Morbid Obesity and Obstructive Sleep Apnea: The Challenging Link

Abstract

Abstract:Obstructive sleep apnea (OSA) is a common medical condition that is increasing in prevalence and is associated with substantial morbidity and a 40% eight-year mortality rate if left untreated. Morbidly obese patients have a greater incidence of co-morbid disease, including OSA. OSA is characterized by repeated upper airway obstruction and arousal during sleep, sympathetic activation, hypertension and daytime somnolence. In morbidly obese OSA patients undergoing surgical procedures, the perioperative period is more challenging than in non obese OSA patients. Their airway anatomy is often abnormal with excess pharyngeal tissue and tongue size making it difficult to ventilate thru a facemask and to establish tracheal intubation. Several suggestions for optimizing the anesthetic induction, emergence, and early recovery periods in these patients are offered. Most important are positioning of the patient (both during and post surgery), pre-oxygenation prior to intubation, proper dosing of anesthetic maintenance drugs to ideal body weight, alveolar recruitment maneuvers, full reversal of paralysis at the end of surgery, and careful drug titration in recovery to improve pulmonary mechanics. With proper preparation and precautions it is possible to avoid the significant high frequency of respiratory and cardiac complications observed in these patients and to avoid or better manage length of hospital stay, unplanned ICU admission and/or reintubation.

Perioperative management of obstructive sleep apnea in bariatric surgery: a consensus guideline

“…This position improves oxygenation and the laryngoscopic view during intubation. Other positions such as the flat supine position should be avoided in morbidly obese patients who may desaturate readily if there are difficulties with mask ventilation or intubation, because of the effects of obesity on lung volumes and thereby oxygen stores and gas exchange (Table 4, Q 4.1) (93; [114][115][116][117].…”

Identification of significant obstructive sleep apnoea in the obese patient: development of the novel DX-OSA score

“…The importance of diagnosing and treating OSA in obese patients prior to surgery is widely recognized [9]. In OSA patients, preoperative CPAP improves exercise tolerance, and reduces daytime sleepiness and negative cardiopulmonary physiological consequences, especially hypertension [10][11][12].…”

EDITORIAL - Sleep and Anesthesia

“…This is important, because it is challenging to make diagnosis of sleep disordered breathing in patients while they are asymptomatic, which is typically the case during wakefulness. Tom Ebert and coworkers [13] focus on the relation between morbid obesity and OSA -Obesity is an epidemic with major health consequences, and obesity and OSA are related: about 50% of patients with morbid obesity have OSA. Both, obesity and OSA have important *Address correspondence to this author at the Department of Anesthesia, Critical Care, and Pain Medicine Massachusetts General, Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA; Tel: 617-643-4408; Fax: 617-726-5985; E-mail: meikermann@partners.org implications with regard to perioperative safety of patients presenting with these diseases.…”