Is obstructive sleep apnea associated with difficult airway? Evidence from a systematic review and meta-analysis of prospective and retrospective cohort studies

The STOP-Bang questionnaire: A narrative review on its utilization in different populations and settings

STUDY RATIONALE

Although the STOP-Bang questionnaire has been validated for its efficacy and diagnostic performance in various settings, there is no review that summarizes the pertinent evidence of the STOP-Bang questionnaire in the different populations. We aimed to review the evidence of the diagnostic performance of the STOP-Bang questionnaire, correlation between STOP-Bang scores and the probability of obstructive sleep apnea (OSA), and its clinical application in various populations.

STUDY IMPACT

This review guides healthcare providers in the sleep medicine and perioperative medicine disciplines to be better informed when using the STOP-Bang questionnaire in the different populations. It provides a greater understanding for both patients and clinicians when making decisions regarding OSA screening for each population.

Evaluation of the relationship between the STOP-Bang score with oxygen reserve index and difficult airway: a prospective observational study

BACKGROUND

Patients diagnosed with Obstructive Sleep Apnea (OSA) syndrome have a tendency towards hypoventilation, hypoxia, and hypercarbia in the perioperative period. This study hypothesized that the Oxygen Reserve Index (ORi) could predict possible hypoxia and determine difficult airways in patients at risk for OSA, as determined by the STOP-Bang questionnaire.

METHODS

This prospective study included adult patients undergoing elective surgery under general anesthesia with endotracheal intubation, divided into two groups: low risk (0-2 points) and high risk (3-8 points) based on their STOP-Bang questionnaire results. The primary outcome measure was the highest ORi value reached during preoxygenation and the time to reach this value. Data were recorded at four time points: before preoxygenation (T1), end of preoxygenation (T2), end of mask ventilation (T3), and end of intubation (T4), as well as partial oxygen pressure values in T1, T2, and T4. The secondary outcome measures were the grading scale for mask ventilation, Cormack-Lehane score, tonsil dimensions, use of a stylet, and application of the burp maneuver during intubation.

RESULTS

In the high-risk group, preoperative peripheral oxygen saturation values, the highest ORi value reached in preoxygenation, and ORi values at T3 and T4 times were lower, and the time to reach the highest ORi value was longer (p < 0.05).

CONCLUSION

Using ORi in patients with OSA may be useful in evaluating oxygenation, and since difficult airway is more common, ORi monitoring will better manage possible hypoxic conditions.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Prevalence and risk factors of difficult mask ventilation: A systematic review and meta-analysis

STUDY OBJECTIVE

This meta-analysis aimed at identifying the risk factors for and their strengths in predicting difficult mask ventilation (MV) through a systematic approach.

DESIGN

Meta-analysis of observational studies.

SETTING

Operating room.

INTERVENTION

Airway- or patient-related risk factors for difficult MV reported in over 20% of eligible studies identified through literature review.

PATIENTS

Adults receiving anesthetic induction with requirement of MV.

MEASUREMENTS

Databases including EMBASE, MEDLINE, Google Scholar, and Cochrane Library were searched from inception to July 2022. The primary outcomes were the identification of commonly reported risk factors for MV and a comparison of their strengths in difficult MV prediction, while the secondary outcomes were the prevalence of difficult MV in the general population and those with obesity.

MAIN RESULTS

Meta-analysis of 20 observational studies involving 335,846 patients identified 13 risk factors with predictive strengths (all p < 0.05): neck radiation (OR = 5.0, five studies, n = 277,843), increased neck circumference (OR = 4.04, 11 studies, n = 247,871), obstructive sleep apnea (OSA) (OR = 3.61, 12 studies, n = 331,255), presence of beard (OR = 3.35, 12 studies, n = 295,443), snoring (OR = 3.06, 14 studies, n = 296,105), obesity (OR = 2.99, 11 studies, n = 278,297), male gender (OR = 2.76, 16 studies, n = 320,512), Mallampati score III-IV (OR = 2.36, 17 studies, n = 335,016), limited mouth opening (OR = 2.18, six studies, n = 291,795), edentulous (OR = 2.12, 11 studies, n = 249,821), short thyroid-mental distance (OR = 2.12, six studies, n = 328,311), old age (OR = 2, 11 studies, n = 278,750), and limited neck movement (OR = 1.98, nine studies, n = 155,101). The prevalence of difficult MV was 6.1% (16 studies, n = 334,694) and 14.4% (four studies, n = 1152) in the general population and those with obesity, respectively.

