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## Complete Summary

#### GUIDELINE TITLE

Practice guidelines for the perioperative management of patients with
obstructive sleep apnea: a report by the American Society of
Anesthesiologists Task Force on Perioperative Management of Patients
with Obstructive Sleep Apnea.

#### BIBLIOGRAPHIC SOURCE(S)

Practice guidelines for the perioperative management of patients with
obstructive sleep apnea: a report by the American Society of
Anesthesiologists Task Force on Perioperative Management of Patients
with Obstructive Sleep Apnea. Anesthesiology 2006 May;104(5):1081-93.
\[3 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16645462)

#### GUIDELINE STATUS

This is the current release of the guideline.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references drugs for which important revised regulatory information has
been released:

On April 7, 2005, the U.S. Food and Drug Administration (FDA) asked
manufacturers of non-prescription (over the counter \[OTC\])
non-steroidal anti-inflammatory drugs (NSAIDs) to revise their labeling
to include more specific information about potential gastrointestinal
(GI) and cardiovascular (CV) risks, and information to assist consumers
in the safe use of the drugs. See the [FDA Web
site](http://www.fda.gov/medwatch/SAFETY/2005/safety05.htm#Bextra) for
more information.

Subsequently, on June 15, 2005, the FDA requested that sponsors of all
NSAIDs make labeling changes to their products. FDA recommended proposed
labeling for both the prescription and OTC NSAIDs and a medication guide
for the entire class of prescription products. See the [FDA Web
site](http://www.fda.gov/medwatch/SAFETY/2005/safety05.htm#NSAID) for
more information.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Perioperative complications related to obstructive sleep apnea (OSA)

#### GUIDELINE CATEGORY

Evaluation\
Management\
Prevention\
Risk Assessment

#### CLINICAL SPECIALTY

Anesthesiology\
Internal Medicine\
Obstetrics and Gynecology\
Otolaryngology\
Pediatrics\
Sleep Medicine\
Surgery

#### INTENDED USERS

Advanced Practice Nurses\
Hospitals\
Nurses\
Physician Assistants\
Physicians\
Respiratory Care Practitioners

#### GUIDELINE OBJECTIVE(S)

To improve the perioperative care and reduce the risk of adverse
outcomes in patients with obstructive sleep apnea (OSA) who receive
sedation, analgesia, or anesthesia for diagnostic or therapeutic
procedures under the care of an anesthesiologist

#### TARGET POPULATION

Patients with obstructive sleep apnea (OSA) who may be at increased risk
for perioperative morbidity and mortality because of potential
difficulty in maintaining a patent airway. This population includes but
is not limited to patients who have sleep apnea resulting from obesity,
pregnancy, and other skeletal, cartilaginous, or soft tissue
abnormalities causing upper airway obstruction.

These Guidelines are [not]{.underline} intended for use in patients with
the following:

-   Pure central sleep apnea

-   Abnormalities of the upper or lower airway not associated with sleep
    apnea (e.g., deviated nasal septum)

-   Daytime hypersomnolence from other causes

-   Patients younger than 1 year

-   Obesity in the absence of sleep apnea

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Preoperative Evaluation**

1.  Medical records review

2.  Patient and family interview

3.  Screening questionnaire

4.  Focused physical examination

5.  Sleep study

**Preoperative Preparation**

1.  Preoperative treatment/optimization for obstructive sleep apnea
    (OSA) (e.g., continuous positive airway pressure \[CPAP\],
    noninvasive positive-pressure ventilation \[NIPPV\], mandibular
    appliances, medical treatment)

2.  Consulting the American Society of Anesthesiologists \"Practice
    Guidelines for Management of the Difficult Airway\"

3.  Limiting procedures to facilities with full hospital services

**Intraoperative Management**

1.  Anesthetic technique

    -   Local or regional anesthesia versus general anesthesia

    -   Combined regional and general anesthesia versus general
        anesthesia

    -   Sedation versus general anesthesia

2.  Monitoring

    -   Continuously monitoring the respiratory depressant effects of
        sedatives and/or opioids (e.g., level of consciousness,
        pulmonary ventilation, oxygenation, automated apnea monitoring)

    -   Special intraoperative monitoring techniques (arterial line,
        pulmonary artery catheter)

3.  Extubation

    -   Verifying the full reversal of neuromuscular block before
        extubation

    -   Extubating patients after they are fully awake (versus asleep or
        partially awake)

    -   Extubating patients in the semiupright, lateral, or prone
        positions (versus supine)

