway obstruction can be allevi-
ated by a simple head tilt and chin lift. If this does
not resolve the obstruction, airway adjuncts must be
used. For the patient with a partial airway obstruction,
a nasal airway can be helpful. Unlike an oral airway,
a nasal airway is easily tolerated by conscious patients.
It should be inserted cautiously and with lubricant so as
to prevent bleeding from nasal trauma. If the airway
obstruction is not resolved with the nasal airway and
the patient will tolerate it, an oral airway would be
the next appropriate choice.
Immediately after opening the airway, supplemental
oxygen should be delivered. A nasal cannula delivering
up to 6 L/min can deliver an FiO2 of up to 0.45. If this
fails to improve oxygenation, a nonrebreather face-
mask should be used, which will deliver an FiO2 up
to 1.0 in a spontaneously ventilating patient.
For patients who use CPAP delivery devices at
home, it is imperative that it is brought with them
for the recovery period. Even patients who have not
been diagnosed with OSA or do not use CPAP at
home may benefit from using CPAP in the recovery pe-
riod. It is important that there is a complete seal be-
tween the device and the patient’s face. The principle
behind the usage of CPAP is that positive pressure
air maintains patency in the easily obstructed upper
airway.
A basic understanding of the pharmacology of com-
monly used sedative medications is helpful when caring
for recovering patients. Generally speaking, opioids
(e.g., fentanyl and morphine) are primarily used for
their analgesic properties; however, they also have sed-
ative properties and all have the side effect of dose-de-
pendent respiratory depression. Benzodiazepines are
commonly used sedative medications and are probably
the most appropriate for procedural sedation.
When determining how long a patient should be
monitored during recovery, it is important to take into
consideration the dose, timing, and type of sedatives be-
ing given. Ideally, a sedative medication with duration
of action appropriate for the procedure should always
be given. Some common benzodiazepine medications,
dosages, and half-lives are listed in Table 1.
In the event a benzodiazepine overdose has oc-
curred, flumazenil is the only antagonist for this class
of medications. For opioid overdoses causing respira-
Table 1. Basic pharmacokinetic parameters of drugs
used for short sedation (Katzung, 1998)
Drug Adult dose Half-life (hr)
Midazolam 1e2 mg intravenous 2e4
Alprazolam 0.25e0.50 mg peroral 12e15
Lorazepam 1e2 mg peroral 10e20
Diazepam 5 mg peroral 20e80
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Obstructive Sleep Apnea
tory depression, naloxone can be used. An important
point to consider with the usage of both flumazenil
and naloxone is that the duration of these medications
is often shorter than that of the drugs they are antago-
nizing. The use of these medications can lead to a period
of immediate reversal of sedation, followed much later
by a resedation.
Discharge Criteria
Patients with OSA should be observed for at least
1 hr in a recovery area after sedation. Other minimum
criteria for discharge include the following:
1. Easily arousable
2. Full orientation
3. The ability to maintain and protect airway
4. Stable vital signs for at least 30e60 min
5. The ability to call for help if necessary (Morgan,
Mikhail, & Murray, 2002)
GENERAL RECOMMENDATIONS
Procedural sedation involves obtaining sublevel states
of consciousness with the aid of medications adminis-
tered either orally or intravenously in a controlled,
sometimes titrated, manner. The risk of oversedation
is a persistent precaution, because this may lead to
loss of airway, hypoxia, tissue injury, and death.
Patients diagnosed with OSA have increased sensi-
tivity to sedatives so that small doses may lead to early
loss of airway. In those with hypopnea syndrome, there
is an increased risk of hypertension (Lavie, Herer, &
Hoffstein, 2000), heart arrhythmias (Harbison,
O’Reilly, & McNicholas, 2000), myocardial infarction
(Peker, Hedner, Kraiczi, & Loth, 2000), and stroke
(Harbison & Gibson, 2000), which can all be exacer-
bated by hypoxia. OSA patients for procedural seda-
tion should be evaluated, prepared, and monitored as
though they are scheduled for general anesthesia. Rec-
ommendations will be described further in terms of pre-
procedure evaluations, intraprocedural management,
and postprocedure care.
The following steps are recommended during the
evaluation, management, and postsedation care of pa-
tients with OSA undergoing procedural sedation.
