Navigating ambulatory perioperative care in patients with obesity and obstructive sleep apnea: a narrative review of ambulatory surgery outcomes and opioid safety

Abstract

Obesity and sleep apnea contribute to significant challenges in ambulatory surgical centers which include airway management and perioperative recovery. This narrative review was written following a literature review of articles available on ScienceDirect, PubMed, and Google Scholar from 2009 to 2024. This article highlights that obesity-related anatomical changes, such as increased neck circumference (NC) and reduced cervical extension, may complicate airway management. Successful ambulatory surgery for these high-risk patients depends on detailed attention throughout the perioperative period. Advanced airway techniques, along with continuous pulse oximetry and capnography, are vital for safe care. The use of continuous positive airway pressure or bilevel positive airway pressure in the perioperative phase is particularly beneficial in preventing respiratory complications. A systematic, multidisciplinary approach emphasizing preoperative screening, risk stratification, and standardized protocols is crucial for optimizing results.

INTRODUCTION

Obesity and its prevalence

Obesity is defined as having a body mass index (BMI) of 30–40 kg/m²; a BMI of 40–50 kg/m² is considered morbid obesity, and a BMI over 50 kg/m² is described as super morbid obesity [1]. Obesity has emerged as a major public health concern worldwide, with a significant impact on various health systems with its prevalence of 40% of adults in the USA in the last 2 decades [1,2]. Similarly, Korea has experienced a comparable upward trajectory in obesity rates, as documented in the 2023 Obesity Fact Sheet [3]. Since Asians have been found to have both an increased percentage of body fat and more visceral fat at the same BMIs compared to Caucasians [4], the BMI for obesity according to the Korean Society for the Study of Obesity is a BMI of > 25 kg/m² instead of a BMI of > 30 kg/m² [5]. Between 2012 and 2021, the overall prevalence of obesity in Korea rose from 30.2% to 38.4%, with notable increases observed among adults in their 20s, 30s, and 80s [3]. As obesity rates continue to rise globally, the number of patients with obesity seeking outpatient surgery has increased significantly. Patients with obesity, especially those with a BMI over 50 kg/m², pose unique challenges to outpatient surgery due to the higher risk of perioperative complications, including airway management issues, increased anesthesia risks, and potential for postoperative complications [6].

Obstructive sleep apnea (OSA) and ambulatory surgical outcomes

OSA, a common comorbidity in patients with obesity, is a prevalent condition characterized by recurrent upper airway collapse during sleep, leading to intermittent hypoxia and sleep fragmentation [7,8]. OSA affects a significant portion of adults, occurring in about 9–38% of the general population. In Korea, the prevalence of high risk for OSA is 12% which equates to almost 6 million people [9]. The vast majority of patients are untreated or undiagnosed [10]. This rate is notably higher in people undergoing surgery, particularly among bariatric surgery candidates, where it can affect as many as 70% of patients [6]. Patients with OSA are often at an increased risk for adverse respiratory events following surgery due to the interplay between opioid-induced respiratory depression and the preexisting vulnerabilities associated with their condition [8,11,12].

OSA, independently and synergistically with obesity, influences the management of anesthesia, particularly in the context of ambulatory surgeries [13]. Ambulatory surgery has become an increasingly preferred choice for numerous procedures due to its cost efficiency and convenience, influenced by global shifts toward more streamlined healthcare practices. However, this approach presents specific challenges when caring for patients with obesity and OSA including opioid-induced respiratory depression, effective airway management, use of appropriate anesthetic agents, and the complexity of postoperative recovery.

Objective

This narrative review aims to evaluate the current literature on the safety of ambulatory surgeries for patients with obesity and those with sleep apnea, with a particular focus on the risks associated with opioid use. By examining the impact of opioid and non-opioid analgesic strategies, anesthesia considerations, and patient-specific risk factors, this review seeks to provide evidence-based insights into optimizing perioperative care for patients with OSA while minimizing the incidence of postoperative respiratory complications.

