Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea

Click on the links below to access all the ArticlePlus for this article.Please note that ArticlePlus files may launch a viewer application outside of your web browser.PRACTICE guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints. Practice guidelines are not intended as standards or absolute requirements. The use of practice guidelines cannot guarantee any specific outcome. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by analysis of the current literature and by a synthesis of expert opinion, open forum commentary, and clinical feasibility data.Obstructive sleep apnea (OSA) is a syndrome characterized by periodic, partial, or complete obstruction of the upper airway during sleep. This, in turn, causes repetitive arousal from sleep to restore airway patency, which may result in daytime hypersomnolence or other daytime manifestations of disrupted sleep such as aggressive or distractible behavior in children. The airway obstruction may also cause episodic sleep-associated oxygen desaturation, episodic hypercarbia, and cardiovascular dysfunction. It is estimated that the adult prevalence of sleep disordered breathing, as measured in a sleep laboratory, is 9% in women and 24% in men, whereas the prevalence of overt OSA has been estimated to be 2% in women and 4% in men.1These figures are likely to increase as the population becomes older and more obese. In the perioperative period, both pediatric and adult patients with OSA, even if asymptomatic, present special challenges that must be systematically addressed to minimize the risk of perioperative morbidity or mortality. It is the opinion of the Task Force that the perioperative risk to patients increases in proportion to the severity of sleep apnea.Because procedures differ among laboratories, it is not possible to use specific values of indices (such as the apnea-hypopnea index [AHI]) to define the severity of sleep apnea. Therefore, for the purposes of these Guidelines, patients will be stratified using the terms mild , moderate , and severe as defined by the laboratory where the sleep study was performed.The purpose of these Guidelines is to improve the perioperative care and reduce the risk of adverse outcomes in patients with OSA who receive sedation, analgesia, or anesthesia for diagnostic or therapeutic procedures under the care of an anesthesiologist. The Task Force recognizes that it is not possible to determine with 100% accuracy whether a given patient will develop perioperative complications related to OSA. Therefore, these Guidelines should be implemented with the goal of reducing the likelihood of adverse outcomes in patients who are judged to be at the greatest risk, with the understanding that it may be impractical to eliminate OSA-related perioperative morbidity and mortality completely. However, it is hoped that the implementation of these Guidelines will reduce the likelihood of adverse perioperative outcomes in patients with OSA.These Guidelines focus on the perioperative management of patients with OSA who may be at increased risk for perioperative morbidity and mortality because of potential difficulty in maintaining a patent airway. This population includes but is not limited to patients who have sleep apnea resulting from obesity, pregnancy, and other skeletal, cartilaginous, or soft tissue abnormalities causing upper airway obstruction. Excluded from the focus of these Guidelines are patients with the following: (1) pure central sleep apnea, (2) abnormalities of the upper or lower airway not associated with sleep apnea (e.g. , deviated nasal septum), (3) daytime hypersomnolence from other causes, (4) patients younger than 1 yr, and (5) obesity in the absence of sleep apnea.These Guidelines apply to both inpatient and outpatient settings, and to procedures performed in an operating room, as well as in other locations where sedation or anesthesia is administered. They are directly applicable to care administered by anesthesiologists and individuals who deliver care under the medical direction or supervision of an anesthesiologist. They are also intended to serve as a resource for other physicians and patient care personnel who are involved in the care of these patients. In addition, these Guidelines may serve as a resource to provide an environment for safe patient care.The American Society of Anesthesiologists appointed a Task Force of 12 members to (1) review the published evidence, (2) obtain the opinion of a panel of consultants including anesthesiologists and nonanesthesiologist physicians and researchers who regularly care for patients with OSA, and (3) build consensus within the community of practitioners likely to be affected by the Guidelines. The Task Force included anesthesiologists in both private and academic practices from various geographic areas of the United States, a bariatric surgeon, an otolaryngologist, and two methodologists from the American Society of Anesthesiologists Committee on Practice Parameters.The Task Force developed the Guidelines by means of a six-step process. First, they reached consensus on the criteria for evidence of effective perioperative management of patients with OSA. Second, original published research studies from peer-reviewed journals relevant to the perioperative management of patients with OSA were evaluated. Third, the panel of expert consultants was asked to (1) participate in opinion surveys on the effectiveness of various perioperative management strategies for patients with OSA and (2) review and comment on a draft of the Guidelines developed by the Task Force. Fourth, the Task Force held open forums at two major national meetings to solicit input on its draft recommendations. National organizations representing most of the specialties whose members typically care for patients with OSA were invited to participate in the open forums. Fifth, the consultants were surveyed to assess their opinions on the feasibility and financial implications of implementing the Guidelines. Sixth, all available information was used to build consensus within the Task Force