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Surgical risk and the preoperative evaluation and management of adults with obstructive

sleep apnea

Authors
Eric Olson, MD
Frances Chung, MBBS, FRCPC
Edwin Seet, MBBS, MMed

Section Editors
Stephanie B Jones, MD
Nancy Collop, MD

Deputy Editors
Marianna Crowley, MD
Geraldine Finlay, MD

Disclosures:Eric Olson, MD Nothing to disclose. Frances Chung, MBBS, FRCPC Nothing to


disclose. Edwin Seet, MBBS, MMed Nothing to disclose. Stephanie B Jones, MD
Consultant/Advisory Boards (Spouse): Allurion Technologies [Obesity (Non-surgical weight
loss device)]. Nancy Collop, MD Nothing to disclose. Marianna Crowley, MD Nothing to
disclose. Geraldine Finlay, MD Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When
found, these are addressed by vetting through a multi-level review process, and through
requirements for references to be provided to support the content. Appropriately referenced
content is required of all authors and must conform to UpToDate standards of evidence.
Conflict of interest policy
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: May 2015. | This topic last updated: Sep 03, 2014.
INTRODUCTION Obstructive sleep apnea (OSA) is a disorder characterized by repetitive
episodes of apnea or reduced inspiratory airflow due to upper airway obstruction during
sleep. OSA is the most common type of sleep-disordered breathing, with an estimated
prevalence of 1 in 4 males and 1 in 10 females for mild OSA, and 1 in 9 males and 1 in 20
females for moderate OSA [1]. OSA has been increasing in prevalence over the last two
decades in parallel with the increase in obesity [2-5]. Over half of patients with OSA who
present for surgery are undiagnosed [6,7].

The incidence of perioperative complications is greater in patients with OSA [8-11], leading
the American Society of Anesthesiologists, the American Academy of Sleep Medicine, and
others to develop clinical practice guidelines and protocols for the perioperative management
of patients with OSA [3,12-14]. Recommendations include maintaining a high index of
suspicion for OSA, careful use of medications, vigilant monitoring for upper airway
obstruction, and an integrated team approach to perioperative management. There is little
direct evidence that these precautions improve outcomes, so recommendations are generally
based upon indirect evidence, clinical rationale, and expert opinion.
The preoperative evaluation and management of patients with known or suspected OSA are
reviewed here. The intraoperative and postoperative management of patients with OSA are
discussed separately. (See "Intraoperative management of adults with obstructive sleep
apnea" and "Postoperative management of adults with obstructive sleep apnea".)
The diagnosis, general management, and other issues related to OSA are discussed
separately. (See "Overview of obstructive sleep apnea in adults" and "Clinical presentation
and diagnosis of obstructive sleep apnea in adults" and "Management of obstructive sleep
apnea in adults".)
PERIOPERATIVE RISKS Patients with obstructive sleep apnea (OSA) are at higher risk
for complications from procedures with sedation, analgesia, and/or anesthesia. Adverse
events include respiratory complications, postoperative cardiac events, and transfer to the
intensive care unit [8-11]. A 2012 meta-analysis examining the association between OSA and
postoperative outcomes showed that OSA increased the odds of various postoperative
complications by a factor of approximately two to four [8]. Subsequently published studies
have also noted independent associations between OSA and escalation of care, increased
healthcare resource utilization, and length of stay [15,16].
OSA disease severity and the invasiveness of the surgical procedure are probably the most
important determinants of perioperative risk in patients with OSA [12,14]. OSA-related
comorbidities (eg, obesity, systemic hypertension, pulmonary hypertension, cardiac
arrhythmias, coronary artery disease, and heart failure) may also contribute to the increased
perioperative complication rate. (See "Obstructive sleep apnea and cardiovascular disease".)
Patients with undiagnosed OSA who are identified as high risk according to screening tools
also have a high risk of postoperative complications [17,18]. (See 'Screening tools' below.)
Exacerbation of OSA Clinical manifestations of OSA are caused by recurrent collapse of
the pharyngeal airway during sleep, leading to intermittent hypercapnia and hypoxemia.
Multiple perioperative and anesthetic factors may exacerbate OSA disease severity and
contribute to an increased risk of complications (table 1):
Perioperative medications (eg, sedatives, general anesthetic agents, opioids, neuromuscular
blocking agents) may reduce upper airway dilator tone and inhibit protective airway reflexes,
central ventilatory drive, and arousal mechanisms. These effects mimic sleep and therefore
may exacerbate repetitive upper airway collapse in patients with OSA. (See "The effects of
medications on sleep quality and sleep architecture".)

