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Semin Respir Crit Care Med 2014; 35(05): 571-581
DOI: 10.1055/s-0034-1390079
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Diagnosis and Management of Obstructive Sleep Apnea in the Perioperative Setting

Patrick G. Lyons
1   Internal Medicine Residency Program, University of Chicago, Chicago, Illinois
,
Babak Mokhlesi
2   Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois
› Author Affiliations
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Publication History

Publication Date:
29 October 2014 (online)

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Abstract

Obstructive sleep apnea (OSA) is a chronic prevalent condition which may be under-recognized in surgical populations. Patients with OSA may be at increased perioperative risk, in part due to the effects sedatives and anesthetics have on upper airway tone and respiratory drive. A growing amount of data suggests that OSA patients have increased odds for adverse postoperative outcomes including intensive care unit transfer, respiratory failure, arrhythmias, and cardiac ischemia. Several screening tools have been developed to identify patients at risk for OSA preoperatively, but it remains to be seen whether routine implementation of these tools improves outcomes. In this review, we discuss the perioperative complications of OSA, the tools with which physicians can screen surgical patients, and the perioperative management of these patients.

Keywords

sleep-disordered breathing - obstructive sleep apnea - perioperative - postoperative - complications - continuous positive airway pressure
 

  • References

  • 1 Bixler EO, Vgontzas AN, Lin HM , et al. Prevalence of sleep-disordered breathing in women: effects of gender. Am J Respir Crit Care Med 2001; 163 (3, Pt 1) 608-613
    Google Scholar
  • 2 Bixler EO, Vgontzas AN, Ten Have T, Tyson K, Kales A. Effects of age on sleep apnea in men: I. Prevalence and severity. Am J Respir Crit Care Med 1998; 157 (1) 144-148
    CrossrefPubMedGoogle Scholar
  • 3 Durán J, Esnaola S, Rubio R, Iztueta A. Obstructive sleep apnea-hypopnea and related clinical features in a population-based sample of subjects aged 30 to 70 yr. Am J Respir Crit Care Med 2001; 163 (3, Pt 1) 685-689
    CrossrefPubMedGoogle Scholar
  • 4 Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993; 328 (17) 1230-1235
    Google Scholar
  • 5 Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med 2002; 165 (9) 1217-1239
    CrossrefPubMedGoogle Scholar
  • 6 Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol 2013; 177 (9) 1006-1014
    CrossrefPubMedGoogle Scholar
  • 7 Chung F, Yegneswaran B, Liao P , et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology 2008; 108 (5) 812-821
    CrossrefPubMedGoogle Scholar
  • 8 Fidan H, Fidan F, Unlu M, Ela Y, Ibis A, Tetik L. Prevalence of sleep apnoea in patients undergoing operation. Sleep Breath 2006; 10 (3) 161-165
    CrossrefPubMedGoogle Scholar
  • 9 Finkel KJ, Searleman AC, Tymkew H , et al. Prevalence of undiagnosed obstructive sleep apnea among adult surgical patients in an academic medical center. Sleep Med 2009; 10 (7) 753-758
    CrossrefPubMedGoogle Scholar
  • 10 Ramachandran SK, Kheterpal S, Consens F , et al. Derivation and validation of a simple perioperative sleep apnea prediction score. Anesth Analg 2010; 110 (4) 1007-1015
    CrossrefPubMedGoogle Scholar
  • 11 Hallowell PT, Stellato TA, Schuster M , et al. Potentially life-threatening sleep apnea is unrecognized without aggressive evaluation. Am J Surg 2007; 193 (3) 364-367 , discussion 367
    CrossrefPubMedGoogle Scholar
