Management of Untreated Sleep Apnea in Hospitalized Patients

Risk Stratification and Monitoring

The American Society of Anesthesiologists recommends continuous pulse oximetry monitoring for hospitalized OSA patients after leaving the recovery room, maintained throughout their hospital stay as long as they remain at increased risk, with monitoring provided in critical care or stepdown units, telemetry on hospital wards, or with a dedicated trained observer in the patient's room 3
The American Society of Anesthesiologists suggests that increased monitoring intensity is warranted for patients with obesity, unstable medical conditions, concomitant opioid or sedative-hypnotic use, or extremes of age 4

The American College of Physicians recommends using the STOP questionnaire to screen for high OSA risk, with a score ≥2 indicating high risk 6

The American Journal of Respiratory and Critical Care Medicine suggests that for patients with respiratory failure suspected of having obesity hypoventilation syndrome or severe OSA, noninvasive ventilation should be started before hospital discharge, with a substantial mortality benefit, adjusted odds ratio of 0.16 (95% CI 0.08-0.33) for death at 3 months when discharged on PAP versus without PAP 1, 2, 5
The American Journal of Respiratory and Critical Care Medicine recommends not waiting for formal sleep study confirmation before initiating therapy in high-risk hospitalized patients, and discharging with NIV is not a substitute for arranging outpatient sleep study and PAP titration, which should occur within 3 months 1, 5

The American College of Physicians recommends exercising extreme caution or avoiding opioid analgesics, sedative-hypnotics, and alcohol in patients with OSA, due to increased risk of respiratory depression and upper airway obstruction 4, 6
The American Society of Anesthesiologists suggests using regional analgesia techniques without neuraxial opioids when possible, and monitoring respiratory rate hourly for the first 12 hours, then every 2 hours for the next 12 hours, when neuraxial opioids are required 4

The American Society of Anesthesiologists recommends that supplemental oxygen should be available but not routinely administered to all OSA patients, and should only be used for documented hypoxemia, altered level of consciousness, or respiratory depression 3, 4

The American Society of Anesthesiologists recommends major conduction anesthesia (spinal/epidural) over general anesthesia for peripheral procedures in patients with OSA, and securing the airway is preferable to deep sedation without airway protection 3

The American Society of Anesthesiologists recommends that patients should not be discharged to unmonitored settings until they are no longer at risk of postoperative respiratory depression, able to maintain adequate oxygen saturation on room air, and have verified respiratory function 3
The American Journal of Respiratory and Critical Care Medicine suggests arranging sleep study and PAP titration within 3 months of hospital discharge, and targeting completion of these arrangements before discharge 1, 5

The American Journal of Respiratory and Critical Care Medicine recommends initiating CPAP rather than NIV as first-line therapy for patients with confirmed severe OSA and obesity hypoventilation syndrome, as CPAP is the most extensively studied and effective therapy 1, 2, 7
The American College of Physicians suggests continuing PAP therapy even if used <4 hours per night, as evidence shows benefits with mean use of 3.4-3.8 hours per night, including improved quality of life and reduced cardiovascular events 6
The American College of Physicians recommends mandibular advancement devices as alternative therapy for patients who prefer them or experience adverse effects with CPAP, though CPAP remains superior in reducing AHI 6, 7