Inside Sleep

OSA Raises Surgery Risk

• By Gerald Suh
• Sep 01, 2010

Numerous cases of poor or adverse outcomes following routine surgery, including reintubations, prolonged hospital stays, transfers to ICUs, cardiac events and even death, have been linked to underlying undiagnosed obstructive sleep apnea in patients.1

Overall, OSA is thought to affl ict at least 2 percent to 4 percent of the adult U.S. population, with 80 percent to 90 percent of people undiagnosed. With the current obesity epidemic and aging population, some articles speculate the prevalence is closer to 10 percent. Many of these people will likely need surgery at some point in their lives. A recent prospective observational study of all adult patients undergoing surgery screened for OSA at a single hospital (Washington University) and found 23 percent of the surgical patients were at high risk for significant OSA.2 This points to the fact that we, as health and home care providers, must do a much better job of diagnosing and treating this widespread condition.

Most physicians now understand that patients with sleep apnea are especially vulnerable during the perioperative period, particularly if they receive general anesthesia and opiate analgesia, sedatives or sleep medication following surgery.3 However, there has never been any emphasis on systematically screening surgical patients for OSA to ensure optimal patient outcome and avoid prolonged hospital stays, especially in this day and age of denying reimbursement for preventable complications while in the hospital. Ultimately, if a patient is known to have OSA, precautions can be taken beforehand to ensure safety in both the operating room and postoperatively, including proper orders for medications, monitoring, and possibly a CPAP or APAP device while in the hospital. Even for surgeries typically considered ambulatory, knowledge of underlying OSA could impact where the surgery can be performed safely.

Initial screening for OSA can be performed preoperatively using any of several validated screening tools that can be self-administered, such as the Berlin Questionnaire, the Watermark-ARES screen or the STOPBang Questionnaire. In general, the Epworth Sleepiness Scale would not be an adequate screening tool for OSA. Screening can be performed by the surgeon, clearing physician, anesthesiologist or hospital staff.

Of note, in response to a few significant adverse patient outcomes, several large hospital centers around the country have recently initiated OSA screening for all patients undergoing any type of surgery during preoperative testing, similar to obtaining a cardiac work-up or clearance for patients with a significant cardiac history. Those at high risk for OSA are encouraged to undergo a validated home sleep study, with results available prior to surgery.

This degree of screening may be extreme, but it is reasonable to advocate screening for all patients undergoing any major elective surgery requiring general anesthesia. This practice would undoubtedly have a significant impact on both improving patient safety as well as decreasing overall health care and hospital costs due to adverse outcomes. For patients with a high risk for significant OSA, home sleep testing would appear to be the most cost-effective diagnostic modality. However, given sufficient lead time, formal lab-based polysomnography would also be a consideration. Ideally, if the patient was diagnosed with OSA, the patient would either undergo a formal CPAP trial and have a CPAP device available prior to surgery or be prescribed an APAP. Ultimately, the patient should also be monitored by a sleep specialist.

For the home care provider, there is a tremendous opportunity to be at the forefront of this push to provide screening, diagnosis and treatment for this large patient population, whether it is by educating the community physicians and hospitals on the importance of screening, marketing and providing home sleep testing services, and/or ultimately treating those patients diagnosed either in the hospital or subsequent to hospitalization. Forming alliances with hospital centers to provide a fullservice home sleep program centered on screening and treating preoperative patients would be another potential avenue. There is definitely a large unmet need here and, in the end, advocating for improved patient care should truly be one of our main priorities.

1. Obstructive Sleep Apnea May Block the Path to a Positive Postoperative Outcome. Pennsylvania Patient Safety Reporting System Patient Safety Advisory 2007 Sep;4(3):91-96.

2. Finkel KJ, Saager L, Safar-Zadeh E, et al. Obstructive Sleep Apnea: The Silent Pandemic, in press.

3. Chung F, Elsaid H. Screening for Obstructive Sleep Apnea Before Surgery; Why Is it Important? Current Opinion in Anesthesiology 2009 Jun;22(3):405-411.

This article originally appeared in the Respiratory & Sleep Management September 2010 issue of HME Business.