CONCLUSIONS

Our results demonstrated the strengths of 13 most common risk factors for predicting difficult MV, which may serve as an evidence-based reference for clinicians to incorporate into their daily practice.

Expert consensus on difficult airway assessment

Background

Identifying a potentially difficult airway is crucial both in anaesthesia in the operating room (OR) and non-operation room sites. There are no guidelines or expert consensus focused on the assessment of the difficult airway before, so this expert consensus is developed to provide guidance for airway assessment, making this process more standardized and accurate to reduce airway-related complications and improve safety.

Methods

Seven members from the Airway Management Group of the Chinese Society of Anaesthesiology (CSA) met to discuss the first draft and then this was sent to 15 international experts for review, comment, and approval. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) is used to determine the level of evidence and grade the strength of recommendations. The recommendations were revised through a three-round Delphi survey from experts.

Results

This expert consensus provides a comprehensive approach to airway assessment based on the medical history, physical examination, comprehensive scores, imaging, and new developments including transnasal endoscopy, virtual laryngoscopy, and 3D printing. In addition, this consensus also reviews some new technologies currently under development such as prediction from facial images and voice information with the aim of proposing new research directions for the assessment of difficult airway.

Conclusions

This consensus applies to anesthesiologists, critical care, and emergency physicians refining the preoperative airway assessment and preparing an appropriate intubation strategy for patients with a potentially difficult airway.

Preoperative risk evaluation and perioperative management of patients with obstructive sleep apnea: a narrative review

Obstructive sleep apnea (OSA) is a common sleep-breathing disorder associated with significant comorbidities and perioperative complications. This narrative review is aimed at comprehensively overviewing preoperative risk evaluation and perioperative management strategies for patients with OSA. OSA is characterized by recurrent episodes of upper airway obstruction during sleep leading to hypoxemia and arousal. Anatomical features, such as upper airway narrowing and obesity, contribute to the development of OSA. OSA can be diagnosed based on polysomnography findings, and positive airway pressure therapy is the mainstay of treatment. However, alternative therapies, such as oral appliances or upper airway surgery, can be considered for patients with intolerance. Patients with OSA face perioperative challenges due to difficult airway management, comorbidities, and effects of sedatives and analgesics. Anatomical changes, reduced upper airway muscle tone, and obesity increase the risks of airway obstruction, and difficulties in intubation and mask ventilation. OSA-related comorbidities, such as cardiovascular and respiratory disorders, further increase perioperative risks. Sedatives and opioids can exacerbate respiratory depression and compromise airway patency. Therefore, careful consideration of alternative pain management options is necessary. Although the association between OSA and postoperative mortality remains controversial, concerns exist regarding adverse outcomes in patients with OSA. Understanding the pathophysiology of OSA, implementing appropriate preoperative evaluations, and tailoring perioperative management strategies are vital to ensure patient safety and optimize surgical outcomes.

PREOPERATIVE SINGLE ANTHROPOMETRIC SCREENING TESTS OF DIFFICULT FACE MASK VENTILATION AND DIFFICULT DIRECT LARYNGOSCOPY INTUBATION IN PATIENTS UNDERGOING OTORHINOLARYNGOLOGICAL SURGERY: A PROSPECTIVE, OBSERVATIONAL, SINGLE CENTER STUDY

The aim of this study was to assess preoperative airway history data and single anthropometric screening tests of difficult face mask ventilation (FMV) and difficult direct laryngoscopy intubation (DLI) in otorhinolaryngological surgery. Final analysis included 62 patients aged ≥14 years undergoing elective surgery with endotracheal intubation at a single center during a one-month period. Data on difficult intubation history, airway symptoms and pathology related to difficult airway were prospectively collected. Han scoring classification of FMV and Intubation Difficulty Score (IDS) were used. There were 14 (22.6%) patients with a history of current airway tumors or abscesses. Only two (3.2%) patients were preoperatively evaluated as anticipated difficult airway. Both were slightly difficult to ventilate and scored IDS 5 and IDS 8. FMV was graded as easy in 50 (80.5%), slightly difficult in 10 (16.1%) and difficult in 2 (3.2%) cases. There were 29 (46.78%) slightly difficult DLIs and one (1.6%) case of difficult DLI. The study confirmed clinically relevant incidence of difficulties with FMV and DLI in otorhinolaryngologic surgery patients. However, there should be stronger evidence to identify a single preoperative variable predicting difficult airway.

