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      Society of Anesthesia and Sleep Medicine Guidelines on Preoperative Screening and Assessment of Adult Patients With Obstructive Sleep Apnea

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        , MBBS, FRCPC * , , , MD, PhD , , MD , , MD § , , MD , , MD ¶# , , MD **†† , , BSc * , , BSc , , MD ‡‡ , , MD §§ , , MD ‖‖ , , MD ¶¶ , , MD, PhD ## , , MD, PhD *** , , HBA, MLIS ††† , , MD ‡‡‡ , , MD §§§ , , MD, PhD ‖‖‖ , , MD ¶¶¶ , , MD, MPH ### , , MD **** , , MD †††† , , MD ‡‡‡‡ , , MD §§§§ , , MD ‖‖‖‖¶¶¶¶ , , MD #### , , MD *****
      Anesthesia and Analgesia
      Lippincott Williams & Wilkins

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          Abstract

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          Abstract

          The purpose of the Society of Anesthesia and Sleep Medicine guideline on preoperative screening and assessment of adult patients with obstructive sleep apnea (OSA) is to present recommendations based on the available clinical evidence on the topic where possible. As very few well-performed randomized studies in this field of perioperative care are available, most of the recommendations were developed by experts in the field through consensus processes involving utilization of evidence grading to indicate the level of evidence upon which recommendations were based. This guideline may not be appropriate for all clinical situations and all patients. The decision whether to follow these recommendations must be made by a responsible physician on an individual basis. Protocols should be developed by individual institutions taking into account the patients’ conditions, extent of interventions and available resources. This practice guideline is not intended to define standards of care or represent absolute requirements for patient care. The adherence to these guidelines cannot in any way guarantee successful outcomes and is rather meant to help individuals and institutions formulate plans to better deal with the challenges posed by perioperative patients with OSA. These recommendations reflect the current state of knowledge and its interpretation by a group of experts in the field at the time of publication. While these guidelines will be periodically updated, new information that becomes available between updates should be taken into account. Deviations in practice from guidelines may be justifiable and such deviations should not be interpreted as a basis for claims of negligence.

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          Most cited references170

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          Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study.

          The effect of obstructive sleep apnoea-hypopnoea as a cardiovascular risk factor and the potential protective effect of its treatment with continuous positive airway pressure (CPAP) is unclear. We did an observational study to compare incidence of fatal and non-fatal cardiovascular events in simple snorers, patients with untreated obstructive sleep apnoea-hypopnoea, patients treated with CPAP, and healthy men recruited from the general population. We recruited men with obstructive sleep apnoea-hypopnoea or simple snorers from a sleep clinic, and a population-based sample of healthy men, matched for age and body-mass index with the patients with untreated severe obstructive sleep apnoea-hypopnoea. The presence and severity of the disorder was determined with full polysomnography, and the apnoea-hypopnoea index (AHI) was calculated as the average number of apnoeas and hypopnoeas per hour of sleep. Participants were followed-up at least once per year for a mean of 10.1 years (SD 1.6) and CPAP compliance was checked with the built-in meter. Endpoints were fatal cardiovascular events (death from myocardial infarction or stroke) and non-fatal cardiovascular events (non-fatal myocardial infarction, non-fatal stroke, coronary artery bypass surgery, and percutaneous transluminal coronary angiography). 264 healthy men, 377 simple snorers, 403 with untreated mild-moderate obstructive sleep apnoea-hypopnoea, 235 with untreated severe disease, and 372 with the disease and treated with CPAP were included in the analysis. Patients with untreated severe disease had a higher incidence of fatal cardiovascular events (1.06 per 100 person-years) and non-fatal cardiovascular events (2.13 per 100 person-years) than did untreated patients with mild-moderate disease (0.55, p=0.02 and 0.89, p<0.0001), simple snorers (0.34, p=0.0006 and 0.58, p<0.0001), patients treated with CPAP (0.35, p=0.0008 and 0.64, p<0.0001), and healthy participants (0.3, p=0.0012 and 0.45, p<0.0001). Multivariate analysis, adjusted for potential confounders, showed that untreated severe obstructive sleep apnoea-hypopnoea significantly increased the risk of fatal (odds ratio 2.87, 95%CI 1.17-7.51) and non-fatal (3.17, 1.12-7.51) cardiovascular events compared with healthy participants. In men, severe obstructive sleep apnoea-hypopnoea significantly increases the risk of fatal and non-fatal cardiovascular events. CPAP treatment reduces this risk.
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            Obstructive sleep apnoea and its cardiovascular consequences.

