Perioperative Assessment and Risk

Management in Patients With

Obstructive Sleep Apnea
Edwin Seet, MBBS, MMed and Frances Chung, MBBS, FRCPC
Department of Anesthesia
Alexandra Health Private Limited
Khoo Teck Puat Hospital, Singapore
Department of Anesthesia
University Health Network
University of Toronto
Toronto, Ontario, Canada

Learning Objectives:
As a result of completing this activity, the participant
will be able to
 Explain the comorbidities associated with obstructive sleep apnea
 Describe the anesthetic management for patients
with obstructive sleep apnea
 Create a plan for the postoperative care of a
patient with obstructive sleep apnea

bstructive sleep apnea (OSA) is a clinical syndrome

defined by repetitive partial or complete upper
airway obstruction, characterized by episodes of
breathing cessation during sleep lasting 10 or more
seconds. The inherent pharyngeal collapsibility due to
depression of pharyngeal muscle regulation during sleep
and anesthesia predisposes to impaired respiration.1 Recurring airway obstruction causes repeated arousals and
increased sympathetic output, cumulating in daytime hypersomnolence, memory loss, executive dysfunction, and other
psychological disturbances.2

Author Disclosure Information:

Dr. Seet has disclosed that he has no financial
interests in or significant relationship with any
commercial companies pertaining to this educational
activity. Dr. Chung has disclosed that she receives
funding for research from Pfizer, the ResMed
Foundation, and the Respironic Foundation.

Obstructive sleep apnea (OSA) is a clinical

syndrome defined by repetitive partial or
complete upper airway obstruction, characterized by episodes of breathing cessation
during sleep lasting 10 or more seconds.
OSA is the most prevalent type of sleep-disordered
breathing.3 Its reported prevalence varies widely depending on the demographics of the population studied, the
definition of the disorder, and the method of diagnosis. The
estimates of mild OSA are in the range of one in four

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Seet and Chung

male patients and one in 10 female patients in the general

population.4 Moderate OSA estimates are in the range of
one in nine male patients and one in 20 female patients.5,6
A significant proportion of OSA patients are undiagnosed
when they come to surgery.7 About a quarter (24%) of
elective surgical patients were found to be at high risk for
OSA, of whom four of five (81%) had not been diagnosed
with OSA.8 Even in the context of ambulatory surgery, undiagnosed OSA may be frequently present.9 Furthermore,
OSA may be associated with increased risk for postoperative complications. Therefore, OSA patients can be a
potential management challenge for the anesthesiologist in
the perioperative period, and anesthesiologists need to have
a thorough understanding of this disorder.
This chapter presents evidence-based principles and
functional algorithms to aid anesthesiologists in the perioperative management of the OSA patient: addressing
OSA evaluation in the preoperative period, perioperative
OSA risk mitigation, and postoperative OSA patient disposition. Because of the paucity of published literature in
several aspects of perioperative management, some recommendations are based on expert opinion. These guidelines are not intended to substitute for bedside clinical
judgment, in which circumstantial and patient-specific
factors may lead to modification in patient management.

The American Academy of Sleep Medicine

defines mild OSA as an apneahypopnea
index (AHI) between 5 and 15, moderate OSA
as AHI between 15 and 30, and severe OSA as
AHI > 30.

CLASSIC DIAGNOSTIC CRITERIA FOR OSA

The classic diagnosis of OSA is established by overnight
polysomnography, or sleep study. The apneahypopnea index (AHI) is the number of abnormal respiratory events
(complete cessation, or apnea, and partial obstructions, or
hypopnea) per hour of sleep. These pauses in breathing must
last for 10 seconds and are associated with a decrease in
oxygenation of blood. There is a lack of conformity on the
diagnostic criteria for OSA. In 1999, a task force of the
American Academy of Sleep Medicine (AASM) stipulated
the minimal clinical diagnostic criteria for OSA as an AHI of
10 or more and symptoms of excessive daytime sleepiness.10
The Canadian Thoracic Society guidelines specify an AHI of
5 or more on polysomnography and either (1) daytime
sleepiness not explained by other factors or (2) at least 2
other symptoms of OSA (choking and/or gasping during
sleep, recurrent awakenings from sleep, unrefreshing sleep,
daytime fatigue, or impaired concentration).11 AHI cutoffs
have been used to describe the severity of OSA. The AASM
defines mild OSA as AHI between 5 and 15, moderate OSA

