Surgical risk and the preoperative evaluation and management of adults with obstructive sleep apnea


Obstructive sleep apnea (OSA) is a disorder characterized by repetitive episodes of apnea or reduced inspiratory airflow due to upper airway obstruction during sleep. The incidence of perioperative complications (ie, preoperative, intraoperative, and postoperative complications collectively) is increased among patients with OSA [1,2]. The Joint Commission has suggested that a National Patient Safety Goal be the reduction of perioperative complications among patients with OSA [3], while the American Society of Anesthesiology (ASA) and American Academy of Sleep Medicine (AASM) have developed clinical practice guidelines for the perioperative management of patients with OSA [4-6]. Common among the guidelines is an emphasis on maintaining a high index of suspicion for OSA, careful use of medications, vigilant monitoring for evidence of upper airway obstruction, an integrated team approach to perioperative management, and recognition that many recommendations are based upon clinical rationale and indirect evidence because direct evidence is scarce. Such interest in the perioperative management of patients with OSA probably reflects in part the recognition that the number of patients with OSA encountered in operating rooms is likely to increase as recognition of the disease and the prevalence of obesity increase [4,7].

Factors that contribute to the increased surgical risk of patients with OSA and the preoperative evaluation and management of patients with OSA are reviewed here. The intraoperative and postoperative management of patients with OSA are discussed elsewhere. (See "Postoperative management of adults with obstructive sleep apnea" and "Intraoperative management of adults with obstructive sleep apnea".)


Contributing factors — Patients with OSA who are undergoing procedures that require sedation, anesthesia, and/or analgesia are at higher risk for periprocedural complications than patients who do not have OSA [1,2]. This may be related to upper airway collapse and/or OSA-related comorbidities.

Upper airway collapse contributes to perioperative complications by inducing hypoxemia and other physiological perturbations. The following perioperative factors may increase the frequency and/or duration of upper airway collapse in patients with OSA (table 1):

Perioperative medications (eg, sedatives, general anesthetic agents, narcotic analgesics) — Perioperative medications reduce upper airway dilator tone, while inhibiting protective airway reflexes, central ventilatory drive, and arousal mechanisms. These effects mimic sleep and, therefore, may exacerbate repetitive upper airway collapse in patients with OSA. (See "The effects of medications on sleep quality and sleep architecture".)


