Airway Management in Surgical Patients With Obstructive Sleep Apnea

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


Anesth Analg. 2021;132(5):1321-1327. 

In This Article

Predicting the Difficult Airway in Patients With OSA

Quantitative meta-analysis evidence has demonstrated that patients with a known diagnosis of OSA have a 3- to 4-fold increased risk of either tracheal intubation and/or mask ventilation (Table).[6,11] Patients suspected of and previously diagnosed with OSA have a higher incidence of difficult airway because characteristics of a difficult airway share common morphological features with patients with OSA—a reduced skeletal structure (cervico-maxillomandibular enclosure) and/or increased oropharyngeal soft tissue. This combination results in a pharyngeal-anatomical imbalance.[7] Features associated with OSA (eg, increase in neck circumference, short thyromental distance, large tongue, snoring) are also known predictors for the difficult airway.[16]

A commonly used bedside screening test for OSA is the STOP-Bang (Snoring, Tiredness, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference, and Gender) questionnaire,[25] which consists of an 8-point dichotomous assessment where a score of ≥3 places a patient at risk of OSA. Higher STOP-Bang scores of ≥3 correlated with difficult airway prediction in obese patients,[26] and may be a useful tool to predict difficulty in intubation.[27] In addition, front of neck access would be expected to be difficult if the OSA patient has a large neck circumference.

A retrospective review of the legal literature over a 20-year period (1991–2010) in patients suspected or known to have OSA undergoing surgical procedures revealed that severe complications (death and hypoxic brain injury) were because of the difficult airway.[28] More than one-third were from otorhinolaryngology and OSA-related operations.[28] It would be prudent, therefore, to regard OSA-related upper airway surgeries as a predictor for the difficult airway. Drug-induced sleep endoscopy is a commonly used method used by otorhinolaryngologists in the evaluation of upper airway obstruction for patients with OSA.[29] These images and recordings may be a useful adjunct in characterizing the pattern of upper airway obstruction, visualization of supraglottic structures, assessing intraluminal anatomy, and thereby anticipating difficulties in airway management.