METHODOLOGY

This narrative literature review was conducted using a systematic approach to examine relevant research on obesity, OSA, and ambulatory surgery, with a particular focus on opioid use. Prior to starting the review process, we obtained an exemption from MetroHealth Institutional Review Board since our review involved analyzing publicly available literature without direct human subject involvement.

The primary databases utilized for this review included ScienceDirect, PubMed, and Google Scholar, which were chosen for their extensive biomedical literature collections. We selected research papers based on their relevance to our research question, concentrating on the intersection of obesity, OSA, opioid use, and the management of patients undergoing ambulatory surgical procedures.

To ensure a comprehensive search, we employed various combinations of keywords in different combinations: “obesity,” “obstructive sleep apnea,” “ambulatory surgery,” and “opioid.” The selected papers underwent a systematic review process, enabling us to extract key information regarding the challenges and strategies for managing patients with obesity and OSA in ambulatory settings.

In our review, we incorporated a diverse range of studies, including randomized controlled trials that assess anesthetic interventions, cohort studies examining long-term outcomes, case-control studies, conducted between 2009 and 2024, identifying risk factors for adverse events, and cross-sectional studies evaluating the prevalence of obesity and OSA among surgical patients. We also included systematic reviews and meta-analyses summarizing existing evidence, epidemiological studies exploring public health implications, and clinical guidelines offering evidence-based recommendations for managing these conditions. By integrating these various study types, we aimed to highlight the complexities of anesthetic management for adult patients undergoing ambulatory surgery.

Artificial intelligence (Napkin AI Beta, 2024) was utilized in the creation of the figures included in this paper.

Limitations

This narrative literature review has several limitations. First, our search was restricted to studies published in English, which may have excluded relevant research in other languages, potentially affecting the comprehensiveness of our findings and the generalizability of our conclusions. Additionally, our review primarily focused on existing clinical guidelines and literature summaries, which, while providing significant insights and evidence-based recommendations, may have led to a reliance on established interpretations rather than newer, original research findings. Consequently, some emerging studies and novel perspectives may not be fully represented in our review.

DISCUSSION

Obesity, OSA, and surgical outcomes: current evidence

1. Impact on perioperative complications

Several studies have investigated the impact of obesity on ambulatory surgery outcomes [14-17], with some highlighting an increased risk of unanticipated admission and postoperative complications.

Multiple studies have found an overall admission rate of approximately 2.6–2.67% for ambulatory procedures in patients with obesity, with rates increasing proportionally with BMI [18]. Whippey et al.’s [14] case-controlled study revealed that patients with BMI between 30–35 kg/m² had significantly higher odds of unanticipated admission (odds ratio [OR] 2.81, 95% confidence interval [CI] 1.31–6.04). This risk increases further with BMI, as demonstrated by Gabriel et al. [15]’s national registry analysis, which found that patients with BMI > 50 kg/m² had nearly double the admission rate (4.7%) compared to those with BMI < 30 kg/m² (2.5%).

A meta-analysis by Kaw et al. [17] examined 16 studies on postoperative complications in patients with OSA. The analysis found that patients with OSA had significantly higher odds of experiencing cardiac complications (3.76% vs. 1.69%; OR 2.07, P = 0.007) and respiratory failure (1.96% vs. 0.70%; OR 2.43, P = 0.003) compared to patients without OSA. OSA was also associated with increased rates of postoperative desaturation (10.71% vs. 5.58%; OR 2.27, P = 0.010) and intensive care unit (ICU) transfers (5.09% vs. 1.57%; OR 2.81, P = 0.002), with moderate heterogeneity in these outcomes. Additionally, patients with OSA had longer hospital stays (mean difference: 1.79 days, P < 0.001). Overall, the findings underscore the increased risk of adverse postoperative outcomes in patients with OSA, emphasizing the need for careful management in this population.

A qualitative systematic review by Opperer et al. [19] analyzed 61 studies, with 50 focusing on general or neuraxial anesthesia and 11 on sedation-based procedures. The review found that 15 studies reported increased pulmonary complications in patients with obstructive OSA undergoing general or neuraxial anesthesia, while 10 studies identified a correlation between OSA and cardiac complications, including atrial fibrillation. Mortality outcomes varied, with some studies showing no significant associations and others reporting either increased or decreased mortality rates in patients with OSA. In sedation-based procedures, OSA was associated with higher rates of oxygen desaturation and a greater need for rescue airway maneuvers.

