Introduction
There is a push towards day surgery as the default option for elective
surgery in the UK. It is increasingly recognized that day surgery is
cost-effective, reduces hospital-acquired infections and thromboembolic
events, and increases patient satisfaction (1). The range and complexity
of procedures that can be performed as day surgery have also expanded,
facilitated by dedicated day case units, experienced teams, and
protocols.
Surgical patients with obstructive sleep apnoea (OSA) have a higher risk
of perioperative complications such as hypoxaemia, cardiac arrhythmias
and myocardial infarction (2). These patients also often have multiple
comorbidities associated with OSA such as hypertension, diabetes or
heart failure. Anaesthetic agents and sedatives given during surgery may
further exacerbate upper airway collapsibility in these patients and
worsen sleep apnoea. Strong opioid analgesics given during and after
surgery for pain relief may cause respiratory depression in these
patients that are already vulnerable. Thus, patients with OSA are often
monitored in intensive care units post-operatively.
In patients with OSA, nasal surgery can improve symptoms, reduce the
severity of OSA and also improve compliance with CPAP (continuous
positive airway pressure) devices. Palatopharyngeal surgery optimizes
upper airway anatomy and again may provide symptomatic relief in these
patients as well as reduce the severity of OSA. In the UK, nasal surgery
and palatopharyngeal surgery are generally performed as day cases in
patients without OSA. In patients with OSA, they are more likely to be
inpatients and may even require post-operative monitoring in a high
dependency or intensive care setting. This is due to concerns regarding
serious respiratory or cardiac complications post-operatively, and
mortality has been reported (3). There is also concern that nasal
packing in patients with OSA makes the use of CPAP post-operatively more
difficult and thus increases risk of hypoxaemia and respiratory
complications. Inpatient bed shortages often lead to these operations
being cancelled. Recent day surgery guidelines suggest OSA is not an
absolute contraindication for same day discharge (1). However, no
recommendation was provided for airway surgery specifically due to the
lack of evidence and inherently higher risks with these patients (4).
Our aim was to conduct a systematic review to evaluate current evidence
base on the feasibility and safety of day case nasal and/or
palatopharyngeal surgery in patients with OSA or suspected OSA.