The perioperative implications of the patient with Obstructive Sleep Apnea (OSA) – a narrative review

Abstract

The prevalence of obesity and OSA are increasing world-wide. Concomitantly, the number of surgical procedures being performed in an outpatient setting is increasing. Both the American Society of Anesthesiology (ASA) and the Society of Anesthesia and Sleep Medicine (SASM) have published guidelines for the perioperative care of the OSA patient. These guidelines were published in 2014 and 2016, respectively. While they serve as an excellent resource for the perioperative management of the OSA patient, the increasing number of obese, OSA patients having procedures performed in the ambulatory setting call into question the feasibility of some of these recommendations in 2024. This review highlights the current recommendations as well as the challenges in caring for the OSA patient in the perioperative setting.

ARTICLE HIGHLIGHTS

Introduction

• Obesity rates have risen dramatically in recent decades, driving a parallel increase in the prevalence of obstructive sleep apnea (OSA).

• OSA, characterized by intermittent airway obstruction during sleep, is associated with increased perioperative and long-term morbidity and mortality.

• This narrative review outlines perioperative anesthetic considerations for patients with known or suspected OSA.

Pre-operative evaluation

• An estimated 80% of OSA cases remain undiagnosed; thus, screening tools like STOP-BANG are essential for identifying high-risk surgical patients.

• STOP-BANG demonstrates high sensitivity for detecting moderate-to-severe OSA and is recommended by the Society of Ambulatory Anesthesia and SASM.

• Even with screening, many cases of symptomatic OSA go undetected preoperatively, highlighting a need for additional diagnostic measures like overnight oximetry.

Preoperative surgical setting planning

• Ambulatory surgery is not contraindicated in all OSA patients—those with optimized comorbidities and good CPAP adherence may safely undergo outpatient procedures.

• Studies show no significant difference in postoperative respiratory events between OSA and non-OSA patients when care is well-coordinated.

• Cost savings are substantial with outpatient surgery when appropriate; patients should be advised to bring CPAP machines on the day of surgery.

Intraoperative management

• OSA patients have increased risk of difficult mask ventilation and intubation due to upper airway anatomy and physiology.

• Difficulty correlates with severity: those with AHI >70 have a ∼28% chance of difficult intubation.

• Guidelines emphasize treating known or suspected OSA as independent risk factors for difficult airway and implementing appropriate precautions.

Neuromuscular blocking agents

• OSA patients may be more susceptible to prolonged neuromuscular blockade and respiratory complications

• Reversal with sugammadex may reduce postoperative complications compared to neostigmine/glycopyrrolate, though evidence remains mixed.

• Succinylcholine use may be associated with increased pulmonary complications in this population.

Opioids

• Opioids increase risk for respiratory depression, particularly in OSA patients.

• OSA increases the risk of opioid-induced respiratory depression by up to 50%.

• Multimodal analgesia reduces complications, opioid requirement, and postoperative opioid prescriptions.

Sedatives and hypnotics

• Sedatives like propofol significantly increase airway collapsibility and require careful use, especially during monitored anesthesia care (MAC).

• Dexmedetomidine, clonidine, and ketamine appear to be safer options with reduced risk of upper airway obstruction.

Multimodal analgesia

• Multimodal pain regimens, including neuraxial techniques and regional blocks, reduce respiratory complications and improve outcomes.

• Neuraxial anesthesia may offer advantages in reducing airway risks and postoperative respiratory events, though evidence is mixed.

Postoperative recovery and respiratory support

• OSA patients, especially those with severe or undiagnosed disease, are at heightened risk for desaturation, respiratory failure, and cardiac events.

• CPAP use in the postoperative period reduces complications and improves oxygenation metrics.

• High-flow nasal cannula (HFNC) is a viable alternative for patients intolerant to CPAP, with higher comfort and compliance.

Discharge guidelines

• ASA recommends delaying discharge until the risk of respiratory depression resolves and oxygenation can be maintained without support.

• Continuous monitoring is advised for patients with recurrent respiratory events or pain-sedation mismatch.

• More research is needed to define safe discharge timelines and protocols for OSA patients.

