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Timothy I. Morgenthaler, MD, FCCP; Peter C. Gay, MD, FCCP; Susan M. O’Gorman, MBBCh
Author and Funding Information

From the Division of Pulmonary and Critical Care Medicine (Drs Morgenthaler and Gay) and Internal Medicine Residency Program (Dr O’Gorman), Mayo Clinic.

Correspondence to: Timothy I. Morgenthaler, MD, FCCP, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905; e-mail: tmorgenthaler@mayo.edu


Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Morgenthaler was a recipient of a grant from ResMed for a different study evaluating treatment of complex sleep apnea syndrome. Drs Gay and O’Gorman 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. See online for more details.


Chest. 2013;144(6):1973. doi:10.1378/chest.13-1889
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To the Editor:

We thank Dr Hunasikatti for his comments regarding our article on the management of patients with suspected OSA in the postoperative period.1 Although we agree that all institutions should have established protocols for patients with OSA in the postoperative period2 and that positive airway pressure plays a role in preventing postoperative complications, he makes some assertions that we believe are unsupported.

Our study specifically addressed patients without OSA presenting before surgery. We used screening to identify those at high risk for OSA; they could not have been on CPAP for the past several months. Furthermore, Dr Hunasikatti states that autotitrating positive airway pressure (APAP) therapy was a poor selection for therapy because positive airway pressure (PAP) takes 1 to 3 months to show clinical benefit, which is incorrect. The most pressing concern for the postoperative patient with OSA is preservation of airway patency and ventilation. During the first night of PAP titration, airway patency is restored, and ventilation resumes very quickly. It takes minutes. Additionally, although improving sleepiness and psychomotor performance was not a goal of the study, CPAP significantly improves sleepiness after only 1 day and significantly improves simulated driving performance after only 2 to 7 days of treatment.3 Thus, we believe it reasonable that APAP could acutely improve airway patency and potentially reduce delirium.

Dr Hunasikatti also suggested that using bilevel PAP would have been a better choice in part because “many patients” tolerate bilevel PAP better than CPAP. The literature indicates no significant difference in control of OSA, mask discomfort, adverse nasal symptoms, or treatment adherence.4 Additionally, when a decision is made to empirically treat suspected OSA, one must either guess the pressure, use an algorithm to determine pressure,5 or use APAP to provide therapy, and overtitrated bilevel PAP can provoke central apnea. We chose APAP because of abundant evidence that these devices often provide similar efficacy when treating OSA in the outpatient environment.6

The use of APAP as empirical treatment of patients with suspected OSA in the hospital practice setting is common. The data showed that APAP (incompletely) reduced sleep-related respiratory events, but we did not see a significant reduction in complications. We agree that this could be partly due to an underpowered study. However, we assert that addressing this important safety issue will likely require more than just PAP and instead will require better risk stratification plus intensified monitoring of those at highest risk. Finding this population and determining its needs is an important next step.

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]
 
Gali B, Whalen FX Jr, Gay PC, et al. Management plan to reduce risks in perioperative care of patients with presumed obstructive sleep apnea syndrome. J Clin Sleep Med. 2007;3(6):582-588. [PubMed]
 
Tregear S, Reston J, Schoelles K, Phillips B. Continuous positive airway pressure reduces risk of motor vehicle crash among drivers with obstructive sleep apnea: systematic review and meta-analysis. Sleep. 2010;33(10):1373-1380. [PubMed]
 
Gay P, Weaver T, Loube D, Iber C; Positive Airway Pressure Task Force; Standards of Practice Committee; American Academy of Sleep Medicine. Evaluation of positive airway pressure treatment for sleep related breathing disorders in adults. Sleep. 2006;29(3):381-401. [PubMed]
 
Oliver Z, Hoffstein V. Predicting effective continuous positive airway pressure. Chest. 2000;117(4):1061-1064. [CrossRef] [PubMed]
 
Morgenthaler TI, Aurora RN, Brown T, et al; Standards of Practice Committee of the AASM; 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;31(1):141-147. [PubMed]
 

Figures

Tables

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]
 
Gali B, Whalen FX Jr, Gay PC, et al. Management plan to reduce risks in perioperative care of patients with presumed obstructive sleep apnea syndrome. J Clin Sleep Med. 2007;3(6):582-588. [PubMed]
 
Tregear S, Reston J, Schoelles K, Phillips B. Continuous positive airway pressure reduces risk of motor vehicle crash among drivers with obstructive sleep apnea: systematic review and meta-analysis. Sleep. 2010;33(10):1373-1380. [PubMed]
 
Gay P, Weaver T, Loube D, Iber C; Positive Airway Pressure Task Force; Standards of Practice Committee; American Academy of Sleep Medicine. Evaluation of positive airway pressure treatment for sleep related breathing disorders in adults. Sleep. 2006;29(3):381-401. [PubMed]
 
Oliver Z, Hoffstein V. Predicting effective continuous positive airway pressure. Chest. 2000;117(4):1061-1064. [CrossRef] [PubMed]
 
Morgenthaler TI, Aurora RN, Brown T, et al; Standards of Practice Committee of the AASM; 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;31(1):141-147. [PubMed]
 
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