Obstructive Sleep Apnea (OSA)


Epidemiology

Risk Groups

Risk Factors/Clinical Predictors


Physiology


Diagnosis

Arterial Blood Gas (ABG) (see Arterial Blood Gas)

Pulmonary Function Tests (PFT’s) (see Pulmonary Function Tests)

Actigraphy (see Actigraphy)

Sleep Study (see Sleep Study)

Attended Polysomnography

Unattended Portable Sleep Study

Echocardiogram (see Echocardiogram)


Clinical Manifestations

Cardiovascular Manifestations

Hypertension (see Hypertension)

Increased Risk of Coronary Artery Disease (CAD) (see Coronary Artery Disease)

Increased Risk of Post-Operative Cardiac Complications [MEDLINE] [MEDLINE]

Endocrinologic Manifestations

Impaired Glucose Tolerance/Diabetes Mellitus (DM) (see Diabetes Mellitus)

Gastrointestinal Manifestations

Increased Risk of Hepatic Steatosis/Non-Alcoholic Fatty Liver Disease (NAFLD) (see Non-Alcoholic Fatty Liver Disease)

Neuropsychiatric Manifestations

Excessive Daytime Somnolence (EDS) (see Excessive Daytime Somnolence)

Increased Risk of Cerebrovascular Accident (CVA)

Sleep Disruption/Frequent Arousals

Pulmonary Manifestations

Chronic Hypoventilation/Chronic Hypoxemic, Hypercapnic Respiratory Failure (see Respiratory Failure)

Habitual Snoring

Increased Risk of General Anesthesia-Related Laryngospasm (see Laryngospasm)

Increased Risk of Post-Operative Respiratory Complications [MEDLINE] [MEDLINE]

Observed Apneas During Sleep

Pulmonary Hypertension/Cor Pulmonale (see Pulmonary Hypertension)

Snoring

Nocturnal Oxygen Desaturations

Other Manifestations

Decreased Quality of Life [MEDLINE]


Treatment

General Management

Transtracheal Oxygen (see Oxygen)

Positive Airway Pressure (PAP)

Modalities

Technique of CPAP/BPAP Titration (American Academy of Sleep Medicine, Guidelines, 2008) (J Clin Sleep Med, 2008) [MEDLINE]

Clinical Benefits of Continuous Positive Airway Pressure (CPAP)

Clinical Efficacy-CPAP

Autotitrating Continuous Positive Airway Pressure (CPAP) (see Continuous Positive Airway Pressure)

Expiratory Positive Airway Pressure (EPAP) (Provent)

Continuous Positive Airway Pressure (CPAP) Adherence

Complications of Continuous Positive Airway Pressure (CPAP)

Management of Residual Excessive Daytime Sleepiness (see Excessive Daytime Sleepiness)

Implantable Upper Airway Stimulation Device (Hypoglossal Nerve Stimulator)

Dental Appliance (Most are Mandibular Advancement Devices)

Adenotonsillectomy

Maxillomandibular Advancement

Uvulopalatopharyngoplasty (UPPP)

Tracheostomy (see Tracheostomy)

Atomoxetine and Oxybutynin (see Atomoxetine and Oxybutynin)

Perioperative Management of Obstructive Sleep Apnea (OSA)

Clinical Efficacy

  • An Observational Study Reported Lower Frequency of Serious Postoperative Complications (i.e. Cardiac Events, Complications Needing Intensive Care Unit Transfer or Urgent Respiratory Support) When Preoperative At-Home CPAP is Compared with No Preoperative CPAP (Category B1-B Evidence) (Mayo Clin Proc, 2001) [MEDLINE]
    • Literature is Insufficient to Evaluate the Impact of the Preoperative Use of NIPPV

Recommendations (American Society of Anesthesiologists Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea 2014) (Anesthesiology, 2014) [MEDLINE]

