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Guideline Summary
Guideline Title
Evidence-based patient safety advisory: patient assessment and prevention of pulmonary side effects in surgery. Part 1 - obstructive sleep apnea and obstructive lung disease.
Bibliographic Source(s)
Haeck PC, Swanson JA, Iverson RE, Lynch DJ, ASPS Patient Safety Committee. Evidence-based patient safety advisory: patient assessment and prevention of pulmonary side effects in surgery. Part 1--obstructive sleep apnea and obstructive lung disease. Plast Reconstr Surg. 2009 Oct;124(4 Suppl):45S-56S. [73 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)
  • Perioperative pulmonary complications
  • Obstructive sleep apnea
  • Obstructive lung disease
Guideline Category
Evaluation
Management
Prevention
Treatment
Clinical Specialty
Anesthesiology
Otolaryngology
Plastic Surgery
Pulmonary Medicine
Surgery
Intended Users
Advanced Practice Nurses
Health Care Providers
Physician Assistants
Physicians
Guideline Objective(s)
  • To provide an overview of the preoperative steps that should be performed to ensure appropriate patient selection and the safety of patients with obstructive sleep apnea and obstructive lung disease
  • To provide recommendations for perioperative management and strategies for minimizing complications
Target Population

Patients with obstructive sleep apnea and obstructive lung disease who are undergoing plastic or reconstructive surgery

Interventions and Practices Considered

Risk Assessment/Evaluation

  1. Assessment of patients with obstructive sleep apnea (OSA)
    • Assessment of signs and symptoms of OSA
    • Referral for additional tests (sleep studies, more extensive airways assessment) and OSA treatment
    • Physical examination (airway, nasopharyngeal characteristics, tonsil and tongue size, neck circumference, body mass index [BMI])
    • Determination of whether patient able to undergo ambulatory surgery in facility with appropriate equipment
  2. Assessment of patients with obstructive lung disease
    • Assessment of signs and symptoms of obstructive lung disease
    • Medical history
    • Physical examination
    • Chest radiography as indicated
    • Referral to pulmonologist for assessment of pulmonary function
    • Determination of whether patient is able to undergo ambulatory surgery in facility with appropriate equipment

Management/Prevention/Treatment

  1. Management of patients with OSA
    • Preoperative continuous positive airway pressure (CPAP)
    • Continuous monitoring following premedication administration
    • Use of local or regional anesthesia if possible
    • Ventilation monitoring by capnography if sedatives administered
    • Securing the airway (if general anesthesia used)
    • Endotracheal intubation
    • Determination of time to extubation
    • Avoidance of opioids for pain management
    • Supplemental oxygen
    • Postoperative pain management
    • CPAP plus supplemental oxygen (for postoperative hypoxia)
    • Postoperative monitoring
  2. Management of patients with obstructive lung disease
    • Preoperative steroid support
    • Preoperative prophylaxis for endotracheal intubation (corticosteroids, lidocaine, beta-2 adrenergic agonists)
    • Preoperative sedation with benzodiazepines
    • Endotracheal intubation
    • General anesthesia (volatile anesthetics, e.g., halothane, sevoflurane, propofol)
    • Avoidance of anesthetics, analgesics, and muscle relaxants with histamine-releasing properties
    • Extubation under deep anesthesia
    • Treatment of intraoperative bronchospasm
    • Use of lung expansion maneuvers postoperatively
Major Outcomes Considered
  • Pulmonary complications following surgery
  • Intraoperative and postoperative morbidity and mortality

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

PubMed and the Cochrane Library were searched. The search terms used were: perioperative pulmonary complications, pulmonary complications, respiratory complications, patient selection, preoperative assessment, physical examination, medical history, predictors, risk factors, comorbidity, chronic obstructive lung disease (COPD), asthma, obstructive lung disease, severity, location of surgery, type of surgery, intraoperative care, postoperative care, continuous positive airway pressure (CPAP), intubation, extubation, Mallampati classification, sedation, anesthesia, analgesia. No limits were set on publication dates in the searches. The searches included all types of published articles. However, articles that were critically appraised and rated for level of evidence were limited to systematic reviews, meta-analyses, randomized controlled trials (RCTs), clinical trials, comparative studies, case series and case reports.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Evidence Rating Scale for Studies Reviewed

