OBESITY AND OSA

Dr ABHISHEK
 OBESITY means
excessive body fat

Obesus  fattened
by eating

The amount of fat

tissue is increased to
such an extent that
mental and physical
health is affected
 Obesity
is defined as
BMI > 30.0 (M)

> 28.6 (F)

 Bodymass index (or)

Quetelet’s index =

Weight (Kg)

Height in m2
 W.H.O classification of overweight by cut – off
points of the BMI
25.0 – 29.9 Over weight
30.0 – 34.9 Grade I Obesity
35 - 39.9 Grade II
40- 49.9 Grade III
>50 super obese
Aetiology
Genetic Predisposition :
- 25-30 % of human variations
in BMI are genetic and the
rest are due to environment
factors (70%)

- Tends to be familial

- Children of two obese parents

have a 70% chance to
become obese
- Genetic susceptibilities may
predispose to environmental
issues
Ethnic influences :
In USA, the African Americans and Mexicans have
higher rate of obesity than the whites.
Asian migrates have a central distribution of fat
associated with increased risk of diabetes and
coronary artery disease.
Medical diseases :
Cushings disease
Hypothyrodium
Medication like steroids
Antidepressents and antihistamines predipose to
obesity
Risk factors :
Male gender, middle age, night sedation evening
alcohol can all compound the problem
Medical and surgical
conditions associated
with obesity:

1. Cardiovascular :

HTN, Ischemic heart

Disease hyperlipidemia,
cerebrovascular
disease, peripheral
vascular disease,
varicose veins, Deep
vein thrombosis &
pulmonary embolism
2. Respiratory:
Restrictive lung disease,
obstructiveSleepapnoea,
Obesity hypoventilation
syndrome

3. Endocrine :
DM, Hypothyroidism, Cushings
disease.

4. Gastrointestinal :
Hiatus hernia, gall stones,
inguinal hernia

5. Malignancy :
Breast, Prostate, Colorectal,
Cervical Endometrial

6. Musculo Skeletal :
Osteo artrihtis, Back pain
 Distribution of body fat and health risk
a. Central or android type of distribution
- MC in males
- Fat predominally distributed in upper body
  Deposits of intraabdominal or visceral fat
- Metabolically more active
- Associated with dyslipidaemias, glucose intolerance
and DM
b. Peripheral or gynaecoid type :
- Fat distributed around hips, buttocks or
thighs
- Female pattern of distribution
- Metabolically less active
- Associated with less metabolic
complications
Physiological changes associated with obesity :
Respiratory system :
Obstructive sleep apnoea – 5%
→ frequent episodes of apnoea or hypoapnoea
→ snoring
→ daytime sleepness
Apnoea → complete cessation of airflow for atleast 10
sec.
Hypoapnoea → reduction in airflow associated with
arrosal or O2 desaturation

When pt.s have 5 or more apnoeas per hr. or sleep,

apnoeic episodes are associated with ↓ in O2 Hb
desaturation
Pathogenesis :
narrowing or collapse of upperairway during
sleep is primary abnormality in OSA
Inspiration : Normally, the negative pressure
applied to upperairway
→ counter balanced by activity of
upperairway muscles which maintain
airway patency
→ any factor that reduces airway size, upper
airway resistance, muscle tone or leads to a
greater negative inspiratory force predispose
to OSA
Obesity – Hypoventilation syndrome
→ OSA → Daytime respiratory failure with hypercapnia and hypoxia
in the absence of significant lung disease
Impaired ventilatory response ot hypoxia + hypercapnia
↓
Mechanical load of obesity + upper airway obstruction
↓
Prolonged hypoxia + Hypercapnia at night
↓
Alteration in control of breathing
↓
Progressive desensitization of respiratory centres to hypercapnia
↓
Type II Resp. Failure

 Pick wickian syndrome : -

 Obesity, HYPERSOMNOLENCE, hypoxia, hypercapnia, RVF,
polycythemia
 Diagnosis of OSA
Clinical features:
1. Snoring
2. Day time sleepiness
3. Polysomnography / sleep study
 Apnea hyponea index
 mild: AHI of 5-15 per hour
 Moderate: AHI of 15-30 per hour
 Severe : AHI more than 30 per hour
Airway:
- Difficulties with mask
ventilation and trached
intubation
- Incidence of difficult
intubation – 13%
- Features : –

Excessive fat at upper airway

large breasts
Short neck
Large tongue
Excessive palatal and
pharyngeal soft tissue
High and anterior larynx
Restricted mouth opening
Limitation of cervical spine
and atlanto occipital
flexion and extension
Gas exchange:
Lung volumes are decreased
FRC exponentially with increase BMI
ERV
TLC
FRC  closing capacity

