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


OSA is the most common sleep-related breathing disorder, and the difficult airway is perhaps the anesthesiologists' quintessential concern. OSA and the difficult airway share certain similar anatomical, morphological, and physiological features. Individual studies and systematic reviews of retrospective, case-control and large database studies have shown a consistent association between patients with OSA and the difficult airway; OSA patients have a 3- to 4-fold higher risk of difficult intubation, difficult mask ventilation, or a combination of both. For future research, OSA-specific large prospective studies with reduced vulnerability of bias are suggested to confirm and quantify the association between this common sleep disorder and the difficult airway.

Nevertheless, current knowledge strongly suggests that anticipation and proactive perioperative management of the difficult airway should be undertaken in these airway-at-risk patients with OSA. Prudent intraoperative management comprises the use of regional anesthesia where possible, considering an awake intubation technique where there is the presence of notable difficult airway predictors and risk of rapid desaturation following induction of general anesthesia. Familiarity with difficult airway algorithms, cautious extubation, and appropriate postoperative monitoring of patients with OSA are necessary to mitigate perioperative risks.