Personal CPAP Machines in PACU of Uncertain Benefit

Requiring patients with obstructive sleep apnea (OSA) to bring personal breathing devices with them on the day of surgery may be an unnecessary and clinically irrelevant burden for both patients and hospital staff, Baltimore researchers have found.

In 2012, the Society for Ambulatory Anesthesia (SAMBA) issued a consensus statement recommending that individuals with OSA bring their personal continuous positive airway pressure (CPAP) machines to the hospital on the day of surgery if a hospital machine is not available. But the new study, by a group at Johns Hopkins University, in Baltimore, suggests that few, if any, patients require CPAP in the ICU.

Asha Manohar, MD, assistant professor of anesthesia at Johns Hopkins, and her colleagues sought to determine how frequently personal CPAP machines were used at Johns Hopkins Outpatient Center Surgical Suites, where all OSA patients undergoing ambulatory surgery are instructed to bring their breathing devices with them on the day of surgery. They performed a retrospective observational study of all patients with OSA who underwent ambulatory surgery in the past 10 years.

“None of these patients required postoperative CPAP in the PACU [postanesthesia care unit],” Manohar said. “Given this finding, we are reconsidering current guidelines at Johns Hopkins.”

The study, presented at SAMBA’s 2013 annual meeting, builds on a 2010 prospective study, also at Johns Hopkins, that found no correlation in 2,139 patients between OSA and the need for postoperative ventilatory assistance such as CPAP (J Clin Sleep Med 2010;6:467-472).

Frances Chung, FRCPC, professor in the Department of Anesthesiology at the University of Toronto, Canada, was author of the 2012 SAMBA statement in support of patients bringing personal CPAP machines with them on the day of surgery. Chung noted that after surgery and while recovering from the effects of sedation, patients with OSA might be vulnerable to acute episodes of apnea.

“Patients can be sleepy in the PACU and thus may need a CPAP machine to help maintain their open airways,” Chung told Anesthesiology News. “Also, some patients may need to be admitted after ambulatory surgery and stay overnight, which would also mean they may need their CPAP machine.”

However, CPAP devices can be used only for patients who are arousable, cooperative and able to maintain their protective airway reflexes, Manohar said. “If there is an acute event where the patient is unstable, then you may need more invasive measures like intubation,” she said. “But usually if the patient is arousable, we can wake them up and encourage deep breathing with supplemental oxygen. Then their oxygen saturation levels return to their baseline.”

Furthermore, she said, the use of personal CPAP machines in the PACU requires additional hospital resources. Not only does each machine require staff time for processing and inspection, but the variety of machines available presents its own challenge. “Our technicians cannot be educated on how to use all these different machines,” Dr. Manohar explained.

Contamination is another concern, either from CPAP machine to hospital patients and staff, or from hospital-acquired microbes coming home with patients on their machines after surgery. “One study found that patients with OSA who are treated with CPAP have an increased risk for upper airway infections compared with sleep apnea patients who receive conservative treatment,” Manohar said (Respiration 2001;68:483-487).

To address the rare but real possibility of OSA patients needing CPAP in the PACU, Manohar suggested the use of standardized hospital-based machines in conjunction with patients bringing their personal CPAP masks.

“We are looking at having a policy that would allow a standardized hospital-issued CPAP machine be available for use across the hospital,” she said. “Asking patients to bring in new or clean CPAP masks, provided in advance by their home health care companies, on the day of surgery would address the potential need while minimizing the drawbacks of patients bringing in their own machines.”

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