Secondary Logo

Journal Logo

Obstructive sleep apnoea in adults: peri-operative considerationsA narrative review

Roesslein, Martin; Chung, Frances

European Journal of Anaesthesiology: April 2018 - Volume 35 - Issue 4 - p 245–255
doi: 10.1097/EJA.0000000000000765
Review article
Free

Obstructive sleep apnoea (OSA) is a common breathing disorder of sleep with a prevalence increasing in parallel with the worldwide rise in obesity. Alterations in sleep duration and architecture, hypersomnolence, abnormal gas exchange and also associated comorbidities may all feature in affected patients.

The peri-operative period poses a special challenge for surgical patients with OSA who are often undiagnosed, and are at an increased risk for complications including pulmonary and cardiovascular, during that time. In order to ensure the best peri-operative management, anaesthetists caring for these patients should have a thorough understanding of the disorder, and be aware of the individual's peri-operative risk constellation, which depends on the severity and phenotype of OSA, the invasiveness of the surgical procedure, anaesthesia and also the requirement for postoperative opioids.

The objective of this review is to educate clinicians in the epidemiology, pathogenesis and diagnosis of OSA in adults and also to highlight specific tasks in the preoperative assessment, namely to select a suitable intra-operative anaesthesia regimen, and manage the extent and duration of postoperative care to facilitate the best peri-operative outcome.

From the Department of Anesthesiology and Critical Care Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Germany (MR), and Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada (FC)

Correspondence to Martin Roesslein, MD, University Medical Center, Department of Anesthesiology and Critical Care Medicine, Hugstetter Str. 55, D - 79106 Freiburg, Germany Tel: +49 761 270 23 470; fax: +49 761 270 23 930; e-mail: martin.roesslein@uniklinik-freiburg.de

Published online 2 January 2018

Back to Top | Article Outline

Introduction

The prevalence of sleep-related breathing disorders (SBDs) has been increasing in recent years, mainly due to the worldwide rise in obesity and chronic diseases.1–4 Obstructive sleep apnoea (OSA), the most common SBD, is characterised by repetitive obstruction of the upper airway resulting in abnormal ventilation during sleep. Consequently, affected individuals often suffer from sleep fragmentation, hypersomnolence, abnormal gas exchange and also significant cardiovascular and metabolic morbidity.5–10

Surgical patients afflicted with OSA pose a challenge to their treatment providers, as they may be at an increased risk for peri-operative complications.11–19 Furthermore, the disorder may not have been diagnosed preoperatively, potentially aggravating the associated risks.20–22

This review is based on the sources of information currently available within the public domain. It intends to inform on the epidemiology, pathogenesis and diagnosis of OSA in adult surgical patients, and also examine recommended measures for appropriate peri-operative management, including preoperative assessment, selection of suitable intra-operative anaesthesia regimens and for the management of the extent and duration of postoperative monitoring and care.

Back to Top | Article Outline

Definition of obstructive sleep apnoea

The American Academy of Sleep Medicine defines OSA as a disorder with repetitive episodes of complete (apnoea) or partial upper airway obstruction (hypopnoea) during sleep, often resulting in the reduction of blood oxygen saturation and usually terminated by brief arousals.23 The number of these predominantly obstructive respiratory events per hour of sleep determines the apnoea-hypopnoea index (AHI).

The term OSA syndrome refers to the existence of excessive daytime sleepiness or other health consequences of OSA.24 It is considered a chronic disease6 associated with the following cardiovascular and metabolic pathologies:5,23 systemic hypertension, pulmonary hypertension, coronary artery disease, atrial fibrillation, cerebrovascular accidents and type 2 diabetes mellitus.

Back to Top | Article Outline

Epidemiology of obstructive sleep apnoea

Depending on the diagnostic and sample criteria, the prevalence in the general population is estimated to vary between 3 and 24%,25–28 but is generally much higher in patients undergoing surgery (24 to 41%),19,29,30 reaching up to 70% in certain groups such as those seeking bariatric surgery.31 In the majority of cases, the diagnosis has not been established and hence therapy has not been commenced.30,31

Back to Top | Article Outline

Pathogenesis of obstructive sleep apnoea

The pathophysiology of OSA is complex and the underlying mechanisms involve impaired airway anatomy, ineffective control and function of upper-airway dilator muscles and also low arousal thresholds in association with impaired ventilatory control. The fact that these mechanisms seem to affect the genesis of the disease in individual patients to different extents has led to the perception of the existence of different OSA phenotypes.32,33

Being overweight with BMI (≥25 kg m−2) and obese (BMI ≥ 30 kg m−2) seem to be of utmost importance in the development of the disease. This is reflected in the fact that about 70% of OSA patients are overweight or obese; the prevalence of OSA in the obese is about twice as high as in adults of normal weight.4,34 Unsurprisingly, therefore, weight loss has been shown to significantly reduce severity and symptoms of OSA.35

Nonobese patients may suffer from OSA if certain characteristics in craniofacial anatomy are present such as inferior positioning of the hyoid bone, retropositioning of the mandible, an increase in the craniocervical extension angle or craniofacial skeletal restrictions.33,36

Next in importance to alterations in the anatomy of the upper airway, a decreased activity of the involved dilating muscles may contribute to the progression of the disease. In addition, pathological sensory processing of the upper airway leading to decreased stability of ventilatory control seems to be relevant to the pathogenesis.32,33

Back to Top | Article Outline

Diagnosis of obstructive sleep apnoea

According to the International Classification of Sleep Disorders (ICSD-3), diagnosis of OSA requires the following:24

  1. A breathing disorder not caused by another sleep disorder or medical cause or medication or other substances, and
  2. AHI at least 15 or AHI at least 5 in combination with relevant comorbidities.

