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Does Obstructive Sleep Apnea Influence Perioperative Outcome? A Qualitative Systematic Review for the Society of Anesthesia and Sleep Medicine Task Force on Preoperative Preparation of Patients with Sleep-Disordered Breathing

Opperer, Mathias, MD; Cozowicz, Crispiana, MD; Bugada, Dario, MD; Mokhlesi, Babak, MD, MSc; Kaw, Roop, MD; Auckley, Dennis, MD; Chung, Frances, MBBS, FRCPC; Memtsoudis, Stavros G., MD, PhD, FCCP

doi: 10.1213/ANE.0000000000001178
Ambulatory Anesthesiology and Perioperative Management: Review Article
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SDC

Obstructive sleep apnea (OSA) is a commonly encountered problem in the perioperative setting even though many patients remain undiagnosed at the time of surgery. The objective of this systematic review was to evaluate whether the diagnosis of OSA has an impact on postoperative outcomes. We performed a systematic review of studies published in PubMed-MEDLINE, MEDLINE In-Process, and other nonindexed citations, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Health Technology Assessment up to November 2014. Studies of adult patients with a diagnosis of OSA or high risk thereof, published in the English language, undergoing surgery or procedures under anesthesia care, and reporting ≥1 postoperative outcome were included. Overall, the included studies reported on 413,304 OSA and 8,556,279 control patients. The majority reported worse outcomes for a number of events, including pulmonary and combined complications, among patients with OSA versus the reference group. The association between OSA and in-hospital mortality varied among studies; 9 studies showed no impact of OSA on mortality, 3 studies suggested a decrease in mortality, and 1 study reported increased mortality. In summary, the majority of studies suggest that the presence of OSA is associated with an increased risk of postoperative complications.

From the *Department of Anesthesiology, Hospital for Special Surgery, New York, New York; Department of Anesthesiology, Paracelsus Medical University, Salzburg, Austria; Department of Surgical Sciences, University of Parma, Parma, Italy; §Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois; Departments of Hospital Medicine and Anesthesia Outcomes Research, Cleveland Clinic, Cleveland, Ohio; Division of Pulmonary, Critical Care, and Sleep Medicine, Metro Health Medical Center, Case Western Reserve Hospital, Cleveland, Ohio; and #Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada.

Accepted for publication December 16, 2015.

Funding: B. Mokhlesi is supported by National Institutes of Health grant R01HL119161.

Conflict of Interest: See Disclosures at the end of the article.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Reprints will not be available from the authors.

Address correspondence to Stavros G. Memtsoudis, Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th St., New York, NY 10021. Address e-mail to MemtsoudisS@HSS.edu.

Obstructive sleep apnea (OSA) is the most commonly encountered form of sleep-disordered breathing (SDB) characterized as repetitive cessation in airflow during sleep associated with intermittent hypoxemia. The prevalence of OSA is more frequent in surgical patients than in the general population,1 and most patients remain undiagnosed at the time of presentation for surgery. With both surgical volume and predisposing factors for OSA increasing,2 there has been growing interest in the impact of OSA on perioperative outcomes.3 Accordingly, several single-center studies as well as large-scale analyses of administrative databases have examined the association between OSA and perioperative outcomes. In recent years, 2 independent meta-analyses have evaluated studies comparing outcomes in patients with and without a diagnosis of OSA and concluded that this diagnosis is associated with increased risk for postoperative complications.4,5 Nevertheless, these analyses used fairly strict inclusion criteria, resulting in the inclusion of 13 and 17 studies only. Additional literature available on the topic was not considered, including recent analyses generated from data collected in large national databases on millions of patients.6–10 With the large heterogeneity of settings and different end points measured, there is no consensus on whether OSA by itself is a risk factor for adverse outcomes in the perioperative setting.4 Without such evidence, it is difficult to justify some of the currently suggested and often expensive perioperative interventions targeted to improve outcomes among this growing patient population.

