Vous êtes sur la page 1sur 31

Author’s Accepted Manuscript

Morbid Obesity, Sleep Apnea, Obesity

Hypoventilation Syndrome: Are We Sleepwalking
Into Disaster?

Raviraj Raveendran, Jean Wong, Frances Chung


PII: S2405-6030(17)30045-6
DOI: https://doi.org/10.1016/j.pcorm.2017.11.010
Reference: PCORM52
To appear in: Perioperative Care and Operating Room Management
Received date: 6 October 2017
Accepted date: 2 November 2017
Cite this article as: Raviraj Raveendran, Jean Wong and Frances Chung, Morbid
Obesity, Sleep Apnea, Obesity Hypoventilation Syndrome: Are We
Sleepwalking Into Disaster?, Perioperative Care and Operating Room
Management, https://doi.org/10.1016/j.pcorm.2017.11.010
This is a PDF file of an unedited manuscript that has been accepted for
publication. As a service to our customers we are providing this early version of
the manuscript. The manuscript will undergo copyediting, typesetting, and
review of the resulting galley proof before it is published in its final citable form.
Please note that during the production process errors may be discovered which
could affect the content, and all legal disclaimers that apply to the journal pertain.
Morbid Obesity, Sleep Apnea, Obesity Hypoventilation Syndrome: Are We Sleepwalking
Into Disaster?
Raviraj Raveendran. MBBS, FANZCA

Consultant Anesthesiologist, Department of Anesthesiology, Palmerston North Hospital, Mid

Central District Health Board, Palmerston North, New Zealand
Jean Wong MD FRCPC

Associate Professor, Department of Anesthesiology, Toronto Western Hospital, University

Health Network, University of Toronto


Frances Chung. MBBS FRCPC

Professor, Department of Anesthesiology, Toronto Western Hospital, University Health

Network, University of Toronto


(Corresponding Author)

Based on a presentation given at the 12th Annual Perioperative Medicine Summit (March 9th,

2017), Fort Lauderdale, FL.


An increase in the prevalence of obesity globally has been associated with the increase in sleep

disordered breathing conditions (SBD) like obstructive sleep apnea and obesity hypoventilation

syndrome. These high-risk patients are prone for increased perioperative morbidity and mortality

because of associated comorbid conditions, difficult intubation and postoperative

cardiorespiratory complications. However, a significant number of patients with SDB are not

diagnosed at the time of surgery due to lack of awareness among perioperative team members.

Identification of these high-risk patients and optimizing them preoperatively may improve the

perioperative outcome. Various perioperative organizations have made guidelines on managing

patients with morbid obesity and sleep disordered breathing. Every hospital should have a

written policy on preoperative assessment, intraoperative and postoperative management of

obese patients with sleep disordered breathing.


Obesity is a chronic, multisystem, proinflammatory disorder. Obesity is defined as a body mass

index (BMI) >30 kg/m2; morbid obesity is defined as a BMI >35 kg/m2; super morbid obesity

BMI >50 kg/m2 and ultra-obesity BMI >70 kg/m2. The recent increase in obesity in various parts

of the world has been termed ‘globesity’. The prevalence of obesity among adults in the United

States is 34.9 % and the prevalence of morbid obesity is 6.3 %.1

Obesity is an important risk factor for sleep disordered breathing (SBD) conditions like

obstructive sleep apnea (OSA) and obesity hypoventilation syndrome (OHS). SBD is associated

with various comorbidities such as myocardial ischemia, heart failure, hypertension, arrhythmias,

metabolic syndrome, insulin resistance, cerebrovascular disease, and gastroesophageal reflux.

Patients with OSA and OHS are prone to perioperative complications posing challenges for the

perioperative management. A significant number of patients with OSA and OHS are

undiagnosed when they present for elective surgery.2 To improve the perioperative outcomes,

various guidelines have been published for these high-risk patients.3,4,5,6,7 However, a recent

nationwide survey in the United States on attitudes regarding perioperative care showed that only

27% of the hospitals have written policies for the perioperative care of patients with OSA.8 The

purpose of this review is to provide an update of evidence on the perioperative management of

morbid obesity, OSA and OHS.

Obstructive sleep apnea

Obstructive sleep apnea is the most common type of sleep disordered breathing. OSA is

a disease characterized by recurrent episodic cessation of breathing lasting ≥ 10 sec during sleep.

The severity of OSA is identified by the apnea hypopnea index (AHI), defined as the number of

abnormal breathing events per hour of sleep. Apnea is a reduction of airflow of ≥ 90% of

baseline for ≥ 10 sec, while hypopnea is considered a decrease in airflow by ≥ 30% baseline for

≥ 10 sec in association with either ≥ 3% oxygen desaturation from pre-event baseline and/or the

event is associated with an arousal.9 The American Academy of Sleep Medicine (AASM) criteria

for diagnosing OSA requires either an AHI ≥15, or AHI ≥5 events/hr with symptoms such as

daytime sleepiness, loud snoring, or observed obstruction during sleep.10 The severity of OSA is

graded as mild, moderate and severe with AHI ≥ 5 to < 15, AHI ≥ 15 to ≤ 30, and AHI > 30

events/hr respectively. 10

In general, sleep reduces the upper airway muscle tone leading to an enhanced

collapsibility, which is more pronounced during REM sleep. This normal physiological alteration

is exaggerated in OSA patients. OSA may be due to excess soft tissue of the upper airway with a

normal skeletal frame (obesity) or normal soft tissue of the upper airway with a restricted

skeletal frame (craniofacial abnormality). The prevalence of OSA in the general population aged

30 to 70 years is 5% in women and 14% in men,11 and is 78% in morbidly obese patients

undergoing bariatric surgery.12 The incidence of OSA increases with age and males have a three-

fold increased risk for OSA. Craniofacial abnormalities including short mandibular size or

abnormal maxilla, a wide craniofacial base, and adenoid or tonsillar hypertrophy increases the

risk of OSA.13 Smokers have a three–fold greater risk for OSA than non-smokers. The incidence

of OSA during pregnancy in the first and third trimesters is 10.5 and 26.7 percent, respectively.14

Other medical conditions associated with OSA include congestive heart failure, acromegaly,

hypothyroidism, chronic obstructive pulmonary disease (COPD), and end stage renal disease.

