Obstructive sleep apnea surgery: risk management and complications

Perioperative adverse cardiac events in maxillofacial surgery: A systematic review and meta-analysis

Background and Aims

Maxillofacial surgeries, including procedures to the face, oral cavity, jaw, and head and neck, are common in adults. However, they impose a risk of adverse cardiac events (ACEs). While ACEs are well understood for other non-cardiac surgeries, there is a paucity of data about maxillofacial surgeries. This systematic review and meta-analysis report the incidence and presentation of perioperative ACEs during maxillofacial surgery.

Methods

We included primary studies that reported on perioperative ACEs in adults. To standardise reporting, ACEs were categorised as 1. heart rate and rhythm disturbances, 2. blood pressure disturbances, 3. ischaemic heart disease and 4. heart failure and other complications. The primary outcome was ACE presentation and incidence during the perioperative period. Secondary outcomes included the surgical outcome according to the Clavien-Dindo classification and trigeminocardiac reflex involvement. STATA version 17.0 and MetaProp were used to delineate proportion as effect size with a 95% confidence interval (CI).

Results

Twelve studies (34,227 patients) were included. The incidence of perioperative ACEs was 2.58% (95% CI 1.70, 3.45, I2 = 96.17%, P = 0.001). Heart rate and rhythm disturbances resulted in the greatest incidence at 3.84% among the four categories. Most commonly, these ACEs resulted in intensive care unit admission (i.e. Clavien-Dindo score of 4).

Conclusion

Despite an incidence of 2.58%, ACEs can disproportionately impact surgical outcomes. Future research should include large-scale prospective studies that may provide a better understanding of the contributory factors and long-term effects of ACEs in patients during maxillofacial surgery.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Adult Palatopharyngoplasty: Trends in Morbidity and Mortality from the NSQIP Database

OBJECTIVES

Describe the postop morbidity of adults undergoing palatopharyngoplasty (PPP).

METHOD

Adults who underwent PPP were studied using ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database (2016-2017) via CPT code 42145. Analyzed outcomes included length of stay (LOS), readmission, reoperation, and postop complications. Predictive variables were age, gender, BMI, comorbidities.

RESULTS

A total of 1081 patients (73.7% male, mean age 42.0 years, range 18-79 years) were included. 95 (8.8%) were diabetic, 183 (16.9%) were smokers, 30 (2.8%) had preoperative dyspnea. 328 (30.3%) took medicine for hypertension. Concurrent procedures occurred in 646 (59.76%), 357 (33.02%) had nasal procedures, 320 (29.60%) had tonsil procedures, 66 (6.11%) had tongue procedures. Within 30 days postop, there were two (0.19%) mortalities. Complications included six wound infections, two dehiscences, four with pneumonia, two pulmonary embolisms, three myocardial infarctions, one DVT, three sepsis, one UTI, one who required CPR, and two who were ventilated for >48 hours. Five required reintubation. A total of 41 (3.79%) returned to OR for a related reason, at least 27 (65.90%) for bleeding. LOS ranged from 0 to 15 days, median 1 day. Overall 38 (3.52%) were readmitted for a related reason, 12 (31.58%) for bleeding and three (7.89%) for pain. Using a significance level of 0.002 (Bonferroni correction), LOS varied with presence of any concurrent procedure, BMI, and estimated probability of mortality and morbidity indices; readmission and reoperation had no significantly associated variables.

CONCLUSION

PPP is associated with low frequency but significant morbidity and mortality.

Long-term Results for Maxillomandibular Advancement to Treat Obstructive Sleep Apnea: A Meta-analysis

Objective

To examine outcomes in the intermediate term (1 to <4 years), long term (4 to <8 years), and very long term (≥8 years) for maxillomandibular advancement (MMA) as treatment for obstructive sleep apnea (OSA).

Data Sources

The Cochrane Library, Google Scholar, Embase, Cumulative Index to Nursing and Allied Health, and PubMed/MEDLINE.

Review Methods

Three authors systematically reviewed the international literature through July 26, 2018.

