Postoperative management of adults with obstructive sleep apnea

INTRODUCTION — Obstructive sleep apnea (OSA) is increasing in prevalence [1-3]. The number of perioperative patients with OSA is likely to continue to increase in parallel with the increase in obesity [2,4,5]. OSA leads to perioperative morbidity, such that prompt recognition and treatment is prudent to offset postoperative complications. While a significant proportion of patients who present for surgery have a known diagnosis of OSA, more than one-half do not have a diagnosis in place resulting in challenges in management [6-8].

The postoperative management of patients with OSA (including those with obesity hypoventilation syndrome [OHS]) is reviewed here. The preoperative and intraoperative management of patients with known or suspected OSA and perioperative management of obese patients are reviewed separately. (See "Surgical risk and the preoperative evaluation and management of adults with obstructive sleep apnea" and "Intraoperative management of adults with obstructive sleep apnea" and "Preanesthesia medical evaluation of the patient with obesity" and "Anesthesia for the patient with obesity".)

POSTOPERATIVE COMPLICATIONS — The incidence of perioperative cardiorespiratory complications is greater in patients with OSA compared with those who do not have OSA [9]. Most events (>80 percent) occur in the first 24 hours, such that vigilant monitoring particularly in the early postoperative period is critical. The postoperative 30 day complication rate is also increased in patients with severe unrecognized OSA. Further details regarding the incidence and type of complications that occur postoperatively in patients with OSA are described separately. (See "Surgical risk and the preoperative evaluation and management of adults with obstructive sleep apnea", section on 'Perioperative complications'.)

GENERAL STRATEGIES — General strategies including lateral or semi-upright positioning, pain control, and judicious fluid management apply to all patients with known or suspected OSA throughout their postoperative course.

Our management strategy is keeping with guidelines issued by experts including the American Society of Anesthesiologists, the American Academy of Sleep Medicine, and the Society of Anesthesia and Sleep Medicine [10-19]. A North American OSA registry reported that death and brain damage were more likely to occur with unwitnessed events, no supplemental oxygen, lack of respiratory monitoring, and coadministration of opioids and sedatives. It is important that efforts be directed toward these issues [20]. Thus general recommendations include maintaining a high index of suspicion for OSA in the perioperative patient, careful use of sedative medications including opioids, vigilant monitoring for upper airway obstruction, and an integrated team approach to perioperative management. There is little direct evidence that these precautions improve outcomes, so recommendations are generally based upon indirect evidence, clinical rationale, and expert opinion. Postoperative care should begin in the post-anesthesia care unit (PACU) and continue throughout the patient's stay (if hospitalization is warranted) through recovery at home, since OSA may worsen postoperatively for several days after surgery until normal sleep architecture is restored [21].

Upright positioning — Because the supine position worsens OSA, it is prudent to maintain postoperative OSA patients in the upright or semi-upright position, if not contraindicated by the surgical procedure [17]. The lateral position is an alternative if a semi-upright position is not feasible or tolerated by the patient. (See "Obstructive sleep apnea: Overview of management in adults", section on 'Nonsupine sleep position'.)

Data supporting non-supine positions in this population come partly from studies of nonsurgical patients with OSA that have shown that sleeping in a non-supine position improves the apnea-hypopnea index (AHI) and oxyhemoglobin saturation [22], while a change in position from lateral to supine increases the passive pharyngeal collapsibility [23]. A prospective cohort study in postoperative patients reported that postoperative patients spent a significant proportion of time in the supine position and that the AHI was significantly greater while in this position [21]. In a randomized crossover study of 55 postpartum patients with OSA, 45 degree elevation of the upper body after delivery compared with the supine position reduced the AHI (7.7±2.2 per hour versus 4.5±1.4 per hour) during sleep [24].

The upright position may also potentially help reduce rostral fluid shift and thereby reduce postoperative airway obstruction. (See 'Fluid management' below.)

