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

Anesthesia Technique

Obviating the Need for Airway Manipulation

In some situations, airway management issues may be circumvented, favoring the safe conduct of surgery. Various options involving nonmanipulation of the upper airway for intraoperative anesthesia should be considered, such as regional anesthesia techniques and judicious use of minimal and moderate sedation. There is a moderate level of evidence to favor the use of regional anesthesia in patients with OSA.[11] From retrospective studies, intraoperative neuraxial anesthesia was found to be associated with a lower incidence of major complications (eg, requirement for mechanical ventilation, intensive care services, postoperative pulmonary complications) compared to when general anesthesia was administered in joint arthroplasty patients.[30,31] Certain anxiolytic agents may have a safer profile with less respiratory depression and upper airway obstruction effects, as well as better maintenance of airway patency. These include ketamine and dexmedetomidine,[11,32,33] and should be titrated as required utilizing lower doses. Conversely, patients with OSA may be at increased risk of desaturation and other adverse respiratory events from the use of intravenous propofol and benzodiazepine for sedation.[11,21] Continuous oxygenation and ventilation monitoring are recommended during procedural sedation in patients with OSA.[22]

Awake Intubation

In the situation where general anesthesia is necessary or preferable due to surgical considerations and where there is a known difficult airway, evidence of multiple predictors of a difficult airway or risk of rapid desaturation, an awake tracheal intubation (ATI) technique may be favored. The Difficult Airway Society published airway management guidelines for ATI in 2020.[34] If performed correctly, the ATI technique confers an element of safety because airway patency is maintained and the patient is breathing spontaneously. The intubationist would therefore be able to manage the airway in an unhurried manner.

Supplemental oxygen (high-flow or low-flow nasal oxygen) and administration of effective topicalization (lidocaine maximum dose of <9 mg/kg lean body weight) are recommended.[34] Sedation should not be a substitute for ineffective airway topicalization with minimal sedation administered judiciously, preferably by an independent anesthesiologist (Table). Remifentanil and dexmedetomidine are viable options due to lower oversedation risk.[35] ATI using either flexible bronchoscopy, or videolaryngoscopy, or as a combined technique are feasible options with comparable success rate.[36] Current evidence does not support any particular videolaryngoscope as having an advantage; familiarity with the device would be a more important consideration.[34]

Asleep Intubation

Adequate preparation for difficult airway in a patient suspected or diagnosed with OSA is the prerequisite to successful airway management—with the availability of skilled assistance, onsite difficult airway cart, and supplemental oxygen administration.[3] Preoxygenation should be strictly observed to delay the onset of hypoxia, targeted to an end-tidal oxygen fraction of 0.87–0.90.[4] Apneic oxygenation techniques (eg, nasal cannula 15 L·min−1 insufflation) have been found from randomized trials and meta-analysis to be useful in increasing the safe apnea period and reducing hypoxemia in obese patients and emergency intubations, respectively (Table).[37–39] Other useful difficult airway techniques include adopting the head-elevated laryngoscopy position (alignment of ear and sternal notch) for patients with OSA who have concurrent obesity. This serves a 2-fold purpose of increasing the functional residual capacity during preoxygenation and improving the laryngoscopic view.[40]

The airway manager and the assisting team should be familiar with difficult airway algorithms.[3,4] The benefits of videolaryngoscopy include improved visualization of the larynx and increased intubation success.[3] These advantages may make using videolaryngoscope-assisted intubation from the outset a reasonable airway management option. Videolaryngoscopes and supraglottic airway devices may be useful in failed initial intubation attempts and rescue ventilation.[4] The latter may be used as a conduit for intubation. If videolaryngoscopy fails, consideration should be given for hybrid techniques, such as (1) videolaryngoscopy and flexible bronchoscopic intubation and (2) supraglottic airway device and flexible bronchoscopic intubation. Some of the newer second-generation supraglottic airway devices are purpose-made to permit the direct passage of a sufficiently sized adult endotracheal tube with flexible bronchoscopic guidance, such as the LMA Protector™a, or Ambu AuraGain™. These are preferred to utilizing an intermediate exchange catheter (eg, LMA Unique™b, LMA ProSeal™c).