Small airway closure

V/Q mismatch

Rt  Lt shunting

Hypoxemia
 desaturate rapidly at the induction of
anaesthesia despite preoxygenation due to
smaller O2 reservoir and increased O2
consumption

 Residual volume  N or 
O2 consumption and CO2 production Both are 
as a result of metabolic activity of excess fat
and increased work load on supportive
tissues.
 Compliance and Resistance:
 Chest wallcompliance – due to  fat
 lung compliance   Work of breathing
 Total respiratory
resistance

 Work of Breathing:
- 30% increased in WOB
- Hypoventilation – 4 times increased WOB
Cardiovascular System: -
1. HTN – Mild to moderate
HTN – 60-70% Severe
HTN – 5- 10%
2. IHD – Increased central
Obesity
3. Increased extracellular
volume
- Increased Blood vol.
and Cardiac output

Obesity induced hypertension
,

4. Concentric hypertrophy of
the left ventricle – cardiac
failure
5. Splanchnic blood flow – increased by 20%
Renal and cerebral blood flow are normal
6. Cardiac arrhythmias – hypoxia, hypercarbia,
electrolyte imbalance, diuretic therapy or fatty
infiltration of the conducting tissue.
7. Cardiac function – left ventricle systolic and
diastolic function are affected.
Obesity induced cardiomyopathy
Co increased by 20-30% ml/kg of excess body
fat
- exercise tolerance is poor
 Co is by increased HR
Obesity & diabetes:
Type II DM is an
independence risk factor
- insulin resistance
syndrome – metabolic
syndrome
 Thromboembolic disease:
- DVT – Twice as common obese patient
- 2.4% to 4.5% - Bariatric surgery
- Prolonged immobilization that leads to venous
stasis and polycythemia
- Increased abdominal pressure – increased
pressure on the deep veins
- Decrease fibrinolytic activity with increased
fibrinogen concentration.
 Obesity and GI disorders:
1. Increased intraabdominal pressure
2. High volume and low PH of gastric contents
3. Delayed gastric emptying
4. Increased incidence of gastro oesophageal
reflex

High risk for aspiration Pneumonia
DRUGS, PHARMCODYNAMICS &
KINETICS
- Alteration in the distribution binding and
elimination of many drugs.
- Drug dose should be calculated keeping the
lean body mass in view
Volume of distribution:
* VD  is influenced by number of factors
1. The size of the fat organ
2.  in lean body mass
3.  in blood volume & cardiac output
4. Reduced total body water
5. Alterations in plasma protein binding
6. Lipophilicity of the drug
* Highly lipophilic drugs have an increased
volume of distribution
* Thiopentone, Benzodiazepines and potent
inhalation agents may persist for longer time
after discontinuation
Elimination:
 Clearance is reduced
 Cardiac failure and  liver blood flow may slow
elimination of midazolam and lignocaine
 Renal clearance is increased &  renal blood flow
& GFR
Inhalational agents:
 Hepatic metabolism  Reductive metabolism of
halothane is more  liver injury
 Nephrotoxicity  High fluoride  Halothane
enfluane
 Isoflurane does not increase fluoride
concentration and remain agent of choice in the
obese
 Sevoflurane
lower blood solubility which will
Desflurane speed the anesthetic uptake
distribution and also recovery.
Anaesthetic Implications:
- Preoperative :
 Thorough clinical examination

 Excellent and relevant history taking

 Assessment of the respiratory system for OSA is

very essential

 BP  appropriate sized cuff

 Signs of CCF  JVP, added heart sounds

pulmonary crackles hepato jugular reflux,
peripheral edema
Investigations:
1) ECG
2) Echo  Eccentric LVH
3) Cardiological evaluation optimization of BP,
Treatment of CF, coronary angioplasty
4) X-ray chest
5) Lung function tests
6) Baseline arterial blood gases
7) OSA  polysomnography (Noninvasive
ventilation CPAP or BIPAP therapy)
 Airway assessment:
1) Assessment of the head and neck; flexion,
extension and lateral rotation
2) Assessment of jaw mobility and mouth
opening
3) Checking the patency of the nostrils
4) Inspection of previous anesthetic charts

 Direct or indirect laryngoscopy, CT scan of soft

tissues
 Assessment of veins for placing infusion
 Examination of the feet and back for any
ulcer
 Examination of the calf muscles for any redness or
tenderness  DVT.
Preoperative medication:
Avoid narcotics and sedatives
Avoid IM and SC injections
If fiber optic intubation is planned, include an anti
sialogogue.
Acid aspiration prophytaxis
HZ receptd antogonist - Rantidine 150mg
Prokinetic – Metaclopromide l0 mg orally 12 hrs &