**Postoperative Management**

1.  Analgesic use

    -   Regional analgesic techniques without neuraxial opioids versus
        systemic opioids

    -   Neuraxial opioids versus systemic opioids

    -   Oral analgesics versus parenteral opioids

    -   Patient-controlled analgesia (PCA) without a background infusion
        versus PCA with a background infusion

    -   Titration or lower dosage levels of systemic opioids

2.  Oxygenation

    -   Supplemental oxygen versus no supplemental oxygen

    -   CPAP versus no CPAP (oxygen or room air)

    -   CPAP for patients who had previously been on CPAP versus CPAP
        for patients not previously on CPAP

    -   NIPPV versus no NIPPV (CPAP, oxygen, or room air)

3.  Positioning patients in the lateral, prone, or tonsil position
    versus the supine position

4.  Monitoring

    -   Telemetry monitoring systems versus no telemetry monitoring
        systems

    -   Monitored settings versus routine hospital wards

5.  Duration of stay

    -   Extended stay in postanesthesia care unit \[PACU\] versus no
        extended stay in PACU

    -   Hospital admission versus discharge home

#### MAJOR OUTCOMES CONSIDERED

Adverse outcomes in patients with obstructive sleep apnea

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Scientific evidence was derived from aggregated research literature, and
opinion-based evidence was obtained from surveys, open presentations,
and other consensus-oriented activities (e.g., Internet posting). For
purposes of literature aggregation, potentially relevant clinical
studies were identified via electronic and manual searches of the
literature. The electronic and manual searches covered a 53-year period
from 1953 through 2005. More than 2000 citations were initially
identified, yielding a total of 622 nonoverlapping articles that
addressed topics related to the evidence linkages. After review of the
articles, 332 studies did not provide direct evidence and were
subsequently eliminated. A total of 290 articles contained direct
linkage related evidence.

#### NUMBER OF SOURCE DOCUMENTS

A total of 290 articles contained direct linkage related evidence.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

When sufficient numbers of studies are available for evaluation, the
following terms describe the strength of the findings.

*Supportive*: Meta-analyses of a sufficient number of adequately
designed studies indicate a statistically significant relationship (*P*
\< 0.01) between a clinical intervention and a clinical outcome.

*Suggestive*: Information from case reports and descriptive studies
permits inference of a relationship between an intervention and an
outcome. This type of qualitative information does not permit a
statistical assessment of significance.

*Equivocal*: Qualitative data are not adequate to permit inference of a
relationship between an intervention and an outcome and (1) there is
insufficient quantitative information or (2) aggregated comparative
studies have found no significant differences among groups or
conditions.

The *lack* of scientific evidence in the literature is described by the
following terms.

*Silent*: No identified studies address the specified relationship
between an intervention and outcome.

*Insufficient*: There are too few published studies to investigate a
relationship between an intervention and an outcome.

*Inadequate*: The available studies cannot be used to assess the
relationship between an intervention and an outcome. These studies
either do not meet the criteria for content as defined in the Focus of
the original Guideline document, or do not permit a clear causal
interpretation of findings due to methodologic concerns.

#### METHODS USED TO ANALYZE THE EVIDENCE

Meta-Analysis\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

The scientific assessment of these Guidelines was based on evidence
linkages or statements regarding potential relationships between
clinical interventions and outcomes. The interventions were examined to
assess their relationship to a variety of outcomes related to the
management of patients with obstructive sleep apnea (OSA) in the
perioperative setting.

Initially, each pertinent outcome reported in a study was classified as
supporting an evidence linkage, refuting a linkage, or equivocal. The
results were then summarized to obtain a directional assessment for each
evidence linkage before conducting a formal meta-analysis. Literature
pertaining to six evidence linkages contained enough studies with
well-defined experimental designs and statistical information sufficient
for meta-analyses. These linkages were (1) medical records review (OSA
and body mass index; OSA and hypertension); (2) focused physical
examination (OSA associated with neck circumference and various
cephalometric measurements); (3) preoperative treatment/optimization for
OSA (continuous positive airway pressure \[CPAP\] \[nonperioperative
patients\] and apnea-hypopnea index \[AHI\] scores, respiratory
depression index scores, and oxygen saturation levels; nonperioperative
mandibular appliance and AHI scores); (4) postoperative analgesic use
(neuraxial opioids versus systemic opioids \[in non-OSA patients\] and
oxygen saturation levels), postoperative analgesic use (neuraxial
opioids versus systemic opioids \[in non-OSA patients\] and respiratory
depression), and postoperative patient-controlled analgesia \[PCA\]
opioids (background infusion versus no background infusion \[in non-OSA
patients\] and hypoxemia); (5) postoperative oxygenation (supplemental
oxygen versus no supplemental oxygen \[in non-OSA patients\] and
hypoxemia); and (6) postoperative positioning of patients (lateral,
prone, or tonsil versus supine \[nonperioperative patients\] and AHI
scores).

