What are the pre-operative considerations for obstructive sleep apnea (OSA) management in older adult patients with a history of obesity or other comorbidities undergoing shoulder surgery?

Pre-Operative OSA Considerations for Shoulder Surgery

All older adult patients scheduled for shoulder surgery must be screened for OSA at least by history, and if OSA is confirmed preoperatively, nasal CPAP should be initiated prior to hospital admission with equipment brought to the hospital, as the postsurgical period harbors significant risk due to anesthetic agents and opiates worsening OSA in unprotected individuals. 1

Preoperative Screening and Evaluation

Mandatory Screening Components

• Conduct a comprehensive medical records review checking specifically for history of airway difficulty with previous anesthetics, hypertension, cardiovascular problems, stroke, myocardial infarction, diabetes mellitus, and congenital conditions like Down syndrome or acromegaly. 1

• Perform a focused patient and family interview asking specifically about snoring, witnessed apneic episodes, frequent arousals during sleep (vocalization, shifting position, extremity movements), morning headaches, and daytime somnolence. 1

• Complete a physical examination evaluating airway characteristics, nasopharyngeal anatomy, neck circumference (>17 inches in men, >16 inches in women indicates high risk), tonsil size, tongue volume, and adequacy of dentition (at least 8 healthy teeth in upper and lower jaws if oral appliances are considered). 1, 2

• Use the STOP-Bang questionnaire as it has been validated in surgical patients at preoperative clinics with 83.6% sensitivity for identifying OSA patients, though specificity is only 56.4%. 3

Risk Stratification for Obesity and Comorbidities

• Identify patients with BMI ≥35 kg/m² as they have 10-20% prevalence of severe OSA, often undiagnosed, and face doubled incidence of postoperative desaturation, respiratory failure, cardiac events, and ICU admission. 1

• Screen for hypothyroidism and acromegaly in all OSA patients, as these conditions can cause or exacerbate OSA and treatment directly improves outcomes—order thyroid function tests first as hypothyroidism is more prevalent, then evaluate for acromegaly with IGF-1 levels if TFTs are normal. 4

• Assess for congestive heart failure as older patients with CHF and sleep apnea have 2.7-fold greater risk of reduced survival than patients with CHF or apnea alone. 1

Decision Algorithm: Objective Testing vs. Clinical Management

If preoperative screening suggests high OSA risk, the anesthesiologist and surgeon must jointly decide whether to: 1

1. Obtain formal sleep studies and initiate OSA treatment before surgery (preferred approach when time permits and OSA severity appears significant)
2. Manage perioperatively based on clinical criteria alone (acceptable when surgery is urgent or OSA appears mild)

The decision should account for: 1

• Severity of suspected OSA based on screening
• Invasiveness of the shoulder procedure
• Requirement for postoperative opioids (shoulder surgery typically requires significant opioid analgesia)
• Patient age and comorbidities

Preoperative Optimization When OSA is Confirmed

CPAP Initiation Protocol

• Initiate nasal CPAP prior to hospital admission if OSA is confirmed during preoperative assessment, as this is the most critical intervention to reduce perioperative complications. 1

• Instruct patients to bring their CPAP equipment to the hospital at admission for continued use throughout the perioperative period. 1

• For patients not responding adequately to CPAP, consider noninvasive positive pressure ventilation (NIPPV) as an alternative. 1

• Verify CPAP compliance preoperatively as approximately 50% of patients are poorly compliant with therapy and will not obtain benefit, usually due to mask fitting problems. 1

Alternative Interventions

• Consider mandibular advancement devices or oral appliances when feasible, particularly for mild-to-moderate OSA, but ensure adequate dentition (at least 8 healthy teeth in upper and lower jaws). 1

• Recommend preoperative weight loss when feasible, as weight reduction plays an important role in OSA management and one study of older OSA patients monitored for 18 years found reduction in apnea severity associated with weight loss. 1

• For patients with BMI ≥40 kg/m², discuss referral to bariatric surgery evaluation, as this produces clinically meaningful improvements in AHI/RDI reduction, blood pressure, oxygen desaturation index, and quality of life. 5

Critical Perioperative Medication Considerations

Substances That Worsen OSA

• Avoid or minimize alcohol, sedative-hypnotics, and opiates as these agents depress upper airway tone and worsen OSA syndrome—this is particularly critical in older patients undergoing surgery who will receive opiates during the perioperative period. 1

• Recognize that anesthetic agents worsen OSA in unprotected individuals, making the postsurgical period particularly high-risk. 1

• Plan multimodal analgesia strategies to reduce opioid exposure, as OSA patients demonstrate higher sensitivity to opioid analgesic potency and increased pain perception due to intermittent hypoxemia and sleep fragmentation. 6

Regional Anesthesia Considerations

• Strongly consider regional anesthesia techniques (interscalene or supraclavicular nerve blocks for shoulder surgery) to reduce intraoperative and postoperative opioid requirements, as this approach is strongly supported in literature for reducing perioperative complication risk in OSA patients. 6, 7

Inpatient vs. Outpatient Determination

Before scheduling surgery, determine whether the procedure should be performed on an inpatient or outpatient basis by evaluating: 1

• Sleep apnea status and severity
• Anatomical and physiologic abnormalities
• Status of coexisting diseases (particularly cardiovascular disease, diabetes, obesity)
• Nature and invasiveness of the shoulder surgery
• Type of anesthesia required
• Need for postoperative opioids (shoulder surgery typically requires significant analgesia)
• Patient age (older adults have higher risk)
• Adequacy of postdischarge observation
• Capabilities of the outpatient facility (availability of emergency difficult airway equipment, respiratory care equipment, radiology, clinical laboratory, and transfer agreement with inpatient facility)

Patients with severe OSA, significant comorbidities, or requiring substantial postoperative opioids should be managed as inpatients with enhanced monitoring. 1

Special Considerations for Older Adults

• Older patients tolerate nightly CPAP use according to several studies, though cognitively-impaired patients may require help from family members or caregivers for mask application and equipment cleaning. 1

• Patients without adequate dentition face challenges for CPAP treatment due to bone resorption in upper and lower jaws causing mask fitting difficulties, and cannot use oral appliances. 1

• Assume continued OSA risk even in patients who have had corrective airway surgery (uvulopalatopharyngoplasty, surgical mandibular advancement) unless a normal sleep study has been obtained and symptoms have not returned. 1

Common Pitfalls to Avoid

• Do not proceed without screening even if surgery seems minor—shoulder surgery requires significant postoperative analgesia which dramatically increases OSA-related complications. 1

• Do not assume diagnosed OSA is adequately treated—verify CPAP compliance and symptom control, as 50% of patients are poorly compliant. 1

• Do not overlook treatable secondary causes—hypothyroidism and acromegaly can directly cause OSA and treatment improves outcomes beyond CPAP alone. 4

• Do not rely solely on BMI—older adults may have significant OSA without obesity, presenting instead with nocturia, morning headaches, or cognitive impairment rather than classic daytime sleepiness. 2