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Adebola O. Adesanya, MD, FCCP; Won Lee, MD; Nancy B. Greilich, MD; Girish P. Joshi, MD
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From the Department of Anesthesiology (Drs Adesanya, Greilich, and Joshi), the Department of Medicine (Dr Adesanya), and the Department of Medicine, Pulmonary and Critical Care Medicine (Dr Lee), University of Texas Southwestern Medical Center.

Correspondence to: Adebola O. Adesanya, MD, FCCP, University of Texas Southwestern Medical Center, 5223 Harry Hines Blvd, Dallas, TX 75390-9069; e-mail: Adebola.Adesanya@UTSouthwestern.edu


Financial/nonfinancial disclosures: The authors have reported to CHEST 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):1098. doi:10.1378/chest.11-1200
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To the Editor:

We thank Dr Gregoretti et al for their interest in our recent article1 and are happy to respond to their comments. The diagnosis and treatment of obstructive sleep apnea (OSA) in the perioperative setting is still evolving and will undoubtedly be modified as clinical evidence becomes available. The meta-analysis by Ramachandran and Josephs2 suggests that the STOP-Bang (snoring tiredness, observed apneas, elevated BP and BMI, age, neck circumference, and male gender) questionnaire is an average predictor of the diagnosis of OSA and an excellent predictor of severe OSA. Given the paucity of evidence to support the view that mild to moderate OSA is associated with significant adverse perioperative outcomes, we believe that substantial effort should focus on identifying and treating patients with severe OSA. In fact, identifying and treating patients with mild OSA in the nonperioperative setting3 has had the same impact on systemic disease as treating patients with severe OSA. Accordingly, some authors4 have suggested that mild OSA without hypoxia can be treated with standard postoperative monitoring.

With regard to the American Society of Anesthesiologists checklist, elements of the checklist have been incorporated into other validated questionnaires,5,6 with improved sensitivity for the diagnosis of OSA. We believe that, in addition to the American Society of Anesthesiologists checklist, these questionnaires should be administered to further identify patients with severe OSA.

The acronym PAP in the article depicts positive airway pressure and refers to the use of either continuous positive airway pressure (CPAP) or bi-level positive airway pressure. Since patients may be treated with either modality for sleep-disordered breathing, we intentionally left this open to interpretation for the treating physician, based on the patient’s current treatment. We agree with Dr Gregoretti et al that auto-CPAP should ideally be used for patients with an established diagnosis of OSA, although we also believe that auto-CPAP can be useful in the postoperative setting since opioids can lead to the exacerbation of obstructive respiratory events and higher PAP pressures than previously prescribed may be needed. It is also not uncommon that the patient is unaware of his or her actual PAP settings, and auto-CPAP can be used for in this setting for uncomplicated OSA treated in the hospital wards. It is important to highlight that not all patients with OSA who are being treated with opioids develop central events. However, if hypercapnia and alveolar hypoventilation occur as a result of sedation, noninvasive mechanical ventilation with a backup ventilatory rate should be used.

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]
 
Barnes M, Houston D, Worsnop CJ, et al. A randomized controlled trial of continuous positive airway pressure in mild obstructive sleep apnea. Am J Respir Crit Care Med. 2002;1656:773-780 [PubMed]
 
Seet E, Chung F. Management of sleep apnea in adults—functional algorithms for the perioperative period: continuing professional development. Can J Anaesth. 2010;579:849-864 [CrossRef] [PubMed]
 
Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;1085:812-821 [CrossRef] [PubMed]
 
Chung F, Ward B, Ho J, Yuan H, Kayumov L, Shapiro C. Preoperative identification of sleep apnea risk in elective surgical patients, using the Berlin questionnaire. J Clin Anesth. 2007;192:130-134 [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]
 
Barnes M, Houston D, Worsnop CJ, et al. A randomized controlled trial of continuous positive airway pressure in mild obstructive sleep apnea. Am J Respir Crit Care Med. 2002;1656:773-780 [PubMed]
 
Seet E, Chung F. Management of sleep apnea in adults—functional algorithms for the perioperative period: continuing professional development. Can J Anaesth. 2010;579:849-864 [CrossRef] [PubMed]
 
Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;1085:812-821 [CrossRef] [PubMed]
 
Chung F, Ward B, Ho J, Yuan H, Kayumov L, Shapiro C. Preoperative identification of sleep apnea risk in elective surgical patients, using the Berlin questionnaire. J Clin Anesth. 2007;192:130-134 [CrossRef] [PubMed]
 
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