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Empiric Postoperative Autotitrating Positive Airway Pressure TherapyPostoperative Auto-Positive Airway Pressure: Generating Evidence in the Perioperative Care of Patients at Risk for Obstructive Sleep Apnea FREE TO VIEW

Babak Mokhlesi, MD, FCCP
Author and Funding Information

From the Section of Pulmonary and Critical Care Medicine, Sleep Disorders Center, University of Chicago Pritzker School of Medicine.

Correspondence to: Babak Mokhlesi, MD, FCCP, University of Chicago Pritzker School of Medicine, 5841 S. Maryland Ave, MC 6076, Room M630, Chicago, IL 60637; e-mail: bmokhles@medicine.bsd.uchicago.edu


Financial/nonfinancial disclosures: The author has reported to CHEST the following conflicts of interest: Dr Mokhlesi has received consultant fees from Koninklijke Philips Electronics NV.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;144(1):5-7. doi:10.1378/chest.13-0017
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Obstructive sleep apnea (OSA) is a prevalent sleep disorder characterized by recurrent episodes of complete or partial collapse of the upper airway that lead to intermittent hypoxemia and recurrent arousals from sleep. Although prevalence estimates of OSA from community-based studies have ranged from 5% to 28%, the prevalence of clinically significant and symptomatic OSA is significantly lower, at 2% to 9%.1-4 In contrast, the prevalence of OSA in presurgical cohorts remains less well defined. Studies that have reported a high prevalence have been subject to significant selection bias, because not all patients underwent diagnostic testing.5-7 In the largest single academic center registry study of presurgical patients undergoing anesthesia, Ramachandran et al8 reported an OSA prevalence of 7%. Importantly, chronically untreated moderate to severe OSA has been associated with significant morbidity and mortality, and treatment with CPAP has been shown to reduce cardiovascular risk in patients with severe OSA.9-11 Given the important long-term implications of untreated OSA, in 2006 the American Society of Anesthesiologists recommended screening patients prior to surgery and implementing treatment if OSA is present.12 Interestingly, these recommendations were made despite the lack of significant empirical evidence in the perioperative diagnosis and management of OSA. Since the American Society of Anesthesiologists’ publication, there has been a growing interest in the perioperative care of patients with OSA or suspected of having OSA. To date, most studies have focused on developing effective screening tools in the preoperative population13-15 or have outlined adverse postoperative outcomes in patients with OSA.5,16-21 However, despite this growing awareness, there is a paucity of well-controlled prospective studies examining the impact of OSA treatment on postoperative outcomes.

Consequently, the study by O’Gorman and colleagues22 in this issue of CHEST (see page 72) is an important and timely contribution to the field. These investigators enrolled 86 CPAP-naive patients undergoing elective total knee or total hip arthroplasty who were deemed at high risk for having OSA based on a validated prediction model. The patients were randomized to either standard care or standard care plus empirical autotitrating positive airway pressure (APAP) therapy during the postoperative period. Although the primary outcome of interest was hospital length of stay (LOS), the authors also examined several other important postoperative outcomes. Based on an intention-to-treat analysis, they found no significant difference in the primary or secondary outcomes between the two groups. These unexpected results were in spite of a median APAP use of 373 min on the first postoperative night and a median of 185 min per night during the entire postoperative period. Post hoc analyses revealed that in patients with moderate or severe OSA (apnea-hypopnea index [AHI] ≥15, derived from a portable cardiorespiratory study performed the night before hospital discharge), the LOS increased by 1 day in patients treated with APAP (4 days vs 5 days; P = .02). Similarly, when the data were analyzed based on APAP adherence, the LOS increased by 1 day in patients with usage >4 h per night compared with those with <4 h per night (P = .04). Another important finding was that patients randomized to APAP experienced a significantly longer period of time with oxygen saturation below 90% on the first postoperative day. This occurred despite a reduction in the AHI with APAP therapy (from a median of 22 to a median of 13.5, as estimated by the APAP device). Although the cause of the hypoxemia remains unclear, the authors speculated that it may have been related to poor blending of supplemental oxygen with air while on APAP compared with supplemental oxygen delivered by nasal cannula in the standard of care group.

First and foremost, the authors are to be commended for undertaking the monumental task of screening 2,375 patients over a 4-year period and implementing a rigorous and well-designed research protocol. Although empirical APAP therapy is widely used during the postoperative period in patients suspected of having OSA, O’Gorman and colleagues22 have provided the first line of evidence regarding postoperative management of patients with OSA with APAP in a well-controlled randomized clinical trial.

