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10 Perioperative Care ofPatients withObstructive Sleep Apnea Syndrome
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193
other patient comorbidities, and past difculties with anesthesia or intubation in
addition to screening for OSA [60].
The left side of Fig.10.1 summarizes one possible preoperative approach in the
suspected OSA patient. Those with ≥2 on the STOP, or ≥3 on the STOP-Bang
Questionnaire are considered high risk of having undiagnosed OSA.
In certain situations, preoperative assessment by a sleep physician may be warranted for consideration of polysomnography or home sleep testing if time and
resources permit. An early consult would typically allow the sleep physician adequate time to prepare a perioperative management plan, which may include a
period of at-home positive airway pressure (PAP) treatment prior to surgery for the
Suspected OSA patient
Screening using STOP or
STOP-Bang questionnaire
High risk of OSA
≥ 2 on STOP
≥ 3 on STOP-Bang
Major Elective Surgery &
Significant Comorbidities
• Heart failure
• Arrhythmias
• Uncontrolled hypertension
• Cerebrovascular disease
• Metabolic syndrome
• Obesity with BMI > kg/m
No
Possibility of
moderate
OSA:
Perioperative
OSA
precautions
Consider
preoperative referral
to sleep medicine
physician,
polysomnography,
and PAP therapy
Low risk of OSA
≤ 2 on STOP
≥ 3 on STOP-Bang
Rountine mangement.
No peroperative PAP
therapy required.
2
Yes
‡
.
Known OSA patient
Severity Assessment from History
or Polysomnography
Mild OSA
AHI 5 1 15
Oximetry ≥ 94 %
on room air
Yes
Moderate or
Servere OSA
AHI > 15
Oximetry < 94%
on room air
Changes is OSA Status
• Recent exacerbation
of OSA symptoms
• Non-compliant to
PAP therapy
• Recently undergone
OSA-related surgery
• Lost to sloop
medicine follow-up
Preoperative PAP
therapy‡,
Perioperative OSA
precautions
‡
No
Fig. 10.1 An approach to those with suspected or known obstructive sleep apnea (OSA) prior to
surgery in the ambulatory setting. ‡ Positive airway pressure (PAP) therapy may include continuous, bi-level, or auto-titrating PAP. (Adapted with kind permission from Springer Science + Business
Media [60])
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purpose of acclimatization. Ultimately, the decision for further preoperative sleep
study testing would depend on the clinical judgment and expertise of the team of
physicians providing perioperative care after careful screening and assessment.
Patients determined to be at low risk for presence of OSA may be managed expectantly with no further diagnostic testing prior to surgery. For those deemed at high
risk for OSA, there are a variety of possible courses of action. In some cases,
major elective surgery may be deferred in patients with a high clinical suspicion
of complicated, severe OSA.In other cases, there may be patients who are deemed
high risk according to an OSA screening questionnaire, but who otherwise are
without signicant comorbidities or are scheduled to undergo a low risk procedure, and in that case, the physician team may elect to proceed to surgery without
delay [61]. And there may be other situations where the risk of delaying the surgery outweighs the benets of identifying and treating OSA preoperatively and so
the patient is taken to surgery even in the setting of clinical suspicion of severe or
complicated OSA.The literature is vague and lacking in the scientic evidence to
support denitive guidelines regarding risks and benets of cancelling most types
of procedures.
K. L. Dupuy-McCauley et al.
Preoperative Screening inKnown OSA
A potential preoperative evaluation approach for patients with known OSA is illustrated on the right side of Fig. 10.1. Although the original severity of the sleepdisordered breathing must be known or estimated in this case, the treatment status
would be an important factor in preoperative risk assessment. The use of PAP
devices (CPAP, bi-level PAP [BPAP], auto-titrating CPAP [APAP]), and the compliance should be assessed for those who have been prescribed PAP therapy. Patients
who have been lost to sleep medicine follow-up and/or those who are noncompliant
with therapy, those who have had recent exacerbation of OSA symptoms, and those
who have undergone OSA-related airway surgery may benet from preoperative
referral for additional evaluation with a sleep medicine physician. Long-standing
OSA, especially in the case of suboptimal treatment or lack of treatment, may have
systemic complications, including hypoxemia, hypercarbia, polycythemia, and cor
pulmonale. Pulse oximetry may be a simple screening tool in the preoperative
clinic. Some advocate that an oxygen saturation value of <94% on room air in the
absence of other causes should be a red ag for possible severe long-standing OSA
[60], which may be another reason to refer to sleep preoperatively.
