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SPECIAL ARTICLE
Year : 2008  |  Volume : 52  |  Issue : 2  |  Page : 140-147 Table of Contents     

Perioperative Management of Patients with Obstructive Sleep Apnoea - A Review


1 Professor, Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan
2 Senior Instructor, Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan

Date of Acceptance10-Feb-2008
Date of Web Publication19-Mar-2010

Correspondence Address:
Fauzia A Khan
Department of Anaesthesiology, Aga Khan University,Stadium Road, PO Box 3500, Karachi 74800
Pakistan
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Source of Support: None, Conflict of Interest: None


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Obstructive sleep apnoea (OSA) is a sleep disorder of particular concern to anaesthetist. Its exact prevalence is not known but it is said to affect 5% of the population in the west. It is a syndrome characterized by periodic, partial, or complete obstruction of the upper airway during sleep. The diagnostic gold standard is polysomnography.
The anaesthetic implications include the presence of comorbidities like cardiovascular, respiratory and cerebrovascular sequelae. Obesity is a commonly associated condition. Effects of sedatives, hypnotics and other anaesthetic drugs are of major concern and there are potential complications associated with the postoperative period. The purpose of this review is to update the readers on the recent literature available on the topic. The American Society of Anesthesiologists has recently suggested guidelines on the perioperative management of these patients.

Keywords: Obstructive sleep apnoea, Obesity


How to cite this article:
Khan FA, Ali M. Perioperative Management of Patients with Obstructive Sleep Apnoea - A Review. Indian J Anaesth 2008;52:140-7

How to cite this URL:
Khan FA, Ali M. Perioperative Management of Patients with Obstructive Sleep Apnoea - A Review. Indian J Anaesth [serial online] 2008 [cited 2019 Dec 8];52:140-7. Available from: http://www.ijaweb.org/text.asp?2008/52/2/140/60612


   Introduction Top


The presence of obstructive sleep apnoea (OSA) presents a major challenge to the anaesthetists. The as­sociation of OSA with obesity has long been recognized but the first detailed description of episodic diurnal and nocturnal manifestations of Pickwickiain syndrome were given by Gastaut et al in 1966 [1] . The problem now ap­pears to be more common in general population than originally thought, and this has been confirmed by sev­eral epidemiological studies [2],[3] .

There are anaesthetic implications for preopera­tive evaluation and medication, intra-operative manage­ment, post operative care and pain management in pa­tients with OSA. These patients are likely to have sev­eral co-morbidities of importance to the anaesthetist. Patient may also present for surgery without prior diag­nosis [4] . The effects of sedatives, analgesics, and anaesthetics can worsen OSA by several mechanisms and there is increased risk of anaesthetic and post op­erative complications.

This review will discuss the current definition, inci­dence, anaesthetic management of the disorder, and avail­ability of current guidelines.


   Definition Top


There is no broad consensus definition. An attempt was made in 1999 to address this issue [5] . In this particu­lar report "apnoea" was defined as a cessation of air­flow exceeding 10 second duration. "Obstructive sleep apnoea (OSA)" was defined as persistent efforts with­out air flow. The term "obstructive sleep apnoea syn­drome" (OSAS) was applied when OSA was accompa­nied by day time sequelae e.g. excessive day time sleepi­ness.

A recent practice guideline by American Society of Anesthesiologists (ASA) defines obstructive sleep apnoea (OSA) as a syndrome characterized by periodic, partial or complete obstruction of the upper airway dur­ing sleep [6] .


   Incidence Top


The epidemiological data shows the prevalence of OSAS at about 5% in general population in western coun­tries [7] and 1-9% in surgical patients [4] . Eighty to 90% of patients probably, still remain undiagnosed [8] . The incidence is higher in males, obese patients and in patients with upper airway malignancies [9] . In a recent survey of Ca­nadian anaesthesiologists, 67% of respondents provided perioperative care to one to five OSA patients per month [10] .

The incidence data from the subcontinent is scarce. One study from Delhi, reports the incidence of OSA to be 13.7%, and for OSA syndrome as 3.57% [11] . Another from Mumbai reports a higher incidence of OSAS of 7.5% [12] . A preliminary study from Karachi, Pakistan re­ports the incidence in one centre to be the same as in the west, in patients studied in a sleep lab [13] .


