Jpn J Clin Oncol1999;29(3)l27-131
The Difference between Delayed Extubation and Tracheostomy in
Post-operative Sleep Apnea after Glossectomy or Laryngectomy
Toshiyuki Saito 1, ShuIan Den 1, Kazuaki Hiraga 1, Kiyotaka Uchiyama2 and Christer Carlsson 3
1Department of Anesthesia, National Cancer Center Hospital, Tokyo,
20 epartment of Plastic Surgery, The National
Cancer Center Hospital East, Chiba, Japan and 3Department of Anesthesiology, Lund University, Sweden
Background: Patients with cancer of the tongue or larynx require glossectomies or laryngectomies and subsequent reconstruction. These procedures remove part of the patient's upper
airway. In cancer of the tongue, the removed part of the airway is substituted by a flap of their skin.
Post-operatively, it is possible that the patients have problems respiring comfortably. In addition
to this, long surgical procedures may simply interfere with their circadian rhythm. To elucidate the
possible change in their post-operative respiration, we monitored the patient's respiratory pattern
with an apnea monitor.
Methods: We attached an apnea monitor to the patients and recorded their respiratory pattern
and arterial oxygen saturation. The patients were monitored for a total of five days: three days prior
to the operation, one day before the operation, the day of operation, two days after, and on the
fourth day after the operation. The period of monitoring was from 8:00 p.m. to 6:00 a.m. the next
morning.
Results: Sixteen patients completed this study. The patients whose tube was extubated after
glossectomy showed frequent apnea, low mean oxygen saturation and low comfort score as
compared to the patients with tracheostomy after laryngectomy. Because two failed cases of free
skin flap were among the former, it is possible that the frequent apnea is a factor of failed free skin
graft after glossectomy and laryngectomy.
Conclusion: Further studies are required to improve the patient's respiration during their sleep
after tracheal extubation in glossectomy.
Key words: sleep apnea - hypoxemia - glossectomy -laryngectomy
INTRODUCTION
Stress from surgery disturbs patients' sleep (1-3). Even minor
surgery like inguinal hernia repair can disrupt sleep with a
reduction of total sleep and REM sleep (4). Major surgery curtails
sleep even further. REM sleep on the first and second post-operative night is virtually eliminated (5,6). Knill et al. (7) reported that
the REM sleep reappeared thereafter and even increased to a level
greater than the pre-operative amount.
In the post-operative period, hypoxemia is another well-known
threat (8-10). The hypoxemia in this stage is predominantly
caused by a corruption of the airway patency, i.e. obstructive
apnea (11,12). The obstructive apnea is often observed in the
patients during REM sleep after major surgery (13-15).
Glossectomy and laryngectomy are major surgical procedures.
These procedures are stressful to patients and may not only
simply disrupt their sleep, they simultaneously interfere with the
Received September 4, 1998; accepted November 19, 1998
For reprints and all correspondence: Toshiyuki Saito, 1236-7 Kagawa,
Chigasaki, Kanagawa 253, Japan. E-mail: [email protected]
air flow in the upper airway because of surgery and post-operative
edema. Hence, we suspected that after glossectomies and
laryngectomies, patients could show disturbance as described,
and have studied their breathing during the perioperative nights
using an apnea monitor.
METHODS
With approval from the ethics committee of the National Cancer
Center Hospital, 16 patients, aged 63 ± 8 years, ASA 1-2 (ASA is
the risk grade for patients by the American Society of Anesthesiologists), gave informed consent for the study. Patients with
carcinoma of the tongue, base of the tongue or mesopharynx who
underwent glossectomy with microsurgical transfer of the rectus
abdorninis or antero-Iateral thigh musculocutaneous flap, and
patients with hypopharyngeal carcinoma or laryngeal carcinoma
who underwent pharyngo-laryngo-esophagectomy with free jejunum transfer or laryngectomy, were subjects for the study. The
patient characteristics are shown in Table 1. Simple partial
glossectomy was excluded from the study. General exclusion
criteria were pre-existing symptoms of neurological, cardiac or
respiratory disease, including excessive daytime sleepiness.
© 1999 Foundation for Promotion of Cancer Research
128
Sleep apnea after radical neck surgeries
Table 1. Patient characteristics
Number of patients
16
Weight (kg)
61.6±8.0
Height (em)
167.0±5.1
Laryngectomy (n)
9
Glossectomy (n)
7
Data are the mean
± SD.
ANESTHESIA
Anesthesia was induced with thiopental (5 mg/kg) , vecuronium
(0.1 mg/kg). It was maintained with sevoflurane and nitrous
oxide. Muscle relaxant was not administered after the induction.
An arterial line was placed for repeated blood analysis. Fluid was
administered in milliliters at the rate of three times the body
weight (in kilograms) per hour. Blood transfusion was given
when the blood lost was over 900 g.