to finalize the Guidelines.Tables 1 and 2are meant to serve as examples of how patients with OSA might be identified and stratified with respect to their perioperative risk. While they were developed by the Task Force with input from the consultants and open forum participants, these tables are not evidence based and have not been clinically validated.Preparation of these Guidelines followed a rigorous methodologic process (appendix). To convey the findings in a concise fashion, these Guidelines use several descriptive terms that are easier to understand than the technical terms used in the actual analyses.When sufficient numbers of studies are available for evaluation, the following terms describe the strength of the findings.The lack of scientific evidence in the literature is described by the following terms.The following terms describe survey responses from the consultants for any specified issue. Responses were solicited on a five-point scale; ranging from 1 (strongly disagree) to 5 (strongly agree), with a score of 3 being equivocal.Preoperative evaluation of a patient for potential identification of OSA includes (1) medical record review, (2) patient or family interview, (3) physical examination, (4) sleep studies, and (5) preoperative x-rays for cephalometric measurement in selected cases. Although the comparative literature is insufficient to evaluate the impact of preprocedure identification of OSA status, it suggests that OSA is associated with airway characteristics that may predispose patients to difficulties in perioperative airway management.*The literature identified certain patient characteristics that are associated with OSA. These characteristics include such features as a higher body mass index, hypertension, and abnormal cephalometric measurements. Additional literature, although insufficient for statistical analysis, suggests that an association may exist between OSA and a larger neck circumference, a history of snoring or respiratory pauses, lower oxygen saturation values during sleep, clinical signs of difficult airway management, and certain congenital conditions (e.g. , Down syndrome, craniofacial abnormality, muscular dystrophy) or disease states (e.g. , diabetes mellitus, cerebral palsy).The consultants agree that, in the absence of a sleep study, a presumptive diagnosis of OSA may be made based on consideration of the following criteria: increased body mass index, a weight or body mass index greater than 95th percentile for age (pediatric patients), increased neck circumference, snoring, congenital airway abnormalities, daytime hypersomnolence, inability to visualize the soft palate, and tonsillar hypertrophy. They strongly agree that observed apnea during sleep is an additional criterion. The consultants agree that preprocedure identification of a patient’s OSA status improves perioperative outcomes, and they are equivocal regarding whether overall costs are decreased. The consultants agree that a patient’s perioperative risk depends on both the severity of the OSA and the invasiveness of the surgical procedure.Anesthesiologists should work with surgeons to develop a protocol whereby patients in whom the possibility of OSA is suspected on clinical grounds are evaluated long enough before the day of surgery to allow preparation of a perioperative management plan. This evaluation may be initiated in a preanesthesia clinic (if available) or by direct consultation from the operating surgeon to the anesthesiologist. A preoperative evaluation should include a comprehensive review of previous medical records (if available), an interview with the patient and/or family, and conducting a physical examination. Medical records review should include (but not be limited to) checking for a history of airway difficulty with previous anesthetics, hypertension or other cardiovascular problems, and other congenital or acquired medical conditions. Review of sleep studies is encouraged. The patient and family interview should include focused questions related to snoring, apneic episodes, frequent arousals during sleep (vocalization, shifting position, extremity movements), morning headaches, and daytime somnolence. A physical examination should include an evaluation of the airway, nasopharyngeal characteristics, neck circumference, tonsil size, and tongue volume. If any of these characteristics suggest that the patient has OSA, the anesthesiologist and surgeon should jointly decide whether to (1) manage the patient perioperatively based on clinical criteria alone or (2) obtain sleep studies, conduct a more extensive airway examination, and initiate indicated OSA treatment in advance of surgery. If this evaluation does not occur until the day of surgery, the surgeon and anesthesiologist together may elect for presumptive management based on clinical criteria or a last-minute delay of surgery. For safety, clinical criteria (table 1) should be designed to have a high degree of sensitivity (despite the resulting low specificity), meaning that some patients may be treated more aggressively than would be necessary if a sleep study were available.The severity of the patient’s OSA, the invasiveness of the diagnostic or therapeutic procedure, and the requirement for postoperative analgesics should be taken into account in determining whether a patient is at increased perioperative risk from OSA (table 2). The patient and his or her family as well as the surgeon should be informed of the potential implications of OSA on the patient’s perioperative course.Preoperative preparation is intended to improve or optimize an OSA patient’s perioperative physical status and includes (1) preoperative airway or or airway (2) preoperative use of or (3) preoperative or (4) preoperative weight is insufficient literature to evaluate the impact of the preoperative use of or on perioperative is insufficient literature to evaluate the of preoperative or weight However, the literature the of in respiratory index and oxygen saturation in the literature the of in reducing in consultants agree that preoperative use of airway or may improve the preoperative of patients