Another literature review article [20] indicates that OSA has been linked to severe postoperative complications, including respiratory arrest, anoxic brain injury, and increased rates of ICU admission. In another study [21], the occurrence of postoperative respiratory failure in orthopedic surgery patients has been linked to longer hospital stays, increased mortality rates, and elevated healthcare costs. Risk factors such as preexisting pulmonary conditions, OSA, and prolonged anesthesia duration have been associated with an increased likelihood of respiratory decompensation requiring ICU admission.

The impact of obesity appears to vary by procedure type. In patients presenting for outpatient tonsillectomy, patients with a BMI ≥ 40 kg/m² showed incrementally higher risks of same-day admission, with relative risks increasing from 1.31 (99% CI 1.03–1.65) for BMI 40–50 kg/m² to 1.99 (99% CI 1.43–2.78) for BMI > 50 kg/m². Notably, while a higher BMI was associated with increased same-day admissions, it did not correlate with higher 30-day readmission rates, suggesting that obesity may primarily affect immediate post-operative outcomes rather than long-term complications [14].

Additionally, a systematic review by Ankichetty et al. [22] examining the impact of sedatives and anesthetics in patients with OSA, identified concerns regarding respiratory events, hemodynamics, and medication requirements. Midazolam and fentanyl were implicated in adverse respiratory events, while propofol and isoflurane were associated with postoperative desaturation. The perioperative use of alpha-2 agonists was shown to reduce anesthetic, analgesic, and antihypertensive medication needs. While intraoperative opioids decreased postoperative pain scores, data on hospital length of stay remained limited.

2. Conflicting evidence in literature

Several studies [13,14,18,23-26] challenge traditional assumptions as mentioned in the previous section. Vertosick et al. [27]’s study on cancer surgeries found that most patients with a BMI up to 50 kg/m² experienced no major complications. Analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database showed no significant difference in postoperative complications between patients with super-morbid obesity (BMI > 50 kg/m²) and patients with morbid obesity (BMI 40–50 kg/m²) [12,22].

A study by Barbat et al. [23] focused on comparing outcomes for 408,895 ambulatory surgery patients who were undergoing either sleeve gastrectomy or Roux-en-Y gastric bypass and were discharged within 24 h to those who stayed in the hospital for a longer period. The study found no significant difference in 30-day mortality, reoperation rates, or readmission rates between the two groups, suggesting that with appropriate patient selection and postoperative management, ambulatory surgery can be as safe as traditional hospitalization. However, the study did highlight an increased incidence of surgical site infections among sleeve gastrectomy patients.

Several unexpected findings emerged from the literature. Interestingly, a study [13] on patients with morbid obesity undergoing ambulatory surgery found that these patients had a lower incidence of postoperative nausea and vomiting (PONV) compared to non-obese patients. The etiology of this finding is unknown, and further studies are needed to determine the mechanism(s) of why patients with obesity, in general, have been found to have lower PONV as Kim et al. [28] note. In addition to that, current smoking status was found to be associated with reduced admission rates [14]. In one study, outcomes for sleep apnea surgery (i.e., uvulopalatopharyngoplasty or concomitant procedures on the base of the tongue, maxilla, palate, nose/turbinate, or tracheotomy) were comparable between outpatient and inpatient settings, even in patients with morbid obesity [25].

Regarding airway management, a review of 45,447 cases by Moon et al. [26] found that morbid obesity did not significantly increase the likelihood of difficult intubation; however, difficult mask ventilation was more frequent among patients with obesity. Key risk factors for difficult intubation included age > 46 years, male sex, higher Mallampati scores (3–4), and reduced thyromental distance, whereas intact dentition appeared protective against difficult mask ventilation.

The literature emphasizes that BMI should not be considered in isolation when assessing anesthetic risk and appropriateness for surgery at ambulatory surgery centers (ASCs). One study [18] identified independent predictors of complications following day-case surgery which included overweight and obese BMI, chronic obstructive pulmonary disease (COPD), a history of transient ischemic attack or stroke, hypertension, previous cardiac surgery, prolonged operative time, advanced age, and higher American Society of Anesthesiologists classification. These factors need to be carefully considered when planning for ambulatory surgery.