Preoperative OSA Treatment
The ASA, SASM, and AASM agree that patients with OSA who have been on PAP
therapy should continue PAP therapy in the preoperative period [3, 5, 7]. The ASA
recommends that initiation of PAP should be considered, particularly in patients
10 Perioperative Care ofPatients withObstructive Sleep Apnea Syndrome
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with severe OSA, but that the preoperative use of an oral appliance, or weight loss,
may also be acceptable considerations [3]. Initiation of PAP therapy for those with
untreated OSA or re-initiation of preoperative PAP in the non-PAP-adherent OSA
patient should be considered, although the benet of using PAP in the time period
leading up to surgery as a means to reduce postoperative cardiopulmonary risk in
patients with OSA is uncertain [62].
195
Intraoperative OSA Management
Tracheal Intubation
The surgical and anesthesia team should be aware of a patient’s previous diagnosis
of OSA, or that the patient is “high risk” for OSA but has not undergone a formal
sleep evaluation. The ASA guidelines state that patients with OSA should be presumed to have a “difcult airway,” meaning there would potentially be difculty
with tracheal intubation, facemask ventilation, or both [3], and the patient should be
managed in accordance with the ASA practice guidelines for management of the
difcult airway [63]. The SASM advocates that patients at high risk for OSA should
proceed to surgery in the same manner as those who have conrmed OSA, but that
known or suspected OSA should be considered an independent risk factor for difcult intubation, difcult mask ventilation, or a combination of both [5, 6]. The
AASM recommends that the patient be considered a “high-risk intubation,” and
advocates against the use of unsupervised preoperative sedation [7].
These recommendations are based upon literature suggesting OSA is associated
with difcult intubation [36, 37, 64–68]. The reverse association is true as well,
patients with a history of difcult intubation have a high prevalence of OSA.This
was discovered retrospectively by Hiremath and colleagues [36], and subsequently
conrmed with a prospective study done by Chung and colleagues [69]. A variety
of other studies examining this association exist as well. A retrospective casecontrolled study of 253 patients was conducted to determine the occurrence of difcult intubation in OSA patients. The OSA patients were matched with controls of
the same age, gender, and type of surgery. Difcult intubation was assessed by
laryngoscopy using the Cormack and Lehane classication [70], and was found to
occur eight times as often in OSA patients versus controls (22% vs. 3%, P<0.05)
[37]. In OSA patients undergoing ear, nose, and throat surgery, a 44% prevalence of
difcult intubation has similarly been reported [71]. Furthermore, patients with
severe OSA (AHI >40) were found to have a much higher prevalence of difcult
intubation [72]. Increased prevalence of obesity in the OSA population is not the
only factor that explains this association. A study of more than 1500 nonobese and
obese patients concluded that increased age, male gender, pharyngo-oral pathology,
and the presence of OSA are all associated with a more frequent occurrence of difcult intubation [73]. This suggests that patients who are found to have a difcult
airway in the absence of any documented OSA should be referred for evaluation by
a sleep medicine provider.
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K. L. Dupuy-McCauley et al.
Choice ofAnesthetics/Anesthetic Technique
One aspect of planning and preparation for surgical procedures in patients with
OSA is the choice of anesthesia strategy, which may present an opportunity to
reduce risk in patients with OSA.Sedative, anesthetic, and analgesic medications
mimic the sleep state by increasing collapsibility of the upper airway, reducing
hypoxic and hypercapnic respiratory drives, decreasing activity of the respiratory
muscles, increasing dependence upon the diaphragm, decreasing respiratory stimulation, and decreasing lung volumes, which may be especially detrimental to patients
with OSA [74–81]. The ASA recommends general anesthesia with tracheal intubation as opposed to deep sedation without a secure airway [3]. The ASA also recommends that CPAP or a mandibular advancement device may be used during sedation
to facilitate the airway remaining open.