Conclusion and future perspectives

• An individualized, multimodal approach to anesthesia is critical for managing perioperative OSA risk.

• Innovation in screening, monitoring, and drug delivery—potentially through AI or real-time feedback systems—may enhance future care.

Collaboration across specialties is essential for improving safety and outcomes in this growing patient population.

Introduction

The prevalence of obesity worldwide has been increasing steadily over recent decades. In the United States, obesity rates in those 20 and over have ballooned from a rate of 13.4% in 1962 to 42.8% in 2018 [1]. Notably, the largest rate of increase has been seen in the morbidly obese and super obese categories, defined as a Body Mass Index (BMI) of 40 kg/m² and 50 kg/m², respectively [2]. Obesity is a known risk factor for the development of obstructive sleep apnea (OSA), which has increased in prevalence along with rising BMIs [3]. Recent estimates suggest that more than 900 million adults are affected worldwide [4].

OSA is a pathologic state of repetitive obstruction, partial or complete, to airflow by collapsing pharyngeal tissue during sleep [5]. This leads to compromised ventilation, reduced oxygen levels, poor sleep, and negative downstream effects throughout the body, most notably in the brain and cardiovascular system [3]. OSA is known to cause excessive sleepiness and neurocognitive impairment, such as mood changes, forgetfulness, and difficulty concentrating [3]. Recent population-based research has revealed that the prevalence of moderate-to-severe obstructive sleep apnea (OSA) is higher than previously recognized, especially among individuals with cardiovascular risk factors [6]. Furthermore, a study by Mokhlesi et al. demonstrated that OSA is independently associated with an increased incidence of coronary heart disease and heart failure, underscoring its role as a modifiable risk factor for cardiovascular disease, which remains the leading cause of death in the United States [7]. These findings suggest that the widespread and often undiagnosed presence of OSA may contribute to the burden of cardiovascular morbidity and mortality in the US

Both all-cause and cardiovascular mortality are elevated in OSA patients, with all-cause mortality over 14 years being 33% in those with moderate-severe sleep apnea, vs 6–7% in those without the disorder [8]. In addition to deleterious long-term health effects known to be secondary to OSA, several studies have recognized OSA as a risk factor for adverse postoperative events [9–13]. The purpose of this narrative review is to discuss considerations anesthesia providers must account for throughout the perioperative period to optimize the treatment of patients with known or suspected OSA.

Methods:

This narrative review was conducted by evaluating clinical guidelines and peer-reviewed primary literature relevant to the perioperative management of patients with obstructive sleep apnea (OSA). The primary sources of guidelines included documents published by the American Society of Anesthesiologists (ASA) and the Society of Anesthesia and Sleep Medicine (SASM), both of which provide recommendations specific to the anesthetic care of OSA patients.

Additionally a structured search of the literature was performed using PubMed, Google Scholar, and Embase databases. Search terms included combinations of: “obstructive sleep apnea,” “OSA,” “perioperative management,” “anesthesia,” “postoperative complications,” “screening tools,” “STOP-BANG,” “CPAP,” “ambulatory surgery,” “opioids,” “sedatives,” “neuromuscular blockade,” “sugammadex,” and “postoperative monitoring.”

Inclusion criteria were as follows:

Primary research studies, systematic reviews, meta-analyses, and clinical trials published within the last 10 years (2014–2024).

Articles written in English and accessible in full text.

Studies involving adult surgical patients with diagnosed or suspected OSA.

Resources that provided evidence relevant to preoperative screening, intraoperative anesthetic management, postoperative respiratory care, or discharge planning for OSA patients.

Studies focusing on pediatric populations, case reports, or those lacking a perioperative anesthetic focus were excluded. Preference was given to studies that explored clinical outcomes, comparative anesthetic strategies, or validated screening and risk assessment tools in the context of OSA.

The literature was reviewed for consistency with existing guidelines and to identify emerging practices or areas where further research is warranted. Recommendations were synthesized based on the strength of the evidence, with emphasis on studies with larger sample sizes, rigorous methodology, and relevance to perioperative care.