as AHI between 15 and 30, and severe OSA as AHI more

than 30.12

COMORBIDITIES ASSOCIATED WITH OSA

OSA has known associations with several comorbidities,
including cardiovascular disease (acute myocardial infarction, heart failure, arrhythmias, hypertension), cerebrovascular disease, metabolic syndrome, gastroesophageal
reflux disease, and obesity.13 In bariatric surgery, seven of
every 10 patients were found to have OSA.14 Certain
patient profiles (male, above 50 years of age, neck circumference > 40 cm), endocrine disorders (Cushing disease,
hypothyroidism), connective tissue disorders (Marfan syndrome), lifestyle habits (alcohol, smoking), and anatomical
abnormalities may predispose to OSA.15 Altered upper airway anatomy (craniofacial abnormalities, macroglossia,
retrognathia) may also reduce the lumen diameter, increasing the propensity for episodic airway obstruction.

POSTOPERATIVE COMPLICATIONS IN PATIENTS

WITH OSA
In the general community, long-standing untreated OSA is
an independent risk factor for increased all-cause mortality.16,17 In the perioperative setting, serious complications
occur more frequently in OSA patients because of alterations
in airway anatomy and pathophysiology of the disease. This
was demonstrated in several studies. Two single-center retrospective trials investigated postoperative complications in
diagnosed OSA patients. Gupta et al.18 demonstrated that
serious postoperative complications occurred in 24% of
OSA patients undergoing hip or knee replacement surgery
compared with 9% in the control group. These serious
complications included unplanned days in the intensive care
unit, reintubations, and cardiac events. Similarly, Liao and
colleagues found that, in 240 matched OSA and non-OSA
patients who underwent elective surgery, the incidence of
postoperative complications in the OSA group was 44%
compared with 28% in the non-OSA group.19

In the perioperative setting, serious complications occurred more frequently in OSA

patients because of alterations in airway
anatomy and pathophysiology of the disease.
In another prospective cohort study, Chung et al.20
demonstrated that the incidence of postoperative complications in 147 OSA patients compared with those without
OSA was 27.4% versus 12.3%. Gali et al.21 found an increased risk for postoperative complications in 221 highrisk OSA patients. In a recent published propensity-scored
casecontrol study by Kaw et al.,22 OSA was reported to
be independently associated with increased postoperative
hypoxemia, intensive care unit transfers, and longer hospital

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OSA Assessment and Risk Management

stays after noncardiac surgery. Memtsoudis et al.23 found

that sleep apnea patients, compared with matched controls, developed a two-fold higher risk for pulmonary
complications after both orthopedic and general surgeries
compared with non-OSA patients (Supplemental Digital
Content 1, http://links.lww.com/ASA/A147). Flum and
colleagues showed that a diagnosis of OSA in patients
undergoing bariatric surgery was an independent risk factor for adverse postoperative outcomes.24 Convincingly,
OSA patients pose an increased risk for postoperative
complications; therefore, perioperative precautions should
be undertaken by the anesthesiologist to mitigate possible
adverse outcomes in this susceptible patient group.

PREOPERATIVE EVALUATION OF THE KNOWN

OSA PATIENT
Preoperative evaluation of the known OSA patient begins
with taking a detailed history and performing a physical
examination. More specifically, both the diagnosis and
severity of OSA should be determined by questioning
the patient about OSA symptoms and reviewing polysomnography results. Long-standing OSA may have systemic complications, including hypoxemia, hypercapnia,
polycythemia, and cor pulmonale. The presence of significant comorbidities such as uncontrolled hypertension,
arrhythmias, cerebrovascular disease, heart failure, metabolic syndrome, and morbid obesity should be determined.
It is noteworthy that pulmonary arterial hypertension in
patients with OSA has been reported to be in the range of
15 to 20%.25 However, the Evidence-Based Clinical Practice Guidelines of the American College of Chest Physicians do not recommend routine evaluation for the
presence of pulmonary arterial hypertension in the management of patients with OSA.26 Intraoperative triggers
for elevation of pulmonary arterial hypertension should be
avoided in the OSA patient. In the preoperative clinic,
pulse oximetry may be a simple screening tool for OSA
patients with complications. In the absence of other causes
such as chronic obstructive pulmonary disease, an oxygen
saturation value o94% in room air should be a red flag for
severe, long-standing OSA.
The OSA patients use of and compliance with positive
airway pressure (PAP) devices (continuous PAP, bilevel
PAPs, autotitrating PAP) should be assessed. Some patients
with known OSA may have to be referred to a sleep
medicine physician for preoperative reassessment. These
include patients who have been lost to sleep medicine follow-up, have had a recent exacerbation of OSA symptoms,
have undergone OSA-related airway surgery, or have been
noncompliant with PAP therapy. Due consideration should
be given for the reinitiation of preoperative PAP therapy
in the noncompliant OSA patient, although evidence of
its efficacy is lacking in this preoperative context and
the duration of preoperative OSA treatment necessary to
decrease perioperative risk is unknown.

