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Anesthesiology:
doi: 10.1097/ALN.0000000000000354
Correspondence

Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea: Navigating through Uncertainty

Corso, Ruggero M. M.D.; Gregoretti, Cesare M.D.; Braghiroli, Alberto M.D.; Fanfulla, Francesco M.D., Ph.D.; Insalaco, Giuseppe M.D., Ph.D.

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To the Editor:

We read with interest the update of Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea, by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea.1 However, it is our belief that the document, although flawless from a methodological point of view, fails to convey the intended message to the reader. We found that all the recommendations listed in the document defer from the final decision to the clinicians, leaving “too much room” for individual maneuvers. As a matter of fact, as far as patient’s safety is concerned, the document falls short of the aim of a guideline, which should be able to indicate the best among all possible options. A few points seem more critical than the others:
1. Preoperative evaluation. It is recommended in a general way to consider the possibility of sending a patient suspected of being susceptible to obstructive sleep apnea (OSA) to the sleep physician for further diagnosis and therapy. In the present Guidelines, it is surprising and unjustified, that on the basis of the evidence, authors do not recommend the use of the STOP BANG questionnaire. This simple questionnaire has been shown to identify patients at risk of moderate-to-severe OSA,2 with reasonable certainty and can be easily implemented in the clinical setting. More importantly it is able to identify patients with increased risk of perioperative complications, proving to be an excellent tool for triage of surgical patients,3 requiring a limited and predictable amount of time, a crucial issue in the busy setting of daily hospital practice.
2. Assessment of perioperative risk. The suggested scoring system for preoperative risk from OSA, although very practical and interesting from a clinical point of view, has never been validated. The proposed scoring system could potentially work with patients with a polisomnographic diagnosis of OSA severity. Nevertheless, how do we manage a suspected OSA patient where the degree of OSA is merely supposed? Again the STOP BANG questionnaire can be used as a triage tool, providing an estimate of the severity of OSA. Indeed the probability of OSA increases with the increase of the score, with a cut-off of 5 as an optimal compromise to reduce the number of false positives.3
3. Criteria for discharge to unmonitored settings. The Guidelines state that in order to decide if the patient should to be discharged to an unmonitored bed, it is necessary to observe “patients in an unstimulated environment, preferably while asleep.”1 This is a generic statement (i.e. for how long should the observation period last?), equivalent to tossing a coin and awaiting a heads or tails outcome. Patients with OSA are at risk of complications even in the days following surgery.4 A decision based on such criteria would expose them to a foreseeable risk.
In conclusion, the evidence that patients with OSA are at increased risk of perioperative complications is well established.5 As such, it is imperative to adopt strategies to reduce perioperative risk. The implementation of such strategies requires expenditure, however, this does not justify a lack of clarity. Patient safety requires us to unambiguously inform anesthesiologists of the best strategies to use in the front line rather than generic suggestions, which leave them navigating in a detrimental sea of uncertainty.
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Competing Interests

The authors declare no competing interests.
Ruggero M. Corso, M.D., Cesare Gregoretti, M.D., Alberto Braghiroli, M.D., Francesco Fanfulla, M.D., Ph.D., Giuseppe Insalaco, M.D., Ph.D.
“G.B. Morgagni” Hospital, Forlì, Italy (R.M.C.). rmcorso@gmail.com
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References

1. . Practice guidelines for the perioperative management of patients with obstructive sleep apnea: An updated report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea. ANESTHESIOLOGY. 2014;120:268–86

2. Chung F, Subramanyam R, Liao P, Sasaki E, Shapiro C, Sun Y. High STOP-Bang score indicates a high probability of obstructive sleep apnoea. Br J Anaesth. 2012;108:768–75

3. Corso R, Petrini F, Buccioli M, Nanni O, Carretta E, Trolio A, De Nuzzo D, Pigna A, Di Giacinto I, Agnoletti V, Gambale G:. Clinical utility of preoperative screening with STOP-Bang questionnaire in elective surgery. Minerva Anestesiol. 2013 [Epub ahead of print]

4. Chung F, Liao P, Elsaid H, Shapiro CM, Kang W. Factors associated with postoperative exacerbation of sleep-disordered breathing. ANESTHESIOLOGY. 2014;120:299–311

5. Memtsoudis SG, Stundner O, Rasul R, Chiu YL, Sun X, Ramachandran SK, Kaw R, Fleischut P, Mazumdar M. The impact of sleep apnea on postoperative utilization of resources and adverse outcomes. Anesth Analg. 2014;118:407–18

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