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Mar 2014. | This topic last updated: Mar 12, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
  1. Hillman DR, Loadsman JA, Platt PR, Eastwood PR. Obstructive sleep apnoea and anaesthesia. Sleep Med Rev 2004; 8:459.
  2. Boushra NN. Anaesthetic management of patients with sleep apnoea syndrome. Can J Anaesth 1996; 43:599.
  3. (Accessed on June 10, 2010).
  4. Benumof JL. Obstructive sleep apnea in the adult obese patient: implications for airway management. Anesthesiol Clin North America 2002; 20:789.
  5. 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.
  6. Gross JB, Bachenberg KL, Benumof JL, et al. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology 2006; 104:1081.
  7. Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults, 1999-2000. JAMA 2002; 288:1723.
  8. Esclamado RM, Glenn MG, McCulloch TM, Cummings CW. Perioperative complications and risk factors in the surgical treatment of obstructive sleep apnea syndrome. Laryngoscope 1989; 99:1125.
  9. Gabrielczyk MR. Acute airway obstruction after uvulopalatopharyngoplasty for obstructive sleep apnea syndrome. Anesthesiology 1988; 69:941.
  10. Fairbanks DN. Uvulopalatopharyngoplasty complications and avoidance strategies. Otolaryngol Head Neck Surg 1990; 102:239.
  11. Burgess LP, Derderian SS, Morin GV, et al. Postoperative risk following uvulopalatopharyngoplasty for obstructive sleep apnea. Otolaryngol Head Neck Surg 1992; 106:81.
  12. McColley SA, April MM, Carroll JL, et al. Respiratory compromise after adenotonsillectomy in children with obstructive sleep apnea. Arch Otolaryngol Head Neck Surg 1992; 118:940.
  13. Persson HE, Svanborg E. Sleep deprivation worsens obstructive sleep apnea. Comparison between diurnal and nocturnal polysomnography. Chest 1996; 109:645.
  14. Haraldsson PO, Carenfelt C, Knutsson E, et al. Preliminary report: validity of symptom analysis and daytime polysomnography in diagnosis of sleep apnea. Sleep 1992; 15:261.
  15. Stoohs RA, Dement WC. Snoring and sleep-related breathing abnormality during partial sleep deprivation. N Engl J Med 1993; 328:1279.
  16. Guilleminault C, Rosekind M. The arousal threshold: sleep deprivation, sleep fragmentation, and obstructive sleep apnea syndrome. Bull Eur Physiopathol Respir 1981; 17:341.
  17. Kaw R, Pasupuleti V, Walker E, et al. Postoperative complications in patients with obstructive sleep apnea. Chest 2012; 141:436.
  18. Hiremath AS, Hillman DR, James AL, et al. Relationship between difficult tracheal intubation and obstructive sleep apnoea. Br J Anaesth 1998; 80:606.
  19. Siyam MA, Benhamou D. Difficult endotracheal intubation in patients with sleep apnea syndrome. Anesth Analg 2002; 95:1098.
  20. Reeder MK, Goldman MD, Loh L, et al. Postoperative obstructive sleep apnoea. Haemodynamic effects of treatment with nasal CPAP. Anaesthesia 1991; 46:849.
  21. Rennotte MT, Baele P, Aubert G, Rodenstein DO. Nasal continuous positive airway pressure in the perioperative management of patients with obstructive sleep apnea submitted to surgery. Chest 1995; 107:367.
  22. Ostermeier AM, Roizen MF, Hautkappe M, et al. Three sudden postoperative respiratory arrests associated with epidural opioids in patients with sleep apnea. Anesth Analg 1997; 85:452.
  23. Lee JW. Recurrent delirium associated with obstructive sleep apnea. Gen Hosp Psychiatry 1998; 20:120.
  24. Gupta RM, Parvizi J, Hanssen AD, Gay PC. Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: a case-control study. Mayo Clin Proc 2001; 76:897.
  25. Cullen DJ. Obstructive sleep apnea and postoperative analgesia--a potentially dangerous combination. J Clin Anesth 2001; 13:83.
  26. 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.
  27. Riley RW, Powell NB, Guilleminault C, et al. Obstructive sleep apnea surgery: risk management and complications. Otolaryngol Head Neck Surg 1997; 117:648.
  28. Weingarten TN, Flores AS, McKenzie JA, et al. Obstructive sleep apnoea and perioperative complications in bariatric patients. Br J Anaesth 2011; 106:131.
  29. Young T, Evans L, Finn L, Palta M. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep 1997; 20:705.
  30. Singh M, Liao P, Kobah S, et al. Proportion of surgical patients with undiagnosed obstructive sleep apnoea. Br J Anaesth 2013; 110:629.
  31. Sareli AE, Cantor CR, Williams NN, et al. Obstructive sleep apnea in patients undergoing bariatric surgery--a tertiary center experience. Obes Surg 2011; 21:316.
  32. Chung F, Yegneswaran B, Liao P, et al. Validation of the Berlin questionnaire and American Society of Anesthesiologists checklist as screening tools for obstructive sleep apnea in surgical patients. Anesthesiology 2008; 108:822.
  33. Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology 2008; 108:812.
  34. Netzer NC, Stoohs RA, Netzer CM, et al. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med 1999; 131:485.
  35. Chung F, Elsaid H. Screening for obstructive sleep apnea before surgery: why is it important? Curr Opin Anaesthesiol 2009; 22:405.
  36. Flemons WW, Whitelaw WA, Brant R, Remmers JE. Likelihood ratios for a sleep apnea clinical prediction rule. Am J Respir Crit Care Med 1994; 150:1279.
  37. Gali B, Whalen FX, Schroeder DR, et al. Identification of patients at risk for postoperative respiratory complications using a preoperative obstructive sleep apnea screening tool and postanesthesia care assessment. Anesthesiology 2009; 110:869.
  38. Friedman M, Hamilton C, Samuelson CG, et al. Diagnostic value of the Friedman tongue position and Mallampati classification for obstructive sleep apnea: a meta-analysis. Otolaryngol Head Neck Surg 2013; 148:540.
  39. Nuckton TJ, Glidden DV, Browner WS, Claman DM. Physical examination: Mallampati score as an independent predictor of obstructive sleep apnea. Sleep 2006; 29:903.