   Brief pathophysiology Top


A narrow and floppy upper airway is the basis of OSA. Sleep specially rapid eye movement sleep makes the airway more floppier and narrower due to muscle relaxation, resulting in partial or complete obstruction [14] . Each cycle is followed by arousal, and in severe cases this scenario is repeated hundreds of times every night. These repeated cycles of hypoxemia and hypercarbia may result in several potential sequelae like pulmonary hypertension [15] , systemic hypertension, ischemic heart disease, right heart failure [16] , gastro-oesophageal reflux, intra-cranial hypertension [17] , polycythemia and right heart failure, all of which are of potential anaesthetic signifi­cance.


   Pre-operative screening for OSAS Top


Early identification of OSAS is important in the surgical patient population. A recent publication by Kaw et al recommends that heavy snoring, sudden awaken­ing from sleep with a choking sensation and witnessed apnoea by a bed partner should be a routine component of the pre-operative visit [4] . ASA guidelines [6] recommend history of snoring, headaches, and day time somnolence in addition to above. Physical examination may reveal associated features like nasal obstruction, tonsillar hy­pertrophy, retrognathia and obesity. These features may not be a reliable predictor of the severity. In addition to airway assessment physical examination should include neck circumference and tongue volume.

Polysomnography still remains the gold standard for diagnosing the disorder if feasible in a given clinical situation. Alternative screening tools like overnight oxim­etry have been explored by some authors[18] . Nocturnal oximetry only identified one third of those who experi­enced post operative complications [18] . A study by Fidan et al recommends polysomnography in all surgical pa­tients who have two or more major symptoms of OSA present [19] . Nasopharyngoscopy is sometimes performed to assess the benefits of surgery [14] .

If sleep studies are available, the results of the sleep lab assessment in terms of mild, moderate or severe disease should be used to determine the anaesthetic man­agement [6] . Scoring systems to estimate peri-operative risks have been proposed but not validated [6] . In case of diagnosed sleep apnoea the severity of apnoea, treat­ment received and patient's compliance with the treat­ment and complications of OSA should be reviewed.

If the patient is suspected to have OSA and sleep studies are not available or the surgery is emergency, patients should be treated as though they have moderate sleep apnoea [6] .

Anaesthetic management should be carefully planned in consultation with the surgeon.


   Preoperative preparation Top


The recommendation of the American Society of Anesthesiologists state that preoperative continuous posi­tive airway pressure (CPAP) should be considered in severe OSA and in patients who do not respond to CPAP, non invasive positive pressure ventilation (NIPPV) is of benefit [6] .

Patients who have had prior corrective surgery e.g. uvulopalatopharyngoplasty should still be assumed at higher risk until a normal sleep study pattern has been obtained. Weight loss should be considered when fea­sible.


   Premedication Top


Preoperative sedation with benzodiazepines for anxiolysis may cause considerable relaxation of the up­per airway musculature. It causes an appreciable re­duction of the pharyngeal space which may lead to a higher risk of preoperative phases of hypopnoea and consecutive hypoxia and hypercapnia [20],[21] . Oxygen satu­ration needs to be monitored during preoperative period and patient should be kept in a monitored area. In pa­tients on CPAP there is no real contraindication to pre­medication as their CPAP may be applied if they get sleepy and oxygen can be added if necessary [22] .

Many patients with OSA are morbidly obese. This places them at increased risk for aspiration of acidic gastric fluid at the time of induction of anaesthesia. These patients should receive medications to suppress gastric acid production, neutralize the acid, or to stimulate emp­tying of the stomach [20] .


   Perioperative management Top


The anaesthetic care of patients with OSA is chal­lenging because anaesthetic drugs profoundly influence control of an already dysfunctional respiratory system, and presence of significant co-morbidities. Hyperten­sion and cardiovascular diseases is more common often than other patients [23] .

