Risk of major cardiovascular and cerebrovascular complications after elective surgery in patients with sleep-disordered breathing

Obstructive Sleep Apnea and Risk of Postoperative Complications after Non-Cardiac Surgery

Obstructive sleep apnea (OSA), a common sleep disorder, poses significant challenges in perioperative management due to its complexity and multifactorial nature. With a global prevalence of approximately 22.6%, OSA often remains undiagnosed, and increases the risk of cardiac and respiratory postoperative complications. Preoperative screening has become essential in many institutions to identify patients at increased risk, and experts recommend proceeding with surgery in the absence of severe symptoms, albeit with heightened postoperative monitoring. Anesthetic and sedative agents exacerbate upper airway collapsibility and depress central respiratory activity, complicating intraoperative management, especially with neuromuscular blockade use. Additionally, OSA patients are particularly prone to opioid-induced respiratory depression, given their increased sensitivity to opioids and heightened pain perception. Thus, regional anesthesia and multimodal analgesia are strongly advocated to reduce perioperative complication risks. Postoperative care for OSA patients necessitates vigilant monitoring and tailored management strategies, such as supplemental oxygen and Positive Airway Pressure therapy, to minimize cardiorespiratory complications. Health care institutions are increasingly focusing on enhanced monitoring and resource allocation for patient safety. However, the rising prevalence of OSA, heterogeneity in disease severity, and lack of evidence for the efficacy of costly perioperative measures pose challenges. The development of effective screening and monitoring algorithms, alongside reliable risk predictors, is crucial for identifying OSA patients needing extended postoperative care. This review emphasizes a multidimensional approach in managing OSA patients throughout the perioperative period, aiming to optimize patient outcomes and minimize adverse outcomes.

The effectiveness of supplemental oxygen and high-flow nasal cannula therapy in patients with obstructive sleep apnea in different clinical settings: A systematic review and meta-analysis

STUDY OBJECTIVE

To evaluate the effectiveness of supplemental oxygen therapy and high-flow nasal cannula (HFNC) therapy in patients with obstructive sleep apnea (OSA) in different clinical settings to assess its application to surgical patients in the postoperative setting.

DESIGN

A systematic search was conducted on MEDLINE and other databases from 1946 to December 16th, 2021. Title and abstract screening were conducted independently, and the lead investigators resolved conflicts. Meta-analyses were performed using a random-effects model and are presented as mean difference and standardized mean difference with 95% confidence intervals. These were calculated using RevMan 5.4.

PATIENTS

1395 and 228 OSA patients underwent oxygen therapy and HFNC therapy respectively.

INTERVENTIONS

Oxygen therapy and HFNC therapy.

MEASUREMENTS

Apnea-hypopnea index (AHI), oxyhemoglobin saturation (SpO₂), cumulative time with SPO₂ < 90% (CT90).

MAIN RESULTS

Twenty-seven oxygen therapy studies were included in the review, with ten randomized controlled trials (RCT), seven randomized crossovers, seven non-randomized crossovers, and three prospective cohorts. Pooled analyses showed that oxygen therapy significantly reduced AHI by 31% and increased SpO₂ by 5% versus baseline, and CPAP significantly reduced AHI by 84%, and increased SpO₂ by 3% versus baseline. CPAP was 53% more effective in reducing AHI than oxygen therapy, but both treatments had similar effectiveness in increasing SpO₂. Nine HFNC studies were included in the review, with five prospective cohorts, three randomized crossovers, and one RCT. Pooled analyses showed that HFNC therapy significantly reduced AHI by 36% but did not substantially increase SpO₂.

CONCLUSIONS

Oxygen therapy effectively reduces AHI and increases SpO₂ in patients with OSA. CPAP is more effective in reducing AHI than oxygen therapy. HFNC therapy is effective in reducing AHI. Although both oxygen therapy and HFNC therapy effectively reduce AHI, more research is needed to draw conclusions on clinical outcomes.

Perioperative management of obstructive sleep apnea in lower extremity orthopedic procedures: A review of evidence to inform the development of a clinical pathway

Obstructive sleep apnea (OSA) is unrecognized in as high as 80% of patients before surgery. When untreated, OSA increases a surgical patient's propensity for airway collapse and sleep deprivation lending to a higher risk for emergent re-intubation, prolonged recovery time, escalation of care, hospital readmission, and longer length of stay. We have reviewed the evidence regarding diagnostic performance of OSA screening methods and the impact of perioperative management strategies on postoperative complications among patients with diagnosed or suspected OSA who are undergoing orthopedic surgery. We then integrated the data and recommendations from professional society guidelines to develop an evidence-based clinical care pathway to optimize the perioperative management of this surgical population. Successful management of patients with diagnosed or suspected OSA encompass five facets of care: screening, education, airway management, medications, and monitoring. This narrative review revealed two gaps in the evidence to inform management of patients undergoing orthopedic surgery 1) during the perioperative setting to include evidence-based interventions that reduce postoperative complications and 2) after discharge to an unmonitored environment. The clinical care pathway as well as perspectives for future research are discussed.