Results

A total of 445 studies were screened, and 6 met criteria (120 patients). Thirty-one patients showed a reduction in apnea-hypopnea index (AHI) from a mean 48.3 events/h (95% CI, 42.1-54.5) pre-MMA to 8.4 (95% CI 5.6, 11.2) in the intermediate term. Fifty-four patients showed a reduction in AHI from a mean 65.8 events/h (95% CI, 58.8-72.8) pre-MMA to 7.7 (95% CI 5.9, 9.5) in the long term. Thirty-five showed a reduction in AHI from a mean 53.2 events/h (95% CI 45, 61.4) pre-MMA to 23.1 (95% CI 16.3, 29.9) in the very long term. Improvement in sleepiness was maintained at all follow-up periods. Lowest oxygen saturation improvement was maintained in the long term.

Conclusion

The current international literature shows that patients with OSA who were treated with MMA maintained improvements in AHI, sleepiness, and lowest oxygen saturation in the long term; however, the mean AHI increased to moderate OSA in the very long term. Definitive generalizations cannot be made, and additional research providing individual patient data for the intermediate term, long term, and very long term is needed.

Sleep Surgery in the Elderly: Lessons from the National Surgical Quality Improvement Program

Objective Assess the frequency and nature of postoperative complications following sleep surgery. Examine these issues specifically in elderly patients to provide guidance for their perioperative care. Study Design Retrospective cohort study. Setting American College of Surgeons National Surgical Quality Improvement Program. Methods We identified patients with obstructive sleep apnea undergoing sleep surgery procedures from 2006 to 2013 in the American College of Surgeons National Surgical Quality Improvement Program, a multi-institutional outcomes program designed to improve surgical quality. We analyzed patients by comparing age groups: <65 and ≥65 years. Summary data were analyzed, and multivariate regression was used to adjust for patient characteristics, comorbidities, and surgical procedure. Results We identified 2230 patients who had sleep surgery, which included 2123 patients <65 years old and 107 patients ≥65 years old. Elderly patients were significantly more likely to have hypertension requiring medication ( P < .001) and higher American Society of Anesthesiologists scores ( P < .001). There were no significant differences in the rates of nasal ( P = .87), palate ( P = .59), tongue base ( P = .73), and multilevel ( P = .95) surgery being performed on both groups of patients. Elderly patients had higher rates of wound complications and urinary tract infections as compared with younger patients. On multivariate analysis, age ≥65 was significantly associated with complications from sleep surgery (odds ratio, 2.35; 95% CI, 1.04-5.35). Conclusion Elderly patients undergoing sleep surgery have increased postoperative complication risk as compared with younger patients treated similarly. This information can help direct quality improvement efforts in the care of older patients.

Length of Stay in Ambulatory Surgical Oncology Patients at High Risk for Sleep Apnea as Predicted by STOP-BANG Questionnaire

Background. The STOP-BANG questionnaire has been used to identify surgical patients at risk for undiagnosed obstructive sleep apnea (OSA) by classifying patients as low risk (LR) if STOP-BANG score < 3 or high risk (HR) if STOP-BANG score ≥ 3. Few studies have examined whether postoperative complications are increased in HR patients and none have been described in oncologic patients. Objective. This retrospective study examined if HR patients experience increased complications evidenced by an increased length of stay (LOS) in the postanesthesia care unit (PACU). Methods. We retrospectively measured LOS and the frequency of oxygen desaturation (<93%) in cancer patients who were given the STOP-BANG questionnaire prior to cystoscopy for urologic disease in an ambulatory surgery center. Results. The majority of patients in our study were men (77.7%), over the age of 50 (90.1%), and had BMI < 30 kg/m² (88.4%). STOP-BANG results were obtained on 404 patients. Cumulative incidence of the time to discharge between HR and the LR groups was plotted. By 8 hours, LR patients showed a higher cumulative probability of being discharged early (80% versus 74%, P = 0.008). Conclusions. Urologic oncology patients at HR for OSA based on the STOP-BANG questionnaire were less likely to be discharged early from the PACU compared to LR patients.

[Tracheotomy or planned prolonged intubation after surgery for patients with OSAS]

BACKGROUND

Patients suffering from obstructive sleep apnea syndrome (OSAS) and obesity have an elevated risk of postoperative complications independent of each other. Within the framework of expert opinions for courts the question arose whether postoperative prolonged intubation or tracheotomy are standard routine approaches which are to be carried out in the normal course of operations on patients with OSAS.

MATERIAL AND METHODS

A search of the literature was performed using PubMed, Web of Science, Scopus, EMBASE, the Cochrane database of systematic reviews and the Cochrane central register of controlled trials. Furthermore, 78 German otorhinolaryngology (ENT) departments participated in a nationwide survey.