Upper airway narrowing caused by post-intubation edema, postoperative edema, nasal


packing, nasal tubes, hematomas, and prolonged head-down and/or prone positioning
decreases the extent of upper airway collapse needed to cause obstruction [19-23]. (See
"Mechanisms and anatomic sites of upper airway obstruction in obstructive sleep apnea in
adults".)
Supine positioning is often required perioperatively. Many patients have OSA that develops
or worsens in the supine position. (See "Management of obstructive sleep apnea in adults",
section on 'Sleep position' and "Postoperative management of adults with obstructive sleep
apnea", section on 'Positioning'.)
Perioperative discontinuation of continuous positive airway pressure (CPAP) therapy due to
pain, anxiety, nausea, agitation, the nature of surgery, the presence of a nasogastric tube,
failure to bring equipment to the hospital, or failure of the hospital to resume CPAP
postoperatively, may lead to a return of pathophysiologic respiratory and airway problems
alleviated by CPAP.
Sleep deprivation is common perioperatively (related to anxiety, pain, the disease leading to
surgery, and sleep disturbance in the hospital environment) and has been observed to be
associated with worsening OSA [24-28]. One potential explanation is that sleep deprivation
may lead to an increase in rapid eye movement (REM) sleep, which is the stage of sleep
when OSA is typically most severe. Sleep architecture disturbance is greatest during the first
postoperative night in patients with and without OSA, and breathing disturbance (ie, apnea
hypopnea index) is greatest on the third postoperative night [28]. (See "Postoperative
management of adults with obstructive sleep apnea", section on 'Post-PACU discharge risk
and precautions'.)

More invasive surgical procedures may have higher risk for complications, because they
typically require more anesthetic agents, sedatives, and opioids, and because they are more
likely to affect airway and cardiorespiratory function.
Experts believe that increased severity of OSA (as assessed by apnea hypopnea index) is
associated with a greater rate of perioperative complications; however, this has not been
confirmed in retrospective population-based studies [29,30].
Respiratory complications The greatest concern for perioperative patients with OSA
relates to respiratory and pulmonary problems. In a 2012 meta-analysis, OSA was associated
with increased acute respiratory failure (OR 2.4) and postoperative oxygen desaturation (OR
2.3) [8].

OSA was associated with a wide range of increased pulmonary complications according to a
database study of over six million surgical procedures [9]. For patients having general
surgery, OSA was associated with higher rates of intubation/mechanical ventilation (10.80
versus 5.94 percent), aspiration pneumonia (2.79 versus 2.05 percent), and acute respiratory

