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Key Points

  • Patients with obstructive sleep apnea (OSA) demonstrate an increased sensitivity to sedative-hypnotic medications, opioids, and inhaled anesthetics.
  • OSA is independently associated with a difficult airway and adequate precautions are warranted.
  • Enhanced postoperative monitoring is needed in view of the higher risk of postoperative cardiorespiratory complications and increased resource utilization.

Intraoperative Considerations1,2

  • Airway management
    • OSA is an independent risk factor for difficult mask ventilation and intubation. Preparation for anticipated difficult bag-mask ventilation, supraglottic airway insertion, laryngoscopy, intubation, or surgical airway access should be considered on a case-by-case basis.
  • Hypnotic/sedative medications
    • OSA leads to an increased susceptibility to upper airway collapsibility and respiratory depression caused by propofol, benzodiazepines and inhalational agents. The risk is accentuated in the setting of use of multiple central nervous system depressant medications.
    • There is a lack of evidence to assess the residual effects of inhaled anesthetic agents, ketamine, and α-2 agonists in the OSA population.
  • Opioids
    • Patients with OSA are at an increased risk of opioid-induced respiratory depression.
    • An altered pain perception and increased opioid potency should be anticipated in these patients.
  • Neuromuscular blockade
    • Patients with OSA are at an increased risk of postoperative residual neuromuscular blockade, postoperative apneas and hypopneas, hypoxemia, or respiratory failure.
  • Anesthesia technique
  • Regional anesthesia is preferable, whenever applicable. Low-dose intrathecal morphine (100 mcg) has been found to reduce systemic opioids, and to be safe in observational studies.
    • Local anesthesia, peripheral nerve blocks, neuraxial anesthesia with or without moderate sedation should be considered for superficial surgical procedures.
      Patients should be monitored continuously with capnography during moderate sedation.
    • General anesthesia with a secure airway is preferable to deep sedation without an advanced airway.
  • Emergence
    • Potential difficult extubation should be anticipated.
    • Patients with OSA should be extubated when fully awake, if not contraindicated.
    • Complete reversal of neuromuscular blockade with objective neuromuscular monitoring should be verified before extubation.
    • Patients with OSA should be extubated in the semi-sitting position and recovered in the semi-sitting or lateral positions when possible.

Airway Management Strategies2

  • Specific predictors of a difficult airway
    • High risk of OSA on screening questionnaires
    • Crowded oropharynx, large neck circumference, short neck
    • Moderate to severe OSA
    • Head and neck surgery
  • The American Society of Anesthesiologists difficult airway guidelines should be followed.
  • An awake intubation should be considered if the patient has a known difficult airway or there is a high index of suspicion for difficult airway.
    • Judicious sedation should be provided by an independent anesthesiologist.
    • Supplemental oxygen should be administered throughout the intubation attempt.
    • The airway should be adequately topicalized with a local anesthetic.
    • Patients with OSA are at a higher risk of obstructive events following sedative and anxiolytic medication.
    • There is a higher risk of difficult surgical airway access.
  • For asleep intubation
    • The availability of skilled help should be ensured.
    • The difficult airway cart should be present in the operating room.
    • Adequate preoxygenation should be performed.
    • Use of apneic oxygenation techniques (nasal cannula, high-flow nasal oxygen) should be considered.
    • The patient should be positioned in the head-up position
    • Two-handed mask ventilation may be necessary.
    • Sugammadex should be available for immediate reversal of rocuronium paralysis in case of a cannot-intubate cannot-oxygenate scenario.

Postoperative Considerations1,2

  • Postoperative analgesia
    • The risks and benefits of neuraxial opioids should be weighed against local anesthetics alone.
    • If using neuraxial opioids, enhanced postoperative monitoring should be arranged to detect delayed respiratory depression.
    • If patient-controlled systemic opioids are used, continuous background infusions should be avoided.
    • The increased risk of respiratory depression when using sedative agents and opioids concurrently should be considered.
    • Multimodal analgesia regimens are preferred.
  • Supplemental oxygen and pulse oximetry
    • Supplemental oxygen should be administered continuously in the postoperative period, until the patient returns to baseline oxygen saturation on room air.
    • Continuous pulse oximetry is recommended as long as patients remain at increased risk.
  • Positioning in recovery
    • Nonsupine positions are preferred whenever feasible.
  • Continuous positive airway pressure (CPAP)
    • CPAP should be used continuously during the postoperative period in patients using CPAP preoperatively.
    • CPAP or noninvasive positive pressure ventilation should be initiated in the setting of frequent or severe airway obstruction or hypoxemia.
  • Postoperative disposition
    • Postoperative disposition depends upon the type of surgery, OSA severity and treatment, parenteral opioid requirements, and occurrence of respiratory events in postanesthesia care unit (PACU).
    • Patients with diagnosed or suspected OSA should be monitored in the PACU after having received deep sedation or general anesthesia.
    • Patients at an increased risk for respiratory compromise should be monitored carefully for signs of respiratory depression and transferred to a postoperative monitored bed (telemetry utilizing oximetry, or minute ventilation, step-down bed, or intensive care unit).

Principles of Perioperative OSA Management3-5

  • Avoid sedative premedication
  • Use regional anesthesia techniques, if possible
  • Anticipate a difficult airway
  • Consider preoxygenation, head-up positioning, rapid sequence induction and preoperative proton pump inhibitors
  • Use short-acting agents like remifentanil, propofol, etc.
  • Use benzodiazepines cautiously
  • Minimize and objectively monitor neuromuscular blocking agents and completely reverse before extubation
  • Extubate once awake, conscious, able to obey commands, and maintain a patent airway
  • Recover in semi-upright or lateral position after extubation
  • Use multimodal techniques for analgesia


  1. Memtsoudis SG, Cozowicz C, Nagappa M, et al. Society of Anesthesia and Sleep Medicine guidelines on intraoperative management of adult patients with obstructive sleep apnea. Anesth Analg. 2018;127(4):967-87. PubMed
  2. Cozowicz C, Memtsoudis SG. Perioperative management of the patient with obstructive sleep apnea: A narrative review. Anesth Analg. 2021;132(5):1231-43. PubMed
  3. Seet E, Nagappa M, Wong D. Airway Management in surgical patients with obstructive sleep apnea. Anesth Analg 2021; 132 (5): 1321-7. PubMed
  4. Singh M, Pappu A, Chung F. Basics of Sleep Medicine and Anesthesia. In: Miller RD, editor(s). Miller’s Anesthesia Review. 4th edition. (United States): Elsevier; 2022 (in press).
  5. Singh M, Chung F. Basics of Sleep Medicine and Anesthesia. In: Miller RD, editor(s). Basics of Anesthesia. 8th edition. (United States); Elsevier, Philadelphia, PA. 2022. 855-73.