Intraoperative management of adults with obstructive sleep apnea
- Eric Olson, MD
Eric Olson, MD
- Associate Professor of Medicine
- Mayo Clinic College of Medicine
- Frances Chung, MBBS, FRCPC
Frances Chung, MBBS, FRCPC
- Professor, Department of Anesthesiology and Pain Management
- University Health Network
- University of Toronto
- Edwin Seet, MBBS, MMed
Edwin Seet, MBBS, MMed
- Clinical Senior Lecturer
- Yong Loo Lin School of Medicine, National University of Singapore
- Section Editors
- Stephanie B Jones, MD
Stephanie B Jones, MD
- Editor-in-Chief — Anesthesiology
- Section Editor — Anesthesia with Comorbid Non-Cardiopulmonary Conditions
- Associate Professor of Anesthesia
- Harvard Medical School
- Nancy Collop, MD
Nancy Collop, MD
- Editor-in-Chief — Sleep Medicine
- Section Editor — Sleep Related Breathing Disorders
- Professor of Medicine and Neurology
- Director, Emory Sleep Center, Emory University
- Deputy Editors
- Marianna Crowley, MD
Marianna Crowley, MD
- Deputy Editor — Anesthesiology
- Assistant Professor of Anesthesiology
- Harvard Medical School
- Geraldine Finlay, MD
Geraldine Finlay, MD
- Senior Deputy Editor — UpToDate
- Deputy Editor — Pulmonary, Critical Care, and Sleep Medicine
- Associate Professor
- Tufts University School of Medicine
Obstructive sleep apnea (OSA) is a disorder characterized by repetitive episodes of apnea or reduced inspiratory airflow due to upper airway obstruction during sleep. OSA is the most common type of sleep-disordered breathing, with an estimated prevalence of 1 in 4 males and 1 in 10 females for mild OSA, and 1 in 9 males and 1 in 20 females for moderate OSA . OSA has been increasing in prevalence over the last two decades in parallel with the increase in obesity [2-5]. Over half of patients with OSA who present for surgery are undiagnosed [6,7].
The incidence of perioperative complications is greater in patients with OSA [8-11], leading the American Society of Anesthesiologists, the American Academy of Sleep Medicine, and others to develop clinical practice guidelines and protocols for the perioperative management of patients with OSA [3,12-14]. Recommendations include maintaining a high index of suspicion for OSA, careful use of medications, vigilant monitoring for upper airway obstruction, and an integrated team approach to perioperative management. There is little direct evidence that these precautions improve outcomes, so recommendations are generally based upon indirect evidence, clinical rationale, and expert opinion.
The intraoperative management of patients with OSA is reviewed here, using risk mitigation strategies and precautions. This includes determining whether the surgery should be performed on an inpatient or outpatient basis, anesthesia techniques, premedication, and airway management. The increase in perioperative complications, preoperative evaluation and management, and postoperative management of patients with OSA are discussed separately. (See "Surgical risk and the preoperative evaluation and management of adults with obstructive sleep apnea" and "Postoperative management of adults with obstructive sleep apnea".)
CHOICE OF ANESTHETIC TECHNIQUE
In general, the choice of anesthetic technique is determined by the surgical procedure and preferences of the patient, anesthesiologist, and surgeon. Patient-related factors such as airway concerns and high levels of anxiety also influence the choice of technique.
In obstructive sleep apnea (OSA), a general principle is to use an anesthetic technique that minimizes the use of respiratory depressants whose effects will continue into the postoperative period. Most anesthetic techniques can be modified to conform to this goal.
- Seet E, Han TL, Chung F. Perioperative Clinical Pathways to Manage Sleep-Disordered Breathing. Sleep Med Clin 2013; 8:105.
- Peppard PE, Young T, Barnet JH, et al. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol 2013; 177:1006.
- Benumof JL. Obstructive sleep apnea in the adult obese patient: implications for airway management. Anesthesiol Clin North America 2002; 20:789.
- Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults, 1999-2000. JAMA 2002; 288:1723.
- Memtsoudis SG, Besculides MC, Mazumdar M. A rude awakening--the perioperative sleep apnea epidemic. N Engl J Med 2013; 368:2352.
- Singh M, Liao P, Kobah S, et al. Proportion of surgical patients with undiagnosed obstructive sleep apnoea. Br J Anaesth 2013; 110:629.
- Lockhart EM, Willingham MD, Abdallah AB, et al. Obstructive sleep apnea screening and postoperative mortality in a large surgical cohort. Sleep Med 2013; 14:407.
- Kaw R, Chung F, Pasupuleti V, et al. Meta-analysis of the association between obstructive sleep apnoea and postoperative outcome. Br J Anaesth 2012; 109:897.
- Memtsoudis S, Liu SS, Ma Y, et al. Perioperative pulmonary outcomes in patients with sleep apnea after noncardiac surgery. Anesth Analg 2011; 112:113.
