Chest
Volume 138, Issue 6, December 2010, Pages 1489-1498
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Postgraduate Education Corner
Contemporary Reviews in Sleep Medicine
Perioperative Management of Obstructive Sleep Apnea

https://doi.org/10.1378/chest.10-1108Get rights and content

Obstructive sleep apnea (OSA) is the most common breathing disorder, with a high prevalence in both the general and surgical populations. OSA is frequently undiagnosed, and the initial recognition often occurs during medical evaluation undertaken to prepare for surgery. Adverse respiratory and cardiovascular outcomes are associated with OSA in the perioperative period; therefore, it is imperative to identify and treat patients at high risk for the disease. In this review, we discuss the epidemiology of OSA in the surgical population and examine the available data on perioperative outcomes. We also review the identification of high-risk patients using clinical screening tools and suggest intraoperative and postoperative treatment regimens. Additionally, the role of continuous positive airway pressure in perioperative management of OSA and a brief discussion of ambulatory surgery in patients with OSA is provided. Finally, an algorithm to guide perioperative management is suggested.

Section snippets

Epidemiology of OSA in the Surgical Population

Various epidemiologic studies have demonstrated that sleep-disordered breathing occurs in approximately 20% of adults, with nearly 7% exhibiting moderate to severe OSA.7, 8, 9, 10, 11 It has been estimated that up to 80% of patients with OSA in the general population are undiagnosed and therefore untreated.9 Even higher rates of OSA have been identified in the surgical population, but these rates are influenced by the higher prevalence of obesity in these studies. Published data of morbidly

Perioperative Outcomes in Patients With OSA

Several studies have described the perioperative complications associated with OSA.14, 15, 16, 17 These complications include higher reintubation rates, hypercapnia, oxygen desaturations, cardiac arrhythmias, myocardial injury, delirium, unplanned ICU transfers, and longer hospitalization stays. More recently, Liao and colleagues4 compared patients with OSA with matched control subjects undergoing similar non-upper airway surgeries. They found a higher prevalence of postoperative complications

The Impact of Anesthesia on OSA

In general, the administration of anesthesia exacerbates the upper airway anatomic alterations that result in pharyngeal collapse during normal sleep in patients with OSA.18, 19, 20, 21, 22 Predictably, anesthetics also abolish or blunt arousal from sleep, an important defense mechanism that occurs during natural sleep to overcome airway obstruction. Anesthetic agents, such as pentothal, propofol, opioids, benzodiazepines, and inhaled halogenated agents, reduce the tone of the pharyngeal

Diagnosis of OSA

The standard diagnostic test for OSA is an attended in-laboratory polysomnogram (PSG) that records physiologic variables, such as EEG, ECG, chin and leg electromyograms, and pulse oximetry. Nasal and oral airflow as well as chest and abdominal efforts are also measured.29 Obstructive apneas are defined as complete or near-complete cessation of airflow lasting for at least 10 s. Obstructive hypopneas are characterized by at least 30% reduction in airflow for a minimum of 10 s and are associated

Clinical Screening Tools

Screening tools assist with the identification of patients at highest risk for OSA using established risk factors. Obesity and old age are the strongest risk factors for OSA.38 Other risk factors include male sex, excessive alcohol intake, and female menopause.39 Craniofacial abnormalities, such as retrognathia and macroglossia, and wide neck circumference (17 inches for men and 16 inches for women),40 are also considered as risk factors for OSA. Common signs and symptoms include loud snoring,

Management Strategies

The approach to the management of patients diagnosed with OSA presenting for surgery can be divided into preoperative, intraoperative, and postoperative strategies. Figure 1 shows suggested steps in the management of adult patients with OSA and adult patients at high risk of OSA undergoing elective non-upper airway surgery.

The Role of CPAP in the Perioperative Period

CPAP remains the most effective therapy for OSA, acting as a pneumatic splint to maintain upper airway patency.66 A study67 of patients with severe OSA showed that patients who were compliant with CPAP therapy had significantly decreased rates of both fatal and nonfatal cardiovascular events over a 10-year period. However, the impact of CPAP therapy on short-term reduction in cardiovascular events is controversial.

Gupta et al15 found that patients with OSA who were using CPAP preoperatively had

Ambulatory Surgery in Patients With OSA

The literature regarding the safety of ambulatory surgery in patients with OSA is sparse and of limited quality,56 and whether ambulatory surgery is suitable in patients with OSA remains controversial.41, 56 In determining eligibility for ambulatory surgery, an overall assessment of perioperative risk should be performed using guidelines suggested by the ASA41 as shown in Table 4. This risk estimation takes into account the severity of sleep apnea, the invasiveness of the surgery, and the

Summary

Patients with OSA are at high risk for perioperative complications and pose multiple challenges, including difficult airway management and increased incidence of postoperative complications. Because undiagnosed OSA is common, a focused history and physical examination followed by the administration of clinical screening tools should be used to identify patients at high risk for OSA. Patients at high risk for OSA should be managed similarly to patients with known OSA in the perioperative period.

Acknowledgments

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: This work was performed in the Departments of Anesthesiology and Internal Medicine at the University of Texas Southwestern Medical Center in Dallas, Texas.

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