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Featured Articles: Editorial

Anesthesia and Sleep Medicine

Weingarten, Toby N. MD*; Chung, Francis MBBS, FRCPC; Hillman, David R. MD

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doi: 10.1213/ANE.0000000000005421
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For thousands of years, humans have exploited naturally occurring chemicals to induce dream-like states for pleasure, enlightenment, or blunt the senses to pain. One of the great miracles of the 19th century was the advance of anesthesiology, when the practice of medicine learned to precisely harness the power of these substances to alter the sensorium so patients could undergo lifesaving surgeries, comfortably and safely. Surgical patients have taken comfort that they will “go to sleep” and “wake up once it’s all over.” However, while the sleep analogy is widely used and the states have shared traits, their differences have meant that the parallels between sleep and anesthesia have been inadequately examined until recent years.

For more than a decade, a diverse group of researchers have explored the similarities and differences between sleep and anesthesia, gained a better understanding of how breathing behavior during sleep relates to that during anesthesia, how anesthesia affects sleep, and how sleep and its disorders affect perioperative outcomes.1,2 Much of this study has centered on respiratory-related issues. Ten years ago, under the leadership of Frances Chung and David R. Hillman, individuals from the specialties of anesthesia and sleep medicine joined forces to establish the Society of Anesthesia and Sleep Medicine (SASM, www.sasmhq.org).3 SASM is highly successful, publishing practice guidelines on the preoperative screening and assessment of adult patients with obstructive sleep apnea,4 and intraoperative management of patients with obstructive sleep apnea.5 Among other publications from this group, SASM has published novel findings on death or near-death from obstructive sleep apnea registry,6 systemic reviews on opioids for acute pain management in patients with obstructive sleep apnea,7 and how obstructive sleep apnea influences perioperative outcomes.2

During the fall of 2019, Anesthesia &Analgesia asked leaders in this field to contribute special articles highlighting state-of-the-art information, as well as knowledge gaps on the interface between anesthesia and sleep. In this resulting thematic anesthesia and sleep issue, many topics are covered, from fundamental relationships between anesthesia and sleep states to the implications of behaviors in one state for those in the other. Moody et al8 examine the function of cortical and subcortical neural circuits during natural sleep and contrasts these with functional changes observed in response to administration of different anesthetic agents. This foundation is critical to understand how the sedative medications interact with central ventilatory circuits to inhibit both ventilatory drive and upper airway patency.9,10 In studying these relationships, it is important to recognize individual variability in responses, examined here in terms of differences in the phenotypes of patients with obstructive sleep apnea. Altree et al10 explore the 4 main mechanistic phenotypes relating to variations in anatomy, upper airway responsiveness, respiratory arousal threshold, and control of breathing. It is now clear that unfavorable characteristics in these terms place patients with breathing-related sleep disorders at increased risk of ventilatory failure, respiratory arrests, anoxic brain injury, and death.9 Characterizing the phenotypic characteristics that predispose to these outcomes is an important area of inquiry with potential opportunities for translational research to mitigate risk.

Recognizing that patients with sleep-related breathing disorders are at increased risk for postoperative complications,9 Cozowicz and Memtsoudis11 provide a state-of-the-art overview of management of patients with obstructive sleep apnea, and Kaw et al12 provide an overview of the subset with obesity and obesity hypoventilation. Rosero and Joshi13 provide reassuring evidence of surgical patients with obstructive sleep apnea undergoing ambulatory procedures. Given the anatomical common ground between obstructive sleep apnea and difficult airways, Seet et al14 explore the implications for airway management in these patients and describe an association between severity of obstructive sleep apnea and difficulty with mask ventilation and direct laryngoscopy. While most hospitals use screening tools such as STOP-Bang (Snoring, Tiredness, Observed apnea, high blood Pressure, Body mass index > 35 kg/m2, Age > 50 years, Neck circumference > 40 cm, male Gender) to identify surgical patients at risk of obstructive sleep apnea,15 critical events still occur. Driver et al16 examine the temporal relationship between pharmacological-induced ventilator depression and the end of surgery, importantly highlighting that these events take place both in the late afternoon and early evening, as well as the more obvious overnight occurrence. The use of positive airway pressure therapy to treat these problems in the perioperative setting is examined by Jonsson Fagerlung and Franklin.17

While a primary focus of research in the sleep-anesthesia interface has been on obstructive sleep apnea, important advancements have occurred in understanding the interaction of other sleep disorders and anesthesia. Hershner and Auckley18 explore our current understanding of anesthetic management of patients with insomnias, restless leg disorders, narcolepsy, and parasomnias. In view of the opioid epidemic, Wang et al19 examine the use of chronic opioids and the common associated occurrence of central sleep apnea, readily identified using home oximetry.

Adequate sleep is a fundamental requirement for human well-being, and its importance for patients and their postoperative recovery patients20 and for the health care workers that look after them21 has been examined in these pages.

The ventilatory depression and reduced muscle activation that accompany anesthesia have their parallels in sleep and so breathing behavior during sleep has predictive value for that during anesthesia. Given these relationships, improved understanding of sleep benefits the practice of anesthesia in general terms, as well as in the specifics related to perioperative management of patients with sleep disorders, both respiratory and nonrespiratory. Add to this, the contribution of sleep to rest and recovery of both patients and medical staff and the case for better sleep education in anesthesiology is compelling. This can range from subspecialty certification in sleep medicine to enhancements in the current curriculum for residents in North America.22,23

There has been a decade of research achievements in the common ground between sleep and anesthesia, reflected in the studies published in this issue of Anesthesia & Analgesia. Among other things, these studies build the case for greater awareness of sleep issues among anesthesiologists and enhanced sleep training in anesthesia. It is time for these issues to be awoken from their slumber.

DISCLOSURES

Name: Toby N. Weingarten, MD.

Contribution: This author helped draft and revise the manuscript.

Conflicts of Interest: T. N. Weingarten is a consultant for Medtronic and Merck and has received research support from Merck, Respiratory Motion, and Baxter.

Name: Francis Chung, MBBS, FRCPC.

Contribution: This author helped draft and revise the manuscript.

Conflicts of Interest: F. Chung is a member of STOP-Bang questionnaire proprietary to University Health Network.

Name: David R. Hillman, MD.

Contribution: This author helped draft and revise the manuscript.

Conflicts of Interest: None.

This manuscript was handled by: Jean-Francois Pittet, MD.

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