Patients with moderate or severe OSA who have been on

PAP therapy should continue it in the preoperative period.27 The intraoperative anesthesia team should be alerted
in advance so that an anesthetic plan can be formulated.
Perioperative OSA risk mitigation strategies and precautions should be undertaken. It is unclear from the current literature whether mild OSA would be a significant
disease entity under anesthesia and in the perioperative
period. On the basis of expert opinion, patients with mild
OSA would not require preoperative PAP therapy. A published opinion-based algorithm addressing the preoperative management of the known OSA patient is shown
in Figure 1.28

SCREENING METHODS FOR OSA IN THE

SURGICAL SETTING
The gold standard for diagnosing OSA is by overnight
polysomnography. However, cost, expertise, equipment,
and time constraints make routine polysomnography
screening prohibitive. Therefore, practical screening tools
for OSA are needed to filter out the patients at higher risk
for OSA. Several questionnaire-based screening tools have
been developed, including the Epworth Sleepiness Scale,29
the Berlin Questionnaire,30 the ASA checklist,27 the Sleep
Apnea Clinical Score,31 and the P-SAP score.32
Concise clinical screening tools have been developed
for anesthesiologists: the STOP and STOP-Bang questionnaires (Supplemental Digital Content 2, http://links.
lww.com/ASA/A148).33 The STOP-Bang questionnaire is a
scoring model based on yes/no answers to eight easily
administered questions using the acronym STOP-Bang
(Table 1), whereas the STOP questionnaire includes only
the first four questions and is less specific. Patients are
considered at high risk for OSA if 2 or more items are
scored positive on the STOP portion of the questionnaire
(see Supplemental Digital Content 3, http://links.lww.com/
ASA/A149) or three or more items are scored positive on
the STOP-Bang questionnaire (Supplemental Digital Content 4, http://links.lww.com/ASA/A150).

Concise clinical screening tools have been

developed for anesthesiologists: the STOP and
STOP-Bang questionnaires.
For safety reasons, OSA screening tools should have a
high degree of sensitivity at the expense of lower specificity. The STOP-Bang questionnaire has a high level of
sensitivity and negative predictive value, especially for
patients with moderate or severe OSA.33 A patient rated as
low risk for OSA by the STOP-Bang questionnaire is unlikely to have moderate to severe OSA. The corollary is
that the STOP-Bang score may be falsely positive. At AHI
cutoff values of >15 and >30, the STOP-Bang questionnaire has a sensitivity of 93 and 100%, respectively, with

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Seet and Chung

Suspected OSA patient

Known OSA patient

Screening using STOP or STOP-Bang

questionnaire

High risk of OSA

(2 on STOP, 3 STOP-Bang)

Severity assessment from history or

polysomnography

Low risk of OSA

(<2 on STOP, <3 on STOP-Bang)

Mild OSA
AHI 5 15
Oximetry 94% on
room air

Moderate or
severe OSA
AHI > 15
Oximetry < 94% on
room air

Major elective surgery &

significant comorbidities
Changes in OSA Status
Recent exacerbation of OSA
symptoms

Heart failure
Arrhythmias
Uncontrolled hypertension
Cerebrovascular disease
Metabolic syndrome
Obesity with BMI > 35 kg/m2

No

Routine perioperative
management
No preoperative PAP
therapy*required

Noncompliant to PAP
therapy*
Recently undergone OSArelated surgery
Lost to sleep medicine
follow-up

Yes

Yes
Consider
preoperative referral
to sleep medicine
physician,
polysomnography,
and preoperative
PAP therapy*

Assume possibility
of moderate OSA
Perioperative OSA
precautions and risk
mitigation (Table 2)

No

Preoperative PAP
therapy*
Perioperative OSA
precautions and risk
mitigation (Table 2)

Figure 1. Preoperative evaluation of a known or suspected obstructive sleep apnea patient in the anesthesia clinic. Adapted from Seet and Chung.28
c 2010 by Canadian Anesthesiologists Society. With kind permission from Springer Science Business Media. *Positive airway pressure (PAP)
Copyright 
therapy: including continuous PAP, bilevel PAP, or autotitrating PAP. OSA obstructive sleep apnea.