RESULTS

The results of the survey showed that after normal complication-free surgery planned postoperative prolonged intubation is not performed in the majority of ENT departments and no department performs a tracheotomy. In contrast, the standard approach for patients with OSAS and obesity who undergo two-level surgery is intubation and subsequent monitoring without ventilation for the first postoperative day. In the literature no evidence of a scientific basis for carrying out prolonged intubation or a tracheotomy could be found.

CONCLUSION

Neither tracheotomy nor prolonged intubation are standard procedures for OSAS patients with obesity after complication-free surgery.

Safety of Outpatient Surgery for Obstructive Sleep Apnea

Objective

Determine the safety experience of adult obstructive sleep apnea patients undergoing airway surgery.

Study Design

A retrospective cohort study.

Setting

The experience of members of a large Medicaid managed care organization between January 10, 2009, and June 30, 2011.

Subjects and Methods

Four hundred fifty-two adult Medicaid obstructive sleep apnea (OSA) patients (404 ambulatory, 48 inpatient) receiving head and neck airway surgery form the basis of this report. Four safety indicators were reported from administrative data for 30 days: emergency room visit, inpatient admission, observation day, and 3 or more primary care physician visits. The occurrence of myocardial infarction, deep venous thrombosis, stroke, pulmonary embolism, tracheostomy, or transfusion was noted.

Results

Ninety-four percent of the nasal, 86% of the palatal, and 79% of the nasal/palatal surgeries (89% overall) were ambulatory. The observed catastrophic complication rate among ambulatory patients was zero (95% confidence interval, 0.0%-1.1%). Emergency room visits for pain-related diagnoses were the most common adverse outcome (51%). Administrative data sets can be used to provide insight into practice safety questions.

Conclusion

Contrary to guidelines, most OSA patients underwent ambulatory head and neck airway surgery. The observed catastrophic complication rate was zero. Administrative data sets can be used to provide insight into practice safety questions. Further study is warranted of ambulatory surgery management of adult sleep apnea patients.

The incidence of early post-operative complications following uvulopalatopharyngoplasty: identification of predictive risk factors

OBJECTIVE

Characterize complications following uvulopalatopharyngoplasty (UPPP) for obstructive sleep apnea.

STUDY DESIGN

Retrospective chart review.

SUBJECTS AND METHODS

Charts of patients undergoing UPPP at an academic teaching hospital from 1999 to 2005 were reviewed.

RESULTS

345 consecutive patients (248 inpatients; 97 outpatients) were studied. The most common post-operative complication in the entire study was oxyhemoglobin desaturation (12.8%). Three patients suffered major complications (airway obstruction, pulmonary edema, arrhythmia). Regarding complications limited to the post-anaesthetic care unit alone, only 8.2% of patients had oxyhemoglobin desaturation after discontinuation of oxygen supplementation. Inpatients requiring supplemental oxygen on the ward had significantly higher mean AHI (37.4 vs. 31.4; p=0.05) and BMI (32.3 kg/m(2) vs. 28.9 kg/m(2); p=0.004) than those who did not. Those inpatients who were obese (BMI > 30 kg/m(2)) with an AHI≥22 were associated with an increased risk of requiring oxygen on the ward (odds ratio = 3.48, 95% CI = 1.56 - 7.78).

CONCLUSION

The incidence of post-UPPP complications is much lower than the literature has historically suggested. Selected patients should be able to safely undergo outpatient UPPP. Patients with higher AHI, higher BMI, or multiple comorbidities are at higher risk for postoperative complications and are most appropriate for overnight monitoring.

Respiratory perioperative management of patients with obstructive sleep apnea

Obstructive sleep apnea (OSA) has become a major public health problem in the United State and Europe. However, perioperative strategies regarding diagnostic options and management of untreated OSA remain inadequate. Preoperative screening and identification of patients with undiagnosed OSA may lead to early perioperative interventions that may alter cardiopulmonary events associated with surgery and anesthesia.(1) Hence, clinicians need to become familiar with the preoperative screening and diagnosis of OSA. Perioperative management of a patient with OSA should be modified and may include regional anesthesia and alternative analgesic techniques such as nonsteroidal anti-inflammatory drugs that may reduce the need for systemic opioids. Additionally, supplemental oxygen and continuous pulse oximetry monitoring should be utilized to maintain baseline oxygen saturation. Postoperatively patients should remain in a semi-upright position and positive pressure therapy should be used in patients with high-risk OSA.