We performed a systematic review of available literature, aiming to contribute to the elucidation of the question of whether OSA is indeed associated with adverse outcomes in the perioperative setting. This review was prepared as part of the Society of Anesthesia and Sleep Medicine (SASM) work group on a Guideline on Preoperative Assessment of Patients with Sleep Disordered-Breathing. Because of the wide heterogeneity of published studies in terms of sample size, data source (database versus clinical settings), surgical populations, different OSA, and outcome definitions, this review was limited to a qualitative assessment. The objective of this systematic review was to examine the influence of a preoperative diagnosis of OSA, by polysomnography, International Classification of Diseases, Ninth Revision (ICD-9) coding, or risk assessment using various screening tools, on various perioperative outcomes.

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METHODS

Literature Search Strategy

With the assistance of a research librarian, a literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines on PubMed-MEDLINE (1946 to November 16, 2014), MEDLINE In-Process and other nonindexed citations (to November 16, 2014), Embase (1947 to November 16, 2014), Cochrane Central Register of Controlled Trials (to November 16, 2014), Cochrane Database of Systematic Reviews (from 2005 to November 16, 2014), and Health Technology Assessment (to fourth Quarter 2013). The search used the MESH key words “sleep apnea, obstructive,” “postoperative period,” “complications” or “outcome,” “perioperative care,” “intraoperative monitoring,” “postoperative monitoring,” “perioperative complications,” “intraoperative complications,” “postoperative complications,” “outcome,” “risk,” “morbidity,” “mortality” and “death and also “obstructive sleep apnea,” “obstructive sleep apnea syndrome,” “sleep disordered breathing,” “obesity hypoventilation syndrome,” “apnea or apnoea,” and “hypopnea or hypopnoea.” The full search strategy used is shown in Appendix 1 and in Supplemental Digital Content 1 (http://links.lww.com/AA/B361).

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Eligibility Criteria

All study designs including randomized controlled trials, prospective, or retrospective observational studies of adult (>18 years old) patients published in the English language were included. All studies included were required to define the presence or high risk of OSA based on polysomnography, questionnaires, clinical assessment, chart diagnosis (medical history), or ICD-9 code (administrative/billing records) in patients undergoing surgery or procedures under anesthesia care and report ≥1 postoperative outcome.

In the next step, studies were excluded if they met one of the following criteria: (1) nonpertinent papers as judged by 2 independent reviewers, (2) studies on surgical treatment of OSA, upper airway surgery, or catheter lab procedures, (3) studies that did not include a non-OSA or low-risk control group, and (4) reviews, case reports, or publications without available full text.

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Study Selection

We assessed titles and abstracts to identify whether inclusion/exclusion criteria were fulfilled in the following manner as proposed by the SASM consensus group. The search results were assessed in a stepwise manner by 2 independent reviewers. Duplicate records were deleted before manual review. In the first step of the review, relevant studies were selected after reviewing the title of the search results. In the second step, the abstracts were screened to decide whether eligibility criteria were met. In the third step, the selected full-text articles were reviewed, and relevant data were extracted. A citation search by manual review of references from primary or review articles was performed, and all relevant results were compiled. The number and reason for exclusion were recorded. Any disagreements were resolved by consensus or by consulting with the main SASM work group.

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Data Extraction

All publications were divided into studies investigating procedures under general or regional anesthesia and procedural sedation. Reported associations of OSA with perioperative outcomes such as combined complications, cardiac complications with atrial fibrillation analyzed separately, pulmonary complications, desaturation, difficult intubation, airway rescue maneuvers, mortality, and resource utilization (length of hospital stay and intensive care unit [ICU] admissions) were recorded and tabulated. The category “combined complications” was adopted from studies that either defined an outcome as such or reported on outcomes that did not fit into the above-mentioned categories. It must be mentioned that definitions and mode of determination of these outcomes varied significantly among publications. Studies were graded based on the Oxford Centre for Evidence-based Medicine Levels of Evidence (Appendix 2).11

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RESULTS

Figure 1

Figure 1

The initial search yielded 5617 references. After title screening, 510 abstracts were identified and reviewed and 449 were excluded. Reasons for exclusion are listed in Figure 1. Finally, we identified 61 studies pertinent to this review with 50 studies investigating patients undergoing surgery with general or neuraxial anesthesia and 11 studies reporting on procedures under sedation.