Pre-operative evaluation

A knowledge of best practices in perioperative OSA management is necessary for the care of a wide swath of the American population. The American Academy of Sleep Medicine states OSA impacts about 30 million Americans and estimates 80% of cases remain undiagnosed. Several organizations have published guidelines and recommendations for identifying and caring for patients with OSA in the perioperative period. The American Society of Anesthesiology (ASA) guidelines for preoperative evaluation of OSA are to be applied to patients with known or suspected OSA. A preoperative evaluation consisting of a review of medical records, an interview with the patient and family members, and a physical exam is recommended. Society of Anesthesia and Sleep Medicine (SASM) guidelines made a strong recommendation to use pre-operative screening tools to identify patients with suspected OSA. The Society of Ambulatory Anesthesia guideline recommends the STOP-BANG questionnaire as the preferred pre-operative screening tool as it is both easy to complete and is the most validated screening tool used for surgical patients thought to be at high risk for OSA [5,14–19]. Several studies have shown that patients who were at an intermediate risk or higher per STOP-BANG scoring, had a greater rate of perioperative complications such as difficulty with intubation, desaturation, and unplanned admission to the Intensive Care Unit (ICU), in comparison to those considered to have low-risk OSA [20–22]. STOP-BANG has a high pooled sensitivity to screen for all cases of OSA, with the sensitivity being highest for those with severe OSA (Apnea-Hypopnea Index (AHI) of 30 or greater).

Table 1.

General considerations for determining appropriate surgical setting between ASC vs hospital.

Considerations	Ambulatory surgical center	Hospital
OSA classification
Severity (diagnosed)	Mild to moderate OSA (AHI ≤30)	Severe OSA (AHI >30)
Risk (undiagnosed)	High (STOP-BANG greater than 3)	Low (STOP-BANG 2 or less)
Management	Treated (compliant with CPAP use)	Untreated (non-compliant)
Procedure related factors
Patient Age	Less likely for elderly	All ages
Patient Comorbidities	Healthy to minimal	Multiple, complex medical history
Surgical Complexity	Minor (Colonoscopy, Cataract), Moderate- Cases of 3h duration or less across the spectrum of surgical specialties in appropriate patients	Major (Cardiothoracic, Neurosurgery), Cases requiring admission, blood administration, prolonged duration, or other markers of increased complexity
Postoperative Care Requirements	Minimal (Outpatient)	Prolonged (Possible inpatient stay)
Comorbidities
Comorbid conditions	Optimized	Poorly controlled
Postoperative
Pain Management	Non opioid analgesics	Opioid utilization
Social Disposition	Normal	Poor social situation
Facility overview
Resources	Limited beyond ASC	Increased access (ICU, consult services)

STOP-BANG is a highly utilized screening tool and can direct further intervention prior to surgery. However, a retrospective nested cohort study showed that in those screened in the preoperative setting using the STOP-BANG questionnaire, who then underwent a pre-operative polysomnogram, both anesthesiologists and surgeons missed a significant number of patients with preexisting OSA and symptomatic undiagnosed OSA [23]. The United Kingdom’s National Institute for Health and Care Excellence (NICE) recommends that those undergoing elective surgery be evaluated with a STOP-BANG questionnaire, and those scoring 3 or higher are referred for overnight oximetry evaluation prior to surgery. Shaw et al evaluated this approach and found that ⅓ of patients evaluated by overnight oximetry prior to surgery met the threshold for initiating CPAP therapy before surgery and that with the initiation of CPAP, there was no significant difference in the rate of complications between those with moderate to severe OSA and those unaffected by or diagnosed with mild OSA [24].

Pre-Op: planning surgical setting

Approximately 23 million procedures annually are completed in ambulatory surgery centers, making up more than half of the outpatient surgery market [25]. The use of ambulatory surgical centers for OSA patients remains controversial. ASA guidelines recommend considering patient age, status of coexisting diseases, nature of surgery, type of anesthesia that will be used, need for postoperative opioids, support system following discharge, and resources at the outpatient facility when making this determination. The Society for Ambulatory Anesthesia (SAMBA) issued a statement stating that patients with a known or presumed diagnosis of OSA, with optimized comorbid conditions, who will comply with postoperative PAP recommendations, and whose postoperative pain can be managed predominantly with nonopioid analgesics, can be considered for ambulatory surgery [26].