Patients meeting the diagnostic criteria for OSA have traditionally been classified as having mild, moderate or severe disease on the basis of AHI with symptoms and associated medical complications taken into account.37 While the AHI, with underlying respiratory events that have not been consistently defined, helps to differentiate degrees of OSA severity, it may oversimplify the complex pathophysiology of the disease.2,3 Additional indices from polysomnography (PSG) and/or oximetry such as oxygen desaturation index, cumulative duration of oxygen desaturation less than 90%, the lowest SpO2 and/or mean SpO2 may help to improve the predictive value for postoperative complications in OSA patients.38,39

Back to Top | Article Outline

Peri-operative complications of obstructive sleep apnoea

Surgical patients with OSA undergoing procedures that require the use of opioids and/or general anaesthesia have been demonstrated to have a higher rate of various complications throughout the peri-operative period, mostly evident during the postoperative phase (Table 1).12–19

Table 1

Table 1

Several peri-operative and anaesthetic factors may contribute to these complications:

  1. Medication: drugs commonly used during general anaesthesia (hypnotics, opioids and muscle relaxants) have been shown to have a negative influence on the tone of the upper-airway dilating muscles, the protective airway reflexes, the central respiratory drive and arousability.40,41 Although direct evidence is still lacking, these effects may be of immediate relevance to OSA patients who display compromised upper airway stability and ventilatory control.42,43
  2. Anaesthesia and the patient's position can negatively affect longitudinal traction forces in the trachea, leading to increased pharyngeal closing pressure and collapse of the upper airway.40,44
  3. Narrowing of the upper airway caused by pharyngeal oedema following intubation, haematoma or protracted prone positioning of the patient;21,45
  4. Protracted postoperative supine positioning of the patient leading to decreased airway stability;46
  5. Peri-operative discontinuation of continuous positive airway pressure (CPAP) therapy;47 and
  6. Disruption of sleep architecture favouring apnoeic episodes at night with increased periods of rapid eye movement (REM) following surgery.48

Existing cardiovascular and metabolic comorbidities associated with OSA not only contribute to the peri-operative risk profile of these patients but also make it more difficult to attribute complications to OSA specifically.49–51

Back to Top | Article Outline

Pulmonary complications

In several studies, a diagnosis of OSA has been associated with challenging airway management, including difficult or impossible mask ventilation,52 intubation53–57 or both.58 Interestingly, OSA as a predictor of difficult mask ventilation combined with difficult laryngoscopy seems to be independent of BMI or Mallampati status.58

The reciprocity of this relation is underlined by the fact that patients with unexpected difficult intubation may have previously undiagnosed OSA.59

The risk for pulmonary complications associated with OSA extends into the postoperative period. A meta-analysis was able to associate OSA with a decrease in peripheral oxygen saturation [odds ratio (OR) 2.27; 95% confidence interval (95% CI) 1.20 to 4.26, P = 0.01] and even acute respiratory failure (OR 2.43; CI 1.20 to 4.26, P = 0.01).12

In a large observational study of almost six million cases, orthopaedic and surgical patients suffering from OSA had higher rates of aspiration pneumonia, re-intubation and acute respiratory distress syndrome.14 These findings were confirmed by a recent systematic review that found OSA to be a risk factor for postoperative pulmonary complications in nine out of 15 studies under investigation.18

Back to Top | Article Outline

Cardiovascular complications

The increased risk of OSA patients for peri-operative cardiovascular complications may be due to the haemodynamic, autonomic, inflammatory and metabolic effects of an abnormal breathing and arousal pattern.60

Although not all studies confirmed the significant impact of OSA on postoperative cardiac complications,18 severe undiagnosed OSA was associated with higher rates of cardiac arrest.61 In addition, a meta-analysis demonstrated a higher incidence of postoperative cardiac events, including myocardial ischaemia, arrhythmias and cardiac arrest (OR 2.07; 95% CI 1.23 to 3.50, P = 0.007) in OSA patients.12

Back to Top | Article Outline

Peri-operative mortality

The available data concerning the impact of OSA on peri-operative mortality are inconsistent. There is evidence of an increased, unchanged and even decreased associated risk, something that might be explained by studies with different control groups and different peri-operative management regimens, their use of monitoring and treatment of patients with OSA.16,17,62–64

In this context, some studies have even suggested that the effect of intermittent ischaemia/hypoxia associated with OSA on blood vessel collaterality and production of reactive oxygen species might potentially have protective effects, leading to preconditioning phenomena of the organs at risk.65,66

Back to Top | Article Outline

Preoperative management

Because the preoperative identification of OSA may help to decrease peri-operative complications,61,67,68 patients with suspected or proven OSA should be presented to the anaesthetist as soon as possible in order to facilitate the best peri-operative management.69 Factors that should be taken into consideration when evaluating a patient for OSA preoperatively are listed in Table 2.

Table 2

Table 2

Back to Top | Article Outline

Preoperative screening for obstructive sleep apnoea

Polysomnography and related procedures

Full-night, attended, in-laboratory PSG is regarded as the gold standard in the diagnosis of sleep-related breathing disorders including OSA.24 PSG enables the diagnosis, determines the severity and phenotype of OSA, and allows specific therapy tailored to the underlying cause.32 However, the execution of PSG is associated with logistical and financial expenses and may delay the scheduled surgery.26,27,29 Hence, sleep testing using portable polychannel monitoring devices at home may be appropriate as an alternative in patients with high pretest probability (daytime sleepiness, nocturnal apnoea and snoring).70,71

Back to Top | Article Outline

Screening tools and questionnaires

Patients identified by screening tools as having a high risk for OSA have been shown to be at an increased risk for postoperative complications.29 Therefore, these patients may benefit from further diagnostic evaluation and treatment.72

While preoperative screening has not been shown to reduce complications per se, the recent Society of Anesthesia and Sleep Medicine Guideline on preoperative screening and assessment of patients with OSA indicates that it may guide peri-operative management of patients identified to be at risk towards targeted precautions and interventions.73

Screening tools that have been evaluated in surgical patients with comparable accuracy are the American Society of Anesthesiologists (ASA) checklist,74 the Berlin questionnaire,29,75 Peri-operative Sleep Apnoea Prediction (P-SAP) score76 and the STOP-Bang tool.77

The ASA checklist is categorised under headings: physical characteristics, history of apparent airway obstruction during sleep, and complaints of somnolence requiring a clinician for resolution.74 The sensitivity of the ASA checklist was found to be 79 and 87% at AHI cutoff levels of more than 15 and more than 30, respectively.29

The Berlin questionnaire is a self-reporting instrument validated initially in the primary care setting.75 It consists of questions on snoring, excessive daytime sleepiness, sleepiness while driving, hypertension and information on age, sex, weight, height and neck circumference. A study screening preoperative patients using the Berlin questionnaire determined that it identified preoperative patients with OSA (AHI >5) with a sensitivity of 69% and a specificity of 56%.29 The large number of questions and the rather complicated scoring system are drawbacks of this tool.