Perioperative management of obstructive sleep apnea in lower extremity orthopedic procedures: A review of evidence to inform the development of a clinical pathway

Obstructive sleep apnea (OSA) is unrecognized in as high as 80% of patients before surgery. When untreated, OSA increases a surgical patient's propensity for airway collapse and sleep deprivation lending to a higher risk for emergent re-intubation, prolonged recovery time, escalation of care, hospital readmission, and longer length of stay. We have reviewed the evidence regarding diagnostic performance of OSA screening methods and the impact of perioperative management strategies on postoperative complications among patients with diagnosed or suspected OSA who are undergoing orthopedic surgery. We then integrated the data and recommendations from professional society guidelines to develop an evidence-based clinical care pathway to optimize the perioperative management of this surgical population. Successful management of patients with diagnosed or suspected OSA encompass five facets of care: screening, education, airway management, medications, and monitoring. This narrative review revealed two gaps in the evidence to inform management of patients undergoing orthopedic surgery 1) during the perioperative setting to include evidence-based interventions that reduce postoperative complications and 2) after discharge to an unmonitored environment. The clinical care pathway as well as perspectives for future research are discussed.

Anesthetic Considerations in the Electrophysiology Laboratory: A Comprehensive Review

Catheter ablation procedures for arrhythmias or implantation and/or extraction of cardiac pacemakers can present many clinical challenges. It is imperative that there is clear communication and understanding between the anesthesiologist and electrophysiologist during the perioperative period regarding the mode of ventilation, hemodynamic considerations, and various procedural complications. This article provides a comprehensive narrative review of the anesthetic techniques and considerations for catheter ablation procedures, ventilatory modes using techniques such as high-frequency jet ventilation, and strategies such as esophageal deviation and luminal temperature monitoring to decrease the risk of esophageal injury during catheter ablation. Various hemodynamic considerations, such as the intraprocedural triaging of cardiac tamponade and fluid administration during catheter ablation, also are discussed. Finally, this review briefly highlights the early research findings on pulse-field ablation, a new and evolving ablation modality.

Obstructive sleep apnoea and perioperative medicine: a growing concern

Obstructive sleep apnoea represents a sizable public health and economic burden. Owing to rising obesity rates, the prevalence of obstructive sleep apnoea is increasing, and it is a condition that is significantly underdiagnosed. Exacerbated by the COVID-19 pandemic, the backlog of elective surgeries is also sizable and growing. A combination of these factors means that many patients due to have surgery will have obstructive sleep apnoea, either diagnosed or otherwise.

Patients with obstructive sleep apnoea have a significantly increased risk of operative complications, but the evidence base for optimum perioperative management of these patients is limited. This article reviews sleep apnoea, its prevalence and its impact on operative management and perioperative outcomes for patients. The evidence base for screening and treating undiagnosed obstructive sleep apnoea is also comprehensively assessed. Finally, a pathway to manage patients with possible undiagnosed obstructive sleep apnoea is proposed, and areas for further research identified.

