Airway management in obstructive sleep apnea: a comprehensive review of assessment strategies, techniques, and technological advances

Background: Airway management in patients with obstructive sleep apnea (OSA) presents unique challenges for anesthesiologists and other airway practitioners. This comprehensive review examines current evidence and clinical practices for managing difficult airways in this high-risk population. OSA is characterized by specific anatomical and physiological alterations that increase both the likelihood of encountering difficult intubation and the risk of rapid desaturation during airway manipulation. Methods: Preoperative assessment of OSA patients requires integration of traditional difficult airway evaluation with OSA-specific considerations, including severity indices, oxygen desaturation patterns, and continuous positive airway pressure dependency. Conventional direct laryngoscopy often proves inadequate in these patients, prompting the development and refinement of alternative approaches. Videolaryngoscopy has emerged as a particularly valuable technique in OSA patients, offering improved glottic visualization while maintaining physiologic positioning. Flexible endoscopic techniques, particularly awake flexible bronchoscopic intubation, remain essential for high-risk scenarios, though they require considerable expertise. Results: Recent technological innovations have produced hybrid devices combining multiple modalities to address the specific challenges presented by OSA patients. Adjunctive tools and techniques, including specialized introducers, exchange catheters, and high-flow nasal oxygen, play critical roles in extending safe apnea time and facilitating successful intubation. Professional society guidelines now incorporate OSA-specific recommendations, emphasizing thorough preparation, appropriate device selection, and comprehensive monitoring. Conclusions: Effective management ultimately requires not only appropriate technology but also systematic preparation, strategic device selection, and meticulous execution. As OSA prevalence continues to rise globally, optimizing airway management approaches for this challenging population remains a critical priority for patient safety.