  • Preoperative Evaluation
    • Anesthesiologists/Surgeons Should Develop a Protocol Whereby Patients in Whom the Possibility of Obstructive Sleep Apnea is Suspected on Clinical Grounds are Evaluated Long Enough Before the Day of Surgery to Allow Preparation of a Perioperative Management Plan
      • Evaluation May Be Initiated in Preanesthesia Clinic (if Available) or By Direct Consultation from the Surgeon to the Anesthesiologist
    • Preoperative Evaluation Should Include Comprehensive Review of Medical Records (if Available), Interview with the Patient/Family, and Physical Examination
      • Medical Records Review Should Include Checking for a History of Airway Difficulty with Prior Anesthetics, History of Hypertension or Other Cardiovascular Problems, and History of Other Congenital/Acquired Medical Conditions
    • Review of Sleep Study is Encouraged
      • Patient/Family Interview Should Include Questions Related to Snoring, Apnea Episodes, Frequent Sleep Arousals (e.g. Vocalization, Shifting Position, and Extremity Movements), Morning Headaches, and Daytime Somnolence
      • Physical Examination Should Include Evaluation of the Airway, Nasopharyngeal Characteristics, Neck Circumference, Tonsil Size, and Tongue Volume
    • If Any Characteristics Noted During Preoperative Evaluation Suggest that the Patient has Obstructive Sleep Apnea, the Anesthesiologist/Surgeon Should Jointly Decide Whether to Manage the Patient Perioperatively Based on Clinical Criteria Alone or to Obtain a Sleep Study, Conduct a More Extensive Airway Examination, and Initiate Indicated Obstructive Sleep Apnea Treatment in Advance of Surgery
    • If the Preoperative Evaluation Does Not Occur Until the Day of Surgery, the Surgeon and Anesthesiologist Together May Elect for Presumptive Management Based on Clinical Criteria or a Last-Minute Delay of the Surgery
    • For Safety, Clinical Criteria Should Have a High Degree of Sensitivity (Despite the Resulting Low Specificity), Meaning that Some Patients May Be Treated More Aggressively than Would Be Necessary than if a Sleep Study was Available
    • Severity of the Patient’s Obstructive Sleep Apnea, the Invasiveness of the Diagnostic or Therapeutic Procedure, and the Requirement for Postoperative Analgesics Should Be Considered in Determining Whether a Patient is at Increased Perioperative Risk from Obstructive Sleep Apnea
    • Patient/Family and Surgeon Should Be Informed of the Potential Implications of Obstructive Sleep Apnea on the Patient’s Perioperative Course
  • Inpatient vs Outpatient Surgery
    • Before Patients at Increased Perioperative Risk from Obstructive Sleep Apnea are Scheduled to Undergo Surgery, Determination Should Be Made Regarding Whether a Surgical Procedure is Most Appropriately Performed on an Inpatient vs Outpatient Basis
      • Factors to Be Considered in Determining Whether Inpatient vs Outpatient Care is Appropriate Include the Following
        • Anatomical and Physiologic Abnormalities
        • Sleep Apnea Status
        • Status of Coexisting Diseases
        • Nature of Surgery
        • Type of Anesthesia
        • Need for Postoperative Opiates
        • Patient Age
        • Adequacy of Postdischarge Observation
        • Capabilities of the Outpatient Facility
        • Availability of Emergency Difficult Airway Equipment and Respiratory Care Equipment
        • Radiology Facilities
        • Clinical Laboratory Facilities
        • Transfer agreement with an Inpatient Facility
  • Preoperative Preparation
    • Preoperative Initiation of Continuous Positive Airway Pressure (CPAP) Should Be Considered, Particularly if Obstructive Sleep Apnea is Severe
      • For Patients Who Do Not Respond Adequately to CPAP, Noninvasive Positive Pressure Ventilation Should Be Considered
    • Preoperative Use of Mandibular Advancement Devices or Oral Appliances and Preoperative Weight Loss Should Be Considered When Feasible
      • Patient Who Has Had Corrective Airway Surgery (Uvulopalatopharyngoplasty, Surgical Mandibular Advancement, etc) Should Be Assumed to Remain at Risk of Obstructive Sleep Apnea Complications Unless a Normal Sleep Study Has Been Obtained and Symptoms Have Not Returned
    • Patients with Known or Suspected Obstructive Sleep Apnea May Have Difficult Airways and Therefore Should Be Managed According to the American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway
  • Intraoperative Management
    • Because of Their Propensity for Airway Collapse and Sleep Deprivation, Patients at Increased Perioperative Risk from Obstructive Sleep Apnea are Especially Susceptible to the Respiratory Depressant and Airway Effects of Sedatives, Opiates, and Inhaled Anesthetics
      • Therefore, the Potential for Postoperative Respiratory Compromise Should Be Considered in Selecting Intraoperative Medications