2hrs before surgery

Continue normal mediation on the day of surgery
Prophylactic antibiotics
Low dose subcutaneous heparin as prophylaxis against DVT
Position and transfer
Extra care, special tables and adequate padding of
pressure areas should be provided
Appropriate manpower to shift
Compression of IVC is avoided by lateral tilt or
wedge
IV lines:
Peripheral lines may be difficult
 Establish central lines in the beginning
Doppler or ultrasound guided placements could
reduce complications
Monitoring:
Intra-arterial blood pressure measurement is
advocated
ECG,
Pulseoximetry
Capnography
Neuro muscular monitors
Central venous catheters
Regional Anaesthesia:
Airway intubation difficulties are avoided
Risk of gastric aspiration is reduced
Cardiovascular stability may be greater than with
GA
Need for relaxant drugs and potential problems
associated with the reversal are avoided
Regional blocks can be technically challenging
because important landmarks are obscured
Local anaesthetic dose requirement should be
reduced by 20-25% for both epidural and sub
arachnoids blocks
General anesthesia:
 Risk of aspiration is high
 If a difficult tracheal intubation is anticipated,
an awake intubation using topical anesthesia
and sedation with or without fiber optic
bronchoscope is required.
 Supplemental O2 must be continuously given
 Preoxygenation until O2 saturation remains at
100% for several min.
 GA + Regional anaesthesia offers
advantages : -
1. Lower incidence of post op resp. complications
2. Shorter hospital stays
3. Excellent post op analgesia obtained by
administering opiods (with or without LA)
through Epidural catheter
4. Reduced opiods, muscle relaxants and potent
inhalational agents intraoperatively
5. Earlier tracheal extubation
 Proper positioning with the head, neck and
shoulder elevated helps facilitate intubation
attempts
 Rapid induction with thiopentone & scoline with
cricoid pressure
 Two anaesthetists should be present.
 Variety of laryngoscope blades, a short
laryngoscope handle and LMA should be
available
( Mccoy laryngoscope, gum elastic bougies)
 Correct
position of tracheal tube must be
confirmed by both auscultation and
capnograpy.

 Serial
ABG analysis should be used to
assess adequacy of minute ventilation

 Patient should only be extubated when

he is fully awake.
 Postoperative mechanical
ventilation

1. coexisting cardio respiratory disease,

2. Co2 retension,
3. prolonged surgery,
4. patient with pyrexia.
 Position: Placing the patient in
semirecumbent (30 - 45º) position
increase oxygenation

 Excellent postoperative analgesia

improves patient outcome – NSAIDS, LA
for incision infiltration, peripheral Blocks
 Patient with H/O OSA should be monitored
intensively for early detection of unacceptable
oxygenation or ventilation.
- Benefit from nocturnal nasal CPAP

 Early post operative ambulation and

prophylactic subcutaneous heparin – to
prevent DVT – pulmonary embolism
Obese patient in the ICU:
 Outcome is poor
 Mechanical ventilation – TV based on IBW
adjusted a/c inflation pressures and blood gas
analysis
 PEEP to prevent airway closure and atelectasis
– decreased CO

 During weaning, 45º head up tilt

 Invasive hemodynamic monitoring – fluid

management

 Nutritional support – 20-30 K cal/Kg of IBW

1.5 – 2gm / Kg of IBW of proteins
Obese patients and trauma:
 More blunt trauma and chest trauma
 Investigations are more difficult to handle and
interpret
 Earlier respiratory support and higher oxygen
concentration
Obstetrics and morbidity obese:
 All attending complications are compounded
 RA is a better choice
 Avoid GA as far as possible
 Putting epidural catheter during labor is a
better option
 LA requirement may be reduced by up to 25%
in the obese pregnant state
Bariatric surgery:
 Indication for
bariatric surgery
 BMI > 40kg /m2
 BMI > 35kg/m2
with co morbidites
- The patients must
have a clear
understanding of
the risks, benefits
and complications
and may require life
long management
strategies
Types of bariatric surgery:
 Restrictive
 Malabsorptive
Roux – en – y grade bypass
vertical banded gastroplasty
Bitro pancreatic diversion
Gastric banding procedures
Gastric bypass procedures
Conclusions:
Obese pts are encountered in practice of
anaesthesia for different types of surgical
procedures, bariatric surgeries, trauma and in
the ICU setup.
- They do pose tremendous challenges
- Understanding the pathophysiology,
anticepating the problem and preventing
calamities by a systematic approach will
certainly bring down the rate of complications.