An epidural catheter was inserted before the induction of
anesthesia at Tll-12 or Ll-2 intervertebral space to control
post-operative pain at the location from where the free skin flap
was taken. Three to four milligrams of morphine hydrochloride
in a vehicle of 5 m1 saline were administered through the epidural
catheter about one hour before termination of surgery. Five to
fifteen milligrams of pentazocine and 50 mg of flurbiprofen axetil
were administered intravenously when the patients required
further analgesics.
SURGERY
Surgery comprised glossectomy with mandibular resection,
radical neck dissection and free flap reconstruction from the
abdomen or lateral thigh; pharyngo-laryngo-esophagcctomy with
radical neck dissection and free jejunum transfer; or laryngectomy with radical neck dissection (16). Eight patients who
received either pharyngo-Iaryngo-esophagectomy or laryngectomy received tracheostomies at the end of the surgical procedure. The rest were kept intubated over the night of the
operation and extubated the next morning. For both of the patients
kept intubated and tracheostomized, I mg of midazolam hydrochloride per hour was used for sedation until the next morning. The
success of the free skin flap was judged tentatively two weeks
after the operation.
APNEA MONITORING
All patients were attached to an apnea monitor (Apnomonitor IT,
Chest Co., Tokyo, Japan) three days prior to the operation, one
day before the operation, on the day of the operation, two days
after, and on the fourth day after the operation. The Apnomonitor
was to detect air flow (thermistor on airway) and air flow sound
(microphone). The built in pulse oximeter detected arterial
oxygen saturation (17). The air flow sensor thermistor was
positioned at the naris [Fig. leA)]. When the patient received a
tracheostomy after the glossectomy or laryngectomy, a custombuilt thermosensor was put at the tracheostoma [Fig. I (B)]. When
Figure 1. The air flow sensor thermistors at the naris (A), at the tracheostoma
(B) and the built-in air flow thermistor in an air circuit (C). The air flow sensor
at the tracheostoma and the built-in air flow thermistors are custom made for
this study.
the patient was kept intubated, we made another custom-built
thermosensor which could be connected to the intratracheal tube
[Fig. I(C)]. The thermosensor detects changes in temperature as
low as 1 0 C. The microphone sensor was put on the throat to detect
the air flow turbulence in the trachea. The microphone sensor
detects sound as low as -65 dB. A built-in microcomputer in the
Apnomonitor analyzes no air flow when input sound changes
within 9.5 dB. A band filter was used for the microcomputer to
detect only the sounds from 200 to 1000 Hz in order to suppress
heart sounds and carotid pulsations. Apnea was identified when
the thermosensor and nose sensors detected no airway temperature change and no airway sound simultaneously for a period of
10s(18).
The probe of the built-in pulse oximeter was put on the second
finger to monitor arterial blood oxygen saturation. The Apnomonitor records the data from the pulse oximeter every three
seconds as well as the occurrence of apneic episodes. Routine
daily arterial blood gas measurement correlates well with pulse
oximeter readings. A decrease in Sp02 (saturation of oxygen in
pulse oximeter) of <90% for >60 s was considered significant. All
of the patients had a baseline Sp02 value of>95%. The period of
monitoring was from 8:00 p.m. to 6:00 a.m. the next morning.
THE PATIENTS' LEVEL OF COMFORT
The patients' level of comfort during the study nights was
evaluated by a blinded anesthesiologist the next day by means of
a visual analog scale. The imaginably most dreadful feeling in the
night was counted as 0 nun. The imaginably most peaceful feeling
in the night should be counted as the 1,00 mm point on the scale.
STATISTICS
The comparison of the values between the extubated and the
tracheostornized group was calculated with the Cochran Cox test
or Student's t-test where adequate. Sp02 changes within the same
surgical group of patients were also analyzed by the Wilcoxon
Signed Rank Test. A P value of <0.05 was considered statistically
significant.
RESULTS
Sixteen patients completed the study where respiration was
recorded for a total of five days. All anesthetic and surgical
procedures were uneventful. The patients underwent glossec-
Jpn J Clin OncoI1999;29(3)
Apnea
Index
129
Apnea
Index
40
30
•
0
not - tracheostomized .
tracheostomized.
**
30
**
**
20
**
I
20
10
I
10
OL.-~---I-----+----+------j---
-3
-1
o
2
4
The day
before, of and
after the
surgery
Figure 2. Apnea record of all the patients for the study. Sleep apnea was
frequently observed on the second and fourth operative nights, and second and
fourth post-operative nights. The value of the Apnea Index of each day was
compared with that three days prior to surgery. **p < 0.01 in paired Student's
r-test,
tomies or laryngectomies (including pharyngo-laryngo-esophagectomies) with an average duration of 507.6 ± 68.4 min. They
were administered 3.56 ± 0.30 mg of morphine during the
operation through the epidural catheter. These measurements and
the patients' characteristics were not statistically different in
groups of glossectomies and laryngectomies. They did not
receive any other narcotics during the operation. After surgery,
however, the patients received 6 mg of morphine with a vehicle
of 20 m1 saline per day continuously through the epidural catheter
up to three days. We did not use patient-controlled analgesia
during the study.
