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Chapter 13. Obstructive Sleep Apnea

Edward C. Lin, MD

  • Syndrome characterized by sleep-induced relaxation of pharyngeal muscle tone leading to upper airway obstruction
  • Risk factors include obesity, tonsillar hypertrophy, craniofacial abnormalities (e.g., micrognathia), ingestion of alcohol/sedatives, male gender, and middle age
  • Signs and symptoms: snoring, observed apnea during sleep, daytime somnolence, difficulty concentrating, morning headache
  • Associated findings may include episodic hypoxemia, hypercarbia, polycythemia, hypertension, pulmonary hypertension, RV failure
  • “Gold standard” test is polysomnography
  • Severity may be measured by the apnea/hypopnea index (AHI), the number of apneic or hypopneic events per hour:
    • Mild—5–20
    • Moderate—21–40
    • Severe—>40
  • Treatment is essentially medical (nasal CPAP) and reduces the incidence and severity of CV complications. Surgical treatment (UPPP, turbinectomy, septoplasty, etc.) is only an adjuvant

  • Focused history and physical examination to evaluate patient’s likelihood of having OSA
  • Consider use of STOP-BANG questionnaire, a validated scoring system to assess risk of obstructive sleep apnea
  • If likelihood of sleep apnea is high:
    • Decide to either manage patient based on clinical criteria alone or have patient obtain additional workup or treatment (typically takes several weeks)
    • Decide whether procedure should be performed on an outpatient or an inpatient basis
    • Assess for difficult airway and obtain specialized airway equipment if deemed necessary
    • Use preoperative sedation cautiously if at all
    • Consider gabapentin premedication (900 mg po preoperatively) followed by 300 mg every 6 hours for at least 24 hours to reduce analgesic requirements

Table 13-1 STOP-BANG Questionnaire
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Table 13-1 STOP-BANG Questionnaire

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

  2. Do you often feel tired, fatigued, or sleepy during daytime?

  3. Has anyone observed you stop breathing during your sleep?

  4. Do you have or are you being treated for high blood pressure?

  5. BMI more than 35?

  6. Age over 50 years old?

  7. Neck >40 cm?

  8. Male gender?

Three or more “yes” answers indicate a high risk for sleep apnea.

  • If possible, completely avoid benzodiazepines
  • Preoxygenate thoroughly as these patients are more prone to desaturation
  • Have video laryngoscope (i.e., GlideScope, McGrath laryngoscope, etc.) and/or fiber-optic available to aid in intubation because majority of OSA patients are obese with difficult airways
  • Avoid nitrous oxide if patient has history of pulmonary hypertension
  • If general anesthesia, extubate fully awake and with full muscle strength
  • Consider the use of regional or local techniques when appropriate
  • Consider limiting opioids and instead relying on local/regional analgesia (field block, epidural catheter)
  • If moderate sedation is used, continuously monitor adequacy of ventilation
  • Dexmedetomidine might be a better option for sedation (MAC) than propofol
  • Consider use of CPAP during sedation

  • Consider use of nonopioid postoperative analgesia (e.g., regional techniques, NSAIDs)
  • Especially avoid continuous infusion of opioids
  • Continue CPAP if feasible
  • Consider discharge of patient from PACU into a monitored setting (step-down)
  • Avoid discharge of patient from PACU to home/unmonitored setting until patient is no longer at risk of postoperative respiratory depression

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1. Gross JB, Bachenberg KL, ...

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