Preoperative preparation and premedication of bariatric surgical patient

The prevalence of obesity has tripled worldwide over the past four decades. The United States has the highest rates of obesity, with 88% of the population being overweight and 36% obese. The UK has the sixth highest prevalence of obesity. The problem of obesity is not isolated to the developed world and has increasingly become an issue in the developing world as well. Obesity carries an increased risk of many serious diseases and health conditions, including type 2 diabetes, heart disease, stroke, sleep apnea, and certain cancers. Our ability to take care of this population safely throughout the perioperative period begins with a thorough and in-depth preoperative assessment and meticulous preparation. The preoperative assessment begins with being able to identify patients who suffer from obesity by using diagnostic criteria and, furthermore, being able to identify patients whose obesity is causing pathologic and physiologic changes. A detailed and thorough anesthesia assessment should be performed, and the anesthesia plan individualized and tailored to the specific patient's risk factors and comorbidities. The important components of the preoperative anesthesia assessment and patient preparation in the patient suffering from obesity include history and physical examination, airway assessment, medical comorbidities evaluation, functional status determination, risk assessment, preoperative testing, current weight loss medication, and review of any prior weight loss surgeries and their implications on the upcoming anesthetic. The preoperative evaluation of this population should occur with sufficient time before the planned operation to allow for modifications of the preoperative management without needing to delay surgery as the perioperative management of patients suffering from obesity presents significant practical and organizational challenges.

Neck Circumference Predicts Mortality in Hospitalized COVID-19 Patients

We aimed to determine whether neck circumference predicts mortality among hospitalized COVID-19 patients with respiratory failure. We performed a prospective multicenter (Italy and Brasil) study carried out from March to December 2020 on 440 hospitalized COVID-19 patients with respiratory failure. Baseline neck circumference was measured. The study outcome was 30- and 60-days mortality. Female and male participants were classified as “large neck” when exceeding fourth-quartile. Patients had a median age of 65 years (IQR 54–76), 68% were male. One-quarter of patients presented with grade-1 or higher obesity. The median neck circumference was 40 cm (IQR 38–43): 38 cm (IQR 36–40) for female and 41 cm (IQR 39–44) for male subjects. “Large neck” patients had a significantly higher prevalence of hypertension (63 vs. 48%), diabetes (33 vs. 19%), obesity (26 vs. 14%), and elevated C-reactive protein (CRP) (98 vs. 88%). The cumulative mortality rate was 13.1% (n = 52) and 15.9% (n = 63) at 30 and 60 days, respectively. After adjusting for age, BMI, relevant comorbidities, and high C-reactive protein to albumin ratio, “large neck” patients showed a significantly increased risk of death at 30- (adjusted HR 2.50; 95% CI 1.18–5.29; p = 0.017) and 60-days (adjusted HR 2.26; 95% CI 1.14–4.46; p = 0.019). Neck circumference is easy to collect and provides additional prognostic information to BMI. Among hospitalized COVID-19 patients with respiratory failure, those with large neck phenotype had a more than double risk of death at 30 and 60 days.

Impact of obstructive sleep apnea on clinical outcomes in patients hospitalized with COVID-19

Purpose

Data from large patient registry studies suggested an increased incidence and increased mortality in coronavirus disease-2019 (COVID-19) in patients with a history of obstructive sleep apnea (OSA). This study aimed to compare the prevalence of OSA in patients with and without COVID-19 among patients admitted to the same hospital in the same time period. In addition, the impact of OSA on clinical outcomes of COVID-19 infection was investigated.

Methods

Observational cohort study. Clinical data were collected retrospectively from the complete medical records for each patient individually from March 1st 2020 to May 16th 2020.

Results

A total of 723 patients were diagnosed with COVID-19 and 1161 with non-COVID-19 disease. The prevalence of OSA did not differ between these groups (n = 49; 6.8% versus n = 66; 5.7%; p = 0.230). In patients with COVID-19, mortality was increased in the group of 49 patients with OSA (n = 17; 34.7%) compared to 674 COVID-19 patients without OSA (n = 143; 21.2%; p = 0.028). This increased risk of mortality in COVID-19 patients with OSA (OR = 2.590; 95%CI 1.218–5.507) was independent from Body Mass Index (BMI), male gender, age, diabetes, cardiovascular disease, and obstructive lung disease. Presence of OSA in COVID-19 disease was further associated with an increased length of hospital stay (12.6 ± 15.7 days versus 9.6 ± 9.9 days; p = 0.049).

Conclusion

The prevalence of OSA did not differ between patients with or without COVID-19, but mortality and hospital length of stay were increased in patients with OSA and comorbid COVID-19. Hence, OSA should be included in COVID-19 risk factor analyses, Clinicians should be aware of the association and the mechanism should be further explored.