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Procedures Under General or Neuraxial Anesthesia

Studies reporting the association of OSA on select perioperative outcomes in surgeries under general or neuraxial anesthesia are summarized in Table 1. Eleven studies based on the diagnosis of OSA on ICD-9 coding,6–10,12,13,18,46,52,55 17 on polysomnography results,14–16,19–21,23,24,29,30,34,39,40,43,49–51 6 on chart diagnosis,35,36,38,44,47,53 15 on screening questionnaires,17,22,25–27,31–33,37,41,42,45,48,51,54,56 and 1 study referred to clinical diagnosis.28 The level of evidence for the included studies consisted predominantly of 2b level studies but ranged from 1b to 3b as judged by the reviewers (Table 2).

Table 1

Table 1

Table 2

Table 2

Overall, the included studies reported on 413,304 OSA and 8,556,279 control patients. In summary, 13 studies reported on the outcome of mortality,7,9,10,12,15,18–21,27,49,55,56 15 on pulmonary complications,6,7,9,10,12–22 10 on cardiac complications,7,12–18,20,27 13 on oxygen desaturation events,13,14,23–33 6 on atrial fibrillation,9,10,27,40–42 6 on difficult intubation/airway management,34–39 19 on resource utilization,7–9,12–14,18,20,25,27,33,37,44,46–51 and 10 on varying composite outcomes of minor/major complications.7,8,13–15,21,25,43–45

The majority of studies reported worse outcomes among patients with OSA compared with the control group. For example, 9 of 15 studies reported increased pulmonary complications among OSA patients compared with controls.6,7,10,12–17 Atrial fibrillation was reported in 5 of 6 studies to be associated with OSA,9,10,40–42 whereas this association was found in 8 of 10 studies reporting on a combined complication outcome7,8,13–15,25,43,44 (Table 2). Reports on the association between OSA and postoperative mortality yielded mixed results: 9 studies reported no association,7,15,18–21,27,49,56 3 reported lower mortality in the OSA group,9,10,55 and 1 study reported an increase of mortality in the OSA group.12

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Procedures Under Sedation

Studies reporting negative, positive, or no significant association of OSA with select perioperative outcomes of surgeries under sedation are summarized in Table 3. Of these studies, 3 defined the presence of OSA based on polysomnography,60,61,66 2 by chart diagnosis,57,62 and 6 by administration of screening questionnaires.58,59,63–65,67 The level of evidence for the included studies ranged from 2b to 4. Details can be found in Table 4.

Table 3

Table 3

Table 4

Table 4

In summary, 7 studies reported on oxygen desaturation as an outcome,57–63 3 on composite minor/major complications,65–67 and 3 on the need for rescue airway maneuvers in OSA.58,64,65 Three studies reported adverse effects regarding oxygen desaturation57–59 and 1 study reported on necessary airway maneuvers.58 No study reported an improved outcome. Outcomes for procedures under sedation are summarized in Table 3.

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DISCUSSION

This systematic review of 61 studies meeting our prespecified inclusion criteria demonstrates that the majority of studies support the notion that OSA is indeed a risk factor for perioperative adverse events.