3. Opioid-related challenges and alternatives

Opioids, commonly used for pain management following surgery, are known to exacerbate sleep-disordered breathing by depressing respiratory drive, increasing the risk of hypoxia, and leading to potentially fatal respiratory events [19]. A study [7] investigating remifentanil’s impact on sleep and respiratory function in patients with OSA highlighted the increased risks of central apneas and reduced oxygen saturation, suggesting that opioid-induced central apnea may be a greater concern than worsening obstructive apnea. In a study by Turan et al. [29] postoperative opioid use in bariatric surgery patients demonstrated an inverse relationship between opioid consumption and nocturnal hypoxia, implying heightened opioid sensitivity due to chronic intermittent hypoxia. Opioid-induced ventilatory impairment is a significant concern, particularly in the context of altered pain sensitivity due to intermittent hypoxia and sleep fragmentation [8] as is the case with patients with OSA.

Studies indicate that patients with OSA who receive opioids postoperatively are more likely to require naloxone intervention [30]. Alternative pain management strategies, including regional anesthesia and non-opioid analgesics, are recommended for this population [6,31]. Additionally, postoperative extubation should be conducted in a non-supine position, with full neuromuscular recovery confirmed through objective monitoring (train-of-four ratio ≥ 0.9) [32,33].

Institutional protocols should integrate comprehensive monitoring strategies tailored to patients with obesity and OSA, ensuring adequate postoperative assessment prior to discharge [19,30,34].

Perioperative risk assessment for patients with OSA

OSA poses challenges in ambulatory anesthesia, requiring careful preoperative assessment and perioperative management. The Society of Anesthesia and Sleep Medicine (SASM) [19] emphasizes OSA screening due to its association with increased perioperative complications such as respiratory depression, airway obstruction, and cardiovascular instability. Many patients with moderate-to-severe OSA remain undiagnosed [10], highlighting the need for standardized preoperative protocols. The SASM recommends integrating OSA evaluations into routine anesthesia assessments to ensure appropriate monitoring and management. Current recommendations focus on preoperative evaluation, leaving anesthesiologists to make individualized decisions on anesthesia techniques and postoperative monitoring. The SASM advises against delaying surgery solely for OSA treatment but recommends cardiopulmonary optimization for high-risk patients.

1. Criteria for ambulatory surgery candidacy

Preventing complications in patients with obesity and OSA undergoing ambulatory surgery begins with comprehensive preoperative screening (Fig. 1) [6,7,17-19,35-38]. This includes assessing BMI, the severity of OSA, and associated comorbidities. Tools such as the STOP-Bang (snoring, tiredness, observed apnea, high blood pressure, body mass index, age, neck circumference, and gender) and Berlin questionnaires are invaluable in identifying patients at high risk for perioperative complications (Table 1) [6,10,12,17-19,35-38]. Additionally, preoperative optimization of comorbid conditions, such as hypertension and diabetes, as well as preemptive use of continuous positive airway pressure (CPAP) therapy for patients with OSA, can significantly reduce the risk of complications [6].

Fig. 1.

Strategies that should be implemented in preoperative patient evaluation to support improved patient outcomes include comprehensive screening, optimizing comorbid conditions, and preemptive continuous positive airway pressure (CPAP) use in patients with obstructive sleep apnea (OSA).

Table 1.

