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Review
June 27, 2019

Perioperative Care of Patients With Obstructive Sleep Apnea Undergoing Upper Airway Surgery: A Review and Consensus Recommendations

Author Affiliations
  • 1Department of Otorhinolaryngology, OLVG, Amsterdam, the Netherlands
  • 2Department of Otorhinolaryngology, Medical Centre Jan van Goyen, Amsterdam, the Netherlands
  • 3Department of Surgery, Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands
  • 4Department of Otorhinolaryngology–Head and Neck Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
  • 5Translational Neurosciences Research Group, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
  • 6Department of Surgery–Anesthesia and Intensive Care Section, GB Morgagni-L. Pierantoni Hospital, Forlì, Italy
  • 7Department of Anesthesiology and Intensive Care, Klinikum rechts der Isar, Technical University Munich, Germany
  • 8Medical Library, Department of Research and Education, OLVG, Amsterdam, the Netherlands
  • 9Academic Centre for Dentistry Amsterdam, Department of Oral and Maxillofacial Surgery, Amsterdam Universitaire Medische Centra, University of Amsterdam, Amsterdam, the Netherlands
  • 10Department of Otorhinolaryngology–Head and Neck Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
  • 11Keck School of Medicine, University of Southern California, Los Angeles
  • 12Department of Anesthesiology, University Hospital of Antwerp, Antwerp, Edegem, Belgium
  • 13Department of Anesthesiology, AZ Sint Jan, Brugge, Belgium
  • 14Institute of Pneumology, Centre of Sleep Medicine and Respiratory Care, Clinic for Pneumology and Allergology, Bethanien Hospital, University of Cologne, Solingen, Germany
  • 15Department of Otorhinolaryngology–Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
  • 16Department of Pulmonary Medicine and Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
  • 17Department of Otolaryngology, University of Washington, Seattle
  • 18Department of Oral Kinesiology, Academic Centre for Dentistry Amsterdam, Amsterdam, the Netherlands
JAMA Otolaryngol Head Neck Surg. 2019;145(8):751-760. doi:10.1001/jamaoto.2019.1448
Abstract

Importance  To date, no consensus exists regarding optimal perioperative care of patients with obstructive sleep apnea (OSA) undergoing upper airway (UA) surgery. These patients are at risk related to anesthesia and postoperative analgesia, among other risks associated with difficult airway control, and may require intensified perioperative management.

Objective  To provide a consensus-based guideline by reviewing available literature and collecting expert opinion during an international consensus meeting with experts from relevant speciliaties.

Evidence Review  In a consensus meeting conducted on April 4, 2018, a total of 47 questions covering preoperative, intraoperative, and postoperative care were formulated by 12 international experts with extensive clinical experience in the field of UA surgery for OSA. Systematic literature searches were performed by an independent information specialist and 6 researchers according to the Oxford and GRADE systems, and 164 articles published on or before December 31, 2011, were included in the analysis. Two moderators chaired the meeting according to the Amsterdam Delphi Method, including iteration of literature conclusions, expert discussion, and voting rounds. Consensus was reached when there was 70% or more agreement among experts.

Findings  Of 47 questions, 35 led to a recommendation or statement. The remaining 12 questions provided no additional information and were excluded in the judgment of experts. Consensus was reached for 32 recommendations. For 1 question there was less than 70% agreement among experts; therefore, consensus was not achieved. Highlights of these recommendations include (1) postoperative bleeding is a complication described for all types of UA surgery; (2) OSA is a relative risk factor for difficult mask ventilation and intubation, and plans for difficult airway management should be considered and implemented; (3) safe perioperative care should be provided, with aspects such as OSA severity, adherent use of positive airway pressure, type of surgery, and comorbidities taken into account; (4) although there is no direct evidence to date, in patients undergoing UA surgery, preoperative treatment with positive airway pressure may reduce the risk of postoperative airway complications; and (5) alternative pain management options perioperatively to reduce opioid use should be considered.

Conclusions and Relevance  This consensus contains 35 recommendations and statements on the perioperative care of patients with OSA undergoing UA surgery and may be used as a guideline in daily practice.

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