Pain control — Whenever feasible, we prefer opioid-sparing analgesic techniques to avoid or minimize the postoperative use of opioids [1,17,19]. Patients with OSA may have increased pain perception, and therefore increased analgesic requirements, compared with patients without OSA, as well as enhanced sensitivity to the respiratory depressant effects of opioids [25]. These combined effects may predispose patients with OSA to postoperative respiratory depression, particularly in the first 24 hours after surgery [26,27].

Benefits of multimodal analgesia were reported in a large population-based retrospective cohort study of postoperative analgesia in over 180,000 patients with OSA who underwent total knee or total hip arthroplasty [28]. Multimodal analgesia in this study was defined as opioid use with the addition of one, two, or more analgesic modalities including nonsteroidal antiinflammatory drugs, cyclooxygenase-2 inhibitors, acetaminophen, peripheral nerve blocks, glucocorticoids, gabapentin or pregabalin, or ketamine. Compared with opioid analgesia alone, multimodal analgesia with two or more additional modalities was associated with decreased odds of critical care admission (odds ratio [OR] 0.60, 95% CI 0.48-0.75), mechanical ventilation (OR 0.23, 95% CI 0.16-0.32), and gastrointestinal complications (OR 0.65, 95% CI 0.53-0.78) and resulted in a 15 percent reduction in opioid prescription dose on postoperative day 1.

Opioid-sparing techniques are especially useful in patients who complain of pain when aroused but are otherwise sedated (ie, they have concurrent high pain and sedation scores). This "pain-sedation mismatch" identifies patients with OSA who are at risk for airway obstruction or respiratory failure, and should also be considered in determining the level of monitoring needed if opioids are used in these patients (algorithm 1). (See 'Discharge from the post-anesthesia care unit' below.)

Opioid-sparing techniques include the following:

●Nonopioid analgesics include nonsteroidal antiinflammatory drugs (NSAIDs), acetaminophen, and selective cyclooxygenase-2 (COX-2) inhibitors. Analgesic adjuvants such as ketamine, dexmedetomidine, and clonidine may also decrease postoperative opioid requirements [29,30]. (See "Approach to the management of acute pain in adults".)

●The use of regional analgesia with local anesthetic (eg, peripheral nerve blocks, epidural analgesia) may also decrease or eliminate the need for opioid administration. Peripheral nerve blocks with long-acting local anesthetics or infusions via continuous catheters may provide analgesia for several hours to days. (See "Approach to the management of acute pain in adults", section on 'Regional anesthesia techniques'.)

●Additional recommendations for the management of postoperative pain in the obese patient are provided separately. (See "Anesthesia for the patient with obesity", section on 'Management of postoperative pain'.)

While these techniques decrease the need for opioids, some patients need additional analgesia, which may be provided with low doses of systemic or neuraxial opioids. A low-dose epidural infusion with a lipophilic opioid (eg, fentanyl or sufentanil) may cause less respiratory depression than intravenous opioids [17,31]. Patients who receive epidural or intrathecal bolus doses of more hydrophilic opioids (ie, morphine or hydromorphone) should be monitored for delayed respiratory depression for 24 hours after the dose [32,33]. The incidence of cardiorespiratory complications after administration of neuraxial opioids in patients with OSA is unknown and the literature on this issue is limited. A 2013 systematic review included five studies (two retrospective chart reviews and three case reports) and 121 patients with OSA who had received neuraxial opioids [34]. Six major cardiorespiratory complications were reported among five (4.1 percent) patients, including three deaths, one cardiorespiratory arrest, and two episodes of severe respiratory depression. (See "Continuous epidural analgesia for postoperative pain: Technique and management", section on 'Monitoring during epidural analgesia'.)

Regardless of the route of opioid administration, the lowest effective dose should be used with vigilant monitoring for respiratory depression. The majority of respiratory depression events occur within 24 hours of surgery, with one closed claims analysis concluding that most events were probably preventable with increased vigilance and monitoring of oxygenation and ventilation [35]. Thus, vigilance should be maintained throughout the patient's postoperative recovery period. After leaving a closely monitored environment (eg, PACU or intensive care unit), continuous infusions of opioids is contraindicated when patient-controlled analgesia is used. (See "Use of opioids for postoperative pain control", section on 'Patient controlled analgesia'.)