  • 12 Pollak L, Shpirer I, Rabey JM, Klein C, Schiffer J. Polysomnography in patients with intracranial tumors before and after operation. Acta Neurol Scand 2004; 109 (1) 56-60
    CrossrefPubMedGoogle Scholar
  • 13 Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet 2005; 365 (9464) 1046-1053
    CrossrefPubMedGoogle Scholar
  • 14 Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med 2000; 342 (19) 1378-1384
    Google Scholar
  • 15 Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med 2005; 353 (19) 2034-2041
    CrossrefPubMedGoogle Scholar
  • 16 Kendzerska T, Gershon AS, Hawker G, Leung RS, Tomlinson G. Obstructive sleep apnea and risk of cardiovascular events and all-cause mortality: a decade-long historical cohort study. PLoS Med 2014; 11 (2) e1001599
    CrossrefPubMedGoogle Scholar
  • 17 Marshall NS, Wong KK, Liu PY, Cullen SR, Knuiman MW, Grunstein RR. Sleep apnea as an independent risk factor for all-cause mortality: the Busselton Health Study. Sleep 2008; 31 (8) 1079-1085
    PubMedGoogle Scholar
  • 18 Punjabi NM, Caffo BS, Goodwin JL , et al. Sleep-disordered breathing and mortality: a prospective cohort study. PLoS Med 2009; 6 (8) e1000132
    CrossrefPubMedGoogle Scholar
  • 19 Young T, Finn L, Peppard PE , et al. Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort. Sleep 2008; 31 (8) 1071-1078
    PubMedGoogle Scholar
  • 20 Catley DM, Thornton C, Jordan C, Lehane JR, Royston D, Jones JG. Pronounced, episodic oxygen desaturation in the postoperative period: its association with ventilatory pattern and analgesic regimen. Anesthesiology 1985; 63 (1) 20-28
    CrossrefPubMedGoogle Scholar
  • 21 Isono S. Obstructive sleep apnea of obese adults: pathophysiology and perioperative airway management. Anesthesiology 2009; 110 (4) 908-921
    CrossrefPubMedGoogle Scholar
  • 22 Robinson RW, Zwillich CW, Bixler EO, Cadieux RJ, Kales A, White DP. Effects of oral narcotics on sleep-disordered breathing in healthy adults. Chest 1987; 91 (2) 197-203
    CrossrefPubMedGoogle Scholar
  • 23 Isono S, Remmers JE, Tanaka A, Sho Y, Sato J, Nishino T. Anatomy of pharynx in patients with obstructive sleep apnea and in normal subjects. J Appl Physiol (1985) 1997; 82 (4) 1319-1326
    PubMedGoogle Scholar
  • 24 Doufas AG, Tian L, Padrez KA , et al. Experimental pain and opioid analgesia in volunteers at high risk for obstructive sleep apnea. PLoS ONE 2013; 8 (1) e54807
    CrossrefPubMedGoogle Scholar
  • 25 Gislason T, Almqvist M, Boman G, Lindholm CE, Terenius L. Increased CSF opioid activity in sleep apnea syndrome. Regression after successful treatment. Chest 1989; 96 (2) 250-254
    CrossrefPubMedGoogle Scholar
  • 26 Hwang JC, St John WM, Bartlett Jr D. Respiratory-related hypoglossal nerve activity: influence of anesthetics. J Appl Physiol 1983; 55 (3) 785-792
    PubMedGoogle Scholar
  • 27 Chung F, Liao P, Elsaid H, Shapiro CM, Kang W. Factors associated with postoperative exacerbation of sleep-disordered breathing. Anesthesiology 2014; 120 (2) 299-311
    CrossrefPubMedGoogle Scholar
  • 28 Chung F, Liao P, Yegneswaran B, Shapiro CM, Kang W. Postoperative changes in sleep-disordered breathing and sleep architecture in patients with obstructive sleep apnea. Anesthesiology 2014; 120 (2) 287-298
    CrossrefPubMedGoogle Scholar
  • 29 Flink BJ, Rivelli SK, Cox EA , et al. Obstructive sleep apnea and incidence of postoperative delirium after elective knee replacement in the nondemented elderly. Anesthesiology 2012; 116 (4) 788-796
    CrossrefPubMedGoogle Scholar
  • 30 Gupta RM, Parvizi J, Hanssen AD, Gay PC. Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: a case-control study. Mayo Clin Proc 2001; 76 (9) 897-905
