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Correspondence |

Autotitrating Positive Airway Pressure Therapy in OSAPositive Airway Pressure Therapy in OSA FREE TO VIEW

Mahadevappa Hunasikatti, MD, DPM, FCCP
Author and Funding Information

From the Division of Internal Medicine, Department of Pulmonary Medicine, Critical Care Medicine and Sleep Medicine, and Department of Internal Medicine, Inova Fairfax Hospital.

Correspondence to: Mahadevappa Hunasikatti, MD, DPM, FCCP, Inova Fairfax Hospital, 2826 Old Lee Hwy, #250, Fairfax, VA 22031; e-mail: drhunasikatti@gmail.com


Financial/nonfinancial disclosures: The author has 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. See online for more details.


Chest. 2013;144(6):1972-1973. doi:10.1378/chest.13-1659
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To the Editor:

I read with interest the article by O’Gorman et al1 in a recent issue of CHEST (July 2013) on autotitrating positive airway pressure (APAP) therapy in postoperative patients. It is not surprising that APAP did not show any benefit for patients postoperatively at high risk for sleep apnea. For positive airway pressure therapy to be of benefit, it probably should have been used for at least 1 to 3 months before the surgery. On clinical grounds, it would take at least that much time to derive any clinical improvement in symptoms. The other reason why it did not show much benefit is that the total number of patients needed to show significant benefit was small. Bilevel pressure ventilation would be a better choice because many patients believe that they tolerate it better than CPAP. More so, bilevel pressure ventilation is important in the treatment of patients who are new to the therapy.

However, the physician should use one of these therapies (CPAP, APAP, or bilevel pressure ventilation) in the immediate postoperative period in patients with clinically significant OSA not yet diagnosed and should observe for > 24 h. Even in patients admitted for outpatient surgery, it is preferable to observe them for longer periods because in the immediate perioperative period, respiratory depressant drugs, such as anesthetics and opioids, could worsen OSA.2 Indeed, every hospital should have the proper protocol for all patients undergoing outpatient or inpatient surgery. Surveys suggest that < 25% of US health-care institutions have hospital policies on the perioperative treatment of patients with OSA.3 I suggest that if the surgery is elective, postpone the procedure until the patient with OSA is treated for 2 to 3 months.

As pointed out elsewhere, many apneas in the immediate postoperative period, particularly while the patient is receiving opioid analgesia, may be central and may respond well to bilevel pressure ventilation rather than to APAP. Future research should involve therapy with BiPAP automatic Servo Ventilation (Respironics) in the perioperative period.4

References

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]
 
Gross JB, Bachenberg KL, Benumof JL, et al; 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;104(5):1081-1093. [CrossRef] [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]
 
Eckert DJ, Jordan AS, Merchia P, Malhotra A. Central sleep apnea: pathophysiology and treatment. Chest. 2007;131(2):595-607. [CrossRef] [PubMed]
 

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References

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]
 
Gross JB, Bachenberg KL, Benumof JL, et al; 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;104(5):1081-1093. [CrossRef] [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]
 
Eckert DJ, Jordan AS, Merchia P, Malhotra A. Central sleep apnea: pathophysiology and treatment. Chest. 2007;131(2):595-607. [CrossRef] [PubMed]
 
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