Level of Evidence Qualifying Studies
I High-quality, multi-centered or single-centered, randomized controlled trial with adequate power; or a systematic review of these studies
II Lesser-quality, randomized controlled trial; prospective cohort study; or a systematic review of these studies
III Retrospective comparative study; case-control study; or a systematic review of these studies
IV Case series
V Expert opinion; case report or clinical example; or evidence based on physiology, bench research, or "first principles"
Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence

The supporting literature was critically appraised for study quality according to criteria referenced in key publications on evidence-based medicine. Depending on study design and quality, each reference was assigned a corresponding level of evidence (I through V) with the American Society of Plastic Surgeons (ASPS) Evidence Rating Scales, and the evidence was synthesized into practice recommendations (see "Rating Scheme for the Strength of the Evidence").

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations
Grade Descriptor Qualifying Evidence Implications for Practice
A Strong Recommendation Level I evidence or consistent findings from multiple studies of levels II, III, or IV Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.
B Recommendation Levels II, III, or IV evidence and findings are generally consistent Generally, clinicians should follow a recommendation but should remain alert to new information and sensitive to patient preference.
C Option Levels II, III, or IV evidence, but findings are inconsistent Clinicians should be flexible in their decision-making regarding appropriate practice, although they may set bounds on alternatives; patient preference should have a substantial influencing role.
D Option Level V; little or no systematic empirical evidence Clinicians should consider all options in their decision-making and be alert to new published evidence that clarifies the balance of benefit versus harm; patient preference should have a substantial influencing role.
Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

The guideline was approved by the American Society of Plastic Surgeons (ASPS) Executive Committee on October 25, 2007.

Recommendations

Major Recommendations

Definitions for the levels of evidence (I–V) and the grades of the recommendations (A–D) are provided at the end of the "Major Recommendations" field.

Recommendations Supporting Evidence Grade
Obstructive Sleep Apnea (OSA)
Patient Selection

For patients without previous diagnosis of OSA, inquire about the following symptoms: airway obstruction during sleep; loud and frequent snoring; frequent arousal from sleep, especially with choking sensation; daytime somnolence or fatigue; falling asleep in nonstimulating environments (e.g., watching television, reading, driving); it may also be helpful to interview family members, as they may have witnessed some of the symptoms (e.g., apneic events, restless sleep, vocalizations).

Expert opinion

D

For patients with suspected OSA, the surgeon and anesthesia provider may decide to refer the patient for additional tests (e.g., sleep studies, more extensive airway assessment) and OSA treatment before surgery.

   

The physical examination should include an evaluation of the airway, nasopharyngeal characteristics, tonsil and tongue size, neck circumference, and body mass index (BMI).

Liistro et al., 2003; Kheterpal et al., 2006

B
Surgical Setting

Only minor procedures under local or regional anesthesia should be performed in a freestanding ambulatory or office-based settings.

Expert opinion

D

Much consideration should be given to factors such as sleep apnea status, anatomical and physiologic abnormalities, status of comorbidities, nature of surgery, type of anesthesia, need for postoperative opioids, patient age, adequacy of postdischarge observation, and capabilities of the outpatient facility.

   

The American Society of Anesthesiologists (ASA) believes that patients at significantly increased risk of perioperative complications generally are not appropriate candidates for procedures in free standing outpatient settings.

   

If it is determined that a patient with OSA can safely undergo ambulatory surgery, the facility should be appropriately equipped to handle potential complications and have transfer arrangements with an inpatient facility.

   
Preoperative

Continuous positive airway pressure (CPAP) has been shown to be effective at treating OSA; preoperative CPAP may be beneficial, especially in patients who are already using home CPAP

Gupta et al., 2001; Rennotte et al., 1995; Ballester et al., 1999; Jenkinson et al., 1999; Spicuzza et al., 2006

A, B

If premedication, such as benzodiazepines, will be administered, patients must be monitored continuously for any signs of respiratory compromise; CPAP should be available for use if the patient becomes sleepy and cannot control his or her own airway.

