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Correspondence |

Anesthesiologists and Obstructive Sleep ApneaAnesthesiologists and Obstructive Sleep Apnea: Simple Things May Still Work FREE TO VIEW

Cesare Gregoretti, MD; Ruggero M. Corso, MD; Giuseppe Insalaco, MD, FCCP; Francesco Fanfulla, MD; Alberto Braghiroli, MD
Author and Funding Information

From the Department of Anesthesia, Post Anesthesia Care Unit and Pain Service (Dr Gregoretti) and the Department of Emergency and Intensive Care CTO (Dr Gregoretti), M. Adelaide Hospital; the Emergency Department (Dr Corso), Anesthesia and Intensive Care Unit, G. B. Morgagni Hospital; the National Research Council of Italy (Dr Insalaco), Institute of Biomedicine and Molecular Immunology ‘‘A. Monroy’’; the Sleep Center (Dr Fanfulla), Istituto Scientifico di Pavia and Montescano, Fondazione S. Maugeri, IRCCS; and the Salvatore Maugeri Foundation (Dr Braghiroli), IRCCS, Division of Respiratory Disease, Scientific Institute of Veruno.

Correspondence to: Cesare Gregoretti, MD, Anesthesia, Post Anesthesia Care Unit, Pain Service, M. Adelaide Hospital, Emergency and Intensive Care, CTO, via Zuretti 29, 10100 Torino, Italy; e-mail: c.gregoretti@gmail.com


Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Over the past 3 years, Dr Braghiroli has received speaker’s fees from Vitalaire Italy, Sorin, and Medigas. Drs Gregoretti, Corso, Insalaco, and Fanfulla have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;140(4):1097-1098. doi:10.1378/chest.11-0912
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To the Editor:

We read with interest the article published by Adesanya et al1 in a recent issue of CHEST (December 2010) on the perioperative management of patients with obstructive sleep apnea (OSA). We appreciate the excellent review of published articles on the topic, but we have to raise some concerns about the flowchart of the possible perioperative management of these patients:

  • 1. A recent meta-analysis2 that included the STOP-Bang (snoring tiredness, observed apneas, elevated BP and BMI, age, neck circumference, and male gender), American Society of Anesthesiologists (ASA), and Berlin questionnaires concluded that only the ASA and STOP-Bang questionnaires had sufficient power to identify patients with OSA in the perioperative setting.

  • 2. The STOP-Bang questionnaire has good sensitivity for identifying patients with high or moderate OSA but not for finding mild OSA, and its use leads to a high number of false-positives (ie, men > 50 y with a history of hypertension).

  • 3. The ASA article by Gross et al3 published in 2006 states that when cardiopulmonary monitoring is lacking, a patient should always be considered as having moderate OSA. It also states that the patient should be considered as having severe OSA when he or she has a BMI > 35 kg/m2 or a neck circumference > 43 cm in men (> 41 cm in women), or when an observer witnesses the patient stop breathing during sleep.

  • 4. The acronym PAP is used in the article for both positive airway pressure and pulmonary artery pressure. This is confusing (and wrong in the flowchart legend); in the flowchart, it is not clear which positive airway pressure should be applied.

  • 5. Autocontinuous positive airway pressure has several limitations and should not be proposed to a patient without a well-established OSA diagnosis.4 Moreover, it should be avoided when central apneas can occur (ie, opioids). Before considering auto-adjustable positive airway pressure, conventional noninvasive ventilation with a back-up rate ventilation should be recommended.

In daily practice, anesthesiologists need “simple things” in order to avoid “choking” the postanesthesia unit and overcrowding the critical care environments. We feel strongly that the OSA scoring system proposed by the ASA at present is one of the tools we have in our hands to decide the postoperative patient’s path. At the same time, anesthesiologists have the opportunity to closely observe their patients in the postanesthesia care unit and can give important information on where “the patient is going.”5 We hope that these observations can further support the authors’ proposals for managing patients who have a high risk of OSA and promote follow up for those who develop respiratory symptoms in the first hours after surgery. Simple things may still work.

Adesanya AO, Lee W, Greilich NB, Joshi GP. Perioperative management of obstructive sleep apnea. Chest. 2010;1386:1489-1498 [CrossRef] [PubMed]
 
Ramachandran SK, Josephs LA. A meta-analysis of clinical screening tests for obstructive sleep apnea. Anesthesiology. 2009;1104:928-939 [CrossRef] [PubMed]
 
Gross JB, Bachenberg KL, Benumof JL, et al; American Society of Anesthesiologists Task Force on Perioperative Management American Society of Anesthesiologists Task Force on Perioperative Management Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology. 2006;1045:1081-1093 [CrossRef] [PubMed]
 
Morgenthaler TI, Aurora RN, Brown T, et al; Standards of Practice Committee of the AASM Standards of Practice Committee of the AASM American Academy of Sleep Medicine American Academy of Sleep Medicine Practice parameters for the use of autotitrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome: an update for 2007. An American Academy of Sleep Medicine report. Sleep. 2008;311:141-147 [PubMed]
 
Gali B, Whalen FX, Schroeder DR, Gay PC, Plevak DJ. Identification of patients at risk for postoperative respiratory complications using a preoperative obstructive sleep apnea screening tool and postanesthesia care assessment anesthesiology. Anesthesiology. 2009;1104:869-877 [CrossRef] [PubMed]
 

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References

Adesanya AO, Lee W, Greilich NB, Joshi GP. Perioperative management of obstructive sleep apnea. Chest. 2010;1386:1489-1498 [CrossRef] [PubMed]
 
Ramachandran SK, Josephs LA. A meta-analysis of clinical screening tests for obstructive sleep apnea. Anesthesiology. 2009;1104:928-939 [CrossRef] [PubMed]
 
Gross JB, Bachenberg KL, Benumof JL, et al; American Society of Anesthesiologists Task Force on Perioperative Management American Society of Anesthesiologists Task Force on Perioperative Management Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology. 2006;1045:1081-1093 [CrossRef] [PubMed]
 
Morgenthaler TI, Aurora RN, Brown T, et al; Standards of Practice Committee of the AASM Standards of Practice Committee of the AASM American Academy of Sleep Medicine American Academy of Sleep Medicine Practice parameters for the use of autotitrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome: an update for 2007. An American Academy of Sleep Medicine report. Sleep. 2008;311:141-147 [PubMed]
 
Gali B, Whalen FX, Schroeder DR, Gay PC, Plevak DJ. Identification of patients at risk for postoperative respiratory complications using a preoperative obstructive sleep apnea screening tool and postanesthesia care assessment anesthesiology. Anesthesiology. 2009;1104:869-877 [CrossRef] [PubMed]
 
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