    CrossrefPubMedGoogle Scholar
  • 31 Hwang D, Shakir N, Limann B , et al. Association of sleep-disordered breathing with postoperative complications. Chest 2008; 133 (5) 1128-1134
    CrossrefPubMedGoogle Scholar
  • 32 Kaw R, Pasupuleti V, Walker E, Ramaswamy A, Foldvary-Schafer N. Postoperative complications in patients with obstructive sleep apnea. Chest 2012; 141 (2) 436-441
    CrossrefPubMedGoogle Scholar
  • 33 Liao P, Yegneswaran B, Vairavanathan S, Zilberman P, Chung F. Postoperative complications in patients with obstructive sleep apnea: a retrospective matched cohort study. Can J Anaesth 2009; 56 (11) 819-828
    CrossrefPubMedGoogle Scholar
  • 34 Mador MJ, Goplani S, Gottumukkala VA , et al. Postoperative complications in obstructive sleep apnea. Sleep Breath 2013; 17 (2) 727-734
    CrossrefPubMedGoogle Scholar
  • 35 Kaw R, Chung F, Pasupuleti V, Mehta J, Gay PC, Hernandez AV. Meta-analysis of the association between obstructive sleep apnoea and postoperative outcome. Br J Anaesth 2012; 109 (6) 897-906
    CrossrefPubMedGoogle Scholar
  • 36 Memtsoudis SG, Stundner O, Rasul R , et al. The impact of sleep apnea on postoperative utilization of resources and adverse outcomes. Anesth Analg 2014; 118 (2) 407-418
    CrossrefPubMedGoogle Scholar
  • 37 Gami AS, Howard DE, Olson EJ, Somers VK. Day-night pattern of sudden death in obstructive sleep apnea. N Engl J Med 2005; 352 (12) 1206-1214
    CrossrefPubMedGoogle Scholar
  • 38 Chung F, Mokhlesi B. Postoperative complications associated with obstructive sleep apnea: time to wake up!. Anesth Analg 2014; 118 (2) 251-253
    CrossrefPubMedGoogle Scholar
  • 39 Mokhlesi B, Hovda MD, Vekhter B, Arora VM, Chung F, Meltzer DO. Sleep-disordered breathing and postoperative outcomes after elective surgery: analysis of the nationwide inpatient sample. Chest 2013; 144 (3) 903-914
    CrossrefPubMedGoogle Scholar
  • 40 Mokhlesi B, Hovda MD, Vekhter B, Arora VM, Chung F, Meltzer DO. Sleep-disordered breathing and postoperative outcomes after bariatric surgery: analysis of the nationwide inpatient sample. Obes Surg 2013; 23 (11) 1842-1851
    CrossrefPubMedGoogle Scholar
  • 41 D'Apuzzo MR, Browne JA. Obstructive sleep apnea as a risk factor for postoperative complications after revision joint arthroplasty. J Arthroplasty 2012; 27 (8, Suppl) 95-98
    PubMedGoogle Scholar
  • 42 Bucholz EM, Rathore SS, Reid KJ , et al. Body mass index and mortality in acute myocardial infarction patients. Am J Med 2012; 125 (8) 796-803
    CrossrefPubMedGoogle Scholar
  • 43 Carnethon MR, De Chavez PJ, Biggs ML , et al. Association of weight status with mortality in adults with incident diabetes. JAMA 2012; 308 (6) 581-590
    CrossrefPubMedGoogle Scholar
  • 44 Jackson RS, Black III JH, Lum YW , et al. Class I obesity is paradoxically associated with decreased risk of postoperative stroke after carotid endarterectomy. J Vasc Surg 2012; 55 (5) 1306-1312
    CrossrefPubMedGoogle Scholar
  • 45 Martino JL, Stapleton RD, Wang M , et al. Extreme obesity and outcomes in critically ill patients. Chest 2011; 140 (5) 1198-1206
    CrossrefPubMedGoogle Scholar
  • 46 Memtsoudis SG, Bombardieri AM, Ma Y, Walz JM, Chiu YL, Mazumdar M. Mortality of patients with respiratory insufficiency and adult respiratory distress syndrome after surgery: the obesity paradox. J Intensive Care Med 2012; 27 (5) 306-311
    CrossrefPubMedGoogle Scholar
  • 47 Chang VW, Asch DA, Werner RM. Quality of care among obese patients. JAMA 2010; 303 (13) 1274-1281
    CrossrefPubMedGoogle Scholar
  • 48 Doehner W, Clark A, Anker SD. The obesity paradox: weighing the benefit. Eur Heart J 2010; 31 (2) 146-148
    CrossrefPubMedGoogle Scholar