who they are at increased perioperative risk from OSA, and they are equivocal regarding the of for these patients. The consultants agree that a preoperative should be made regarding whether surgery in patients at increased perioperative risk from OSA should be performed on an inpatient of should be if OSA is For patients who not to should be In addition, the preoperative use of or and preoperative weight should be A patient who has airway surgery (e.g. , surgical should be to at risk for OSA complications a sleep study has been and have not with or suspected OSA may have difficult and should be according to the Guidelines for of the patients at risk for perioperative complications from OSA, a preoperative must be made regarding whether surgery should be performed on an inpatient or outpatient in patients at increased perioperative risk from OSA include (1) of (2) airway management, and (3) patient The literature is insufficient to evaluate the of various on patients with OSA. the literature is insufficient to evaluate the impact of specific airway management (e.g. , or patient for patients with consultants agree that the use of anesthesia or than anesthesia improves outcomes in patients surgery. The consultants agree that the use of major anesthesia , or than anesthesia improves outcomes for surgery. The consultants are equivocal regarding the of major anesthesia than anesthesia for surgery. The consultants are equivocal regarding whether the use of and anesthesia improves consultants agree that patients at increased perioperative risk from OSA should be and they strongly agree that of should be before They agree that these patients should be in the for and consultants agree that respiratory should be used during moderate or sedation in these consultants agree that anesthesia with a airway is to sedation for and they are equivocal regarding whether anesthesia with a airway is to moderate sedation for The consultants agree that anesthesia with a airway is to moderate or sedation for patients with OSA procedures the upper airway (e.g. , upper of their for airway and sleep patients at increased perioperative risk from OSA are to the respiratory and airway of and in the potential for postoperative respiratory should be For should the use of anesthesia or with or moderate If moderate sedation is should be by or if because of the increased risk of airway obstruction in these patients. should or using an during sedation to patients treated with these anesthesia with a airway is to sedation a airway, for procedures that may the airway. anesthesia should be for is a medical or surgical patients at increased perioperative risk from OSA should be of should be before and should be in the or other in the management of patients with OSA include (1) analgesia, (2) (3) patient and (4) for respiratory include the and of of and invasiveness of surgical procedure, and the severity of the sleep apnea. In addition, of respiratory may occur on the or postoperative day as sleep are and literature is insufficient to evaluate the of various postoperative on patients with OSA. However, the literature is equivocal regarding the use of with or in reducing respiratory among surgical patients. The literature is insufficient to evaluate the of a to on the of patients with OSA. However, the literature the that a in an increased of in surgical consultants agree that than reduce the likelihood of adverse outcomes in patients at increased perioperative risk from OSA. The consultants agree that the of from postoperative as with which include The consultants agree that the use of adverse outcomes their The consultants are equivocal regarding whether with as with or In addition, the consultants are equivocal regarding whether a of in patients at increased perioperative risk from OSA the likelihood of adverse the literature is insufficient to evaluate the of postoperative oxygen in patients with OSA, it the use of oxygen to improve the oxygen saturation of surgical patients. is insufficient literature to evaluate the of or on the postoperative respiratory status of patients with OSA. However, the literature the of in consultants agree that oxygen should be administered as to oxygen saturation and that oxygen may be patients are to their oxygen saturation The consultants strongly agree that or should be administered as as surgery to patients with OSA who were it but they are equivocal regarding the of or in patients who were not treated with these The consultants are equivocal regarding whether patients postoperative or should have the in the patients are not literature an in adult patients with OSA sleep in the or than the in settings, but the literature is insufficient to provide for the postoperative The literature is insufficient to provide for of pediatric patients with OSA. The consultants agree that the should be possible during the of adult and pediatric patients who they are at increased perioperative risk from literature is insufficient to evaluate the of (e.g. , for or in the risk of adverse perioperative in patients with OSA. the literature is insufficient to the impact of postoperative (e.g. , or care for patients with or suspected OSA. The literature is insufficient to regarding the of postoperative respiratory in patients with consultants agree that in a or by the likelihood of perioperative complications among patients who they are at increased perioperative risk from OSA. They are equivocal regarding the of in an care or by a in a patient’s The consultants that patient The consultants agree that should be these patients are in They are equivocal regarding whether should be until these patients are They agree that should be until oxygen saturation during should be to reduce or eliminate the requirement for in patients at increased perioperative risk from OSA. If is the analgesia, for and from of using an or as with a If are should be used with or and other (e.g. , should be if to reduce requirements. are that the of (e.g. , increases the risk of respiratory and airway oxygen should be administered to all patients who are at increased perioperative risk from OSA