The Peri-operative Sleep Apnoea Prediction Score (P-SAP) comprises personal (age, sex, obesity) and clinical (snoring, diabetes mellitus Type 2, hypertension) variables together with qualitatively assessed airway measurements (large neck circumference, modified Mallampati class 3 or 4, reduced thyromental distance).76 Although the implications for the peri-operative setting remain to be elucidated, the score may have the advantage of detecting lower grades of OSA with a relatively high sensitivity depending on the threshold score.

The STOP-Bang tool was developed to screen for OSA quickly and concisely in a presurgical group. STOP is an acronym for the dichotomous OSA predictor variables Snoring, Tiredness, Observed apnoea during sleep and high blood Pressure.

The addition of four variables with the acronym Bang, BMI more than 35 kg m−2, Age more than 50 years, Neck circumference more than 40 cm and male sex, improved the sensitivity to 93%, and 100% at AHI cut-offs of more than 15 and more than 30 respectively.77 STOP-Bang has been validated in different groups, including surgical patients, sleep clinic patients and the general public.78 While lacking subtlety to exclude mild grades of OSA,79 a high score of 5 to 8 correlates well with the probability for moderate to severe OSA.80–82 One retrospective cohort study of over 5000 undergoing elective surgery revealed that the risk of unexpected intra-operative and early postoperative adverse events increased fivefold with STOP-Bang scores at least 5.83 A combination of a STOP score at least 2 and BMI more than 35 kg m−2 or male sex is also associated with a higher risk of OSA.82,84

The current guidelines with the exception of those of the Society of Ambulatory Anesthesia do not provide recommendations for specific screening tests.67,73,85 The set thresholds for screening tests have a direct impact on the sensitivity and specificity, with implications for missed diagnoses with the increased use of resources that entails. In addition, predictive performance is affected by the prevalence of OSA in the population to be screened. All these factors need to be taken into account when screening for OSA preoperatively.73

Back to Top | Article Outline

Preoperative evaluation

Assessing the peri-operative risk of the individual patient with OSA may be quite challenging for the attending anaesthetist. The guidelines of the ASA provide an example of a scoring system to assess this risk (Table 3) that is based on the severity of OSA, the invasiveness of surgery and anaesthesia and the projected requirement for postoperative opioids.67 This scoring system is neither evidence based nor clinically validated, but it may be helpful in the stratification of risk of the individual OSA patient based on the clinical scenario.

Table 3

Table 3

The recent Society of Anesthesia and Sleep Medicine Guideline recommends additional preoperative cardiopulmonary evaluation for a formal diagnosis of OSA in preoperative patients with evidence of uncontrolled systemic disease or problems with ventilation or gas exchange such as hypoventilation syndromes, severe pulmonary hypertension and resting hypoxaemia in the absence of other cardiopulmonary disease.73

Back to Top | Article Outline

Preoperative continuous positive airway pressure therapy

Pneumatic splinting of the airway by applying CPAP is regarded as the gold standard in the treatment for OSA.86 It improves daytime sleepiness, accident risk and quality of life in OSA patients. A majority of studies have also shown that it decreases the risk of several adverse cardiovascular outcomes associated with OSA such as hypertension and atrial fibrillation, especially when OSA was severe and adherence to therapy was good.10,20,87–92

The value of using CPAP prior to hospital admission to prevent postoperative complications is not unequivocally confirmed in published reports.11,13,93–96 As the efficacy of CPAP is proven in a nonsurgical setting, according to several clinical guidelines, its continued preoperative application is recommended and its initiation should be considered in severe cases.67,73 Recent studies show that the effects of CPAP in the preoperative period may extend postoperatively, reducing AHI and also length of stay.47,97

Back to Top | Article Outline

Pharmacological premedication

The administration of anxiolytic and/or sedating medication such as benzodiazepines may expose OSA patients to an additional risk for airway collapse and/or respiratory depression during a period when adequate monitoring may not be available.79

Studies on the use of alpha-2-agonists in this setting are limited in their design and do not show consistent results.43,98,99 One study comparing orally administered clonidine versus placebo in surgical OSA patients was able to demonstrate significantly higher values in the postoperative nadir of oxygen saturation in the clonidine group, possibly due to an analgesic, opioid-sparing effect.99 However, dexmetomidine, another alpha-2-agonist, has been shown to impair ventilatory control in conjunction with upper airway obstruction in healthy individuals without a history of snoring or obesity.98

Pharmacological premedication in OSA patients, irrespective of substance class, should only be applied with extreme caution and when adequate monitoring is available.

A potential algorithm of preoperative risk evaluation is shown in Fig. 1. The algorithm is based on the risk for OSA and whether effective therapy is in place in diagnosed patients. However, it has not been clinically validated and serves only as a guide to aid the clinical decision process. Adjustments need to be made for the individual patient, type of surgery, type of anaesthesia, requirements of postoperative opioids and the healthcare facility.

Fig. 1

Fig. 1

Back to Top | Article Outline

Intra-operative management

Anaesthesia technique

There are insufficient data available regarding the safety of anaesthetic drugs in OSA patients, but due to the mentioned side-effects of intravenous and volatile anaesthetics, the use of local or regional anaesthesia should be considered whenever possible.67 When conducting additional sedation or general anaesthesia, it may be advantageous to use anaesthetic drugs and opioids with a favourable pharmacokinetic profile, that is with a short context-sensitive half-time.79

Back to Top | Article Outline

Use of muscle relaxants

Data regarding the safety of using muscle relaxants in OSA patients are likewise insufficient. Because incomplete reversal of muscle relaxants increases the risk for postoperative pulmonary complications in surgical patients irrespective of OSA status,100 it is prudent to use short-acting muscle relaxants and/or antagonising drugs with a low profile of adverse side-effects in patients suspected or known to have OSA.