Notwithstanding the strengths and novelty of the study, there are several limitations that are noteworthy. As correctly recognized by the authors, their main challenge was the inability to achieve adequate statistical power because of low enrollment (94% of screened patients refused participation). Another limitation is that although APAP improved OSA, it did not lead to a full resolution of sleep-disordered breathing. Indeed, the median residual AHI as estimated by the APAP units was 13.5 events/h. This suggests that either OSA was not fully resolved, which is unlikely since the median 95% pressure on the APAP units was 9.2 cm H2O, or that there were significant central apneas (PAP-emergent or opioid-related central respiratory events). Unfortunately, the APAP units were not equipped with forced oscillation technology to distinguish between obstructive and central apneas. Another limiting factor was that patients randomized to APAP therapy were not fully adherent to therapy (median usage of 185 min per night). However, post hoc analysis did not reveal any benefit in those who were more adherent. Although low CPAP adherence in the perioperative period has been previously reported,23 it is important to consider that hospitalized patients may have a significant reduction in total sleep time, and, therefore, 3 h of APAP use may have covered most of their sleep period.24,25 Last, APAP may have adversely impacted sleep duration and consolidation in these CPAP-naive patients, which in turn may have negatively impacted their postoperative recovery.

Undoubtedly, many important and clinically relevant questions remain unanswered. How should OSA be diagnosed in high-risk presurgical patients? Which subgroups of patients with sleep-disordered breathing are more likely to benefit from PAP therapy? When is the most appropriate time to implement PAP therapy? Can PAP adherence be improved during the perioperative period? What are the obstacles to implementing a postoperative APAP protocol? Would the benefits of empirical APAP therapy differ between highly staffed academic tertiary care centers and nonacademic settings? What therapeutic options should be explored in PAP-intolerant patients? Indeed, with the challenges O’Gorman and colleagues22 faced in recruiting patients, it is clear that only large multicenter randomized trials with clinically important and relevant end points will be able to test the validity and cost-effectiveness of various approaches in diagnosing and treating OSA in the perioperative setting. For the time being, clinical equipoise persists in the postoperative management of patients suspected of having OSA with empirical APAP given that standard care was just as good as standard care plus APAP. However, the results of this study should not be overinterpreted since the clinical trial was performed in a very selective group of patients under significant postoperative monitoring at a highly staffed tertiary care center. Clinicians should exercise their best judgment in the perioperative management of patients suspected of having OSA at their own institutions. Specifically, I believe that perioperative PAP therapy should be strongly considered in patients with an established diagnosis of clinically significant OSA as well as in patients suspected of having severe forms of sleep-disordered breathing based on validated screening tools. If the decision is made not to implement empirical postoperative APAP therapy, then at least a robust postoperative monitoring mechanism needs to be in place to avoid the well-described life-threatening complications associated with untreated OSA during the postoperative period. Given the large volume of elective surgeries performed globally, implementation of systematic screening and empirical APAP therapy in those patients at risk for OSA would impose a significant cost burden, underlying the urgency for further clinical research to determine whether PAP therapy is helpful or harmful in the immediate postoperative period.

References

Bixler EO, Vgontzas AN, Lin HM, et al. Prevalence of sleep-disordered breathing in women: effects of gender. Am J Respir Crit Care Med. 2001;163(3 pt 1):608-613. [CrossRef] [PubMed]
 
Bixler EO, Vgontzas AN, Ten Have T, Tyson K, Kales A. Effects of age on sleep apnea in men: I. Prevalence and severity. Am J Respir Crit Care Med. 1998;157(1):144-148. [CrossRef] [PubMed]
 
Durán J, Esnaola S, Rubio R, Iztueta A. Obstructive sleep apnea-hypopnea and related clinical features in a population-based sample of subjects aged 30 to 70 yr. Am J Respir Crit Care Med. 2001;163(3 pt 1):685-689. [CrossRef] [PubMed]
 
Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993;328(17):1230-1235. [CrossRef] [PubMed]
 
Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108(5):812-821. [CrossRef] [PubMed]
 
Fidan H, Fidan F, Unlu M, Ela Y, Ibis A, Tetik L. Prevalence of sleep apnoea in patients undergoing operation. Sleep Breath. 2006;10(3):161-165. [CrossRef] [PubMed]
 
Finkel KJ, Searleman AC, Tymkew H, et al. Prevalence of undiagnosed obstructive sleep apnea among adult surgical patients in an academic medical center. Sleep Med. 2009;10(7):753-758. [CrossRef] [PubMed]
 
Ramachandran SK, Kheterpal S, Consens F, et al. Derivation and validation of a simple perioperative sleep apnea prediction score. Anesth Analg. 2010;110(4):1007-1015. [CrossRef] [PubMed]
 