One of the contributing factors for OSA with heart and renal failure is due to nocturnal rostral

fluid shift. During sleep in the supine position, gravity moves fluid from the legs rostrally and

increases fluid volume in the neck, increasing tissue pressure and collapsibility of the pharynx.15

Interaction of obesity and sleep disordered breathing

Obesity is a major risk factor for SDB. An increase of 10% weight gain in patients with

mild OSA can increase the severity of OSA by six fold. A 10% weight loss can result in a more

than 20% improvement in OSA. Obesity causes pharyngeal airway narrowing by the

enlargement of soft tissue structures within and surrounding the airway. Obesity also contributes

to significant reduction of lung volumes by a combination of increased abdominal fat mass and

supine position. The reduction of lung volume decreases longitudinal tracheal traction forces and

pharyngeal wall tension, which causes narrowing of the airway. Hence, males with central or

android obesity (apple shape) are more prone to have OSA than the gynecoid obesity (pear

shape). Though OSA is not a component of metabolic syndrome (central obesity, hypertension,

hyperlipidemia and insulin resistance), there are experimental and clinical evidence to show a

relationship between OSA and increased cardiometabolic risk.16

Obesity hypoventilation syndrome

OHS is a combination of obesity with body mass index (BMI) > 30 kg/m2, daytime

hypercapnia with PaCO2 > 45 mmHg during wakefulness and absence of other alternative neuro-

muscular, mechanical, or metabolic explanation for hypoventilation. Although 90% of OHS

patients have OSA, 10% do not. The prevalence of OHS is 0.15–0.6% of the general population

and increases up to 50% with increase in BMI > 50 kg/m2.17 The prevalence of OHS in obese

patients referred to sleep clinics is 9 to 20%17 and as high as 51% in obese patients with chronic

hypoxemia.18 In contrast with OSA, a recent study in the Saudi population showed a higher

prevalence of OHS in women (15.4%) versus men (4.5%) who were referred to sleep clinic.19

Compared to OSA patients, OHS patients have a restrictive respiratory pattern with increased

work of breathing. As well, OHS patients have a blunted respiratory drive, in contrast with

increased minute ventilation in obese patients with OSA. The increased level of leptin from

adipose tissue in obesity is a respiratory stimulant, which helps to maintain eucapnia by

increasing the minute ventilation in obese patients with OSA. But, there is a leptin resistance in

OHS patents, which predispose them to hypoventilation. Most OHS patients are diagnosed after

hypercapnic respiratory failure versus obese patients without hypercapnia, and they are more

likely to have cardiorespiratory complications.20 Currently there is no criteria to grade the

severity of OHS like OSA. A recent study has shown that the severity of the OHS can be

determined by the PaCO2 level in the blood gas.21 The Malignant Obesity Hypoventilation

Syndrome is a new terminology, a triad defined as a patient with a BMI > 40 kg/m2 with daytime

hypercapnia, the metabolic syndrome and multi-organ dysfunction related to obesity.22

The overlap syndrome is a co-existence of OSA and COPD, a hypercapnic SDB. The

incidence of daytime hypercapnia, respiratory failure and pulmonary hypertension is higher in

the overlap syndrome patients than in isolated OSA or COPD. These patients present with

hypoxemia and hypercapnic respiratory failure and are more difficult to treat than OHS.

Perioperative risk of Obesity, OSA and OHS

In the American College of Surgeons National Surgical Quality Improvement Program

(ACS-NSQIP) database analysis of 16 major cardiovascular, orthopedic, and oncologic surgical

outcomes, a BMI > 40 kg/m2 significantly increased the odds of venous thromboembolism,

surgical site infection, acute kidney injury and cardiac complication with cardiac surgery.23 It did

not show any increase in cardiopulmonary complications or mortality.23 The morbidly obese

parturient is at increased risk for antenatal comorbidities, failed labor analgesia, longer first stage

of labor and operative delivery.24 The Metabolic Syndrome is a risk factor for post-operative

pulmonary complications, deep venous thrombosis, atrial fibrillation and congestive heart

failure.25 A recent outcome study on the bariatric surgical population showed that pulmonary

complications and metabolic syndrome were significantly associated with increased

postoperative mortality.26

Though morbid obesity increases the perioperative risk, mild to moderately obese

patients without comorbidities have a protective effect (Obesity Paradox) on the postoperative

complications and cardiac morbidity.27,28 OSA has a significant impact on perioperative

outcome.29 A recent review of 24 legal claims for perioperative complications due to OSA

showed that 58% claims favored the plaintiff with an average financial compensation of 2.5

million dollars.30 More than half of the complications were related to anesthesia and the majority

of them resulted in a vegetative state. OSA patients have a 2 times higher risk of pulmonary

complications after non-cardiac surgery.31 In bariatric surgical patients, the presence of OSA was

found to be an independent risk factor for adverse postoperative events. A meta-analysis showed

that the presence of OSA increased the chances of postoperative cardiac events including

myocardial infarction, cardiac arrest and arrhythmias (OR 2.1), respiratory failure (OR 2.4),

desaturation (OR 2.3), intensive care unit (ICU) transfers (OR 2.8), and reintubations (OR 2.1).32

A recent meta-analysis showed that patients with STOP-Bang score 3 or greater are at higher risk

of adverse post-operative events and longer length of stay.33 Ninety percent of patients with OHS

were misdiagnosed and the 3-year mortality was worse than breast and colon cancer patients.34

Studies and meta-analysis suggest that patients with OSA, who have been managed with

preoperative continuous positive airway pressure (CPAP), have fewer perioperative adverse

events, especially cardio-pulmonary complications than those who are untreated.35,36,37,38,39