In this context, the use of suggamadex, a modified gamma-cyclodextrin able to completely and selectively reverse aminosteroid-induced neuromuscular blockade, may be advantageous, as it has been shown to decrease the incidence of postoperative respiratory complications and related costs in OSA patients in comparison to neostigmine.101

Back to Top | Article Outline

Airway management

In OSA patients according to current guidelines, general anaesthesia with a secured airway is favoured over deep sedation with the airway unsecured.67 Pharyngeal airway size is increased so in preparation for securing the airway anaesthetised OSA patients may benefit from being placed in the sniffing position with elevation of torso and head under close haemodynamic monitoring until the airway is secured. This position reduces the chance of pharyngeal collapse.102,103

When performing awake fibre-optic intubation, topical anaesthesia of the upper airway may impair protective reflexes and lead to airway obstruction after extubation.104,105 If heavy sedation is performed, the use of an oro- or nasopharyngeal airway or CPAP should be considered.67

Back to Top | Article Outline

Postoperative management

Postoperative analgesia

Current data do not permit a consensus as to whether withholding or minimising opioid use leads to fewer postoperative complications irrespective of OSA status.106 However, a prospective observational study found that the cumulative opioid dose during the first 72 h after surgery was one of the factors associated with worsening breathing disorder during sleep as measured by AHI.107

Interestingly, it has been shown that intermittent hypoxia and sleep disruption – both common in postoperative OSA patients – may enhance pain, while intermittent hypoxia may amplify opioid-mediated analgesic effects.42,108 This reflects the complex nature of individual OSA phenotypes, which are influenced by different levels of chemoreflex responsiveness and arousal thresholds.109,110 Accordingly, it seems prudent to individualise therapy and titrate the systemic and neuraxial administration of opioids in these patients.111 A multimodal approach including local anaesthetics, nonopioids and co-analgesics reduces the demand for postoperative opioids and should therefore be considered in this situation. 67,112

Back to Top | Article Outline

Oxygenation

The fact that OSA patients are at an increased risk of hypoxaemia in the early postoperative period may justify the continuous administration of supplementary oxygen until basal levels of oxygen saturation have been reached while breathing room air.48,107 This measure was found to improve oxygenation and decrease AHI in OSA patients without increasing the duration of apnoea-hypopnoea events.113

There are potential risks, however, if oxygen therapy masks apnoea or hypoventilation leading to atelectasis or retention of carbon dioxide. It may be advisable to decrease the level of inspired oxygen as much as adequate saturation allows and monitor adequate ventilation, for example by capnography.114

Back to Top | Article Outline

Postoperative continuous positive airway pressure therapy

A limited number of studies have evaluated the role of postoperative CPAP therapy in OSA patients. A recent prospective, randomised crossover trial in morbidly obese patients with high OSA prevalence demonstrated that overall, postoperative AHI was reduced and opioid-mediated AHI increase was mitigated by CPAP.51 Similarly, a meta-analysis showed that postoperative CPAP therapy decreased AHI and length of hospital stay.47 However, the study failed to demonstrate a significant reduction in postoperative complications due to its relatively small sample size, the overall low incidence of complications and suboptimal CPAP adherence.47 A large retrospective matched-cohort study, however, did demonstrate an increased risk for cardiovascular complications (including cardiac arrest, acute coronary syndrome, cerebrovascular accident and atrial fibrillation/flutter) in undiagnosed OSA patients compared with those who were prescribed CPAP.61 This has been corroborated by a recent study that demonstrated that surgical patients with untreated OSA suffered from more adverse events including myocardial infarction and reintubation than those who were treated with CPAP.68 The advantages of noninvasive positive pressure ventilation over supplementary oxygen in the postoperative period were seen in obese patients with a high prevalence of OSA.115

Measures such as nasal high-flow therapy or incentive spirometry may also prove beneficial in this context but require further investigation.116–118

Current guidelines do recommend immediate postoperative resumption of CPAP therapy – if feasible – or even initiation in patients with recurring respiratory events.67,73,85

Back to Top | Article Outline

Postoperative monitoring

Although OSA patients are at an increased risk for postoperative complications 14–16,119,120 and may benefit from postoperative monitoring,121 it is unclear to what extent and duration it should be sustained.67 This is of interest considering the increasing appearance of these patients in the peri-operative setting against a background of limited healthcare resources.15 In this context, neither using a telemetry-system nor transfer to a monitored setting have shown clear benefit in OSA patients.67 One study indicated that the implementation of a surveillance system using pulse oximetry was associated with a decrease in the number of respiratory events and transfers to an ICU.122 Another investigation demonstrated that patients at risk for OSA who have respiratory events (apnoea, bradypnoea, decreased oxygen saturation) in the immediate postoperative period are at an increased risk for further respiratory complications.123 On the basis of these findings, Fig. 2 shows a possible algorithm for the postoperative management of OSA patients. The algorithm, which has not been clinically validated, is meant only as a guide to clinical decision making. Adjustments need to be made for the individual patient, type of surgery, type of anaesthesia, requirements of postoperative opioids and the healthcare facility.

Fig. 2

Fig. 2

Back to Top | Article Outline

Conclusion

OSA in surgical patients is increasing in prevalence and is associated with an increased risk for various peri-operative complications. Many affected patients are not diagnosed and, hence, therapeutic measures are not in place preoperatively.

Even though the level of evidence for any single intervention is limited, there is broad agreement among expert clinicians that diligent peri-operative management of affected patients may limit the risk for potential complications. This includes early diagnosis and risk evaluation, peri-operative continuation or even commencement of therapy, appropriate anaesthetic regimen including choice of medication and airway management and adequate postoperative monitoring.

While current guidelines do exist, many important questions concerning the peri-operative management of affected patients remain to be elucidated:

  1. To what degree do factors associated with patient, surgery and anaesthesia determine the peri-operative risk of the individual OSA patient?
  2. Which of these factors justifies preoperative optimisation and potential delay of surgery? Would this approach benefit the patient and be cost-effective?
  3. What phenotype characteristics determine pain and opioid responsiveness in the individual OSA patient?
  4. What criteria may be predictive of postoperative complications beyond the immediate recovery period?
  5. How can medical and legal burdens concerning the appropriate use of patient-owned devices in a hospital setting be overcome?