No evidence exists regarding perioperative risk in patients with sleep apnoea whether it depends on the type of anaesthetic technique employed [24] . It is gener­ally believed that regional anaesthesia (RA) is prefer­able over general anaesthesia (GA) whenever possible. Regional anaesthesia minimally affects respiratory drive and can reduce the effect of anaesthetic agents on sub­sequent sleep patterns as well as maintain arousal re­sponses during apnoeic episodes. Regional anaesthesia may obviate the need for sedative and opioid drugs both intraoperatively and postoperatively [25] . One should be ready for airway management because the regional tech­nique may result in unconsciousness or respiratory pa­ralysis unintentionally [14] . Landmarks may be difficult to identify if the patient is obese.

If general anaesthesia is the only option, controlled ventilation with tracheal intubation should be the choice. There is compelling evidence in the literature that obese OSA patients are, in general, more difficult to intubate than normal controls. Obesity, short thick neck and ex­cess pharyngeal tissue deposits in the lateral pharyngeal walls are causative factors for difficult intubation. Benumof recommends that all patients who have a tra­chea that is difficult to intubate should be regarded as having OSA until excluded by clinical features and, where doubt exists, sleep studies [25] .


   Intubation technique Top


The equipment for management of a difficult air­way should be in place before induction of general ana­esthesia. Orotracheal tubes in various sizes, gum elastic bougie as well as a McCoy laryngoscope and a laryn­geal mask airway are necessary. Fibreoptic devices may be helpful but have no impact in acute emergency situa­tions. A strategy or algorithm for establishing a secure airway should be defined. With the increased index of suspicion of difficult intubation in patients with OSA, the decision to do tracheal intubation with the patient awake or under general anaesthesia must be individualized on the basis of a complete preoperative airway evaluation. If difficulty with either mask ventilation or tracheal intu­bation is expected, then, according to the ASA Difficult Airway Algorithm, intubation and extubation should be performed while the patient is awake[25] .

If tracheal intubation is to be done while the pa­tient is awake using flexible fiberscope, it is essential that the patient be properly prepared by topical and nerve block anaesthesia of the upper airway.

If intubation is to be done with the patient asleep, the patient should be fully preoxygenated because an obese patient with a relatively small functional residual capacity (FRC) and high oxygen consumption desaturates much more rapidly during obstructive apnoea than does a normal patient [26] . Effective preoxgygenation is achieved by delivering FIO2 = 1.0 for more than three minutes duration with a properly sealed face mask [27] . Oxygen insufflation into the pharynx via a small nasopharyngeal catheter during laryngoscopy of the obese patient may further delay the onset of arterial oxygen desaturation [28] .

Patient should be in sniffing position before induc­tion of GA. Use of optimal external laryngeal manipula­tion during laryngoscopy may improve the laryngeal view [29] . Mask ventilation may require two anaesthesia providers. The airway pressure relief valve and mask seal should be set in a way to deliver CPAP (5-15 cm H2O) [25] .

In the context of difficult airway one should be ready for "cannot ventilate, cannot intubate" situation. Equipment (cricothyrotomy set, jet ventilator) and per­sonnel (ENT surgeon) to deal with this situation should be readily available.


   Rapid sequence induction in sleep aponea Top


In a recent review article, Freid concluded that rapid sequence induction remains important in obese and sleep apnoea syndrome patients with symptomatic gastroe­sophageal reflux or other predisposing condition such as diabetes mellitus, pregnancy, emergency surgery, and gastrointestinal conditions. In the case of elective sur­gery in a fasted patient with no risk factors other than obesity or sleep apnoea syndrome, the requirement for rapid sequence induction is debatable. Cricoid pressure is probably efficacious but has not been proven in a ran­domized, controlled trial to prevent gastric aspiration. The clinician should be aware of the possibility that cricoid pressure will worsen mask ventilation and laryngoscopy and be prepared to loosen or release the pressure if mask ventilation or intubation is compromise [30] .


   The effect of anaesthetic drugs Top


There is evidence that many anaesthetic agents cause exaggerated responses in patients with sleep ap­noea. Drugs such as thiopentone, propofol, opioids, ben­zodiazepines, and nitrous oxide may reduce the tone of the pharyngeal musculature that acts to maintain airway patency [25],[31] .

The choice of induction and maintenance agents is probably not important although it would seem sensible to avoid large doses of longer acting drugs, especially neuromuscular blocking agents. Anaesthesia techniques using shorter acting drugs are attractive because it would be reasonable to expect a more rapid return to baseline respiratory function when shorter-acting drugs are used. Opioids should be used judiciously although the avail­ability of CPAP will obviate potential difficulty postop­eratively, particularly if the patient is already familiar with it [25] .