Somers VK, White DP, Amin R, et al. Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation scientific statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing. J Am Coll Cardiol. 2008;52(8):686-717. [CrossRef] [PubMed]
 
Campos-Rodriguez F, Martinez-Garcia MA, de la Cruz-Moron I, Almeida-Gonzalez C, Catalan-Serra P, Montserrat JM. Cardiovascular mortality in women with obstructive sleep apnea with or without continuous positive airway pressure treatment: a cohort study. Ann Intern Med. 2012;156(2):115-122. [CrossRef] [PubMed]
 
Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365(9464):1046-1053. [PubMed]
 
Gross JB, Bachenberg KL, Benumof JL, et al. 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;104(5):1081-1093.
 
Chung F, Yegneswaran B, Liao P, et al. Validation of the Berlin questionnaire and American Society of Anesthesiologists checklist as screening tools for obstructive sleep apnea in surgical patients. Anesthesiology. 2008;108(5):822-830. [CrossRef] [PubMed]
 
Ramachandran SK, Josephs LA. A meta-analysis of clinical screening tests for obstructive sleep apnea. Anesthesiology. 2009;110(4):928-939. [CrossRef] [PubMed]
 
Chung F, Chau E, Yang Y, Liao P, Hall R, Mokhlesi B. Serum bicarbonate level improves specificity of STOP-Bang screening for obstructive sleep apnea. Chest. 2013;143(5):1284-1293.
 
Gupta RM, Parvizi J, Hanssen AD, Gay PC. Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: a case-control study. Mayo Clin Proc. 2001;76(9):897-905. [PubMed]
 
Kaw R, Pasupuleti V, Walker E, Ramaswamy A, Foldvary-Schafer N. Postoperative complications in patients with obstructive sleep apnea. Chest. 2012;141(2):436-441. [CrossRef] [PubMed]
 
Mador MJ, Goplani S, Gottumukkala VA, et al. Postoperative complications in obstructive sleep apnea [published online ahead of print July 21, 2012]. Sleep Breath. doi:10.1007/s11325-012-0750-y.
 
Liao P, Yegneswaran B, Vairavanathan S, Zilberman P, Chung F. Postoperative complications in patients with obstructive sleep apnea: a retrospective matched cohort study. Can J Anaesth. 2009;56(11):819-828. [CrossRef] [PubMed]
 
Flink BJ, Rivelli SK, Cox EA, et al. Obstructive sleep apnea and incidence of postoperative delirium after elective knee replacement in the nondemented elderly. Anesthesiology. 2012;116(4):788-796. [CrossRef] [PubMed]
 
Hwang D, Shakir N, Limann B, et al. Association of sleep-disordered breathing with postoperative complications. Chest. 2008;133(5):1128-1134. [CrossRef] [PubMed]
 
O’Gorman SM, Gay PC, Morgenthaler TI. Does autotitrating positive airway pressure therapy improve postoperative outcome in patients at risk for obstructive sleep apnea syndrome? A randomized controlled clinical trial.. Chest. 2013;144(1):72-78.
 
Guralnick AS, Pant M, Minhaj M, Sweitzer BJ, Mokhlesi B. CPAP adherence in patients with newly diagnosed obstructive sleep apnea prior to elective surgery. J Clin Sleep Med. 2012;8(5):501-506. [PubMed]
 
Arora VM, Chang KL, Fazal AZ, et al. Objective sleep duration and quality in hospitalized older adults: associations with blood pressure and mood. J Am Geriatr Soc. 2011;59(11):2185-2186. [CrossRef] [PubMed]
 
Yoder JC, Staisiunas PG, Meltzer DO, Knutson KL, Arora VM. Noise and sleep among adult medical inpatients: far from a quiet night. Arch Intern Med. 2012;172(1):68-70. [CrossRef] [PubMed]
 

Figures

Tables

References

Bixler EO, Vgontzas AN, Lin HM, et al. Prevalence of sleep-disordered breathing in women: effects of gender. Am J Respir Crit Care Med. 2001;163(3 pt 1):608-613. [CrossRef] [PubMed]
 
Bixler EO, Vgontzas AN, Ten Have T, Tyson K, Kales A. Effects of age on sleep apnea in men: I. Prevalence and severity. Am J Respir Crit Care Med. 1998;157(1):144-148. [CrossRef] [PubMed]
 
Durán J, Esnaola S, Rubio R, Iztueta A. Obstructive sleep apnea-hypopnea and related clinical features in a population-based sample of subjects aged 30 to 70 yr. Am J Respir Crit Care Med. 2001;163(3 pt 1):685-689. [CrossRef] [PubMed]
 
Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993;328(17):1230-1235. [CrossRef] [PubMed]
 
Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108(5):812-821. [CrossRef] [PubMed]
 
Fidan H, Fidan F, Unlu M, Ela Y, Ibis A, Tetik L. Prevalence of sleep apnoea in patients undergoing operation. Sleep Breath. 2006;10(3):161-165. [CrossRef] [PubMed]
 
Finkel KJ, Searleman AC, Tymkew H, et al. Prevalence of undiagnosed obstructive sleep apnea among adult surgical patients in an academic medical center. Sleep Med. 2009;10(7):753-758. [CrossRef] [PubMed]
 
Ramachandran SK, Kheterpal S, Consens F, et al. Derivation and validation of a simple perioperative sleep apnea prediction score. Anesth Analg. 2010;110(4):1007-1015. [CrossRef] [PubMed]
 
Somers VK, White DP, Amin R, et al. Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation scientific statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing. J Am Coll Cardiol. 2008;52(8):686-717. [CrossRef] [PubMed]
 
Campos-Rodriguez F, Martinez-Garcia MA, de la Cruz-Moron I, Almeida-Gonzalez C, Catalan-Serra P, Montserrat JM. Cardiovascular mortality in women with obstructive sleep apnea with or without continuous positive airway pressure treatment: a cohort study. Ann Intern Med. 2012;156(2):115-122. [CrossRef] [PubMed]
 
Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365(9464):1046-1053. [PubMed]
 
Gross JB, Bachenberg KL, Benumof JL, et al. 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;104(5):1081-1093.
 
Chung F, Yegneswaran B, Liao P, et al. Validation of the Berlin questionnaire and American Society of Anesthesiologists checklist as screening tools for obstructive sleep apnea in surgical patients. Anesthesiology. 2008;108(5):822-830. [CrossRef] [PubMed]
 
Ramachandran SK, Josephs LA. A meta-analysis of clinical screening tests for obstructive sleep apnea. Anesthesiology. 2009;110(4):928-939. [CrossRef] [PubMed]
 
Chung F, Chau E, Yang Y, Liao P, Hall R, Mokhlesi B. Serum bicarbonate level improves specificity of STOP-Bang screening for obstructive sleep apnea. Chest. 2013;143(5):1284-1293.
 
Gupta RM, Parvizi J, Hanssen AD, Gay PC. Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: a case-control study. Mayo Clin Proc. 2001;76(9):897-905. [PubMed]
 
Kaw R, Pasupuleti V, Walker E, Ramaswamy A, Foldvary-Schafer N. Postoperative complications in patients with obstructive sleep apnea. Chest. 2012;141(2):436-441. [CrossRef] [PubMed]
 
Mador MJ, Goplani S, Gottumukkala VA, et al. Postoperative complications in obstructive sleep apnea [published online ahead of print July 21, 2012]. Sleep Breath. doi:10.1007/s11325-012-0750-y.
 
Liao P, Yegneswaran B, Vairavanathan S, Zilberman P, Chung F. Postoperative complications in patients with obstructive sleep apnea: a retrospective matched cohort study. Can J Anaesth. 2009;56(11):819-828. [CrossRef] [PubMed]
 
Flink BJ, Rivelli SK, Cox EA, et al. Obstructive sleep apnea and incidence of postoperative delirium after elective knee replacement in the nondemented elderly. Anesthesiology. 2012;116(4):788-796. [CrossRef] [PubMed]
 
Hwang D, Shakir N, Limann B, et al. Association of sleep-disordered breathing with postoperative complications. Chest. 2008;133(5):1128-1134. [CrossRef] [PubMed]
 
O’Gorman SM, Gay PC, Morgenthaler TI. Does autotitrating positive airway pressure therapy improve postoperative outcome in patients at risk for obstructive sleep apnea syndrome? A randomized controlled clinical trial.. Chest. 2013;144(1):72-78.
 
Guralnick AS, Pant M, Minhaj M, Sweitzer BJ, Mokhlesi B. CPAP adherence in patients with newly diagnosed obstructive sleep apnea prior to elective surgery. J Clin Sleep Med. 2012;8(5):501-506. [PubMed]
 
Arora VM, Chang KL, Fazal AZ, et al. Objective sleep duration and quality in hospitalized older adults: associations with blood pressure and mood. J Am Geriatr Soc. 2011;59(11):2185-2186. [CrossRef] [PubMed]
 
Yoder JC, Staisiunas PG, Meltzer DO, Knutson KL, Arora VM. Noise and sleep among adult medical inpatients: far from a quiet night. Arch Intern Med. 2012;172(1):68-70. [CrossRef] [PubMed]
 
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