Kurrek et al showed in a retrospective study of 746 patients with suspected or known OSA undergoing ambulatory laparoscopic adjustable gastric banding (LAGB) showed that there were no cases of reintubation or respiratory failure in those with controlled comorbidities, despite a lack of modification of anesthetic management from standard practice for the OSA patients [27]. Patients included in this study either had a known history of OSA and used CPAP or were deemed high risk for OSA by the STOP-BANG screening tool. A prospective, observational study from Hudson et al reported on ambulatory patients undergoing orthopedic surgery conducting home sleep apnea tests after the first and third night of surgery [28]. Results showed minimal effect on sleep parameters overall. Additionally, there was no increase in adverse events following surgery in patients with OSA, either untreated or treated. All patients received routine perioperative care as planned by the surgical and anesthesia teams. Szeto et al showed in a retrospective study that there was no significant difference between the risk of OSA and length of stay, postoperative respiratory events, or hospital transfer in either typical outpatient or ambulatory extended recovery procedures. Additionally, there was no increased rate of urgent care visits or readmissions seen within 30 days between high-risk or diagnosed OSA compared to low or moderate-risk patients. In those cases where ambulatory surgery does not appear contraindicated, economic data favors an ambulatory surgery setting as most cost-effective. Data shows that the cost of an outpatient procedure is less than that of an inpatient one, secondary to a host of factors. Exact cost savings will vary widely depending on surgery, but one study from Moon et al examining the cost of inpatient vs outpatient hindfoot surgery found a cost savings of more than 4000 dollars per surgery when the surgery was performed in an outpatient setting [29].

Overall, there is a growing body of evidence indicating that ambulatory surgery in suspected or known OSA patients is safe. As both the prevalence of OSA and number of cases performed in an ambulatory setting are increasing, additional studies assessing safety compared to the hospital setting are needed.

Regardless of surgical setting, Patients with at-home CPAP machines should be instructed to bring them on the day of surgery. A retrospective cohort match study showed that 30% of patients with OSA not using an at-home CPAP device experienced upper airway obstruction, hypoxemia, or additional adverse events post-operatively [30]. In a prospective, randomized controlled trial Chung et al showed that those who underwent perioperative auto-adjusting positive airway pressure (APAP) treatment had decreased postoperative AHI and greater oxygen saturation in surgical patients with moderate to severe OSA, in comparison to those who did not receive APAP treatment [31]. Finally, mandibular advancement, oral appliances, or preoperative weight loss could be considered to optimize OSA patients, though support in the literature is weak. According to the ASA, each of these interventions has insufficient evidence in improving postoperative outcomes for patients with OSA, though use is recommended when feasible. More research needs to be done to validate suggested perioperative interventions aimed at minimizing adverse outcomes in surgical patients with OSA.

Intra-Op

Patients with OSA pose both anatomic and physiologic peri-induction challenges. Not only are they prone to obstruction, but changes in the mandible seen in sleep apnea patients create a characteristic “crowded and collapsible pharyngeal space” and can make obtaining a view of the glottic opening difficult [32,33]. During awake periods, patients compensate for this by “increasing craniocervical angulation” to decrease obstruction [33]. These patients also tend to have smaller functional residual capacity and increased oxygen consumption [32].

OSA patients are three times more likely than the general population to be difficult to mask-ventilate and intubate [34]. The risk of difficult intubation can be approximated by looking at a patient’s AHI - those with 40 or fewer events per hour have a 3% incidence of difficult intubation, while in those with greater than 70 events per hour, the incidence climbs to nearly 28% [35]. It is known that airway complication rates rise similarly in the obese population, which has a significant overlap with those diagnosed with OSA. In reviewing major airway issues in both the ICU and operating room, deJong found “major airway complications occurring in ICU and [operating room (OR)] involved obese patients in 47% and 40%, respectively.”

