Obstructive Sleep Apnea Syndrome and Perioperative Complications: A Systematic Review of the Literature

Abstract

Obstructive sleep apnea syndrome (OSAS) is a common sleep related breathing disorder. Its prevalence is estimated to be between 2% and 25% in the general population. However, the prevalence of sleep apnea is much higher in patients undergoing elective surgery. Sedation and anesthesia have been shown to increase the upper airway collapsibility and therefore increasing the risk of having postoperative complications in these patients. Furthermore, the majority of patients with sleep apnea are undiagnosed and therefore are at risk during the perioperative period. It is important to identify these patients so that appropriate actions can be taken in a timely fashion. In this review article, we will discuss the epidemiology of sleep apnea in the surgical population. We will also discuss why these patients are at a higher risk of having postoperative complications, with the special emphasis on the role of anesthesia, opioids, sedation, and the phenomenon of REM sleep rebound. We will also review how to identify these patients preoperatively and the steps that can be taken for their perioperative management. OSAS has been shown to be associated with various healthrelated consequences, including increased rate of motor vehicle accidents, hypertension, diabetes mellitus, congestive heart failure, stroke, and all-cause mortality. [1][2][3][4][5][6][7][8][9] Recently, numerous studies have demonstrated that surgical patients with sleep apnea are at increased risk of having perioperative complications, including hypoxemia, pneumonia, diffi cult intubation, myocardial infarction, pulmonary embolism, atelectasis, cardiac arrhythmias, and unanticipated admission to the ICU. The majority of patients with OSA are undiagnosed upon admission and are at risk during the perioperative period, presumably due to their underlying sleep apnea. Therefore, it is very important to identify these patients preoperatively so that one can initiate appropriate perioperative measures. EpidemiologyOSAS is an extremely common sleep related breathing disorder, and its prevalence has been increasing throughout the world because of obesity and increasing age of the general population. Its prevalence is between 2% and 25% in the general population, depending upon how sleep apnea is defi ned. In an epidemiological study, Young et al. noted that the prevalence of sleep apnea, defi ned as apnea-hypopnea index (AHI) ≥ 5/h was 9% for women and 24% for men. 10 However, the prevalence of OSAS (defi ned as AHI ≥ 5/h and daytime sleepiness) was 2% in women and 4% in men. 10 The National Sleep Foundation (NSF) Sleep in America 2005Poll found that 1 in 4 Americans are at high risk of having sleep apnea based on the Berlin Questionnaire. 11 The prevalence of sleep apnea is much higher in surgical patients and depends on the type of surgery. In the bariatric surgery population, the prevalence of sleep apnea has been found to be > 70%. 12,13 It is the standard of care for these patients to get a formal sleep evaluation prior to undergoing the bariatric surgery. Howev...

Obstructive Sleep Apnea: Preoperative Screening and Postoperative Care

“…3,24,[35][36][37] Although several large retrospective cohort studies indicated only mild risk 38,39 or decreased risk of perioperative complications in patients with OSA, 40 the controls in these studies were patients who were not actually proven to not have OSA, but were simply lacking OSA-related International Classification of Diseases, 9th Revision (ICD-9), diagnosis codes in their charts, thus confounding the result, considering that Ͼ80% of patients with OSA are undiagnosed. 4,32,41 A meta-analysis by Kaw et al, comparing patients with OSA with controls who tested negative for OSA or screened at low risk of OSA (and excluding studies using "no ICD-9 codes for OSA" as controls), showed a uniform increase in perioperative morbidity from OSA, with significant heterogeneity of the effect among studies.…”

“…Because of a lack of a uniform definition of obstructive sleep apnea (OSA) severity, the American Society of Anesthesiologists' latest guideline on perioperative management of OSA uses the terms mild, moderate, and severe "as defined by the laboratory where the sleep study was performed." If overall severity is not indicated by the sleep laboratory, they classify OSA severity from Apnea-Hypopnea Index (AHI) as none (0 -5), mild (6 -20), moderate (21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40), severe (Ͼ40).…”

Perioperative Complications in Obstructive Sleep Apnea Patients

“…A sufficient number of controlled trials have now been performed such that two meta-analyses and two systematic reviews have examined this topic in detail [77][78][79]80••]. The most comprehensive, and most recent, of these reviews analyzed 61 studies and included over 400,000 OSA patients (due to the inclusion of large database studies) [80••].…”

Obstructive sleep apnea syndrome and anesthesia

“…Artmış cerrahi stres ve uzamış cerrahi sürenin komplikasyonları arttırdığı gösterilmiştir (1). Bilinen ya da kuşkulanılan OUAS hastalarında havayolu sağlanmasında güçlük yaşanabileceği için, ASA'nın "Zor Havayolu Yönetimi Kılavuzu"na göre plan yapılmalıdır (2,33).…”

“…Sedasyon altında yapılabilecek girişimlerde ise havayolu açıklığının garanti altına alındığı genel anestezi uygulaması daha güvenli gibi görünmekle birlikte havayolu sağlamadan sadece sedasyon tercih ediliyorsa solunum sürekli olarak kapnograf ile monitörize edilmelidir (2 Oksijenasyon. Bu hastalarda erken postoperatif dönemde oksijen uygulamasının etkilerini değerlendiren yeterli çalışma bulunmamakla beraber ekstübasyon sonrasında oksijen satürasyonunu kabul edilebilir sınırlarda tutmaya yetecek kadar oksijen uygulaması önerilmektedir (1,2). Hastalar oda havasını solurken oksijen satürasyonlarını operasyon öncesindeki düzeyde tutmayı başarabildiklerinde de oksijen uygulaması sonlandırılmalıdır (2).…”