  • 49 Hastie CE, Padmanabhan S, Slack R , et al. Obesity paradox in a cohort of 4880 consecutive patients undergoing percutaneous coronary intervention. Eur Heart J 2010; 31 (2) 222-226
    CrossrefPubMedGoogle Scholar
  • 50 Oreopoulos A, McAlister FA, Kalantar-Zadeh K , et al. The relationship between body mass index, treatment, and mortality in patients with established coronary artery disease: a report from APPROACH. Eur Heart J 2009; 30 (21) 2584-2592
    CrossrefPubMedGoogle Scholar
  • 51 Schenkeveld L, Magro M, Oemrawsingh RM , et al. The influence of optimal medical treatment on the 'obesity paradox', body mass index and long-term mortality in patients treated with percutaneous coronary intervention: a prospective cohort study. BMJ Open 2012; 2: e000535
    PubMedGoogle Scholar
  • 52 Berger S, Aronson D, Lavie P, Lavie L. Endothelial progenitor cells in acute myocardial infarction and sleep-disordered breathing. Am J Respir Crit Care Med 2013; 187 (1) 90-98
    CrossrefPubMedGoogle Scholar
  • 53 Lavie L, Lavie P. Ischemic preconditioning as a possible explanation for the age decline relative mortality in sleep apnea. Med Hypotheses 2006; 66 (6) 1069-1073
    CrossrefPubMedGoogle Scholar
  • 54 Lavie L, Lavie P. Coronary collateral circulation in sleep apnea: a cardioprotective mechanism?. Chest 2010; 137 (3) 511-512
    CrossrefPubMedGoogle Scholar
  • 55 Ozeke O, Ozer C, Gungor M, Celenk MK, Dincer H, Ilicin G. Chronic intermittent hypoxia caused by obstructive sleep apnea may play an important role in explaining the morbidity-mortality paradox of obesity. Med Hypotheses 2011; 76 (1) 61-63
    CrossrefPubMedGoogle Scholar
  • 56 Shah N, Redline S, Yaggi HK , et al. Obstructive sleep apnea and acute myocardial infarction severity: ischemic preconditioning?. Sleep Breath 2013; 17 (2) 819-826
    CrossrefPubMedGoogle Scholar
  • 57 Steiner S, Schueller PO, Schulze V, Strauer BE. Occurrence of coronary collateral vessels in patients with sleep apnea and total coronary occlusion. Chest 2010; 137 (3) 516-520
    CrossrefPubMedGoogle Scholar
  • 58 Fleischut PM, Mazumdar M, Memtsoudis SG. Perioperative database research: possibilities and pitfalls. Br J Anaesth 2013; 111 (4) 532-534
    CrossrefPubMedGoogle Scholar
  • 59 Lockhart EM, Willingham MD, Abdallah AB , et al. Obstructive sleep apnea screening and postoperative mortality in a large surgical cohort. Sleep Med 2013; 14 (5) 407-415
    CrossrefPubMedGoogle Scholar
  • 60 Campos-Rodriguez F, Martinez-Garcia MA, de la Cruz-Moron I, Almeida-Gonzalez C, Catalan-Serra P, Montserrat JM. Cardiovascular mortality in women with obstructive sleep apnea with or without continuous positive airway pressure treatment: a cohort study. Ann Intern Med 2012; 156 (2) 115-122
    CrossrefPubMedGoogle Scholar
  • 61 American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. 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 (2) 268-286
    CrossrefPubMedGoogle Scholar
  • 62 Chung F, Yegneswaran B, Liao P , et al. Validation of the Berlin questionnaire and American Society of Anesthesiologists checklist as screening tools for obstructive sleep apnea in surgical patients. Anesthesiology 2008; 108 (5) 822-830
    CrossrefPubMedGoogle Scholar
  • 63 Abrishami A, Khajehdehi A, Chung F. A systematic review of screening questionnaires for obstructive sleep apnea. Can J Anaesth 2010; 57 (5) 423-438
    CrossrefPubMedGoogle Scholar
  • 64 Senthilvel E, Auckley D, Dasarathy J. Evaluation of sleep disorders in the primary care setting: history taking compared to questionnaires. J Clin Sleep Med 2011; 7 (1) 41-48
    PubMedGoogle Scholar
