To the Editor

I read with great interest your recent article by Drs. Ogan and Plevak regarding the anesthetic care of patients with Obstructive Sleep Apnea (OSA). While it was a good review article, it did not address an issue which has become of increasing concern to myself and my colleagues at our ambulatory surgery center. That is: Is the patient with OSA an appropriate candidate for ambulatory surgery?

Given the current climate in health care deliver, physicians are increasingly pressured to perform procedures and provide anesthetics to patients in the ambulatory setting. How does the diagnosis of OSA change our decisions regarding the appropriate setting for surgery for a particular patient? Is there a difference between patients with mild versus severe OSA? If there is less risk for the patient if the patient has an operation not involving the airway? Does the risk of increased apnea and hypopnea decrease in patients who have received a MAC anesthetic versus those who have received a general anesthetic?

My recent review of the literature provided me with no answers to these questions. All studies regarding in-patient surgery for patients with OSA uniformly agree with the need for perioperative monitoring, oxygen and CPAP usage. The surgical literature does have several studies suggesting a laser-assisted uvulopalatoplasty (LAUP) procedure under local anesthesia alone as a safe alternative. However, a study by Terris recently demonstrated clear exacerbation of OSA symptoms in a series of eight patients who had the LAUP procedure.¹

I spoke with Ms. Christin Engelhardt, Executive Director of the American Sleep Apnea Association. Neither she nor he medical advisory board are aware of any scientific studies addressing this issue or any clinical protocols developed for OSA patients having ambulatory surgery.

I would be interested in what information your foundation has regarding this issue as well as the experiences of other practitioners. Given that by the year 2000 it is predicted that 80% of surgery will be ambulatory surgery, we as anesthesiologists must continue to be strong advocates for patient safety regardless of outside pressures.

Martha R. Eshleman, M.D. Assistant Professor of Anesthesiology UCLA Medical Center Los Angeles, CA

Reference

1. Terris, DJ, et al. Characterization of postoperative edema following laser-assisted uvulopalatoplasty using MRI polysomnography: implications for the outpatient treatment of obstructive sleep apnea syndrome. Laryngoscope 1996 Feb., 106 (2 Pt 1): 124-8.