A DOCS Education member writes:
Any suggestions about how I can safely manage a healthy 40-year-old man with class IV Mallampati and a diagnosis of sleep apnea?
Dr. John Hexem, a member of the DOCS Education faculty, responds:
The quick answer is "very carefully." Sleep apnea can have both an abnormal pharyngeal anatomy and abnormal dysfunctional respiratory drive apparatus in the medulla. If the patient falls asleep they will easily have upper airway obstruction, initially manifested by snoring, and left on their own, they may not arouse if and when they become apneic and/or hypoxemic. You and your monitoring staff should constantly assess the presence of consciousness and respiratory drive and patient upper airway, especially in the recovery period.
I ask my patients to bring their CPAP machines for use during the recovery period. I would recommend a single-dose protocol without the Valium™ the night before. The expectations of the patient should be confined to anxiolysis without any promise of amnesia. Even referral for general anesthesia if the proposed procedure is extensive could conceivably involve awake intubation—due to the Mallampati IV—and overnight observation. I assume the patient is also morbidly obese.
Dr. Anthony Feck, Dean of DOCS Education faculty responds:
The other thing I would add is to keep the sedation light, pay close attention to the airway, and use 100 percent supplemental oxygen throughout the appointment. As Dr. Hexem said, forego the diazepam the night before. I am OK with an incremental-dosing technique since you can dose to effect using small increments versus the tendency to aim high with a bolus dose. Do not use lorazepam in these patients; use triazolam instead.
Dr. Leslie Fang, a member of the DOCS Education faculty, responds:
This scenario is growing increasingly common.
Sleep apnea is being diagnosed at an ever-greater rate, largely because of:
- General tendencies to weight increase
- Growing awareness about the disease
- The fact that we actually have an intervention for the disease, the CPAP machine
I agree that this is a population that can be sedated, but CAREFULLY since they are most prone to CO2 retention.
If you sense you'll begin to see this population for sedation in significant numbers, I would advocate for capnography in your monitoring system.