Though positive airway pressure therapy (PAP) is a “one size fits all” solution for most SDB, the

goal is to relieve upper airway obstruction in OSA and increase the alveolar ventilation (i.e.,

PaCO2 <45 mmHg) in OHS. The two common modes of PAP therapy are CPAP and non-

invasive ventilation (NIV). CPAP works by creating a positive pharyngeal transmural pressure

and increasing the end-expiratory lung volume. The advantage of NIV over CPAP is that it

augments the tidal volume with inspiratory pressure support. CPAP opens the airway obstruction

of OSA and works in most OHS patients with OSA, but it may be inadequate to improve the

alveolar ventilation in some. The most common type of NIV is Bi-level PAP (BPAP). This mode

involves individual titration of inspiratory and expiratory PAP, the difference between these two

settings correlates with the tidal volume. The average volume-assured pressure-support

(AVAPS) ventilation is a newer mode of PAP therapy, which guarantees the delivery of a preset

tidal volume with BPAP mode.

Compared to OSA patients, surgical patients with OHS and overlap syndrome are more likely to

experience prolonged intubation (OR, 3.1), postoperative heart failure (OR, 5.4), postoperative

respiratory failure (OR, 10.9), postoperative ICU transfer (OR, 10.9), and longer hospital stay.20

Untreated OHS patients have higher mortality than treated OHS (23% vs 9%).40 Supplemental

oxygen may be necessary for a group of OHS patients who desaturate even with PAP therapy.

Preoperative assessment

Screening tests are imperative in this high-risk population.41, 42 Recent guidelines by the

Society of Anesthesia and Sleep Medicine recommends routine OSA screening at pre-operative

clinic for obese patients.6 Further preoperative testing should be individualized based on the co-

morbid conditions. Various screening tools like the Berlin questionnaire, STOP-Bang

questionnaire and Epworth Sleepiness Scale are available.43 The STOP-Bang questionnaire has

the highest validity and accuracy in predicting OSA in the perioperative setting.44,45 A STOP-

Bang score of 5 - 8 identifies patients with a high probability of moderate-to-severe OSA46

(Table 1). The addition of serum HCO3- level ≥ 28 mmol/L to a STOP-Bang score ≥ 3 improves

the specificity.47 Patients with a positive STOP-Bang score are more likely to have increased

postoperative complications.33,48

The oxygen desaturation index from a high resolution nocturnal oximeter is a sensitive

and specific screening tool to detect SDB in the surgical patients.49 Patients with mean overnight

SpO2 < 93%, or oxygen desaturation index > 29 events/h were more likely to have postoperative

adverse events.50 These screening tests are not helpful in distinguishing OSA from other sleep

disorders, such as OHS and central sleep apnea.

If OHS is suspected, a blood gas analysis is the definitive test for identifying daytime

hypercapnia in patients with OHS. Since it is an invasive test, other simple markers are an

increase in serum bicarbonate level and low oxygen saturation. Increased serum HCO3- level due

to metabolic compensation for chronic respiratory acidosis is common in OHS and other

hypoventilation conditions. Recent data show an increase in serum bicarbonate without daytime

hypercapnia can predict the early stage OHS among obese patients.51 The three clinical

predictors of OHS are serum HCO3-, AHI, and lowest oxygen saturation during sleep. In

addition, hypoxemia (SaO2 < 90%, corresponding to PaO2 < 60 mm Hg) during wakefulness

should lead clinicians to suspect OHS in patients with OSA. A primary screening care pathway

during the preoperative workup could identify the patients with SBD (Fig 1). Then suspected

OHS patients can have a serum HCO3- as the initial test and polysomnography for the definite

diagnosis. (Fig 2)

A modified STOP-Bang score with additional points for BMI (1 point for BMI ≥ 35–40

kg/m2, 2 points for BMI ≥ 40–45 kg/m2, 3 points for BMI ≥ 45 kg/m2) and HCO3- (1 point for

bicarbonate ≥ 26–28 mmol/L, 2 points for bicarbonate ≥ 28 mmol/L) can increase the sensitivity
for predicting OHS. Since the incidence of pulmonary hypertension is higher in OHS, simple

clinical signs to identify right heart failure such as evaluation for ankle edema and high jugular

venous pressure is important. Though brain natriuretic peptide (BNP) measurement is not

specific for right heart failure, it can be used to assess the level of severity and treatment effect in

chronic hypercapnic respiratory failure.53

Risk stratification

The ASA physical status classification system is the most commonly used risk scoring

system for surgical patients. Though the original scoring did not include obesity as a risk factor,

BMI ≥ 40 kg/m2 is considered as ASA Status III in the recent update.54 The Obesity Surgery

Mortality Risk Score is mainly used for patients undergoing gastric bypass, but it can be used for

non-bariatric surgeries. This includes 5 risk factors: hypertension, BMI ≥ 50 kg/m2, male sex, ≥

45 years, and known risk factors for pulmonary embolism (OHS, previous thromboembolism,

preoperative vena cava filter, pulmonary hypertension).55 This risk score stratifies mortality risk

into low (0 or 1 comorbidity), intermediate (2 to 3 comorbidities) and high (4 to 5 comorbidities)

with mortality of 0.2%, 1.2%, and 2.4% respectively.55 However, obesity is not included in other

commonly used surgical risk scoring systems like POSSUM (Physiological and Operative

Severity Score for the enumeration of Mortality and Morbidity), SORT (Surgical Outcome Risk

Tool) and NSQIP (National Surgical Quality Improvement Program) surgical risk


Suitability for ambulatory surgery

Based on the severity of sleep apnea, the type of anesthesia, invasiveness of surgery and the need

of postoperative opioids, ASA has published guidelines on the perioperative management of

OSA patients.4, The Society for Ambulatory Anesthesia (SAMBA) has endorsed a consensus

statement on the preoperative selection of patients with OSA for ambulatory surgery.5 It

recommends the STOP-Bang questionnaire as a screening tool for OSA. According to SAMBA

guidelines, patients with a diagnosis of OSA with optimized comorbid conditions, compliant

with CPAP, and minimal postoperative opioid requirements can be considered for ambulatory

surgery (Fig. 3). Patients with moderate to severe OSA, who are noncompliant with CPAP may

not be suitable for ambulatory surgery. At the same time, patients with a diagnosis of OSA based

on the screening tool and optimized comorbid conditions may be considered for ambulatory

surgery, if postoperative pain relief can be managed mainly with non-opioid analgesic


Currently there is no evidence on the optimal cut-off BMI for ambulatory surgery. A

systematic review indicated that super-obese patients with BMI >50 kg/m2 are at increased risk

for perioperative complications.59 Since patients with hypercapnic conditions like OHS are at

higher risk for significant perioperative complications and more likely to have significant

comorbid conditions, they may not be suitable for ambulatory surgery.