Association of Obstructive Sleep Apnea With Difficult Intubation: Prospective Multicenter Observational Cohort Study

BACKGROUND

Obstructive sleep apnea (OSA) has been found to be associated with difficult airway, although there is a paucity of prospective studies investigating thresholds of OSA severity with difficult airway outcomes. The aim of this study was to examine the association between OSA and difficult intubation or difficult mask ventilation. We also explored the utility of the Snoring, Tiredness, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference, and Gender (STOP-Bang) score for difficult airway prediction.

METHODS

The Postoperative Vascular Complications in Unrecognized Obstructive Sleep Apnea (POSA) trial was an international prospective cohort study of surgical patients 45 years or older with one or more cardiac risk factor presenting for noncardiac surgery, with planned secondary analyses of difficult airway outcomes. Multivariable logistic regression analyses tested associations between OSA severity and predictors of difficult airway with difficult intubation or difficult mask ventilation. Overall, 869 patients without prior diagnosis of OSA were screened for OSA risk with the STOP-Bang tool, underwent preoperative sleep study, and had routine perioperative care, including general anesthesia with tracheal intubation. The primary outcome analyzed was difficult intubation, and the secondary outcome was difficult mask ventilation.

RESULTS

Based on the sleep studies, 287 (33%), 324 (37%), 169 (20%), and 89 (10%) of the 869 patients had no, mild, moderate, and severe OSA, respectively. One hundred and seventy-two (20%) had a STOP-Bang score of 0-2 (low risk), 483 (55%) had a STOP-Bang score of 3-4 (intermediate risk), and 214 (25%) had a STOP-Bang score 5-8 (high risk). The incidence of difficult intubation was 6.7% (58 of 869), and difficult mask ventilation was 3.7% (32 of 869). Multivariable logistic regression demonstrated that moderate OSA (odds ratio [OR] = 3.26 [95% confidence interval {CI}, 1.37-8.38], adjusted P = .010) and severe OSA (OR = 4.05 [95% CI, 1.51-11.36], adjusted P = .006) but not mild OSA were independently associated with difficult intubation compared to patients without OSA. Relative to scores of 0-2, STOP-Bang scores of 3-4 and 5-8 were associated with increased odds of difficult intubation (OR = 3.01 [95% CI, 1.13-10.40, adjusted P = .046] and 4.38 [95% CI, 1.46-16.36, adjusted P = .014]), respectively. OSA was not associated with difficult mask ventilation, and only increasing neck circumference was found to be associated (adjusted P = .002).

CONCLUSIONS

Moderate and severe OSA were associated with difficult intubation, and increasing neck circumference was associated with difficult mask ventilation. A higher STOP-Bang score of 3 or more may be associated with difficult intubation versus STOP-Bang score of 0-2. Anesthesiologists should be vigilant for difficult intubation when managing patients suspected or diagnosed with OSA.

Perioperative Management of the Patient With Obstructive Sleep Apnea: A Narrative Review

The prevalence of obstructive sleep apnea (OSA) has reached 1 billion people worldwide, implying significant risk for the perioperative setting as patients are vulnerable to cardiopulmonary complications, critical care requirement, and unexpected death. This review summarizes main aspects and considerations for the perioperative management of OSA, a condition of public health concern. Critical determinants of perioperative risk include OSA-related changes in upper airway anatomy with augmented collapsibility, diminished capability of upper airway dilator muscles to respond to airway obstruction, disparities in hypoxemia and hypercarbia arousal thresholds, and instability of ventilatory control. Preoperative OSA screening to identify patients at increased risk has therefore been implemented in many institutions. Experts recommend that in the absence of severe symptoms or additional compounding health risks, patients may nevertheless proceed to surgery, while heightened awareness and the adjustment of postoperative care is required. Perioperative caregivers should anticipate difficult airway management in OSA and be prepared for airway complications. Anesthetic and sedative drug agents worsen upper airway collapsibility and depress central respiratory activity, while the risk for postoperative respiratory compromise is further increased with the utilization of neuromuscular blockade. Consistently, opioid analgesia has proven to be complex in OSA, as patients are particularly prone to opioid-induced respiratory depression. Moreover, basic features of OSA, including intermittent hypoxemia and repetitive sleep fragmentation, gradually precipitate a higher sensitivity to opioid analgesic potency along with an increased perception of pain. Hence, regional anesthesia by blockade of neural pathways directly at the site of surgical trauma as well as multimodal analgesia by facilitating additive and synergistic analgesic effects are both strongly supported in the literature as interventions that may reduce perioperative complication risk. Health care institutions are increasingly allocating resources, including those of postoperative enhanced monitoring, in an effort to increase patient safety. The implementation of evidence-based perioperative management strategies is however burdened by the rising prevalence of OSA, the large heterogeneity in disease severity, and the lack of evidence on the efficacy of costly perioperative measures. Screening and monitoring algorithms, as well as reliable risk predictors, are urgently needed to identify OSA patients that are truly in need of extended postoperative surveillance and care. The perioperative community is therefore challenged to develop feasible pathways and measures that can confer increased patient safety and prevent complications in patients with OSA.

