Practice Guidelines for the Perioperative Management of ...

1 SPECIAL ARTICLESA nesthesiology 2006; 104:1081 93 2006 american society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Guidelines for the Perioperative Management ofPatients with Obstructive Sleep ApneaA Report by the american society of Anesthesiologists Task Force onPerioperative Management of Patients with Obstructive Sleep ApneaThis article has been selected for theAnesthesiologyCME Program. After reading the article, go to to take the test and apply forCategory 1 credit. Complete instructions may be found inthe CME section at the back of this guidelinesare systematically developed rec-ommendations that assist the practitioner and patient inmaking decisions about health care. These recommen-dations may be adopted, modified, or rejected accordingto clinical needs and constraints. Practice Guidelines arenot intended as standards or absolute requirements.

2 Theuse of Practice Guidelines cannot guarantee any specificoutcome. Practice Guidelines are subject to revision aswarranted by the evolution of medical knowledge, tech-nology, and Practice . They provide basic recommenda-tions that are supported by analysis of the current liter-ature and by a synthesis of expert opinion, open forumcommentary, and clinical feasibility Definition of Obstructive Sleep ApneaObstructive sleep apnea(OSA) is a syndrome charac-terized by periodic, partial, or complete obstruction ofthe upper airway during sleep. This, in turn, causesrepetitive arousal from sleep to restore airway patency,which may result in daytime hypersomnolence or otherdaytime manifestations of disrupted sleep such as aggres-sive or distractible behavior in children. The airwayobstruction may also cause episodic sleep-associated ox-ygen desaturation, episodic hypercarbia, and cardiovas-cular dysfunction.

3 It is estimated that the adult preva-lence of sleep disordered breathing, as measured in asleep laboratory, is 9% in women and 24% in men,whereas the prevalence of overt OSA has been estimatedto be 2% in women and 4% in figures arelikely to increase as the population becomes older andmore obese. In the Perioperative period, both pediatricand adult patients with OSA, even if asymptomatic,present special challenges that must be systematicallyaddressed to minimize the risk of Perioperative morbid-ity or mortality. It is the opinion of the Task Force thatthe Perioperative risk to patients increases in proportionto the severity of sleep procedures differ among laboratories, it is notpossible to use specific values of indices (such as theapnea-hypopnea index [AHI]) to define the severity ofsleep apnea.

4 Therefore, for the purposes of these Guide-lines, patients will be stratified using the termsmild,moderate, andsevereas defined by the laboratory wherethe sleep study was Purpose of the GuidelinesThe purpose of these Guidelines is to improve the peri-operative care and reduce the risk of adverse outcomes inpatients with OSA who receive sedation, analgesia, or an-esthesia for diagnostic or therapeutic procedures under thecare of an anesthesiologist . The Task Force recognizes thatit is not possible to determine with 100% accuracy whethera given patient will develop Perioperative complicationsrelated to OSA. Therefore, these Guidelines should be im-plemented with the goal of reducing the likelihood ofadverse outcomes in patients who are judged to be at theThis article is featured in This Month in Anesthesiology. Please see this issue of ANESTHESIOLOGY, page 5A.

5 Additional material related to this article can be found on theANESTHESIOLOGYWeb site. Go to , click on Enhancements Index, and then scroll down tofind the appropriate article and link. Supplementary materialcan also be accessed on the Web by clicking on the Arti-clePlus link either in the Table of Contents or in the HTML version of the article. Developed by the american society of Anesthesiologists Task Force on Peri-operative Management of Obstructive Sleep Apnea: Jeffrey B. Gross, (Chair), Farmington, Connecticut; Kenneth L. Bachenberg, , Bellingham,Washington; Jonathan L. Benumof, , San Diego, California; Robert A. Caplan, , Seattle, Washington; Richard T. Connis, , Woodinville, Washington;Charles J. Cote , , Boston, Massachusetts; David G. Nickinovich, ,Bellevue, Washington; Vivek Prachand, , Chicago, Illinois; Denham S.

