Is obstructive sleep apnea associated with difficult airway? Evidence from a systematic review and meta-analysis of prospective and retrospective cohort studies

PLoS One. 2018 Oct 4;13(10):e0204904. doi: 10.1371/journal.pone.0204904. eCollection 2018.


Background: Difficult airway management and obstructive sleep apnea may contribute to increased risk of perioperative morbidity and mortality. The objective of this systematic review and meta-analysis (SRMA) is to evaluate the evidence of a difficult airway being associated with obstructive sleep apnea (OSA) patients undergoing surgery.

Methods: The standard databases were searched from 1946 to April 2017 to identify the eligible articles. The studies which included adult surgical patients with either suspected or diagnosed obstructive sleep apnea must report at least one difficult airway event [either difficult intubation (DI), difficult mask ventilation (DMV), failed supraglottic airway insertion or difficult surgical airway] in sleep apnea and non-sleep apnea patients were included.

Results: Overall, DI was 3.46-fold higher in the sleep apnea vs non-sleep apnea patients (OSA vs. non-OSA: 13.5% vs 2.5%; OR 3.46; 95% CI: 2.32-5.16, p <0.00001). DMV was 3.39-fold higher in the sleep apnea vs non-sleep apnea patients (OSA vs. non-OSA: 4.4% vs 1.1%; OR 3.39; 95% CI: 2.74-4.18, p <0.00001). Combined DI and DMV was 4.12-fold higher in the OSA vs. non-OSA patients (OSA vs. non-OSA: 1.1% vs 0.3%; OR 4.12; 95% CI: 2.93-5.79, p <0.00001). There was no significant difference in the supraglottic airway failure rates in the sleep apnea vs non-sleep apnea patients (OR: 1.34; 95% CI: 0.70-2.59; p = 0.38). Meta-regression to adjust for various subgroups and baseline confounding factors did not impact the final inference of our results.

Conclusion: This SRMA found that patients with obstructive sleep apnea had a three to four-fold higher risk of difficult intubation or mask ventilation or both, when compared to non-sleep apnea patients.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Adult
  • Aged
  • Airway Management / instrumentation*
  • Female
  • Humans
  • Male
  • Middle Aged
  • Polysomnography
  • Postoperative Complications / mortality*
  • Prospective Studies
  • Retrospective Studies
  • Risk Factors
  • Sleep Apnea, Obstructive / complications
  • Sleep Apnea, Obstructive / surgery*
  • Treatment Outcome

Grant support

The authors received no specific funding for this work.