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Procedures Under General or Neuraxial Anesthesia

Difficult Intubation

OSA has been frequently linked to abnormal airway anatomy thus posing the question whether this disease predisposes to difficult airway management.68

In a consecutive case-series of laparoscopic gastric banding patients, Iyer et al.34 determined that severe OSA (apnea-hypopnea index [AHI] ≥30) was significantly associated with difficult intubation (odds ratio [OR], 4.46; 95% confidence interval [CI], 1.6–12.3; P = 0.004). Furthermore, a review of 50,000 general anesthesia cases identified OSA as an independent predictor for impossible mask ventilation (adjusted hazards ratio, 2.4; 95% CI, 1.3–4.3; P = 0.005).36 This was later confirmed in a large multicenter study containing >500,000 cases identifying OSA as a significant predictor of difficult mask ventilation and laryngoscopy.35 This relation, however, has not been found consistently.38,39

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Pulmonary Complications

The study by Gupta et al.44 was one of the earliest to report postoperative cardiopulmonary complications in patients with OSA after noncardiac surgery. Ever since, respiratory failure has been linked to OSA by numerous studies.6,7,9,10,13–17 Memtsoudis et al.,6 in the largest observational study on patients with OSA (identified by ICD-9 diagnosis), reported a 5-fold increase in intubation and mechanical ventilation after orthopedic surgery (OR, 5.2; 95% CI, 5.05–5.37) and a 2-fold increase after general surgery (OR, 1.95; 95% CI, 1.91–1.98) compared with controls. Another study using the same database showed that the incidence for emergent intubation and mechanical ventilation was highest in the first 24 hours, and no difference was noted across different types of surgical categories.10

Both of these studies used administrative data from the Nationwide Inpatient Sample database; the sample was dominated by the orthopedic surgical cohort (n = 3,441,2626; n = 783,72310) and showed a steadily increasing prevalence of OSA over the duration of the study period. A meta-analysis of 3942 patients with OSA, the majority of whom were affirmed by polysomnography, confirmed an increased incidence of respiratory failure compared with patients without OSA (OR, 2.43; 95% CI, 1.34–4.39; P = 0.003).4 More recently, Mutter et al.16 compared >2500 patients with OSA, half of them undiagnosed at the time of surgery, with 16,000 controls in the Manitoban health administrative database and confirmed increased postoperative respiratory complications regardless of early diagnosis and prescription of continuous positive airway pressure. Early reports among patients with obesity hypoventilation syndrome undergoing elective surgery show that the incidence of postoperative respiratory failure may be even higher and that obesity hypoventilation syndrome is more likely to be unrecognized before elective noncardiac surgery when compared with OSA.69

In contrast, studies reporting postoperative outcomes after bariatric surgery reported no significant difference in mortality (albeit no death occurred in either group), pulmonary complications, length of hospital stay, and incidence of minor complications such as wound infections or anastomotic leakage.19,21,49 Some have concluded that there is no need for postoperative ICU admission in patients with OSA after laparoscopic Roux-en-Y gastric bypass procedures.49 However, using the large Nationwide Inpatient Sample, Mokhlesi et al. reported a higher risk of pulmonary complications and atrial fibrillation in patients with a diagnosis of SDB undergoing bariatric surgery.

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Cardiovascular Complications

Higher incidences of postoperative cardiovascular events were reported in a meta-analysis, but data on specific cardiac complications remain rare. In an analysis of the Nationwide Inpatient Sample, Mokhlesi et al.9,10 found that SDB was independently associated with atrial fibrillation in a variety of elective surgeries (orthopedic, cardiovascular, prostate, abdominal, and bariatric surgery). However, the study was limited because it was not clear whether this was new-onset or chronic atrial fibrillation. Recently, however, OSA has been shown to be a strong predictor of new-onset atrial fibrillation after coronary arterial bypass grafting, which in turn led to higher postoperative length of hospital stay.42 In the largest administrative cohort study of postoperative outcomes to date comparing treated and untreated patients with OSA, higher rates of cardiac arrest and shock were only significantly increased in patients with severe undiagnosed OSA.16 More recently, Abdelsattar et al.70 suggested in their analysis of data from hospitals in Michigan that patients treated for their OSA were at reduced risk for perioperative complications compared with those that were not.