Impact of sleep disordered breathing on postoperative atrial fibrillation in patients who underwent cardiac surgery: a meta-analysis

Objective: An increasing number of studies suggest that sleep disordered breathing (SDB) may be associated with postoperative atrial fibrillation (POAF), but these studies present discrepant results. Thus, this meta-analysis aimed to synthesize the data associating SDB with POAF in patients who underwent cardiac surgery.Methods: A literature search was performed in the Scopus, PubMed, Web of Science, EMBASE, CENTRAL, Weipu, Wanfang Data, and China National Knowledge Infrastructure databases before August 2022. Data were extracted, and the strength of the relationship between SDB and the risk of POAF was evaluated using odds ratio (OR) and 95% confidence intervals (CIs). All statistical analysis was carried out using the Stata 12.0 software.Results: A total of 24 studies with 660,685 subjects were included in current meta-analysis. SDB was significantly associated with the risk of POAF in the patients who underwent cardiac surgery (OR = 1.49; 95% CI, 1.30-1.70; p < .001). Next subgroup analysis revealed that such association may be increased in the group with medical equipment-measured SDB (OR = 2.27; 95% CI, 1.59-3.23; p < .001), prospective studies (OR = 2.17; 95% CI, 1.55-3.03; p < .001), patients without a previous history of atrial fibrillation (OR = 2.04; 95% CI, 1.47-2.82; p < .001), and patients who received a coronary artery bypass graft (OR = 2.10; 95% CI, 1.45-3.05; p < .001). No publication bias was identified.Conclusion: The results of meta-analysis support that SDB may be associated with an increased risk of POAF in patients who had undergone cardiac surgery, and these results should be confirmed in more rigorously designed studies.KEY MESSAGESPatients with SDB who underwent cardiac surgery showed increased risk of POAF.The relationship between SDB and POAF should be explained with caution with the consideration of various covariate.The effect of pre-treatment of SDB on POAF should be examined in future.

Perioperative Management of the Patient With Obstructive Sleep Apnea: A Narrative Review

The prevalence of obstructive sleep apnea (OSA) has reached 1 billion people worldwide, implying significant risk for the perioperative setting as patients are vulnerable to cardiopulmonary complications, critical care requirement, and unexpected death. This review summarizes main aspects and considerations for the perioperative management of OSA, a condition of public health concern. Critical determinants of perioperative risk include OSA-related changes in upper airway anatomy with augmented collapsibility, diminished capability of upper airway dilator muscles to respond to airway obstruction, disparities in hypoxemia and hypercarbia arousal thresholds, and instability of ventilatory control. Preoperative OSA screening to identify patients at increased risk has therefore been implemented in many institutions. Experts recommend that in the absence of severe symptoms or additional compounding health risks, patients may nevertheless proceed to surgery, while heightened awareness and the adjustment of postoperative care is required. Perioperative caregivers should anticipate difficult airway management in OSA and be prepared for airway complications. Anesthetic and sedative drug agents worsen upper airway collapsibility and depress central respiratory activity, while the risk for postoperative respiratory compromise is further increased with the utilization of neuromuscular blockade. Consistently, opioid analgesia has proven to be complex in OSA, as patients are particularly prone to opioid-induced respiratory depression. Moreover, basic features of OSA, including intermittent hypoxemia and repetitive sleep fragmentation, gradually precipitate a higher sensitivity to opioid analgesic potency along with an increased perception of pain. Hence, regional anesthesia by blockade of neural pathways directly at the site of surgical trauma as well as multimodal analgesia by facilitating additive and synergistic analgesic effects are both strongly supported in the literature as interventions that may reduce perioperative complication risk. Health care institutions are increasingly allocating resources, including those of postoperative enhanced monitoring, in an effort to increase patient safety. The implementation of evidence-based perioperative management strategies is however burdened by the rising prevalence of OSA, the large heterogeneity in disease severity, and the lack of evidence on the efficacy of costly perioperative measures. Screening and monitoring algorithms, as well as reliable risk predictors, are urgently needed to identify OSA patients that are truly in need of extended postoperative surveillance and care. The perioperative community is therefore challenged to develop feasible pathways and measures that can confer increased patient safety and prevent complications in patients with OSA.