Surgical risk and the preoperative evaluation and 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 preoperative evaluation and management of patients with known or suspected OSA are reviewed here. The intraoperative and postoperative management of patients with OSA are discussed separately. (See "Intraoperative management of adults with obstructive sleep apnea" and "Postoperative management of adults with obstructive sleep apnea".)
The diagnosis, general management, and other issues related to OSA are discussed separately. (See "Overview of obstructive sleep apnea in adults" and "Clinical presentation and diagnosis of obstructive sleep apnea in adults" and "Management of obstructive sleep apnea in adults".)
Patients with obstructive sleep apnea (OSA) are at higher risk for complications from procedures with sedation, analgesia, and/or anesthesia. Adverse events include respiratory complications, postoperative cardiac events, and transfer to the intensive care unit [8-11,15]. A 2012 meta-analysis examining the association between OSA and postoperative outcomes showed that OSA increased the odds of various postoperative complications by a factor of approximately two to four . Subsequently published studies have also noted independent associations between OSA and escalation of care, increased healthcare resource utilization, and length of stay [16,17].
- 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.
- 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.
- 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.
- Abdelsattar ZM, Hendren S, Wong SL, et al. The Impact of Untreated Obstructive Sleep Apnea on Cardiopulmonary Complications in General and Vascular Surgery: A Cohort Study. Sleep 2015; 38:1205.
- Memtsoudis SG, Stundner O, Rasul R, et al. The impact of sleep apnea on postoperative utilization of resources and adverse outcomes. Anesth Analg 2014; 118:407.
- Lindenauer PK, Stefan MS, Johnson KG, et al. Prevalence, treatment, and outcomes associated with OSA among patients hospitalized with pneumonia. Chest 2014; 145:1032.
- 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.
- Chia P, Seet E, Macachor JD, et al. The association of pre-operative STOP-BANG scores with postoperative critical care admission. Anaesthesia 2013; 68:950.
- 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.
- Gabrielczyk MR. Acute airway obstruction after uvulopalatopharyngoplasty for obstructive sleep apnea syndrome. Anesthesiology 1988; 69:941.
- Fairbanks DN. Uvulopalatopharyngoplasty complications and avoidance strategies. Otolaryngol Head Neck Surg 1990; 102:239.
- Burgess LP, Derderian SS, Morin GV, et al. Postoperative risk following uvulopalatopharyngoplasty for obstructive sleep apnea. Otolaryngol Head Neck Surg 1992; 106:81.
- 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.
- Persson HE, Svanborg E. Sleep deprivation worsens obstructive sleep apnea. Comparison between diurnal and nocturnal polysomnography. Chest 1996; 109:645.
- 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.
- Stoohs RA, Dement WC. Snoring and sleep-related breathing abnormality during partial sleep deprivation. N Engl J Med 1993; 328:1279.
- Guilleminault C, Rosekind M. The arousal threshold: sleep deprivation, sleep fragmentation, and obstructive sleep apnea syndrome. Bull Eur Physiopathol Respir 1981; 17:341.
- Chung F, Liao P, Yegneswaran B, et al. Postoperative changes in sleep-disordered breathing and sleep architecture in patients with obstructive sleep apnea. Anesthesiology 2014; 120:287.
- Weingarten TN, Flores AS, McKenzie JA, et al. Obstructive sleep apnoea and perioperative complications in bariatric patients. Br J Anaesth 2011; 106:131.
- Kaw R, Pasupuleti V, Walker E, et al. Postoperative complications in patients with obstructive sleep apnea. Chest 2012; 141:436.
- Hiremath AS, Hillman DR, James AL, et al. Relationship between difficult tracheal intubation and obstructive sleep apnoea. Br J Anaesth 1998; 80:606.
- Siyam MA, Benhamou D. Difficult endotracheal intubation in patients with sleep apnea syndrome. Anesth Analg 2002; 95:1098.
- Reeder MK, Goldman MD, Loh L, et al. Postoperative obstructive sleep apnoea. Haemodynamic effects of treatment with nasal CPAP. Anaesthesia 1991; 46:849.
- 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.
- 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.