Perioperative infrastructure

The health care team should have specific training in the issues relating to the care of

morbidly obese patients. Patients should be encouraged to move themselves whenever possible

during the perioperative care. The operating table, bed trolley and specific equipment such as

the spine frame for spine surgery should be checked and labeled for its maximum limit on weight

bearing capacity. For emergency surgeries, an “obesity pack” (including specific equipment, air

assisted patient transfer system, protocol guidelines and contact numbers) should be readily

available. The Society of Obesity and Bariatric Anesthesia (SOBA) has published a

comprehensive one sheet guideline for managing the obese patients. (www.SOBAuk.com) The

Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) has

recently published a consensus guideline on perioperative and periprocedural airway

management and respiratory safety for the obese patient.60 Hospitals without intensive care

facilities are not suitable for managing super morbid obese, OHS patients, and severe OSA

patients noncompliant with CPAP.

Intraoperative management

Obese patients present a different set of challenges and require specific perioperative care

due to the possibility of difficult intubation, difficult mask ventilation, associated comorbidity,

increased sensitivity to opioids, intraoperative and postoperative cardiorespiratory complications.

SOBA has published guidelines on the perioperative care of obese patient.61 Induction of general

anesthesia can precipitate a rapid fall in oxygen saturation, which can be minimized by a 25

degree head-up position during preoxygenation, the combination of preoxygenation with

nasopharyngeal oxygen insufflation, and positive end-expiratory pressure (PEEP) of 10 cm H2O.

Transnasal Humidified Rapid-Insufflation Ventilatory Exchange technique (THRIVE) is a

promising new tool mainly used for apneic oxygenation and it can be used in obese patients for

preventing desaturation with difficult airway management.62 The United Kingdom Fourth

National Audit Project (NAP 4) reported a four fold increase in the risk of serious airway related

complications in the morbidly obese patient.63 The incidence of difficult intubation in obese

patients was twice as frequent in ICU than in the operating room and life-threatening

complications related to airway management occurred 20-fold more often in ICU.64

Positioning patients with TROOP or OXFORD pillow in the head elevated laryngoscopy

position (“HELP”) facilitates direct laryngoscopy. A neck circumference greater than 42 cm and

BMI more than 50  kg /m2 are associated with an increased risk of difficult intubation.65,66 The

second generation double-lumen supraglottic airways, such as the LMA ProSealTM and the

LMA SupremeTM, provide higher leak pressures and may be safer in patients with obesity.67

Securing the airway with an endotracheal tube would be a safer option for morbidly obese

patients with gastric reflux disease or lithotomy position. Video laryngoscopic assisted intubation

has a high success rate in the morbidly obese patients with a difficult airway.68 The use of awake

video laryngoscopy-assisted tracheal intubation using topical local anesthesia of the airway has

also been described as an alternate to flexible bronchoscopic intubation.69 According to the

Difficult Airway Society guidelines,70 obesity and OSA are stratified into a category of ‘‘at risk’’

of a major complication during extubation. Reversal of neuromuscular block with sugammadex

may reduce inadequate reversal of muscle relaxant in morbidly obese patients.71

The morbidly obese patients need protective ventilation with low tidal volumes

(approximately 8 ml/kg) to avoid volutrauma and judicious use of oxygen to avoid absorption

atelectasis.72,73 Recruitment maneuvers (PEEP & Valsalva) can counteract these effects. A recent

meta-analysis shows that a recruitment maneuver added to PEEP compared with PEEP alone

improves intraoperative oxygenation and compliance without adverse effects.74 Since morbidly

obese patients are prone to postoperative hypoxemia due to atelectasis, patients should be

extubated wide-awake in the sitting position if possible. Obese patients with OSA should have

perioperative precautions and risk mitigation to achieve the best possible outcome (Table 2).

Since obese patients are prone for DVT and rhabdomyolysis, careful positioning and precautions

need to be taken with longer surgeries.

Regional anesthesia offers distinct advantages, which allows minimal airway manipulation,

avoidance of anesthetic drugs with cardiopulmonary depression, reduced post-operative nausea

and vomiting and reduced perioperative opioid requirements. However, the rate of block failure

increased parallel with the level of obesity. Ultrasound-guided regional anesthesia for peripheral

nerve blocks can improve the success rate in the obese population. Epidural analgesia can be

utilized in obese patients undergoing laparotomy to improve postoperative respiratory function.75

Ultrasound guided neuraxial anesthesia is a viable option to increase the success in obese

patients. 76 A recent study on more than 40,000 patients with OSA who underwent hip and knee

arthroplasty, the use of neuraxial anesthesia vs. general anesthesia was associated with a

reduction in need for mechanical ventilation, use of ICU, prolonged length of stay and cost.77

Postoperative management

The morbidly obese patients with SDB who received general anesthesia should be

observed for an additional 30-60 minutes in PACU after the modified Aldrete criteria for
discharge has been met. (Fig. 4) The PACU team should be advised to look for recurrent

respiratory events (episodes of apnea ≥ 10 seconds, bradypnea <8 breaths/min, pain-sedation

mismatch, or repeated O2 desaturation <90%).79 Any of the above events occurring repeatedly in

separate 30-minute intervals should prompt the perioperative team for arranging a monitored bed

or ICU care. Patients with suspected OSA and who develop recurrent PACU respiratory events

are at increased risk of postoperative respiratory complications.79 These patients may require

postoperative PAP therapy with postoperative monitoring.80

A recent trial has shown that postoperative oxygen therapy can improve the oxygenation

and AHI in untreated OSA patients.81 However, 11.5% of these patients showed evidence of

respiratory depression with elevated CO2. High concentrations of oxygen or providing oxygen

alone without PAP to OHS patients should be avoided as this may worsen hypercapnia.