specificity of 43 and 37%, respectively (Supplemental

Digital Content 5, http://links.lww.com/ASA/A151).33
A higher score of 5, 6, 7, or 8 is more predictive of severe
OSA. By using a higher cutoff value of STOP-Bang 5, 6, and
7, the specificity for AHI >30 (severe OSA) was increased to
74, 88, and 95%, respectively (Supplemental Digital Con-

tent 6, http://links.lww.com/ASA/A152).34 A high risk for

OSA on the STOP-Bang questionnaire is associated with
higher postoperative complications.20,35 Screening questionnaires such as the STOP-Bang can be used in the preoperative clinic to categorize OSA severity, triage patients for
diagnostic evaluation, or exclude them from harm.36

Table 1. Screening Tools for OSA: STOP and STOP-Bang Questionnaire

S

Snoring: Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?

Tired: Do you often feel tired, fatigued, or sleepy during daytime?

Yes

No

Observed: Has anyone observed you stop breathing during your sleep?

Yes

No

Blood Pressure: Do you have or are you being treated for high blood pressure?

Yes

No

Yes

No

BMI: BMI more than 35 kg/m ?

Yes

No

Age: Age over 50 years old?

Yes

No

Neck circumference: Neck circumference greater than 40 cm?

Yes

No

Gender: Male?

Yes

No

High risk of OSA: Yes to two or more questions for STOP questionnaire, or yes to three or more questions for STOP-Bang.
BMI body mass index; OSA obstructive sleep apnea.
c 2010 by Canadian Anesthesiologists Society. With kind permission from Springer Science Business Media.
Adapted from Seet and Chung.28 Copyright 

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OSA Assessment and Risk Management

PREOPERATIVE EVALUATION OF THE

SUSPECTED OSA SURGICAL PATIENT
Urgent or emergent surgery should not be delayed for the
detailed evaluation of suspected OSA. As mentioned,
a patient is at risk for OSA if 2 or more items score positive
on the STOP questionnaire or 3 or more items score
positive on the STOP-Bang questionnaire. A published
opinion-based algorithm addressing the preoperative
management of the suspected OSA patient is shown in
Figure 1.28
The anesthesiologist could consider a preoperative referral to a sleep physician for polysomnography if the patient screens as high risk for OSA and is scheduled for
major elective surgery and has significant comorbidities
suggestive of long-standing OSA. These comorbidities
include uncontrolled hypertension, heart failure, arrhythmias, cerebrovascular disease, morbid obesity, and
metabolic syndrome. A timely and early consult would
be helpful so that the sleep physician has adequate time to
prepare a perioperative management plan, which may
include PAP treatment.27 Major elective surgery might
have to be deferred in patients with a high clinical
suspicion of severe OSA with systemic complications.
Ultimately, the decision for further preoperative sleep
study testing should depend on the clinical judgment and
expertise of the attending physician, taking into account
patient-specific and logistical considerations in their
totality.
In contrast, there may be patients who are at high risk
according to the OSA screening questionnaires but
who are otherwise without significant comorbidities and
are not scheduled to undergo major surgery. Some of these
patients may have undergone uneventful anesthetic procedures in the past. These at risk patients may represent
false positives on screening or may have less severe OSA.
A positive screening test would alert the anesthesiologist so
that perioperative risk mitigation and precautions for possible OSA may be undertaken. If subsequent intraoperative
difficult airway37 or recurrent respiratory events in the
postanesthesia care unit (PACU)21 suggest a higher probability for OSA, polysomnography and referral to a sleep
physician after the surgery may be indicated.
Because of the high sensitivity and negative predictive
value of the OSA screening tools, the incidence of false
negatives will be low. Therefore, patients who are at low
risk for OSA (< 2 on STOP or < 3 on STOP-Bang) are unlikely to have OSA. These patients may be managed with
routine perioperative care.

HOME SLEEP TESTING AND NOCTURNAL

OXIMETRY
If there is a high index of suspicion for an undiagnosed
OSA patient scheduled for elective surgery, home sleep
testing may also be a viable diagnostic alternative to
standard polysomnography.38 Level 2 portable sleep

devices have proved to be reliable alternatives to standard

polysomnography in surgical patients.39 In addition, nocturnal oximetry is a sensitive and specific tool to detect
OSA in surgical patients who are STOP-Bang positive.40
There is a strong correlation between the oxygen desaturation index from nocturnal oximetry and AHI from
polysomnography.40 If polysomnography is unavailable
because of resource constraints, these surrogate investigations may help to identify patients at higher risk for
OSA-related complications so that preoperative PAP therapy may be considered and appropriate perioperative
precautionary measures may be undertaken.

