Airway obstruction at the base of the tongue in a patient with obstructive sleep apnea

Clinical Case for Discussion: You’re the anesthesiologist for a 51-year-old man scheduled for arthroscopic rotator cuff surgery at a freestanding surgery center.  His wife volunteers that the patient is a loud snorer.  The patient denies ever being diagnosed with obstructive sleep apnea.  Should you proceed with the surgery?  Can the patient safely be discharged home after surgery at a freestanding facility ?  What would you do?

You discuss the case with an anesthesia colleague.  She recommends you utilize a STOP-BANG questionnaire on the patient.  What is she talking about?

Discussion: Frequent snoring is present in 34% of men and women over the age of 40. (Baldwin, et al, Sleep disturbances, quality of life, and ethnicity: the sleep heart health study, J Clin Sleep Med. 2010 Apr 15;6(2):176-83).  Does any physician ever cancel a surgery at a freestanding surgery center because the patient is a snorer?  Should we?  Is there any data?

STOP-BANG may sound like a title from the next James Bond movie, but it has nothing to do with spies, guns, or crime.  STOP-BANG is a tool for diagnosing obstructive sleep apnea.

Obstructive sleep apnea (OSA) is a common comorbidity in surgical populations. It’s estimated that approximately 4% of men and 2% of women, 18 million Americans overall, have OSA (Miller’s Anesthesia, 2010, p 2776). An estimated 82% of men and 92% of women with moderate or severe sleep apnea have not been diagnosed (Chung F, Elsaid H, Screening for obstructive sleep apnea before surgery: why is it important? Curr Opin Anaesthesiol. 2009 Jun;22(3):405-11). Patients with OSA are at higher risk for post-operative respiratory arrest (Cullen DJ: Obstructive sleep apnea and postoperative analgesia—a potentially dangerous combination. J Clin Anesth  2001; 13:83).

OSA is defined as complete cessation of airflow during breathing lasting 10 seconds or longer despite maintenance of neuromuscular ventilatory effort, and occurring five or more times per hour of sleep, accompanied by a decrease of at least 4% in Sao2. (Miller’s Anesthesia, 2010, p 2092). The gold standard for diagnosis is an overnight sleep study, or polysomnography, which is both expensive and resource-intensive. The results of polysomnography are reported as the apnea/hypopnea index (AHI).  The AHI is derived from the total number of episodes of apnea and hypopnea divided by the total sleep time.  The American Academy of Sleep Medicine classifies the disease as follows:

Mild OSA = AHI of 5 to 15 events per hour

Moderate OSA = of 15 to 30 events per hour

Severe OSA = AHI of greater than 30 events per hour

The STOP questionnaire was first published in Anesthesiology in 2008, where it was validated in surgical patients at preoperative clinics as a screening tool. (Chung F, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008 May;108(5):812-21).

The STOP questionnaire queried patients on:

(S) Snoring: Do you snore loudly (loud enough to be heard through closed doors?”

(T) Tired:  Do you often feel tired, fatigued, or sleepy during daytime?

(O) Observed:  Has anyone observed you stop breathing during sleep?

(P) Blood Pressure:  Do you have high blood pressure?

A patient with a STOP score of 2 out of 4 was considered at high risk for OSA.  Patients’ scores from the STOP questionnaire were evaluated versus his or her AHI total from polysomnography. In Chung’s study, the STOP questionnaire was given to 2,467 patients, and 211 of these patients underwent polysomnography. The sensitivities of the STOP questionnaire in identifying patients with an AHI greater than 5, greater than 15, and greater than 30 were 65.6, 74.3, and 79.5%, respectively.

In the same study, the STOP questionnaire was expanded into a STOP-BANG questionnaire, which also queried patients on:

(B) Body mass index>35 kg/m2?

(A) Age>50?

(N) Neck circumference >40 cm (15 ¾ inches)?

(G) Gender=male?

With the added four questions, a patient with a score of 3 out of the possible 8 was considered at high risk for OSA. With STOP-BANG, sensitivities in identifying patients with an AHI greater than 5, greater than 15, and greater than 30 were increased to 83.6, 92.9, and 100%.

In a recent study, (Ong TH, et al, Simplifying STOP-BANG: use of a simple questionnaire to screen for OSA in an Asian population. Sleep Breath. 2010 Apr 26), 348 patients undergoing polysomnography were asked to fill in the 8-question STOP-BANG questionnaire. The sensitivities of the STOP-BANG screening tool for an AHI of >5, >15, and >30 were 86.1%, 92.8%, and 95.6%, respectively.