Two-hand facemask ventilation techniques may be necessary in the difficult mask ventilation situation, where the thenar eminence grip has been found to be superior compared to the conventional E-C clamp grip.[41] In a cannot-intubate-cannot-oxygenate scenario with deep paralysis by rocuronium, high-dose sugammadex (16 mg/kg) has been shown to bring about the reversal of paralysis within 3 minutes of administration.[42] In situations where reversal of paralysis is unsuccessful in averting the cannot-intubate-cannot-oxygenate scenario, timely surgical or front-of-neck access should be performed. The Difficult Airway Society suggests the scalpel-bougie technique;[4] yet, which front-of-neck access technique to use would be dependent on the availability of equipment, training, and familiarity. For patients with concomitant obesity and OSA, a cutdown may be required.[4]

Other General Principles and Considerations

The anesthesia technique used should aim toward minimizing respiratory depression and upper airway obstruction postsurgery by avoiding carry-over sedation. With this goal in mind, short-acting intravenous-cum-inhalational agents and multimodal analgesia may be used, including but not restricted to utilization of remifentanil infusions, desflurane, dexmedetomidine, ketamine, acetaminophen, nonsteroidal anti-inflammatory drugs, dexamethasone, intravenous lidocaine, and peripheral nerve blocks.[11,18,19] Opioids and gabapentinoids should be administered sparingly and with caution because these may cause airway obstruction, suppress arousal responses, and depress respiratory drive (Table).[11,22,43,44]

Gastroesophageal reflux disease (GERD) has been found to be associated with OSA.[45] If GERD is suspected to be present, preanesthesia administration of gastric acid–reducing agents (H2-receptor antagonists, proton pump inhibitors), rapid sequence induction, and induction with cricoid pressure may be considered to mitigate the risk of aspiration.[19]

Emergence From Anesthesia and Extubation

A corollary for OSA patients with difficult initial airway management is an anticipated difficult extubation course. This is especially so if the patient has concurrent obesity and risks of pulmonary aspiration of gastric contents. Other red flags would be difficult mask ventilation and/or tracheal intubation at induction. To avoid postextubation airway obstruction, particular attention should be given for extubation, with verification of neuromuscular blockade reversal (with a quantitative train-of-four monitor) and performance in a semiupright position with the patient cooperative and fully conscious.[19,22] The Difficult Airway Society has promulgated guidelines on dealing with such situations, where awake extubation on remifentanil infusions, insertion of airway exchange catheters, and transition to supraglottic airway–guided extubation may be utilized (Table).[46]

OSA patients who have undergone upper airway surgery are particularly at risk of postextubation complications because of bleeding, edema, or anatomical distortion associated with the procedure on the background of a difficult airway. According to a consensus publication on the care of patients with OSA undergoing upper airway surgery, both OSA and upper airway surgery are risk factors for difficult extubation, and postextubation monitoring is recommended.[18] In some cases, such as after base-of-tongue intervention and invasive lower pharyngeal airway surgery, there is an established increased risk of bleeding, edema, and airway obstruction.[18]

Patients at higher risk of postoperative airway complications should be monitored for oxygenation and ventilation for a longer period in the postanesthesia care unit and, subsequently, a high acuity area, with the accessibility of expeditious intervention.[19,22] These would comprise patients with severe OSA, uncontrolled comorbidities, nonadherence to perioperative positive airway pressure therapy, particular types of surgery (eg, upper gastrointestinal, thoracic, upper airway surgeries), and the need for higher dose postoperative intravenous opioids for analgesia.[19,22] Patient's own positive airway pressure therapy should be recommenced at previously prescribed settings during sleep as soon as deemed feasible.[19,21,22]

aLMA Protector is a registered trademark of Teleflex Incorporated or its affiliates.
bLMA Unique is a registered trademarks of Teleflex Incorporated or its affiliates.
cLMA ProSeal is a registered trademarks of Teleflex Incorporated or its affiliates.