   Intraoperative monitoring Top


There is no evidence to suggest that patients with OSA need more aggressive, intensive, or invasive intra­operative monitoring than normal patients. The intensity of monitoring should be dictated by the type of surgery planned and by the presence of other co-morbidities. If the patient with sleep apnoea is morbidly obese, an in­tra-arterial catheter may be necessary if noninvasive blood pressure monitoring is unreliable or not feasible for technical reasons

[24]
.


   Extubation Top


Depending upon surgical procedure, condition of the patient and any documented or suspected trauma to the upper airway due to airway manipulations, leaving the patient intubated for a short period of postoperative mechanical ventilation should be considered.

Whenever the patient is to be extubated (either in the operating room or later in the recovery room or ICU), the patient should be fully awake. Full recovery from neuromuscular blockade should be proven by a neuro­muscular blockade monitor, sustained head lift for 5 sec­onds and, in the ICU, with an adequate vital capacity and peak inspiratory pressure. The patient should not have a high blood level of opioid as indicated by a respi­ratory rate less than 12-14 breaths/min while the endot­racheal tube is in situ. It is helpful for regional analgesia to be operative at the time of extubation [25] .

Extubation in the reverse Trendelenburg or semi­upright position minimizes compression of the diaphragm by abdominal contents [32] .


   Postoperative care Top


There are multiple issues regarding postoperative care of OSA patients which need to be addressed.


   Patient positioning Top


The elevated head side position to 30° should be used for the OSA patient at all times while in the post anaesthesia care unit (PACU) and throughout his or her hospital stay. Upper body elevation relieves OSA by in­creasing the stability of the upper airway [33] . Loadsman suggested a lateral posture during postoperative care for a particular tendency to upper airway obstruction during supine position [14] .


   Postoperative complications Top


These patients are more prone to have respiratory (episodic desaturations, hypercapnoea, re-intubations) and cardiovascular (hypertension, arrhythmia, myocardial ischaemia and infarction) complications in postoperative period. These risks are associated with OSA-related as well as non-OSA surgeries. Gupta et al found a twofold increased risk of developing complications in patients with obstructive sleep apnoea who had knee or hip surgery compared with patients without obstructive sleep apnoea after the same operations. Use of nasal continuous air­way pressure preoperatively and postoperatively greatly reduced this complication risk [34] .


   Role of CPAP Top


Nasal continuous positive airway pressure (N­CPAP) should be applied if airway obstruction is persis­tent despite proper positioning of the patient and nasophryngeal airway. Rennotte et al found that N-CPAP started before surgery and resumed immediately after extubation allowed to safely manage a variety of surgi­cal procedures in patients with OSAS, and to freely use sedative, analgesic, and anaesthetic drugs without major complications. They recommended that every effort should be made to identify patients with OSAS and insti­tute N-CPAP therapy before surgery [22] . Oxygen can be added to CPAP treatment. The most economical place to add it is via a side port on the CPAP mask where relatively low flows (2-4 liter /min) can produce a high FIO2. This addition does not change the CPAP pressure supplied by most modern machines [14]. During CPAP therapy patients may need direct supervision while they are sedated and not familiar with its use, until they are capable, unaided, of applying their therapy correctly. It may need high dependency unit admission for few days [14] .


   Location of patient Top


It is important that the patient with OSA is nursed in the appropriate postoperative environment. This is­sue is closely related to the patient's analgesic require­ments.

Factors to be considered for decision about loca­tion of postoperative care are the body mass index (BMI) of the patient, the severity of the OSA, the de­gree of associated cardiopulmonary disease, intraop­erative complications and the postoperative opioid re­quirement. When all of these factors are mild, then the patient may go to a relatively unmonitored environment. When any of these factors are severe, the patient should go to an intensive care unit (ICU). The large gray zone in between these extremes requires careful judgment. The most suitable postoperative environment is also de­termined by the particular conditions within each hospi­tal [25],[35] .