Further work is needed to provide a stronger foundation for current and future recommendations concerning the peri-operative safety in patients with sleep-related breathing disorders.

Back to Top | Article Outline

Acknowledgements relating to this article

Assistance with the review: none.

Financial assistance and sponsorship: none.

Conflicts of interest: MR has received nonrecurring compensation in 2015 for consultatory work for Covidien AG, Switzerland.

FC has received research grant support from Ontario Ministry of Health and Long-Term Care Innovation Fund, University Health Network Foundation, ResMed Foundation, Acacia Pharma and Medtronics. STOP Bang questionnaire: proprietary to University Health Network.

Back to Top | Article Outline

References

1. Franklin KA, Lindberg E. Obstructive sleep apnea is a common disorder in the population-a review on the epidemiology of sleep apnea. J Thorac Dis 2015; 7:1311–1322.
2. Rapoport DM. POINT: is the apnea-hypopnea index the best way to quantify the severity of sleep-disordered breathing? Yes. Chest 2016; 149:14–16.
3. Punjabi NM. COUNTERPOINT: is the apnea-hypopnea index the best way to quantify the severity of sleep-disordered breathing? No. Chest 2016; 149:16–19.
4. Resta O, Foschino-Barbaro MP, Legari G, et al. Sleep-related breathing disorders, loud snoring and excessive daytime sleepiness in obese subjects. Int J Obes Relat Metab Disord 2001; 25:669–675.
5. Drager LF, Togeiro SM, Polotsky VY, Lorenzi-Filho G. Obstructive sleep apnea: a cardiometabolic risk in obesity and the metabolic syndrome. J Am Coll Cardiol 2013; 62:569–576.
6. Heatley EM, Harris M, Battersby M, et al. Obstructive sleep apnoea in adults: a common chronic condition in need of a comprehensive chronic condition management approach. Sleep Med Rev 2013; 17:349–355.
7. Kanagala R, Murali NS, Friedman PA, et al. Obstructive sleep apnea and the recurrence of atrial fibrillation. Circulation 2003; 107:2589–2594.
8. Konecny T, Kara T, Somers VK. Obstructive sleep apnea and hypertension: an update. Hypertension 2014; 63:203–209.
9. Friedman M, Hamilton C, Samuelson CG, et al. Diagnostic value of the Friedman tongue position and Mallampati classification for obstructive sleep apnea: a meta-analysis. Otolaryngol Head Neck Surg 2013; 148:540–547.
10. Somers VK, White DP, Amin R, et al. Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing. J Am Coll Cardiol 2008; 52:686–717.
11. Gupta RM, Parvizi J, Hanssen AD, Gay PC. Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: a case-control study. Mayo Clin Proc 2001; 76:897–905.
12. Kaw R, Chung F, Pasupuleti V, et al. Meta-analysis of the association between obstructive sleep apnoea and postoperative outcome. Br J Anaesth 2012; 109:897–906.
13. Kaw R, Golish J, Ghamande S, et al. Incremental risk of obstructive sleep apnea on cardiac surgical outcomes. J Cardiovasc Surg (Torino) 2006; 47:683–689.
14. Memtsoudis S, Liu SS, Ma Y, et al. Perioperative pulmonary outcomes in patients with sleep apnea after noncardiac surgery. Anesth Analg 2011; 112:113–121.
15. Memtsoudis SG, Stundner O, Rasul R, et al. The impact of sleep apnea on postoperative utilization of resources and adverse outcomes. Anesth Analg 2014; 118:407–418.
16. Mokhlesi B, Hovda MD, Vekhter B, et al. Sleep-disordered breathing and postoperative outcomes after elective surgery: analysis of the nationwide inpatient sample. Chest 2013; 144:903–914.
17. Mokhlesi B, Hovda MD, Vekhter B, et al. Sleep-disordered breathing and postoperative outcomes after bariatric surgery: analysis of the nationwide inpatient sample. Obes Surg 2013; 23:1842–1851.
18. Opperer M, Cozowicz C, Bugada D, et al. Does obstructive sleep apnea influence perioperative outcome? A qualitative systematic review for the society of anesthesia and sleep medicine task force on preoperative preparation of patients with sleep-disordered breathing. Anesth Analg 2016; 122:1321–1334.
19. Vasu TS, Grewal R, Doghramji K. Obstructive sleep apnea syndrome and perioperative complications: a systematic review of the literature. J Clin Sleep Med 2012; 8:199–207.
20. Tregear S, Reston J, Schoelles K, Phillips B. Continuous positive airway pressure reduces risk of motor vehicle crash among drivers with obstructive sleep apnea: systematic review and meta-analysis. Sleep 2010; 33:1373–1380.
21. Gabrielczyk MR. Acute airway obstruction after uvulopalatopharyngoplasty for obstructive sleep apnea syndrome. Anesthesiology 1988; 69:941–943.
22. Sareli AE, Cantor CR, Williams NN, et al. Obstructive sleep apnea in patients undergoing bariatric surgery: a tertiary center experience. Obes Surg 2011; 21:316–327.
23. Abrishami A, Khajehdehi A, Chung F. A systematic review of screening questionnaires for obstructive sleep apnea. Can J Anaesth 2010; 57:423–438.
24. American Academy of Sleep Medicine. International classification of sleep disorders, 3nd ed. Westchester, IL: American Academy of Sleep Medicine; 2014.
25. Kezirian EJ, Maselli J, Vittinghoff E, et al. Obstructive sleep apnea surgery practice patterns in the United States: 2000 to 2006. Otolaryngol Head Neck Surg 2010; 143:441–447.
26. Lee W, Nagubadi S, Kryger MH, Mokhlesi B. Epidemiology of obstructive sleep apnea: a population-based perspective. Expert Rev Respir Med 2008; 2:349–364.
27. Yang YX, Spencer G, Schutte-Rodin S, et al. Gastroesophageal reflux and sleep events in obstructive sleep apnea. Eur J Gastroenterol Hepatol 2013; 25:1017–1023.
28. Young T, Palta M, Dempsey J, et al. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993; 328:1230–1235.