Monitoring with continuous oximetry and/or capnography is recommended with parenteral

opioids due to possible drug induced respiratory depression.82

Continuing PAP therapy in the postoperative period in the bariatric surgery patients may

mitigate the risk of postoperative complications.83 An opioid-sparing multimodal analgesic

package, including local anesthetic-infused nerve block catheters, wound catheters and non-

opioid adjuncts (acetaminophen, nonsteroidal anti-inflammatory drugs), should be considered. If

postoperative parenteral opioids are necessary, consideration should be made for the use of

patient controlled analgesia with no background infusion and a strict hourly dose limit. Though

patients with OSA are suitable for ambulatory surgery based on their level of optimization of

comorbid conditions, patients with OHS or overlap syndrome who had general anesthetic and

require postoperative opioids may not be suitable. There should be a team agreement in place

regarding the post-operative pain prescription. Avoiding or minimizing opioid prescription for

ambulatory surgery patients will prevent the worsening of obstructive episodes during the post-

operative period.


Morbidly obese patients with sleep disordered breathing are at risk of perioperative

morbidity. Identifying these high-risk patients and optimizing them with PAP therapy could

reduce the risk significantly. The availability of care pathways is important to improve the

outcomes of morbidly obese patients with or without SDB. Every perioperative team should have

a written policy for managing these high-risk patients.

Table 1
STOP-Bang Questionnaire

Do you Snore Loudly (loud enough to be heard through closed doors or your bed-
Yes No partner
elbows you for snoring at night)?
Yes No Do you often feel Tired, Fatigued, or Sleepy during the daytime (such as falling asleep
during driving)?
Yes No Observed?
Has anyone Observed you Stop Breathing or Choking/Gasping during your sleep?
Yes No Pressure?
Do you have or are being treated for High Blood Pressure?
Yes No
Body Mass Index more than 35 kg/m2?
Yes No
Age older than 50 year old?
Neck size large? (Measured around Adams apple)
Yes No For male, is your shirt collar 17 inches or larger?
For female, is your shirt collar 16 inches or larger?
Yes No
Gender = Male?
Scoring Criteria:
For general population
Low risk of OSA: Yes to 0-2 questions
Intermediate risk of OSA: Yes to 3-4 questions
High risk of OSA: Yes to 5-8 questions
Yes to 2 of 4 STOP questions + individual’s gender is male
Yes to 2 of 4 STOP questions + BMI > 35 kg/m2
Yes to 2 of 4 STOP questions + neck circumference male 17”
Female 16”

Proprietary to University Health Network

Table 2
Perioperative Precautions and Risk Mitigation for Patients with Sleep Disordered
Anesthetic Concern Principles of Management

Screening  OSA screening recommended to be a part of standard pre-
SASM Guidelines6 anesthetic evaluation
 Additional evaluation for hypoventilation syndrome,
severe pulmonary hypertension, and resting
hypoxemia in the absence of other cardiopulmonary
 Continue PAP therapy, advise patients to bring PAP
equipment to the surgical facility

Ambulatory surgery criteria  OSA patients with optimized co-morbid conditions

SAMBA Guideline5  Patient using PAP therapy
 Postoperative pain mainly managed mainly with non-
opioid analgesia
Airway management  HELP positioning (Head Elevated Laryngoscopy
(difficult mask ventilation Position)
and tracheal intubation)  Pre-oxygenation with 25-degree head-up position &

Nasal oxygen insufflation or THRIVE technique62
 Anticipated difficult airway – Difficult airway equipment
 Rapid sequence induction with cricoid pressure for
patients with GERD

Ventilation  Recruitment maneuver + PEEP to avoid atelectasis

 Protective ventilation - low TV & plateau pressure
 Second generation supraglottic device for better seal
Opioid-related respiratory  Minimize opioid use
depression  Use of short-acting agents (e.g. remifentanil)
 Multimodal approach to analgesia (NSAIDs,
acetaminophen, tramadol, ketamine, gabapentin,
pregabalin, dexmedetomidine, clonidine, dexamethasone)
 Consider local and regional anesthesia where appropriate

Extubation  Extubate wide-awake in the sitting position if possible

 Consider Sugammadex to prevent inadequate reversal

Monitored anesthetic care  Avoid deep sedation with unsecured airway

 Intraoperative capnography for monitoring of ventilation

Postoperative  Resume PAP therapy to avoid postoperative atelectasis
 Monitored bed for OSA patients with recurrent respiratory
events, OHS and overlap syndrome patient
 Avoid long acting opioid prescription for ambulatory
surgical patient

SASM: Society of Anesthesia and Sleep Medicine, PAP therapy: positive airway pressure
therapy, SAMBA: Society for Ambulatory Anesthesia, CPAP: continous positive airway
pressure. THRIVE: Transnasal Humidified Rapid-Insufflation Ventilatory Exchange. GERD:
gastroesophageal reflux disease, PEEP: Positive end-expiratory pressure, TV: Tidal Volume,
NSAIDs: Non-steroidal anti-inflammatory drugs, OSA: Obstructive sleep apnea, OHS: Obesity
hypoventilation syndrome.

Raveendran R. Curr Opin Anaesthesiol. 2017;30:146-155.

Figure 1: Screening algorithm for identifying patients with SBD

Subramani Y, et al. Sleep Med Clin. 2017;12:123-135.

Figure: 2 Perioperative management of the patient suspected to have OHS.

