Severe sleep apnoea for nasal and palatal surgery52-year-old man, 112 kg, BMI 36, for elective septoplasty and uvulopalatopharyngoplasty; nasal packs planned

The patient

The examiner asks

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1. Consider

   What are the key issues?

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   • A 52-year-old with severe untreated OSA and a past difficult mask, for palatal surgery with nasal packs. Patient
   • His STOP-Bang of 7 is in the 5–8 band: moderate to severe OSA. Disease
   • His earlier difficult mask ventilation is the strongest warning that it will happen again. Airway
   • The surgery narrows his airway further, and packs rule out nasal CPAP afterwards. Surgery
   • Years of night-time hypoxaemia can strain his right heart, as in lung disease. Disease

2. Prepare

   What does your preoperative work-up include?

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   • His sleep study shows severe OSA, so I ask for CPAP to be started before surgery. Disease
   • Airway: neck 46 cm, BMI 36, male, OSA and a past difficult mask all predict mask difficulty. Airway
   • ECG and echo for pulmonary hypertension before I commit to the plan. Disease
   • Airway surgery under GA with opioids gives him a high OSA risk score. Surgery
   • So he is an inpatient with a monitored bed booked, not a day case. After surgery

3. Plan

   Describe your anaesthetic.

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   • Sniffing position with reverse Trendelenburg, pre-oxygenated with CPAP. Airway
   • Videolaryngoscope, oral and nasal airways, and a two-person mask technique ready.
   • Short-acting agents whose breathing effects wear off fast, such as propofol and remifentanil. Stem trigger
   • Rocuronium guided by quantitative monitoring, reversed only when block is present.
   • Opioid-sparing: paracetamol 1 g IV and ketamine about 0.25 mg/kg. After surgery

4. Plan

   How do you extubate him and manage the first night?

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   • Train-of-four ratio at least 0.9 before the tube comes out. Airway
   • Fully awake, then extubated semi-upright or lateral, never supine and drowsy.
   • He is told before induction to breathe through his mouth with the packs in. Surgery
   • Face mask or face tent oxygen; packs block nasal cannulae. After surgery
   • No background infusion on any opioid PCA.
   • Continuous pulse oximetry overnight on a monitored ward.

5. Crisis

   Two minutes after extubation he obstructs with strong efforts; SpO2 falls to 78%. Once cleared, he coughs pink frothy sputum. BP 168/98, HR 120. What do you do?

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   • Obstruction against a closed airway, then pink froth: negative-pressure pulmonary oedema. Crisis
   • First clear the airway: jaw thrust, oral airway, two-person mask, 100% oxygen.
   • Then positive pressure by face mask CPAP, since his packs block the nose.
   • A diuretic and a chest film for bilateral fluffy shadowing.
   • If he stays hypoxic on CPAP, I reintubate and ventilate with PEEP.
   • He stays monitored at least 2–12 hours; HDU overnight. After surgery
   • Treated early, it usually clears in 12–48 hours.