Figure 2 shows the change in apneic episodes in a survey of all
the patients. The number of apneic episodes per hour (Apneic
Index) increased greatly after the glossectomy, pharyngo-laryngo-esophagectomy or laryngectomy. The increase on the second
and fourth post-operative days was significant and more than
four-fold.
In Fig. 3, the two groups, delayed extubation versus tracheostomy, are separated for analyses. The glossectomy is classified in
the delayed extubation group, the pharyngo-laryngo-esophagectomy and laryngectomy are in the tracheostomy group. Several
patients with delayed extubation increased their Apnea Index
more than 20-fold, while patients with tracheostomy only
0
~
!
-3
-1
~
I
0
I
t
1
2
4
The day
before, of and
after the
surgery.
Figure 3. Apnea record of two patient groups: the patients who were
tracheostomized, and patients who were kept intubated and later extubated. The
value of the patients who were not tracheostomized was compared with that of
the patients who were tracheostomized. **P < 0.0 1 in unpaired Student's r-test,
increased the same index by less than five times. Changes for
patients with delayed extubation were significant, while the
changes for tracheostomized patients were not.
Similarly, patients with delayed extubation after glossectomy
showed a significant decrease in pulse oxymetry (Fig. 4). This
change occurred on both the second and fourth post-operative
days. In patients with tracheostomy, there were no significant
changes in oxygenation.
In our evaluation of patient comfort, patients with tracheostomy were much more comfortable in the post-operative period
than those with delayed extubation (Fig. 5).
DISCUSSION
A high value of the Sleep Apnea Index was seen in the patients after
extubation. Before the extubation, it was not seen. Although we
suspected there would be frequent central apnea before the
extubation because the remaining anesthetic agents, epidural
morphine and midazolam hydrochloride may all have participated
in factors for central sleep apnea, our suspicion was unfounded. It
is noticeable, therefore, that central apnea was found to be
130
Sleep apnea after radical neck surgeries
mean
Mark of
Comfort
SpO,
•
0
100
not - tracheostomized .
•
tracheostomized.
C tracheostomized.
I I
(mm)
100
1
95
r I
r 19
90 1....----+-_ _--+
-3
-1
I~
d
I
*l
2
I
-2
~
*
6
**! **!
I
1
+--_ _-+-_ _-+-
o
not - tracheostomized.
50
_
4
The day
before. of and
after the
surgery.
Figure 4. Mean hemoglobin saturation of oxygen measured by pulse oximeter.
All recorded values were averaged to calculate the mean, except when we
considered that the changes were caused simply by the patient's movements
during the monitoring and excluded from the average calculation. The value of
the patients who were not tracheostomized was compared with that of the
patients who were tracheostomized. "P < 0.05, unpaired Student's r-test,
negligible after glossectomies, pharyngo-laryngo-esophagectomies
and laryngectomies, as reported in other operations (5,6). With
assurance of airway and secured sleep with midazolam, all the
patients slept well during the night following surgery.
The post-operative sleep apnea after the glossectomy was
obstructive sleep apnea. The results coincide with previous
reports (11,12). The glossectomy patients who were extubated
the next morning showed an acute rise in sleep apnea frequency
and a decrease in mean values in the pulse oximeter. There were
frequent temporary hypoxemias after the extubation in the
glossectomy patients. In the questionnaire on the patient's level
of comfort, glossectomy patients reported that they had a dream,
a part of which was dreadful. Because they did not receive any
sedation on the first operative night and during the days after, it
was possible that their REM sleep resumed (7). Study with
electroencephalography to elucidate their sleep is preferable to
maintain the patient's post-operative condition better in future.
To keep a free flap viable, the posture of the patients is
important. The free flap is fed by the blood circulation through the
anastomoses of feeding arteries and draining veins. The patient's
posture, when it interferes with the blood circulation, causes a
failure of the tissue transplantation. It is preferable that the
0'----+----+----+----+----+----1
-3
2
4
o
The day
before, of and
after the
surgery.
Figure 5. Comfort of perioperative sleep. The value of the patients who were
not tracheostomized was compared with that of those who were tracheostomized. **p < 0.01 in unpaired Student's r-test.
patients keep a posture in which the local circulation is at its best.
In seven extubated patients, we found reports of two skin flaps
that had failed, while none out of four with pharyngo-laryngoesophagectomy had a failed free jejunum flap. We need to pursue
the relationship between their nightmare and the skin flap
failures. To keep the best posture further maintained, a longer
more strict sedation may be beneficial for the patients undergoing
glossectomies.
We conclude that patients with extensive head and neck surgery
need at least a comfortable first and second post-operative night
with close monitoring to keep them free from discomfort, and the
free flap in the best possible condition.
Acknowledgment
We acknowledge the kind suggestions and provision of information by Dr Jacob Rosenberg.
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