Prevalence: OSA affects about 10-17% of US population (depending on criteria used) [MEDLINE]
Sex: 2-3x more common in adult men than adult women
May be related to hormonal differences, differential fat deposition, craniofacial morphology, and genioglossus muscle activation
OSA prevalence increases after menopause
Age: OSA has 2-4x higher prevalence in elderly than in middle age
Some studies have shown the prevalence (using AHI 5/hr) is as high as 80% in patients >71 y/o
Risk Groups
Long-Distance Commercial Truck Drivers
Examination of OSA Prevalence Rates in Long-Distance Commercial Truck Drivers (Sleep, 2012) [MEDLINE]: 41% of long-distance heavy vehicle drivers were likely to have sleep apnea by in-home diagnostic testing (importantly, patient self-report measures showed poor agreement with the in-home detected sleep apnea)
36% of drivers were overweight/50% of drivers were obese
49% of drivers were cigarette smokers
Risk Factors/Clinical Predictors
Acid Maltase Deficiency: OSA has been reported
Acromegaly (see Acromegaly): OSA occurs in 60-70% of cases
Most cases are due to anterior pituitary somatotrophin-secreting adenoma
Best screening test is serum insulin growth factor level (GH levels can be elevated, due to increased dietary carbohydrate intake)
Age: prevalence of OSA increases from young adulthood through the 6th-7th decade of life, then plateaus
Methadone (see Methadone): studies report an association between chronic methadone use and sleep-disordered breathing, with obstructive sleep apnea being observed more commonly than central sleep apnea (Drug Alcohol Depend, 2010) [MEDLINE]
Strong Association of Obstructive Sleep Apnea and Hypertension
Longitudinal Sleep Heart Health Study in Adults 40-98 (2009) [MEDLINE]: odds ratios for the presence of hypertension increased with increasing AHI levels
Longitudinal Wisconsin Sleep Cohort Study in Adults 30-60 (2008) [MEDLINE]: for even small baseline AHI elevations (1 to 5), there was an increased likelihood of developing hypertension at the 4 and 8-year time points
70-80% of Patients with Treatment-Resistant Hypertension Have OSA
30% of patients in essential hypertension clinics have OSA
Age/male sex/AHI/BMI are all associated with hypertension, but snoring is not in OSA patients (however, in Upper Airways Resistance Syndrome, snoring is associated with hypertesnion)
Increased Risk of Post-Operative Cardiac Complications [MEDLINE] [MEDLINE]
Epidemiology
Endocrinologic Manifestations
Impaired Glucose Tolerance/Diabetes Mellitus (DM) (see Diabetes Mellitus)
Epidemiology: impaired glucose tolerance and insulin resistance are observed in OSA (independent of age and obesity): probably due to sleep deprivation and sleep-associated hypoxemia
General Comments: OSA with chronic intermittent hypoxemia results in increased lipogenesis, increased triglyceride levels, and decreased hepatic beta oxidation
Study Reporting an Association Between OSA and Elevated Liver Function Tests/Fatty Liver (2013) [MEDLINE]
Study Reporting an Association Between OSA and Hepatic Steatosis in Patients with Median BMI 34.2 (2014) [MEDLINE]: 61.5% of referred OSA patients exhibited moderate or severe steatosis (with 38% manifesting borderline or possible non-alcoholic steatohepatitis)
Risk Factors for Hepatic Steatosis
Nocturnal Cumulative Time Spent <90% SaO2: dose-response relationship was observed between nocturnal hypoxemia and liver injury in subset of patients with BMI >37.8
Presence of Insulin Resistance
Triglyceride Level
Study Reporting an Association Between OSA and Hepatic Steatosis in Patients with BMI <35 (2014) [MEDLINE]: OSA syndrome with sleepiness was strongly associated with NASH and fibrosis >1 (independent of known clinical risk factors such as age, gender, BMI, diabetes, and ALT levels)
Increased Probability of Motor Vehicle and Other Accidents