6 Ward, , Rochester, New York; Edward M. Weaver, , , Seattle, Washing-ton; Lawrence Ydens, , Santa Fe, New Mexico; Song Yu, , Farmington, for publication November 1, 2005. Accepted for publication No-vember 1, 2005. Supported by the american society of Anesthesiologists underthe direction of James F. Arens, , Chair, Committee on Practice by the House of Delegates on October 25, 2005. A complete list ofreferences used to develop these Guidelines is available by writing the AmericanSociety of Anesthesiologists. These Guidelines have been endorsed by the Amer-ican Academy of Sleep Medicine and the american Academy of Otolaryngology Head and Neck Surgery. They have received an Affirmation of Value from theAmerican Academy of reprint requests to the american society of Anesthesiologists: 520 North Northwest Highway, Park Ridge, Illinois 60068-2573.

7 This Practice Guide-lines article, as well as all published ASA Practice Parameters, may be accessed atno charge through the Journal Web site, , V 104, No 5, May 20061081greatest risk, with the understanding that it may be imprac-tical to eliminate OSA-related Perioperative morbidity andmortality completely. However, it is hoped that the imple-mentation of these Guidelines will reduce the likelihood ofadverse Perioperative outcomes in patients with FocusThese Guidelines focus on the Perioperative manage-ment of patients with OSA who may be at increased riskfor Perioperative morbidity and mortality because ofpotential difficulty in maintaining a patent airway. Thispopulation includes but is not limited to patients whohave sleep apnea resulting from obesity, pregnancy, andother skeletal, cartilaginous, or soft tissue abnormalitiescausing upper airway obstruction.

8 Excluded from thefocus of these Guidelines are patients with the follow-ing: (1) pure central sleep apnea, (2) abnormalities of theupper or lower airway not associated with sleep apnea( , deviated nasal septum), (3) daytime hypersomno-lence from other causes, (4) patients younger than 1 yr,and (5) obesity in the absence of sleep ApplicationThese Guidelines apply to both inpatient and outpa-tient settings, and to procedures performed in an oper-ating room, as well as in other locations where sedationor anesthesia is administered. They are directly applica-ble to care administered by anesthesiologists and indi-viduals who deliver care under the medical direction orsupervision of an anesthesiologist . They are also in-tended to serve as a resource for other physicians andpatient care personnel who are involved in the care ofthese patients.

9 In addition, these Guidelines may serve as aresource to provide an environment for safe patient Task Force Members and ConsultantsThe american society of Anesthesiologists appointed aTask Force of 12 members to (1) review the publishedevidence, (2) obtain the opinion of a panel of consultantsincluding anesthesiologists and nonanesthesiologist physi-cians and researchers who regularly care for patients withOSA, and (3) build consensus within the community ofpractitioners likely to be affected by the Guidelines . TheTask Force included anesthesiologists in both private andacademic practices from various geographic areas of theUnited States, a bariatric surgeon, an otolaryngologist, andtwo methodologists from the american society of Anesthe-siologists Committee on Practice Task Force developed the Guidelines by means of asix-step process.

10 First, they reached consensus on the cri-teria for evidence of effective Perioperative Management ofpatients with OSA. Second, original published researchstudies from peer-reviewed journals relevant to the periop-erative Management of patients with OSA were , the panel of expert consultants was asked to (1)participate in opinion surveys on the effectiveness of vari-ous Perioperative Management strategies for patients withOSA and (2) review and comment on a draft of the Guide-lines developed by the Task Force. Fourth, the Task Forceheld open forums at two major national meetings to solicitinput on its draft recommendations. National organizationsrepresenting most of the specialties whose members typi-cally care for patients with OSA were invited to participatein the open forums. Fifth, the consultants were surveyed toassess their opinions on the feasibility and financial impli-cations of implementing the Guidelines .