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Resource Utilization

In a study investigating whether OSA increases the risk for unplanned readmissions after ambulatory surgery, Bryson et al.51 found no significant effect of OSA, when treated with continuous positive airway pressure (OR, 1.26; 95% CI, 0.83–1.91 for unplanned readmissions; P = 0.246). Sabers et al.50 reported similar results in outpatient surgery for polysomnography-confirmed OSA patients under general or neuraxial anesthesia. Similarly, Stierer et al.37 reported no significant effect on readmission rates for ambulatory patients classified as high risk for OSA.

The impact of OSA on resource utilization among inpatients has also been studied. In a larger study including >50,000 patients after bariatric surgery, patients with OSA had 50% higher risk for 30-day hospital readmission.47 In a 2013 investigation of >5000 elective surgical cases, multivariate analysis demonstrated higher odds for critical care unit admission in patients with OSA (OR, 2.2; 95% CI, 1.1–4.6; P = 0.037; OR, 3.2; 95% CI, 1.2–8.1; P = 0.017; and OR, 5.1; 95% CI, 1.8–14.9; P = 0.002 for STOP-Bang scores of 4, 5, and ≥6, respectively).48 Although the rate of ICU admission was also found to be higher in additional investigations,8,14 some authors argue that this might have been attributable to regional practice patterns rather than a consequence of perioperative complications. However, according to a meta-analysis, if elective transfers to an ICU for observation are excluded, the presence of OSA appears to be significantly associated with higher odds of ICU use (OR, 2.29; 95% CI, 1.62–3.24; P ≤ 0.00001; I2 = 57%–68%, P ≤ 0.02) after surgery. OSA was also identified as a risk factor for unplanned ICU admission after total hip arthroplasties (THA)46 and longer ICU stays after cardiac surgery.20 In contrast, some studies do not report a significant effect of OSA diagnosis or OSA risk category on ICU admissions.15,27 However, database studies suggest a higher utilization of ICU and step-down units for OSA patients after orthopedic surgeries, with sex, complicated hypertension, and obesity being important interaction terms.7

Data on elective arthroplasties and posterior lumbar fusions also suggest an increased length of hospital stay and economic burden in OSA patients.7,8,44 Counterintuitively, Mokhlesi et al.9 reported a decreased length of hospital stay and cost for OSA patients after bariatric surgery. Further analysis confirmed these differing results by surgery type with OSA being associated with shorter length of hospital stay and reduced costs in abdominal and cardiovascular procedures and the reverse applying to orthopedic surgeries.10 Smaller studies found an increased length of hospital stay following noncardiac, nonneurologic, or elective surgery for patients screened as high risk for OSA by the STOP-Bang score.33,45

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Other Outcomes

Researchers have further linked the presence of OSA to an increased risk of delirium. An increased incidence of postoperative encephalopathy was reported in a sample of 37 patients with AHI ≥5 undergoing elective cardiac surgery compared with 185 propensity-matched controls. Analysis of 106 patients after total knee arthroplasty (TKA) showed that of the 15 patients with OSA, 53% experienced postoperative delirium, whereas it was only 21% in the 91 patients without OSA (OR, 4.3; P = 0.0123). In multivariate analysis, OSA was the only statistically significant predictor of postoperative delirium.29 More recently, in a prospective cohort study of 92 patients undergoing elective cardiac surgery with extracorporeal circulation, a median AHI ≥19 was associated with an almost 6-fold increased risk of postoperative delirium (OR, 6.4; 95% CI, 2.6–15.4; P < 0.001).71 No significant differences were noted in the mean oxygen saturation or the mean proportion of time with oxygen saturation <90% between patients with and without postoperative delirium.