- D'Apuzzo MR, Browne JA. Obstructive sleep apnea as a risk factor for postoperative complications after revision joint arthroplasty. J Arthroplasty 2012; 27:95.
- Flink BJ, Rivelli SK, Cox EA, et al. Obstructive sleep apnea and incidence of postoperative delirium after elective knee replacement in the nondemented elderly. Anesthesiology 2012; 116:788.
- 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.
- 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.
- 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.
- 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.
- Nuckton TJ, Glidden DV, Browner WS, Claman DM. Physical examination: Mallampati score as an independent predictor of obstructive sleep apnea. Sleep 2006; 29:903.
- Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology 2008; 108:812.
- 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.
- Chung F, Subramanyam R, Liao P, et al. High STOP-Bang score indicates a high probability of obstructive sleep apnoea. Br J Anaesth 2012; 108:768.
- Chung F, Yang Y, Liao P. Predictive performance of the STOP-Bang score for identifying obstructive sleep apnea in obese patients. Obes Surg 2013; 23:2050.
- Chung F, Chau E, Yang Y, et al. Serum bicarbonate level improves specificity of STOP-Bang screening for obstructive sleep apnea. Chest 2013; 143:1284.
- Chung F, Yang Y, Brown R, Liao P. Alternative scoring models of STOP-bang questionnaire improve specificity to detect undiagnosed obstructive sleep apnea. J Clin Sleep Med 2014; 10:951.
- 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.
- Gali B, Whalen FX Jr, Gay PC, et al. Management plan to reduce risks in perioperative care of patients with presumed obstructive sleep apnea syndrome. J Clin Sleep Med 2007; 3:582.
- Chau EH, Lam D, Wong J, et al. Obesity hypoventilation syndrome: a review of epidemiology, pathophysiology, and perioperative considerations. Anesthesiology 2012; 117:188.
- Wise SK, Wise JC, DelGaudio JM. Gastroesophageal reflux and laryngopharyngeal reflux in patients with sleep-disordered breathing. Otolaryngol Head Neck Surg 2006; 135:253.
- Morse CA, Quan SF, Mays MZ, et al. Is there a relationship between obstructive sleep apnea and gastroesophageal reflux disease? Clin Gastroenterol Hepatol 2004; 2:761.
- 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.
- Giles TL, Lasserson TJ, Smith BJ, et al. Continuous positive airways pressure for obstructive sleep apnoea in adults. Cochrane Database Syst Rev 2006; :CD001106.
- Liao P, Luo Q, Elsaid H, et al. Perioperative auto-titrated continuous positive airway pressure treatment in surgical patients with obstructive sleep apnea: a randomized controlled trial. Anesthesiology 2013; 119:837.
- 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.
- Joshi GP, Ankichetty SP, Gan TJ, Chung F. Society for Ambulatory Anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery. Anesth Analg 2012; 115:1060.
- Kurrek MM, Cobourn C, Wojtasik Z, et al. Morbidity in patients with or at high risk for obstructive sleep apnea after ambulatory laparoscopic gastric banding. Obes Surg 2011; 21:1494.
- Sabers C, Plevak DJ, Schroeder DR, Warner DO. The diagnosis of obstructive sleep apnea as a risk factor for unanticipated admissions in outpatient surgery. Anesth Analg 2003; 96:1328.
- Hathaway B, Johnson JT. Safety of uvulopalatopharyngoplasty as outpatient surgery. Otolaryngol Head Neck Surg 2006; 134:542.
- Kieff DA, Busaba NY. Same-day discharge for selected patients undergoing combined nasal and palatal surgery for obstructive sleep apnea. Ann Otol Rhinol Laryngol 2004; 113:128.
- PERIOPERATIVE RISKS
- Exacerbation of OSA
- Respiratory complications
- Cardiovascular complications
- Other complications
- INITIAL ASSESSMENT
- Screening for OSA
- - Who to screen
- - Screening tools
- Patients with known OSA
- - Assessment of OSA
- - OSA-associated conditions
- INDICATIONS FOR FURTHER EVALUATION
- MANAGEMENT OF PATIENTS PROCEEDING TO SURGERY
- INPATIENT OR OUTPATIENT SURGERY
- SUMMARY AND RECOMMENDATIONS