In patients with OSA who are receiving systemic opioids, concurrent administration of sedatives (eg, anxiolytics) should be avoided, if feasible, to minimize the risk of respiratory depression and upper airway collapse. Clinicians should anticipate respiratory depression when these drug combinations are used, by providing more intensive monitoring and ensuring the availability of specific antagonists (ie, naloxone [for opioids], flumazenil [for benzodiazepines]). Likewise, combination therapy with gabapentinoids should be used with caution because of its association with postoperative respiratory depression [36]. In an analysis of 72 cases of patients with OSA, death or brain damage was more common in patients who received sedatives in addition to opioids, compared with patients who received opioids without sedatives (OR 4.133, 95% CI 1.34-12.7) [20].

The interactions between nocturnal hypoxemia and sleep disruption from untreated OSA, postoperative pain, opioid analgesia, and the role of positive airway pressure (PAP) therapy are unclear [37]. On one hand, sleep disruption and intermittent hypoxia may worsen postoperative pain [38], and sleep restoration with continuous PAP (CPAP) treatment in OSA patients may reduce pain sensitivity [39]. In contrast, a retrospective study of bariatric patients with OSA reported that chronic intermittent hypoxemia was associated with reduced opioid consumption in the postoperative period [40]. Further research in this field is necessary to explore these interactions.

Fluid management — Many experts believe that patients with OSA may benefit from a restrictive or goal-directed strategy for perioperative fluid therapy, and from fluids with relatively lower salt content (ie, Ringer's Lactate or Plasmalyte) rather than normal saline.

The rationale for this approach is based upon the observations that intravenous fluids with a high salt content (eg, normal saline), the supine position, and compression stockings, all common in the perioperative period, may together potentially result in rostral fluid shifts, thereby predisposing to airway collapse in the postoperative OSA patient [41,42]. Postoperatively, and when feasible, we prefer that patients with OSA be positioned upright or semi-upright to ameliorate this phenomenon. Whether adopting this approach or utilizing crystalloids with lower salt content leads to improved outcomes is unknown. Further details regarding restrictive and goal-directed fluid management and the pathogenesis of rostral fluid shifts are discussed separately. (See "Intraoperative fluid management", section on 'Restrictive (zero-balance) strategy' and "Intraoperative fluid management", section on 'Goal-directed fluid therapy' and "Pathophysiology of upper airway obstruction in obstructive sleep apnea in adults", section on 'Rostral fluid displacement'.)

Positive airway pressure therapy

General considerations — The routine use of postoperative noninvasive PAP therapy, typically CPAP, depends upon whether or not patients have a known diagnosis of OSA and are adherent to therapy preoperatively. In a prospective study of 132 surgical patients with a preoperative diagnosis of OSA and a CPAP prescription, approximately 61 percent of patients reported using the CPAP device ≥4 hours per night preoperatively [43].

We suggest the routine use of PAP therapy postoperatively in patients with a known diagnosis of OSA who are compliant preoperatively with PAP. For patients without a diagnosis of OSA, or those who have diagnosed OSA but are noncompliant with or intolerant of PAP therapy, we suggest using PAP selectively, when hypoxemia, airway obstruction, apnea, or hypoventilation occur. PAP therapy is preferably started in the PACU and continued on the floor through recovery and discharge home. PAP should be in place whenever the patient is resting in bed and likely to sleep, since postoperative patients often sleep during the day. While on PAP therapy, it is prudent that patients be monitored for oxygenation and ventilation as outlined below. (See 'Post-anesthesia care unit management' below.)