Patients with OSA are felt to be at higher risk for adverse respiratory events from
the use of propofol and neuromuscular blockade, but there is insufcient data to
assess the risk associated with inhalational anesthetic agents, alpha-2-agonists (such
as dexmedetomidine and clonidine), and ketamine [6]. However, data from studies
of obese patients suggest that desurane and sevourane may facilitate or more
rapid and consistent postoperative recovery, which may be relevant to many patients
with OSA, given the high association between OSA and obesity [82]. A strategy of
regional anesthesia is preferred over general anesthesia in patients with OSA due to
ndings from several population-based studies showing decreased odds for mechanical ventilation, critical care admission, and prolonged hospital length of stay [3, 6,
52, 83–86].
Use of intravenous benzodiazepines may put patients with OSA at increased
risk for upper airway collapse and subsequent respiratory complications. Much of
this literature comes from the use of intravenous benzodiazepines during druginduced sleep endoscopy (DISE), where IV benzodiazepines are used to induce
collapse of the upper airway [87]. There are additional retrospective studies to
suggest that patients with OSA are more prone to hypoxia and airway collapse
when subjected to IV midazolam than those with primary snoring and no OSA
diagnosis [88].
There are no prospective, randomized, controlled trials comparing the safety,
efcacy, and impact on respiratory status of different anesthetic, analgesic, and sedative strategies in patients with OSA.However, a promising technique of opioidfree analgesia is emerging and may be a safer approach to anesthesia in the OSA
population. This opioid-free strategy is based in the principle of multimodal anesthesia and would typically consist of using multiple anesthetic and analgesic agents
in subtherapeutic doses simultaneous. For example, a continuous infusion of lidocaine and dexmedetomidine might be supplemented with a low dose of a volatile
anesthetic agent and intermittent dosing of acetaminophen, ketamine, ibuprofen,
and ketorolac. This innovative technique may provide adequate anesthesia and analgesia without exposing patients to the unwanted respiratory side-effects and possible addictive properties of opioids [89].
10 Perioperative Care ofPatients withObstructive Sleep Apnea Syndrome
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Extubation
The ASA and AASM recommend that patients with OSA be extubated awake and
in the non-supine position unless contraindicated [3, 7], and the ASA adds that neuromuscular blockade should be fully reversed prior to extubation [3].
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Postoperative OSA Management
Postoperative Pain Control
Postoperative analgesia can adversely inuence respiration in surgical patients with
OSA.In the acute setting, analgesia is commonly achieved with opioids, which may
affect the central nervous system and whose effects may be potentiated by other
sedative and anesthetic agents. Opioids depress the central respiratory drive,
decrease consciousness, and decrease supraglottic muscle tone, leading to increased
risk of upper airway obstruction [90]. In a retrospective study of 1600 patients who
had received postoperative patient-controlled analgesia with IV opioids, eight cases
of serious respiratory depression were reported [91]. Contributing factors were the
concurrent use of a background infusion of opioids, advanced age, concomitant
administration of sedative or hypnotic medications, and a preexisting history of
sleep apnea. A review conducted to identify the risk factors for respiratory depression subsequent to patient-controlled analgesia concluded that there is no single
indicator for respiratory depression but that OSA, whether suspected or veried by
patient history, is a risk factor [92].
A recent review of critical perioperative complications (including death) in
patients with OSA identied morbid obesity, male sex, undiagnosed/untreated
OSA, suboptimal use of postoperative CPAP, need for opioid analgesia, and lack of
appropriate postoperative monitoring as risk factors [28]. The majority of patients
who had adverse outcomes in this study had consumed a typical, or even a less-thantypical amount of opioids, which may suggest increased sensitivity to opioids in this
population as an explanation [93].
Because of the myriad effects of opioids on the CNS and respiratory systems,
and the complex interaction between sleep disordered breathing, obesity, and sleep
architecture, it is difcult to predict the respiratory consequences of opioid administration in the OSA population. Opioids can cause increased severity of obstructive
events, elicitation of centrally mediated apneic events (central sleep apnea [CSA] or
ataxic breathing), and hypoventilation. For instance, a randomized study of remifentanil use in patients with moderate OSA actually showed a decrease in the number of obstructive events with an increase in central apneas [94]. This decrease in
obstructive events may be attributed to the decrease in REM sleep that typically
occurs on the rst night after surgery, but this report highlights the complex interaction between multiple factors postoperatively. And the literature on this subject
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must be interpreted with caution as there may be varying measures of respiratory
changes.
