Perioperative Management of Patients with Obstructive Sleep Apnea

Publication Date: February 1, 2014
Last Updated: March 14, 2022

Summary of Recommendations

Preoperative Evaluation

Anesthesiologists should work with surgeons to develop a protocol whereby patients in whom the possibility of obstructive sleep apnea (OSA) is suspected on clinical grounds are evaluated long enough before the day of surgery to allow preparation of a perioperative management plan.

  • This evaluation may be initiated in a preanesthesia clinic (if available) or by direct consultation from the operating surgeon to the anesthesiologist.

  • A preoperative evaluation should include a comprehensive review of previous medical records (if available), an interview with the patient and/or family, and conducting a physical examination.
  • Medical records review should include (but not be limited to) checking for a history of airway difficulty with previous anesthetics, hypertension, or other cardiovascular problems, and other congenital or acquired medical conditions.

  • Review of sleep studies is encouraged.

  • The patient and family interview should include focused questions related to snoring, apneic episodes, frequent arousals during sleep (e.g., vocalization, shifting position, and extremity movements), morning headaches, and daytime somnolence.‡‡‡

  • A physical examination should include an evaluation of the airway, nasopharyngeal characteristics, neck circumference, tonsil size, and tongue volume.

  • If any characteristics noted during the preoperative evaluation suggest that the patient has OSA, the anesthesiologist and surgeon should jointly decide whether to (1) manage the patient perioperatively based on clinical criteria alone or (2) obtain sleep studies, conduct a more extensive airway examination, and initiate indicated OSA 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 surgery.

  • For safety, clinical criteria should be designed to have a high degree of sensitivity (despite the resulting low specificity), meaning that some patients may be treated more aggressively than would be necessary if a sleep study was available.

  • The severity of the patient’s OSA, the invasiveness of the diagnostic or therapeutic procedure, and the requirement for postoperative analgesics should be taken into account in determining whether a patient is at increased perioperative risk from OSA.

  • The patient and his or her family as well as the surgeon should be informed of the potential implications of OSA on the patient’s perioperative course.

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Inpatient versus Outpatient Surgery

Before patients at increased perioperative risk from OSA are scheduled to undergo surgery, a determination should be made regarding whether a surgical procedure is most appropriately performed on an inpatient or outpatient basis. Factors to be considered in determining whether outpatient care is appropriate include (1) sleep apnea status, (2) anatomical and physiologic abnormalities, (3) status of coexisting diseases, (4) nature of surgery, (5) type of anesthesia, (6) need for postoperative opioids, (7) patient age, (8) adequacy of postdischarge observation, and (9) capabilities of the outpatient facility. The availability of emergency difficult airway equipment, respiratory care equipment, radiology facilities, clinical laboratory facilities, and a transfer agreement with an inpatient facility should be considered in making this determination.
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Preoperative Preparation

Preoperative initiation of continuous positive airway pressure (CPAP) should be considered, particularly if OSA is severe. For patients who do not respond adequately to CPAP, noninvasive positive pressure ventilation should be considered. The preoperative use of mandibular advancement devices or oral appliances and preoperative weight loss should be considered when feasible. A patient who has had corrective airway surgery (e.g., uvulopalatopharyngoplasty, surgical mandibular advance ment) should be assumed to remain at risk of OSA complications unless a normal sleep study has been obtained and symptoms have not returned. Patients with known or suspected OSA may have difficult airways and therefore should be managed according to the “Practice Guidelines for Management of the Difficult Airway: An Updated Report.”**
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Intraoperative Management

Because of their propensity for airway collapse and sleep deprivation, patients at increased perioperative risk from OSA are especially susceptible to the respiratory depressant and airway effects of sedatives, opioids, 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 that may mechanically compromise the airway. Major conduction anesthesia (spinal/epidural) should be considered for peripheral procedures. Unless there is a medical or surgical contraindication, patients at increased perioperative risk from OSA should be extubated while awake. Full reversal of neuromuscular block should be verified before extubation. When possible, extubation and recovery should be carried out in the lateral, semiupright, or other nonsupine position.
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Postoperative Management

  • Regional analgesic techniques should be considered to reduce or eliminate the requirement for systemic opioids in patients at increased perioperative risk from OSA.
  • If neuraxial analgesia is planned, weigh the benefits (improved analgesia and decreased need for systemic opioids) and risks (respiratory depression from rostral spread) of using an opioid or opioid–local anesthetic mixture rather than a local anesthetic alone.
  • If patient-controlled systemic opioids are used, continuous background infusions should be avoided or used with extreme caution.
  • To reduce opioid requirements, nonsteroidal antiinflammatory agents and other modalities (e.g., ice, transcutaneous electrical nerve stimulation) should be considered if appropriate.
  • Clinicians are cautioned that the concurrent administration of sedative agents (e.g., 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 OSA until they are able to maintain their baseline oxygen saturation while breathing room air.
  • The Task Force cautions that 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 or 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 OSA should be placed in nonsupine positions throughout the recovery process.
Hospitalized patients who are at increased risk of respiratory compromise from OSA 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 patients remain 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.
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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 of 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.
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Recommendation Grading

Overview

Title

Perioperative Management of Patients with Obstructive Sleep Apnea

Authoring Organization

American Society of Anesthesiologists

Publication Month/Year

February 1, 2014

Last Updated Month/Year

June 26, 2023

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

Improve the perioperative care and reduce the risk of adverse outcomes in patients with confirmed or suspected OSA who receive sedation, analgesia, or anesthesia for diagnostic or therapeutic procedures under the care of an anesthesiologist.

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Infant, Older adult

Health Care Settings

Ambulatory, Emergency care, Hospice, Hospital, Operating and recovery room, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Counseling, Diagnosis, Management

Diseases/Conditions (MeSH)

D020181 - Sleep Apnea, Obstructive

Keywords

obstructive sleep apnea, perioperative

Source Citation

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(2):268-286. 

Supplemental Methodology Resources

Data Supplement