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A. A. Valadez et al.
20.7 Preoperative Evaluation
The main objective of the preoperative evaluation is to develop an adequate anesthesia plan to reduce transoperative morbidity and mortality and prevent immediate
and late postoperative complications. The patient must be informed of the planned
procedure, and informed consent must be obtained. All components of the preanesthesia evaluation should be assessed in an orderly manner and classied considering
the surgical procedure and its indication.
A history of previous surgeries and anesthesia should be obtained, emphasizing
a personal and family interview. A comprehensive review of systems and physical
examination must include a correct and complete assessment of the upper airway to
avoid difcult intubation and identify the presence of OSA [15].
Aspects to consider in the preoperative assessment should be those described for
a conventional clinical assessment, but a comprehensive examination of all parameters that can identify if a patient has a difcult airway or not should be considered [41].
Although obesity has been associated with OSA, it is important not to forget that
not all patients suffer this syndrome. It frequently occurs in patients with average
weight; therefore, it is necessary to start from a basic interview where the parameter
“snoring” is positive [12, 15].
As previously mentioned in physiopathology, the anatomical characteristics of
the airway in these patients inuence the tendency for OSA.Examination of patients
with suspicion or diagnosis of OSA should be thorough [17].
In several reviews on this topic, the characteristics of the mandible and soft tissues of the oral cavity and neck are relevant for the presence of OSA.There are
parameters in airway exploration that should not be overlooked, such as macroglossia, dentition, the Mallampati test, thyromental distance, neck circumference, and
the sternomental distance [42–44] (Figs.20.1, 20.2, 20.3, and 20.4).
The review of systems should emphasize and specically focus on the cardiovascular and respiratory systems to detect or rule out heart rhythm disorders, hypertension, chest pain (angina), or a history of previous myocardial infarction, which are
strongly associated with OSA.
The main risk factors that develop or increase OSA symptoms are age greater
than 50years, male gender, obesity, and menopause, among others. A history of
smoking and alcohol and sedative use increases the severity of OSA.In cases of
chronic tobacco use, the risk of difcult extubation should be evaluated since bronchospasm can occur [3].
Patients’ drug history gives us an idea of their metabolic status and if they need
a specic drug intraoperatively. A history of previous surgeries or anesthesia helps
us prevent problems if the patient had difcult intubation or an adverse event [15].
Patients with a history of an ischemic or hemorrhagic cerebrovascular disease should be evaluated since they usually have OSA.Also, patients with a
history of domestic, work, or traffic accidents regularly suffer from OSA
[45, 46].
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Fig. 20.2 Sternomentonian
distance
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Fig. 20.3 Interincisor
distance
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Fig. 20.4 Mallampati score
A. A. Valadez et al.
Finally, the laboratory and special tests that ideally should be carried out with
OSA patients include polysomnography and DISE, which provide specic OSA
data and its severity. The Berlin questionnaire, The Stop-Bang questionnaire, laboratory studies, X-rays, and an electrocardiogram should also be used.
20.8 Intraoperative
OSA is a risk factor for postoperative complications. The most common are respiratory, such as oxygen desaturation. Other factors that can increase this risk are upper
airway resistance syndrome, which occurs in young, nonobese patients who snore
and have interrupted sleep with an AHI of less than 5 events per hour, and obesity
hypoventilation syndrome, which is demonstrated by daytime hypercapnia
(CO2>45mmHg) and obesity (BMI >30kg/m2). The latter syndrome is present in
0.3% of the general population, with a prevalence of up to 8% in bariatric surgery
patients [47].
The main concerns in the intraoperative anesthetic management of patients with
OSA are choosing the most convenient anesthetic technique for the surgical procedure, airway management, and the type of monitoring the patient will need [15].
Patient management should be individualized according to the surgery and type
of anesthesia. It is also relevant to dene if postoperative opioids and in-hospital or
ambulatory care are necessary. Patients with OSA have an increased anesthetic risk
of difcult intubation, mask ventilation, and maintaining a patent airway after
extubation.
These patients are susceptible to respiratory depression and airway effects such
as relaxation of pharyngeal structures and airway collapse when sedatives (benzodiazepines), opioids, and inhaled anesthetics are used. Therefore, potential postoperative respiratory compromise should be considered when choosing transoperative
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drugs [15]. Sedation as premedication should be avoided unless the patient is monitored and there is adequate equipment for airway management.
The American Society of Anesthesiologists considers regional or local anesthesia preferable for supercial procedures.
If sedation or general anesthesia is necessary for OSA patients, noninvasive
blood pressure monitoring, pulsometry, electrocardiography, capnography, permeable venous access, and equipment for difcult intubation should be used. If there
are ndings (right heart failure, pulmonary hypertension) during the assessment of
an OSA patient, intraoperative cardiovascular monitoring should be considered [10].
In procedures that require sedation, anesthetic drugs and short-acting opioids
should be used. Combining fentanyl and propofol causes depression of laryngeal
reexes, with the cough reex being the most affected (protective reex of the airway) [48].