Gupta et al., 2001; Rennotte et al., 1995; Hoijer et al., 1994; Dolly & Block, 1982

B
Intraoperative

If possible, consider local or regional anesthesia.

Expert opinion

D

If sedatives will be used, ventilation should be monitored by capnography.

   

Patients who have been using CPAP preoperatively may benefit from its continued use during sedation.

Gupta et al., 2001; Rennotte et al., 1995

B

If general anesthesia is necessary, it is important to secure the airway, especially for procedures that may compromise the airway; consider short acting drugs; avoid large doses of long-acting drugs, such as neuromuscular blockers.

Expert opinion

D

If endotracheal intubation is necessary, consider intubating in the sniffing position under fiberoptic scope.

Isono et al., 2005

D*

Time to extubate should be based on severity of OSA, surgical site, cardiopulmonary comorbidities, difficult intubation, and intraoperative course; if possible, extubate in semiupright, lateral, or prone position when patient is fully awake with adequate airway muscle tone.

   
Postoperative

If possible, systemic opioids should be avoided; other options, such as local or regional anesthetics and analgesics, a pain pump, nonsteroidal antiinflammatory drugs, or ice, should be considered to avoid use of opioids.

Waters et al., 2002

D*

For patients at increased perioperative risk from OSA, consider administering continuous supplemental oxygen.

Expert opinion

D

If patient experiences recurrent hypoxemia, consider treatment with CPAP and supplemental oxygen.

Gupta et al., 2001; Rennotte et al., 1995

B

If patient used CPAP preoperatively, resume CPAP when patient is awake and alert.

   

Monitor patients longer than non-OSA counterparts; if an episode of airway obstruction or hypoxemia occurs, patients should be continually monitored after the last episode while breathing room air in unstimulated environment; if the patient is in an ambulatory setting, transfer arrangements to an inpatient facility should be made for further monitoring.

Expert opinion

D
Obstructive Lung Disease
Patient Selection

The medical history should include questions about current symptoms (e.g., cough, dyspnea, wheezing) and frequency of symptoms; intensity of treatment (did patient require therapy at a medical facility?); current medications; recent use of rescue medications; tolerance to aspirin, cold air, dust, or smoke; smoking history; and previous exposures to general anesthesia and endotracheal intubation.

Warner, 2000

D**

A complete physical examination should be performed, including chest auscultation, assessment of skin coloration, and chest radiography when indicated.

   

Patients should be free of symptoms and have optimal lung function. If a patient presents with symptoms, elective surgery should be postponed, if possible, pending resolution of symptoms.

   

Patients with severe or uncontrolled disease, or those in which pulmonary status is uncertain, should be referred to a pulmonologist for assessment of pulmonary function.

   

If patients have been on steroid therapy during the past 6 mo before surgery, additional steroid support may be necessary.

   
Preoperative

If endotracheal intubation is required, consider preoperative prophylaxis (corticosteroids, topical lidocaine, beta2-adrenergic agonists).

Groeben et al., 2000; Maslow et al., 2000; Groeben et al., "Both local anesthetics and salbutamol," 2002; Silvanus, Groeben, & Peters, 2004

A

Consider preoperative sedation with benzodiazepines.

Expert opinion

D
Intraoperative

If possible, consider regional anesthesia over general anesthesia.

Groeben et al., "Lung function," 2002

D**

If general anesthesia is required, consider the volatile anesthetics, halothane and sevoflurane, or intravenous propofol.

Goff et al., 2000; Brown, Greenberg, & Wagner, 2001; Pizov et al., 1995

A

Avoid anesthetics and muscle relaxants with histamine-releasing properties (e.g., thiopental, atracurium, mivacurium, succinylcholine).

Celiker & Basgul, 2003

D**

If endotracheal intubation is necessary, consider extubating under deep anesthesia.