The ASA guidelines recommend avoidance of opioids when possible in patients
with OSA, especially in the form of continuous infusion, and they recommend caution with other known respiratory depressants such as benzodiazepines and barbiturates [3]. The AASM and SASM recommend caution with the use of sedatives,
hypnotics, and anxiolytics in the postoperative period [6, 7]. Bearing in mind these
guidelines, one might consider strategies to minimize opioid exposure in this population. One such strategy might involve careful titration of opioids so as to provide
the minimum amount required to achieve adequate pain control [7]. Another potential strategy would be a multimodal approach using combinations of analgesics
from different classes and different sites of analgesic administration for perioperative pain management [95–97]. Such an approach may include peripheral nerve
block catheters or neuro-axial catheters dispensing local anesthetic agents (without
opioids) and opioid-sparing analgesic agents, such as nonsteroidal anti- inammatory
drugs, COX-2 inhibitors, acetaminophen, pregabalin, tramadol, and dexamethasone
[98]. But caution should still be exercised even despite opioid-sparing techniques. A
large retrospective study of patients who had undergone laparoscopic surgery found
an association between use of gabapentin and respiratory depression. This association tended to be present in patients who were older, had received midazolam, and
had a slightly higher intraoperative dose of opioids [99]. This might suggest that
even in the absence of postoperative opioid use, there may still be consequences to
polypharmacy, and an effective postoperative monitoring strategy to identify those
at risk for respiratory complications is important.
K. L. Dupuy-McCauley et al.
Postoperative Monitoring
The preservation of arousal mechanisms is vital when it comes to self-protection
from airway obstruction and hypoventilation. When arousal responses are suppressed by sedative, anesthetic, and analgesic medications, the patient can have
increased risk of asphyxia, cardiopulmonary arrest, and death [100]. Proper monitoring for return of these arousal mechanisms is key in ensuring patient safety in the
postoperative setting. In patients with OSA, most respiratory complications occur
on the general hospital ward in the rst 24 hours post-surgery [28, 35, 101]. A
closed claims analysis of postoperative opioid-induced respiratory depression
revealed that 25% of claims were related to OSA [101], highlighting the importance
of proper postoperative monitoring, especially for those patients who are within the
24-hour postoperative window, who have a diagnosis or are at high risk for OSA,
and who are receiving opioid analgesia. A recent review of postoperative critical
events associated with OSA by Bolden and colleagues found events were most
likely to occur in the rst 24hours after surgery and that death or brain damage was
10 Perioperative Care ofPatients withObstructive Sleep Apnea Syndrome
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less common in patients receiving supplemental oxygen and in patients with respiratory monitoring in place at the time of the event. Death or brain damage was more
common in patients receiving sedatives in addition to opioids, and in patients who
were not being closely observed [102]. This would seem to advise use of supplemental oxygen when appropriate, close observation, and avoidance of polypharmacy with multiple CNS depressants if feasible.
199
Oximetry
While there is no general consensus on an appropriate postoperative monitoring
strategy for patients with OSA, the ASA and AASM both recommend continuous
pulse oximetry postoperatively for this patient population [3, 7], although no mention is made of the setting in which this monitoring should occur (e.g., PACU vs.
general medical ward), and the ASA acknowledges that the optimal duration for
postoperative monitoring has not been established [3].
Gali and colleagues found that patients at risk for OSA who had recurrent respiratory events (bradypnea, apnea, oxygen desaturation, and pain–sedation mismatch)
in the immediate postoperative period had the highest oxygen desaturation index on
continuous pulse oximetry and were at the highest risk of postoperative respiratory
complications. In this study, patients were assessed at 30, 60, and 90minutes postoperatively, which may be an acceptable strategy to identify patients who may benet from a higher level of care or more intensive monitoring [58].
Chan and colleagues also looked at postoperative patients at high risk for OSA
and found that prolonged oxygen desaturations <80% during the rst three postoperative nights portended a higher risk of postoperative cardiovascular events [103],
again suggesting that oximetry may provide a clue as to which patients may benet
from closer monitoring.
