TABLE IX.B.1a.

Evidence for perioperative outcomes associated with OSA and upper airway surgery

Study	Year	LOE	Study design	Study groups	Clinical endpoint	Conclusion
Opperer et al.468	2016	2a	SR	OSA (n = 413,304) and non-OSA (n = 8,556,279) patients undergoing non-sleep surgery with general/neuraxial anesthesia or sedation.	Varying postoperative outcomes including pulmonary complications, cardiac complications, oxygen desaturation, difficult airway management.	The presence of OSA is associated with an increased risk of postoperative complications.
Kaw et al.467	2012	2a	SR	Patients undergoing non-cardiac, non-sleep surgery (n = 3942).	Varying postoperative outcomes, primarily cardiac/respiratory complications.	The incidence of postoperative desaturation, respiratory failure, postoperative cardiac events, and ICU transfers was higher in patients with OSA.
Hai et al.466	2014	2a	SR	Patients undergoing non-sleep surgery (n = 7162).	Outcomes: acute respiratory failure, cardiac complications, postoperative ICU transfer.	OSA was associated with significant increase in risk of respiratory failure, cardiac events, and ICU transfer postoperatively.
Vasu et al.1511	2012	2a	SR	Patients undergoing surgery, excluding bariatric, and sleep-apnea procedures (n = 108,968).	Varying perioperative complications.	Patients with OSA are at increased risk for perioperative complications.
Corso et al.1509	2018	2a	SR	Patients with OSA undergoing surgery (46 studies).	All articles containing relevant evidence on epidemiology, pathophysiologic mechanisms, and perioperative interventions on OSA.	Preoperative screening of OSA patients is of relevance given the increased perioperative morbidity of these patients.
Riley et al.1517	1997	2b	Retrospective cohort	OSA patients undergoing various upper airway procedures (n = 182).	Fifty-four perioperative factors were analyzed.	Intraoperative airway risks can be reduced by use of fiberoptic intubation in patients with increased neck circumference and skeletal deficiency. Patients with OSA are at a significantly increased risk for hypertension. Nasal CPAP eliminated the postoperative risk of hypoxemia, which allowed the use of adequate analgesics.
Vest et al.1514	2013	3b	Retrospective case–control	Ninety adults with difficult tracheal intubation were compared with 81 gender-matched controls.	Predictors of difficult intubation.	In adult subjects, OSA history was not a predictor of difficult intubation. Other patient or anesthesiologist factors (lower BMI, higher Mallampati scores) should be assessed for their association with difficult intubation.
Iyer et al.1530	2011	2b	Retrospective cohort	Consecutive series of patients who had undergone laparoscopic gastric banding (n = 267).	The incidence of difficult intubation, early postoperative complications, and its attendant risk factors were studied.	Severe OSA and neck circumference greater than 44 cm were factors associated with difficult intubation in morbidly obese patients who presented for bariatric surgery.
Kheterpal et al.1531	2009	2b	Prospective cohort	Consecutive of patients undergoing general anesthesia over 4-year period (n = 50,000).	The primary outcome was impossible mask ventilation defined as the inability to exchange air during bag-mask ventilation attempts, despite multiple providers, airway adjuvants, or neuromuscular blockade. Secondary outcomes included the final, definitive airway management technique and direct laryngoscopy view.	A total of 77 cases of impossible mask ventilation (0.15%) were observed. Neck radiation changes, male sex, sleep apnea, Mallampati III or IV, and presence of beard were identified as independent predictors.
Kim et al.1516	2006	3b	Retrospective case–control	Patients who had undergone UPPP (n = 90).	OSA patients were compared with 90 age and sex-matched control patients with respect to the prevalence of difficult intubation.	The occurrence of difficult intubation can be predicted using AHI in patients who undergo UPPP surgery for OSAS.
Leong et al.1510	2017	3a	SR	Patients with (n = 4626) and without OSA (n = 64,684) who underwent airway management for surgery.	Difficulty of airway management (mask ventilation, tracheal intubation, failed supraglottic airway device).	OSA was found to bea risk factor associated with difficult tracheal intubation and difficult mask ventilation. There was no association between OSA and difficult supraglottic airway use.
Corso et al.1515	2011	3b	Retrospective case–control	OSA patients (n = 145) who underwent sleep surgery were compared with control patients (n = 1263) who underwent other otolaryngologic surgery.	Difficult intubation.	Difficult intubation occurred more frequently in patients with OSA. In OSA patients in whom difficult intubation was found, body mass index (BMI), AHI, and LSAT were not different from values obtained in OSA patients who underwent easy intubation.
Siyam et al.1518	2002	3b	Retrospective case–control	Anesthetic management of OSA patients (n = 36 were compared with non-OSA controls (n = 77).	Difficult intubation.	Difficult intubation occurred more often in sleep apnea patients. No relationship was found between severity of OSA and the occurrence of difficult intubation.
Ulnik et al.1532	2000	2b	Prospective Cohort	Patients who underwent sleep surgery (n = 38).	Postoperative course and occurrence of complications within 72 h.	Within the first 72 h after surgery, no complications were observed. Patients with BMIs greater than 35 were at increased risk for postoperative desaturations. The uncomplicated OSAS patient, one without significant comorbid factors, can be treated in a safe and prudent fashion outside of an intensive care unit.
Kim et al.1525	2005	2b	Retrospective cohort	OSA who underwent UPPP surgery with/without tonsillectomy under general anesthesia (n = 90).	Apnea-hypopnea indices (AHI), preoperative lowest arterial saturation (LSAT-PREOP) levels, percentages of obstruction at the upper level of the uvula during apnea (AL-U), need for an airway in the postanesthesia care unit (PACU) or during the first postoperative night in a ward (POPN1), LSAT-PACU, LSAT-POPN1, and the incidence of postoperative bleeding or other complications.	Immediate postoperative complications and oxygen saturation are associated with OSAS severity and the level of obstruction, inducing apnea in those who have undergone UPPP for OSAS.
Talei et al.1533	2013	2b	Retrospective cohort	Patients who underwent UPPP with or without septoplasty for OSA (n = 32).	Perioperative, clinical, and anesthetic records were reviewed for any complications and risks, defined as any adverse event delaying surgical progress or recovery along with any additional risk to patient safety.	Review of 32 patients failed to show any life-threatening risks or complications.