Does obstructive sleep apnea (OSA) require treatment prior to surgery?

From the Guidelines

Sleep apnea should be treated before surgery whenever possible to minimize the risk of perioperative complications. Patients with known or suspected sleep apnea should be evaluated and optimized prior to elective procedures, as untreated sleep apnea increases the risk of perioperative complications including respiratory depression, difficult intubation, cardiac arrhythmias, and postoperative complications 1. Treatment typically involves continuous positive airway pressure (CPAP) therapy, which should be used consistently for at least several weeks before surgery if time permits. For patients already on CPAP, they should bring their device to the hospital for use immediately after surgery.

Key Considerations

• In urgent surgical situations where prior treatment isn't possible, extra precautions should be taken, including careful airway management, judicious use of sedatives and opioids, and enhanced postoperative monitoring.
• The anesthesia team should be informed about the sleep apnea diagnosis, as they may modify anesthetic techniques accordingly.
• This approach is necessary because sleep apnea causes intermittent hypoxia and sympathetic activation, which can worsen with anesthesia and pain medications that suppress respiratory drive.

Evidence-Based Recommendations

• A prospective multicenter study analyzed the preoperative sleep study results of 1218 patients without a prior diagnosis of OSA who were scheduled for major noncardiac surgery, and found that 67.6% were assigned a new diagnosis of previously recognized OSA, 30.5% had at least moderate OSA, and 11.2% had severe OSA 1.
• The study also found that patients with severe OSA had an increased risk of the composite outcome of myocardial injury, cardiac death, heart failure, thromboembolism, atrial fibrillation, and stroke within 30 days of surgery.
• Although prospective evidence to support routine OSA screening before surgery is lacking, the increased prevalence of OSA in surgical patients with cardiovascular disease and potential for benefit with OSA treatment provide a reasonable rationale for OSA screening before noncardiac surgery 1.

From the Research

Importance of Treating Sleep Apnea Pre-Operatively

• Sleep apnea is a common disorder that can increase the risk of postoperative complications, intensive care unit admission, and length of hospital stay 2, 3.
• The perioperative use of continuous positive airway pressure (CPAP) therapy has been shown to improve oxygenation and reduce the need for reintubation and mechanical ventilation after surgery 2.
• CPAP therapy can also reduce apnea and hypopnea frequency and related hypoxemia after surgery, highlighting the importance of treating sleep apnea pre-operatively 2.

Screening for Sleep Apnea

• Screening for obstructive sleep apnea (OSA) before surgery is crucial to identify patients at risk and reduce perioperative complications 4.
• The STOP questionnaire is a concise and easy-to-use screening tool to identify patients with a high risk of OSA, and incorporating BMI, age, neck size, and gender into the STOP questionnaire (STOP-Bang) can further increase the sensitivity and negative predictive value 4.

Treatment Options for Sleep Apnea

• CPAP is the golden standard treatment for moderate to severe OSA, but bilevel positive airway pressure (BPAP) is potentially capable of treating OSA at a lower mean pressure than CPAP and can help augment ventilation via pressure support 5.
• Other modes of positive airway pressure therapy, such as autotitrating CPAP, adaptive servoventilation, and volume-assured pressure support, can also be used to control airflow and pressure 6.

Pre-Operative Management

• Adequate screening of patients preoperatively and initiation of CPAP therapy perioperatively could prevent serious complications, including hypoxemia, arrhythmias, myocardial infarction, and respiratory arrest 3.
• Recognition of OSA during conscious sedation or in the perioperative period is important to prevent the occurrence of adverse outcomes, and sedative, analgesic, and anesthetic agents used perioperatively play a major role in the development of sleep-disordered breathing during the postoperative period 3.