These two studies would suggest that continuous pulse oximetry might be an
important tool for risk stratication; however, other studies have failed to show a
signicant impact on clinical outcomes as a results of continuous pulse oximetry in
the postoperative setting. A systematic review and meta-analysis of continuous
pulse oximetry and capnography monitoring found that continuous remote pulse
oximetry improved detection of oxygen desaturation and was associated with a
trend toward decreased ICU transfer when compared to intermittent oxygen assessment, but did not signicantly reduce mortality [104]. In the previously mentioned
closed claims analysis by Lee and colleagues, it should be noted that one-third of
the patients who experienced complications from postoperative opioid-induced
respiratory depression were being monitored with oximetry [101], which reinforces
concerns that while continuous pulse oximetry may bring attention to oxygen desaturation, we are not currently able to translate that into denitively improved patient
outcomes.
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K. L. Dupuy-McCauley et al.
Capnography
One conjecture as to why continuous oximetry does not necessarily translate into
improved postoperative outcomes is that oxygen desaturation is a late sign of
hypoventilation particularly for patients receiving supplemental oxygen, and perhaps continuous capnography monitoring might more effectively predict respiratory
failure. In the assessment of capnography, a systematic review found that capnography derangements preceded changes in oxygen saturation in the setting of supplemental oxygen administration [104].
But capnography may not be accurate in the setting of PAP use. End-tidal carbon
dioxide tension (ET-CO
accuracy have been compared in a sleep laboratory with PaCO2 levels in patients
wearing a nasal cannula or using nocturnal positive-pressure ventilatory assistance
[105]. ET-CO2 tension and tc-CO2 during diagnostic and therapeutic sleep studies
did not accurately reect the simultaneous PaCO2 levels when PAP therapy was
applied. It may be that ET-CO2 and tc-CO2 could be used to identify trends in CO2
levels in patients on PAP rather than serving as a surrogate for arterial PaCO2 levels,
but more research is needed to dene the clinical utility of such a strategy.
Capnography is not used on a routine basis in a clinical setting and there is no
prospective data on whether capnography may improve outcomes or reduce postoperative complications. But although there are no current guideline recommendations advocating its use in postoperative patients, emerging research suggests that
capnography may soon become more widely adopted as a tool for early detection of
respiratory failure. A prospective, blinded, multicenter, observational trial found
that adding capnography and the Integrated Pulmonary Index algorithm, an
algorithm- derived value based on SpO2, EtCO2, pulse, and respiratory rate, to traditional pulse oximetry afforded an average additional 8–11minutes lead time prior
to an adverse respiratory event when compared to standard postoperative monitoring with pulse oximetry alone [106]. This suggests that capnography may soon
become an important tool to facilitate early detection of postoperative respiratory
compromise, hopefully leading to early intervention and decreased respiratory risk.
) and transcutaneous carbon dioxide monitoring (tc-CO2)
2
Management Algorithms
PACU
While the literature is insufcient to provide evidence-based guidance regarding
specic postoperative monitoring strategies, one might consider the surgery type
and risk, patient characteristics, as well as anesthesia and analgesia-specic factors
when planning for the postoperative period. The 2006 ASA guidelines, directed by
expert consensus in the absence of good clinical evidence at the time, urged guidance of OSA patient disposition by a weighted scoring system and patient risk factors [52]. Perioperative risk was broadly divided into severity and treatment of OSA,
10 Perioperative Care ofPatients withObstructive Sleep Apnea Syndrome
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invasiveness of the surgery, anesthesia used, and postoperative opioid requirements.
The scoring system was somewhat involved and did not recognize the importance
of recurrent PACU events in predicting more episodes of oxygen desaturation and
increased postoperative respiratory complications [59].
Taking into account 2006 ASA guidelines and recent evidence for identifying
patients most at risk for postoperative respiratory complications, Seet and Chung
[60] proposed an algorithm using recurrent PACU events as a predictive indicator to
guide postoperative disposition of the known or suspected OSA patient (Fig.10.2).
A PACU event occurs if in one 30-min time block, the patient has any of the following: (1) apnea for ≥10s (only one episode needed for yes), (2) bradypnea of ≤8bpm
(three episodes needed for yes), (3) desaturations to <90% (three episodes needed
for yes), or (4) pain-sedation mismatch, as characterized by high pain scores and
high sedation levels observed simultaneously.