29. Chung F, Yegneswaran B, Liao P, et al. Validation of the Berlin questionnaire and American Society of Anesthesiologists checklist as screening tools for obstructive sleep apnea in surgical patients. Anesthesiology 2008; 108:822–830.
30. Finkel KJ, Searleman AC, Tymkew H, et al. Prevalence of undiagnosed obstructive sleep apnea among adult surgical patients in an academic medical center. Sleep Med 2009; 10:753–758.
31. Ravesloot MJ, van Maanen JP, Hilgevoord AA, et al. Obstructive sleep apnea is underrecognized and underdiagnosed in patients undergoing bariatric surgery. Eur Arch Otorhinolaryngol 2012; 269:1865–1871.
32. Eckert DJ. Phenotypic approaches to obstructive sleep apnoea: new pathways for targeted therapy. Sleep Med Rev 2016; pii: S1087-0792(16)30154-X. doi: 10.1016/j.smrv.2016.12.003. [Epub ahead of print].
33. Subramani Y, Singh M, Wong J, et al. Understanding phenotypes of obstructive sleep apnea: applications in anesthesia, surgery, and perioperative medicine. Anesth Analg 2017; 124:179–191.
34. Romero-Corral A, Caples SM, Lopez-Jimenez F, Somers VK. Interactions between obesity and obstructive sleep apnea: implications for treatment. Chest 2010; 137:711–719.
35. Peppard PE, Young T, Palta M, et al. Longitudinal study of moderate weight change and sleep-disordered breathing. JAMA 2000; 284:3015–3021.
36. Cuccia AM, Campisi G, Cannavale R, Colella G. Obesity and craniofacial variables in subjects with obstructive sleep apnea syndrome: comparisons of cephalometric values. Head Face Med 2007; 3:41.
37. Epstein LJ, Kristo D, Strollo PJ Jr, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009; 5:263–276.
38. Chung F, Zhou L, Liao P. Parameters from preoperative overnight oximetry predict postoperative adverse events. Minerva Anestesiol 2014; 80:1084–1095.
39. Jordan AS, McSharry DG, Malhotra A. Adult obstructive sleep apnoea. Lancet 2014; 383:736–747.
40. Sasaki N, Meyer MJ, Eikermann M. Postoperative respiratory muscle dysfunction: pathophysiology and preventive strategies. Anesthesiology 2013; 118:961–978.
41. Ehsan Z, Mahmoud M, Shott SR, et al. The effects of anesthesia and opioids on the upper airway: a systematic review. Laryngoscope 2016; 126:270–284.
42. Lam KK, Kunder S, Wong J, et al. Obstructive sleep apnea, pain, and opioids: is the riddle solved? Curr Opin Anaesthesiol 2016; 29:134–140.
43. Ankichetty S, Wong J, Chung F. A systematic review of the effects of sedatives and anesthetics in patients with obstructive sleep apnea. J Anaesthesiol Clin Pharmacol 2011; 27:447–458.
44. Isono S. Obstructive sleep apnea of obese adults: pathophysiology and perioperative airway management. Anesthesiology 2009; 110:908–921.
45. Esclamado RM, Glenn MG, McCulloch TM, Cummings CW. Perioperative complications and risk factors in the surgical treatment of obstructive sleep apnea syndrome. Laryngoscope 1989; 99:1125–1129.
46. Neill AM, Angus SM, Sajkov D, McEvoy RD. Effects of sleep posture on upper airway stability in patients with obstructive sleep apnea. Am J Respir Crit Care Med 1997; 155:199–204.
47. Nagappa M, Mokhlesi B, Wong J, et al. The effects of continuous positive airway pressure on postoperative outcomes in obstructive sleep apnea patients undergoing surgery: a systematic review and meta-analysis. Anesth Analg 2015; 120:1013–1023.
48. Chung F, Liao P, Yegneswaran B, et al. Postoperative changes in sleep-disordered breathing and sleep architecture in patients with obstructive sleep apnea. Anesthesiology 2014; 120:287–298.
49. Bahammam A, Delaive K, Ronald J, et al. Healthcare utilization in males with obstructive sleep apnea syndrome two years after diagnosis and treatment. Sleep 1999; 22:740–747.
50. McNicholas WT, Ryan S. Obstructive sleep apnoea syndrome: translating science to clinical practice. Respirology 2006; 11:136–144.
51. Zaremba S, Shin CH, Hutter MM, et al. Continuous positive airway pressure mitigates opioid-induced worsening of sleep-disordered breathing early after bariatric surgery. Anesthesiology 2016; 125:92–104.
52. Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics. Anesthesiology 2009; 110:891–897.
53. Brousseau CA, Dobson GR, Milne AD. A retrospective analysis of airway management in patients with obstructive sleep apnea and its effects on postanesthesia care unit length of stay. Can J Respir Ther 2014; 50:23–26.
54. Corso RM, Piraccini E, Calli M, et al. Obstructive sleep apnea is a risk factor for difficult endotracheal intubation. Minerva Anestesiol 2011; 77:99–100.
55. Iyer US, Koh KF, Chia NC, et al. Perioperative risk factors in obese patients for bariatric surgery: a Singapore experience. Singapore Med J 2011; 52:94–99.
56. Kim JA, Lee JJ. Preoperative predictors of difficult intubation in patients with obstructive sleep apnea syndrome. Can J Anaesth 2006; 53:393–397.
57. Siyam MA, Benhamou D. Difficult endotracheal intubation in patients with sleep apnea syndrome. Anesth Analg 2002; 95:1098–1102. table of contents.
58. Kheterpal S, Healy D, Aziz MF, et al. Incidence, predictors, and outcome of difficult mask ventilation combined with difficult laryngoscopy: a report from the multicenter perioperative outcomes group. Anesthesiology 2013; 119:1360–1369.
59. Chung F, Yegneswaran B, Herrera F, et al. Patients with difficult intubation may need referral to sleep clinics. Anesth Analg 2008; 107:915–920.
60. Bradley TD, Floras JS. Obstructive sleep apnoea and its cardiovascular consequences. Lancet 2009; 373:82–93.
61. Mutter TC, Chateau D, Moffatt M, et al. A matched cohort study of postoperative outcomes in obstructive sleep apnea: could preoperative diagnosis and treatment prevent complications? Anesthesiology 2014; 121:707–718.