The known incidence of difficult intubation in patients diagnosed with OSA has long been incorporated into practice guidelines. The Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients with OSA states plainly, “Known or suspected OSA should be considered an independent risk factor for difficult intubation, difficult mask ventilation, or both. Adequate difficult airway management precautions should be taken [36]. A retrospective review of the legal literature done by Fouldapour et al noted that OSA patients were at increased risk for airway management misadventure in both the OR and PACU, in addition to increased risk of cardiorespiratory arrest [37]. When these led to catastrophic outcomes, the review found that these complications were noted as the “central contention of malpractice suits.” [37] However, a systematic review and meta-analysis by Nagappa noted: “No significant difference in the supraglottic airway failure rates exists between the OSA and non-OSA patients” [34,38].

In response to these challenges, artificial intelligence (AI) is emerging as a promising adjunct to airway management in high-risk populations such as those with OSA. Recent innovations include the application of large language models like GPT and Med-PaLM to provide real-time clinical decision support, simulate airway emergencies, and enhance provider training. These tools can deliver step-by-step guidance based on current guidelines, generate dynamic patient scenarios for education, and offer predictive analytics for difficult airway identification. Additionally, integration of AI with video laryngoscopy, capnography, and point-of-care ultrasound allows for real-time anatomical recognition, confirmation of tube placement, and improved accuracy in identifying structures such as the cricothyroid membrane. By analyzing data from electronic health records, AI systems may also offer patient-specific risk stratification, assisting clinicians in planning airway interventions with greater precision. These advancements hold the potential to reduce error, standardize care, and support providers in high-stakes situations where human cognitive bias and time pressure pose significant risks [39].

Neuromuscular blocking agents

Those afflicted with OSA “may have increased vulnerability to the effects of neuromuscular blocking drugs and reversal agents” [40]. A retrospective cohort study of more than 200,000 noncardiac adult surgical patients from Schaefer found that succinylcholine administration actually leads to an increase in the rate of postoperative pulmonary complications [41]. Several studies describe a higher risk of pulmonary complications when using succinylcholine in OSA patients [37,42,43]. Unal et al compared rates of respiratory complications seen in two patient populations, one reversed with neostigmine and glycopyrrolate, the other with sugammadex [44]. Roughly one-third of the neostigmine/glycopyrrolate group was found to have some respiratory complication (most commonly desaturation). The rate of desaturation in those patients receiving cyclodextrin reversal was found to be 10% [44]. Another study examining chest x-rays in patients who were extubated following laparoscopic bariatric surgery found that “less pathologic chest x-ray changes were found in the group whose neuromuscular blockade was reversed with sugammadex” [45]. However, no clinical difference was noted in desaturation rates or other postoperative respiratory complications between their two patient populations. As sugammadex efficacy is limited to rocuronium and vecuronium, this reversal strategy is not a panacea, but it does apply to a wide array of general anesthesia cases.

Quantitative neuromuscular monitoring (QNM) is increasingly recognized as an essential adjunct in the anesthetic management of OSA patients. These individuals are particularly susceptible to residual neuromuscular blockade (RNMB), which can exacerbate postoperative airway obstruction and prolong hypoventilation. A recent prospective observational study demonstrated that intraoperative neuromuscular monitoring significantly reduced the incidence of RNMB and postoperative pulmonary complications, emphasizing the importance of achieving a train-of-four (TOF) ratio ≥0.9 before extubation [46]. The Society of Anesthesia and Sleep Medicine (SASM) guideline on intraoperative management of OSA patients explicitly recommends the use of QNM to mitigate postoperative respiratory complications [47].

The importance of neuromuscular monitoring is further underscored by large-scale analyses such as the STRONGER study, a multicenter matched cohort investigation which found that patients who received sugammadex, alongside quantitative neuromuscular monitoring, had significantly lower rates of postoperative pulmonary complications compared to those reversed with neostigmine. These complications included pneumonia, respiratory failure, and other adverse pulmonary events such as pneumonitis, pulmonary congestion, and iatrogenic etiologies like pulmonary embolism, infarction, or pneumothorax. The study highlights the potential for sugammadex, when guided by objective monitoring, to reduce the incidence of residual neuromuscular blockade and improve pulmonary outcomes in the postoperative setting [48]. While the higher acquisition cost of sugammadex has historically limited its use, studies in high-risk populations such as OSA have shown that reduced rates of PACU utilization, reintubation, and ICU admissions may ultimately render its use cost-effective [49].