   Role of nasal obstruction Top


Presence of nasogastric tubes and nasal packing after nasal surgery may pose an extra risk. The pres­ence of a nasogastric tube does not preclude the appli­cation of CPAP as the nasal mask can be applied over the tube, which runs under the mask cushion, but leak­age and comfort may be a problem. After nasal sur­gery a nasopharyngeal airway may be passed and the surgeon may pack the nose around it, although it may have limited calibre. In such cases full face continuous positive airway pressure is needed to prevent danger­ous apneas [25],[36] . If serious compromise of upper air­way patency is anticipated after upper airway surgery then undue reliance on CPAP is inappropriate. The pa­tient may require prolonged tracheal intubation or, where several days or more of airway compromise is antici­pated, tracheostomy should be considered [14] .


   Postoperative analgesia Top


The provision of adequate postoperative analge­sia is an integral part of the anaesthetic plan. Multimodal analgesia is preferable wherever possible. Obese OSA patients have an increased risk of opioid induced upper airway obstruction. Sedation and narcotic-based anal­gesia may exacerbate symptoms of sleep apnoea re­sulting in respiratory depression and respiratory arrest even if given intramuscularly, epidurally or via patient controlled analgesia [37] . There are no adequately pow­ered studies to guide analgesic therapy of these patients. If narcotics are required for pain control then patient controlled analgesia with no basal rate and restricted dosing may help to limit dosing [4] .

The use of nonsteroidal anti inflammatory drugs, local anaesthetics for incision infiltration, epidural anal­gesia and peripheral nerve blocks, when appropriate, can minimize the necessity for the administration of large doses of narcotic drugs to achieve adequate analge­sia [24],[25].


   Sleep apnoea syndrome in children Top


Preoperative assessment

The symptoms, polysomnographic findings, patho­physiology and treatment of Obstructive Sleep Apnoea (OSA) in children are significantly different from those seen in adults. It is most commonly associated with adenotonsillar hypertrophy [21] . Preanaesthesia screening should routinely include a detailed birth and medical his­tory, growth assessment, review of systems for recent respiratory infection, behavioral issues, and school per­formance. Troublesome behavior often can be addressed by the relief of SA [38] .


   Premedication Top


Cultrara and colleagues after a retrospective study suggested that preoperative sedation might be safely administered to children with mild or moderate sleep­disordered breathing, and possibly to children with se­vere obstructive sleep apnoea (OSA), if children are closely observed prior to surgery. They recommended further prospective studies to confirm their results [39]. Francis et. al in a recent study of 70 children, premedi­cated with midazolam (0.5 mg.Kg -1 ) planned for adenotonsillectomy for treatment of sleep-disordered breathing concluded that many of these children may safely be pre- medicated [40]. Antireflux medications and antisialagogue drugs are important adjuncts to be considered for the preven­tion of aspiration and laryngospasm [41]


   Perioperative management Top


Both inhaled and intravenous anaesthesia should be carefully titrated to the effect, particularly when used in combination. Children with OSA show an exaggera­tion of the blunted respiratory drive in response to opioid and benzodiazepine administration [42] .

Hullett et al compared tramadol with morphine in adenotonsillectomy for OSA in children. They found that children in tramadol group had fewer episodes of desaturation (<94%) in postoperative period therefore they recommended the use of tramadol for this proce­dure in children with OSA [43] .

Luscre et al recently described a case series of three children with OSA given monitored anaesthesia care with a combination of ketamine and dexmedetomidine during magnetic resonance imaging. This combination provided effective sedation with no clinically significant haemodynamic or respiratory ef­fects [44] . Difficult airway may also be anticipated in chil­dren with OSA because of craniofacial or known ana­tomical airway abnormalities. Skilled clinicians and the equipment for managing a difficult airway, such as a fiber-optic laryngoscope as well as a laryngeal mask airway, also should be readily available. Jaw thrust to treat airway obstruction in these patients is the most useful and is superior to the chin lift [45] .

The greatest concern when extubating a child from deep anaesthesia is laryngospasm. When possible, chil­dren with OSA are extubated when they are fully awake. [41]


   Postoperative care Top


During the postoperative period, children with OSA are at risk for respiratory failure because of increased episodes of apnoea from baseline, acute airway obstruc­tion, atelectasis, and postobstructive pulmonary edema. Risk factors for respiratory distress after surgery for OSA are, age less than 3 years, bleeding, concurrent respiratory infection, congenital heart defects, cranio­facial disease, failure to thrive, history of cor pulmonale, history of premature birth, neuromuscular disease, obe­sity, other congenital abnormalities or genetic syndrome and severe obstructive sleep apnoea [46].