General variance-based effect-size estimates or combined probability
tests were obtained for continuous outcome measures, and Mantel-Haenszel
odds ratios were obtained for dichotomous outcome measures. Two combined
probability tests were used as follows: (1) The Fisher combined test,
producing chi-square values based on logarithmic transformations of the
reported *P* values from the independent studies, and (2) the Stouffer
combined test, providing weighted representation of the studies by
weighting each of the standard normal deviates by the size of the
sample. An odds ratio procedure based on the Mantel-Haenszel method for
combining study results using 2 by 2 tables was used with outcome
frequency information. An acceptable significance level was set at *P*\<
0.01 (one tailed). Tests for heterogeneity of the independent studies
were conducted to assure consistency among the study results.
DerSimonian-Laird random effects odds ratios were considered when
significant heterogeneity was found (*P*\< 0.01). To control for
potential publishing bias, a \"fail-safe n\" value was calculated. No
search for unpublished studies was conducted, and no reliability tests
for locating research results were done.

Meta-analytic results are reported in table 4 of the original guideline
document. To be accepted as significant findings, Mantel-Haenszel odds
ratios must agree with combined test results whenever both types of data
are assessed. In the absence of Mantel-Haenszel odds ratios, findings
from both the Fisher and weighted Stouffer combined tests must agree
with each other to be acceptable as significant.

Interobserver agreement among Task Force members and two methodologists
was established by interrater reliability testing. Agreement levels
using a kappa statistic for two-rater agreement pairs were as follows:
(1) type of study design, kappa = 0.50 to 0.69; (2) type of analysis,
kappa = 0.43 to 0.60; (3) evidence linkage assignment, kappa = 0.88 to
1.00; and (4) literature inclusion for database, kappa = 0.44 to 0.87.
Three-rater chance-corrected agreement values were (1) study design, Sav
= 0.56, Var (Sav) = 0.009; (2) type of analysis, Sav = 0.54, Var (Sav) =
0.011; (3) linkage assignment, Sav = 0.87, Var (Sav) = 0.003; and (4)
literature database inclusion, Sav = 0.58, Var (Sav) = 0.030. These
values represent moderate to high levels of agreement.

Consensus was obtained from multiple sources, including (1) survey
opinion from consultants who were selected based on their knowledge or
expertise in perioperative management of patients with OSA, (2)
testimony from attendees of two publicly held open forums at two
national anesthesia meetings, and (3) Task Force opinion and
interpretation. An initial survey obtained consultant opinions regarding
the management of patients with known or suspected OSA. The survey rate
of return was 65% (n = 69 of 106). Results of this survey are reported
in table 5 and the text of the original guideline document.

A second survey obtained consultant opinions regarding the feasibility
of implementing the Guidelines in relation to their clinical practices.
Results of this survey are reported in the Appendix and table 6 of the
original guideline document.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The American Society of Anesthesiologists appointed a Task Force of 12
members to (1) review the published evidence, (2) obtain the opinion of
a panel of consultants including anesthesiologists and
nonanesthesiologist physicians and researchers who regularly care for
patients with obstructive sleep apnea (OSA), and (3) build consensus
within the community of practitioners likely to be affected by the
Guidelines. The Task Force included anesthesiologists in both private
and academic practices from various geographic areas of the United
States, a bariatric surgeon, an otolaryngologist, and two methodologists
from the American Society of Anesthesiologists Committee on Practice
Parameters.