Swedish Traffic Accident Registry Data Examining OSA and Risk of Motor Vehicle Accidents (2015) [MEDLINE]: OSA increased the risk of motor vehicle accidents with a risk ratio of 2.45, as compared with controls (p <0.001)
Increased Risk of Cerebrovascular Accident (CVA)
Epidemiology
Sleep Heart Health Study (Am J Resp Crit Care Med, 2010) [MEDLINE]: there is a strong adjusted association between ischemic stroke and obstructive apnea-hypopnea index in community-dwelling men with mild-moderate sleep apnea
Sleep Disruption/Frequent Arousals
xxx
Pulmonary Manifestations
Chronic Hypoventilation/Chronic Hypoxemic, Hypercapnic Respiratory Failure (see Respiratory Failure)
Epidemiology
Habitual Snoring
xxx
Increased Risk of General Anesthesia-Related Laryngospasm (see Laryngospasm)
xxx
Increased Risk of Post-Operative Respiratory Complications [MEDLINE] [MEDLINE]
Pulmonary hypertension (usually mild) occurs in 15-20% of OSA patients (usually moderate-severe OSA)
Pulmonary hypertension is believed to be associated with nocturnal hypoxemic events (therefore, in upper airway resistance syndrome, where hypoxemic events do not occur, pulmonary HTN is absent)
There are no clinical differences between OSA patients with and without pulmonary hypertension
Decreases hypoxemia and AHI (possibly due to delivery of oxygen below site of obstruction with increase in mean airway pressure and improved hypoxemia)
Technique of CPAP/BPAP Titration (American Academy of Sleep Medicine, Guidelines, 2008) (J Clin Sleep Med, 2008) [MEDLINE]
CPAP (or IPAP and/or EPAP for BPAP) Should Be Increased Until Respiratory Events are Eliminated: oxygen desaturations without associated obstructive respiratory events should not be considered in the decision to increase CPAP in adult patients
Apneas
Hypopneas
Respiratory Effort-Related Arousals (RERA’s)
Snoring
Starting CPAP Should Be 4 cm H2O in Adults: higher starting CPAP may be used in patient with elevated BMI or for retitration studies
Higher BMI Has Been Demonstrated to be Associated with Higher CPAP Pressures to Abolish Apneas
CPAP Should Be Increased By at Least 1 cm H2O No More Often than q5 min
Increase in CPAP Pressures to Target Respiratory Events
CPAP Should Be Increased if at Least 2 Obstructive Apneas are Observed for Patients >12 y/o
CPAP Should Be Increased if at Least 3 Hypopneas are Observed for Patients >12 y/o
CPAP Should Be Increased if at Least 5 RERA’s are Observed for Patients >12 y/o
CPAP Should Be Increased if at Least 3 min of Loud or Unambiguous Snoring is Observed for Patients >12 y/o
“Exploration” of CPAP Above the Pressure at Which Respiratory Events are Controlled Should Not Exceed 5 cm H2O
Maximum CPAP Should Be 20 cm H2O in Patients >12 y/o
“Down” Titration of CPAP
If Patient Awakens and Complains that Pressure is Too High, CPAP Should Be Restarted at a Lower Pressure Which Patient Finds Comfortable
Down Titration May Be Considered, But is Not Required: due to a “hysteresis” phenomenon, during upward titration, the pressure level at which flow limitation disappears is 2-5 cm H2O higher than the pressure level at which it reappears during downward titration
Split-Night Titration Study: same protocol should be used as for full-night titration study
Split-Night Study is Comparable to Full-Night Titration Study, in Most Cases: except that pressures determined from split-night studies may be lower for patients with mild-to-moderate OSA who may not manifest the maximal severity of their condition during the first portion of the night
Switch to BPAP
If Patient is Uncomfortable/Intolerant of CPAP or if There are Continued Obstructive Respiratory Events at CPAP 15 cm H2O During a Titration Study, BPAP May Be Tried
Use of BPAP
Starting BPAP Pressures Should Be 8/4 in Adult Patients
Minimum EPAP should be 4 cm H2O or the level of CPAP pressure at which obstructive events were eliminated
Higher starting IPAP/EPAP may be used in patient with elevated BMI or for retitration studies