- Mokhlesi B, Hovda MD, Vekhter B, et al. Sleep-disordered breathing and postoperative outcomes after elective surgery: analysis of the nationwide inpatient sample. Chest 2013; 144:903.
- Mokhlesi B, Hovda MD, Vekhter B, et al. Sleep-disordered breathing and postoperative outcomes after bariatric surgery: analysis of the nationwide inpatient sample. Obes Surg 2013; 23:1842.
- Meoli AL, Rosen CL, Kristo D, et al. Upper airway management of the adult patient with obstructive sleep apnea in the perioperative period--avoiding complications. Sleep 2003; 26:1060.
- American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology 2014; 120:268.
- Seet E, Chung F. Management of sleep apnea in adults - functional algorithms for the perioperative period: Continuing Professional Development. Can J Anaesth 2010; 57:849.
- Memtsoudis SG, Stundner O, Rasul R, et al. Sleep apnea and total joint arthroplasty under various types of anesthesia: a population-based study of perioperative outcomes. Reg Anesth Pain Med 2013; 38:274.
- Hillman DR, Loadsman JA, Platt PR, Eastwood PR. Obstructive sleep apnoea and anaesthesia. Sleep Med Rev 2004; 8:459.
- Sabaté JM, Jouët P, Merrouche M, et al. Gastroesophageal reflux in patients with morbid obesity: a role of obstructive sleep apnea syndrome? Obes Surg 2008; 18:1479.
- Chung SA, Yuan H, Chung F. A systemic review of obstructive sleep apnea and its implications for anesthesiologists. Anesth Analg 2008; 107:1543.
- Hillman DR, Platt PR, Eastwood PR. The upper airway during anaesthesia. Br J Anaesth 2003; 91:31.
- Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013; 118:251.
- Sato Y, Ikeda A, Ishikawa T, Isono S. How can we improve mask ventilation in patients with obstructive sleep apnea during anesthesia induction? J Anesth 2013; 27:152.
- Delay JM, Sebbane M, Jung B, et al. The effectiveness of noninvasive positive pressure ventilation to enhance preoxygenation in morbidly obese patients: a randomized controlled study. Anesth Analg 2008; 107:1707.
- Langeron O, Masso E, Huraux C, et al. Prediction of difficult mask ventilation. Anesthesiology 2000; 92:1229.
- Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics. Anesthesiology 2009; 110:891.
- Ramachandran SK, Mathis MR, Tremper KK, et al. Predictors and clinical outcomes from failed Laryngeal Mask Airway Unique™: a study of 15,795 patients. Anesthesiology 2012; 116:1217.
- Parmet JL, Colonna-Romano P, Horrow JC, et al. The laryngeal mask airway reliably provides rescue ventilation in cases of unanticipated difficult tracheal intubation along with difficult mask ventilation. Anesth Analg 1998; 87:661.
- Siyam MA, Benhamou D. Difficult endotracheal intubation in patients with sleep apnea syndrome. Anesth Analg 2002; 95:1098.
- Ezri T, Medalion B, Weisenberg M, et al. Increased body mass index per se is not a predictor of difficult laryngoscopy. Can J Anaesth 2003; 50:179.
- Kim JA, Lee JJ. Preoperative predictors of difficult intubation in patients with obstructive sleep apnea syndrome. Can J Anaesth 2006; 53:393.
- Hiremath AS, Hillman DR, James AL, et al. Relationship between difficult tracheal intubation and obstructive sleep apnoea. Br J Anaesth 1998; 80:606.
- Chung F, Yegneswaran B, Herrera F, et al. Patients with difficult intubation may need referral to sleep clinics. Anesth Analg 2008; 107:915.
- Chau EH, Lam D, Wong J, et al. Obesity hypoventilation syndrome: a review of epidemiology, pathophysiology, and perioperative considerations. Anesthesiology 2012; 117:188.
- Murphy GS, Brull SJ. Residual neuromuscular block: lessons unlearned. Part I: definitions, incidence, and adverse physiologic effects of residual neuromuscular block. Anesth Analg 2010; 111:120.
- Desborough JP. The stress response to trauma and surgery. Br J Anaesth 2000; 85:109.
- Holte K, Sharrock NE, Kehlet H. Pathophysiology and clinical implications of perioperative fluid excess. Br J Anaesth 2002; 89:622.
- Lam T, Singh M, Yadollahi A, Chung F. Is Perioperative Fluid and Salt Balance a Contributing Factor in Postoperative Worsening of Obstructive Sleep Apnea? Anesth Analg 2016; 122:1335.
- CHOICE OF ANESTHETIC TECHNIQUE
- ANESTHETIC MANAGEMENT
- Monitored anesthesia care
- Regional anesthesia
- General anesthesia
- - Anesthetic agents
- - Airway management
- - Positioning
- - Preoxygenation
- - Mask ventilation
- - Supraglottic airways
- - Laryngoscopy and intubation
- - Ventilation
- - Reversal and extubation
- Intravenous fluid management
- Pain control
- SUMMARY AND RECOMMENDATIONS