Obstructive Sleep Apnea and Surgery: Quality Improvement Imperatives and Opportunities

Safety of Ambulatory Surgery For Obstructive Sleep Apnea: A Retrospective Review

OBJECTIVE

Assess the safety of ambulatory surgery performed for obstructive sleep apnea.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary care hospital.

METHODS

Demographic data including age, gender, race, body mass index, insurance status, socioeconomic status, and distance traveled for surgery was collected, as well as comorbidities, and apnea-hypopnea index (AHI). Outcome variables included continuous positive airway pressure reinitiation, planned/unplanned postoperative admission, emergency department (ED) presentation, or readmission within 7 and 14 days of surgery.

RESULTS

A total of 601 patients were included, who underwent sleep surgery between 2017 and 2022. The median age was 55 years [interquartile range: 19]. A total of 437 patients (73%) were male, 502 (84%) were Caucasian, and the median distance traveled was 20 miles [27]. The median AHI was 27.1 [26]. A total of 286 hypoglossal nerve stimulators, 12 tonsillectomies, 160 expansion sphincteroplasties (ESP), and 201 nasal procedures were performed. There were 9 (1%) planned and 23 (4%) total admissions postoperatively. Sixteen patients (2%) presented to ED within 7 days, and 22 (3%) within 14 days. Nine (1%) were readmitted within 7 days, and 12 (2%) within 14 days. There were significantly more planned admissions, unplanned admissions, ED presentations, and readmissions for ESP. There were no significant differences in demographic or clinical data between patients who underwent single versus multiple surgeries.

CONCLUSION

Outpatient sleep surgery is generally safe. Close postoperative monitoring is necessary and overnight observation should be considered in those with very severe sleep apnea and/or significant comorbidities. The distance a patient travels should also be considered for overnight admission.

Admission of Patients With Obstructive Sleep Apnea Undergoing Ambulatory Surgery in Otolaryngology-Head and Neck Surgery

Objectives:

Within Otolaryngology—Head and Neck Surgery (OHNS), obstructive sleep apnea (OSA) patients are frequently encountered. To implement policies and screening measures for admission of OSA patients undergoing ambulatory surgery, actual rates of admission must first be determined. We aimed to evaluate rates and reasons for admission of OSA patients after ambulatory OHNS surgery.

Methods:

Retrospective chart review was undertaken of all OSA patients undergoing elective day-surgery OHNS procedures at a tertiary center from January 1, 2018 to December 31, 2019. The primary outcome measure was percentage of OSA patients admitted to hospital after ambulatory OHNS surgery. Secondary outcome measures included reasons for admission. American Society of Anesthesiologists (ASA) score, perioperative complications, and patient demographics were captured.

Results:

There were 118 OSA patients, out of 1942 cases performed during the review period. Thirty-eight were excluded as the procedures were not considered ambulatory. The remaining 80 OSA patients were included for analysis, with an average age of 51.7, SD 13.8, and 30 (38%) females. The admission rate was 47.5% (38/80 patients). Admitted patients were older (P = .0061), and had higher ASA (P = .039). Indication for surgery or type of surgery did not differ among admitted and non-admitted patients. The majority of patients, 97% (37/38 patients), were admitted for post-operative monitoring.

Conclusion:

More than half of OSA patients did not require admission to hospital after ambulatory OHNS surgery, unaffected by indications for surgery or type of surgery. Higher ASA score and older age were found in admitted as compared to non-admitted patients.

Immediate impact of pharyngeal surgery on respiratory parameters in adults with obstructive sleep apnea

PURPOSE

One of the concerns regarding surgical treatment of the obstructive sleep apnea syndrome (OSAS) has been the possibility that these patients may experience a higher rate of perioperative complications, which could be aggravated by the upper airway edema caused by surgical trauma. The purpose of this study was to evaluate the immediate impact of pharyngeal surgery on the respiratory parameters of adult patients with OSAS.

METHODS

Twenty-three adults with moderate to severe OSAS and indications for pharyngeal surgery (with or without nasal surgery) were consecutively selected. The subjects underwent surgical treatment and monitoring of sleep parameters preoperatively (by type I polysomnography, PSG) and in the immediate postoperative period (arterial tonometry).