PREPROCEDURE EVALUATION
- Adequate history should be obtained to verify the
severity of the OSA as well as other complications
of hypopnea syndrome (Peker, Hedner, Norum,
Kraiczi, & Carlson, 2002). The use of home oxy-
gen and CPAP devices is essential information
that suggests the severity of the OSA.
- Physical examination should be performed to de-
termine the presence and severity of OSA and its
complications. Elective procedures may be
MARCH 2006
Obstructive Sleep Apnea JOURNAL OF RADIOLOGY NURSING
deferred for proper evaluations, investigations,
and treatments, if indicated.
- Preprocedure sedation should be avoided unless
the patient is extremely anxious (Schellenberg,
Maislin, & Schwab, 2000). Continuous nursing
supervision, monitoring of oxygen saturation,
and oxygen administration should be a standard.
Intravenous access for possible administration of
sedative antagonist medications should be
available.
- The presence of emergency airway equipment and
an expert in managing difficult airways should be
at close proximity.
INTRAPROCEDURE MANAGEMENT
- A dedicated staff with credentials for administer-
ing conscious sedation is needed. Pulse oximetry,
electrocardiography, and blood pressure monitors
should be the minimum acceptable.
- Emergency airway equipment and an expert must
be available.
- The use of regional anesthetic techniques (spinal,
epidural, nerve blocks) whenever possible may
completely eliminate the need for sedation, or de-
crease quite significantly the amount of sedation
needed.
- The choice of sedative agents should be made with
caution. Those with direct antagonists are pre-
ferred: benzodiazepinesdmidazolam and diaze-
pam (antagonist is flumazenil); opioidsd
morphine and fentanyl (antagonist is naloxone).
- Medications with short duration of action, such as
midazolam, fentanyl, propofol, and ketamine,
may be preferred to the longer-acting sedatives
such as morphine and diazepam.
- Slow titration of sedatives using specialized infu-
sion pumps may be preferred to bolus administra-
tion, because it leads to a more steady plasma
concentration with less chance of oversedation.
- Emphasis on the difficulty in securing the airway
in many OSA patients who are obese must be
stressed. In obese patients, because of low func-
tional residual capacity and other factors (Schel-
lenberg et al., 2000), desaturation occurs within
a few minutes of apnea or airway obstruction. En-
dotracheal intubation during these anxious pe-
riods may be a nightmare and can be followed
with negative, sometimes fatal, outcomes.
- Procedures likely to require profound sedation be-
cause of pain, long duration, etc. with a high risk
of emergent airway loss may actually be com-
menced with a secured airway and further moni-
toring by an experienced anesthesia provider
(Benumof, 1991).
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Okwuone et al
- The supine position makes breathing difficult for
obese OSA patients; it exacerbates upper airway
obstruction while under sedation. The lateral de-
cubitus position helps to reduce this problem
and should be encouraged if appropriate for the
desired procedure. Similar improvement in
breathing can be achieved by the head-up position
(reverse trendelenburg).
- Oral or nasopharyngeal airway devices can assist
in preventing upper airway obstruction in OSA
patients. The drawback is the significant irritabil-
ity associated with these devices that may necessi-
tate a deeper plane of sedation for their tolerance
(Benumof, 1991).
- It may be beneficial for a patient using a CPAP
mask device at home to continue its use during
the procedure. An OSA patient who under normal
circumstances does not require a CPAP device
may benefit from it during profound sedation.
POSTPROCEDURE CARE
- Close observation in a high-dependency area (re-
covery room, postanesthesia care unit) is indicated
until the patient is deemed fully awake and able to
maintain an unaided patent airway, can apply
a CPAP mask if needed, or is back to baseline
level of consciousness (Rosenberg et al., 1999).
- Oxygen administration, pulse oximetry, ECG, and
blood pressure monitoring should continue until
discharge.
- Emergency airway equipment and personnel
should remain available.
- Postprocedure pain relief, if indicated, should be
with nonsedative analgesics such as ketorolac
(Toradol) or acetaminophen (Tylenol) whenever
possible or by regional techniques (Pellecchia,
Bretz, & Barnette, 1987).
- If OSA is a new diagnosis, a referral to a sleep
physician for further evaluation and investigation
should be considered.
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