The Impact of Obstructive Sleep Apnea on the Sleep of Critically Ill Patients

Obstructive sleep apnea is becoming increasingly prevalent in society and thus critical care practitioners need to be prepared to care for these patients in the intensive care unit. Preparation begins with equipping the critical care nurse with the knowledge necessary to provide interventions which can enhance patient outcomes and mitigate complications.

Utilization of apnea-hypopnea index as a novel predictive factor for difficult mask ventilation in the Chinese population under general anesthesia

Purpose

Difficult mask ventilation (DMV) is a potentially life-threatening situation that can arise during anesthesia. However, most clinical predictors of DMV are based on European and US populations. On the other hand, most predictive models consist of multiple factors and complicated assessments. Since obstructive sleep apnea (OSA) is among the most important risk factors associated with DMV, the apnea-hypopnea index (AHI) may play an important role in determining patient risk.The purpose of this study was to investigate the relationship between DMV and AHI, and to determine preoperative risk factors for DMV in Chinese patients.

Methods

A prospective cohort trial enrolled patients scheduled for elective surgery. After obtaining informed consent, patient demographic information was collected, and patients were tested with pre-operative polysomnography. The anesthesiologist who managed the airway graded the mask ventilation. The difficult mask ventilation was defined as the mask ventilation provided by an unassisted anesthesiologist without oral airway or other adjuvant. A logistic regression model was used to analyze the association between AHI and DMV.

Results

A total of 159 patients were analyzed. For both primary and secondary outcomes, the unadjusted and adjusted odds ratio for DMV showed significant increases by 5 AHI units. AHI, age, and the Mallampati classification were found to be independent predictive factors for DMV.

Conclusions

AHI is associated with DMV as a novel independent risk factor in Chinese patients. Along with age and Mallampati classification, AHI should be included in establishing a superior predictive strategy for DMV screening.

Trial registration

Chinese Clinical Trial Registry ChiCTR-DDD-17013076

Stickler Syndrome: Airway Complications in a Case Series of 502 Patients

BACKGROUND

Patients with Stickler syndrome often require emergency surgery and are often anesthetized in nonspecialist units, typically for retinal detachment repair. Despite the occurrence of cleft palate and Pierre-Robin sequence, there is little published literature on airway complications. Our aim was to describe anesthetic practice and complications in a nonselected series of Stickler syndrome cases. To our knowledge, this is the largest such series in the published literature.

METHODS

We retrospectively identified patients with genetically confirmed Stickler syndrome who had undergone general anesthesia in a major teaching hospital, seeking to identify factors that predicted patients who would require more than 1 attempt to correctly site an endotracheal tube (ETT) or supraglottic airway device (SAD). Patient demographics, associated factors, and anesthetic complications were collected. Descriptive statistical analysis and logistic regression modeling were performed.

RESULTS

Five hundred and twoanesthetic events were analyzed. Three hundred ninety-five (92.7%) type 1 Stickler and 63 (96.9%) type 2 Stickler patients could be managed with a single attempt of passing an ETT or SAD. Advanced airway techniques were required on 4 occasions, and we report no major complications. On logistic regression, modeling receding mandible (P = .0004) and history of cleft palate (P = .0004) were significantly associated with the need for more than 1 attempt at airway manipulation.