The management of surgical patients with obstructive sleep apnea

Obstructive sleep apnea (OSA) is a leading public health problem in both developed and developing nations. However, awareness regarding diagnostic options, management, and consequences of untreated OSA remains inadequate in the perioperative period. Adverse surgical outcomes appear to be more frequent in OSA patients. Immediate postoperative complications may be partially attributed to the negative effects of sedative, analgesic, and anesthetic agents that can worsen OSA by decreasing pharyngeal tone and the arousal responses to hypoxia, hypercarbia, and obstruction. Rebound rapid eye movement sleep after anesthesia and the use of opioids may contribute to adverse events in the postoperative period. Even though data to guide clinicians in the perioperative period is scarce, heightened awareness is recommended.

Multilevel radiofrequency ablation for snoring and OSAHS patients therapy: long-term outcomes

Our objective is to evaluate the outcomes of the Radio-Frequency (RF) energy for tissue thermo-ablation therapy in sleep-disordered breathing patients and retrospective evaluation of the RF therapy after a 5-year follow-up period, in terms of snoring and apnea reduction. From June 1999 to June 2009, we enrolled patients suffering from simple snoring and patients with obstructive apnea hypopnoea syndrome (OSAHS). A visual analog scale (VAS) questionnaire was used to evaluate the level of snoring and was filled out in short- and long-term periods, whereas in OSAHS patients an unattended polysomnography was performed before and after a minimum of 6 months from the last RF therapy treatment session. The presence of post-operative pain was assessed by means of a specific VAS. Results stated that 187/250 patients finished the RF therapy. In the simple snoring group, mean snoring VAS decreased from 7.48 to 3.7 (P < 0.0001). In the post-operative snoring group, mean snoring VAS decreased from 7.6 to 3.6 (P < 0.0001). In the mild-to-moderate grade OSAHS group, AHI decreased from a mean value of 18.1 to a mean value of 12.9 (P < 0.0001). Furthermore, we recorded a mean post-operative pain VAS of one in each group of patients. Our results suggest an important role of RF therapy in the improvement of snoring solution, but not for a significant AHI reduction. Level of evidence 2c.

Contemporary surgery for obstructive sleep apnea syndrome

Surgical treatment of obstructive sleep apnea syndrome (OSAS) has been available in some form for greater than three decades. Early management for airway obstruction during sleep relied on tracheotomy which although life saving was not well accepted by patients. In the early eighties two new forms of treatment for OSAS were developed. Surgically a technique described as a uvulopalatopharyngoplasty (UPPP) was used to treat the retropalatal region for snoring and sleep apnea. Concurrently sleep medicine developed a nasal continuous positive airway pressure (CPAP) device to manage nocturnal airway obstruction. Both of these measures were used to expand and stabilize the pharyngeal airway space during sleep. The goal for each technique was to limit or alleviate OSAS. Almost 30 yr later these two treatment modalities continue to be the mainstay of contemporary treatment. As expected, CPAP device technology improved over time along with durable goods. Surgery followed suit and additional techniques were developed to treat soft and bony structures of the entire upper airway (nose, palate and tongue base). This review will only focus on the contemporary surgical methods that have demonstrated relatively consistent positive clinical outcomes. Not all surgical and medical treatment modalities are successful or even partially successful for every patient. Advances in the treatment of OSAS are hindered by the fact that the primary etiology is still unknown. However, both medicine and surgery continue to improve diagnostic and treatment methods. Methods of diagnosis as well as treatment regimens should always include both medical and surgical collaborations so the health and quality of life of our patients can best be served.

The Safety of Outpatient UPPP for Obstructive Sleep Apnea: A Retrospective Review of 40 Cases

We retrospectively reviewed the outcomes of 40 patients who had undergone outpatient uvulopalatopharyngoplasty (UPPP) for the treatment of moderate to severe obstructive sleep apnea (OSA) in order to determine the safety of the procedure in an outpatient setting. Postoperatively, 36 of the 40 patients (90%) were discharged home the day of surgery without morbidity; 3 other patients stayed overnight for nonmedical reasons, and 1 patient who was already an inpatient remained hospitalized for unrelated medical issues. No postoperative complications occurred, and all patients reported a resolution of OSA symptoms and improvement in sleep. Based on a combination of our data and those of previous studies, we conclude that patients with significant OSA can safely undergo UPPP as an outpatient procedure. We recommend that guidelines regarding the perioperative care of patients with OSA be adjusted to include consideration of treatment in an outpatient setting.