62. D’Apuzzo MR, Browne JA. Obstructive sleep apnea as a risk factor for postoperative complications after revision joint arthroplasty. J Arthroplasty 2012; 27:95–98.
63. Lockhart EM, Willingham MD, Abdallah AB, et al. Obstructive sleep apnea screening and postoperative mortality in a large surgical cohort. Sleep Med 2013; 14:407–415.
64. Lyons PG, Zadravecz FJ, Edelson DP, et al. Obstructive sleep apnea and adverse outcomes in surgical and nonsurgical patients on the wards. J Hosp Med 2015; 10:592–598.
65. Lavie L. Oxidative stress in obstructive sleep apnea and intermittent hypoxia–revisited–the bad ugly and good: implications to the heart and brain. Sleep Med Rev 2015; 20:27–45.
66. Lavie L, Lavie P. Ischemic preconditioning as a possible explanation for the age decline relative mortality in sleep apnea. Med Hypotheses 2006; 66:1069–1073.
67. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology 2014; 120:268–286.
68. Abdelsattar ZM, Hendren S, Wong SL, et al. The impact of untreated obstructive sleep apnea on cardiopulmonary complications in general and vascular surgery: a cohort study. Sleep 2015; 38:1205–1210.
69. Cordovani L, Chung F, Germain G, et al. Perioperative management of patients with obstructive sleep apnea: a survey of Canadian anesthesiologists. Can J Anaesth 2016; 63:16–23.
70. Collop NA, Anderson WM, Boehlecke B, et al. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Portable Monitoring Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med 2007; 3:737–747.
71. Qaseem A, Dallas P, Owens DK, et al. Diagnosis of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2014; 161:210–220.
72. Chia P, Seet E, Macachor JD, et al. The association of preoperative STOP-BANG scores with postoperative critical care admission. Anaesthesia 2013; 68:950–952.
73. Chung F, Memtsoudis SG, Ramachandran SK, et al. Society of Anesthesia and Sleep Medicine Guidelines on preoperative screening and assessment of adult patients with obstructive sleep apnea. Anesth Analg 2016; 123:452–473.
74. Gross JB, Bachenberg KL, Benumof JL, et al. 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; 104:1081–1093. quiz 117–118.
75. Netzer NC, Hoegel JJ, Loube D, et al. Prevalence of symptoms and risk of sleep apnea in primary care. Chest 2003; 124:1406–1414.
76. Ramachandran SK, Kheterpal S, Consens F, et al. Derivation and validation of a simple perioperative sleep apnea prediction score. Anesth Analg 2010; 110:1007–1015.
77. Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology 2008; 108:812–821.
78. Nagappa M, Liao P, Wong J, et al. Validation of the STOP-Bang questionnaire as a screening tool for obstructive sleep apnea among different populations: a systematic review and meta-analysis. PLoS One 2015; 10:e0143697.
79. Auckley D, Bolden N. Preoperative screening and perioperative care of the patient with sleep-disordered breathing. Curr Opin Pulm Med 2012; 18:588–595.
80. Chung F, Subramanyam R, Liao P, et al. High STOP-Bang score indicates a high probability of obstructive sleep apnoea. Br J Anaesth 2012; 108:768–775.
81. Farney RJ, Walker BS, Farney RM, et al. The STOP-Bang equivalent model and prediction of severity of obstructive sleep apnea: relation to polysomnographic measurements of the apnea/hypopnea index. J Clin Sleep Med 2011; 7:459–465.
82. Chung F, Abdullah HR, Liao P. STOP-Bang questionnaire: a practical approach to screen for obstructive sleep apnea. Chest 2016; 149:631–638.
83. Seet E, Chua M, Liaw CM. High STOP-BANG questionnaire scores predict intraoperative and early postoperative adverse events. Singapore Med J 2015; 56:212–216.
84. Chung F, Yang Y, Brown R, Liao P. Alternative scoring models of STOP-bang questionnaire improve specificity to detect undiagnosed obstructive sleep apnea. J Clin Sleep Med 2014; 10:951–958.
85. Joshi GP, Ankichetty SP, Gan TJ, Chung F. Society for Ambulatory Anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery. Anesth Analg 2012; 115:1060–1068.
86. Sullivan CE, Issa FG, Berthon-Jones M, Eves L. Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares. Lancet 1981; 1:862–865.
87. Gottlieb DJ, Punjabi NM, Mehra R, et al. CPAP versus oxygen in obstructive sleep apnea. N Engl J Med 2014; 370:2276–2285.
88. Gay P, Weaver T, Loube D, Iber C. Evaluation of positive airway pressure treatment for sleep related breathing disorders in adults. Sleep 2006; 29:381–401.
89. Giles TL, Lasserson TJ, Smith BH, et al. Continuous positive airways pressure for obstructive sleep apnoea in adults. Cochrane Database Syst Rev 2006; Cd001106.
90. Jing J, Huang T, Cui W, Shen H. Effect on quality of life of continuous positive airway pressure in patients with obstructive sleep apnea syndrome: a meta-analysis. Lung 2008; 186:131–144.
91. Qureshi WT, Nasir UB, Alqalyoobi S, et al. Meta-analysis of continuous positive airway pressure as a therapy of atrial fibrillation in obstructive sleep apnea. Am J Cardiol 2015; 116:1767–1773.
92. McEvoy RD, Antic NA, Heeley E, et al. CPAP for prevention of cardiovascular events in obstructive sleep apnea. N Engl J Med 2016; 375:919–931.
93. Kindgen-Milles D, Muller E, Buhl R, et al. Nasal-continuous positive airway pressure reduces pulmonary morbidity and length of hospital stay following thoracoabdominal aortic surgery. Chest 2005; 128:821–828.
94. Liao P, Yegneswaran B, Vairavanathan S, et al. Postoperative complications in patients with obstructive sleep apnea: a retrospective matched cohort study. Can J Anaesth 2009; 56:819–828.
95. Zarbock A, Mueller E, Netzer S, et al. Prophylactic nasal continuous positive airway pressure following cardiac surgery protects from postoperative pulmonary complications: a prospective, randomized, controlled trial in 500 patients. Chest 2009; 135:1252–1259.