distress syndrome (3.79 versus 2.44 percent). Patients with OSA having orthopedic surgery
had similarly increased risk of complications, although at lower absolute rates.
Use of noninvasive ventilation, emergent intubation, difficult endotracheal intubation,
complicated post-extubation courses, postobstructive pulmonary edema (from breathing
against an obstructed upper airway), respiratory arrest, and profound oxyhemoglobin
desaturation in the postoperative period also occur at higher rates in patients with OSA [1012,19,31-35].
Cardiovascular complications OSA was associated with an increase in postoperative
cardiac events (OR 2.1) in a 2012 meta-analysis [8]. Other reported perioperative cardiac
problems associated with OSA include large blood pressure fluctuations, myocardial
ischemia and cardiac arrhythmias (eg, atrial fibrillation) [10,11,33]. (See "Obstructive sleep
apnea and cardiovascular disease".)
Mortality The evidence does not confirm a clear association between OSA and
perioperative mortality, with various studies showing increased [36], comparable [7], and
even decreased mortality [10,11].
Other complications Other adverse perioperative events associated with OSA include
acute renal failure (OR 2.43), wound hematomas or seromas (OR 1.36), postoperative
delirium (OR 4.3), postoperative ICU transfer (OR 2.81), and longer hospital stay after joint
arthroplasty (6.8 versus 5.1 days) [8,36-38].
INITIAL ASSESSMENT Preoperative patients should be screened for obstructive sleep
apnea (OSA), and those with the diagnosis or suspicion of OSA are assessed for the severity
and adequacy of management. Aspects of the preoperative evaluation unrelated to OSA are
discussed separately. (See "Preoperative medical evaluation of the healthy patient" and
"Preanesthesia medical evaluation of the obese patient".)
Screening for OSA OSA is prevalent and often undiagnosed in the surgical population
[6,7,39]. Patients with undiagnosed OSA who are identified as high risk according to
screening tools also have a high risk of postoperative complications, and thus may benefit
from diagnostic evaluation and treatment [17,18]. Either a presumed or confirmed diagnosis
of OSA may change perioperative and anesthetic management. (See "Intraoperative
management of adults with obstructive sleep apnea" and "Postoperative management of
adults with obstructive sleep apnea".)
Who to screen Given the increasing prevalence of OSA, the ease of screening, and
increased perioperative risks of OSA, we recommend screening all preoperative patients for
OSA.
The most critical populations to screen are those with a high prevalence of OSA, such as
obese patients (BMI 30 kg/m2 (calculator 1)) and those scheduled for bariatric surgery
[29,40]. Other important groups are those with medical conditions in which OSA is prevalent
(eg, hypertension, type 2 diabetes, uncontrolled hypothyroidism, congestive heart failure, and
stroke) or a history of difficult intubation or upper airway characteristics that predict a
difficult intubation [31,32,41]. A study of 137 adults being evaluated for OSA found that
every one-point increase in the Mallampati score (figure 1) increased both the odds and
severity of OSA (OR increased by 2.5, 95% CI 1.2-5.0, and AHI increased by 5.2 events/

hour, 95% CI 0.2-10) [42]. (See "Clinical presentation and diagnosis of obstructive sleep
apnea in adults" and "Overview of obstructive sleep apnea in adults", section on 'Risk
factors'.)
Screening tools There are multiple screening tools available to help identify individuals
who may have OSA. The sensitivity of these tools is generally higher than their specificity,
so they are most useful to rule out OSA in patients with a low score [17,43,44]. Because of
the high rate of false-positive results, patients with positive screening need further evaluation
to diagnose OSA. Some screening tools (eg, STOP-Bang) may be used with a higher cutoff
score to increase specificity [45]. (See "Clinical presentation and diagnosis of obstructive
sleep apnea in adults", section on 'Screening questionnaires'.)
Screening tools used in the preoperative setting include:
STOP-Bang questionnaire The STOP-Bang questionnaire requires yes or no
responses to eight questions about snoring, tiredness, observed apneas, and blood pressure;
BMI >35kg/m2, age >50 years, neck circumference >40 cm, and male gender (table 2)
[28,43,45,46]. Patients with zero to two positive responses are considered low risk, those
with three of four are intermediate risk, and those with five to eight positive responses are
high risk of OSA [45]. One validation study showed that 3 positive responses on the
STOP-Bang questionnaire (intermediate to high risk) identified preoperative patients with
any severity of OSA (AHI >5/hour) with a sensitivity of 84 and a specificity of 40 percent
[45]. Patients with a STOP-Bang score 5 or greater are considered high risk of severe OSA
(probability 30.1 percent) (figure 2) [45].
Another study noted that including the presence of a raised serum bicarbonate level (28
mmol/L) in patients with a STOP-Bang score of 3 improves the specificity for moderate to
severe OSA [47]. Patients with a STOP-Bang score of 3 or greater and an elevated serum
HCO3 level should therefore be treated similarly to patients with STOP-Bang score of 5 or
greater.

