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INTRODUCTION

Current studies estimate at least 25 million people in the United States have obstructive sleep apnea (OSA), and in the surgical population the incidence of moderate or severe sleep apnea (defined as a respiratory event index [REI] or apnea-hypopnea index [AHI] ≥15) is approximately 30%.1 Sleep apnea is associated with several perioperative complications, including respiratory failure, delirium, major adverse cardiac events, and mortality, and these risks are likely higher among patients with undiagnosed sleep apnea.2 Although OSA is often the primary focus of clinicians, it is important to note that central sleep apnea is also a major source of morbidity and mortality.

A concomitant problem in many OSA patients (but also in those without sleep apnea) is challenging airway management. Difficult bag-mask ventilation and endotracheal intubation should be identified in advance of surgery to allow for appropriate perioperative care planning.

PREOPERATIVE EVALUATION (SEE ALGORITHM IN FIGURE 12-1)

Sleep Apnea

Previously Diagnosed Sleep Apnea

Surgical patients with known sleep apnea require a thorough history and physical exam to document their management requirements and identify evidence suggestive of inadequate treatment. Previous sleep study reports should be obtained and key findings documented for the perioperative care team (Table 16-1). The number of central sleep apneas and variation in AHI by sleep position (supine) and sleep stage (rapid eye movement [REM]) should also be noted since these may influence perioperative management. For patients using noninvasive ventilatory treatment, the ventilation type (positive airway pressure: automatic [APAP], continuous [CPAP], or bilevel [BiPAP]; or adaptive-servo ventilation [ASV]) and settings, compliance with therapy, and need for oxygen supplementation should be determined. Signs and symptoms of sleep apnea, including daytime sleepiness, snoring/gasping during sleep, morning headaches, and poorly controlled hypertension, should be sought even in patients with good treatment compliance since these may indicate a need for therapy adjustment prior to nonurgent surgery.

TABLE 16-1Sleep Study Parameters Associated with Postoperative Complications1,3

Suspected Sleep Apnea

Guidelines from the Society of Anesthesia and Sleep Medicine (SASM) recommend that all surgical patients without diagnosed sleep apnea should be screened for this condition using a standardized tool.4 Although several tools are available, the STOP-BANG questionnaire is the most studied in the perioperative setting and predicts risk of complications (Table 16-2).5 A STOP-BANG score ...

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