RESULTS

Twenty-two subjects, aged 20 to 59 years (mean ± SD, 38.0 ± 12.1 years), were included in the study. Nineteen (86.4%) were male. The mean apnea-hypopnea index (AHI) was 59.3 ± 26.0 events/h. Comparison between preoperative PSG and postoperative arterial tonometry revealed statistically significant reductions in AHI (p = 0.03), respiratory disturbance index (RDI) (p = 0.05), and oxygen desaturation index (p = 0.001), as well as increases in nadir oxyhemoglobin saturation (p = 0.003) and percentage of REM sleep (p = 0.01).

CONCLUSIONS

In this sample of patients with moderate and severe OSAS who underwent pharyngeal surgery, the vast majority of patients did not exhibit any deterioration of respiratory parameters in the immediate postoperative period. Conversely, there was a significant improvement in the parameters.

Implementation of an Obstructive Sleep Apnea Protocol in the Postanesthesia Care Unit for Patients Undergoing Spinal Fusion Surgery

PURPOSE

The purpose of this project was to implement and evaluate the effectiveness of a postanesthesia care unit (PACU) obstructive sleep apnea (OSA) protocol in patients undergoing spinal fusion surgery.

DESIGN

The structure of this project was a preimplementation and postimplementation design.

METHODS

A convenience sample of 63 patients admitted to the PACU after spinal fusion surgery, with diagnosed or high-risk OSA, was included in protocol implementation.

FINDINGS

The prevalence of diagnosed and high-risk OSA at the project implementation site totaled 74% in the spinal fusion population. The incidence of oxygen desaturations was 41% in the preimplementation group and 35% in the postimplementation group. The PACU to intensive care unit transfers were 10% in the preimplementation group and 3% in the postimplementation group.

CONCLUSIONS

Protocols for surgical patients with OSA require further examination but may function as a guide for postoperative nursing care.

Obstructive Sleep Apnea: Emphasis on Discharge Education After Surgery

In the United States, the prevalence of obstructive sleep apnea (OSA) in the adult population is increasing. More than half of the surgical patients with OSA are predisposed to increased incidence of perioperative complications. Based on the recent evidence, obstructive events are at the highest on the third day after surgery, which predisposes them for postoperative complications. The American Society of Perianesthesia Nurses recommends that discharge education on OSA should be provided after surgery to patients diagnosed with OSA to promote continuous positive airway pressure (CPAP) compliance and self-care behaviors at home. However, CPAP adherence is poor. The purpose of this evidence-based practice project is to evaluate the effectiveness of discharge education on OSA for increasing CPAP compliance after surgery among adult surgical patients diagnosed with OSA, who use CPAP.

Revisit rates and diagnoses following pediatric tonsillectomy in a large multistate population

OBJECTIVES/HYPOTHESIS

Investigate the incidence and characteristics of revisits following ambulatory pediatric tonsillectomy/adenotonsillectomy.

STUDY DESIGN

Cross-sectional study using national databases.

METHODS

Ambulatory pediatric (age <18.0 years) tonsillectomy or adenotonsillectomy cases were extracted from the 2010 State Ambulatory Surgery, Emergency Department, and Inpatient databases for New York, Florida, Iowa, and California. First and second revisits within the 14-day postoperative period were tabulated. Diagnoses, procedure codes, and mortality were examined.

RESULTS

There were 36,221 pediatric tonsillectomies/adenotonsillectomies (mean age 7.4 years, 51.4% male). Overall, 2,740 patients (7.6%) had a revisit after pediatric tonsillectomy; 402 patients (1.1%) had a second revisit. Among revisits, 6.3% revisited the ambulatory surgery center, 77.5% revisited the emergency department, and 16.2% were readmitted as an inpatient. Among all tonsillectomies, bleeding occurred in 2.0% and 0.5% within the first and second revisits, respectively. A second revisit had a statistically higher association with a primary bleeding diagnosis than the first revisit (P < .001). Among all cases, 0.75% underwent a surgical procedure for bleeding at a first revisit compared to 0.25% during a second revisit. Acute pain was the primary diagnosis in 18.4% and 11.2% of first and second revisits; fever/vomiting/dehydration were primary diagnoses in 28.2% and 17.9%, respectively. There were two mortalities (0.0055%) within the 14-day postoperative interval.

CONCLUSIONS

This large-scale analysis describes the current rates and diagnoses of revisits, hospital readmission, and surgical intervention following ambulatory pediatric tonsillectomy. Many revisits centered on pain control and dehydration, suggesting that more adequate symptom control may prevent a large proportion of revisits.

LEVEL OF EVIDENCE

2b.