Development and validation of a Score for Preoperative Prediction of Obstructive Sleep Apnea (SPOSA) and its perioperative outcomes

Christina H Shin, Stephanie D Grabitz, Fanny P Timm, Noomi Mueller, Khushi Chhangani, Karim Ladha, Scott Devine, Tobias Kurth, Matthias Eikermann, Christina H Shin, Stephanie D Grabitz, Fanny P Timm, Noomi Mueller, Khushi Chhangani, Karim Ladha, Scott Devine, Tobias Kurth, Matthias Eikermann

Abstract

Background: Postoperative respiratory complications (PRCs) are associated with significant morbidity, mortality, and hospital costs. Obstructive sleep apnea (OSA), often undiagnosed in the surgical population, may be a contributing factor. Thus, we aimed to develop and validate a score for preoperative prediction of OSA (SPOSA) based on data available in electronic medical records preoperatively.

Methods: OSA was defined as the occurrence of an OSA diagnostic code preceded by a polysomnography procedure. A priori defined variables were analyzed by multivariable logistic regression analysis to develop our score. Score validity was assessed by investigating the score's ability to predict non-invasive ventilation. We then assessed the effect of high OSA risk, as defined by SPOSA, on PRCs within seven postoperative days and in-hospital mortality.

Results: A total of 108,781 surgical patients at Partners HealthCare hospitals (2007-2014) were studied. Predictors of OSA included BMI >25 kg*m-2 and comorbidities, including pulmonary hypertension, hypertension, and diabetes. The score yielded an area under the curve of 0.82. Non-invasive ventilation was significantly associated with high OSA risk (OR 1.44, 95% CI 1.22-1.69). Using a dichotomized endpoint, 26,968 (24.8%) patients were identified as high risk for OSA and 7.9% of these patients experienced PRCs. OSA risk was significantly associated with PRCs (OR 1.30, 95% CI 1.19-1.43).

Conclusion: SPOSA identifies patients at high risk for OSA using electronic medical record-derived data. High risk of OSA is associated with the occurrence of PRCs.

Keywords: In-hospital mortality; Outcomes; Perioperative obstructive sleep apnea; Postoperative respiratory complications; Prediction.

Figures

Fig. 1
Fig. 1
Study flow chart
Fig. 2
Fig. 2
Receiver operating characteristic (ROC) curve for prediction of obstructive sleep apnea. a ROC curve was performed for the logistic regression model derived from significant independent predictors (AUC 0.8218). b A second ROC curve was fitted based on the composite prediction score derived from our prediction model (AUC 0.8211)

