 So let's get to obstructive sleep apnea syndrome now these patients are really at the risk for developing episodes of apnea and desaturation post operatively and they definitely have an increase the risk of pneumonia and respiratory failure and you've really got to be careful with these patients they've got to be assessed by the person who's going to administer the anesthesia and post operatively best to put them in some place like a high care facility where you could monitor their breathing and at least monitor the saturation. So what can you do for them preoperatively now there's some evidence that you could trial them on some preoperative spirometry incentive spirometry in other words a little device that they get from the physiotherapy department if you don't have those facilities you can just try and create a little device that just have to blow into it against resistance to improve all the lung parameters. Other things that you can consider really improving the exercise status and asking to lose some weight now these two things are usually very difficult there's perhaps not the time or the opportunity for them to do so. Fancier things that you can consider is just some continuous positive airway pressure device that they can sleep with the weeks prior to surgery and also mandibular advancement devices. So how do we identify these patients while there is a balloon questionnaire and you see the shortened URL visit that you'll see a PDF of that questionnaire and that will identify for you the patients at the risk of obstructive sleep apnea syndrome. The gold standard though is an overnight sleep test now not all units have that test it's not easy to send a patient for that test but that certainly is the gold standard so be aware of the patient with obstructive sleep apnea syndrome and take particular care of them. So overall how can we improve the patient's chances not only the sleep apnea patient but all patients. Well first of all really think about this incentive spirometry pre-operatively there's a study that looked at patients with laparoscopic olisostectomy some were randomized to nothing and some were randomized to weeks worth of pre-operative incentive spirometry blowing against resistance for a week a couple of times a day just to improve the lung capacity in various lung indices. And there was a difference in outcome when it came to post risk for post operative complications. Other things is improving the nutritional status that makes logical sense I suppose but just really looking at the evidence outside of cardiac surgery hasn't really been shown to make a difference but of course if there are problems with your patient you can try and improve that cessation of smoking is the important one. And it's the period that's involved with that a patient really has to stop smoking for six to eight weeks at least prior to the surgery for there to be a lessening of the risk for post operative complications. Finally these risk calculators Gupta had al did a lot of work they looked at all the VA databases in the United States and then more recent complication databases and they tried to look at the risk factors that were predictive of an increased risk of post operative pneumonia and respiratory failure. And you'll see some of the factors that they found type of procedure the ASA class the age the existence of COPD functional status one we haven't mentioned before pre operative sepsis and then of course smoking so visit www.surgicalriskcalculator.com you can download some of those calculators as apps or you can just use it online. You fill in that data and it gives you a risk of a patient developing for the one calculator pneumonia for the other respiratory failure. We're not quite sure what to do with those but at least it identifies for you the patient that is at risk so that you can monitor them better pre operatively or perhaps think about those things that I mentioned. Do the incentive spirometry for instance but definitely take better care of them it's a risk management in these patients. In the next lecture series we're going to start looking at the diabetic patient.