Chau EH, et al. Anesthesiology 2012; 117:188-205

Figure 3: Decision making in preoperative selection of a patient with obstructive sleep apnea for
ambulatory surgery

Adapted from SAMBA guideline Anesth Analg 2012; 115: 1060-8

Figure 4 - Postoperative Management of the Diagnosed or Suspected OSA Patient after General

Hillman DR et al. Respirology 2017; 22: 230–239


1. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in
the United States, 2011-2012. JAMA. 2014;311:806-814.
2. Singh M, Liao P, Kobah S, Wijeysundera DN, Shapiro C, Chung F. Proportion of surgical
patients with undiagnosed obstructive sleep apnoea. Br J Anaesth. 2013;110:629-636.
3. Gross JB, Bachenberg KL, Benumof JL, Diego S, et al. Practice Guidelines for the
Perioperative Management of Patients with Obstructive Sleep Apnea. Anesthesiology.
4. Gross JB, Apfelbaum JL, Caplan RA, et al. Practice guidelines for the perioperative
management of patients with obstructive sleep apnea: an updated report by the American
Society of Anesthesiologists Task Force on Perioperative Management of patients with
obstructive sleep apnea.. Anesthesiology. 2014;120:268-286.
5. Joshi GP, Ankichetty SP, Gan TJ, Chung F. Society for ambulatory anesthesia consensus
statement on preoperative selection of adult patients with obstructive sleep apnea
scheduled for ambulatory surgery. Anesth Analg. 2012;115:1060-1068.
6. Chung F, Memtsoudis SG, Ramachandran SK, et al. Society of Anesthesia and Sleep
Medicine Guidelines on Preoperative Screening and Assessment of Adult Patients with
Obstructive Sleep Apnea. Anesth Analg. 2016;123:452-473.
7. de Raaff CAL, Gorter-Stam MAW, de Vries N, et al. Perioperative management of
obstructive sleep apnea in bariatric surgery: A consensus guideline. Surg Obes Relat Dis.
8. Auckley D, Cox R, Bolden N, Thornton JD. Attitudes regarding perioperative care of
patients with OSA: a survey study of four specialties in the United States. Sleep Breath.
9. Berry RB, Budhiraja R, Gottlieb DJ, et al. Rules for scoring respiratory events in sleep:
Update of the 2007 AASM manual for the scoring of sleep and associated events. J Clin
Sleep Med. 2012;8:597-619.
10. Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical Practice Guideline for Diagnostic
Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine
Clinical Practice Guideline. J Clin Sleep Med J Clin Sleep Med J Clin Sleep Med.
11. Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased prevalence of
sleep-disordered breathing in adults. Am J Epidemiol. 2013;177:1006-1014.
12. Lopez PP, Stefan B, Schulman CI, Byers PM. Prevalence of sleep apnea in morbidly
obese patients who presented for weight loss surgery evaluation: More evidence for
routine screening for obstructive sleep apnea before weight loss surgery. Am Surg.

13. Young T, Skatrud J, Peppard PE. Risk factors for obstructive sleep apnea in adults.
JAMA. 2004;291:2013-2016.
14. Pien GW, Pack AI, Jackson N, Maislin G, Macones G a, Schwab RJ. Risk factors for
sleep-disordered breathing in pregnancy. Thorax. 2014;69:371-377.
15. White LH, Bradley TD. Role of nocturnal rostral fluid shift in the pathogenesis of
obstructive and central sleep apnoea. J Physiol. 2013;591:1179-1193.
16. Drager LF, Togeiro SM, Polotsky VY, Lorenzi-Filho G. Obstructive sleep apnea: A
cardiometabolic risk in obesity and the metabolic syndrome. J Am Coll Cardiol.
17. Balachandran JS, Masa JF, Mokhlesi B. Obesity hypoventilation syndrome: Epidemiology
and diagnosis. Sleep Med Clin. 2014;9:341-347.
18. Povitz M, James MT, Pendharkar SR, Raneri J, Hanly PJ, Tsai WH. Prevalence of Sleep-
disordered Breathing in Obese Patients with Chronic Hypoxemia. A Cross-Sectional
Study. Ann Am Thorac Soc. 2015;12:921-927.
19. Bahammam AS. Prevalence, clinical characteristics, and predictors of obesity
hypoventilation syndrome in a large sample of Saudi patients with obstructive sleep
apnea. Saudi Med J. 2015;36:181-189.
20. Kaw R, Bhateja P, Paz Y Mar H, et al. Postoperative Complications in Patients with
Unrecognized Obesity Hypoventilation Syndrome Undergoing Elective Non-cardiac
Surgery. Chest. 2015;149:84-91
21. Damiani MF, Falcone VA, Carratù P, et al. Using PaCO2 values to grade obesity-
hypoventilation syndrome severity: a retrospective study. Multidiscip Respir
Med. 2017 May 18;12:14. doi: 10.1186/s40248-017-0093-4
22. Marik PE, Varon J. The Malignant Obesity Hypoventilation Syndrome ( MOHS ). Obes
Rev. 2012 ;13:902-9.
23. Sood A, Abdollah F, Sammon JD, et al. The Effect of Body Mass Index on Perioperative
Outcomes after Major Surgery: Results from the National Surgical Quality Improvement
Program (ACS-NSQIP) 2005-2011. World J Surg. 2015;39:2376-2385.
24. Tonidandel A, Booth J, Angelo RD, Harris L, Tonidandel S. Anesthetic and obstetric
outcomes in morbidly obese parturients : a 20-year follow-up retrospective cohort study.
Int J Obstet Anesth. 2014;23:357-364.
25. Tung a. Anaesthetic considerations with the metabolic syndrome. Br J Anaesth. 2010;105
26. Schumann R, Shikora SA, Sigl JC, Kelley SD. Association of metabolic syndrome and
surgical factors with pulmonary adverse events , and longitudinal mortality in bariatric
surgery. Br J Anaesth. 2015;114:83-90.
27. Nafiu OO, Shanks AM, Hayanga AJ, Tremper KK, Campbell D a. The impact of high
body mass index on postoperative complications and resource utilization in minority

