Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea: A Report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea

Abstract

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 af