Obesity, sleep apnea, the airway and anesthesia

Recent articles indicate that at the present time disastrous respiratory outcomes during the perioperative management of patients with obstructive sleep apnea are a major problem for the anesthesia community.

A recent review of the literature indicates that disastrous respiratory outcomes are due to intubation failure, respiratory obstruction soon after extubation, and respiratory arrest after narcotic and sedative medication. In obese patients, the basic problem is deposition of adipose tissue in the pharynx. The excessive adipose tissue in the pharynx causes both the intubation and respiratory obstruction soon after extubation problems. Finally, opioid administration in the postoperative period adds the insults of depression of ventilation in general and depression of arousal to obstructed breathing during the sleep in specific, which creates in turn, the potential for the arrest of spontaneous ventilation, especially in unmonitored patients.

Adult obese patients with suspected or sleep test confirmed obstructive sleep apnea present a formidable challenge throughout the perioperative period. Tracheal intubation and extubation decisions in obese patients with either a presumptive or sleep study diagnosis of obstructive sleep apnea must be made within the context that there may be excess tissue in the pharynx. If opioids are used in the extubated postoperative obese patient with sleep apnea, then one must seriously consider the need for continuous visual and electronic monitoring. Institutional and national society guidelines on these matters are badly needed.