until they are to their oxygen saturation The Task Force that oxygen may increase the of apneic and may of apnea, and by or with or should be administered (e.g. , patients are not to patients who were using these by the surgical with or may be if patients their to the patients at increased perioperative risk from OSA should be in the process. patients who are at increased risk of respiratory from OSA should have from the may be in a care or by on a or by a in the patient’s should be as long as patients at increased risk. or does not provide the of If frequent or severe airway obstruction or during postoperative of nasal or should be literature is insufficient to regarding which patients with OSA be on an outpatient as to an inpatient and the for of these patients from the surgical consultants agree that procedures typically performed on an outpatient in patients may also be performed on an outpatient in patients who they are at increased perioperative risk from OSA or anesthesia is administered (table The consultants are equivocal regarding whether procedures may be performed during anesthesia in at increased perioperative risk from OSA, but they that airway surgery (e.g. , should be performed on an outpatient in with OSA. They also that in younger than 3 with OSA should be performed on an outpatient and they are equivocal regarding outpatient in older children. The consultants strongly agree that patients at increased perioperative risk from OSA are as the should have difficult airway and they agree on the of respiratory care clinical laboratory They strongly agree that a with an inpatient should be in The Task Force that patients who are at increased risk of perioperative complications of 5 or greater on are not for surgery in a outpatient to outpatient the consultants agree that oxygen saturation should to its and they strongly agree that patients should not or have of clinical airway obstruction in the The consultants indicated that patients with OSA should be for a of 3 than their before from the They also indicated that of patients with OSA should for a of the of airway obstruction or in an patients at increased perioperative risk from OSA are to surgery, a should be made regarding whether a given surgical is most performed on a given patient on an inpatient or outpatient to be in determining whether outpatient care is include (1) sleep apnea status, (2) and abnormalities, (3) status of (4) of surgery, (5) of for postoperative patient of and of the outpatient The of difficult airway respiratory care clinical laboratory and a with an inpatient should be in making this patients should not be from the to an , or until they are at risk for postoperative respiratory of their to develop airway obstruction or central respiratory this may a as with patients of postoperative respiratory may be by patients in an they to be to that they are to their oxygen saturation scientific of these Guidelines was based on evidence or regarding potential between clinical and The below were to assess their to a of outcomes related to the management of patients with OSA in the perioperative evidence was from research literature, and evidence was from open and other (e.g. , For purposes of literature relevant clinical studies were identified and of the The and a from than were a of that addressed related to the evidence review of the studies not provide direct evidence and were A of direct in a study was as an evidence a or The were to obtain a for evidence before conducting a to evidence enough studies with and statistical information sufficient for These were (1) medical records review and body mass OSA and (2) focused physical examination associated with neck and various cephalometric (3) preoperative for OSA and respiratory index and oxygen saturation and (4) postoperative use and oxygen saturation postoperative use and respiratory and postoperative and (5) postoperative oxygen oxygen and and postoperative of patients or tonsil and or were for and were for were used as (1) The values based on of the values from the studies, and (2) the of the studies by of the by the of the based on the for study using tables was used with was at for of the studies were to among the study were was To for potential a was for studies was and for research were are in To be as must agree with both of are In the absence of findings from both the and must agree with other to be as among Task Force members and two methodologists was by using a for were as (1) of study (2) of analysis, (3) evidence and (4) literature for values were (1) study (2) of analysis, (3) and (4) literature These values moderate to high of was from including (1) survey opinion from consultants who were selected based on their or in perioperative management of patients with OSA, (2) from of two held open forums at two national anesthesia (3) Task Force opinion and survey opinions regarding the management of patients with or suspected OSA. The survey of was of of this survey are in in the of the survey opinions regarding the feasibility of implementing the Guidelines in to their clinical of this survey are below and in The of was of Responses by were as sleep or bariatric surgery, and The of the patients who have OSA is and they manage a of patients with OSA They obtain a sleep study for a of patients They would to obtain a sleep study for a of an additional patients to to these recommendations. The of a sleep study at their is They initiate or in preparation for surgery a of a and they that an additional of patients would or to to these Guidelines. They that a of additional patients would postoperative respiratory at their if the Guidelines were and they that the of for which such would be necessary is A of of the with OSA would to be as if the Guidelines were They a of 3 additional of that would be for a OSA patient before from their outpatient if the Guidelines were of the consultants that the sensitivity of the criteria in A of patients with OSA is whereas that they are not and that they are of the consultants indicated that the for of perioperative risk described in whereas that it is not and 4% that it is