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
- 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.
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- 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