Preoperative OSA Screening Checklist to Assist in Perioperative Risk Assessment

OSA screening (STOP-Bang)
Ask the patient the following		Point
Do you snore loudly? (Louder than talking or loud enough to be heard through closed doors)	No	Yes (+1)
Do you often feel tired, fatigued, or sleepy during the daytime?	No	Yes (+1)
Has anyone observed you stop breathing during sleep?	No	Yes (+1)
Do you have (or are you being treated for) high blood pressure?	No	Yes (+1)
Objective measures
BMI	< 35 kg/m2	> 35 kg/m2 (+1)
Age (yr)	< 50	> 50 (+1)
Neck circumference	< 40 cm	> 40 cm (+1)
Gender	F	M (+1)
STOP-Bang Score (total of points in right-hand column)
0–2: Low risk for moderate-to-severe OSA
3–4: Intermediate risk
5–8: High risk
Relevant comorbidities
Hypertension	No	Yes
Diabetes	No	Yes
COPD	No	Yes
Cardiovascular disease	No	Yes

STOP-Bang: snoring, tiredness, observed apnea, high blood pressure, body mass index, age, neck circumference, and gender, BMI: body mass index, OSA: obstructive sleep apnea, COPD: chronic obstructive pulmonary disease.

Selecting appropriate candidates for ambulatory surgery is essential to ensure both patient safety and operational efficiency. Patient characteristics such as BMI, age, frailty, comorbidities, and the presence of OSA significantly influence decision-making. For instance, while BMI is a critical factor, it should not be the sole determinant of eligibility for surgery at an ASC. Patients with obesity, especially those with a BMI over 40 kg/m², should undergo a thorough preoperative evaluation to assess comorbid conditions, including hypertension, diabetes, COPD, and cardiovascular disease. In contrast, patients with a BMI less than 40 kg/m² may still be considered for outpatient surgery if their comorbid conditions are well-managed [18,36].

For patients with OSA, the severity of their condition and the potential for respiratory compromise must be carefully evaluated. Moderate to severe OSA patients may require surgery in facilities capable of monitoring respiratory function postoperatively, and the use of CPAP or non-invasive positive pressure ventilation is advised to prevent airway collapse and respiratory depression. Although CPAP use was associated with increased pain thresholds and reduced pain sensitivity [7], the use of CPAP therapy postoperatively may enhance recovery, particularly in patients with severe OSA [17,19,37,38].

Perioperative anesthetic management strategies

1. Airway management considerations

Patients with obesity, particularly those with a BMI over 40 kg/m², are at an increased risk of difficult intubation and other respiratory complications due to anatomical challenges such as increased NC, reduced thyromental distance, and limited cervical extension [33]. Several factors have been proposed to contribute to difficult intubation, including NC, sex, and higher Mallampati scores [39]. The use of supraglottic airway devices have been explored as an alternative to endotracheal intubation, offering improved postoperative oxygenation and lung function [33].

Effective preoxygenation [40] before [33] and during [41,42] induction is essential in mitigating the risk of hypoxemia, particularly in patients with obesity and OSA due to the high risk of upper airway collapse due to high extraluminal pressure in the upper airway (Fig. 2) [6,33,41-44]. A study by Gander et al. [42] shows, using positive end-expiratory airway pressure while initiating general anesthesia in patients with severe obesity, extends the safe period without oxygen by approximately 50% before blood oxygen levels begin to drop. Traditional methods, such as a tight-fitting facemask, have been widely used; however, alternative approaches, including humidified high-flow nasal oxygen (HFNO) and high-flow standard nasal cannula, have shown comparable efficacy in achieving optimal end-tidal oxygen (EtO₂) levels [6]. Studies indicate that preoxygenation using a standard nasal cannula at 50 L/min with closed-mouth breathing can achieve EtO₂ levels similar to HFNO and facemask techniques [41]. Additionally, normal tidal breathing over three minutes has been found to be more effective than eight vital capacity breaths, underscoring the significance of proper breathing techniques in enhancing preoxygenation efficiency [41].

Fig. 2.

Effective airway management in obstructive sleep apnea includes consideration and application of neuromuscular blockade reversal, head-elevated and video laryngoscopy, reverse Trendelenburg positioning, supraglottic airway devices, preoxygenation, humified high-flow nasal oxygen, and high-flow nasal cannula.

