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Babak Mokhlesi, MD, FCCP
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From the Sleep Disorders Center, Section of Pulmonary and Critical Care, Department of Medicine, The University of Chicago.

Correspondence to: Babak Mokhlesi, MD, FCCP, Sleep Disorders Center and the Section of Pulmonary and Critical Care, Department of Medicine, The University of Chicago, 5841 S Maryland Ave MC6076, 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 served as a consultant for Koninklijke Philips N.V. but has no conflicts of interest relevant to the present study.

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


Chest. 2013;144(4):1422. doi:10.1378/chest.13-1752
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Published online
To the Editor:

I thank Dr Corso and colleagues for their thoughtful comments and careful review of our recent study in CHEST (September 2013).1 I agree with their comment that the term sleep-disordered breathing (SDB) encompasses central sleep apnea as well as sleep hypoventilation syndromes. However, we excluded patients with International Classification of Diseases, Ninth Revision, Clinical Modification codes for central sleep apnea and obesity hypoventilation syndrome from our cohort.

The low in-hospital mortality in our cohort of abdominal surgery is most likely related to the fact that the vast majority of surgeries were elective hemicolectomies and cholecystectomies. The higher in-hospital mortality reported by the European Surgical Outcomes Study was in part because of inclusion of patients undergoing nonelective surgeries (25% of cases) and significant differences in mortality across various European nations.2 A recent report of 14,962 patients undergoing various types of surgery over a 4-year period at a tertiary care academic medical center in the United States reported a 30-day mortality of 0.64%.3 These investigators also did not find an independent association between high risk for OSA and postoperative mortality.

Caution is necessary when drawing inferences from our data. Although we found important associations between OSA and adverse postoperative outcomes, the cross-sectional nature of our study does not establish the direction of causality. Only well-designed prospective studies will provide insights as to whether OSA increases perioperative morbidity and mortality. We wholeheartedly agree with Dr Corso and colleagues that patient safety should be our primary goal. Although it makes intuitive sense that screening, diagnosing, and treating OSA in the perioperative period is “good medicine,” we have seen time and again that many practices that make “clinical sense” result in no clinical benefit or actually increase morbidity and mortality in large clinical trials.4-6 The cost and burden associated with screening and treating all adult patients for OSA prior to surgery could be overwhelming to any medical system, particularly with the large surgical volumes in most advanced countries. Therefore, empirical evidence is urgently needed to establish whether this strategy does indeed improve perioperative outcomes. As we design clinical studies, we cannot simply assume that perioperative CPAP is universally beneficial or that all patients will be able to adhere to it.7,8 Although I personally believe that perioperative CPAP therapy should be strongly considered in patients with OSA, the burden is on us to generate the high-level evidence needed in the perioperative care of patients with OSA. Since very large multicenter randomized clinical trials may not be feasible, we may have to rely on unique approaches to clinical research to provide clarity to the field (eg, practice-based evidence studies).9

References

Mokhlesi B, Hovda MD, Vekhter B, Arora VM, Chung F, Meltzer DO. Sleep-disordered breathing and postoperative outcomes after elective surgery: analysis of the Nationwide Inpatient Sample. Chest. 2013;144(3):903-914. [CrossRef] [PubMed]
 
Pearse RM, Moreno RP, Bauer P, et al; European Surgical Outcomes Study (EuSOS) group for the Trials groups of the European Society of Intensive Care Medicine and the European Society of Anaesthesiology. Mortality after surgery in Europe: a 7 day cohort study. Lancet. 2012;380(9847):1059-1065. [CrossRef] [PubMed]
 
Lockhart EM, Willingham MD, Abdallah AB, et al. Obstructive sleep apnea screening and postoperative mortality in a large surgical cohort. Sleep Med. 2013;14(5):407-415. [CrossRef] [PubMed]
 
Bellomo R, Chapman M, Finfer S, Hickling K, Myburgh J; Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group. Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomised trial. Lancet. 2000;356(9248):2139-2143. [CrossRef] [PubMed]
 
Finfer S, Chittock DR, Su SY, et al; NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283-1297. [CrossRef] [PubMed]
 
Shah MR, Hasselblad V, Stevenson LW, et al. Impact of the pulmonary artery catheter in critically ill patients: meta-analysis of randomized clinical trials. JAMA. 2005;294(13):1664-1670. [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. [CrossRef] [PubMed]
 
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]
 
Memtsoudis SG, Besculides MC, Mazumdar M. A rude awakening—the perioperative sleep apnea epidemic. N Engl J Med. 2013;368(25):2352-2353. [CrossRef] [PubMed]
 

Figures

Tables

References

Mokhlesi B, Hovda MD, Vekhter B, Arora VM, Chung F, Meltzer DO. Sleep-disordered breathing and postoperative outcomes after elective surgery: analysis of the Nationwide Inpatient Sample. Chest. 2013;144(3):903-914. [CrossRef] [PubMed]
 
Pearse RM, Moreno RP, Bauer P, et al; European Surgical Outcomes Study (EuSOS) group for the Trials groups of the European Society of Intensive Care Medicine and the European Society of Anaesthesiology. Mortality after surgery in Europe: a 7 day cohort study. Lancet. 2012;380(9847):1059-1065. [CrossRef] [PubMed]
 
Lockhart EM, Willingham MD, Abdallah AB, et al. Obstructive sleep apnea screening and postoperative mortality in a large surgical cohort. Sleep Med. 2013;14(5):407-415. [CrossRef] [PubMed]
 
Bellomo R, Chapman M, Finfer S, Hickling K, Myburgh J; Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group. Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomised trial. Lancet. 2000;356(9248):2139-2143. [CrossRef] [PubMed]
 
Finfer S, Chittock DR, Su SY, et al; NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283-1297. [CrossRef] [PubMed]
 
Shah MR, Hasselblad V, Stevenson LW, et al. Impact of the pulmonary artery catheter in critically ill patients: meta-analysis of randomized clinical trials. JAMA. 2005;294(13):1664-1670. [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. [CrossRef] [PubMed]
 
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]
 
Memtsoudis SG, Besculides MC, Mazumdar M. A rude awakening—the perioperative sleep apnea epidemic. N Engl J Med. 2013;368(25):2352-2353. [CrossRef] [PubMed]
 
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