Management of sleep apnea in adults - functional algorithms for the perioperative period: Continuing Professional Development

Obstructive sleep apnea (OSA) is defined by repetitive partial or complete upper airway obstruction characterized by episodes of breathing cessation during sleep. It is the most prevalent of sleep disorders, seen in about one in four males and one in ten females. We reviewed current literature, collated expert opinion, and synthesized protocols from several institutions to present practical principles and functional algorithms to assist the anesthesiologist in the perioperative management of known and suspected OSA.

Patients with OSA may have an increase in postoperative adverse respiratory events, sustained arrhythmias, hypertension, and other cardiovascular events. The gold standard for the diagnosis of OSA is polysomnography. The Berlin questionnaire and the American Society of Anesthesiologists OSA checklist are useful screening tools, while the STOP and the STOP-Bang questionnaires are easy to use in adults. Patients scheduled for elective major surgery, who are at high risk of OSA with significant comorbidities, may be referred for preoperative polysomnography. Perioperative precautions, such as anticipation of a possible difficult airway, use of short-acting anesthetic agents, avoidance of opioids, and extubation in a non-supine position, should be undertaken for known or suspected high-risk OSA patients. Postoperative disposition of the OSA patient should be based on the severity of the sleep disorder, recurrent postanesthesia care unit respiratory events, and the need for opioid analgesia.

With adequate screening and vigilance in the preoperative period, risk stratification should be undertaken for known and suspected OSA patients, and care should be individualized. Practical algorithms based on current best evidence and expert opinion may be useful in the perioperative management.