Patients who are intolerant of PAP therapy in the PACU or on the floor can be successfully managed with maneuvers such as adjusting the mask (eg, full-face mask if there is either nasal packing or a nasogastric tube in place) and adding heated humidification and a pressure ramp [44-47]. Thus, using PAP requires that nurses and respiratory therapists be available and trained to assist patients so that compliance can be achieved. (See "Titration of positive airway pressure therapy for adults with obstructive sleep apnea", section on 'Choosing the correct patient-device interface' and "Titration of positive airway pressure therapy for adults with obstructive sleep apnea", section on 'Factors that influence initial success' and "Titration of positive airway pressure therapy for adults with obstructive sleep apnea".)

The use of CPAP seems to be safe in the perioperative setting. Despite concerns that PAP therapy might lead to anastomotic leaks after upper gastrointestinal surgery, in a systematic review of 13 observational studies (5500 patients) who underwent gastric bypass surgery, postoperative noninvasive positive ventilation was not associated with increased risk of anastomotic dehiscence [48]. (See "Bariatric surgery: Postoperative and long-term management", section on 'In-hospital postoperative care' and "Bariatric operations: Early (fewer than 30 days) morbidity and mortality", section on 'Pulmonary complications'.)

Quite often, clinicians adhere to guideline recommendations poorly, with one study reporting that less than 20 percent of patients with a diagnosis of OSA are observed in a high acuity care setting or receive CPAP therapy [5]. Similarly, another review reported that only one-third to two-thirds of patients who were on home CPAP received postoperative CPAP during their hospitalization [49].

Known OSA on treatment — Patients on home PAP should be instructed to bring their devices to the hospital for continuation in the postoperative period to facilitate use. PAP therapy, typically CPAP, should be initiated in the PACU (if feasible) at the level previously prescribed. However, adjustments may need to be made to the settings to account for perioperative changes such as facial swelling, upper airway edema, fluid shifts, pharmacotherapy, and respiratory function [18]. If the previously prescribed level is not known, it is reasonable to begin CPAP at an empiric level of 8 to 10 cm H₂O and then titrate the level until apneas, episodes of oxyhemoglobin desaturation, and snoring are eliminated. Alternatively, auto-titrating CPAP is increasingly being used to eliminate the need for manual titration [47,50,51]. However, there are no data to support superiority of any one of these strategies over the other.

Patients likely to benefit the most from PAP include those with severe OSA (eg, AHI >30 events per hour) and those with concomitant OHS or chronic obstructive pulmonary disease (COPD) [49]. However, even in these populations, evidence of improved outcomes with the routine use of CPAP perioperatively is limited, with mixed outcomes from studies that use both preoperative and postoperative PAP support rather than either method alone [17,47,50,52-59]:

●One meta-analysis of six studies reported that there was no difference in postoperative complications between patients receiving CPAP or no CPAP; although postoperative AHI was lower and there was a trend towards shorter hospital length of stay (0.4 days) in those using CPAP [53]. However, the analysis was fundamentally limited by a small sample size, mixed populations of suspected and known OSA, suboptimal adherence to CPAP in the perioperative period, and a low incidence of postoperative complications.

●In contrast, two large cohort studies, neither of which were included in the above meta-analysis, reported that CPAP treatment was associated with a reduction in cardiovascular complications in patients with known or suspected OSA [54,55].

•One study of over 2000 surgical patients with known or suspected OSA reported that compared with treated OSA, untreated OSA was independently associated with more cardiopulmonary complications (7 versus 4 percent) particularly unplanned reintubations and myocardial infarction [55].

•In the other study, patients with undiagnosed OSA had a higher rate of postoperative cardiac arrest and shock, compared with those who had a known diagnosis who underwent treatment [54].

Several other retrospective studies have shown similar benefits [50,56-59]. These data, together with indirect data that support the use of PAP therapy in postoperative patients who do not have OSA but are at high risk of pulmonary complications [44-46,60], further support the routine use of CPAP in postoperative patients with OSA.