References

    1. Lacasse Y, Godbout C, Series F. Health-related quality of life in obstructive sleep apnoea. Eur Respir J. 2002;19:499–503. doi: 10.1183/09031936.02.00216902.
    1. Engleman HM, Douglas NJ. Sleep. 4: Sleepiness, cognitive function, and quality of life in obstructive sleep apnoea/hypopnoea syndrome. Thorax. 2004;59:618–22. doi: 10.1136/thx.2003.015867.
    1. Logan AG, Perlikowski SM, Mente A, Tisler A, Tkacova R, Niroumand M, et al. High prevalence of unrecognized sleep apnoea in drug-resistant hypertension. J Hypertens. 2001;19:2271–7. doi: 10.1097/00004872-200112000-00022.
    1. Lyons OD, Ryan CM. Sleep apnea and stroke. Can J Cardiol. 2015;31:918–27. doi: 10.1016/j.cjca.2015.03.014.
    1. Naughton MT. Respiratory sleep disorders in patients with congestive heart failure. J Thorac Dis. 2015;7:1298–310.
    1. Stansbury RC, Strollo PJ. Clinical manifestations of sleep apnea. J Thorac Dis. 2015;7:E298–310.
    1. Kent BD, Grote L, Ryan S, Pépin J-L, Bonsignore MR, Tkacova R, et al. Diabetes mellitus prevalence and control in sleep-disordered breathing: the European Sleep Apnea Cohort (ESADA) study. Chest. 2014;146:982–90. doi: 10.1378/chest.13-2403.
    1. Isono S. Obesity and obstructive sleep apnoea: mechanisms for increased collapsibility of the passive pharyngeal airway. Respirology. 2012;17:32–42. doi: 10.1111/j.1440-1843.2011.02093.x.
    1. Coughlin SR, Mawdsley L, Mugarza JA, Calverley PMA, Wilding JPH. Obstructive sleep apnoea is independently associated with an increased prevalence of metabolic syndrome. Eur Heart J. 2004;25:735–41. doi: 10.1016/j.ehj.2004.02.021.
    1. Gruber A, Horwood F, Sithole J, Ali NJ, Idris I. Obstructive sleep apnoea is independently associated with the metabolic syndrome but not insulin resistance state. Cardiovasc Diabetol. 2006;5:22. doi: 10.1186/1475-2840-5-22.
    1. Memtsoudis SG, Besculides MC, Mazumdar M. A rude awakening--the perioperative sleep apnea epidemic. N Engl J Med. 2013;368:2352–3. doi: 10.1056/NEJMp1302941.
    1. Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013;177:1006–14. doi: 10.1093/aje/kws342.
    1. Young T, Evans L, Finn L, Palta M. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep. 1997;20:705–6. doi: 10.1093/sleep/20.9.705.
    1. Finkel KJ, Searleman AC, Tymkew H, Tanaka CY, Saager L, Safer-Zadeh E, et al. Prevalence of undiagnosed obstructive sleep apnea among adult surgical patients in an academic medical center. Sleep Med. 2009;10:753–8. doi: 10.1016/j.sleep.2008.08.007.
    1. Singh M, Liao P, Kobah S, Wijeysundera DN, Shapiro C, Chung F. Proportion of surgical patients with undiagnosed obstructive sleep apnoea. Br J Anaesth. 2013;110:629–36. doi: 10.1093/bja/aes465.
    1. Wolfe RM, Pomerantz J, Miller DE, Weiss-Coleman R, Solomonides T. Obstructive sleep apnea: preoperative screening and postoperative care. J Am Board Fam Med. 2016;29:263–75. doi: 10.3122/jabfm.2016.02.150085.
    1. Mokhlesi B, Hovda MD, Vekhter B, Arora VM, Chung F, Meltzer DO. Sleep-disordered breathing and postoperative outcomes after elective surgery. Chest. 2013;144:903–14. doi: 10.1378/chest.12-2905.
    1. Sasaki N, Meyer MJ, Eikermann M. Postoperative respiratory muscle dysfunction: pathophysiology and preventive strategies. Anesthesiology. 2013;118:961–78. doi: 10.1097/ALN.0b013e318288834f.
    1. Fouladpour N, Jesudoss R, Bolden N, Shaman Z, Auckley D. Perioperative complications in obstructive sleep apnea patients undergoing surgery: a review of the legal literature. Anesth Analg. 2016;122:145–51. doi: 10.1213/ANE.0000000000000841.
    1. 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. The American Society of A. Anesthesiology. 2014;120(2):268–86. doi: 10.1097/ALN.0000000000000053.
    1. Ramachandran SK, Kheterpal S, Consens F, Shanks A, Doherty TM, Morris M, et al. Derivation and validation of a simple perioperative sleep apnea prediction score. Anesth Analg. 2010;110:1007–15. doi: 10.1213/ANE.0b013e3181d489b0.
    1. Chung F, Yegneswaran B, Liao P, Chung SA, Vairavanathan S, Islam S, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108:812–21. doi: 10.1097/ALN.0b013e31816d83e4.