A recurrent PACU event occurs when any one of the PACU respiratory events
occur in two separate 30-min time blocks (not necessarily the same event or consecutive blocks). Patients who are at high risk of OSA on the screening questionnaires and have recurrent PACU respiratory events are more likely to have
postoperative respiratory complications. It may be prudent to monitor these patients
postoperatively with continuous oximetry in an area where early medical intervention can occur. The monitoring can occur in the step-down unit, on the surgical ward
near the nursing station, or with remote pulse oximetry with telemetry (Fig.10.2).
Close postoperative monitoring would certainly be called for in patients with
known OSA with recurrent PACU events, but also in the absence of recurrent events
if the patient’s OSA is severe or if they are not using PAP (left side of Fig.10.2). In
the absence of severe OSA, nonadherence, and recurrent PACU events, patients
with at least moderate OSA, or parenteral/higher dose oral opioids (codeine 60mg
every 4h or equivalent) may be managed postoperatively on the surgical ward with
periodic oximetry monitoring. The ASA also recommends that all patients be provided supplemental oxygen on a continuous basis until they are able to maintain
their baseline oxygen saturation while on room air [3].
For those with previously undiagnosed but suspected OSA in the postoperative
or medical inpatient setting, our institution has developed an obstructive apnea systematic intervention strategy (OASIS) protocol, as outlined in the top half of
Fig.10.3. PACU utilization, overnight oximetry, ABG, inpatient events, and discussion with the primary team are often enough to guide initial decision-making.
Appropriate setting (outpatient vs. inpatient) and timing (before or after discharge)
of a comprehensive sleep medicine assessment may be determined based on local
resources and testing availability.
201
Postoperative Use ofPositive Airway Pressure
When possible, patients with known OSA who are already on PAP therapy should
bring their own equipment to the hospital and PAP should be used liberally perioperatively unless a contraindication exists [3]. Contraindications to PAP therapy
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K. L. Dupuy-McCauley et al.
(> 30-60 min after modified Aldrete criteria met)
Known OSA
Non-compliant with PAP therapy
Severe OSA (AHI > 30), or
Recurrent PACU Respiratory Event (30-min
block)’
• Oxygen saturation <90% (3 episodes)
• Bradypnea < 8 breaths/min (3 episodes)
• Apnea ≥ 10 s (1 episodes)
• Pain sedation mismatch
No
Moderate OSA (AHI > 16-30),
Postoperative parenteral or
oral opioids required
(> codeine 60 mg q4h, or
equivalent)
No
Discharger to
home if
minor
surgery.
Yes
Postoperative
care on the
surgical ward.
Prolonged stay in PACU
‡
,
Postoperative PAP
therapy
monitored bed
continuous oximetry.
Suspected OSA
(≥2 on STOP, 3 STOP-Bang)
Recurrent PACU Respiratory Event (30 min block)’
• Oxygen saturation <90% (3 episodes)
• Bradypnea < 8 breaths/min (3 episodes)
• Apnea ≥ 10 s (1 episodes)
• Pain sedation mismatch
NoYes
Discharger to home if
minor surgery or
postoperative care on
the surgical ward.
‡
and care in the
‡
with
Yes
12
Fig. 10.2 Postoperative management of the known or suspected OSA patient after general anesthesia Number of occurrences of more than one set of events in each 30-min evaluation period
while in the post-anesthesia care unit (PACU), including repeat occurrence of the same event set.
‡PAP therapy may include continuous, bi-level or auto-titrating PAP. †Monitored bed– inpatient
area that would lend itself to early nursing intervention and includes continuous oximetry monitoring (e.g., intensive care unit, step-down unit, or remote pulse oximetry with telemetry in surgical
ward). (Adapted with kind permission from Springer Science + Business Media [60])
include cardiac or respiratory arrest, severe encephalopathy, severe upper gastrointestinal bleeding, hemodynamic instability, cardiac arrhythmia, upper airway
obstruction, high risk for aspiration, copious secretions, recent facial trauma, inability to clear secretions, and lack of cooperation from the patient [108]. Patients without a formal diagnosis of OSA, or who have OSA but are not on PAP therapy in the
outpatient setting may warrant consideration of initiation of PAP postoperatively
while hospitalized. CPAP and APAP are equally effective in the perioperative management of OSA as demonstrated by decrease in AHI, improvement in oxygenation,
and shortened length of stay [109]. If the patient has a home machine, it is reasonable to start at the home pressure setting, but with the acknowledgement that the
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