    • For Superficial Procedures, Consider the Use of Local Anesthesia or Peripheral Nerve Blocks (with or without Moderate Sedation)
    • If Moderate Sedation is Used, Ventilation Should Be Continuously Monitored by Capnography or Another Automated Method (if Feasible) Because of the Increased Risk of Undetected Airway Obstruction in These Patients
    • Consider Administering CPAP or Using an Oral Appliance During Sedation to Patients Previously Treated with These Modalities
    • General Anesthesia with a Secure Airway is Preferable to Deep Sedation without a secure airway, Particularly for Procedures Which May Mechanically Compromise the Airway
    • Major Conduction Anesthesia (Spinal/Epidural) Should Be Considered for Peripheral Procedures
    • Unless There is a Medical/Surgical Contraindication, Patients at Increased Perioperative Risk from Obstructive Sleep Apnea Should Be Extubated While Awake
    • Full Reversal of Neuromuscular Block Should Be Verified Before Extubation
    • When Possible, Extubation and Recovery Should Be Performed in the Lateral, Semiupright, or Other Nonsupine Position
  • Postoperative Management
    • Regional Analgesic Techniques Should Be Considered to Decrease/Eliminate the Requirement for Systemic Opiates in Patients at Increased Perioperative Risk from Obstructive Sleep Apnea
    • If Neuraxial Analgesia is Planned, Weigh the Benefits (Improved Analgesia, Decreased Requirement for Systemic Opiates) and Risks (Respiratory Depression from Rostral Spread) of Using an Opiate or Opiate–Local Anesthetic Mixture Rather than a Local Anesthetic Alone
    • If Patient-Controlled Systemic Opiates are Utilized, Continuous Background Infusions Should Be Avoided or Utilized with Extreme Caution
    • To Decrease Opiate Requirements, Nonsteroidal Anti-Inflammatory Agents and Other Modalities (Ice, Transcutaneous Electrical Nerve Stimulation) Should Be Considered (If Appropriate)
    • Concurrent Administration of Sedative Agents (Benzodiazepines and Barbiturates) Increases the Risk of Respiratory Depression and Airway Obstruction
    • Supplemental Oxygen Should Be Administered Continuously to All Patients Who are at Increased Perioperative Risk from Obstructive Sleep Apena Until They are Able to Maintain Their Baseline Oxygen Saturation While Breathing Room Air
      • Note that the Use of Supplemental Oxygen May Increase the Duration of Apneic Episodes and May Hinder Detection of Atelectasis, Transient Apnea, and Hypoventilation by Pulse Oximetry
    • When Feasible, CPAP or Noninvasive Positive-Pressure Ventilation (with/without Supplemental Oxygen) Should Be Continuously Administered to Patients Who were Using these Modalities Preoperatively (Unless Contraindicated by the Surgical Procedure)
      • Compliance with CPAP or Noninvasive Positive-Pressure Ventilation May Be Improved if Patients Bring Their Own Equipment to the Hospital
    • If Possible, Patients at Increased Perioperative Risk from Obstructive Sleep Apnea Should Be Placed in the Nonsupine Position throughout the Recovery Process
    • Hospitalized Patients Who are at Increased Risk of Respiratory Compromise from Obstructive Sleep Apnea Should Have Continuous Pulse Oximetry Monitoring After Discharge from the Recovery Room
      • Continuous Monitoring May Be Provided in a Critical Care or Stepdown Unit, by Telemetry on a Hospital Ward, or By a Dedicated, Appropriately Trained Professional Observer in the Patient’s Room
      • Continuous Monitoring Should Be Maintained as Long as the Patient Remains at Increased Risk
    • If Frequent or Severe Airway Obstruction or Hypoxemia Occurs During Postoperative Monitoring, Initiation of Nasal CPAP or Noninvasive Positive-Pressure Ventilation Should Be Considered
  • Criteria for Discharge to Unmonitored Settings
    • Patients at Increased Perioperative Risk from OSA Should Not Be Discharged from the Recovery Area to an Unmonitored Setting (i.e. Home or Unmonitored Hospital Bed) Until They are No Longer at Risk for Postoperative Respiratory Depression
      • Because of Their Propensity to Develop Airway Obstruction or Central Respiratory Depression, This May Require a Longer Stay as Compared with Non-OSA Patients Undergoing Similar Procedures
    • To Establish that Patients are Able to Maintain Adequate Oxygen Saturation Levels While Breathing Room Air, Respiratory Function May Be Determined by Observing Patients in an Unstimulated Environment, Preferably While Asleep

Prognosis


References

General

Risk Factors/Clinical Predictors

CPAP

Adaptive Servo Ventilation

Mandibular Advancement Device

Implantable Upper Airway Stimulation Device

Atomoxetine and Oxybutynin (see Atomoxetine and Oxybutynin)

Perioperative Management of Obstructive Sleep Apnea

Prognosis