IPAP and/or EPAP (Depending on Type of Obstructive Respiratory Evente) Should Be Increased By at Least 1 cm H2O in Both IPAP and EPAP No More Often than q5 min
Maximum IPAP Should Be 30 cm H2O in Patients >12 y/o: IPAP exceeding 30 cm H2O increases the risk of barotrauma and other morbidities
Minimum IPAP-EPAP Differential Should Be 4 cm H2O
Maximum IPAP-EPAP Differential Should Be 10 cm H2O
Increase in BPAP Pressures to Target Respiratory Events
IPAP and EPAP Should be Increased if at Least 2 Obstructive Apnea are Observed for Patients ≥12 y/o
IPAP Should be Increased if at Least 3 Hyopneas are Observed for Patients ≥12 y/o
IPAP Should be Increased if at Least 5 RERA’s are Observed for Patients ≥12 y/o
IPAP Should be Increased if at Least 3 min of Loud or Unambiguous Snoring is Observed for Patients >12 y/o
“Exploration” of IPAP Above the Pressure at Which Respiratory Events are Controlled Should Not Exceed 5 cm H2O
“Down” Titration of BPAP
If Patient Awakens and Complains that Pressure is Too High, IPAP Should Be Restarted at a Lower Pressure Which Patient Finds Comfortable
Decrease in IPAP or Setting BPAP in Spontaneous-Timed (ST) Mode with Backup Rate May Be Helpful if Treatment-Emergent Central Sleep Apneas Complex Sleep Apneas) Develop
Down Titration May Be Considered, But is Not Required:
Quality of Titration
“Optimal” Titration: decrease in RDI to <5/hr for at least 15 min duration and should include supine REM sleep at the selected pressure that is not continually interrupted by spontaneous arousals or awakenings
“Good” Titration: decrease in RDI to ≤10/hr (or by 50% if baseline RDI was <15/hr) and should include supine REM sleep at the selected pressure that is not continually interrupted by spontaneous arousals or awakenings
“Adequate” Titration: one which does not decrease RDI to ≤10/hr but does decrease RDI by 75% from baseline (especially in severe OSA) or if “optimal” or “good” criteria are met but supine REM sleep did not occur at the selected pressure
Leak Management: mask fit or readjustment should be performed when any unintentional leak is observed
Intentional Leak: controlled leak from the port on mask interfaces that washes out CO2 and prevents rebreathing
Mouth Leak: pressurized air escaping via the mouth when a nasal mask is used
Mask Leak: pressurized air escaping between the mask and the face when a nasal mask or full-face mask is used
Supplemental Oxygen Should Be Added to PAP Titration When Supine SpO2 on Room Air is ≤88%: start at 1L/min and titrate up to target a SpO2 88-94%
Supplemental Oxygen May Be Added to PAP Titration When Supine SpO2 is ≤88% for ≥5 min in the Absence of Obstructive Respiratory Events: start at 1L/min and titrate up to target a SpO2 88-94%
ASV May Be Considered if Patient is Observed to Have Cheyne-Stokes Respiration or if Treatment-Emergent Central Sleep Anea (Complex Sleep Apnea) During the Titration Study is Not Eliminated by Down Titration of Pressure
Clinical Benefits of Continuous Positive Airway Pressure (CPAP)
CPAP is Highly Effective in the Treatment of OSA: however, many patients may not be adherent (for various reasons)
CPAP Has Beneficial Effects on Atrial Fibrillation (AF) (see Atrial Fibrillation)
Use of CPAP (>4 hrs/nt) in OSA Patients with AF Has Been Shown to Decrease Recurrence of AF After Cardioversion (42% Recurrence Rate vs. 82% Recurrence Rate)
Effect of CPAP May Be Related to Effects of OSA on Nocturnal Hypoxemia, Hypercapnia, Sympathetic Drive, and Changes in Intrathoracic Pressure
Improvement in Pulmonary Artery Pressure Occurs Independent of Changes in Hypoxemia, Suggesting that Pulmonary Artery Pressure Changes are Related to Changes in Endothelial Function, Rather than Merely a Reversal of Hypoxic Pulmonary Arterial Vasoconstriction
CPAP Has Beneficial Effects on Systemic Hypertension (see Hypertension)
