Airway Management in Surgical Patients With Obstructive Sleep Apnea

Edwin Seet, MBBS, MMed, FAMS; Mahesh Nagappa, MD; David T. Wong, MD, FRCPC

Disclosures

Anesth Analg. 2021;132(5):1321-1327. 

In This Article

The Association of OSA and Difficult Airway

The association between difficult intubation and OSA was first studied formally by Hiremath et al.[12] In this study, patients with difficult intubation were at increased risk of OSA, where apnea-hypopnea index (AHI) was found to be higher in the difficult intubation group versus the control group (AHI 28.4 events/h versus AHI 5.9 events/h, P < .02).[12]

Siyam and Benhamou[13] conducted a retrospective case-control study and demonstrated that the occurrence of difficult intubation was 8-fold higher in OSA patients compared to patients with no OSA (21.9% vs 2.6%; P < .05). Another retrospective study by Kim and Lee[14] indicated that the occurrence of difficult intubation might be predicted using the AHI, because the severity of the OSA was significantly associated with a higher incidence of difficult intubation in patients undergoing uvulopalatopharyngoplasty. For patients with AHI <40 events/h, the incidence of difficult intubation was 3.3%; for AHI 40–70 events/h, 19.3%; and AHI >70 events/h, 27.6%.[14]

Two large database observational studies by Kheterpal et al[15,16] assessed the incidence of difficult airway in patients with OSA. In the first, a multivariate analysis showed that a history of OSA was an independent risk factor for combined difficult mask ventilation and difficult intubation.[15] In 700 patients with OSA, the occurrence of difficult mask ventilation was 4-fold higher (OSA versus no OSA: 8% vs 2%; odds ratio [OR]: 3.96; confidence interval [CI], 2.9–5.3) and the occurrence of combined difficult mask ventilation and difficult intubation was 5-fold higher in OSA patients compared to non-OSA patients (OSA versus no OSA: 2.5% vs 0.5%; OR: 5.44; 95% CI, 3.2–9.2).[15] The second study, conducted in 2013, was a large multicenter observational study.[16] Of 25,661 OSA patients, the occurrence of combined difficult mask ventilation and difficult laryngoscopy was 3-fold higher in OSA compared to non-OSA patients (OSA versus no OSA: 1% vs 0.3%; OR: 3.7; 95% CI, 3.1–4.3). It has been postulated that reduced oropharyngeal space and/or the presence of increased soft tissue within it, as with a large tongue, are causal attributes for OSA and the difficult airway. A prospective observational study by De Jong et al[17] compared the incidence of difficult intubations in OSA patients in the intensive care unit and in operating theater settings. It was found that in patients with OSA, the incidence of difficult intubation was 3 times higher in the intensive care unit than in the operating theater. Of 63 patients with OSA in the ICU, 24 patients (38%) had difficult intubation; and of 213 OSA patients in the operating theater, 28 patients (13%) had difficult intubation.[17] This suggested that intubation conditions in the ICU were less favorable compared to the operating theater and more attention to OSA and the difficult airway has been paid in the latter circumstance.[17]

In the systematic review and meta-analysis by Nagappa et al,[6] the occurrence of the difficult airway was compared between patients with OSA and those without a prior OSA diagnosis undergoing surgical procedures. Of 72,888 patients, difficult mask ventilation was 3-fold higher in the OSA compared to non-OSA patients (OSA versus non-OSA: 4.48% vs 1.11%: pooled OR 3.39; 95% CI, 2.74–4.18). Similarly, in patients with OSA, the odds for difficult intubation were increased by 3-fold compared to patients without OSA (OSA versus non-OSA: 13.5% vs 2.5%; pooled OR 3.46; 95% CI, 2.32–5.16). For combined difficult mask ventilation and difficult intubation, OSA patients had a 4-fold higher incidence than non-OSA patients (OSA versus non-OSA: 1.11% vs 0.3%: pooled OR 4.12; 95% CI, 2.93–5.79). Even though there was a higher risk of difficult airway in patients with OSA, there was no significant difference in the incidence of supraglottic airway failure rates between the groups.[6]

The available evidence on this topic comprises small prospective studies, case-control studies, and large database studies, with the final estimates consistently indicating an increased risk of difficult airway in patients with OSA. Because it is difficult to conduct a sufficiently powered randomized controlled trial to investigate the association between difficult airway and OSA, the quality of evidence on the association between the OSA and difficult airway was considered as moderate.[11] In 2018, the Society of Anesthesia and Sleep Medicine recommended that known or suspected OSA should be considered as a risk factor for difficult intubation, difficult mask ventilation, or a combination of both.[11] Adequate preparations and difficult airway management precautions should be undertaken in OSA patients.

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