The Task Force developed the Guidelines by means of a six-step process.
First, they reached consensus on the criteria for evidence of effective
perioperative management of patients with OSA. Second, original
published research studies from peer-reviewed journals relevant to the
perioperative management of patients with OSA were evaluated. Third, the
panel of expert consultants was asked to (1) participate in opinion
surveys on the effectiveness of various perioperative management
strategies for patients with OSA and (2) review and comment on a draft
of the Guidelines developed by the Task Force. Fourth, the Task Force
held open forums at two major national meetings to solicit input on its
draft recommendations. National organizations representing most of the
specialties whose members typically care for patients with OSA were
invited to participate in the open forums. Fifth, the consultants were
surveyed to assess their opinions on the feasibility and financial
implications of implementing the Guidelines. Sixth, all available
information was used to build consensus within the Task Force to
finalize the Guidelines.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

The Task Force used a survey to obtain consultant opinions regarding the
feasibility, including costs, of implementing the Guidelines in relation
to their clinical practices. See Appendix and table 6 of the original
Guideline document for survey results.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The panel of expert consultants was asked to review and comment on a
draft of the Guidelines developed by the Task Force. The Task Force held
open forums at two major national meetings to solicit input on its draft
recommendations. National organizations representing most of the
specialties whose members typically care for patients with OSA were
invited to participate in the open forums. Next, the consultants were
surveyed to assess their opinions on the feasibility and financial
implications of implementing the Guidelines (See Appendix and table 6 of
the original guideline document for survey results). All available
information was used to build consensus within the Task Force to
finalize the Guidelines.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**[Preoperative Evaluation]{.underline}**

Anesthesiologists should work with surgeons to develop a protocol
whereby patients in whom the possibility of obstructive sleep apnea
(OSA) is suspected on clinical grounds are evaluated long enough before
the day of surgery to allow preparation of a perioperative management
plan. This evaluation may be initiated in a preanesthesia clinic (if
available) or by direct consultation from the operating surgeon to the
anesthesiologist. A preoperative evaluation should include a
comprehensive review of previous medical records (if available), an
interview with the patient and/or family, and conducting a physical
examination. Medical records review should include (but not be limited
to) checking for a history of airway difficulty with previous
anesthetics, hypertension or other cardiovascular problems, and other
congenital or acquired medical conditions. Review of sleep studies is
encouraged. The patient and family interview should include focused
questions related to snoring, apneic episodes, frequent arousals during
sleep (vocalization, shifting position, extremity movements), morning
headaches, and daytime somnolence. A physical examination should include
an evaluation of the airway, nasopharyngeal characteristics, neck
circumference, tonsil size, and tongue volume. If any of these
characteristics suggest that the patient has OSA, the anesthesiologist
and surgeon should jointly decide whether to (1) manage the patient
perioperatively based on clinical criteria alone or (2) obtain sleep
studies, conduct a more extensive airway examination, and initiate
indicated OSA treatment in advance of surgery. If this evaluation does
not occur until the day of surgery, the surgeon and anesthesiologist
together may elect for presumptive management based on clinical criteria
or a last-minute delay of surgery. For safety, clinical criteria (see
table 1 of the original Guideline document) should be designed to have a
high degree of sensitivity (despite the resulting low specificity),
meaning that some patients may be treated more aggressively than would
be necessary if a sleep study were available.

The severity of the patient\'s OSA, the invasiveness of the diagnostic
or therapeutic procedure, and the requirement for postoperative
analgesics should be taken into account in determining whether a patient
is at increased perioperative risk from OSA (see table 2 of the original
Guideline document). The patient and his or her family as well as the
surgeon should be informed of the potential implications of OSA on the
patient\'s perioperative course.

**[Preoperative Preparation]{.underline}**

Preoperative initiation of continuous positive airway pressure (CPAP)
should be considered, particularly if OSA is severe. For patients who do
not respond adequately to CPAP, noninvasive positive-pressure
ventilation (NIPPV) should be considered. In addition, the preoperative
use of mandibular advancement devices or oral appliances and
preoperative weight loss should be considered when feasible. A patient
who has had corrective airway surgery (e.g., uvulopalatopharyngoplasty,
surgical mandibular advancement) should be assumed to remain at risk for
OSA complications unless a normal sleep study has been obtained (Young
et al., 1993) and symptoms have not returned. Patients with known or
suspected OSA may have difficult airways and therefore should be managed
according to the \"Practice Guidelines for Management of the Difficult
Airway.\" (\"American Society of Anesthesiologists Task Force on
Management of the Difficult Airway, 2003) In patients at risk for
perioperative complications from OSA, a preoperative determination must
be made regarding whether surgery should be performed on an inpatient or
outpatient basis (see recommendations for Inpatient versus Outpatient
Surgery and Criteria for Discharge to Unmonitored Settings, below).

