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
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]. 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 [15,16].
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- 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
- SUMMARY AND RECOMMENDATIONS