patients. J Natl Med Assoc. 2011;103:9-15.
28. Geiger TM, Muldoon R. Complications following colon rectal surgery in the obese
patient. Clin Colon Rectal Surg. 2011;24:274-282.
29. Opperer M, Cozowicz C, Bugada D, et al. Does Obstructive Sleep Apnea Influence
Perioperative Outcome? A Qualitative Systematic Review for the Society of Anesthesia
and Sleep Medicine Task Force on Preoperative Preparation of Patients with Sleep-
Disordered Breathing. Anesth Analg. 2016;122:1321-1334.
30. Fouladpour N, Jesudoss R, Bolden N, Shaman Z, Auckley D. Perioperative Complications
in Obstructive Sleep Apnea Patients Undergoing Surgery: A Review of the Legal
Literature . Anesth Analg . 2016;122:145-151.
31. Memtsoudis S, Liu SS, Ma Y, et al. Perioperative pulmonary outcomes in patients with
sleep apnea after noncardiac surgery. Anesth Analg. 2011;112:113-121.
32. Kaw R, Chung F, Pasupuleti V, Mehta J, Gay PC, Hernandez A V. Meta-analysis of the
association between obstructive sleep apnoea and postoperative outcome. Br J Anaesth.
33. Nagappa M, Patra J, Wong J, et al. Association of STOP-Bang Questionnaire as
a Screening Tool for Sleep Apnea and PostoperativeComplications:A Systematic Review
and Bayesian Meta-analysis of Prospective and Retrospective Cohort Studies. Anesth
Analg. 2017;125:1301-1308.
34. Marik PE, Chen C. The clinical characteristics and hospital and post-hospital survival of
patients with the obesity hypoventilation syndrome: analysis of a large cohort. Obes Sci
Pract. 2016:2:40-47.
35. Liao P, Yegneswaran B, Vairavanathan S, Zilberman P, Chung F. Postoperative
complications in patients with obstructive sleep apnea: a retrospective matched cohort
study. Can J Anaesth. 2009;56:819-828.
36. Chung F, Nagappa M, Singh M, Mokhlesi B. CPAP in the perioperative setting: Evidence
of support. Chest. 2016;149:586-597.
37. Nagappa M, Mokhlesi B, Wong J, Wong DT, Kaw R, Chung F. The effects of continuous
positive airway pressure on postoperative outcomes in obstructive sleep apnea patients
undergoing surgery: A systematic review and meta-analysis. In: Anesthesia and
Analgesia. 2015;120:1013-1023.
38. Abdelsattar ZM, Hendren S, Wong SL, Campbell D a, Ramachandran SK. The Impact of
Untreated Obstructive Sleep Apnea on Cardiopulmonary Complications in General and
Vascular Surgery: A Cohort Study. Sleep. 2015;38:1205-1210.
39. Mutter TC, Chateau D, Moffatt M, Ramsey C, Roos LL, Kryger M. A matched cohort
study of postoperative outcomes in obstructive sleep apnea: could preoperative diagnosis
and treatment prevent complications? Anesthesiology. 2014;121:707-718.
40. Nowbar S, Burkart KM, Gonzales R, et al. Obesity-Associated hypoventilation in
hospitalized patients: Prevalence, effects, and outcome. Am J Med. 2004;116:1-7.

41. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS Guideline for the
Management of Overweight and Obesity in Adults. J Am Coll Cardiol. 2014;63:2985-
42. Subramani Y, Wong J, Nagappa M, Chung F. The Benefits of Perioperative Screening for
Sleep Apnea in Surgical Patients. Sleep Med Clin. 2017;12:123-135.
43. Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for
obstructive sleep apnea. Anesthesiology. 2008;108:812-821.
44. Ramachandran SK, Josephs LA. A meta-analysis of clinical screening tests for obstructive
sleep apnea. Anesthesiology. 2009;110:928-939.
45. Chung F, Abdullah HR, Liao P. STOP-Bang Questionnaire: A practical approach to
screen for obstructive sleep apnea. Chest. 2016; 149:631-8
46. Chung F, Subramanyam R, Liao P, Sasaki E, Shapiro C, Sun Y. High STOP-Bang score
indicates a high probability of obstructive sleep apnoea. Br J Anaesth. 2012;108:768-775.
47. Chung F, Chau E, Yang Y, Liao P, Hall R, Mokhlesi B. Serum bicarbonate level improves
specificity of STOP-bang screening for obstructive sleep apnea. Chest. 2013;143:1284-
48. Vasu TS, Doghramji K, Cavallazzi R, et al. Obstructive sleep apnea syndrome and
postoperative complications: clinical use of the STOP-BANG questionnaire. Arch
Otolaryngol Head Neck Surg. 2010;136:1020-1024.
49. Chung F, Liao P, Elsaid H, Islam S, Shapiro CM, Sun Y. Oxygen desaturation index from
nocturnal oximetry: A sensitive and specific tool to detect sleep-disordered breathing in
surgical patients. Anesth Analg. 2012;114:993-1000.
50. Chung F, Zhou L, Liao P. Parameters from Preoperative Overnight Oximetry Predict
Postoperative Adverse Events. Minerva Anestesiol. 2014;80:1084-95
51. Manuel ARG, Hart N, Stradling JR. Is a raised bicarbonate, without hypercapnia, part of
the physiologic spectrum of obesity-related hypoventilation? Chest. 2015;147:362-368.
52. Bingol Z, Pihtili A, Kiyan E. Modified STOP-BANG questionnaire to predict obesity
hypoventilation syndrome in obese subjects with obstructive sleep apnea. Sleep Breath.
53. Budweiser S, Luchner A, Jörres RA, et al. NT-proBNP in chronic hypercapnic respiratory
failure: A marker of disease severity, treatment effect and prognosis. Respir Med.
54. American Society of Anesthesiologists. American Society of Anesthesiologists: ASA
Physical Status Classification System. American Society of Anesthesiologists Web site.
Internet. 2014.
55. DeMaria EJ, Murr M, Byrne TK, et al. Validation of the obesity surgery mortality risk
score in a multicenter study proves it stratifies mortality risk in patients undergoing gastric
bypass for morbid obesity. Ann Surg. 2007;246:578-82.