Celiker & Basgul, 2003

D**
Treatment of Intraoperative Bronchospasm

If intraoperative bronchospasm is suspected, it is important to first rule out alternative diagnoses (e.g., mechanical obstructions, pneumothorax, pulmonary edema).

Expert opinion

D

If the diagnosis of intraoperative bronchospasm is confirmed, initial treatment includes deepening of anesthesia.

   

For persistent bronchospasm, additional options for treatment include administration of beta2-adrenergic agonists, parasympatholytics, systemic corticosteroids, magnesium, and lidocaine.

   
Postoperative

Avoid analgesics with histamine-releasing properties (e.g., meperidine, morphine).

Celiker & Basgul, 2003

D**

Consider the use of lung expansion maneuvers.

Expert opinion

D

*Evidence composed of only one level III or IV study; more than one study would be needed to assign a higher grade of recommendation.

**Evidence composed of only one level II, III, or IV study; more than one study would be needed to assign a higher grade of recommendation.

Definitions:

Evidence Rating Scale for Studies Reviewed

Level of Evidence Qualifying Studies
I High-quality, multi-centered or single-centered, randomized controlled trial with adequate power; or a systematic review of these studies
II Lesser-quality, randomized controlled trial; prospective cohort study; or a systematic review of these studies
III Retrospective comparative study; case-control study; or a systematic review of these studies
IV Case series
V Expert opinion; case report or clinical example; or evidence based on physiology, bench research, or "first principles"

Scale for Grading Recommendations

Grade Descriptor Qualifying Evidence Implications for Practice
A Strong Recommendation Level I evidence or consistent findings from multiple studies of levels II, III, or IV Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.
B Recommendation Levels II, III, or IV evidence and findings are generally consistent Generally, clinicians should follow a recommendation but should remain alert to new information and sensitive to patient preference.
C Option Levels II, III, or IV evidence, but findings are inconsistent Clinicians should be flexible in their decision-making regarding appropriate practice, although they may set bounds on alternatives; patient preference should have a substantial influencing role.
D Option Level V; little or no systematic empirical evidence Clinicians should consider all options in their decision-making and be alert to new published evidence that clarifies the balance of benefit versus harm; patient preference should have a substantial influencing role.
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Prevention and appropriate management of pulmonary side effects following surgery in patients with obstructive sleep apnea and obstructive lung disease

Potential Harms
  • Regional methods of anesthesia are not without risk, as neuroaxial blockade can paralyze respiratory muscles, compounding respiratory problems in patients with obstructive sleep apnea.
  • It is important to note that certain forms of regional anesthesia (e.g., epidural) may be problematic in patients with severe chronic obstructive pulmonary disease or asthma. Respiratory motor blockade that paralyzes accessory breathing muscles (e.g., abdominal) can inhibit spontaneous breathing, and pulmonary sympathetic blockade increases bronchial tone and reactivity.
  • If the type of surgery will require ischemic preconditioning of flap tissue, it is important to note that adenosine-induced bronchospasm has been reported in patients with obstructive lung disease.

Contraindications

Contraindications

Halothane and sevoflurane, the preferred volatile anesthetics, can prevent bronchoconstriction and effectively treat bronchospasm; however, desflurane and sodium thiopental have been found to be ineffective bronchodilators, and some investigators suggest that they should be contraindicated in patients with obstructive lung diseases.

Qualifying Statements

Qualifying Statements
  • Practice advisories are strategies for patient management, developed to assist physicians in clinical decision-making. This practice advisory, based on a thorough evaluation of the present scientific literature and relevant clinical experience, describes a range of generally acceptable approaches to diagnosis, management, or prevention of specific diseases or conditions. This practice advisory attempts to define principles of practice that should generally meet the needs of most patients in most circumstances. However, this practice advisory should not be construed as a rule, nor should it be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the appropriate results. It is anticipated that it will be necessary to approach some patients' needs in different ways. The ultimate judgment regarding the care of a particular patient must be made by the physician in light of all the circumstances presented by the patient, the diagnostic and treatment options available, and available resources.
  • This practice advisory is not intended to define or serve as the standard of medical care. Standards of medical care are determined on the basis of all the facts or circumstances involved in an individual case and are subject to change as scientific knowledge and technology advance, and as practice patterns evolve. This practice advisory reflects the state of knowledge current at the time of publication. Given the inevitable changes in the state of scientific information and technology, periodic review and revision will be necessary.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Safety