Systematic Review/Meta-Analysis of Effects of Positive Pressure Therapy on Hypertension Associated with OSA (J Clin Sleep Med, 2012) [MEDLINE]: positive pressure therapy results in modest, but significant, decreases in systolic and diastolic blood pressure
However, Data Indicate that the Effects of CPAP are Less Clear in the Treatment of OSA without Sleepiness
CPAP Has Beneficial Effects on Sleep Apnea-Related Risk of Motor Vehicle Accidents
Swedish Traffic Accident Registry Data Examining OSA and Risk of Motor Vehicle Accidents (Sleep, 2015) [MEDLINE]
In Patients with OSA, CPAP Use ≥4 hrs/Night Was Associated with a Decrease in the Incidence of Motor Vehicle Accidents (7.6 -> 2.5 Accidents/1,000 Drivers/yr)
Study of Effects of CPAP on PTSD in Veterans with OSA (J Clin Sleep Med, 2014) [MEDLINE]
In Veterans with PTSD and OSA, CPAP Therapy Reduces PTSD-Associated Nightmares and Improves Overall PTSD Symptoms
CPAP Therapy Alone Does Not Result in Weight Loss (see Weight Loss)
Effect of CPAP on Cardiometabolic Parameters in OSA (Thorax, 2012) [MEDLINE]
CPAP Alone Does Not Lead to Weight Loss or Improvement in Insulin Sensitivity
CPAP Therapy Alone Does Not Result in Improvement in Depression (see Depression)
Clinical Efficacy-CPAP
Multicenter, Randomized MERGE Trial of CPAP in Mild Obstructive Sleep Apnea (Lancet Respir Med, 2020) [MEDLINE]
Three Month Treatment of Mild OSA with CPAP Improved Quality of Life
ISAACC Trial of CPAP Effect on the Prevalence of Cardiovascular Events in Patients with Acute Coronary Syndrome (Lancet Respir Med, 2020) [MEDLINE]
Among non-sleepy patients with ACS, the presence of OSA was not associated with an increased prevalence of cardiovascular events and treatment with CPAP did not significantly reduce this prevalence
Rationale: autotitrating CPAP devices may be used in lieu of an in-laboratory CPAP titration study in some patients (and insurers may deny the in-laboratory study, instead requiring that an autotitrating CPAP be used)
Contraindications
Lack of Respiratory Drive: since the pressure delivered is triggered by respiratory effort
Technique
From the Autotitration Report, it is Generally Accepted to Choose the T90 or T95 Pressure (Which is the Pressure the Patient is at or Below 90-95% of the Time)
Due to Limitations of These Devices, Patients Need Follow-Up to Ensure that this is the Correct Setting: if symptoms persist, in-laboratory titration may be required
Factors Which May Decrease Auto-PAP Adherence
Air Leak: auto-PAP systems are very sensitive to air leaks
Clinical Efficacy
Study of Auto-PAP Therapy for OSA (Sleep, 2011) [MEDLINE]
Air Leak was Associated with Poor Adherence with Auto-PAP
Adherence to Auto-PAP Therapy was Strongly Correlated with Subsequent Adherence to CPAP Therapy
Residual OSA (AHI ≥10 Events/hr) was Observed in 24% of Patients During Autotitration: for this reason, clinicians should be aware of the limitations of auto-PAP devices
Education and Early, Frequent Contact with Health Care Providers After CPAP Initiation
Family Involvement
Heated Humidification
More Severe Sleep Apnea Indices
Short Course of Eszopiclone (Lunesta) During the First 2 Weeks of CPAP Therapy (Ann Intern Med, 2009) [MEDLINE] (see Eszopiclone): improves adherence and results in Fewer patients discontinuing CPAP therapy
Complications of Continuous Positive Airway Pressure (CPAP)
Treatment-Emergent Central Sleep Apnea (Complex Sleep Apnea) (see Central Sleep Apnea)
History: recently added to the International Classification of Sleep Disorders, 3rd ed (Chest, 2014) [MEDLINE]
Definition: development of central sleep apnea following the application of CPAP, dental appliance, or following tracheostomy for OSA
These Central Events Cannot Be Attributed to Another Identifiable Comorbidity Such as Cheyne-Stokes Breathing or the Use of Opiates
Mechanism: may be related to hypocapnia or mask leaks in some cases (J Clin Sleep Med, 2013) [MEDLINE]
