Postoperative management of the obstructive sleep apnea patient.

It is now well accepted that disproportionate anatomy of the upper airway exists in obstructive sleep apnea (OSA), which leads to obstruction during sleep [1–3]. Recognizing that most patients with OSA have more than one site of obstruction in the upper airway, modern surgical approach for the treatment of OSA focuses onmultiple sites in the upper airway, including the nose, palate (pharynx), and base of tongue (hypopharynx) [4,5]. Although this treatment approach has achieved a higher cure rate, the risk of postoperative airway compromise may be increased owing to surgically induced edema in multiple regions. In addition to the surgically induced edema, muscle atonia and altered respiration due to general anesthesia and narcotic use further increase the risk in these patients who already have a compromised airway. Indeed, acute airway obstruction after the use of sedatives has been reported in patients with OSA [6,7]. On the basis of a national survey, Fairbanks [8] reported 16 postoperative deaths and 7 near-death incidences after OSA surgery. The most common causes of these catastrophic complications were oversedation and surgical edema. In a retrospective review of 135 patients who had OSA surgery, Esclamando and colleagues [9] identified many complications including death, failed intubation, airway obstruction after extubation, hemorrhage, and arrhythmia. Indeed, patients undergoing OSA surgery often have comorbid issues, especially cardiovascular disease, which can complicate treatment. Based on a retrospective review of 182 patients who had OSA surgery, Riley et al [10] identified 31% (56 patients) with hypertension, 5.5% (10 patients) with arrhythmia, and 3.3% (6 patients) with a history of myocardial infarction. Clearly, many factors can complicate the postoperative management of OSA patients. It is imperative for the sleep surgeon to take necessary precautions to minimize complications. To ensure patient safety, a surgical risk-management protocol was developed at our center in 1988, which included ICUmonitoring on the first postoperative day, the use of nasal continuous positive airway pressure (CPAP) for airway protection during sleep and after discharge, aggressive hypertension management, and a criterion for the administration of analgesics. In recent years, this protocol has been revised to include preoperative and postoperative fiberoptic airway evaluation.