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遐苍
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1 2014 / 10 / 21 R2 林書瑜 VS 劉宏濱主任

2 Introduction Drug-induced sleep endoscopy (DISE)uses sedative-hypnotics to induce moderate obstruction to facilitate anatomic differentiation of obstructive physiolygy. A diagnostic tool for Obstructive sleep apnea (OSA) Common collapse sites: palate, pharyngeal wall, tongue base Real time visual observation of the airway May also provide prognostic information

3 Introduction Polysomnography: Sleep disorder diagnosis Sleep-related symptom evaluation Monitors : Electroencephalogram (EEG) Electro-oculogram(Eye movement) Electromyogram(muscle activity) Electrocardiogram (EKG) Nasal pressure transducer Oronasal thermistor(air flow) Oxygen Saturation

4 Introduction Polysomnography:

5 Introduction Obstruction commonly, but not always, occurs contemporaneously with loss of consciousness. Propofol : Reliable prediction of the necessary porpofoldose to achieve and maintain obstruction without causing prolonged loss of consciousness or oxygen desaturation is challenging!

6 Introduction Propofol: Manual bolus Experienced practitioner to obtain consistent results Target-controlled infusion (TCI) Not available in North America Small serial increments in the target to achieve the desired clinical end point => time-consuming porcess

7 Introduction Both Manual and TCI approaches assume that the anesthesiologist can surmise the appropriate target level for each patient. We have previously demonstrated in simulation a method for producing a continuously increasing probability of loss of consciousness with a simple sequence of infusion rates. We hypothesized that such an approach, with a hybrid pharma-cokinetic/pharmacodynamic model, would permit reliable and efficient titration of propofol to an end point of visible airway collapse and/or loss of genioglossus tone in a population with severe OSA.

8 Method 97patients were enrolled in a prospective study of transoral robotic resection of the tongue base The apnea-hypopneaindex (AHI) for each patient was recorded from the sleep study Defined as cessation of breathing for 10 seconds or more The saturation nadirs The lowest oxygen saturation during the night

9 Method All patients were screened with DISE with propofol infusions determined by custom software written in MATLAB The system uses the Cortínez et al. pharmacokinetic model and the Johnson pharmacodynamicmodel to determine an infusion sequence comprised a bolus, initial infusion, secondary infusion, and a time for transition from the initial to secondary infusion using the age and weight of the individual patient.

10 PROPOFOL PHARMACOKINETIC MODEL the model of Cortínez et al PROPOFOL PHARMACODYNAMICS MODEL The model of Johnson et al.

11 Method Propofol was administered by an anesthesiologist. No topical anesthesia/ No other IV drugs 2L/min supplemental oxygen Pulse oximetry A Baxter AS50 pump: Initial bolus and infusion rates as determined by the control system

12 Method Bronchoscope Observation of the pharynx was performed for a sufficient period to obtain images of the anatomic site(s) of obstruction. Comparison of saturation nadirs from DISE and polysomnographywas performed with both the paired and unpaired Student t test.

13 Results Patient characteristics

14 Results The median time to obstruction, as determined by the otorhi-nolaryngologist, was 3.8 minutes. The mean, predicted effect-site concentration of propofol at obstruction was 4.2 ±1.3 mcg/ml. The median saturation nadir during DISE was significantly higher (91.4 ±5.1% IQR) than that during standard sleep studies (81.0% ± 11.2% IQR)

15 Nadir oxygen saturation: The lowest oxygen saturation during the night

16 Discussion DISE with sedation-hypnotics: Midazolam regimen Propofol by TCI or manual bolus In children: dexmedetomidine after sevoflurane induction has been reported

17 Discussion Narrow range of anesthetic depth Patients with AHI > 30 (severe OHA) Most present study excluded higher risk p tswith BMI>30 kg/m 2 Reports of desaturationrequiring bag-mask ventilation are not uncommon Recent study: Manual group: 65% V.S the TCI group : 5% The effective sedation seen in this study with a low rate of desaturationand infrequent need for airway support is an important result!

18 Discussion The lowest saturation measured in our study (patients received oxygen at 2 L/min via oral cannula) was 74%. The mean oxygen saturation value was significantly higher than the mean during polysomnographyand was comparable with that reported by De Vito during TCI infusion.

19 Discussion The extent of desaturation in obese patients with OSA is multifactorial. In addition to obstruction or apnea, loss of functional residual capacity during sleep and the balance of metabolic rate and oxygen delivery under the effects of propofol also play a role.

20 Discussion TCI: Good reliability but require slow titration Predicted effect-site concentration 2.0 ~ 4.8 μg/mlto achieve obstruction have been reported with the Schnider or Marsh propofol models The predicted effect-site concentration for obstruction we observed (4.2 ±1.3 μg/ml) when using the Cortinezis in a range of similar magnitude.

21 Discussion In one study by De Vito et al. the average time for the procedures : the TCI group => 15.2 minutes the manual control group => 6.2 minutes The mean time to obstruction employing our control system was 3.9 minutes, which is comparable with the manual approach and substantially faster than with TCI control in published studies.

22 Conclusions Propofol infusion strategy Require limited experience with propofol dose selection Produce airway obstruction faster the TCI based system O 2 desaturationis within clinically acceptable range

23 Thanks for your attention!

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