Airway management techniques, including the use of advanced airway devices like video laryngoscopes [44] and reverse Trendelenburg positioning [33], which enhances ventilation by reducing diaphragmatic compression, are useful strategies for ensuring safe airway management during anesthesia. Anesthesia providers should be prepared for the possibility of airway obstruction, particularly during induction and recovery. Techniques such as head-elevated laryngoscopy, preoxygenation, and the use of video laryngoscopy can improve airway management outcomes. Notably, a study by Moon et al. [26] assessing of over 45,000 intubations at a major teaching hospital revealed that morbid obesity, contrary to common belief, does not increase the risk of difficult intubation, but patients with morbid obesity were nearly four times more likely to experience difficult mask ventilation. The study identified several consistent risk factors for both difficult intubation and mask ventilation, including age over 46 years old, male sex, and higher Mallampati scores (3–4). As expected, having natural teeth made mask ventilation easier but intubation more challenging.

Preoxygenation with 100% oxygen and the application of continuous CPAP extend non-hypoxic apnea duration in patients with obesity. The utility of rapid sequence induction in patients with obesity remains debated, with its necessity contingent on factors such as gastroesophageal reflux disease (GERD) and the potential difficulty of intubation [30]. Additionally, ensuring complete reversal of neuromuscular blockade is an important strategy to prevent postoperative airway complications [6,43,44], with sugammadex offering rapid reversal of rocuronium-induced paralysis, thereby enhancing safety in high-risk populations [30].

Airway management in patients with obesity requires specific approaches and equipment. Modern second-generation supraglottic airways may be preferred for their enhanced seal pressures and gastric drainage capabilities during controlled ventilation. In cases where both intubation and mask ventilation might be challenging, physicians should opt for awake intubation. Proper positioning is achieved through ramping techniques, where the upper body and head are elevated to align the external auditory meatus with the sternal notch [45].

For ventilation management, protective strategies employ multiple components: reduced tidal volumes, minimal oxygen levels as tolerated, positive end-expiratory pressure, and carefully timed recruitment maneuvers. These recruitment procedures should only be performed in patients who are hemodynamically stable and have normal blood volume, as they can temporarily reduce cardiac preload. For patients experiencing oxygen saturation issues despite supplementation, especially with altered consciousness, arterial blood gas analysis may be necessary. Healthcare providers must also consider and rule out sedation-induced hypoventilation, potentially requiring reversal of benzodiazepines or opioids when appropriate [45].

2. Choice of anesthetic agents

The choice of anesthetic agents plays a critical role in recovery and postoperative outcomes in ambulatory surgery (Table 2) [42,44,46]. Propofol has demonstrated advantages over inhalational agents, including reduced PONV and earlier discharge readiness [46].

Table 2.

Decision Support Table for Choice of Anesthetic Agent in Patients with OSA

Scenario/patient factor	Preferred anesthetic approach	Rationale/key recommendation
Superficial procedures	Local anesthesia or peripheral nerve block	Avoids respiratory depression associated with general anesthesia
Patient with OSA or high airway risk	Regional anesthesia is preferred over general anesthesia	Minimizes airway obstruction risk
Need for general anesthesia	Propofol-based TIVA	Faster recovery, reduced PONV, earlier discharge readiness compared to inhalational agents; use short-acting agents & minimize sedative doses
Use of inhalational agents	Use at a lower MAC	Reduces residual effects and postoperative complications; titrate to lowest effective dose
Pain management	Multimodal	Prioritize non-opioid and regional techniques; minimizing opioid use reduces risk of respiratory depression, especially in obese/OSA patients

OSA: obstructive sleep apnea, TIVA: total intravenous anesthesia, MAC: minimum alveolar concentration, PONV: postoperative nausea and vomiting.

The American Society of Anesthesiologists guidelines [44] recommend the use of local anesthesia or peripheral nerve blocks when feasible, especially for superficial procedures, to avoid the respiratory depressant effects of general anesthesia [42].

The use of regional anesthesia may help minimize airway obstruction risks associated with general anesthesia, especially for patients with OSA. If general anesthesia is necessary, short-acting anesthetic agents and minimized doses of sedatives should be used to facilitate rapid recovery and reduce the risk of respiratory depression. Inhalational anesthetic agents should be administered at lower minimum alveolar concentrations to reduce residual effects that could exacerbate postoperative complications. Furthermore, multimodal pain management strategies, including regional anesthesia and non-opioid analgesics, should be prioritized to minimize opioid use, which can exacerbate respiratory issues in patients with obesity and OSA [44].

