- Estimated Prevalence for mild OSA:
- 1 in 4 males
- 1 in 10 females
- OVER HALF of patients with OSA who present for surgery are undiagnosed.
- Increasing prevalence parallels the increase of obesity over the last 20 years
Singh M. Proportion of surgical patients with undiagnosed obstructive sleep apnoea. British journal of anaesthesia : BJA. 2013-04;110:629-636.
- The muscle tone of the body relaxes during sleep.
- The airway is composed of collapsible walls of soft tissue and muscle which can obstruct breathing during sleep.
- Patients with low muscle tone and soft tissue around the airway (e.g., obese) and structural features that give rise to a narrowed airway (e.g., large tonsils) are at high risk for obstructive sleep apnea.
- The elderly are more likely to have OSA than young people.
- early hypoxemia
- unplanned reintubation/mechanical ventilation
- aspiration pneumonia
- acute respiratory distress syndrome (ARDS)
- labile intraoperative blood pressures
- arrhythmias (Atrial Fibrillation
Mokhlesi B. Sleep-disordered breathing and postoperative outcomes after elective surgery: analysis of the nationwide inpatient sample. Chest. 2013-09;144:903-914.
- Acute Renal failure
- Postoperative ICU Transfers
- Postoperative Delirium
- Longer hospital stays
Flink BJ. Obstructive sleep apnea and incidence of postoperative delirium after elective knee replacement in the nondemented elderly. Anesthesiology 2012-04;116:788-796.
OSA and the Elderly
Lockhart E, Obstructive sleep apnea screening and postoperative mortality in a large surgical cohort , Sleep Medicine, 2013, 407-415
OSA: Preoperative Evaluation
- Medical records review
- Patient/family interview and screening protocol
- STOP BANG Questionnaire
- Focused physical examination Sleep study
ASA Task Force. Updated Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea. Anesthesiology 2014; 120:268-86
- Medical records review should include(but not be limited to)
- checking for history of difficult airway on previous procedures
- hypertension or other cardiovascular problems
- congenital or acquired medical conditions (cerebral palsy, Down syndrome)
- sleep studies
OSA: Patient/Family Interview
- Questions to ask:
- Apneic episodes (pauses in breathing)
- Frequent arousals during sleep
- Vocalization, shifting positions, choking sensation
- Morning headaches
- Daytime somnolence despite adequate “sleep”
- Falls asleep while driving, watching TV, reading
STOP BANG Questionnaire
- Snoring - Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
- Tired - Do you often feel tired, fatigued, or sleepy during daytime?
- Observed - Has anyone observed you stop breathing during your sleep?
- Pressure - Do you have or are you being treated for high blood pressure?
- BMI - BMI more than 35 kg/m2?
- Age - Age over 50 yr old?
- Neck circumference - Neck circumference greater than 40 cm?
- Gender - Gender male?
High risk of OSA: ≥3 Yes answers
Low risk of OSA: <3 Yes answers
Adapted from: Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108:812–21.
- A physical examination should include an evaluation of the following
- Nasopharyngeal characteristics
- Neck circumference
- Tonsil size
- Tongue volume
- Intended to improve or optimize an OSA patient’s perioperative physical status and includes:
- Preoperative CPAP or noninvasive positive pressure ventilation (NIPPV)
- Preoperative use of mandibular advancement or oral appliances.
- Preoperative weight loss
OSA: Day of Surgery
- Remind patients to bring their own CPAP devices to the hospital for use during their hospital stay.
- Ambulatory surgery (going home the day of the procedure) may not be allowed for patients diagnosed with severe OSA.
- May require overnight observation including pulse oximetry
OSA: Intraoperative Management
- Use local anesthesia or peripheral nerve blocks when possible
- Obtain secure airway for general anesthesia at all times
- Extubate while awake
- Verify reversal of neuromuscular block before extubation.
- Extubation/recovery in lateral, or semiupright position only (nonsupine).