  • 65 Chung F, Chau E, Yang Y, Liao P, Hall R, Mokhlesi B. Serum bicarbonate level improves specificity of STOP-Bang screening for obstructive sleep apnea. Chest 2013; 143 (5) 1284-1293
    CrossrefPubMedGoogle Scholar
  • 66 Farney RJ, Walker BS, Farney RM, Snow GL, Walker JM. The STOP-Bang equivalent model and prediction of severity of obstructive sleep apnea: relation to polysomnographic measurements of the apnea/hypopnea index. J Clin Sleep Med 2011; 7 (5) 459-65B
    PubMedGoogle Scholar
  • 67 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 (5) 768-775
    CrossrefPubMedGoogle Scholar
  • 68 Guralnick AS, Pant M, Minhaj M, Sweitzer BJ, Mokhlesi B. CPAP adherence in patients with newly diagnosed obstructive sleep apnea prior to elective surgery. J Clin Sleep Med 2012; 8 (5) 501-506
    PubMedGoogle Scholar
  • 69 Ramachandran SK, Josephs LA. A meta-analysis of clinical screening tests for obstructive sleep apnea. Anesthesiology 2009; 110 (4) 928-939
    CrossrefPubMedGoogle Scholar
  • 70 Chung F, Liao P, Elsaid H, Islam S, Shapiro CM, Sun Y. Oxygen desaturation index from nocturnal oximetry: a sensitive and specific tool to detect sleep-disordered breathing in surgical patients. Anesth Analg 2012; 114 (5) 993-1000
    CrossrefPubMedGoogle Scholar
  • 71 Cartwright RD. Effect of sleep position on sleep apnea severity. Sleep 1984; 7 (2) 110-114
    PubMedGoogle Scholar
  • 72 Cartwright RD, Diaz F, Lloyd S. The effects of sleep posture and sleep stage on apnea frequency. Sleep 1991; 14 (4) 351-353
    PubMedGoogle Scholar
  • 73 Cartwright RD, Lloyd S, Lilie J, Kravitz H. Sleep position training as treatment for sleep apnea syndrome: a preliminary study. Sleep 1985; 8 (2) 87-94
    Google Scholar
  • 74 George CF, Millar TW, Kryger MH. Sleep apnea and body position during sleep. Sleep 1988; 11 (1) 90-99
    PubMedGoogle Scholar
  • 75 Phillips BA, Okeson J, Paesani D, Gilmore R. Effect of sleep position on sleep apnea and parafunctional activity. Chest 1986; 90 (3) 424-429
    CrossrefPubMedGoogle Scholar
  • 76 Itasaka Y, Miyazaki S, Ishikawa K, Togawa K. The influence of sleep position and obesity on sleep apnea. Psychiatry Clin Neurosci 2000; 54 (3) 340-341
    CrossrefPubMedGoogle Scholar
  • 77 Reeder MK, Goldman MD, Loh L, Muir AD, Casey KR, Lehane JR. Late postoperative nocturnal dips in oxygen saturation in patients undergoing major abdominal vascular surgery. Predictive value of pre-operative overnight pulse oximetry. Anaesthesia 1992; 47 (2) 110-115
    CrossrefPubMedGoogle Scholar
  • 78 Taenzer AH, Pyke JB, McGrath SP, Blike GT. Impact of pulse oximetry surveillance on rescue events and intensive care unit transfers: a before-and-after concurrence study. Anesthesiology 2010; 112 (2) 282-287
    CrossrefPubMedGoogle Scholar
  • 79 Somers VK, White DP, Amin R , et al. Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing. J Am Coll Cardiol 2008; 52 (8) 686-717
    CrossrefPubMedGoogle Scholar
  • 80 Marin JM, Agusti A, Villar I , et al. Association between treated and untreated obstructive sleep apnea and risk of hypertension. JAMA 2012; 307 (20) 2169-2176
    CrossrefPubMedGoogle Scholar
  • 81 Patel SR, White DP, Malhotra A, Stanchina ML, Ayas NT. Continuous positive airway pressure therapy for treating sleepiness in a diverse population with obstructive sleep apnea: results of a meta-analysis. Arch Intern Med 2003; 163 (5) 565-571
    CrossrefPubMedGoogle Scholar
  • 82 Squadrone V, Coha M, Cerutti E , et al; Piedmont Intensive Care Units Network (PICUN). Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial. JAMA 2005; 293 (5) 589-595
    CrossrefPubMedGoogle Scholar
