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OSA, OIRD and Airway Obstruction: Vigilance Required

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Authors:  Davide Cattano, MD, PhD, FASA et al

Anesthesiology News

Opioid-induced respiratory depression (OIRD) has been recognized as one of the most dramatic and serious complications from the perioperative use of opioid analgesics. Current international efforts to publicize to the lay public the potential effects of misusing opioids, such as the risk for addiction, have had a surprising effect on clinical practice by favoring the development of multimodal analgesic strategies designed to reduce, or sometimes avoid altogether, the use of opioids.1

An interesting and specific concern during the perioperative period is the identification of the “at-risk” population. Historically obesity, especially when associated with obstructive sleep apnea (OSA), has been considered a significant risk factor for OIRD, with increased morbidity and mortality rates.2 The correlation between obesity, OSA and OIRD has been challenged by clinical experiences that included patients with these comorbidities during postoperative care who were exposed to opioid-based analgesia and monitored through lung volume capacity calculated from electrical impedance.3,4 Other studies showing an opioid-titrated effect on airway obstruction have indeed pointed out the not-so-common association between OIRD and OSA.5,6 Thus, it seems important to underscore that the common belief that OSA may be a predisposing factor to OIRD is inconsistent. OIRD seems to occur regardless of obesity status or existing OSA, making an argument against considering patients who are obese or have OSA being at greater risk for OIRD.

However, a second and more important factor deserves attention: airway obstruction. Airway obstruction is of great concern in the perioperative period: Patients’ sensitivity to opioids7 may still be observed in a dangerous scenario in which patients experience respiratory depression and ventilatory insufficiency (residual paralysis, atelectasis, splinting, positioning, body habitus). Therefore, we want to stress that, while opioids per se may not necessarily have a greater effect in obese patients or those with OSA, the increased risks for airway obstruction in these patients still call for greater caution and demand an increased level of monitoring, with a meticulous, clinical approach.

A recent update from the Society of Anesthesia and Sleep Medicine’s task force issued practice management guidelines8 to increase awareness that OSA may coexist with and be a complicating factor of OIRD, thus not predisposing but a comorbidity. An effective best practice remains vigilance and appropriate monitoring while we continue to identify which factors will predict patients at risk.

References

  1. Penm J, MacKinnon NJ, Boone JM, et al. Strategies and policies to address the opioid epidemic: a case study of Ohio. J Am Pharm Assoc (2003). 2017;57(2S):S148-S153.
  2. Cozowicz C, Chung F, Doufas AG, et al. Opioids for acute pain management in patients with obstructive sleep apnea: a systematic review. Anesth Analg. 2018;127(4):988-1001.
  1. Cattano D, Brayanov J, George EE. Respiratory volume variability prior to opioid administration as an indicator for opioid-induced respiratory depression. Am J Respir Crit Care Med. 2015;191:A1081.
  2. Mehta JH, Cattano D, Brayanov JB, et al. Assessment of perioperative minute ventilation in obese versus non-obese patients with a non-invasive respiratory volume monitor. BMC Anesthesiol. 2017;17(1):61.
  3. Doufas AG, Shafer SL, Rashid NHA, et al. Non-steady state modeling of the ventilatory depressant effect of remifentanil in awake patients experiencing moderate-to-severe obstructive sleep apnea. Anesthesiology. 2019;130(2):213-226.
  4. Bernards CM, Knowlton SL, Schmidt DF, et al. Respiratory and sleep effects of remifentanil in volunteers with moderate obstructive sleep apnea. Anesthesiology. 2009;110(1):41-49.
  5. Zinchuk AV, Gentry MJ, Concato J, et al. Phenotypes in obstructive sleep apnea: a definition, examples and evolution of approaches. Sleep Med Rev. 2017;35:113-123.
  6. Memtsoudis SG, Cozowicz C, Nagappa M, et al. Society of Anesthesia and Sleep Medicine guideline on intraoperative management of adult patients with obstructive sleep apnea. Anesth Analg. 2018;127(4):967-987.

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