CONCLUSIONS

The majority of Stickler patients can be anesthetized safely with standard management. If patients have a receding mandible or history of cleft, an experienced anesthetist familiar with Stickler syndrome should manage the patient. We recommend that patients identified to have a difficult airway wear an alert bracelet.

Perioperative care of the obese patient

Background

Obesity has become an increasing problem worldwide during the past few decades. Hence, surgeons and anaesthetists will care for an increasing number of obese patients in the foreseeable future, and should be prepared to provide optimal management for these individuals. This review provides an update of recent evidence regarding perioperative strategies for obese patients.

Methods

A search for papers on the perioperative care of obese patients (English language only) was performed in July 2019 using the PubMed, Scopus, Web of Science and Cochrane Library electronic databases. The review focused on the results of RCTs, although observational studies, meta-analyses, reviews, guidelines and other reports discussing the perioperative care of obese patients were also considered. When data from obese patients were not available, relevant data from non-obese populations were used.

Results and conclusion

Obese patients require comprehensive preoperative evaluation. Experienced medical teams, appropriate equipment and monitoring, careful anaesthetic management, and an adequate perioperative ventilation strategy may improve postoperative outcomes. Additional perioperative precautions are necessary in patients with severe morbid obesity, metabolic syndrome, untreated or severe obstructive sleep apnoea syndrome, or obesity hypoventilation syndrome; patients receiving home ventilatory support or postoperative opioid therapy; and obese patients undergoing open operations, long procedures or revisional surgery.

Implementation Science: Incorporating Obstructive Sleep Apnea Screening and Capnography Into Everyday Practice

PURPOSE

This article describes the implementation and maintenance of obstructive sleep apnea (OSA) screening and capnography monitoring.

DESIGN

A quality improvement project.

METHODS

A multidisciplinary team provided staff education to three perianesthesia care units. Using the STOP-Bang screening tool, five or more positive responses indicated high risk for OSA. A postanesthesia care unit audit tool tracked STOP-Bang scores, capnography use, hypoventilation events, nursing interventions, and respiratory complications.

FINDINGS

Among 314 patients with OSA, 36% were identified as high risk. Nurses used capnography on 76% of OSA patients and were able to readily identify hypoventilation and intervene. Respiratory complications occurred in 10.8% (n = 34) requiring a higher level of care. Postimplementation, all six postanesthesia care units employ this best practice.

CONCLUSIONS

Perianesthesia nurses found OSA screening and capnography easy to incorporate into nursing practice. This process can reduce respiratory complications in the surgical patient with OSA. An Evidence-Based Practice Fellowship Program facilitated this practice change.

Impact of obstructive sleep apnea on perioperative complications among patients undergoing hysterectomy: a population-based analysis

INTRODUCTION

Although obstructive sleep apnea (OSA) is a known risk factor for perioperative complications in various patient cohorts data is lacking for patients undergoing hysterectomies, one of the most frequently performed surgeries among women. Using national data we therefore aimed to assess the risk in this patient group.

MATERIALS AND METHODS

We extracted data on patients who underwent a hysterectomy between 2006 and 2014 from a large nationwide database (n = 459,508). OSA patients (identified by ICD-9 CM codes) were compared to non-OSA patients regarding perioperative outcomes: cardiac, central-nervous, gastrointestinal, genitourinary, renal, respiratory, and thromboembolic complications; as well as opioid prescription, need for blood transfusion, cost of hospitalization, length of stay and ICU admission. Odds ratios (OR) and 95% confidence intervals (CI) are reported.

RESULTS

Overall, 2.67% (n = 11,936) of patients were identified as having OSA. Compared to non-OSA patients, OSA was particularly associated with higher odds for renal (OR 1.98; 95% CI 1.70-2.32) and respiratory complications (OR 3.25; 95% CI 2.97-3.56), and ICU admission (OR 2.28; 95% CI 1.77-2.94). Further, while significant, OSA was associated with modestly increased cost of hospitalization (+6.24%; P < 0.0001) and length of stay (+2.58%; P < 0.0001).

CONCLUSIONS

In patients undergoing hysterectomies, OSA was associated with substantially increased risk of complications and modestly increased resource utilization. Further research is needed to assess currently used perioperative care strategies for OSA patients undergoing hysterectomies, with the goal to improve outcomes.