Clinical
Usually Observed When the Patient Has Frequent Arousals from Sleep
Occurs After the Obstructive Events are Controlled During NREM Sleep: occur mainly in the supine position
Treatment
May Resolve Over Time in Some Cases: should reassess patient on CPAP in 2-3 mo
Complex Sleep Apnea Resolution Study (Sleep, 2014) [MEDLINE]: central sleep apnea improves or resolves spontaneously in approximately 66% of patients who continue on CPAP for 90 days
Adaptive Servo Ventilation (ASV) (see Adaptive Servo Ventilation): may be useful, as it treats both obstructive and central apneas
ASV is a form of bi-level positive airway pressure that provides variable pressure support via a servo mechanism-based assessment of the patient’s respiratory output
When There are Hypopneas: ASV increases the pressure support (difference between expiratory PAP and inspiratory PAP)
When There are Hyperpneas: ASV decreases the pressure support (difference between expiratory PAP and inspiratory PAP)
When Central Sleep Apneas Occur: ASV utilizes a backup rate and the EPAP maintains airway patency
ASV increases the mortality rate in patients with central sleep apnea in association with systolic congestive heart failure and EF <45% (NEJM, 2015) [MEDLINE]
OSA with Inability to Tolerate CPAP: device increases upper airway patency (but does not correct central sleep apnea)
Device Has Not Been Tested in Treatment Emergent Central Sleep Apnea (Complex Sleep Apnea)
Clinical Efficacy
Drug-Induced Sleep Endoscopy as a Selection Tool for Upper Airway Stimulation (J Clin Sleep Med, 2013) [MEDLINE]
The Absence of Palatal Complete Concentric Collapse (at the Tongue Level) During Drug-Induced Sleep Endoscopy Predicts Therapeutic Success with Implanted Upper Airway Stimulator Therapy
STAR Trial of Hypoglossal Nerve Stimulator in Moderate-Severe OSA (NEJM, 2014) [MEDLINE]: multi-center, prospective, single group, cohort design trial (n = 126) of surgically implanted upper-airway stimulation device (from Inspire Medical Systems) in moderate-severe OSA patients intolerant of CPAP (BMI <32, no major underlying cardiopulmonary disease, no other sleep disorders, no psychiatric disease)
Hypoglossal Nerve Stimulator Resulted in a 68% Decrease in the Apnea-Hypopnea Index at 12 mo, Less Oxygen Desaturation, and Improved Quality of Life
Patients Used the Device for at Least Part of the Night on 86% of the Nights
Procedure-Related Serious Adverse Events Occurred in <2% of cases (temporary tongue weakness, discomfort with stimulation, tongue soreness)
Dental Appliance (Most are Mandibular Advancement Devices)
Variety of Appliances
There are >80 Dental Appliances Available
Mandibular Advancement Devices: accounts for most of the available devices
Tongue Retaining Devices: accounts for remainder of devices
Indications: second-line therapy
Snoring and Mild-Moderate OSA Intolerant of CPAP Therapy
Technique: polysomnography should be performed to assess efficacy
Clinical Efficacy
Randomized Trial Comparing CPAP with Mandibular Advancement Device in Moderate-Severe OSA (Am J Respir Crit Care Med, 2013) [MEDLINE]
CPAP was More Efficacious than Mandibular Advancement Device in Reducing AHI
Compliance was Higher with Mandibular Advancement Device than with CPAP
Neither Treatment Improved Blood Pressure
Daytime Sleepiness, Driving Simulator Performance, and Disease-Specific Quality of Life Improved on Both Treatments by Similar Amounts
Mandibular Advancement Device was Superior to CPAP in Terms of Improving Four General Quality of Life Domains
Complications
Treatment Emergent Central Sleep Apnea (Complex Sleep Apnea): refers to the development of central sleep following the application of CPAP or a dental appliance
See Above
Adenotonsillectomy
Clinical Efficacy: effective in children and infants
Maxillomandibular Advancement
Technique: surgery to move the upper and lower jaw forward