Although the STOP-Bang questionnaire gives all items equal weight, not all items have equal
predictive value for OSA, and a two-step scoring system may improve performance. For
patients who answer yes to two of the STOP (snoring, tiredness, observed apnea, high blood
pressure) questions, male gender and BMI >35 kg/m2 are more predictive than age 50 and
neck circumference >40 cm [48]. Consequently, with a STOP-Bang score of 3 to 4, the
second step examines the specific combination of factors (eg, STOP score 2 or greater and
BMI >35 kg/m2 or STOP score 2 or greater and male) to identify those at a high risk of
moderate-severe OSA.
The STOP-Bang questionnaire has been validated in both obese (BMI 30 kg/m2) and
obesity class 2 and 3 (BMI 35 kg/m2) patients [46]. Obese patients with zero to three
positive responses are considered low risk, those with four or five are intermediate risk,
and those with six to eight positive responses are high risk of OSA" (figure 3) [46].

Sleep apnea clinical score (SACS) Also known as the Flemons screening tool, the sleep
apnea clinical score plots results of a four-item questionnaire (neck circumference,
hypertension, habitual snoring, and nocturnal gasping or choking) on a table to generate a
score ranging from 0 to 100 (table 3) [49]. Values greater than 15 indicate that the patient has
a high risk for OSA, and correlates with a higher incidence of postoperative oxygen
desaturation [50].
Berlin Questionnaire This uses questions on snoring, excessive daytime sleepiness,
sleepiness while driving, apneas during sleep, hypertension, and BMI to stratify patients as
having a high or low risk for OSA (table 4) [44]. It identified preoperative patients with OSA
(AHI >5/hour) with a sensitivity of 69 percent and a specificity of 56 percent, and those with
severe OSA (AHI >30/hour) with a sensitivity of 87 percent and a specificity of 46 percent
[17].

When a formal screening tool is not used, clinical indicators of a likely diagnosis of OSA
include loud snoring, and either excessive daytime sleepiness or at least two other clinical
features of OSA (table 5). (See "Quantifying sleepiness" and "Clinical presentation and
diagnosis of obstructive sleep apnea in adults", section on 'Indications for diagnostic testing'.)
Patients with known OSA
Assessment of OSA Preoperative evaluation of patients with OSA should specifically
include assessment of severity and adequacy of management of OSA [1,12-14]. Patients with
severe or poorly-controlled OSA, or otherwise at high risk of perioperative complications,
may benefit from initiation or optimization of treatment before surgery. (See 'Indications for
further evaluation' below.)
Severity of the OSA Documentation should include current symptoms and signs of OSA,
particularly daytime sleepiness, snoring, and repeated awakenings, which may indicate the
need for further assessment and treatment prior to planned surgery.
Recent sleep studies, if available, provide an estimate of OSA severity. Such studies report
the apnea hypopnea index (AHI), the nadir of oxyhemoglobin saturation, and arrhythmias
associated with episodes of upper airway obstruction. Mild OSA is typically defined as AHI
5 to 15 events/hour, moderate OSA as AHI 15 to 30 events/hour, and severe OSA as AHI
greater than 30 events/hour. Symptoms, signs, and other physiological variables may also be
included in the severity assessment. (See "Clinical presentation and diagnosis of obstructive
sleep apnea in adults", section on 'Disease spectrum'.)
Adequacy of current treatment Patients who are using therapy should be asked about
residual symptoms, problems with adherence with treatment or technical difficulties, and
reasons for discontinuation if therapy is no longer used.
Documentation of current treatment OSA therapy may include positive airway pressure
(PAP), including continuous (CPAP) or bi-level (BiPAP) therapy, oral appliances, and/or
upper airway surgery. Documentation of settings used for airway pressure therapy will