  • 83 Ferreyra GP, Baussano I, Squadrone V , et al. Continuous positive airway pressure for treatment of respiratory complications after abdominal surgery: a systematic review and meta-analysis. Ann Surg 2008; 247 (4) 617-626
    CrossrefPubMedGoogle Scholar
  • 84 Liao P, Luo Q, Elsaid H, Kang W, Shapiro CM, Chung F. Perioperative auto-titrated continuous positive airway pressure treatment in surgical patients with obstructive sleep apnea: a randomized controlled trial. Anesthesiology 2013; 119 (4) 837-847
    CrossrefPubMedGoogle Scholar
  • 85 Mehta V, Subramanyam R, Shapiro CM, Chung F. Health effects of identifying patients with undiagnosed obstructive sleep apnea in the preoperative clinic: a follow-up study. Can J Anaesth 2012; 59 (6) 544-555
    CrossrefPubMedGoogle Scholar
  • 86 Neligan PJ, Malhotra G, Fraser M , et al. Continuous positive airway pressure via the Boussignac system immediately after extubation improves lung function in morbidly obese patients with obstructive sleep apnea undergoing laparoscopic bariatric surgery. Anesthesiology 2009; 110 (4) 878-884
    CrossrefPubMedGoogle Scholar
  • 87 Kushida CA, Berry RB, Blau A , et al. Positive airway pressure initiation: a randomized controlled trial to assess the impact of therapy mode and titration process on efficacy, adherence, and outcomes. Sleep 2011; 34 (8) 1083-1092
    PubMedGoogle Scholar
  • 88 Masa JF, Jiménez A, Durán J , et al. Alternative methods of titrating continuous positive airway pressure: a large multicenter study. Am J Respir Crit Care Med 2004; 170 (11) 1218-1224
    CrossrefPubMedGoogle Scholar
  • 89 Mulgrew AT, Fox N, Ayas NT, Ryan CF. Diagnosis and initial management of obstructive sleep apnea without polysomnography: a randomized validation study. Ann Intern Med 2007; 146 (3) 157-166
    CrossrefPubMedGoogle Scholar
  • 90 O'Gorman SM, Gay PC, Morgenthaler TI. Does autotitrating positive airway pressure therapy improve postoperative outcome in patients at risk for obstructive sleep apnea syndrome? A randomized controlled clinical trial. Chest 2013; 144 (1) 72-78
    CrossrefPubMedGoogle Scholar
  • 91 Mokhlesi B. Empiric postoperative autotitrating positive airway pressure therapy: generating evidence in the perioperative care of patients at risk for obstructive sleep apnea. Chest 2013; 144 (1) 5-7
    CrossrefPubMedGoogle Scholar
  • 92 Kribbs NB, Pack AI, Kline LR , et al. Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. Am Rev Respir Dis 1993; 147 (4) 887-895
    CrossrefPubMedGoogle Scholar
  • 93 Pamidi S, Knutson KL, Ghods F, Mokhlesi B. The impact of sleep consultation prior to a diagnostic polysomnogram on continuous positive airway pressure adherence. Chest 2012; 141 (1) 51-57
    CrossrefPubMedGoogle Scholar
  • 94 Sawyer AM, Gooneratne NS, Marcus CL, Ofer D, Richards KC, Weaver TE. A systematic review of CPAP adherence across age groups: clinical and empiric insights for developing CPAP adherence interventions. Sleep Med Rev 2011; 15 (6) 343-356
    CrossrefPubMedGoogle Scholar
  • 95 Memtsoudis SG, Besculides MC, Mazumdar M. A rude awakening—the perioperative sleep apnea epidemic. N Engl J Med 2013; 368 (25) 2352-2353
    CrossrefPubMedGoogle Scholar
  • 96 Chan MT, Wang CY, Seet E , et al; POSA Investigators. Postoperative vascular complications in unrecognised Obstructive Sleep apnoea (POSA) study protocol: an observational cohort study in moderate-to-high risk patients undergoing non-cardiac surgery. BMJ Open 2014; 4 (1) e004097
    CrossrefPubMedGoogle Scholar
  • 97 Memtsoudis S, Liu SS, Ma Y , et al. Perioperative pulmonary outcomes in patients with sleep apnea after noncardiac surgery. Anesth Analg 2011; 112 (1) 113-121
    CrossrefPubMedGoogle Scholar