There is a strong correlation between the

oxygen desaturation index from nocturnal
oximetry and AHI from polysomnography.

PERIOPERATIVE STRATEGIES TO MITIGATE

RISKS FOR THE OSA PATIENT
OSA patients are susceptible to several perioperative risks
during anesthesia. Strategies or perioperative precautions
that may be undertaken to mitigate these risks and minimize adverse outcomes are discussed in this section and
listed in Table 2.28
Sedative premedication should be avoided.41 a2-Adrenergic agonists such as clonidine and dexmedetomidine
may reduce intraoperative anesthetic requirements and
have an opioid-sparing effect.42
Difficulty with tracheal intubation occurs eight times as
often in OSA patients compared with non-OSA patients.43
OSA is also a risk factor for difficult mask ventilation.44
A primary and back-up airway plan should be formulated in
advance, identifying skills and additional equipment necessary to enact the plan.48 A variety of airway adjuncts (e.g.,
video laryngoscope, fiberoptic bronchoscope) and skilled
anesthesiology assistance should be available before the induction of anesthesia. The entire anesthesia team should be
familiar with center-specific difficult airway algorithms,
such as the ASA difficult airway management guidelines.46
Patients should be meticulously and adequately preoxygenated. Preoxygenation with 100% oxygen with continuous positive airway pressure (CPAP) at 10 cm H2O for 3
to 5 minutes with the patient at a 25-degree head-up position
is advantageous in achieving a higher end-tidal oxygen
concentration.45 Triple airway maneuvers using a twohanded mask ventilation technique may be required to achieve adequate ventilation before tracheal intubation. Obese
OSA patients may require a ramp to be built under them
from the scapula to the head to allow alignment of the ear
and the sternal notch (head-elevated laryngoscopy position,
or HELP), thus facilitating laryngoscopy. This may be done
by stacking blankets or with specially designed foam devices
(Troop Elevation Pillow, Mercury Medicals).

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Seet and Chung

Table 2. Perioperative Precautions and Risk

Mitigation for OSA Patients
Anesthetic Concern

Principles of Management

Premedication

Avoid sedating premedication41

a2-Adrenergic agonists (clonidine,
dexmedetomidine)42 may reduce
intraoperative anesthetic
requirements and have an opioidsparing effect

Possible difficult airwayMask

ventilation and tracheal
intubation43,44

Place ramp from scapula to head

if patient is obese
Provide adequate preoxygenation
Consider CPAP preoxygenation45
Use two-handed triple airway
maneuvers
Consult American Society of
Anesthesiologists Difficult
Airway Algorithm46

Gastroesophageal reflux
disease47

Consider proton pump inhibitors,

antacids, rapid-sequence
induction with cricoid pressure

Opioid-related respiratory
depression41

Minimize use of opioids for

analgesia
Use short-acting agents
(remifentanil)
Use regional and multimodal
analgesia (NSAIDs,
acetaminophen, tramadol,
ketamine, gabapentin,
pregabalin, dexmedetomidine,
clonidine, dexamethasone)

Carryover sedation effects from

longer-acting intravenous
sedatives and inhaled
anesthetic agents

Use propofol/remifentanil for

maintenance of anesthesia
Use insoluble potent anesthetic
agents (desflurane)
Use regional blocks as a sole
anesthetic technique

Excessive sedation in monitored

anesthetic care

Use intraoperative capnography for

monitoring of respiration27

Postextubation airway obstruction Verify full reversal of

neuromuscular blockade27
Ensure that patient is fully conscious
and cooperative before
extubation27
Use nonsupine posture for
extubation and recovery27
Resume use of positive airway
pressure device27
NSAIDs nonsteroidal antiinflammatory drugs; OSA obstructive sleep apnea.
c 2010 by Canadian AnesthesioAdapted from Seet and Chung.28 Copyright 
logists Society. With kind permission from Springer Science Business Media.