Opioids

Opioids decrease pharyngeal muscle tone and prolong airway obstruction, decrease respiratory drive, and inhibit the arousal response normally triggered by hypoxemia [50,51]. These effects are compounded in OSA patients, with OSA increasing a patient’s risk for opioid induced respiratory depression by 50% [43]. Interestingly, in a review of 100,00+ anesthetics in OSA patients in the US, Mörwald et al found that “higher levels of opioid prescription were associated with increased odds for deep venous thrombosis, gastrointestinal complications, prolonged length of stay, and increased cost [51]. However, higher opioid prescription was not associated with increased odds for pulmonary complications” [51]. Variable response and complication occurrence with opioid administration are likely secondary to individual patient characteristics. In a review of the mechanics of opioid use, Freire highlights the differences in patient susceptibility to opioid induced respiratory depression [52]. She highlights that in one study, “OSA worsened in patients with the A/A Opioid Receptor Mu 1(OPRM1) phenotype and improved with the A/G OPRM1 phenotype” [52]. In another study, 40 mg of morphine extended release tablets reduced chemoreceptor response to hypercapnia, but did nothing to airway collapsibility or arousal threshold [52]. Studies looking at risks and benefits of intra-operative dosing strategies of commonly used peri-operative opioids are lacking in the literature; more data is needed here to support one strategy over another.

Sedative/hypnotics

Like Opioids, sedative and hypnotic medications increase a patient’s susceptibility to airway obstruction due to a reduction in pharyngeal muscle tone and an increase in upper airway collapsibility [53]. This susceptibility increases in a dose-dependent fashion and can be problematic with the induction of general anesthesia and management of the airway [54]. Greatest care should be taken in the context of monitored anesthesia care (MAC), where there is a lack of a secured airway. This is especially true when concerning the use of propofol, which “has a relatively steep dose-response curve compared to other sedatives/hypnotics” [55]. It is particularly wise to ensure the use of capnography in these cases to allow for one to detect airway obstruction as early as possible. Some sedative/hypnotics are supported by the evidence to be a bit more forgiving- both ketamine and alpha 2 agonists, dexmedetomidine and clonidine, were not found to have an increased risk of adverse effects when administered to OSA patients [54].

Multimodal agents

Given the known risks posed to OSA patients by over-narcotization and accounting for the downsides of opioid use in any patient, an obvious solution lies in the multi-modal approach to pain control. Cozowicz et al. contrasted outcomes in OSA patients undergoing total joint arthroplasty between patients who received opioid only analgesia and those who received multimodal pain control modalities [43]. In a retrospective study, they found that as the number of modes of analgesia rose from an opioid only baseline to 1, 2, or greater than 2 modes of analgesia, there was a stepwise decrease in postoperative respiratory complications, resource utilization, and a gradual decrease in overall home opioid prescription volume [43]. A retrospective cohort study by Bai et al examined complication rates in OSA patients having a total joint arthroplasty given a low (100 microgram) dose of intrathecal morphine (ITM) as a component of their spinal anesthetic in conjunction with a multi-modal analgesic approach that included regional anesthesia [56]. No increase was found in complication rates for those with OSA who received ITM [56]. These studies, both of which sidestepped the potential issue of increased complication rates in OSA patients secondary to difficult airway or positive pressure ventilation, illustrate the benefits of a multimodal pain control approach in this population.

The published data on complication rates associated with the various anesthetic modalities are mixed. Habchi et al published a retrospective analysis examining rates of complications in OSA patients undergoing a total knee arthroplasty (TKA) and found no difference in complication or readmission rates when comparing neuraxial and general anesthesia [57]. This directly contrasts with other studies in the same patient population undergoing total joint arthroplasty. Memtsoudis et al found that those with a pure neuraxial anesthetic had lower rates of pulmonary complications, less utilization of prolonged mechanical ventilation and less requirement for critical care services than those whose care involved general anesthesia [36]. In utilizing a neuraxial technique for primary anesthetic, the anesthesia provider may sidestep issues caused by increased difficulty placing an airway device and issues with airway obstruction under sedation. The current evidence is inconclusive as to which anesthetic technique may be safest in the OSA population, and further study could be helpful in drawing a conclusion on this topic.