Identifying Information and Availability

Bibliographic Source(s)
Haeck PC, Swanson JA, Iverson RE, Lynch DJ, ASPS Patient Safety Committee. Evidence-based patient safety advisory: patient assessment and prevention of pulmonary side effects in surgery. Part 1--obstructive sleep apnea and obstructive lung disease. Plast Reconstr Surg. 2009 Oct;124(4 Suppl):45S-56S. [73 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 May
Guideline Developer(s)
American Society of Plastic Surgeons - Medical Specialty Society
Source(s) of Funding

American Society of Plastic Surgeons

Guideline Committee

American Society of Plastic Surgeons Patient Safety Committee

Composition of Group That Authored the Guideline

Committee Members: Phillip C. Haeck, M.D. (Chairman); Stephen B. Baker, M.D., D.D.S., Georgetown University Hospital, Washington, D.C.; Charles W. Bailey, Jr., M.D., J.D., Austin, Texas; C. Bob Basu, M.D., M.P.H., Center for Advanced Breast Restoration and Basu Plastic Surgery, Houston, Texas; Lynn A. Damitz, M.D., University of North Carolina, Chapel Hill, North Carolina; Felmont F. Eaves, III, M.D., Charlotte Plastic Surgery, Charlotte, North Carolina; Paul D. Faringer, M.D., Kaiser Permanente, Honolulu, Hawaii; Scot Bradley Glasberg, M.D., Lenox Hill Hospital and Manhattan Eye Ear and Throat Hospital, New York, New York; Lawrence S. Glassman, M.D., Nyack Hospital, Nyack, New York; Karol A. Gutowski, M.D., North Shore University Health System and University of Chicago, Evanston, Illinois; Elizabeth J. Hall-Findlay, M.D., private practice, Banff, Alberta, Canada; Ronald E. Iverson, M.D., Stanford University Medical School, Palo Alto, California; Linda J. Leffel, M.D., Bend, Oregon; Dennis J. Lynch, M.D., retired, Scott and White Healthcare, Texas A&M University, Temple, Texas; Noel B. McDevitt, M.D., Pinehurst Surgical, Pinehurst, North Carolina; Michael F. McGuire, M.D., David Geffen UCLA School of Medicine, Los Angeles, California; Patrick J. O'Neill, M.D., Medical University of South Carolina, Charleston, South Carolina; Neal R. Reisman, M.D., J.D., St. Luke's Episcopal Hospital and Baylor College of Medicine, Houston, Texas; Gary F. Rogers, M.D., Children's Hospital Boston, Boston, Massachusetts; Loren S. Schechter, M.D., Morton Grove, Illinois; Maria Siemionow, M.D., Ph.D., D.Sc., Cleveland Clinic, Cleveland, Ohio; Robert Singer, M.D., University of California, San Diego, La Jolla, California; Gary A. Smotrich, M.D., Lawrenceville Plastic Surgery, Lawrenceville, New Jersey; Rebecca S. Twersky, M.D., M.P.H., SUNY Downstate Medical Center, Brooklyn, New York; Amy G. Wandel, M.D., Mercy Medical Group, Sacramento, California; Ronald H. Wender, M.D., Cedars-Sinai Medical Center, Los Angeles, California; and James A. Yates, M.D. Grandview Surgery Center, Vista Surgery Center, Plastic Surgery Center, and Holy Spirit Hospital, Camp Hill, Pennsylvania

Financial Disclosures/Conflicts of Interest

The authors have no financial interests related to this article.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the American Society of Plastic Surgeons Web site External Web Site Policy.

Print copies: Available from the American Society of Plastic Surgeons, 444 East Algonquin Road, Arlington Heights, IL 60005-4664

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on June 9, 2010. The information was verified by the guideline developer on August 31, 2010.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Copyright ©2009 by the American Society of Plastic Surgeons

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