●Although guidelines suggest initiating PAP as soon as is feasible, the value of initiating PAP in the PACU is poorly studied. One retrospective series demonstrated successful resumption of PAP therapy in the PACU for patients with OSA after bariatric surgery and these patients had a similar rate of postoperative complications compared with patients without OSA [61].

The PAP mode of choice is usually that administered preoperatively, which in most cases is CPAP, although some patients with concomitant OHS or COPD may be on bilevel PAP (BPAP). Switching to BPAP (with a spontaneous/timed mode) is appropriate in those who develop hypoventilation as a complication of their surgery. For patients on oral devices for OSA treatment, the device should be applied in the PACU, if feasible; PAP is an alternative. (See "Mode selection for titration of positive airway pressure in adults with obstructive sleep apnea".)

Untreated OSA — Patients with a known diagnosis of OSA who are noncompliant or intolerant of PAP therapy preoperatively should be treated similarly to those with suspected OSA. (See 'Suspected OSA' below.)

Suspected OSA — In patients with suspected OSA or those with a diagnosis who are noncompliant or intolerant of PAP preoperatively, we use PAP selectively when periods of hypoxemia, obstruction, apnea, or hypoventilation occur. Most clinicians choose CPAP as the preferred empiric mode of noninvasive PAP for patients with OSA with the sole goal being maintenance of upper airway patency. However, BPAP may be more appropriate in those with obesity, or medication-related hypoventilation. BPAP settings are empirically adjusted based on oxygenation (by oximetry) and patient comfort with PAP, respiratory effort, and presence of breakthrough snoring. Auto-titrating PAP (APAP) may be an option for those not tolerating CPAP with several studies reporting successful application of empiric APAP in the perioperative setting with improved saturation and AHI [47,50,51].

It is uncertain whether patients with undiagnosed or untreated OSA who have not used CPAP preoperatively benefit from its postoperative use; literature on this issue is limited. In an open-label trial of 177 patients with moderate to severe OSA (AHI >15 events/hour) who had not used CPAP previously, those treated with perioperative APAP (initiated two to three days before surgery and continued five days afterward) had improved oxygenation and reduced postoperative AHI (preoperative 30.1 versus postoperative 3.0 events/hour) compared with OSA patients not treated with APAP (preoperative AHI 30.4 versus postoperative 31.9 events/hour), but conclusions in this study were limited by small sample sizes [50].

POST-ANESTHESIA CARE UNIT MANAGEMENT — In addition to the general strategies (upright positioning, pain control, fluid management, and positive airway pressure [PAP] therapy), post-anesthesia care unit (PACU) management of the postoperative OSA patient mostly centers on adequate oxygenation and maintaining airway patency for ventilation. Postoperative areas should be prepared and equipped to detect respiratory depression early and intervene with airway and ventilatory support, and antagonist medications (eg, naloxone, flumazenil), as needed. Most patients should be monitored for at least 60 minutes after usual PACU discharge criteria are met [62]. In cases reported to the OSA Death or Near Miss Registry, death or brain damage was less common in patients with respiratory monitoring (OR 0.109; 95% CI, 0.031-0.384) , and was also less common in patient who received supplemental oxygen (OR 0.227; 95% CI, 0.070-0.740) [20].

Oxygen therapy — Oxygen therapy is routine for adults in most postoperative recovery areas [63]. However, compared with those without OSA, the incidence of perioperative peripheral oxygen desaturations and respiratory complications are higher in patients with OSA, with the highest risk in those who have obesity hypoventilation syndrome (OHS) and the overlap syndrome (chronic obstructive pulmonary disease [COPD] plus OSA). Thus, oxygen therapy is often prolonged, and there is consequently a greater need for close monitoring with continuous pulse oximetry than for patients without OSA [17]. (See "Pulse oximetry".)