Clinical Efficacy: has been uccessful in resolving OSA
Uvulopalatopharyngoplasty (UPPP)
Technique: reduction or removal of portions of the soft palate and uvula
Effects of the combination of atomoxetine and oxybutynin on obstructive sleep apnea endotypic traits. CHEST. doi:10.1016/j.chest.2020.01.012 [MEDLINE]
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
Patients with an Average of >20 Apneas/hr were Found to Have an 8-yr Cumulative Mortality of 37%, as Compared with 4% in Those with an index <20 Apneas/hr
Wisconsin Sleep Cohort Study (Sleep, 2008) [MEDLINE]
Untreated Sleep-Disordered Breathing Increases Mortality, Independent of Age/Sex/BMI
Results Were Similar Even After Accounting for Symptoms of Daytime Sleepiness
Moderate-Severe OSA is Associated with Increased All-Cause Mortality
Sleep Heart Health Study (PLoS Med, 2009) [MEDLINE]
Sleep-Disordered Breathing Increased All-Cause Mortality (and Specifically that Due to Coronary Artery Disease), Particularly in Males age 40-70
Database Study (Otolaryngol Head Neck Surg, 2012) [MEDLINE]: increased OSA severity (quantified by AHI/apnea index/desaturation index) is independently associated with all-cause mortality in patients <50 y/o (after adjustment for confounding factors)
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Risk of obstructive sleep apnea with daytime sleepiness is associated with liver damage in non-morbidly obese patients with nonalcoholic fatty liver disease. PLoS One 2014;9(4):e96349 [MEDLINE]
Diagnosis of obstructive sleep apnea in adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med 2014;161:210-220 [MEDLINE]
International classification of sleep disorders-third edition: highlights and modifications. Chest. 2014 Nov;146(5):1387-94. doi: 10.1378/chest.14-0970 [MEDLINE]
Sleep apnea related risk of motor vehicle accidents is reduced by continuous positive airway pressure: Swedish Traffic Accident Registry Data. Sleep 2015;38:341-349 [MEDLINE]
Risk Factors/Clinical Predictors
Smoking as a risk factor for sleep-disordered breathing. Arch Intern Med. 1994 Oct 10;154(19):2219-24 [MEDLINE]
CPAP
Practice parameters for the use of autotitrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome: an update for 2007. An American Academy of Sleep Medicine report. Sleep 2008;31(1): 141-147 [MEDLINE]
Clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea. J Clin Sleep Med. 2008 Apr 15;4(2):157-71 [MEDLINE]
Portable monitoring and autotitration vs polysomnography for the diagnosis and treatment of sleep apnea. Sleep 2008;31(10):1423-1431 [MEDLINE]
Effects of a short course of eszopiclone on continuous positive airway pressure adherence: a randomized trial. Ann Intern Med. 2009 Nov 17;151(10):696-702. doi: 10.7326/0003-4819-151-10-200911170-00006 [MEDLINE]
A systematic review of CPAP adherence across age groups: Clinical and empiric insights for developing CPAP adherence interventions. Sleep Med Rev 2011;15(6):343-356 [MEDLINE]
Air leak is associated with poor adherence to autoPAP therapy. Sleep. 2011 Jun 1;34(6):801-6. doi: 10.5665/SLEEP.1054 [MEDLINE]
Cardiometabolic changes after continuous positive airway pressure for obstructive sleep apnoea: a randomised sham-controlled study. Thorax 2012;67:1081-1089 [MEDLINE]
The effect of continuous positive airway pressure treatment on blood pressure: a systematic review and meta-analysis of randomized controlled trials. J Clin Sleep Med 2012;8:587-596 [MEDLINE]
The impact of posttraumatic stress disorder on CPAP adherence in patients with obstructive sleep apnea. J Clin Sleep Med 2012;8(6):667-72. doi: 10.5664/jcsm.2260 [MEDLINE]
Health Outcomes of Continuous Positive Airway Pressure versus Oral Appliance Treatment for Obstructive Sleep Apnea. Am J Respir Crit Care Med. 2013 Apr 15;187(8):879-87 [MEDLINE]
