S = Snoring. Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
T = Tired. Do you often feel tired, fatigued, or sleepy during daytime?
O = Observed (apnea). Has anyone observed you stop breathing during your sleep?
P = Pressure. Do you have (or are you being treated for) high blood pressure?
B = BMI > 35 kg/m2
A = Age > 50 years old
N = Neck circumference >40 cm
G = Male gender
Consider OSA in patients with STOP-BANG score of ≥3.
Consider OHS in patients with STOP-BANG score of ≥3 and a serum bicarbonate ≥28 and/or room air hypoxia (SpO2 < 90 %).
In patients with suspected OSA or OHS with elevated serum bicarbonate, consider preoperative arterial blood gas (ABG) to clarify baseline degree of hypercarbia.
If you suspect OSA in a patient undergoing major elective surgery, refer for overnight polysomnogram (PSG).
The American College of Chest Physicians recommends against routine evaluation for pulmonary hypertension in patients with OSA [13]. However, consider a transthoracic echocardiogram (TTE) in the following cases:
Suspicion of heart failure by history or exam (rales, S3, elevated jugular venous pressure)
Suspicion of PAH by history, exam (loud P2, RV heave), or ECG (right axis deviation, right bundle branch block) (see Chap. 30)
Patient with (or at risk for) OHS, who will undergo major surgery
Patient with newly diagnosed severe OSA, who will undergo high-risk surgery and/or is likely to receive high doses of postoperative opioids
Perioperative Management
Preoperative Management
Ascertain and document CPAP or bilevel positive airway pressure (BPAP) settings, type of mask, amount of bleed-in oxygen (if any), and actual patient compliance.
If patients have an ill-fitting mask, refer back to sleep clinic for mask refitting.
Remind patients to bring their mask and machine to the hospital.
Recommend good compliance with CPAP/BPAP preoperatively.
Alert anesthesia and operative team to OSA or OHS diagnosis; these teams may consider regional anesthesia or peripheral nerve block to minimize sedation.
Postoperative Management
After major surgery, consider ICU care, depending on extent of surgery, severity of OSA/OHS, and compliance with CPAP/BPAP.
Keep head of bed elevated (≥30°), or use lateral (side-lying) position [1].
Extubate to CPAP or BPAP at home settings, and continue with naps and overnight sleep.
Minimize the use of sedatives and opiate analgesics (considering scheduled acetaminophen or NSAIDS to augment pain control in appropriate candidates).
Consider hypercarbia (and ABG) in patients with unexpected postoperative sedation or confusion.
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