In several studies, alpha-2 agonists, such as dexmedetomidine, caused less respiratory depression than other sedatives; however, its combination with other sedatives can cause additive effects [49]. The only disadvantage is that a bolus over
10min is required to begin its effect, followed by a continuous infusion. The dose
will depend on the procedure and the time necessary to carry it out. Also, different
authors recommend regional or neuraxial anesthesia that complements general
anesthesia. This option will always be good if the patient’s condition allows it. This
way, opioids, muscle relaxants, and various intravenous infusions are reduced as
much as possible.
Ketamine does not produce respiratory depression or airway obstruction; however, it relaxes bronchial muscle. This drug must be administered with a benzodiazepine to counteract its dissociative effects [48].
If the patient requires general anesthesia, it is important to be prepared for the
risk of difcult intubation. In OSA patients, general anesthesia with a secure airway
is preferable to deep sedation with an unsecured airway [50].
Adequate preoxygenation must be carried out with ventilation equipment adapted
to the patient (face mask, oral and nasopharyngeal cannulas). Nasopharyngeal cannulas are more appropriate in these patients for adequate airway management since
the main area of obstruction is at the nasotracheal level, according to various imaging studies such as MRI.Adequate preoxygenation can be achieved in several ways:
(1) Spontaneous breathing with an FIO2 of 100% for 2–5min; (2) with the four vital
capacities method; (3) with deep breaths. After 3min of preoxygenation, obese
patients tolerate a 3-min apnea, maintaining an SPO2 greater than 90%. The time
needed to increase oxygen saturation above 96% after a desaturation is 37s compared to 22s in healthy individuals [51].
The size of the pharyngeal airway is increased, so anesthetized patients with
OSA may benet from being placed in the snifng position, which reduces the risk
of pharyngeal collapse [50]. Laryngoscopy in obese patients with OSA can be facilitated by placing a ramp under the patient’s head and shoulders to align the ear and
sternal notch [52].
Awake intubation and/or the use of broscopy or video laryngoscopy is recommended for tracheal intubation due to the high risk of airway management
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difculties [41]. A laryngeal mask is inappropriate in these patients because of the
possibility of airway collapse and gastroesophageal reux disease [12].
Patients with OSA present hypotonia of the lower esophageal sphincter; therefore, gastroesophageal reux disease must be considered. Proton pump inhibitors,
antacids, a rapid induction sequence, and pressure on the thyroid or cricoid cartilage
(the BURP maneuver) are recommended to reduce the risk of aspiration [52]. CPAP
or an oral airway management device should be considered during deep sedation in
patients treated with these devices [15].
Opioids should be used with caution in patients with OSA due to the risk of
respiratory depression. For maintenance of anesthesia, short-acting anesthetic
agents or mixtures of propofol, remifentanil (a short-acting opioid), or poorly lipidsoluble inhaled agents, such as desurane, are recommended [48].
However, we must consider desurane’s tendency to trigger sympathetic
responses described during its use [53]. These responses can represent a risk of
cardiac complications previously described in these patients, such as arrhythmias
caused by severe hypoxia or hypercapnia [22, 41].
Extubation is recommended with a fully awake patient (spontaneous eye opening, responding to commands) unless there is a medical or surgical contraindication
and a conrmed patent airway to avoid ventilation failures and subsequent desaturation [15].
Neuromuscular blockade with complete reversal should be mandatory in these
surgical patients due to the increased risk of pulmonary complications regardless of
the degree of OSA. Excessive administration of intravenous infusions of 0.9%
saline solution increases the neck circumference causing an increase in the severity
of apnea–hypopnea events in the postoperative period [47].
Multimodal analgesia is recommended in patients with OSA to reduce the use of
opioids. If intense analgesia is required, buprenorphine is recommended because its
mu receptor agonist effect is less potent, and atypical opioids such as tramadol (a
weak mu agonist that causes less respiratory depression) [47]. Alternative medications such as NSAIDs, COX-2 inhibitors, acetaminophen, ketamine, pregabalin,
and gabapentin, with or without dexamethasone, should be used to help reduce the
use of opioids and avoid respiratory depression. In regional anesthesia, postoperative use of catheters in epidural or nerve blocks with local anesthetics reduces opioid requirements [52].
A. A. Valadez et al.
20.9 Postoperative
As mentioned at the beginning, an apnea–hypopnea index (AHI) ≥5 events/h with
a range between 9% and 38% has been reported. This range was higher in men,
increased with age, and in some older adults, reached 90% in men and 78% in
women [6].
The postoperative period is a time of high risk for patients with OSA due to the
residual effects of narcotic anesthetics and sedatives, which promote the described
complications. Several studies have found that patients with OSA undergoing noncardiac surgery have a higher incidence of postoperative hypoxia, respiratory
20 Anesthesia Considerations in Obstructive Sleep Apnea
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failure, cardiac events, and the need for intensive care than those without
OSA.Unfortunately, 90% of patients with OSA are not recognized before surgery,
leading to an increased risk of complications during the perioperative period [54].