The purpose of oxygen supplementation is to eliminate perioperative desaturation. However, the risk of oxygen delivery in patients with OSA is that it may worsen hypoventilation, particularly in patients with concurrent OHS and COPD [64]. A strategy of titrated low-flow oxygen that achieves adequate oxygenation (eg, >90 percent) and avoids acute hypercapnia from hypoventilation is prudent (see "The evaluation, diagnosis, and treatment of the adult patient with acute hypercapnic respiratory failure", section on 'Titration of oxygen' and "Treatment and prognosis of the obesity hypoventilation syndrome", section on 'Oxygen alone'). In support of this strategy, a prospective randomized-controlled trial of postoperative patients with newly diagnosed untreated OSA reported that compared with no oxygen, oxygen therapy via nasal prongs decreased the apnea-hypopnea index (AHI) and improved oxygenation [65]. However, 11 percent of patients showed elevated arterial carbon dioxide, indicating respiratory depression. Thus, additional methods for detecting hypoventilation should be used for patients with OSA (see 'Ventilatory monitoring' below).  

Supplemental oxygen in the PACU is gradually decreased until the patient is able to maintain adequate oxygenation on room air when left unstimulated. Patients with OSA may become hypoxemic only when sleeping, so it is best to observe the patient in a quiet location. Patients who desaturate when left undisturbed should either remain in the PACU or be monitored by continuous pulse oximetry when transferred to the hospital ward (algorithm 1). (See 'Discharge from the post-anesthesia care unit' below.)

In surgical patients receiving opioids who may have respiratory depression, nasal high-flow oxygen/air may provide respiratory support, improve oxygenation, and overcome the obstructive hypopneas. Small studies of adults and children with OSA suggest that high flow nasal oxygen may be beneficial [66,67]. (See "Overview of the management of postoperative pulmonary complications", section on 'Postoperative respiratory failure' and "Heated and humidified high-flow nasal oxygen in adults: Practical considerations and potential applications".)

Ventilatory monitoring — While not routine for non-OSA patients, we suggest that patients with known or suspected OSA who receive supplemental oxygen should be specifically monitored for ventilation in the PACU and continued on the floor [68,69]. Ventilation can be monitored with clinical evaluation, continuous measurement of respiratory rate, or end-tidal carbon dioxide (CO₂) monitoring (ie, capnography); in addition, we have a low threshold to obtain an arterial blood gas.

●Clinical – Respiratory events (eg, oxygen saturation <90 percent, bradypnea <8 breaths/minute, apnea ≥10 seconds) have been shown in one study to be valuable indicators of hypoventilation in postoperative patients with OSA [62]. (See "The evaluation, diagnosis, and treatment of the adult patient with acute hypercapnic respiratory failure", section on 'When to suspect acute hypercapnia'.)

●Capnography – Assessment of ventilation with capnography, when available, has a high sensitivity and rapid response time for detection of respiratory depression [70]. In a prospective cohort study of 250 patients in PACU, capnography was able to detect respiratory adverse events earlier than standard monitoring [71]. However, it may be less accurate in the spontaneously-breathing patient and mouth breathers compared with intubated patients where measurements are made via the endotracheal tube. (See "Carbon dioxide monitoring (capnography)".)

●Arterial blood gas analysis – When quantitative assessment is needed, arterial blood gas measurement provides the most precise measure of ventilation. (See "Arterial blood gases".)

●Others – While use of chest wall impedance (detected by electrocardiography) is widespread in many PACUs, it has low to moderate sensitivity and low reliability for the detection of hypoventilation. This is because impedance devices may register respirations despite complete airway obstruction if a patient continues to make respiratory effort; skilled clinical assessments are therefore required to assure actual air movement (eg, by auscultation of lung sounds or fogging of the face mask).

The identification of hypercapnia is an indication for reduction in supplemental oxygen (if feasible), application of noninvasive ventilation, and rarely re-intubation and mechanical ventilation, the details of which are discussed separately. (See "The evaluation, diagnosis, and treatment of the adult patient with acute hypercapnic respiratory failure", section on 'Initial bedside therapies'.)