Thus STOP-BANG has been validated as a tool with high sensitivity that can be used to screen patients for moderate and severe OSA.  As a clinician, what do you do with the STOP-BANG information?

You ask your shoulder arthroscopy patient the 8 STOP-GANG questions, and he scores 1 point for snoring, 1 point for age>50, and 1 point for male gender.  These results qualify him for a possible diagnosis of OSA.  Will you still anesthetize him for this outpatient surgery?

The most useful reference to answer this question is the ASA Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea (Anesthesiology 2006; 104:1081–93).  If a sleep study is available, the Practice Guidelines feature an OSA Scoring System which scores on three criteria:  (A) the severity of sleep apnea, (B) the invasiveness of the surgery and anesthesia, and (C) the requirement for post-operative opioids.  Per this OSA Scoring System, our shoulder arthroscopy patient scores (A) 2 points for presumed moderate OSA, (B)  2 points for peripheral surgery with general anesthesia, and (C) 2 points for possible high doses of oral or parenteral opioids post-op.  His OSA Score is the total of (A) and the higher of (B) or (C), or 2 + 2 = 4 points.  The Practice Guidelines state that, “Patients with a score of 4 may be at increased perioperative risk from OSA.”

The Practice Guidelines state that for “minor orthopedic surgery/general anesthesia” on patients suspected of having OSA, the decision to discharge the patient home after outpatient surgery is “equivocal,” as there is no convincing data advising one way or another.  The Practice Guidelines also state that “these patients should not be discharged from the recovery area to an unmonitored setting (i.e., home or unmonitored hospital bed) until they are no longer at risk for postoperative respiratory depression, . . . and may require a longer stay as compared with non-OSA patients undergoing similar procedures.”

The Practice Guidelines suggest regional techniques rather than systemic post-operative opioids, in an attempt to reduce the likelihood of adverse outcomes in patients at increased perioperative risk from OSA.

So what do you do?

You go ahead and anesthetize the patient.  If you’re comfortable with upper extremity regional blocks, you may utilize this technique in your anesthetic.  In any case, you’ll use your excellent judgment to delay discharge until the patient looks safe to be discharged home.  If his oxygen saturation, airway status, or opioid requirements are unsatisfactory, you’ll transfer him to a hospital for overnight stay.

With STOP-BANG or without STOP-BANG, your clinical judgment . . . based on your training . . . will still be your most valuable tool.

Introducing …,  THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a legal mystery. Publication date September 9, 2014 by Pegasus Books.

The first four chapters are available for free at Amazon. Read them and you’ll be hooked! To reach the Amazon webpage, click on the book image below:


Stanford professor Dr. Nico Antone leaves the wife he hates and the job he loves to return to Hibbing, Minnesota where he spent his childhood. He believes his son’s best chance to get accepted into a prestigious college is to graduate at the top of his class in this remote Midwestern town. His son becomes a small town hero and academic star, while Dr. Antone befriends Bobby Dylan, a deranged anesthetist who renamed and reinvented himself as a younger version of the iconic rock legend who grew up in Hibbing. An operating room death rocks their world, and Dr. Antone’s family and his relationship to Mr. Dylan are forever changed.

Equal parts legal thriller and medical thriller, The Doctor and Mr. Dylan examines the dark side of relationships between a doctor and his wife, a father and his son, and a man and his best friend. Set in a rural Northern Minnesota world reminiscent of the Coen brothers’ Fargo, The Doctor and Mr. Dylan details scenes of family crises, operating room mishaps, and courtroom confrontation, and concludes in a final twist that will leave readers questioning what is of value in the world we live in.


5.0 out of 5 stars The Doctor and Mr Dylan, March 3, 2015
prabha venugopal (chicago, il USA) – See all my reviews
Verified Purchase(What’s this?)
Gripping from the beginning to the end. Very well written, bringing to the forefront all the human emotions seen in an operating room spill over into real life. I cannot wait for Dr. Novak to wrote another book! As another physician in the same profession, my admiration for his book knows no limits.

Bang-Up Debut Novel, November 16, 2014

By Norm Goldman “Publisher & Editor of Bookpleasures”

This part legal and medical thriller is structured with a mixed bag of situations involving relationships, jealousy, evil, lies, courtroom drama, operating room mishaps as well as moments that engender conflicting and unexpected outcomes. Noteworthy is that as the suspense builds readers will become eager to uncover the truth involving a mishap concerning Nico and a surgical procedure that has unanticipated ramifications.

