Jashvant Poeran, MD, PhD

In a study conducted at Hospital for Special Surgery (HSS), researchers found that patients with obstructive sleep apnea (OSA) who used continuous positive airway pressure (CPAP) therapy before total hip and knee replacement surgery significantly reduced their risk for complications after surgery compared with OSA patients who did not use CPAP therapy before surgery. The use of CPAP before surgery reduced the risk to the point where there was no difference in emergency department visit rates between patients with OSA and those without. These findings were presented at the Society of Anesthesia and Sleep Medicine (SASM) 14^th annual meeting.¹

“Obstructive sleep apnea affects 40 million adults in the United States and is associated with an increased complication risk among patients undergoing surgery,” said Stavros Memtsoudis, MD, PhD, Anesthesiologist-in-Chief and Chair of the HSS Department of Anesthesiology, Critical Care & Pain Management. “Guidelines on the perioperative management of OSA patients undergoing surgery are backed by limited evidence. Current recommendations include preoperative screening for OSA and preoperative initiation of CPAP therapy. However, it remains unclear how often this recommendation is followed and how much it reduces complication risks.”

This information is especially important as healthcare systems shift from inpatient to outpatient hip and knee replacement surgery, where patients cannot be monitored as closely for perioperative complications.

To evaluate whether CPAP use among OSA patients prior to surgery led to improved outcomes compared with those patients who did not use CPAP, the researchers extracted more than 100,000 cases of outpatient hip and knee replacement surgeries performed between 2018 and 2022 from the Merative MarketScan national claims data (representing patients and their dependents with employer-sponsored healthcare coverage). The primary outcome of interest was a visit to the emergency department within one day post-discharge, which acted as a stand-in to represent post-discharge complications. The researchers conducted three comparisons: 1) patients with OSA who used a CPAP machine before surgery, compared with patients who did not; 2) patients with OSA who did not use a CPAP machine before surgery, compared with patients without OSA; and 3) patients with OSA who used CPAP before surgery, compared with patients without OSA.

The researchers found that OSA patients who underwent CPAP therapy before hip and knee replacement surgery (19% of 123,349 total hip/knee procedures studied) experienced fewer emergency department visits within one day after discharge compared with OSA patients who did not receive CPAP therapy before surgery. In addition, pre-surgical CPAP use in patients with OSA lowered their risk for complications to a similar level as patients without OSA.

“These findings are significant as they support the notion that adhering to these guidelines can benefit OSA patients undergoing surgery,” said Jashvant Poeran, MD, PhD, Director of Research in the HSS Department of Anesthesiology, Critical Care & Pain Management.  “While we had anticipated these results based on the guidelines, this is the first study to demonstrate this on such a large scale.”

This study offers key insights for both patients and clinicians on ways to reduce the risk of complications after surgery.

“It informs patients with OSA to engage in conversations with their perioperative physicians about strategies to lower their complication risk, including the preoperative initiation of CPAP therapy,” said Dr. Poeran. “Additionally, this research highlights the advantages of preoperative initiation of CPAP therapy. We believe that this study strengthens the evidence supporting the benefits of preoperative CPAP therapy and will encourage both patients and clinicians to consider its increased use.”

While further validation of these findings is necessary, particularly in other surgical cohorts such as elective general surgery, these findings represent a significant advancement in recognizing the benefits of preoperative initiation of CPAP therapy.

“These findings could influence care by emphasizing the importance of preoperative identification of OSA patients who are scheduled for surgery and subsequent initiation of CPAP therapy,” Dr. Poeran said.

In addition to replicating these findings in other surgical cohorts, future research should also examine subgroups of patients in which preoperative CPAP therapy may be even more beneficial. “These subgroups might include patients with multiple risk factors, such as OSA and obesity or other chronic conditions, as well as those with varying needs for opioid management.”

“Follow-up studies could investigate looking at other recommendations outlined in the guidelines such as preoperative screening for OSA and enhanced monitoring. This increased monitoring is crucial as hospital stays shorten and more and more surgeries are performed in an outpatient setting without an overnight stay and the subsequent opportunity to monitor these patients,” Dr. Poeran concluded.

Reference

1. Jashvant Poeran MD PhD, Haoyan Zhong MPA, Alex Illescas MPH, Lisa Reisinger MD, Crispiana Cozowicz MD, Periklis Giannakis MD, Jiabin Liu MD PhD, Stavros G. Memtsoudis MD PhD MBA. “Preoperative CPAP Use is Associated with Improved Outcomes in Patients with Obstructive Sleep Apnea Undergoing Orthopedic Surgery.” Presented at: Society of Anesthesia and Sleep Medicine (SASM) 14th Annual Meeting, October 18, 2024; Philadelphia, PA.