Gastroesophageal reflux disease may be more prevalent

in OSA patients because of hypotonia of the lower esophageal sphincter.47 The use of proton pump inhibitors,
antacids, rapid-sequence inductions, and cricoid pressure
may be considered to reduce the risk of aspiration. Notably, cricoid pressure may make tracheal intubation and
mask ventilation more difficult, compounding the problem
of difficult airways in OSA patients.49
The use of regional blocks (neuraxial or peripheral
nerve blocks) as a sole anesthetic may be beneficial to the

OSA patient as it circumvents the issue of upper airway

patency and decreases requirements for opioids in the
perioperative period. Therefore, local and regional techniques may be preferred to general anesthesia.27 Presently,
however, there is no evidence supporting one anesthetic
technique over another. The postoperative use of wound
infiltration, nerve block catheters, or epidural catheters
with local anesthetics reduces opioid requirements and
may be beneficial.
Patients with OSA are sensitive to the respiratory depressant effects of anesthetic agents including sedatives,
opioids, and inhaled anesthetics. This is because of
the propensity of airway collapse, sleep deprivation, and
blunting of the physiological response to hypercapnia and
hypoxia. The use of short-acting agents (propofol, remifentanil, desflurane), and, correspondingly, the avoidance or minimization of the use of longer-acting anesthetic
drugs, is recommended. Intraoperative triggers for elevation in pulmonary arterial hypertension such as hypercapnia, hypoxia, hypothermia, and acidosis should be
avoided. On the basis of a recent novel study, intraoperative administration of intravenous doxapram (a central respiratory stimulant) may be associated with favorable
postanaesthesia recovery and outcomes in bariatric surgery
patients with OSA.50
A multimodal or balanced approach for analgesia is
advocated (nonsteroidal antiinflammatory drugs, COX-2
inhibitors, acetaminophen, tramadol, pregabalin, and
gabapentin) for the opioid-sparing effect. Notably, postoperative oxygen desaturations were 12 to 14 times more
likely to occur in OSA patients receiving postoperative oral
or parenteral opioids compared with those receiving
nonopioid analgesic agents.51 Recently, there has been an
increasing interest in the use of alternative analgesic adjuvants such as corticosteroids (e.g., dexamethasone),
ketamine,52 melatonin,53 clonidine, and dexmedetomidine54 to provide improved pain relief.
Postoperatively, tracheal extubation should be performed only after the OSA patient is fully conscious, airway patency is confirmed, and the patient is able to follow
verbal commands. Importantly, coughing and reflex hand
movements to the tracheal tube should not be confused
with purposeful movements. Because even a small degree
of residual neuromuscular blockade can increase postoperative respiratory morbidity (e.g., aspiration, airway
obstruction, inadequate ventilation, hypoxia, and the need
for reintubation), muscle relaxants should be fully reversed
and this verified,55 especially in the OSA patient. A nonsupine position (semiupright or lateral) is preferred for
postoperative recovery.56
Patients undergoing surgical procedures under monitored anesthetic care or regional anesthesia with sedation
should have intraoperative capnography available to
monitor ventilation. On the basis of expert opinion, patients who use PAP therapy at home should use personal
PAP therapy devices during procedures that utilize mild to
moderate sedation and do not involve the face and neck.57

OSA Assessment and Risk Management

If deep sedation is required, a secure airway is preferable to

an unprotected airway.27

POSTOPERATIVE DISPOSITION OF THE KNOWN

OR SUSPECTED OSA PATIENT AFTER GENERAL
ANESTHESIA
Patient, anesthesia, analgesia, and surgery-specific factors
influence the requirements for postoperative monitoring in
OSA patients. For example, the patient with severe OSA
undergoing major surgery that necessitates postoperative
opioids would likely require close and continuous postoperative monitoring. In contrast, routine postoperative
care might be appropriate in the patient with suspected
OSA undergoing minor elective surgery.
In reality, the final decision of whether the patient requires closer postoperative monitoring is based on the
judgment and discretion of the attending anesthesiologist.
Modeled on similar principles as the ASA 2006 guidelines
on OSA management and on recent evidence, the algorithm presented in Figure 2 was published to guide the
anesthesiologist in taking a decision pertaining to the
postoperative disposition of the OSA patient.28
After general anesthesia, all patients with known or
suspected OSA should be observed in the PACU with
continuous oximetry monitoring for a longer period compared with a patient without OSA.13 There are currently
no evidenced-based recommendations as to how long OSA
patients should be monitored in the PACU. ASA guidelines
based on expert opinion recommended a duration of 7
hours if there is apnea or airway obstruction in the
PACU.27 However, monitoring in the PACU for that length
of time may not be feasible in most community hospitals.57
We propose an extended PACU observation of at least
30 to 60 minutes in an unstimulated environment after
the patient has met the modified Aldrete criteria for
discharge.28
The observation of recurrent PACU respiratory events
can be used as a reliable second-phase indicator to
determine whether the known or suspected OSA patient
requires continuous postoperative monitoring. A PACU
respiratory event occurs when a patient has apnea for 10
seconds or more (one episode needed for a yes), bradypnea
of <8 breaths/min (three episodes needed for a yes), painsedation mismatch, or desaturations of up to 90% (three
episodes needed for a yes) in one 30-minute time block.
Recurrent PACU respiratory events occur when any one
of the PACU respiratory events occurs in two separate
30-minute time blocks (not necessarily the same event).21
Patients who are at high risk for OSA on the basis of the
screening questionnaires and who experience recurrent PACU respiratory events have associated higher postoperative
respiratory complications.20,21,35 It may be prudent to
monitor them continuously postoperatively with oximetry in
a place where early medical intervention can occur (Figure 2). This can be in a step-down unit, in an inpatient ward