Safety of Uvulopalatopharyngoplasty as Outpatient Surgery

OBJECTIVE: Determine the admission rate and characterize the complications in uvulopalatopharyngoplasty (UPPP) patients scheduled to have outpatient surgery.

STUDY DESIGN AND SETTING: Retrospective review of patients undergoing UPPP between 2000 and 2004 in a tertiary care setting.

RESULTS: UPPP alone or in conjunction with tonsillectomy, septoplasty, or supraglottoplasty was carried out in 110 patients. Average preoperative respiratory disturbance index (RDI) was 35. Admission was required in 20 (18%) patients whereas 90 (82%) were discharged on the day of surgery. Admission due to desaturation was noted in 3 (3%) patients. The most common reasons for admission included pain and nausea. There were no major complications.

CONCLUSIONS: Careful preoperative selection of patients should permit many patients to undergo UPPP as outpatient surgery. Factors requiring admission may be assessed in the early postoperative period. The rate of respiratory events requiring postoperative admission after UPPP is low.

SIGNIFICANCE: UPPP can be carried out safely on an outpatient basis.

[Anesthesia and sleep apnea syndrome]

The perioperative risk for patients with obstructive sleep apnea syndrome and the optimal anaesthesiological management of these patients have not been well elucidated. The prevalence of obstructive sleep apnea with significant symptoms is estimated to be 4% in men and 2% in women. However, in 80-95% of patients this syndrome is not sufficiently diagnosed. Thus identification of patients at risk and a thorough multidisciplinary diagnostic approach are essential for optimal perioperative management. The risk of perioperative complications, like cardiopulmonary compromise, and difficulties in airway management is elevated. The most important aspects of perioperative management include evaluation of intubating conditions, careful search for cardiopulmonary morbidity, permanent control of patient airways, sensible use of anaesthetics, sedatives, and narcotics, and strict monitoring of vital signs. If ambulatory nasal continuous positive airway pressure (CPAP) therapy has been established preoperatively, this should be continued in the perioperative period. Postoperative monitoring should be performed in an intensive care or intermediate care unit. Controlled clinical studies on the best perioperative management of patients with obstructive sleep apnea are urgently required.

Efficacy and co-morbidity of oral appliances in the treatment of obstructive sleep apnea-hypopnea: a systematic review

The Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS) is a common sleep-related breathing disorder characterized by repetitive obstructions of the upper airway during sleep. Modification of pharyngeal patency by Oral Appliance (OA) therapy has been suggested as an alternative to various treatment modalities for OSAHS. To determine the evidence base with respect to the efficacy and co-morbidity of OA therapy in OSAHS, we conducted a systematic review of the available literature. Primary outcome measures were the reduction in number of upper-airway obstructions and co-morbidity related to the craniomandibular or craniofacial complex, respectively. Eligible studies regarding efficacy were independently assessed by two assessors using a quality assessment scale. Effect sizes of methodologically sound studies were calculated. In identical interventions, effect sizes were pooled with the use of a random-effects model. Given the scarcity of controlled studies related to co-morbidity, appraisal was confined to a description of eligible studies. Sixteen controlled trials related to efficacy were identified. With respect to the primary outcome measure, OA therapy was clearly more effective than control therapy (pooled effect size, -0.96; 95% confidence interval [CI], -1.49 to -0.42) and possibly more effective than uvulopalatopharyngoplasty. Although patients generally preferred OA therapy, improvement of respiratory variables, such as the number of upper-airway obstructions, was usually better in Continuous Positive Airway Pressure (CPAP) therapy (pooled effect size, 0.83; 95% CI, 0.59 to 1.06). Moreover, specific aspects related to OA design may influence patient-perceived efficacy and preference. Twelve patient-series and one controlled trial related to co-morbidity were identified. Analysis of the data suggests that OA therapy may have adverse effects on the craniomandibular and craniofacial complex. Although CPAP is apparently more effective and adverse effects of OA treatment have been described, it can be concluded that OA therapy is a viable treatment for, especially, mild to moderate OSAHS. Controlled studies addressing the specific indication and co-morbidity of OA therapy are warranted.

