From the Department of Anaesthesia, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
Department of Anaesthesia, Khoo Teck Puat Hospital, National Healthcare Group, Singapore.
Anesth Analg. 2021 Jul 1;133(1):196-204. doi: 10.1213/ANE.0000000000005479.
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.
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.
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).
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.
阻塞性睡眠呼吸暂停（OSA）与困难气道有关，尽管有许多前瞻性研究调查了 OSA 严重程度与困难气道结局之间的阈值。本研究旨在研究 OSA 与困难插管或困难面罩通气之间的关系。我们还探讨了使用打鼾、疲倦、观察到的呼吸暂停、高血压、体重指数、年龄、颈围和性别（STOP-Bang）评分预测困难气道的效用。
未识别的阻塞性睡眠呼吸暂停（POSA）术后血管并发症试验是一项国际前瞻性队列研究，纳入了 45 岁或以上有一个或多个心脏危险因素的择期非心脏手术患者，对困难气道结局进行了二次分析。多变量逻辑回归分析测试了 OSA 严重程度与困难气道预测因素之间的关联，包括困难插管或困难面罩通气。共有 869 例无 OSA 既往诊断的患者接受了 STOP-Bang 工具的 OSA 风险筛查，进行了术前睡眠研究，并接受了常规围手术期护理，包括气管内插管全身麻醉。分析的主要结果是困难插管，次要结果是困难面罩通气。
根据睡眠研究，869 例患者中分别有 287 例（33%）、324 例（37%）、169 例（20%）和 89 例（10%）无、轻度、中度和重度 OSA。172 例（20%）的 STOP-Bang 评分为 0-2（低危），483 例（55%）为 3-4（中危），214 例（25%）为 5-8（高危）。困难插管的发生率为 6.7%（869 例中的 58 例），困难面罩通气的发生率为 3.7%（869 例中的 32 例）。多变量逻辑回归显示，中度 OSA（比值比[OR] = 3.26 [95%置信区间{CI}，1.37-8.38]，调整 P =.010）和重度 OSA（OR = 4.05 [95% CI，1.51-11.36]，调整 P =.006）与无 OSA 患者相比，与困难插管独立相关。与评分 0-2 相比，STOP-Bang 评分 3-4 和 5-8 与困难插管的几率增加相关（OR = 3.01 [95% CI，1.13-10.40，调整 P =.046] 和 4.38 [95% CI，1.46-16.36，调整 P =.014]）。OSA 与困难面罩通气无关，只有颈围增大与困难面罩通气有关（调整 P =.002）。
中度和重度 OSA 与困难插管有关，颈围增大与困难面罩通气有关。STOP-Bang 评分≥3 与 STOP-Bang 评分 0-2 相比，可能与困难插管有关。麻醉师在处理疑似或确诊 OSA 的患者时应警惕困难插管。