Obstructive sleep apnea is a syndrome associated with difcult airway management, due to the morbid obesity of most of these patients or to the anatomical–
physiological alterations that they may present (a thick, short neck, large tongue)
[12]. These alterations require close monitoring in the postoperative period, considering they are susceptible to obstruction, hypoxia, hypercapnia, and total respiratory
depression. The use of nonopioid analgesics is recommended; if these are required,
they should be used in minimal doses [48].
Anesthetic and analgesic agents used in the perioperative period can decrease
pharyngeal tone and depress the ventilatory response to hypoxia and hypercapnia.
These effects may exacerbate the underlying anatomical and physiological abnormalities associated with OSA [55].
A recent study shows that 24% of patients with OSA have signicant postoperative complications compared to only 7% of patients in a control group [56].
Short-acting blockers or antagonists with minimal adverse effects are recommended, such as sugammadex, which can reverse neuromuscular blockade caused
by aminosteroids with fewer postoperative respiratory complications compared to
neostigmine [50].
After extubation, the patient should preferably recover in a semi-Fowler position
(head elevation of 30°) in lateral or any other position other than full supine, with an
inspired fraction of oxygen of 100% and with positive pressure support during the
next 2min before transfer to the recovery room [48].
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20.10 OSA andOutpatient Surgery
The term outpatient can be dened as any medical, organizational, and administratively permissible practice to leave the clinic or a medical stay on the same day of
the intervention in less than or equal to 12h.
According to the NOM-026-SSA3-2012 of Mexico for the practice of major
ambulatory surgery, article 4.2 establishes that discharge of the patient from Major
Outpatient Surgery will be performed in a period no longer than 12h, counted from
the time of admission, during which the surgical act was performed, and postanesthetic recovery was completed [57]. Around 40% of surgeries are of this type, with
a considerable progress margin. The objective is to reach the rates of rst-world
countries, which are near 80%.
The anesthesiologist and the attending physician are responsible for selecting the
patient, the operation, or the outpatient medical procedure. The competence of the
physician administering anesthesia should be tailored to the procedure and the
patient’s condition and comorbidities.
The International Association for Ambulatory Surgery (IAAS) and the
Association Francaise de Chirurgie Ambulatoire (AFCA) agree that the suitability
of ambulatory surgery in OSA patients is controversial. The decision to indicate a
treatment of this type is the responsibility of the surgeon and the anesthesiologist
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A. A. Valadez et al.
according to the patient’s physical condition, the type of surgery, and the conditions
of the healthcare environment [15]. However, it would be convenient to have a clear
consensus among the physicians with previously established rules and procedures,
especially regarding behaviors related to duration and follow-up.
The Society for Ambulatory Anesthesia reached a consensus for the development
of an algorithm for the selection of adult patients with OSA scheduled for ambulatory surgery (Fig.20.5). This algorithm is oriented according to the comorbidities
Preoperative Evaluation
Patient With Presumptive
Patient With Known OSA
Diagnosis of OSA
Optimized
Comorbid Conditions
AND
Able to use CPAP after
discharge.
Proceed With
Ambulatory
Surgery
Preoperative Considerations:
• Comorbid conditions include hypertension, arrhythmia, heart failure,
cerebrovascular disease, and metabolic syndrome.
• If OSA is suspected during the preoperative evaluation, one could proceed with a
presumptive diagnosis of OSA albeit with caution.
• Educate surgeon, patient, and family.
Intraoperative Considerations:
• Non-opioid analgesic techniques, when possible.
Postoperative Considerations:
• Exercise caution in OSA patients who develop prolonged and frequent severe
respiratory events (e.g., sedation analgesic mismatch, desaturation, and apneic
episodes) in the postoperative period.
Patients with Non-optimized
Comorbid Conditions.
Not Suitable for Ambulatory
Surgery, may Benefit from
diagnosis and treatment.
Optimized Co-morbid Conditions
AND
Postoperative pain can be managed
predominantly by using non-opioid
analgesic techniques.
Proceed With
Ambulatory
Surgery
Fig. 20.5 Flowchart of suitable patientfor surgery to take place in an ambulatory setting according to anesthesia evaluation
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and the use of CPAP and other factors, facilitating the specialist’s decision to proceed or not with ambulatory surgery in this type of patient [58].
Take-Home Message
• In the preoperative period, the characteristics of the mandible and soft tissues of
the oral cavity and neck are relevant for the presence of OSA.
• OSA patients are susceptible to respiratory depression and airway effects such as
relaxation of pharyngeal structures and airway collapse when sedatives (benzodiazepines), opioids, and inhaled anesthetics are used.
• Patients with OSA present hypotonia of the lower esophageal sphincter; therefore, gastroesophageal reux disease must be considered. Proton pump inhibitors, antacids, a rapid induction sequence, and pressure on the thyroid or cricoid
cartilage (the BURP maneuver) are recommended to reduce the risk of aspiration.
• Patient extubation is recommended with a fully awake patient (spontaneous eye
opening, responding to commands) unless there is a medical or surgical contraindication and a conrmed patent airway to avoid ventilation failures and subsequent desaturation.
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