Genioglossus advancement and hyoid myotomy under local anesthesia

OBJECTIVE: Obstructive sleep apnea syndrome (OSAS) is a common chronic illness that results in significant morbidity in many patients. Upper airway obstruction of OSAS patients occurring during sleep can appear at multiple sites, including the hypopharynx. Successful results of genioglossus advancement and hyoid myotomy with suspension (GAHM) in the treatment of hypopharyngeal obstruction have been reported when performed under general anesthesia. However, many patients have difficulty at induction of anesthesia and intubation. Patients are predisposed to specific complications, owing to anatomical abnormalities of the airway and existence of underlying syndrome. The purpose of this study was to assess the safety and efficacy of GAHM for the treatment of OSAS with the patient under local anesthesia.

METHODS: Thirty-one OSAS patients with hypopharyngeal obstruction underwent GAHM under local anesthesia. The inferior alveolar nerve was blocked. The osteotomized mandibular segment was advanced and turned to lock the inner surface of the mandible and geniotubercle at the outer surface. The hyoid bone was suspended to the superior aspect of the thyroid cartilage. Uvulopalatal flap was an adjunct surgical procedure for palatal obstruction. Patients had a mean age of 46.2 ± 5.8 years and a body mass index of 28.8 ± 3.2 kg/m 2 . Most of the patients were male. Data on patients were compared between preoperative and postoperative assessment points. Statistical analysis was performed using Student's t test.

RESULTS: All patients tolerated the procedure well. The mean follow-up was 8 months (range, 6 to 10 months). The mean Respiratory Disturbance Index (RDI) decreased from 48.2 ± 10.8 to 14.5 ± 5.8, and the lowest oxygen saturation increased from 81.8 ± 3.8% to 88.8 ± 2.9%. The Epworth Sleepiness Scale score improved from 14.9 ± 2.3 to 8.2 ± 1.7 ( P < 0.001), and the snoring scale improved from 8.1 ± 0.6 to 3.4 ± 0.9 ( P < 0.001). Postoperative complications included wound dehiscence in 3%, transient dysphagia in 3%, and transient paresthesia of the lower jaw in 6%. Bleeding, infection, and airway obstruction were not observed. Most patients had mild-to-moderate pain (visual analog scale, ≤7) for 5 to 7 days after procedures. Responders were defined as OSAS patients who had a reduction in the RDI of ≥50% and an RDI of ≤20 after surgery. By these criteria, 70% of the patients were regarded as having responded to GAHM.

CONCLUSION: Significant reduction in RDI and clinical improvements in snoring and sleepiness were observed after GAHM. It appears to be a safe, inexpensive, and effective procedure that can be performed under local anesthesia with a low chance of complications in carefully selected OSAS patients.

Postoperative treatment of the patient with obstructive sleep apnea

OBJECTIVE

The postoperative management of patients with obstructive sleep apnea syndrome (OSAS) has been based primarily on the potential loss of the airway. Our hypothesis is that not all patients with OSAS require placement in the intensive care unit after surgery.

METHODS

We undertook a prospective, nonrandomized study (N = 38). Data included demographics, polysomnograms, body mass index (BMI), and postoperative course, including any complications within 72 hours.

RESULTS

The average respiratory disturbance index was 66, and the average BMI was 29. The average preoperative and postoperative maximal arterial oxygen desaturation values were 82% and 94%, respectively. Patients with BMIs less than 35 did not have desaturation values below 90%. No complications occurred.

DISCUSSION

Within the first 72 hours after surgery, no complications were observed in our study groups. Patients with BMIs greater than 35 were at increased risk for postoperative desaturations. The uncomplicated OSAS patient, one without significant comorbid factors, can be treated in a safe and prudent fashion outside of an intensive care unit.

Overview of Phase I Surgery for Obstructive Sleep Apnea Syndrome

It is well established that obstructive sleep apnea syndrome is associated with increased morbidity and mortality. Surgical therapy has been demonstrated to be a viable treatment option for cure. Thorough presurgical evaluation with the identification of the type of airway abnormality is mandatory to allow for the utilization of a surgical protocol that results in improved clinical outcomes. Phase I surgical protocol is designed to apply specific surgical procedures to alleviate the obstruction(s) present. Following a logical, stepwise surgical approach in airway reconstruction will minimize surgical interventions and avoid unnecessary operations. The incorporation of a risk-management protocol will minimize treatment complications while achieving cure.