Surgical treatment of obstructive sleep apnea

AORN Journal, Sept, 2005 by Wayne Colin, Susan Duval

For patients with OSA, the cost of medical care and the number of days spent in the hospital are greater before diagnosis and treatment of OSA because of cardiovascular and other comorbidities. (19) Patients with unrecognized and untreated OSA have a greater risk of experiencing a perioperative adverse airway event. (20) Additionally, routine surgery, such as orthopedic joint replacement, is both more costly and associated with longer hospitalization when OSA is not treated. (21) Patients with untreated OSA have more motor vehicle and occupational accidents because OSA causes poor sleep quality resulting in daytime sleepiness and diminished vigilance. (22)

NONSURGICAL TREATMENT OPTIONS

Nonsurgical treatment of OSA includes CPAP, anatomical change of the upper airway by weight loss, (23) and use of an appliance to protrude the jaw. (24) Other nonsurgical recommendations for minimizing OSA risk include decreasing upper airway inflammation by treating gastroesophageal reflux, (25) ceasing tobacco use, (26) and practicing proper sleep hygiene methods (eg, avoiding alcohol, narcotics, tranquilizers, sedatives, or antihistamines). (27) The most common treatment is CPAP, but it is not an ideal therapy for all patients. The mask-tube pump device provides pressurized room air to prevent airway collapse and obstruction (Figure 3). (28) The pneumatic support provided by CPAP does not cure OSA and requires nightly use.

[FIGURE 3 OMITTED]

REASONS FOR CPAP FAILURE

There are multiple reasons why CPAP therapy may fail (Table 1). Failure may be a result of noncompliance or ineffectiveness at reducing the frequency of nocturnal obstructive breathing events to normal range. Intolerance of CPAP therapy can be separated into behavioral, physical, and mechanical issues. There also are contraindications to CPAP use.

NONCOMPLIANCE. Not every patient will comply with CPAP therapy as prescribed. At present, a physiological definition of adequate therapy with CPAP treatment is unknown. The average nightly use that provides cardiovascular protection is unclear; (29) however, adequate therapy currently is presumed to be at least four hours per night because this commonly relieves fatigue and sleepiness. (30,31) The optimal frequency of CPAP use also is not well defined; the physiological benefits of eight hours of CPAP use every other night are likely to be different than those of four hours of CPAP use every night, but both users would have the same average nightly use and would be considered compliant with treatment. Reports indicate that failure to comply with adequate therapy of at least four hours per night ranges from an optimistic 25% (30) to close to 50%, (31) and subjective estimates of CPAP use far exceed those of actual computer-monitored CPAP use. (32)

Optimal compliance with CPAP therapy is vital for individuals who work in public safety. Consider the potential adverse public health impact of sleepy airline pilots or other aviation personnel; boat captains; bus drivers; heavy equipment operators; health care personnel (eg, anesthesia care providers, nurses, physicians, surgeons); police officers; and truck drivers. The US military already recognizes the potential for group harm when a soldier is pathologically sleepy from OSA; therefore, the military will not engage such personnel for "appointment, enlistment ... [or] induction." (33 (p4)) Failure to comply with optimal therapy as supported by objective monitoring (32) should prompt early consideration for surgical intervention.