    1. Deflandre E, Degey S, Brichant J-F, Poirrier R, Bonhomme V. Development and validation of a morphologic obstructive sleep apnea prediction score: the DES-OSA score. Anesth Analg. 2016;122:363–72. doi: 10.1213/ANE.0000000000001089.
    1. Chung F, Yegneswaran B, Liao P, Chung SA, Vairavanathan S, Islam S, 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;108:822–30. doi: 10.1097/ALN.0b013e31816d91b5.
    1. Abrishami A, Khajehdehi A, Chung F. A systematic review of screening questionnaires for obstructive sleep apnea. Can J Anaesth. 2010;57:423–38. doi: 10.1007/s12630-010-9280-x.
    1. Skomro RP, Kryger MH. Clinical presentations of obstructive sleep apnea syndrome. Prog Cardiovasc Dis. 1999;41:331–40. doi: 10.1053/pcad.1999.0410331.
    1. Eastwood PR, Malhotra A, Palmer LJ, Kezirian EJ, Horner RL, Ip MS, et al. Obstructive sleep apnoea: from pathogenesis to treatment: current controversies and future directions. Respirology. 2010;15:587–95. doi: 10.1111/j.1440-1843.2009.01699.x.
    1. Shin CH, Zaremba S, Devine S, Nikolov M, Kurth T, Eikermann M. Effects of obstructive sleep apnoea risk on postoperative respiratory complications: protocol for a hospital-based registry study. BMJ Open. 2016;6 doi: 10.1136/bmjopen-2015-008436.
    1. McLean DJ, Diaz-Gil D, Farhan HN, Ladha KS, Kurth T, Eikermann M. Dose-dependent association between intermediate-acting neuromuscular-blocking agents and postoperative respiratory complications. Anesthesiology. 2015;122:1201–13. doi: 10.1097/ALN.0000000000000674.
    1. Ladha K, Vidal Melo MF, McLean DJ, Wanderer JP, Grabitz SD, Kurth T, et al. Intraoperative protective mechanical ventilation and risk of postoperative respiratory complications: hospital based registry study. BMJ. 2015;351:h3646. doi: 10.1136/bmj.h3646.
    1. Brueckmann B, Villa-Uribe JL, Bateman BT, Grosse-Sundrup M, Hess DR, Schlett CL, et al. Development and validation of a score for prediction of postoperative respiratory complications. Anesthesiology. 2013;118:1276–85. doi: 10.1097/ALN.0b013e318293065c.
    1. Hanley JA, McNeil BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology. 1982;143:29–36. doi: 10.1148/radiology.143.1.7063747.
    1. Liu X. Classification accuracy and cut point selection. Stat Med. 2012;31:2676–86. doi: 10.1002/sim.4509.
    1. McIsaac DI, Gershon A, Wijeysundera D, Bryson GL, Badner N, van Walraven C. Identifying obstructive sleep apnea in administrative data: a study of diagnostic accuracy. Anesthesiology. 2015;123:253–63. doi: 10.1097/ALN.0000000000000692.
    1. Soler X, Gaio E, Powell FL, Ramsdell JW, Loredo JS, Malhotra A, et al. High prevalence of obstructive sleep apnea in patients with moderate to severe chronic obstructive pulmonary disease. Ann Am Thorac Soc. 2015;12:1219–25. doi: 10.1513/AnnalsATS.201506-379LE.
    1. Xu H, Guan J, Yi H, Zou J, Meng L, Tang X, et al. Elevated low-density lipoprotein cholesterol is independently associated with obstructive sleep apnea: evidence from a large-scale cross-sectional study. Sleep Breath. 2016;20(2):627–34. doi: 10.1007/s11325-015-1262-3.
    1. Trzepizur W, Le Vaillant M, Meslier N, Pigeanne T, Masson P, Humeau MP, et al. Independent association between nocturnal intermittent hypoxemia and metabolic dyslipidemia. Chest. 2013;143:1584–9. doi: 10.1378/chest.12-1652.
    1. Shahar E, Whitney CW, Redline S, Lee ET, Newman AB, Nieto FJ, et al. Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med. 2001;163:19–25. doi: 10.1164/ajrccm.163.1.2001008.
    1. Gami AS, Pressman G, Caples SM, Kanagala R, Gard JJ, Davison DE, et al. Association of atrial fibrillation and obstructive sleep apnea. Circulation. 2004;110:364–7. doi: 10.1161/01.CIR.0000136587.68725.8E.
    1. Qureshi WT, Nasir UB, Alqalyoobi S, O’Neal WT, Mawri S, Sabbagh S, et al. Meta-analysis of continuous positive airway pressure as a therapy of atrial fibrillation in obstructive sleep apnea. Am J Cardiol. 2015;116:1767–73. doi: 10.1016/j.amjcard.2015.08.046.
    1. Chou T-C, Liang W-M, Wang C-B, Wu T-N, Hang L-W. Obstructive sleep apnea is associated with liver disease: a population-based cohort study. Sleep Med. 2015;16:955–60. doi: 10.1016/j.sleep.2015.02.542.
    1. Khayat R, Pleister A. Consequences of obstructive sleep apnea: cardiovascular risk of obstructive sleep apnea and whether continuous positive airway pressure reduces that risk. Sleep Med Clin. 2016;11:273–86. doi: 10.1016/j.jsmc.2016.05.002.