3. Post-anesthetic recovery guidelines

Postoperative care for patients with obesity and OSA in ambulatory surgery settings requires heightened vigilance (Table 3) [6,44]. These patients are at increased risk of respiratory depression due to opioid use and sedatives, which can exacerbate apneic events. Extended monitoring in the post-anesthesia care unit (PACU) may be required to ensure patients can maintain their airway and oxygen levels before being discharged. In addition to continuous pulse oximetry, enhanced monitoring with capnography can detect early signs of respiratory compromise. Capnography is particularly effective in identifying respiratory depression in patients with OSA, as it can detect carbon dioxide buildup before changes in oxygen saturation become apparent [6].

Table 3.

Post-Anesthetic Recovery Guidelines for PACU Monitoring, Extubation, CPAP/BiPAP Use, and Discharge

	Detail and rationale
PACU monitoring strategies
Continuous pulse oximetry	Detects hypoxemia early; all OSA/obese patients should have continuous SpO₂ monitoring throughout PACU stay.
Capnography	Recommended for enhanced monitoring; detects hypoventilation and CO₂ retention before oxygen desaturation, especially valuable in OSA.
Extended monitoring	Patients with moderate/severe OSA or those who received opioids/sedatives may require prolonged PACU observation to ensure airway patency and stable oxygenation before discharge.
Positioning	Elevate head of bed or use lateral position to reduce airway obstruction risk.
Extubation criteria
Fully awake and responsive	Extubate only when patient is alert, follows commands, and demonstrates protective airway reflexes.
Adequate spontaneous ventilation	Ensure regular, unassisted breathing with normal tidal volumes and respiratory rate.
Stable oxygenation	SpO₂ ≥ 94% on room air or baseline supplemental O₂; no evidence of hypoventilation on capnography.
Hemodynamic stability	Stable blood pressure and heart rate prior to extubation.
No evidence of airway obstruction	Absence of stridor, snoring, or increased work of breathing; consider airway adjuncts if needed.
CPAP/BiPAP use
Resume preoperative CPAP/BiPAP immediately postoperatively	Patients who use CPAP/BiPAP at home should resume therapy as soon as feasible in PACU to reduce apneic events and hypoxemia.
Initiate CPAP/BiPAP in PACU for moderate/severe OSA	For patients with moderate/severe OSA or those with recurrent desaturation/apnea, initiate or continue positive airway pressure therapy during recovery.
Monitor for need of escalation	If persistent hypoxia or respiratory distress despite CPAP/BiPAP, consider hospital admission for further management.
Discharge criteria
Return to baseline respiratory status	No evidence of airway compromise, stable oxygenation on room air or baseline O₂, and able to maintain airway independently.
No ongoing need for escalated respiratory support	Patients requiring ongoing CPAP/BiPAP or supplemental O₂ beyond baseline should be considered for extended observation or admission.
Meet standard ambulatory surgery discharge criteria	Stable vital signs, minimal pain/nausea, able to ambulate, and responsible adult escort.

PACU: post-anesthesia care unit, CPAP: continuous positive airway pressure, BiPAP: bilevel positive airway pressure, OSA: obstructive sleep apnea.

For patients with moderate to severe OSA, the use of CPAP or bilevel positive airway pressure (BiPAP) in the recovery phase is often necessary to support breathing. In cases of severe respiratory distress or hypoxia, patients may need to be admitted for further observation and management (Fig. 3) [6,44].

Fig. 3.

Effective postoperative monitoring in patients with obesity and obstructive sleep apnea should include continuous pulse oximetry, capnography, and CPAP or BiPAP. PACU: post-anesthesia care unit, CPAP: continuous positive airway pressure, BiPAP: bilevel positive airway pressure.

4. Special considerations for patients with obesity

Invasive blood pressure monitoring may be necessary for reliable monitoring and optimal patient care if noninvasive blood pressure cuffs are ill-fitting and inaccurate. Since venous access can be particularly challenging in these patients, healthcare providers often need to use longer angiocatheters and ultrasound guidance for successful intravenous placement [45].