Nixon and colleagues reported that despite removal of obstructing lymphoid tissue, upper airway obstruc­tion occurred on the first postoperative night in children with OSA [47] . Friedman et al have reported success us­ing bilevel nasal CPAP immediately after tonsillectomy and adenoidectomy in children with severe OSA [48] .

Children who have a history of pulmonary hyper­tension and cor pulmonale also may be at risk for circu­latory failure.

Children with severe OSA or cardiovascular dis­ease should be monitored after surgery in the pediatric intensive care unit. Most children with mild to moderate OSA, however, do not require postoperative monitoring in an intensive care unit [41] .


   Recent reviews and guidelines Top


There are some published reviews on the anaes­thetic management of OSA in recent literature (2005 onwards). Passannante et al [24] reviewed the general anaesthetic management of OSA patients in adults and Bandla et al [41] in children. Bell et al [35] reviewed the post operative complication in these OSA patients. All these reviews were published in the Anesthesiology Clinics of North America.

Kaw et al [4] reviewed the perioperative implications for the sleep apnoea surgical patient in the journal, Chest and Mickelson et al [49] reviewed the pre and post opera­tive management of OSA patients in Otolaryngologeal Clinics of North America (2007).

The only available consensus guidelines are by the American Society of Anesthesiology Task force on the perioperative management of OSA patients which was published in 2006 in Anesthesiology [6] .

 
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36.Herder CD, Schmeck J, Appelboom DJK, Vries ND. Risk of general anaesthesia in people with obstructive sleep apnoea. BMJ 2004; 329: 955-59.  Back to cited text no. 36      
37.Cullen DJ. Obstructive sleep apnea and postoperative analge­sia - A potentially dangerous combination. J Clin Anesth 2001; 13:83- 85.  Back to cited text no. 37  [PUBMED]  [FULLTEXT]  
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39.Cultrara A, Bennett GH, Lazar C, Bernstein J, Goldstein N Preoperative sedation in pediatric patients with sleep-disor­dered breathing. Int J Pediatr Otorhinolaryngol. 2002; 66(3):243-6.  Back to cited text no. 39      
40.Francis A, Eltaki K, Bash T, Cortes S, Mojdehi K, Goldstein NA.The safety of preoperative sedation in children with sleep- disordered breathing Int J Pediatr Otorhinolaryngol. 2006; 70(9):1517-21.  Back to cited text no. 40      
41.Bandla P, Brooks LJ, Trimarchi T, Helfaer M. Obstructive sleep apnea syndrome in children. Anesthesiology Clin N Am 2005; 23:535- 549.  Back to cited text no. 41      
42.Strauss SG, Lynn AM, Bratten SL, et al. Ventilatory response to CO2 in children with obstructive sleep apnea from adenotonsillar hypertrophy. Anesth Analg 1999;89:328- 32.  Back to cited text no. 42      
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44.Luscre N, Tobias JD. Monitored anesthesia care with a combi­nation of ketamine and dexmedetomidine during magnetic reso­nance imaging in three children with trisomy 21 and obstruc­tive sleep apnea Pediatr Anesth 2006; 16:782-86.  Back to cited text no. 44      
45.Arai YC, Fukunaga K, Hirota S, Fujimoto S. The effects of chin lift and jaw thrust while in the lateral position on stridor score in anesthetized children with adenotonsillar hypertrophy. Anesth Analg 2004; 99:1638- 41.  Back to cited text no. 45  [PUBMED]  [FULLTEXT]  
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    Abstract
    Introduction
    Definition
    Incidence
    Brief pathophysi...
    Pre-operative sc...
    Preoperative pre...
    Premedication
    Perioperative ma...
    Intubation technique
    Rapid sequence i...
    The effect of an...
    Intraoperative m...
    Extubation
    Postoperative care
    Patient positioning
    Postoperative co...
    Role of CPAP
    Location of patient
    Role of nasal ob...
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    Sleep apnoea syn...
    Premedication
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