125

near the nursing station, or by remote pulse oximetry with

telemetry. These patients may also require commencement
of postoperative PAP therapy. In a similar manner, Sundar
et al.57 published their sleep trial protocol using desaturation (two or more episodes), bradypnea (o 8 breaths/min),
and obstructive apneic episodes to decide which suspected
OSA patients require PAP therapy.
There are new monitoring technologies. Monitoring can
be continuous and the trend analysis can be incorporated
into the alarm system. Heart rate, respiratory rate, blood
pressure, temperature, end-tidal carbon dioxide levels,
oxygen saturation, and other physiological channels can be
monitored continuously and interpreted concurrently with
smart algorithms to optimize sensitivity and minimize false
alarms. This technology may have the potential to make
surgical wards safer for our OSA patients and reduce the
number of preventable deaths.58,59

Patient, anesthesia, analgesia, and surgeryspecific factors influence the requirements for
postoperative monitoring in OSA patients.
Known OSA patients who have been noncompliant with
PAP therapy or have severe OSA may need to be fitted with
postoperative PAP therapy and cared for in a monitored
environment with continuous oximetry, particularly if
there has been a recurrent PACU respiratory event (Figure 2). Known OSA patients requiring postoperative
parenteral opioids may require continuous oximetry
monitoring to detect drug-induced postoperative respiratory depression.60 In the absence of recurrent PACU respiratory events, patients with moderate OSA who require
higher-dose oral opioids may be managed postoperatively
on the surgical ward with oximetry monitoring (Figure 2).
OSA patients may have upregulation of central opioid
receptors due to recurrent hypoxemia. For that reason,
they are more sensitive to the respiratory depressive effect
of narcotic agents. Opioid delivery through patient-controlled analgesia with no basal infusion rate and restricted
per-hour dosing may limit the narcotic drug. It may also be
expedient to administer supplemental oxygen to patients
requiring postoperative parenteral opioids.61 In a recent
multidisciplinary consensus meeting organized by the Anesthesia Patient Safety Foundation, it was suggested that, if
supplemental oxygen is used, ventilation monitors (e.g.,
capnography) may be required to detect hypoventilation.60
Multimodal analgesic techniques should be utilized to
minimize the postoperative administration of opioids.
These would include local anesthetic wound infiltration;
peripheral nerve block catheters or neuraxial catheters
running local anesthetic agents (without opioids); and the
use of opioid-sparing analgesic agents such as nonsteroidal
anti-inflammatory drugs, COX-2 inhibitors, ketamine,
acetaminophen, pregabalin, gabapentin, tramadol, dexmedetomidine, or dexamethasone.

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Seet and Chung

Patient monitored in postanesthesia care unit for longer duration

(> 30-60 min after modified Aldrete criteria met)

Suspected OSA
(2 on STOP, 3 STOP-Bang)

Known OSA

Noncompliant with PAP therapy,*

Severe OSA (AHI > 30),
Postoperative parenteral opioids, or
Recurrent PACU respiratory event (30-min block)
Oxygen saturation < 90% (3 episodes)
Bradypnea < 8 breaths / min (3 episodes)
Apnea 10 sec (1 episode)
Pain sedation mismatch (high pain and sedation scores
concurrently)

No

Recurrent PACU respiratory event (30-min block)

Oxygen saturation < 90% (3 episodes)
Bradypnea < 8 breaths / min (3 episodes)
Apnea 10 sec (1 episode)
Pain sedation mismatch (high pain and sedation scores
concurrently)

Yes

Yes

No

Moderate OSA (AHI > 16-30)

