Perioperative Management of the Patient With Obstructive Sleep Apnea: A Narrative Review

Abstract

The prevalence of obstructive sleep apnea (OSA) has reached 1 billion people worldwide, implying significant risk for the perioperative setting as patients are vulnerable to cardiopulmonary complications, critical care requirement, and unexpected death. This review summarizes main aspects and considerations for the perioperative management of OSA, a condition of public health concern. Critical determinants of perioperative risk include OSA-related changes in upper airway anatomy with augmented collapsibility, diminished capability of upper airway dilator muscles to respond to airway obstruction, disparities in hypoxemia and hypercarbia arousal thresholds, and instability of ventilatory control. Preoperative OSA screening to identify patients at increased risk has therefore been implemented in many institutions. Experts recommend that in the absence of severe symptoms or additional compounding health risks, patients may nevertheless proceed to surgery, while heightened awareness and the adjustment of postoperative care is required. Perioperative caregivers should anticipate difficult airway management in OSA and be prepared for airway complications. Anesthetic and sedative drug agents worsen upper airway collapsibility and depress central respiratory activity, while the risk for postoperative respiratory compromise is further increased with the utilization of neuromuscular blockade. Consistently, opioid analgesia has proven to be complex in OSA, as patients are particularly prone to opioid-induced respiratory depression. Moreover, basic features of OSA, including intermittent hypoxemia and repetitive sleep fragmentation, gradually precipitate a higher sensitivity to opioid analgesic potency along with an increased perception of pain. Hence, regional anesthesia by blockade of neural pathways directly at the site of surgical trauma as well as multimodal analgesia by facilitating additive and synergistic analgesic effects are both strongly supported in the literature as interventions that may reduce perioperative complication risk. Health care institutions are increasingly allocating resources, including those of postoperative enhanced monitoring, in an effort to increase patient safety. The implementation of evidence-based perioperative management strategies is however burdened by the rising prevalence of OSA, the large heterogeneity in disease severity, and the lack of evidence on the efficacy of costly perioperative measures. Screening and monitoring algorithms, as well as reliable risk predictors, are urgently needed to identify OSA patients that are truly in need of extended postoperative surveillance and care. The perioperative community is therefore challenged to develop feasible pathways and measures that can confer increased patient safety and prevent complications in patients with OSA.

Anesthetic Implications for Patients With Implanted Hypoglossal Nerve Stimulators: A Case Report

“…At the time of this writing, there are no published citations regarding the management of HGNS systems in patients undergoing procedural sedation or general anesthesia. Furthermore, these devices are not mentioned in recent articles pertaining to OSA in the perioperative period [ 1 , 5 ]. We contacted Inspire Medical Systems and were informed that approximately 17,000 patients in the United States have had a HGNS system implanted.…”

“…Obstructive sleep apnea (OSA) affects over one billion people worldwide, including approximately 22 million Americans [ 1 , 2 ]. By maintaining airway patency during sleep, the regular use of continuous positive airway pressure (CPAP) improves the quality of life, vigilance, and cognitive function in patients with OSA [ 1 ]. Despite these favorable outcomes, only 40-60% of patients with OSA are compliant with CPAP therapy [ 2 ].…”

“…As the implantation of these devices becomes increasingly common, more patients with HGNS systems will be present for medical procedures requiring general anesthesia or deep sedation. Currently, guidelines for the anesthetic management of OSA do not address patients with HGNS systems [ 1 , 5 ]. Furthermore, a search of the published literature produced no citations or similar case presentations concerning anesthesia for patients with HGNS systems.…”

Clinical implications of opioid-induced ventilatory impairment

“…46 So while the use of OSA screening tools such as STOP-Bang are widely advocated to indicate likely OSA severity, consensus on how best to apply the findings is lacking. 69,70…”

“…69 High arousal thresholds, and hence greater vulnerability to arousal failure, are commonly observed in moderate and severe OSA. 70 With the high rates of OSA presentation it can seem logical to focus attention on these seemingly higher-risk patients with moderate and severe OSA. However, the AHI cannot be relied on to predict all events, as even mild OSA was a feature of 18% of OSA critical events in one series.…”