Other studies have addressed less commonly studied outcomes. Andrews et al.53 hypothesized that OSA might impair postoperative wound healing by impairing peripheral oxygen saturation after foot amputation. Instead of a negative influence, the authors reported that even after multivariable regression analysis, the odds for satisfactory wound healing within 3 months of surgery were increased in the OSA group. Similarly, a study investigating gastrointestinal tract leakage after gastric bypass surgery reported reduced odds for patients with OSA.52 While speculative, repeated hypoxemic episodes that underlie the disease process may lead to the phenomenon of preconditioning, which could allow organ tissues to withstand subsequent damage during hypoxemia and underperfusion.72

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Postoperative Mortality

The earliest reports of death attributed to sudden postoperative respiratory arrest associated with epidural opioids in patients with OSA were published in 1997.73 Gami et al.74 reported that sudden cardiac death is more likely to occur during the sleep hours (12 AM to 6.00 AM) among patients with OSA compared with those without OSA (50% compared with 21%; RR: 2.57). In 2013, the same group of authors showed that among patients with OSA, the lowest nocturnal oxygen desaturation and AHI were independent predictors of sudden cardiac death.75 However, a few studies that examined postoperative mortality did not find any association between OSA and in-hospital mortality after elective surgery.9,10,56 This observed lack of association between postoperative in-hospital mortality and OSA does not necessarily mean that death cannot be an unexpected sentinel event in a postoperative patient with OSA exposed to additional insults like failed airway and unmonitored respiratory depression related to opioid and/or sedative administration especially with patient-controlled analgesia infusions. In contrast, using the same Nationwide Inpatient Sample, D’Apuzzo et al.12 reported an increased risk of in-hospital mortality in patients with an ICD-9 diagnosis of OSA after THA or TKA revision (OR, 1.9; 95% CI, 1.3–2.8; P = 0.002). Patients undergoing revision THA and TKA may have a higher comorbidity burden and therefore may be at higher risk of in-hospital mortality. Clearly, the incidence of such events in the perioperative setting is low enough to stand the test of statistical rigor of association, even in large administrative databases.

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Procedures Under Sedation

In settings with less invasive procedures performed under sedation, most studies focus on oxygen desaturation events. This is understandable because major complications are rare in this environment. Most available studies investigating procedural sedation for endoscopic procedures report no significant differences on desaturation events during the procedure in OSA patients versus controls.60,62,63 These findings are similar in studies that investigated provider interventions to secure or sustain open airways in low- versus high-risk OSA groups.64,65 However, other authors using similar screening instruments, for example, STOP-Bang score, with adequate sample size calculations, report a significant difference for desaturation events and required airway maneuvers in patients with OSA.58 This is also reflected in findings demonstrating a higher AHI in OSA patients during procedures; however, with no significant differences in oxygen saturation.59 Likewise, others have linked the frequency of desaturation episodes to a previous history of OSA and suggested that the incidence of adverse respiratory events can be reduced with suitable modification of anesthesia technique.57

Even when considering the possibly increased risk of hypoxemic events in OSA patients, no study reports on a significant increase in cardiopulmonary complications after endoscopic sedation.61 Even the largest studies by Mador et al.66,67 with approximately 500 and 350 OSA patients confirmed by sleep studies or screened by questionnaires, respectively, do not report on differences in minor or major complications. However, it has to be mentioned that to date no large-scale trial similar to those under general anesthesia has been performed to elucidate whether rare outcomes do differ in OSA patients undergoing procedures under sedation.

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Strengths and Limitations

One of the major strengths of this review is the inclusion of all available studies regardless of OSA definition, therefore, including various database trials with a high number of patients and allowing for interpretation of results on rare outcomes. However, this broad review of the literature does not allow for the merging of data for meta-analysis because of possible overlap in patient selection and reports on varying outcomes and inclusion definitions. It must be mentioned, however, that more selective meta-analyses including fewer studies have been performed and support the notion that OSA is a risk factor for perioperative adverse events.4,5

Available evidence on this subject is mostly based on studies judged to be level 2b and thus provides a moderate level of confidence in the body of evidence. Nevertheless, because of the nature of this review, we cannot exclude residual selection, reporting, language, or publication bias. Furthermore, as alluded, OSA patients sometimes remain undiagnosed, and therefore, any defined control group in the cited studies may possibly include OSA patients and therefore affect results. However, this bias may have led to an underestimation of the true effect of OSA and therefore was unlikely to have invalidated the findings. This fact may also have to be considered in the interpretation of findings such as those regarding in-hospital mortality.