facilitate the resumption of therapy as soon as practical after surgery. Patients should be
instructed to bring PAP equipment or oral appliances on the day of surgery. (See
"Postoperative management of adults with obstructive sleep apnea", section on 'Positive
airway pressure therapy'.)
OSA-associated conditions In addition, OSA-associated medical conditions should be
identified that may require preoperative optimization, affect the decision to operate, or
change the management of anesthesia:
Airway abnormalities are common in OSA and may affect mask ventilation, intubation, or
use of noninvasive ventilation perioperatively. (See "Preanesthesia medical evaluation of the
obese patient", section on 'Airway assessment' and "Noninvasive positive pressure ventilation
in acute respiratory failure in adults", section on 'Patient selection'.)
Patients with obesity require specific preoperative evaluation of and/or screening for
conditions that are more prevalent in that population, including hypertension, heart disease,
diabetes, metabolic syndrome, and kidney disease. This evaluation is discussed separately.
(See "Preanesthesia medical evaluation of the obese patient".)
Obesity hypoventilation syndrome (OHS) is particularly important, because it is highly
associated with OSA. OHS occurs in 0.15 to 0.3 percent of the general population but in 11
percent of patients with known OSA [51]. The diagnosis of OHS may change the
preoperative management (testing and PAP therapy) as well as the management of anesthesia
(airway, ventilation, and sedative management). (See "Preanesthesia medical evaluation of
the obese patient", section on 'Patients with known comorbidities' and "Preanesthesia medical
evaluation of the obese patient", section on 'Screening for comorbidities'.)
Pulmonary hypertension may develop in patients with longstanding or severe OSA and is
also highly associated with OHS [51]. Valuable clinical predictors of OHS include elevated
serum bicarbonate and hypoxemia. A preoperative raised serum bicarbonate level has a high
sensitivity in predicting hypercapnia in OHS patients [51]. If serum bicarbonate is increased
in the presence of hypoxemia on room air oximetry during wakefulness, arterial blood gas
measurement is recommended for confirmation [51].

Because the diagnosis impacts perioperative management and prognosis, performance of a


preoperative echocardiogram should be considered in patients with moderate to severe OSA
and either signs/symptoms of right heart dysfunction, sleep-related hypoxemia despite PAP,
or morbid obesity. (See "Obstructive sleep apnea and cardiovascular disease", section on
'Pulmonary hypertension' and "Overview of pulmonary hypertension in adults".)
Assessment of other known or suspected associated conditions, including cardiovascular
disease and hypertension, is important in patients with OSA and is discussed separately. (See
"Evaluation of cardiac risk prior to noncardiac surgery", section on 'Initial preoperative
evaluation' and "Perioperative management of hypertension".)

Gastroesophageal reflux disease (GERD) may be more common in patients with OSA; it is
not clear whether this is an independent association or due to common risk factors (eg,
obesity) [52-54].
INDICATIONS FOR FURTHER EVALUATION The majority of patients with known or
suspected obstructive sleep apnea (OSA) may proceed to surgery without additional testing or
treatment. Surgery should be delayed only for those whose management or perioperative
outcomes may be modified by further preoperative evaluation (such as preoperative
polysomnography, home sleep testing, and overnight oximetry) and treatment: those patients
with the combination of high-risk surgical procedures and a high risk for severe,
inadequately-treated OSA.
High-risk surgical procedures include major invasive surgery that will impact airway or
cardiopulmonary function and those requiring substantial postoperative opioid medication.
Patients with known or strongly-suspected OSA may proceed to low-risk (ie, non-airway,
minimally-invasive) surgery without further evaluation or treatment; however, intraoperative
risk mitigation measures and precautions should be used. (See "Intraoperative management of
adults with obstructive sleep apnea".)
High-risk patients on the basis of OSA (known or suspected) include:
Patients with known moderate or severe OSA that is not optimally managed (current signs
and symptoms, particularly excessive sleepiness, observed apneas, and hypercapnia;
nonadherence or technical difficulty with therapy; excessive weight gain since the last
evaluation)
Patients with high risk of OSA based on screening (see 'Screening for OSA' above)
Patients with significant medical comorbidities, particularly if not adequately evaluated and
managed (eg, uncontrolled hypertension, heart failure, cardiac arrhythmias)