Discharge from the post-anesthesia care unit — Timing of discharge from the PACU and disposition (home, unmonitored hospital location, or monitored hospital location) should take into account underlying risk (eg, severity of OSA, high-risk surgery, inability to use postoperative continuous PAP [CPAP], need for opioid-based postoperative analgesic regimen) and clinical events occurring in the PACU. Patients at low risk for complications (eg, mild OSA, minor surgery, low-dose postoperative opioid requirement) who do not have respiratory events in the PACU may generally be discharged to home or to an unmonitored hospital bed. In contrast, patients at high risk of complications (eg, severe OSA, major surgery, high-dose and/or frequent parenteral postoperative opioid requirement) should be admitted to a monitored bed (algorithm 1).

Additional events in an unmonitored environment have been shown to lead to poor outcomes [16,17,62]. Thus, it is prudent to prolong intensive monitoring of patients at higher risk by delaying discharge to home or admitting to a monitored environment with continuous oximetry and possibly capnography such as a telemetry floor or the intensive care unit. Objective data regarding risk factors for adverse events after discharge from the PACU are lacking. Experts have created algorithms and scoring systems that can be used to determine which patients would benefit from continued monitoring [16,17,62]. We consider any one of the following factors to prompt continued monitoring (algorithm 1) [72,73]:

●Recurrent respiratory events in the PACU (more than one of the following per 30 minute period) [1,62]

•Oxygen saturation <90 percent

•Bradypnea <8 breaths/minute (three separate episodes)

•Apnea ≥10 seconds

●High concurrent pain and sedation scores (pain-sedation mismatch)

●Moderate to severe OSA, either known or suspected on the basis of preoperative screening (see "Surgical risk and the preoperative evaluation and management of adults with obstructive sleep apnea", section on 'Screening with a questionnaire')

●OHS and overlap syndrome (combination of COPD and OSA)

●Major invasive surgery (affecting the airway, respiratory, neurologic or cardiovascular systems, eg, ear, nose, and throat [ENT]; neurosurgery; thoracic; upper abdominal; major orthopedic)

●Significant comorbidities (eg, heart failure, arrhythmias, uncontrolled hypertension, pulmonary hypertension, cerebrovascular disease, metabolic syndrome)

●Use of medications that increase OSA symptoms (eg, parenteral or neuraxial opioids or higher oral doses)

●History of noncompliance with CPAP therapy

FLOOR MANAGEMENT — Postoperative disruption in sleep architecture leading to an increased apnea-hypopnea index (AHI) occurs in patients with OSA for a minimum of three days postoperatively. In one observational study, disturbance in sleep architecture was greatest on postoperative night 1, with rapid eye movement (REM) sleep recovering on postoperative night 3; however, the AHI was greatest on postoperative night 3 and did not normalize until several nights later [21]. It is likely that patients continue to be at increased risk until they are no longer taking opioid medications and have returned to normal sleep architecture. During this time, patients should continue to avoid supine positioning if possible, wean pain medications if feasible, and maintain continuous positive airway pressure (CPAP) or oral device use whenever sleep is likely, including daytime sleep.

Continued monitoring of oxygen and ventilation — Recommendations and guidelines regarding continuous oximetry after discharge from the post-anesthesia care unit (PACU) are largely opinion-based [68,69]. Continuous pulse oximetry and ventilation may be monitored at the bedside in a critical care or stepdown unit, on a hospital ward outfitted with remote telemetry, or by a dedicated and trained observer in the patient's room. The optimal method must be selected on a case-by-case basis after considering the severity of the OSA, type of operation performed, opioid and sedative requirements, and available resources. Importantly, postoperative positive airway pressure (PAP) use, supplemental oxygen, and central respiratory monitoring are not completely protective against catastrophic events [20].

Ideally, continuous pulse oximetry and ventilatory monitoring should continue until the patient is no longer considered at high risk as evidenced by:

●Low requirement for opioid analgesics and sedatives

●Ad lib sleep positioning (ie, the patient is no longer confined to the supine position during sleep)

●Adequate oxygenation (ie, an oxyhemoglobin saturation >90 to 92 percent [or the patient's baseline] on room air while awake and asleep)

●Maintenance of clear mental status

●Satisfactory resumption of PAP therapy or oral appliance therapy during sleep

Optimal postoperative monitoring may be challenging because of the large number of patients with known/suspected OSA, the limited availability of monitored beds, and the emphasis on reduced hospital length of stay.