Require postoperative oral
opioids (> codeine 60 mg q4h, or
equivalent)

No

Consider
discharge to
home if minor
surgery

Yes

Consider
postoperative
care on the
surgical ward

Consider care in a
monitored bed with
continuous oximetry and/or
postoperative PAP therapy*

Consider discharge to
home if minor surgery or
postoperative care on the
surgical ward

Figure 2. Postoperative management of the known or suspected obstructive sleep apnea patient after general anesthesia. Adapted from Seet and Chung.28
c 2010 by Canadian Anesthesiologists Society. With kind permission from Springer Science Business Media. *Positive airway pressure (PAP)
Copyright 
therapy: including continuous PAP, bilevel PAP, or autotitrating PAP. Recurrent postanesthesia care unit (PACU) respiratory event: any event occurring more
than once in each 30-minute evaluation period (not necessary to be the same event).21 zMonitored bed: environment with continuous oximetry and the
possibility of early nursing intervention (e.g., intensive care unit, step-down unit, or remote pulse oximetry with telemetry in surgical ward). AHI apnea
hypopnea index; OSA obstructive sleep apnea.

Known OSA patients previously on PAP therapy should

be encouraged to be compliant with PAP therapy postoperatively. PAP therapy should be ordered in the postoperative period even though high-level evidence studies
specifically addressing PAP therapy and postoperative
outcomes in OSA patients are lacking. Notably, a recent
retrospective review of 797 patients scheduled for bariatric
surgery suggested the possibility that recognition and appropriate management of OSA (with 93% of the patients
receiving perioperative CPAP) may mitigate the risk of
postoperative complications.62
Interestingly, a significant increase in AHI occurred on
postoperative night 3, particularly in male patients with
moderate or severe OSA.63 Normalization of sleep architecture and AHI occurs only on the fifth to seventh postoperative nights.64 This may help to explain the late
postoperative complications seen in OSA patients. The
necessary level of monitoring for each individual OSA
patient continues to pose a difficult triage decision. Un-

fortunately, the current paucity of high-level evidence in

the literature does not contribute knowledge that could
assist the practicing anesthesiologist with the decisionmaking process. Further good-quality research on the
postoperative management of OSA patients is essential.

OSA PATIENT AND AMBULATORY SURGERY

Disagreement exists as to whether OSA patients should be
discharged home after surgery. The 2006 ASA guidelines
on OSA highlighted that superficial surgeries or minor
orthopedic surgery using local or regional techniques and
lithotripsy may be performed on an ambulatory basis.27 In
our opinion, patients suspected of OSA or with mild OSA
who have undergone minor surgery without recurrent
PACU respiratory events and not requiring a higher dose of
oral opioids for analgesia may be discharged home at the
discretion of the attending physicians (Figure 2).28,65
However, patients with severe OSA without optimized

OSA Assessment and Risk Management

comorbid conditions are not ideal candidates for ambulatory surgery.65 The threshold for unanticipated hospital
admission should be lowered. OSA patients should not be
allowed to return home without an escort. The patients
escort or caregiver should be provided information regarding possible postoperative complications. As a safety
precaution, ambulatory surgical centers managing OSA
patients should have transfer agreements to inpatient
facilities and be equipped to manage contingencies
associated with OSA.
In contrast, retrospective observational studies of OSA
patients undergoing bariatric surgery in free-standing
ambulatory surgical centers have demonstrated that the
postoperative complication rate can be low (o 0.5%) and
that these surgeries may be performed on an ambulatory
basis or as short-stay surgeries.6668 Judicious patient selection, preoperative optimization of medical conditions
(including PAP therapy for OSA), skilled medical personnel, and experienced high-volume facilities with strict
home-care criteria may be the ingredients for a successful
outcome in this high-risk population. However, such an
approach is still controversial.69

CONCLUSIONS
In the perioperative period, OSA is often unrecognized
and underdiagnosed. It is known to be associated with
increased postoperative complications and morbidity.
Screening tools for OSA, such as the STOP-Bang questionnaire, allow risk stratification of suspected OSA patients. Individualized and tailored patient care is required
to mitigate the perioperative risks of the known or suspected OSA patient. Practical algorithms based on current
best evidence and expert opinion may guide anesthesiologists in the perioperative management of these vulnerable
patients. Looking to the horizon, an interdisciplinary collaboration and cross-fertilization of ideas between
anesthesiology and sleep medicine will provide the substrate for further research with the hope of answering
important questions in OSA management.70

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