Emergency surgery should not be postponed for a formal diagnosis of OSA. If the patient is
judged to have a high risk of OSA and surgery is urgent, the patient should be managed with
a presumptive diagnosis of OSA, with intraoperative risk mitigation measures and
precautions used. (See 'Management of patients proceeding to surgery' below and
"Intraoperative management of adults with obstructive sleep apnea".)
The rationale for beginning treatment prior to surgery is based on evidence in nonsurgical
OSA patients that continuous positive airway pressure (CPAP) for more than two weeks
improves physiologic outcomes (eg, hypertension, oxygen saturation, and AHI) [55].
Evidence is limited in perioperative patients, but in an open-label trial, patients with moderate
OSA (apnea hypopnea index [AHI] >15 events per hour) who were randomized to autotitrated continuous positive airway pressure (APAP) treatment (two or three preoperative and
five postoperative nights) had improved postoperative oxygen saturation and decreased AHI

(preoperative 30.1 versus postoperative 3.0 events/hour) compared with control patients
(preoperative AHI 30.4 versus postoperative 31.9 events/hour) [56]. This improvement was
noted despite a typically low compliance rate (45 percent) and APAP usage of only two to
five hours per night.
In patients who are re-evaluated prior to surgery, and who have therapy initiated or CPAP
settings changed to optimize treatment, we prefer to schedule surgery no sooner than one
week after changes are made, to receive the benefit of the improved treatment and to
accustom the patient to the CPAP device. This time frame may be modified by the urgency of
the surgery and preferences of the patient and surgeon.
MANAGEMENT OF PATIENTS PROCEEDING TO SURGERY All patients treated for
obstructive sleep apnea (OSA) should be encouraged to continue current therapy up to the
day of surgery. Patients expected to remain overnight in the hospital may be asked to bring
continuous positive airway pressure (CPAP) equipment, depending on hospital protocol.
SUMMARY AND RECOMMENDATIONS
The incidence of perioperative complications is increased by a factor of two to four in
patients with obstructive sleep apnea (OSA). Respiratory complications are the most
common. While unproven, it is likely that patients with more severe OSA are at greater risk.
High-risk surgical procedures are those that are invasive, involve the airways or
cardiovascular system, or are associated with need for high levels of postoperative opioids.
(See 'Perioperative risks' above.)
Evaluation of patients with OSA should include results of recent sleep studies, details of
treatment for OSA, current signs and symptoms of OSA, and the presence of OSA-associated
medical conditions (obesity, airway abnormalities, cardiovascular disease). (See 'Patients
with known OSA' above.)
Given the increasing prevalence of OSA, the ease of screening, and increased perioperative
risks of OSA, we screen all preoperative patients for OSA. The most critical populations to
screen are obese patients (BMI 30 kg/m2) (calculator 1) and those scheduled for bariatric
surgery, patients with other medical conditions in which OSA is prevalent (eg, advancing
hypertension, type 2 diabetes, uncontrolled hypothyroidism, congestive heart failure, and
stroke), and patients with a history of a difficult intubation or upper airway characteristics
that predict a difficult intubation (figure 1). Several screening tools have been validated in
preoperative patients. (See 'Screening for OSA' above and 'Screening tools' above.)
No further evaluation prior to surgery is required in patients who are undergoing low-risk
surgical procedures (noninvasive surgery, not likely to require significant postoperative
opioids). Similarly, no further evaluation is required in those who screen at low risk for OSA
and those with known OSA who are asymptomatic, adherent with therapy, and have not
experienced excessive weight gain since their last sleep evaluation. (See 'Indications for
further evaluation' above.)

In other patients, the decision to defer elective surgery for further evaluation is made on a
case-by-case basis, based on the judgement that optimal management of OSA will improve
patient outcome. When possible, we prefer to defer surgery in high-risk patients in order to
allow one week of treatment on optimized settings. (See 'Indications for further evaluation'
above.)
Emergency surgery should not be postponed to establish a formal diagnosis of OSA. (See
'Indications for further evaluation' above.)
Patients who are on continuous positive airway pressure (CPAP) therapy for OSA should
continue treatment up to the day of surgery. (See 'Management of patients proceeding to
surgery' above.)
ACKNOWLEDGMENT The editorial staff at UpToDate would like to acknowledge
Robert Basner, MD, who contributed to an earlier version of this topic review.
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