Medication management includes careful titration of anxiolytics to control anxiety while avoiding hypoventilation and hypoxemia due to the increased sensitivity to sedative medications. The risk of aspiration is increased with delayed gastric emptying, increased intra-abdominal pressure, and GERD, all of which are associated with obesity [47]. Preventive measures to reduce aspiration sequelae and severity can include various medications: antacids such as sodium citrate, gastric motility enhancers like metoclopramide, and histamine-2 receptor antagonists [45].

Safety and quality improvement: preventing complications and improving patient safety

It is essential to ensure that neuromuscular blockade is completely reversed before extubation, particularly in patients with obesity and/or OSA [33]. The use of quantitative monitoring and reversal agents such as sugammadex [6], particularly in patients with OSA, is critical in avoiding prolonged airway obstruction and facilitating early recovery in the PACU [33]. For patients with OSA, minimizing opioid use is critical, and multimodal analgesia should be prioritized [6,13].

Beyond clinical implications, the management of patients with obesity and OSA in the surgical setting carries medicolegal consequences. Litigation related to perioperative complications has been rising, with cases often centering on failure to recognize and appropriately manage OSA-related risks. Financial penalties in such cases underscore the need for improved screening, monitoring, and tailored anesthetic strategies for this patient population [20].

Future perspectives

As ambulatory surgery continues to evolve, an evidence-based, multidisciplinary approach will be essential for enhancing safety and improving patient outcomes. Institutional protocols are recommended that address screening and risk stratification, anesthetic techniques, postoperative monitoring, and follow-up care.

The Joint Commission is an accreditation organization in America whose goal is to promote high-quality patient care by requiring the implementation of safety measures [35]. They have identified gaps in OSA management, including inconsistent screening and inadequate provider training. Addressing these issues through education, protocol development, and collaboration will hopefully further improve patient safety.

Future research should focus on optimizing patient selection criteria and refining perioperative management strategies to improve the safety and feasibility of ambulatory surgery for high-risk patients with OSA. With continued advancements in anesthesiology and patient care protocols, outpatient surgery could become a more viable option for a broader range of these patients. This would ultimately enhance patient safety, reduce healthcare costs, and improve overall patient satisfaction.

By following evidence-based guidelines and implementing standardized protocols, healthcare providers can ensure that patients with obesity and OSA receive safe, high-quality ambulatory surgical care (Fig. 4) [31,35,48].

Fig. 4.

Enhancing safety and improving patient outcomes is multifactorial. Essential steps toward achieving this goal may include utilizing proper anesthetic techniques and postoperative monitoring, screening and risk stratification, attention to follow up-care, provider education, descriptive protocol development, and multidisciplinary involvement.

CONCLUSION

The evidence reviewed demonstrates that ambulatory surgery can only be safely performed in patients with obesity and OSA when patients are carefully selected, comorbidities are optimized, and appropriate perioperative protocols are implemented including the minimization of opioids postoperatively and post-discharge. Analysis of large-scale databases, including ACS-NSQIP, have shown comparable outcomes across different obesity categories, challenging traditional concerns about ambulatory surgery in this population. Success relies on a comprehensive approach that begins with thorough preoperative screening and extends through the entire perioperative period.

The integration of advanced airway management techniques, enhanced monitoring strategies, and proper neuromuscular blockade reversal has proven crucial for optimal outcomes. Particularly noteworthy is the effectiveness of a standard high-flow nasal cannula for preoxygenation, offering a practical alternative to more complex oxygenation methods. The implementation of continuous monitoring through pulse oximetry and capnography, combined with judicious use of CPAP or BiPAP support, has been shown to effectively mitigate postoperative respiratory risks.

As the global prevalence of obesity continues to rise, the demand for ambulatory surgery in this population will inevitably increase. Future research should focus on developing standardized protocols for perioperative management, particularly addressing discharge timing and monitoring criteria. Additionally, studies examining long-term outcomes will be essential for optimizing care delivery. Success in managing this challenging patient population ultimately depends on maintaining a careful balance between patient safety and healthcare efficiency through evidence-based protocols and comprehensive care coordination.