    1. Bady E, Achkar A, Pascal S, Orvoen-Frija E, Laaban JP. Pulmonary arterial hypertension in patients with sleep apnoea syndrome. Thorax. 2000;55:934–9. doi: 10.1136/thorax.55.11.934.
    1. Kholdani C, Fares WH, Mohsenin V. Pulmonary hypertension in obstructive sleep apnea: is it clinically significant? A critical analysis of the association and pathophysiology. Pulm Circ. 2015;5:220–7. doi: 10.1086/679995.
    1. Johnson KG, Johnson DC. Frequency of sleep apnea in stroke and TIA patients: a meta-analysis. J Clin Sleep Med. 2010;6:131–7.
    1. 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;328:1230–5. doi: 10.1056/NEJM199304293281704.
    1. Dimitrov L, Macavei V. Can screening tools for obstructive sleep apnea predict postoperative complications? A systematic review of the literature. J Clin Sleep Med. 2016;12:1293–300. doi: 10.5664/jcsm.6136.
    1. Ustun B, Westover MB, Rudin C, Bianchi MT. Clinical prediction models for sleep apnea: the importance of medical history over symptoms. J Clin Sleep Med. 2016;12(2):161–8. doi: 10.5664/jcsm.5476.
    1. 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;108:768–75. doi: 10.1093/bja/aes022.
    1. Gaziano TA, Young CR, Fitzmaurice G, Atwood S, Gaziano JM. Laboratory-based versus non-laboratory-based method for assessment of cardiovascular disease risk: the NHANES I Follow-up Study cohort. Lancet. 2008;371:923–31. doi: 10.1016/S0140-6736(08)60418-3.
    1. D’Agostino RB, Vasan RS, Pencina MJ, Wolf PA, Cobain M, Massaro JM, et al. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation. 2008;117:743–53. doi: 10.1161/CIRCULATIONAHA.107.699579.
    1. Stephan BCM, Tzourio C, Auriacombe S, Amieva H, Dufouil C, Alpérovitch A, et al. Usefulness of data from magnetic resonance imaging to improve prediction of dementia: population based cohort study. BMJ. 2015;350:h2863. doi: 10.1136/bmj.h2863.
    1. Memtsoudis SG, Stundner O, Rasul R, Chiu YL, Sun X, Ramachandran SK, et al. The impact of sleep apnea on postoperative utilization of resources and adverse outcomes. Anesth Analg. 2014;118:407–18. doi: 10.1213/ANE.0000000000000051.
    1. Gaddam S, Gunukula SK, Mador MJ. Post-operative outcomes in adult obstructive sleep apnea patients undergoing non-upper airway surgery: a systematic review and meta-analysis. Sleep Breath. 2014;18:615–33. doi: 10.1007/s11325-013-0925-1.
    1. 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;23:1842–51. doi: 10.1007/s11695-013-0991-2.
    1. 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;109:897–906. doi: 10.1093/bja/aes308.
    1. Krodel DJ, Bittner EA, Abdulnour R, Brown R, Eikermann M. Case scenario: acute postoperative negative pressure pulmonary edema. Anesthesiology. 2010;113:200–7. doi: 10.1097/ALN.0b013e3181e32e68.
    1. Krodel DJ, Bittner EA, Abdulnour R-EE, Brown RH, Eikermann M. Negative pressure pulmonary edema following bronchospasm. Chest. 2011;140:1351–4. doi: 10.1378/chest.11-0529.
    1. Redolfi S, Yumino D, Ruttanaumpawan P, Yau B, Su M-C, Lam J, et al. Relationship between overnight rostral fluid shift and Obstructive Sleep Apnea in nonobese men. Am J Respir Crit Care Med. 2009;179:241–6. doi: 10.1164/rccm.200807-1076OC.
    1. Pieper D, Mathes T, Neugebauer E, Eikermann M. State of evidence on the relationship between high-volume hospitals and outcomes in surgery: a systematic review of systematic reviews. J Am Coll Surg. 2013;216:1015–8. doi: 10.1016/j.jamcollsurg.2012.12.049.
    1. Lindenauer PK, Stefan MS, Johnson KG, Priya A, Pekow PS, Rothberg MB. Prevalence, treatment, and outcomes associated with OSA among patients hospitalized with pneumonia. Chest. 2014;145:1032–8. doi: 10.1378/chest.13-1544.
    1. Zaremba S, Mojica JE, Eikermann M. Perioperative sleep apnea: a real problem or did we invent a new disease? F1000Res. 2016;5.
    1. Zaremba S, Shin CH, Hutter MM, Malviya SA, Grabitz SD, MacDonald T, et al. Continuous positive airway pressure mitigates opioid-induced worsening of sleep-disordered breathing early after bariatric surgery. Anesthesiology. 2016;125:92–104. doi: 10.1097/ALN.0000000000001160.

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