Postoperative delirium — For patients with OSA who develop postoperative delirium, management should be similar to patients without OSA, with the addition of CPAP. Management of postoperative delirium is discussed in detail separately. (See "Diagnosis of delirium and confusional states" and "Delirium and acute confusional states: Prevention, treatment, and prognosis" and "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies".)

FOLLOW-UP — The same principles of management including limited opioid analgesia, positioning, and positive airway pressure (PAP) therapy while sleeping are all appropriate during recovery once discharged to home. It is prudent to have a responsible adult be available so that should a respiratory event occur, medical personnel can be alerted promptly.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Sleep-related breathing disorders in adults".)

SUMMARY AND RECOMMENDATIONS

●General considerations

•The incidence of perioperative complications is greater in patients with obstructive sleep apnea (OSA) compared with those who do not have OSA, such that prompt recognition and treatment of OSA is appropriate. Management recommendations are generally based upon indirect evidence, clinical rationale, and expert opinion with limited data demonstrating conclusive proof of improved outcomes. (See 'Introduction' above and 'Postoperative complications' above.)

•In patients with OSA, general management strategies include semi-upright or upright positioning, opioid-sparing analgesic techniques, and avoidance of concurrent administration of sedatives. A restrictive or goal-directed strategy for perioperative fluid therapy using fluids with relatively lower salt content (ie, Ringer's Lactate or Plasmalyte rather than normal saline) is preferred to avoid rostral fluid shifts in the neck. (See 'Upright positioning' above and 'Pain control' above and 'Fluid management' above.)

●Postoperative positive airway pressure (PAP) therapy

•In postoperative patients with a known diagnosis of OSA who are treated preoperatively with noninvasive PAP, we suggest the routine application of PAP therapy rather than no PAP (Grade 2C).

•In those without a diagnosis of OSA or in those who have a diagnosis but are noncompliant or previously intolerant with therapy preoperatively, we suggest PAP only in those who exhibit postoperative periods of hypoxemia, obstruction, apnea, or hypoventilation rather than the routine administration of PAP (Grade 2C).

PAP therapy should be started as soon as is feasible after surgery, preferably in the post-anesthesia care unit (PACU) and continued on the floor through recovery and discharge home. (See 'Positive airway pressure therapy' above.)

●Postoperative monitoring

•Patients with known or suspected OSA should be monitored in the PACU with continuous pulse oximetry. A strategy of titrated low-flow oxygen that achieves adequate oxygenation (eg, >90 percent) and avoids acute hypercapnia from hypoventilation is prudent. Supplemental oxygen is gradually decreased until the patient is able to maintain adequate oxygenation on room air when left unstimulated. Patients with supplemental oxygen should also be specifically monitored for ventilation with methods including clinical evaluation, continuous measurement of respiratory rate or end-tidal carbon dioxide (CO₂) monitoring (ie, capnography), and a low threshold to obtain an arterial blood gas. (See 'Post-anesthesia care unit management' above.)

•Timing of discharge from the PACU and disposition (home, unmonitored hospital location, or monitored hospital location) should take into account underlying risk (eg, severity of OSA, high-risk surgery, inability to use postoperative PAP, postoperative opioid use) and clinical events occurring in the PACU. The threshold to admit to a monitored environment should be low (algorithm 1). (See 'Discharge from the post-anesthesia care unit' above.)

●Discontinuation of postoperative measures – In patients with OSA, disturbance in sleep architecture is greatest during the first three days. Patients should continue to avoid supine positioning, wean pain medications, and maintain PAP use during sleep (including daytime sleep) until normal sleep architecture is resumed and the patient is off all opioids. (See 'Follow-up' above.)