This is a bang-up debut from a writer who understands timing and is able to deliver hairpin turns, particularly involving the courtroom drama,that you would expect from a book of this genre. PIONEER PRESS Entertainment

by Mary Ann Grossman, Entertainment Editor, St. Paul Pioneer Press, January 4, 2015

“The Doctor & Mr. Dylan” by Rick Novak (Pegasus Books, $17.50)

Dr. Nico Antone doesn’t hide the fact he hates his wife, but he says he didn’t kill her during an operation. The authorities think otherwise and his trial is the riveting suspense in this novel that is part medical thriller, part legal thriller, part exploration of family relationships.

Nico is an anesthesiologist (as is the author) who leaves his wife, their plush life in California and his job at Stanford to move to his hometown of Hibbing so their son, Johnny, has a better chance of getting into a prestigious college. Johnny hates the idea of moving to a small, cold town, but he’s popular from the first day in school. Nico doesn’t do so well. He’s envied by Bobby, an anesthetist who’s jealous of the better-educated Nico. But it’s hard to take Bobby seriously, since he thinks he’s the young Bob Dylan and lives in the house where Bobby Zimmerman grew up. To complicate matters, Nico is attracted to the mother of the young woman his son is dating. When the two teens get in trouble, Nico’s furious, rich wife comes to Minnesota and needs an emergency operation that puts her on Nico’s operating table.

Novak grew up in Hibbing, where he worked in the iron ore mines and played on the U.S. Junior Men’s Curling championship teams of 1974 and ’75. After graduating from Carleton College, he earned a medical degree at the University of Chicago and spent 30-plus years at Stanford Hospital, where he was an associate professor of anesthesia and Deputy Chief of the Anesthesia Department. His courtroom scenes are based on his experiences as an expert witness.

The Physician’s Late-Night Reading List

Two Pritzker alums pen captivating tales

By Brooke E. O’Neill, University of Chicago Pritzker School of Medicine, editir, Medicine on the Midway Magazine

For most physicians, writing — patient notes, case histories, perhaps journal articles — is part of the job. But for anesthesiologist-novelist Rick Novak, MD’80, and neurosurgeon-memoirist Moris Senegor, MD’82, it’s a second career that consumes early morning hours long before they step into the OR.

Fans of John Grisham will find a kindred spirit in Novak, whose fast-paced medical thriller, The Doctor & Mr. Dylan (Pegasus Books, 2014), transports readers to rural Northern Minnesota, where an accomplished physician and a deranged anesthetist who thinks he’s rock legend Bob Dylan see their worlds collide in the most unexpected ways.

Delivering real-life twists and turns — and a love letter to the Bay Area — is Senegor’s Dogmeat: A Memoir of Love and Neurosurgery in San Francisco (Xlibris, 2014), a coming-of-age tale chronicling the author’s away rotation with renowned neurosurgeon Charles Wilson, MD, at the University of California, San Francisco. Brutally honest, it spares no details of a time Senegor, who also served as a resident under the University of Chicago’s famed neurosurgery chair Sean Mullan, MD, describes as “one of the biggest failures of my life.”

One a vividly imagined nail-biter, the other an intimate peek into the surgical suite, both books deliver an ample dose of intensity and drama.



The Doctor and Mr. Dylan (Pegasus Books, 2014) by Rick Novak, MD’80

“I thought it was a novel way of killing someone,” said Rick Novak, deputy chief of anesthesiology at Stanford University, describing the imagined hospital death that was the genesis of his dark thriller The Doctor & Mr. Dylan. A huge Bob Dylan fan — the rock icon was born in Novak’s hometown of Hibbing, Minnesota, where the story takes place — he then dreamed up a possible culprit: a psychotic anesthetist who thinks he’s Dylan.

From there, the words flowed. “I would write whenever I was with my laptop and had a free moment: in mornings, in evenings, in gaps between cases,” said Novak, who also blogs about anesthesia topics. “I don’t sleep much.”

After finishing the manuscript — one year to write, another to edit — came the challenge of finding a publisher. “In anesthesia, I’m an expert,” Novak said. “In the literary world, I’m an unknown.” After 207 responses of “no, thanks” or no answer at all, he landed an agent. Two months later, she informed him that Pegasus Books had bought his debut novel.

“I started crying,” Novak admits. “I have a third grader and at the time the big word the class was learning was ‘perseverance.’ That was it exactly.”