Post-operative recovery

Patients with OSA are at risk for desaturation, respiratory failure, adverse cardiac events, and prolonged hospital stays [58]. The magnitude of risk for these complications increases with OSA severity. When compared to patients with mild or moderate OSA, patients with severe OSA are prone to increased respiratory complications in the postoperative period.⁴⁵ Furthermore, patients with severe undiagnosed OSA face higher rates of cardiovascular complications including cardiac arrest and shock postoperatively [59].

2014 ASA guidelines recommend the use of supplemental oxygen during recovery for OSA until they can maintain their baseline oxygen saturation while breathing room air [60]. A RCT found that postoperative supplemental oxygen usage in surgical patients with newly diagnosed OSA improved oxygenation and decreased AHI [61]. However, the same RCT noted that eleven percent of the patients with previously undiagnosed OSA receiving supplemental oxygen experienced significant CO2 retention [61]. In addition, the use of supplemental oxygen can impair early detection of hypoventilation via pulse oximetry [61,62]. Avoiding hypoventilation and hypercapnia is critical for OSA patients already prone to CO2 retention. Excessive oxygenation can worsen hypercapnia by suppressing the hypoxic drive [63]. Weighing these factors, supplemental oxygen can be useful in the PACU, but should be paired with monitoring to decrease hypoventilation. Often, supplemental oxygen on it’s own is insufficient to support patient saturation during the post-anesthesia recovery period.

Preventing obstructive events post-operatively

A matched cohort study found that the perioperative prescription of CPAP in patients with previously undiagnosed severe OSA was associated with a reduction in postoperative cardiovascular complications [59]. For surgical patients, ASA guidelines recommend continuing CPAP in the postoperative setting for patients previously diagnosed with OSA and who are CPAP adherent. Several studies have demonstrated the benefits of instituting CPAP preoperatively and continuing its use postoperatively [47]. A further subgroup analysis indicated that preoperative and postoperative use of CPAP improved the oxygenation desaturation index and lowered the risk of postoperative respiratory and cardiac complications [47]. A recent cohort study followed 132 surgical OSA patients with a CPAP prescription of which approximately 50% were consistently adherent preoperatively and postoperatively [64]. Non-adherent CPAP patients were three times more likely to require oxygen therapy than those who were CPAP-adherent [64]. Patient education should include patients bringing their CPAP machine on the day of their surgery.

For those patients who are unable to tolerate CPAP, the use of humidified high-flow nasal cannula (HFNC) may prove efficacious for reducing postoperative desaturation in the first postoperative night. Tsai et al compared CPAP use with the use of HFNC for airway support in adults with a BMI >35 and a moderate or severe score on STOP-BANG screening. HFNC was found to have higher compliance than CPAP, and was non-inferior in terms of the number of desaturation events and need for intervention to resolve desaturation. In addition, “CPAP was used for a significantly fewer number of hours compared to HFNC (at all flow rates) during the first postoperative night from 10 pm to 8 am,” and those in the HFNC arms preferred HFNC to CPAP at a rate of 73%, citing increased comfort and less noise disturbance [65].

While a severe AHI appears to be associated with an increased risk of postoperative complications, a cohort study did note that it is unknown if AHI alone is the best determinant of assessing overall risk [59]. This also highlights the importance of prescreening patients for the severity of their AHI as undiagnosed patients are at an increased risk of developing postoperative complications. One meta-analysis failed to demonstrate this reduced risk effect through the use of CPAP, however, they found that the preoperative AHI in patients without CPAP was reduced significantly following the administration of postoperative CPAP [66]. Even if the previously mentioned postoperative complications may not be reduced, the utilization of CPAP can reduce the severity of apneic events. AHI is used as the standard international metric for determining OSA severity, one should also consider metrics such as the Oxygen Desaturation Index (ODI) or the time spent below an oxygen saturation of 90% (T90), which can better account for the physiologic burden placed on the body by prolonged hypopneic or apneic episodes. While these numbers are not currently commonly included in studies on perioperative management of OSA, it would be interesting to see if their use in the future would allow for better risk stratification of OSA patients undergoing surgery [67].