**[Intraoperative Management]{.underline}**

Because of their propensity for airway collapse and sleep deprivation,
patients at increased perioperative risk from OSA are especially
susceptible to the respiratory depressant and airway effects of
sedatives, opioids, and inhaled anesthetics; therefore, in selecting
intraoperative medications, the potential for postoperative respiratory
compromise should be considered. For superficial procedures, one should
consider the use of local anesthesia or peripheral nerve blocks, with or
without moderate sedation. If moderate sedation is used, ventilation
should be continuously monitored by capnography or another automated
method if feasible because of the increased risk of undetected airway
obstruction in these patients. One should consider administering CPAP or
using an oral appliance during sedation to patients previously treated
with these modalities. General anesthesia with a secure airway is
preferable to deep sedation without a secure airway, particularly for
procedures that may mechanically compromise the airway. Major conduction
anesthesia (spinal/epidural) should be considered for peripheral
procedures. Unless there is a medical or surgical contraindication,
patients at increased perioperative risk from OSA should be extubated
while awake. Full reversal of neuromuscular block should be verified
before extubation. When possible, extubation and recovery should be
carried out in the lateral, semiupright, or other nonsupine position.

**[Postoperative Management]{.underline}**

Regional analgesic techniques should be considered to reduce or
eliminate the requirement for systemic opioids in patients at increased
perioperative risk from OSA. If neuraxial analgesia is planned, weigh
the benefits (improved analgesia, decreased need for systemic opioids)
and risks (respiratory depression from rostral spread) of using an
opioid or opioid--local anesthetic mixture as compared with a local
anesthetic alone. If patient-controlled systemic opioids are used,
continuous background infusions should be used with extreme caution or
avoided entirely. Nonsteroidal antiinflammatory agents and other
modalities (e.g., ice, transcutaneous electrical nerve stimulation)
should be considered if appropriate to reduce opioid requirements.
Clinicians are cautioned that the concurrent administration of sedative
agents (e.g., benzodiazepines, barbiturates) increases the risk of
respiratory depression and airway obstruction.

Supplemental oxygen should be administered continuously to all patients
who are at increased perioperative risk from OSA until they are able to
maintain their baseline oxygen saturation while breathing room air. The
Task Force cautions that supplemental oxygen may increase the duration
of apneic episodes and may hinder detection of atelectasis, transient
apnea, and hypoventilation by pulse oximetry. CPAP or NIPPV, with or
without supplemental oxygen, should be continuously administered when
feasible (e.g., when patients are not ambulating) to patients who were
using these modalities preoperatively, unless contraindicated by the
surgical procedure. Compliance with CPAP or NIPPV may be improved if
patients bring their own equipment to the hospital.

If possible, patients at increased perioperative risk from OSA should be
placed in nonsupine positions throughout the recovery process.
Hospitalized patients who are at increased risk of respiratory
compromise from OSA should have continuous pulse oximetry monitoring
after discharge from the recovery room. Continuous monitoring may be
provided in a critical care or stepdown unit, by telemetry on a hospital
ward, or by a dedicated, appropriately trained professional observer in
the patient\'s room. Continuous monitoring should be maintained as long
as patients remain at increased risk. Intermittent pulse oximetry or
continuous bedside oximetry without continuous observation does not
provide the same level of safety. If frequent or severe airway
obstruction or hypoxemia occurs during postoperative monitoring,
initiation of nasal CPAP or NIPPV should be considered.

**[Inpatient versus Outpatient Surgery and Criteria for Discharge to
Unmonitored Settings]{.underline}**

Before patients at increased perioperative risk from OSA are scheduled
to undergo surgery, a determination should be made regarding whether a
given surgical procedure is most appropriately performed on a given
patient on an inpatient or outpatient basis. Factors to be considered in
determining whether outpatient care is appropriate include (1) sleep
apnea status, (2) anatomical and physiologic abnormalities, (3) status
of coexisting diseases, (4) nature of surgery, (5) type of anesthesia,
(6) need for postoperative opioids, (7) patient age, (8) adequacy of
postdischarge observation, and (9) capabilities of the outpatient
facility. The availability of emergency difficult airway equipment,
respiratory care equipment, radiology facilities, clinical laboratory
facilities, and a transfer agreement with an inpatient facility should
be considered in making this determination.

These patients should not be discharged from the recovery area to an
unmonitored setting (i.e., home or unmonitored hospital bed) until they
are no longer at risk for postoperative respiratory depression. Because
of their propensity to develop airway obstruction or central respiratory
depression, this may require a longer stay as compared with non-OSA
patients undergoing similar procedures. Adequacy of postoperative
respiratory function may be documented by observing patients in an
unstimulated environment, preferably while they seem to be asleep, to
establish that they are able to maintain their baseline oxygen
saturation while breathing room air.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=9308)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

Scientific evidence was derived from aggregated research literature, and
opinion-based evidence was obtained from surveys, open presentations,
and other consensus-oriented activities (e.g., Internet posting). For
purposes of literature aggregation, potentially relevant clinical
studies were identified via electronic and manual searches of the
literature.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Improved perioperative care and reduced risk of perioperative morbidity
and mortality in patients with obstructive sleep apnea (OSA) who receive
sedation, analgesia, or anesthesia for diagnostic or therapeutic
procedures under the care of an anesthesiologist.

