Elevated Upper Body Position Improves Pregnancy-Related OSA Without Impairing Sleep Quality or Sleep Architecture Early After Delivery

Background Bariatric surgery patients are vulnerable to sleep-disordered breathing (SDB) early after recovery from surgery and anesthesia. The authors hypothesized that continuous positive airway pressure (CPAP) improves postoperative oxygenation and SDB and mitigates opioid-induced respiratory depression. Methods In a randomized crossover trial, patients after bariatric surgery received 30% oxygen in the postanesthesia care unit (PACU) under two conditions: atmospheric pressure and CPAP (8 to 10 cm H2O). During 1 h of each treatment, breathing across cortical arousal states was analyzed using polysomnography and spirometry. Arousal state and respiratory events were scored in accordance with American Academy of Sleep Medicine guidelines. Data on opioid boluses in the PACU were collected. The primary and secondary outcomes were the apnea hypopnea index (AHI) and apnea after self-administration of opioids in the PACU. Linear mixed model analysis was used to compare physiologic measures of breathing. Results Sixty-four percent of the 33 patients with complete postoperative polysomnography data demonstrated SDB (AHI greater than 5/h) early after recovery from anesthesia. CPAP treatment decreased AHI (8 ± 2/h vs. 25 ± 5/h, P < 0.001), decreased oxygen desaturations (5 ± 10/h vs. 16 ± 20/h, P < 0.001), and increased the mean oxygen saturation by 3% (P = 0.003). CPAP significantly decreased the respiratory-depressant effects observed during wakefulness–sleep transitions without affecting hemodynamics. The interaction effects between CPAP treatment and opioid dose for the dependent variables AHI (P < 0.001), inspiratory flow (P = 0.002), and minute ventilation (P = 0.015) were significant. Conclusions This pharmacophysiologic interaction trial shows that supervised CPAP treatment early after surgery improves SDB and ameliorates the respiratory-depressant effects of opioids without undue hemodynamic effects.

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“…Our power calculation was based on our previous report 22 . We expected a mean difference in AHI of 4 with a standard deviation of 7/h.…”

Section: Methodsmentioning

confidence: 99%

Continuous Positive Airway Pressure Mitigates Opioid-induced Worsening of Sleep-disordered Breathing Early after Bariatric Surgery

et al. 2016

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“…Post-partum airway obstruction is a major cause of anesthesia-related maternal death [57]. Consistent with findings in OSA, upper body elevation to 45 degrees increases the cross-sectional area of the upper airway as measured by acoustical pharyngometry and mitigates sleep apnea as measured by polysomnography in women 48 h after delivery [49 ▪ ]. It is prudent to extubate patients at risk of extubation failure in the reverse Trendelenburg position to decrease airway collapse after removal of the endotracheal tube [58].…”

Section: Introductionmentioning

confidence: 75%

Prevention of respiratory complications of the surgical patient

Ruscic

Grabitz

Rudolph

et al. 2017

Current Opinion in Anaesthesiology

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Purpose of reviewPostoperative respiratory complications (PRCs) increase hospitalization time, 30-day mortality and costs by up to $35 000. These outcomes measures have gained prominence as bundled payments have become more common.Recent findingsResults of recent quantitative effectiveness studies and clinical trials provide a framework that helps develop center-specific treatment guidelines, tailored to minimize the risk of PRCs. The implementation of those protocols should be guided by a local, respected, and visible facilitator who leads proper implementation while inviting center-specific input from surgeons, anesthesiologists, and other perioperative stakeholders.SummaryPreoperatively, patients should be risk-stratified for PRCs to individualize intraoperative choices and postoperative pathways. Laparoscopic compared with open surgery improves respiratory outcomes. High-risk patients should be treated by experienced providers based on locally developed bundle-interventions to optimize intraoperative treatment and ICU bed utilization. Intraoperatively, lung-protective ventilation (procedure-specific positive end-expiratory pressure utilization, and low driving pressure) and moderately restrictive fluid therapy should be used. To achieve surgical relaxation, high-dose neuromuscular blocking agents (and reversal agents) as well as high-dose opioids should be avoided; inhaled anesthetics improve surgical conditions while protecting the lungs. Patients should be extubated in reverse Trendelenburg position. Postoperatively, continuous positive airway pressure helps prevent airway collapse and protocolized, early mobilization improves cognitive and respiratory function.

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“…Zaremba et al undertook a randomised, cross-over, PSG study in 30 postpartum women sleeping in non-elevated and 45° elevated body position and reported moderate to severe OSA in 20% of the participants 44. The minimum SpO 2 was higher (p 0.03) and AHI was reduced (p 0.03) in the 45° elevated body position in comparison to non-elevated without affecting sleep quantity or quality.…”

Section: Discussionmentioning

confidence: 99%

Modifying maternal sleep position in the third trimester of pregnancy with positional therapy: a randomised pilot trial

et al. 2018

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ObjectiveTo evaluate whether the percentage of time spent supine during sleep in the third trimester of pregnancy could be reduced using a positional therapy device (PrenaBelt) compared with a sham device.DesignA double-blind, randomised, sham-controlled, cross-over pilot trial.SettingConducted between March 2016 and January 2017, at a single, tertiary-level centre in Canada.Participants23 participants entered the study. 20 participants completed the study. Participants were low-risk, singleton, third-trimester pregnant women aged 18 years and older with body mass index <35 kg/m2 at the first antenatal appointment for the index pregnancy and without known fetal abnormalities, pregnancy complications or medical conditions complicating sleep.InterventionsA two-night, polysomnography study in a sleep laboratory. Participants were randomised by computer-generated, one-to-one, simple randomisation to receive either a PrenaBelt or a sham-PrenaBelt on the first night and were crossed over to the alternate device on the second night. Allocation concealment was by unmarked, security-tinted, sealed envelopes. Participants, the recruiter and personnel involved in setting up, conducting, scoring and interpreting the polysomnogram were blinded to allocation.Primary and secondary outcome measuresThe primary outcome was the percentage of time spent supine during sleep. Secondary outcomes included maternal sleep architecture, respiration, self-reported sleep position and feedback.ResultsThe median percentage of sleep time supine was reduced from 16.4% on the sham night to 3.5% on the PrenaBelt night (pseudomedian=5.8, p=0.03). We were unable to demonstrate differences in sleep architecture or respiration. Participants underestimated the time they spent sleeping supine by 7.0%, and six (30%) participants indicated they would make changes to the PrenaBelt. There were no harms in this study.ConclusionsThis study demonstrates that the percentage of sleep time supine during late pregnancy can be significantly reduced via positional therapy.Trial registration numberNCT02377817; Results.

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Elevated Upper Body Position Improves Pregnancy-Related OSA Without Impairing Sleep Quality or Sleep Architecture Early After Delivery

Cited by 47 publications

References 44 publications

Continuous Positive Airway Pressure Mitigates Opioid-induced Worsening of Sleep-disordered Breathing Early after Bariatric Surgery

Continuous Positive Airway Pressure Mitigates Opioid-induced Worsening of Sleep-disordered Breathing Early after Bariatric Surgery

Prevention of respiratory complications of the surgical patient

Modifying maternal sleep position in the third trimester of pregnancy with positional therapy: a randomised pilot trial

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