Discharge guidelines

Current literature is insufficient to provide a timeline for the discharge of patients with increased perioperative risk from OSA. ASA guidelines recommend not discharging patients from the recovery area to an unmonitored area until there is no longer a risk for respiratory depression. Respiratory parameters can be determined by monitoring oxygen saturation levels while in an unstimulated environment, preferably during sleep. Patients with recurrent respiratory events in the Post Anesthesia Care Unit (PACU), defined as more than one of the following per 30-minute period, including oxygen saturation below 90, bradypnea below 8 breaths per minute (3 separate episodes), and apnea greater than equal to 10 seconds should be admitted to a monitored bed with continuous pulse oximetry or consider upgrading level of care if indicated [68]. Additionally, those with pain-sedation mismatch, moderate to severe OSA, major invasive surgery, significant comorbidities, use of opioids, and noncompliance with CPAP machines should be monitored as well [68]. A retrospective study from Balachandran et al showed that urologic oncology patients with high risk for sleep apnea, based on the STOP-BANG questionnaire, were less likely to be discharged from PACU early as compared to low-risk patients. This determination was based on the length of stay in the PACU, equating to more postoperative complications. By the 8-hour mark, low-risk patients had a higher probability of being discharged early [69].

There is limited data available assessing adverse outcomes in those who underwent same-day surgery in comparison to those who were monitored as inpatients overnight following surgery. Additional research is needed to examine this comparison to further determine for which patients with known or suspected OSA are suitable for same-day surgery.

Conclusion

The presence of OSA can influence perioperative management and discharge decision-making. Anesthetic plans for OSA patients must be individually tailored. Limiting opioid use in favor of a multimodal analgesia technique is recommended to mitigate the risk of further worsening respiratory drive. Similarly, certain sedative and hypnotic medications can cause a dose-dependent increased risk of airway collapsibility. Current literature suggests that dexmedetomidine, clonidine, and ketamine are preferred hypnotic and sedative agents in OSA patients through a lower likelihood of airway obstruction. Neuromuscular blocking agents, when used, should be fully reversed with sugammadex. While there appears to be a favorable pharmacological approach with multimodal analgesia and opioid avoidance, complication rates appear to be similar when comparing monitored anesthesia care, general anesthesia, and regional anesthesia modalities. OSA management in the perioperative setting involves a holistic approach prioritizing thorough preoperative screening, tailored intraoperative management, and attentive postoperative care. This narrative review is limited to the perioperative period and does not take into account the entire spectrum of care for patients with OSA. Additionally, as with all narrative reviews, this review is limited by the authors’ interpretation of the existing literature, author objectivity, and completeness of the literature search. The current guidelines issued by the ASA and SASM may require an update, as recent literature suggests little to no differences in outcome in an ambulatory surgery setting for OSA versus non-OSA patients. Additional research will improve upon the most cost-effective and safe way to care for OSA patients in the perioperative period.

Future perspectives

The increasing prevalence of obesity and OSA continues to present challenges in perioperative care. This underscores the need for optimized preoperative screening tools and tailored anesthetic strategies. The integration of reliable biomarkers or machine learning-based predictive tools could further improve screening accuracy. Despite progress in risk stratification and opioid-sparing techniques, significant knowledge gaps remain regarding the optimal intraoperative management of patients with OSA. Future approaches may incorporate real-time, intraoperative respiratory phenotyping, such as closed-loop feedback systems that integrate capnography, tidal volume variability, and neuromuscular transmission monitoring, to guide personalized anesthetic delivery and ventilation strategies. Moreover, while agents like dexmedetomidine and ketamine have shown promise in minimizing opioid-related respiratory depression, further studies are needed to define their safety profiles and dosing regimens specifically in OSA populations [54]. The underutilization of neuromuscular monitoring and variability in reversal agent selection also highlight the need for protocol standardization and innovation [70]. Continued interdisciplinary collaboration among anesthesiologists, sleep specialists, and surgical teams is crucial to implementing evidence-based practices that ensure safety and quality care for this expanding patient population.

Disclosure statement

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.