Dr. Joseph Andresen, Editor, Santa Clara County Medical Association Medical Bulletin, from the January/February 2015 issue:


This past month, Dr. Rick Novak handed me a hardbound copy of his debut novel The Doctor and Mr. Dylan. Rick and I go way back. It was my first week of residency at Stanford when we first met. A newcomer to the operating room, all the smells and sounds were foreign to me despite my previous three years in the hospital as an internal medicine resident. Rick, a soft spoken Minnesotan at heart, in his second year of residency, took me under his wing and guided me through those first few bewildering months, sharing his experience and wisdom freely.

Fast-forward 30 years later. Dr. Rick Novak, a novel and mystery author? This was new to me as I sat down and opened the first page of The Doctor and Mr. Dylan. I have to admit that I didn’t know what to expect. Few books highlight a physician/anesthesiologist as a protagonist, and few books feature a SCCMA member as a physician/author. However, a medical-mystery theme novel wasn’t at the top of my must read list. With my 50-hour workweek, living and breathing medicine, imagining more emotional stress and drama was the furthest thing from my mind. However, three days later, as I turned the last page, and read the last few words. “life is a series of choices. I stuck my forefinger into the crook of the steering wheel, spun it hard to the left and …” This completed my 72-hour journey of and free moments I had, completely immersed in this story of life’s disappointments, human imperfections, and simple joys.

Rick, I can’t wait for your next book. Bravo!

Hibbingite writes twisted medical tale

HIBBING — Readers who are looking for a whodunit that will keep them up all night are in for a treat.

Hibbing native Rick Novak recently released his first book “The Doctor and Mr. Dylan,” a fiction set in Hibbing that merges anesthesia complications, a tumultuous marriage and the legend of Bob Dylan.

“The dialogue is sometimes funny, and there are lots of plot twists,” he said.

Novak said the book will not only entertain readers, but teach them about anesthesiology, Dylanology, the stressful race for elite college admission, and life on the Iron Range.

“The book is very conversational and streamlined,” he said. “I try to write as one would tell a story out loud.”

Novak said “The Doctor and Mr. Dylan” took him three years to perfect. He is currently working on his second book.

5.0 out of 5 stars I Sense We Have Another F.Scott Fitzgerald Emerging on the Literary Scene, December 1, 2014
Deann Brady (Sunnyvale, CA USA) – See all my reviews
I found Rick Novak’s first novel, “The Doctor and Mr. Dylan,” a most exciting combination of biting sarcasm, mystery and daily activity spun with fresh new phrases that made me turn my ear back to listen to the literary cadence of his words again and again even though, on the other hand, I was anxious to turn the pages to see what would happen next. His brilliant handling of scenes is reminiscent of The Great Gatsby by F. Scott Fitzgerald. A compelling read!Deany Brady, author of “An Appalachian Childhood”


allan mishra

This review is from: The Doctor and Mr. Dylan (Kindle Edition)

Just finished Dr. Novak’s delightful novel. I sincerely enjoyed his honest take about the pressures and values that exist within California’s Silicon Valley. He also brought the North Country of Minnesota to life with memorable characters and a twisting, addictive plot. Buried beneath the fun and funny story is a deeper message about how to best care for your kids, your relationships and yourself. Very well written and highly recommended.

Learn more about Rick Novak’s fiction writing at rick by clicking on the picture below:




  1. I am a periodontist who routinely performs IV moderate conscious sedation for ASA class I or ASA class II after medical consultation. One of my patients is diagnosed with sleep apnea and is using a CPAP device. Her medical Hx consists of joint replacement, controlled hypertension. Primary care physician recommended not proceeding with in office sedation but have her procedure in a hospital setting due to sleep apnea. Is that reasonable? If moderate conscious sedation is not recommended could the patient proceed with anxiolysis? How does OSA play into moderate conscious sedation? thank you Dr. Novak.


  2. I am a periodontist who routinely performs IV moderate conscious sedation for ASA class I or ASA class II after medical consultation. One of my patients is diagnosed with sleep apnea and is using a CPAP device. Her medical Hx consists of joint replacement, controlled hypertension. Primary care physician recommended not proceeding with in office sedation but have her procedure in a hospital setting due to sleep apnea. Is that reasonable? If moderate sedation is not recommended could the patient proceed with anxiolysis? How does OSA come into play in moderate conscious sedation? thank you Dr. Novak.


    1. Without reviewing the chart and examining the patient, I’d have to support the judgment of the primary care physician and do the moderate sedation in a hospital or an outpatient surgery center setting.

      Sedating patients with OSA always carries the risk of airway obstruction and hypoxia, and it’s critical that an airway expert is available to manage airway obstruction and hypoxia should they occur. An outpatient surgery center is acceptable if an anesthesiologist attends to the patient.


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