96. Mador MJ, Goplani S, Gottumukkala VA, et al. Postoperative complications in obstructive sleep apnea. Sleep Breath 2013; 17:727–734.
97. Chung F, Nagappa M, Singh M, Mokhlesi B. CPAP in the perioperative setting: evidence of support. Chest 2016; 149:586–597.
98. Lodenius A, Ebberyd A, Hardemark Cedborg A, et al. Sedation with dexmedetomidine or propofol impairs hypoxic control of breathing in healthy male volunteers: a nonblinded, randomized crossover study. Anesthesiology 2016; 125:700–715.
99. Pawlik MT, Hansen E, Waldhauser D, et al. Clonidine premedication in patients with sleep apnea syndrome: a randomized, double-blind, placebo-controlled study. Anesth Analg 2005; 101:1374–1380.
100. Murphy GS, Brull SJ. Residual neuromuscular block: lessons unlearned. Part I: definitions, incidence, and adverse physiologic effects of residual neuromuscular block. Anesth Analg 2010; 111:120–128.
101. Unal DY, Baran I, Mutlu M, et al. Comparison of sugammadex versus neostigmine costs and respiratory complications in patients with obstructive sleep apnoea. Turk J Anaesthesiol Reanim 2015; 43:387–395.
102. Isono S, Tanaka A, Ishikawa T, et al. Sniffing position improves pharyngeal airway patency in anesthetized patients with obstructive sleep apnea. Anesthesiology 2005; 103:489–494.
103. Tagaito Y, Isono S, Tanaka A, et al. Sitting posture decreases collapsibility of the passive pharynx in anesthetized paralyzed patients with obstructive sleep apnea. Anesthesiology 2010; 113:812–818.
104. Berry RB, Kouchi KG, Bower JL, Light RW. Effect of upper airway anesthesia on obstructive sleep apnea. Am J Respir Crit Care Med 1995; 151:1857–1861.
105. Deegan PC, Mulloy E, McNicholas WT. Topical oropharyngeal anesthesia in patients with obstructive sleep apnea. Am J Respir Crit Care Med 1995; 151:1108–1112.
106. Liu SS, Wu CL. Effect of postoperative analgesia on major postoperative complications: a systematic update of the evidence. Anesth Analg 2007; 104:689–702.
107. Chung F, Liao P, Elsaid H, et al. Factors associated with postoperative exacerbation of sleep-disordered breathing. Anesthesiology 2014; 120:299–311.
108. Doufas AG, Tian L, Padrez KA, et al. Experimental pain and opioid analgesia in volunteers at high risk for obstructive sleep apnea. PLoS One 2013; 8:e54807.
109. Wang D, Marshall NS, Duffin J, et al. Phenotyping interindividual variability in obstructive sleep apnoea response to temazepam using ventilatory chemoreflexes during wakefulness. J Sleep Res 2011; 20:526–532.
110. Younes M. Role of respiratory control mechanisms in the pathogenesis of obstructive sleep disorders. J Appl Physiol 19852008; 105:1389–1405.
111. Lamarche Y, Martin R, Reiher J, Blaise G. The sleep apnoea syndrome and epidural morphine. Can Anaesth Soc J 1986; 33:231–233.
112. Maund E, McDaid C, Rice S, et al. Paracetamol and selective and nonselective nonsteroidal anti-inflammatory drugs for the reduction in morphine-related side-effects after major surgery: a systematic review. Br J Anaesth 2011; 106:292–297.
113. Liao P, Wong J, Singh M, et al. Postoperative oxygen therapy in patients with OSA: a randomized controlled trial. Chest 2017; 151:597–611.
114. Gaucher A, Frasca D, Mimoz O, Debaene B. Accuracy of respiratory rate monitoring by capnometry using the Capnomask(R) in extubated patients receiving supplemental oxygen after surgery. Br J Anaesth 2012; 108:316–320.
115. El-Solh AA, Aquilina A, Pineda L, et al. Noninvasive ventilation for prevention of postextubation respiratory failure in obese patients. Eur Respir J 2006; 28:588–595.
116. Jensen C, Tejirian T, Lewis C, et al. Postoperative CPAP and BiPAP use can be safely omitted after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2008; 4:512–514.
117. McGinley BM, Patil SP, Kirkness JP, et al. A nasal cannula can be used to treat obstructive sleep apnea. Am J Respir Crit Care Med 2007; 176:194–200.
118. Sowho MO, Woods MJ, Biselli P, et al. Nasal insufflation treatment adherence in obstructive sleep apnea. Sleep Breath 2015; 19:351–357.
119. Rosslein M, Burkle H, Walther A, et al. [Position Paper: perioperative management of adult patients with obstructive sleep apnea in ENT surgery]. Laryngorhinootologie 2015; 94:516–523.
120. Flink BJ, Rivelli SK, Cox EA, et al. Obstructive sleep apnea and incidence of postoperative delirium after elective knee replacement in the nondemented elderly. Anesthesiology 2012; 116:788–796.
121. Bolden N, Smith CE, Auckley D, et al. Perioperative complications during use of an obstructive sleep apnea protocol following surgery and anesthesia. Anesth Analg 2007; 105:1869–1870.
122. Taenzer AH, Pyke JB, McGrath SP, Blike GT. Impact of pulse oximetry surveillance on rescue events and intensive care unit transfers: a before-and-after concurrence study. Anesthesiology 2010; 112:282–287.
123. Gali B, Whalen FX, Schroeder DR, et al. Identification of patients at risk for postoperative respiratory complications using a preoperative obstructive sleep apnea screening tool and postanesthesia care assessment. Anesthesiology 2009; 110:869–877.
124. Kaw R, Pasupuleti V, Walker E, et al. Postoperative complications in patients with obstructive sleep apnea. Chest 2012; 141:436–441.
125. Seet E, Chung F. Management of sleep apnea in adults: functional algorithms for the perioperative period: continuing professional development. Can J Anaesth 2010; 57:849–864.
126. Zaremba S, Mojica JE, Eikermann M. Perioperative sleep apnea: a real problem or did we invent a new disease? F1000Res 2016; 5:pii: F1000 Faculty Rev-48.
    © 2018 European Society of Anaesthesiology