Finally, one must consider recent publications questioning the validity of the use of various codes to identify OSA patients in large databases, which have been at the forefront of establishing OSA as a perioperative risk factor for adverse events,76 because of low specificity and sensitivity. Factors to consider here are that, while this finding may affect the ability to determine the true prevalence of OSA among the populations studied, however, a determination of an OSA cohort for which the risk of perioperative outcomes is determined is likely to produce valid results because any misclassification would bias the results to the null, thus underestimating the true effect. Furthermore, sensitivity and specificity vary significantly among databases and thus no overarching assessment statement for all data sources can be made.

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CONCLUSIONS

Based on this review, the majority of studies suggest that the presence of OSA does increase the risk for postoperative adverse events and complications. Although some studies imply no outcome differences between OSA versus control patients, only isolated studies suggest a benefit for the outcome of mortality. Because the level of evidence provided by the available literature is limited, further well-designed trials are needed. Until then, the current evidence provides a basis for establishing the presence of OSA as a risk factor for important perioperative complications.

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Appendix 1. Full Search Strategy

Table

Table

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Appendix 2

Table

Table

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DISCLOSURES

Name: Mathias Opperer, MD.

Contribution: This author helped design the study and prepare the manuscript.

Attestation: Mathias Opperer approved the final manuscript.

Conflicts of Interest: Mathias Opperer declares no conflicts of interest.

Name: Crispiana Cozowicz, MD.

Contribution: This author helped design the study and prepare the manuscript.

Attestation: Crispiana Cozowicz approved the final manuscript.

Conflicts of Interest: Crispiana Cozowicz declares no conflicts of interest.

Name: Dario Bugada, MD.

Contribution: This author helped design the study and prepare the manuscript.

Attestation: Dario Bugada approved the final manuscript.

Conflicts of Interest: Dario Bugada declares no conflicts of interest.

Name: Babak Mokhlesi, MD, MSc.

Contribution: This author helped design the study and prepare the manuscript.

Attestation: Babak Mokhlesi approved the final manuscript.

Conflicts of Interest: Babak Mokhlesi has served as a consultant to Philips/Respironics and has received research support from Philips/Respironics. He has also received honorarium from Zephyr Medical Technologies and has served on the advisory board of Itamar Medical.

Name: Roop Kaw, MD.

Contribution: This author helped design the study and prepare the manuscript.

Attestation: Roop Kaw approved the final manuscript.

Conflicts of Interest: Roop Kaw declares no conflicts of interest.

Name: Dennis Auckley, MD.

Contribution: This author helped design the study and prepare the manuscript.

Attestation: Dennis Auckley approved the final manuscript.

Conflicts of Interest: Dennis Auckley declares no conflicts of interest.

Name: Frances Chung, MBBS, FRCPC.

Contribution: This author helped design the study and prepare the manuscript.

Attestation: Frances Chung approved the final manuscript.

Conflicts of Interest: STOP Bang tool is proprietary to University Health Network. Frances Chung receives royalties from UpToDate and grant support from Pfizer Pharma, ResMed Inc.

Name: Stavros G. Memtsoudis, MD, PhD, FCCP.

Contribution: This author helped design the study and prepare the manuscript.

Attestation: Stavros G. Memtsoudis approved the final manuscript.

Conflicts of Interest: Stavros G. Memtsoudis is a non-paid consultant for B. Braun and is funded by the Anna Maria and Stephen Kellen Career Development Award, New York.

This manuscript was handled by: David Hillman, MD.

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ACKNOWLEDGMENTS

The authors thank Marina Englesakis, BA (Hons.) MLIS, Information Specialist, Surgical Divisions, Neuroscience and Medical Education, Health Sciences Library, University Health Network, Toronto, Ontario, Canada, for her assistance with the literature search.

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