The effect of continuous positive air pressure (CPAP) on nightmares in patients with posttraumatic stress disorder (PTSD) and obstructive sleep apnea (OSA). J Clin Sleep Med 2014;10(6):631-636. doi: 10.5664/jcsm.3786 [MEDLINE]
Sleep apnea related risk of motor vehicle accidents is reduced by continuous positive airway pressure: Swedish Traffic Accident Registry Data. Sleep 2015;38:341-349 [MEDLINE]
Continuous positive airway pressure versus standard care for the treatment of people with mild obstructive sleep apnoea (MERGE): a multicentre, randomised controlled trial. Lancet Respir Med. 2020 Apr;8(4):349-358. doi: 10.1016/S2213-2600(19)30402-3 [MEDLINE]
Effect of obstructive sleep apnoea and its treatment with continuous positive airway pressure on the prevalence of cardiovascular events in patients with acute coronary syndrome (ISAACC study): a randomised controlled trial. Lancet Respir Med. 2020 Apr;8(4):359-367. doi: 10.1016/S2213-2600(19)30271-1 [MEDLINE]
Adaptive Servo Ventilation
Efficacy of adaptive servoventilation in treatment of complex and central sleep apnea syndromes. Chest. 2007;132:1839–1846 [MEDLINE]
Adaptive servoventilation improves cardiac function and respiratory stability. Clin Res Cardiol. 2011;100:107–115 [MEDLINE]
A prospective polysomnographic study on the evolution of complex sleep apnoea. Eur Respir J 2011;38(2):329-337 [MEDLINE]
Therapy for sleep hypoventilation and central apnea syndromes. Curr Treat Options Neurol 2012;14(5):427-437 [MEDLINE]
Adaptive servoventilation for treatment of sleep-disordered breathing in heart failure: a systematic review and meta-analysis. Chest. 2012;142:1211–1221 [MEDLINE]
Air leak during CPAP titration as a risk factor for central apnea. J Clin Sleep Med 2013;9(11):1187-1191 [MEDLINE]
The complex sleep apnea resolution study: a prospective randomized controlled trial of continuous positive airway pressure versus adaptive servoventilation therapy. Sleep. 2014 May;37(5):927-34 [MEDLINE]
SERVE-HF Trial. Adaptive servo-ventilation for central sleep apnea in systolic heart failure. N Engl J Med 2015;373:1095-1105 [MEDLINE]
Mandibular Advancement Device
Health Outcomes of Continuous Positive Airway Pressure versus Oral Appliance Treatment for Obstructive Sleep Apnea. Am J Respir Crit Care Med. 2013 Apr 15;187(8):879-87 [MEDLINE]
Implanted upper airway stimulation device for obstructive sleep apnea. Laryngoscope. 2012 Jul;122(7):1626-33. doi: 10.1002/lary.23301. Epub 2012 May 1 [MEDLINE]
Acute upper airway responses to hypoglossal nerve stimulation during sleep in obstructive sleep apnea. Am J Respir Crit Care Med. 2012 Feb 15;185(4):420-6. doi: 10.1164/rccm.201109-1614OC. Epub 2011 Dec 1 [MEDLINE]
Evaluation of drug-induced sleep endoscopy as a patient selection tool for implanted upper airway stimulation for obstructive sleep apnea. J Clin Sleep Med. 2013 May 15;9(5):433-8. doi: 10.5664/jcsm.2658 [MEDLINE]
STAR Trial Group. Upper-airway stimulation for obstructive sleep apnea. N Engl J Med 2014;370:139-149 [MEDLINE]
Randomized controlled withdrawal study of upper airway stimulation on OSA: short- and long-term effect. Otolaryngol Head Neck Surg 2014;151:880-887 [MEDLINE]
Perioperative Management of Obstructive Sleep Apnea
Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: A case-control study. Mayo Clin Proc 2001; 76:897–905 [MEDLINE]
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 Feb;120(2):268-86. doi: 10.1097/ALN.0000000000000053 [MEDLINE]
Prognosis
Sleep disordered breathing and mortality: 18-year follow-up of the Wisconsin sleep cohort. Sleep 2008;31:1071-1078 [MEDLINE]
Sleep apnea as an independent risk factor for all-cause mortality: the Busselton Health Study. Sleep 2008;31:1079-1085 [MEDLINE]
Sleep-disordered breathing and mortality: a prospective cohort study. PLoS Med 2009;6:1-9 [MEDLINE]
All-cause mortality and obstructive sleep apnea severity revisited. Otolaryngol Head Neck Surg 2012;Epub ahead of print Jun 11 2012 [MEDLINE]