            Obstructive sleep apnoea (OSA) is a common disorder in which repetitive apnoeas expose the cardiovascular system to cycles of hypoxia, exaggerated negative intrathoracic pressure, and arousals. These noxious stimuli can, in turn, depress myocardial contractility, activate the sympathetic nervous system, raise blood pressure, heart rate, and myocardial wall stress, depress parasympathetic activity, provoke oxidative stress and systemic inflammation, activate platelets, and impair vascular endothelial function. Epidemiological studies have shown significant independent associations between OSA and hypertension, coronary artery disease, arrhythmias, heart failure, and stroke. In randomised trials, treating OSA with continuous positive airway pressure lowered blood pressure, attenuated signs of early atherosclerosis, and, in patients with heart failure, improved cardiac function. Current data therefore suggest that OSA increases the risk of developing cardiovascular diseases, and that its treatment has the potential to diminish such risk. However, large-scale randomised trials are needed to determine, definitively, whether treating OSA improves cardiovascular outcomes.
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              Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women.

              The proportion of sleep apnea syndrome (SAS) in the general adult population that goes undiagnosed was estimated from a sample of 4,925 employed adults. Questionnaire data on doctor-diagnosed sleep apnea were followed up to ascertain the prevalence of diagnosed sleep apnea. In-laboratory polysomnography on a subset of 1,090 participants was used to estimate screen-detected sleep apnea. In this population, without obvious barriers to health care for sleep disorders, we estimate that 93% of women and 82% of men with moderate to severe SAS have not been clinically diagnosed. These findings provide a baseline for assessing health care resource needs for sleep apnea.
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                Author and article information

                Journal
                Anesth Analg
                Anesth. Analg
                ANE
                Anesthesia and Analgesia
                Lippincott Williams & Wilkins
                0003-2999
                1526-7598
                August 2016
                22 July 2016
                : 123
                : 2
                : 452-473
                Affiliations
                From the [* ]Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; []Department of Anesthesiology, Weill Cornell Medical College and Hospital for Special Surgery, New York, New York; []Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan; [§ ]Department of Anesthesiology and Perioperative Medicine, University Hospital, St. Joseph’s Hospital and Victoria Hospital, London Health Sciences Centre and St. Joseph’s Health care, Western University, London, Ontario, Canada; []Paracelsus Medical University, Department of Anesthesiology, Perioperative Medicine and Intensive Care, Salzburg, Austria; []Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College New York, New York; [# ]Department of Anesthesia, Perioperative Medicine and Intensive Care, Paracelsus Medical University, Salzburg, Austria; [** ]Department of Medicine, University of California San Diego, San Diego, California; [†† ]Sparrow Hospital, Lansing, Michigan; [‡‡ ]Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, Texas; [§§ ]Department of Medicine, Division of Respiratory Medicine, The University of British Columbia, Vancouver, BC, Canada; [‖‖ ]University of British Columbia, Vancouver, BC, Canada; [¶¶ ]Department of Medicine, Emory University, Atlanta, Georgia; [## ]Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Palo Alto, California; [*** ]Department of Anesthesia, Critical Care and Pain Medicine, Harvard University, Cambridge, Massachusetts; [††† ]Library and Information Services, University Health Network, University of Toronto, Toronto, Ontario, Canada; [‡‡‡ ]Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota; [§§§ ]Department of Pulmonary, Critical Care and Sleep Medicine, Mayo Clinic, Rochester, Minnesota; [‖‖‖ ]School of Medicine, Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru; [¶¶¶ ]Departments of Hospital Medicine and Outcomes Research (Anesthesiology Institute), Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio; ###USC Caruso Department of Otolaryngology—Head & Neck Surgery Keck School of Medicine of USC Los Angeles, California; [**** ]Division of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, California; [†††† ]Section of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois; [‡‡‡‡ ]Department of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Arizona, Tucson, Arizona; [§§§§ ]Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland; [‖‖‖‖ ]Department of Anaesthesiology and Intensive Care Medicine, University Witten/Herdecke, Cologne, Germany; [¶¶¶¶ ]Department of Paediatric Anaesthesia, Cologne Medical Centre, Cologne, Germany; ####Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, University of Western Australia, Nedlands, Australia; and [***** ]Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, School of Medicine, Cleveland, Ohio.
                Author notes
                Address correspondence to Frances Chung, MBBS, FRCPC, Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst St, McL 2-405, Toronto, ON, Canada M5T 2S8. Address e-mail to frances.chung@ 123456uhn.ca .
                Article
                00022
                10.1213/ANE.0000000000001416
                4956681
                27442772
                93aeece4-56c3-4ee0-87e1-f28734d0e11a
                Copyright © 2016 International Anesthesia Research Society

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

                History
                : 23 April 2016
                Categories
                Respiration and Sleep Medicine
                Special Article
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