#### POTENTIAL HARMS

-   Concurrent administration of sedative agents (e.g., benzodiazepines,
    barbiturates) increases the risk of respiratory depression and
    airway obstruction.

-   Supplemental oxygen may increase the duration of apneic episodes and
    may hinder detection of atelectasis, transient apnea, and
    hypoventilation by pulse oximetry. Continuous positive airway
    pressure (CPAP) or noninvasive positive-pressure ventilation
    (NIPPV), with or without supplemental oxygen, should be continuously
    administered when feasible (e.g., when patients are not ambulating)
    to patients who were using these modalities preoperatively, unless
    contraindicated by the surgical procedure.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   Practice guidelines are systematically developed recommendations
    that assist the practitioner and patient in making decisions about
    health care. These recommendations may be adopted, modified, or
    rejected according to clinical needs and constraints.

-   Practice guidelines are not intended as standards or absolute
    requirements. The use of practice guidelines cannot guarantee any
    specific outcome. Practice guidelines are subject to revision as
    warranted by the evolution of medical knowledge, technology, and
    practice. They provide basic recommendations that are supported by
    analysis of the current literature and by a synthesis of expert
    opinion, open forum commentary, and clinical feasibility data.

-   The Task Force recognizes that it is not possible to determine with
    100% accuracy whether a given patient will develop perioperative
    complications related to obstructive sleep apnea (OSA). Therefore,
    these Guidelines should be implemented with the goal of reducing the
    likelihood of adverse outcomes in patients who are judged to be at
    the greatest risk, with the understanding that it may be impractical
    to eliminate OSA-related perioperative morbidity and mortality
    completely. However, it is hoped that the implementation of these
    Guidelines will reduce the likelihood of adverse perioperative
    outcomes in patients with OSA.

-   Tables 1 and 2 of the original guideline document are meant to serve
    as examples of how patients with OSA might be identified and
    stratified with respect to their perioperative risk. While they were
    developed by the Task Force with input from the consultants and open
    forum participants, these tables are not evidence based and have not
    been clinically validated.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Staff Training/Competency Material

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Safety

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Practice guidelines for the perioperative management of patients with
obstructive sleep apnea: a report by the American Society of
Anesthesiologists Task Force on Perioperative Management of Patients
with Obstructive Sleep Apnea. Anesthesiology 2006 May;104(5):1081-93.
\[3 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16645462)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2006 May

#### GUIDELINE DEVELOPER(S)

American Society of Anesthesiologists - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American Society of Anesthesiologists

#### GUIDELINE COMMITTEE

Task Force on Perioperative Management of Patients with Obstructive
Sleep Apnea

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Task Force Members*: Jeffrey B. Gross, MD (Chair), Farmington,
Connecticut; Kenneth L. Bachenberg, MD, Bellingham, Washington; Jonathan
L. Benumof, MD, San Diego, California; Robert A. Caplan, MD, Seattle,
Washington; Richard T. Connis, PhD, Woodinville, Washington; Charles J.
Coté, MD, Boston, Massachusetts; David G. Nickinovich, PhD, Bellevue,
Washington; Vivek Prachand, MD, Chicago, Illinois; Denham S. Ward, MD,
Rochester, New York; Edward M. Weaver, MD, MPH, Seattle, Washington;
Lawrence Ydens, MD, Santa Fe, New Mexico; Song Yu, MD, Farmington,
Connecticut

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Anesthesiology Journal Web
site](http://www.anesthesiology.org/pt/re/anes/asapractice.htm;jsessionid=G0ZXdq4pTqBQ4kzjqGpfY6s9HdYZvYczHkQyw1XH0bzffbVCVFJS!-801141804!-949856145!8091!-1).

Print copies: Available from the American Society for Anesthesiologists,
520 North Northwest Highway, Park Ridge, IL 60068-2573.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Anestheiology continuing medical education (CME) program. Available
    at <http://www.asahq.org/journal-cme>.

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on June 1, 2006. The information
was verified by the guideline developer on June 8, 2006.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008