56. Prytherch DR, Whiteley MS, Higgins B, Weaver PC, Prout WG, Powell SJ. POSSUM and
Portsmouth POSSUM for predicting mortality. Br J Surg. 1998;85:1217-1220.
57. Protopapa KL, Simpson JC, Smith NCE, Moonesinghe SR. Development and validation
of the Surgical Outcome Risk Tool (SORT). Br J Surg. 2014;101:1774-1783.
58. Bilimoria KY, Liu Y, Paruch JL, et al. Development and evaluation of the universal ACS
NSQIP surgical risk calculator: A decision aid and informed consent tool for patients and
surgeons. J Am Coll Surg. 2013;217:833-42.
59. Joshi GP, Ahmad S, Riad W, Eckert S, Chung F. Selection of obese patients undergoing
ambulatory surgery: a systematic review of the literature. Anesth Analg. 2013;117:1082-
60. Petrini F, Di Giacinto I, Cataldo R, et al. Perioperative and periprocedural airway
management and respiratory safety for the obese patient: 2016 SIAARTI Consensus.
Minerva Anestesiol. 2016;82:1314-1335.
61. Nightingale CE, Margarson MP, Shearer E, et al. Peri-operative management of the obese
surgical patient 2015. Anaesthesia. 2015;70:859-876.
62. Patel A, Nouraei SAR. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange
(THRIVE): A physiological method of increasing apnoea time in patients with difficult
airways. Anaesthesia. 2015;70:323-329.
63. Cook TM, Woodall N, Frerk C; Fourth National Audit Project. Major complications of
airway management in the UK: results of the Fourth National Audit Project of the Royal
College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J
Anaesth 2011;106:617-631.
64. De Jong A, Molinari N, Pouzeratte Y, et al. Difficult intubation in obese patients:
Incidence, risk factors, and complications in the operating theatre and in intensive care
units. Br J Anaesth. 2015;114:297-306.
65. Gonzalez H, Minville V, Delanoue K, Mazerolles M, Concina D, Fourcade O. The
importance of increased neck circumference to intubation difficulties in obese patients.
Anesth Analg. 2008;106:1132-1136.
66. Riad W, Vaez MN, Raveendran R, et al. Neck circumference as a predictor of difficult
intubation and difficult mask ventilation in morbidly obese patients. Eur J Anaesthesiol.
67. Wong DT, Yang JJ, Jagannathan N. Brief review: The LMA SupremeTM supraglottic
airway. Can J Anaesth. 2012;59:483-493.
68. Maassen R, Lee R, Hermans B, Marcus M, Van Zundert A. A comparison of three
videolaryngoscopes: The macintosh laryngoscope blade reduces, but does not replace,
routine stylet use for intubation in morbidly obese patients. Anesth Analg. 2009;109:1560-
69. Moore AR, Schricker T, Court O. Awake videolaryngoscopy-assisted tracheal intubation
of the morbidly obese. Anaesthesia. 2012;67:232-235.

70. Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult Airway Society
Guidelines for the management of tracheal extubation. Anaesthesia. 2012;67:318-340.
71. Carron M, Veronese S, Foletto M, Ori C. Sugammadex allows fast-track bariatric surgery.
Obes Surg. 2013;23:1558-1563.
72. Fernandez-Bustamante A, Hashimoto S, Serpa Neto A, Moine P, Vidal Melo MF, Repine
JE. Perioperative lung protective ventilation in obese patients. BMC Anesthesiol.
73. Shah U, Wong J, Wong DT, Chung F. Preoxygenation and intraoperative ventilation
strategies in obese patients. Curr Opin Anaesthesiol. 2016;29:109-18.
74. Aldenkortt M, Lysakowski C, Elia N, Brochard L, Tramèr MR. Ventilation strategies in
obese patients undergoing surgery: A quantitative systematic review and meta-analysis. Br
J Anaesth. 2012;109:493-502.
75. von Ungern-Sternberg BS, Regli A, Reber A, Schneider MC. Effect of obesity and
thoracic epidural analgesia on perioperative spirometry. Br J Anaesth. 2005;94:121-127.
76. Shaylor R, Saifi F, Davidson E, Weiniger CF. High success rates using ultrasound for
neuraxial block in obese patients. Isr Med Assoc J. 2016;18:36-39.
77. Memtsoudis SG, Stundner O, Rasul R, et al. Sleep apnea and total joint arthroplasty under
various types of anesthesia: a population-based study of perioperative outcomes. Reg
Anesth Pain Med. 2013;38:274-281.
78. Hillman DR, Chung F. Anaesthetic management of sleep-disordered breathing in adults.
Respirology. 2017;22:230-239.
79. Gali B, Whalen FX, Schroeder DR, Gay PC, Plevak DJ. Identification of patients at risk
for postoperative respiratory complications using a preoperative obstructive sleep apnea
screening tool and postanesthesia care assessment. Anesthesiology. 2009;110:869-877.
80. Sundar E, Chang J, Smetana GW. Perioperative screening for and management of patients
with obstructive sleep apnea. J Clin Outcomes Manag. 2011;18:399-411.
81. Liao P, Wong J, Singh M, et al. Postoperative Oxygen Therapy in Patients With OSA.
Chest. 2017;151:597-611.
82. Weinger MB, Lee LA. No Patient Shall Be Harmed By Opioid-Induced Respiratory
Depression. APSF Newsl. 2011;26:21,26-28.
83. Weingarten TN, Flores AS, McKenzie JA, et al. Obstructive sleep apnoea and
perioperative complications in bariatric patients. Br J Anaesth. 2011;106:131-9.