© 2004 American Thoracic Society
Critical Care and Obstructive Sleep ApneaTo the Editor:The recent Clinical Commentary "Clinical Approach to the Critically Ill, Morbidly Obese Patient" (1) does not mention obstructive sleep apnea, which is common among obese patients and is often not appreciated. In the intensive care unit, intubation or tracheostomy can treat obstructive sleep apnea, but the nonintubated morbidly obese patient likely has obstructive sleep apnea. The incidence of obstructive sleep apnea among patients being considered for bariatric surgery is about 70%, with nearly 90% having an obstruction-related sleeping disorder (2). Unrecognized obstructive sleep apnea is a common reason for serious complications and unexpected intensive care unit transfers in patients after surgery (3), likely related to sedation and pain medications worsening obstructive sleep apnea. With the high incidence of obstructive sleep apnea in these patients and perioperative worsening, it is reasonable to manage perioperative or postextubation morbidly obese patients routinely with positive airway pressure when they are drowsy or sleeping. Most of these patients also require positive airway pressure therapy during sleep throughout their hospital stay. We find previously unsuspected severe sleep apnea among many (some morbidly obese) patients transferred to our rehabilitation hospital after stays in the intensive care unit. Treatment with positive airway pressure can lead to dramatic improvements. Early recognition and treatment of obstructive sleep apnea in these patients should improve outcomes and prevent or shorten stays in the intensive care unit.
Spaulding Rehabilitation Hospital Boston, Massachusetts Acknowledgments D.C.J. does not have a financial relationship with a commercial entity that has an interest in the subject of this letter. REFERENCES
To the Editor: I agree with Dr. Johnson that treatment of morbidly obese patients with documented obstructive sleep apnea should be resumed perioperatively and after extubation to prevent hypoxic complications related to pain management and residual sedation. This recommendation should apply, however, not only to critically ill patients, but also to any hospitalized patient with this syndrome whenever possible. As for the statement of using positive airway pressure routinely for morbidly obese patients who exhibit drowsiness or sleepiness after extubation, there are no prospective studies to my knowledge to document the efficacy or to evaluate the cost analysis of such an approach. It could be argued that the indiscriminate application of positive airway pressure after extubation in critically ill, morbidly obese patients might increase the risk for gastric aspiration for reasons that I detailed in the monograph (1). In the absence of such studies, treatment with positive airway pressure should be tailored to the patient's respiratory and homodynamic status.
University at Buffalo Buffalo, New York FOOTNOTES Conflict of Interest Statement: A.E.-S. does not have a financial relationship with a commercial entity that has an interest in the subject of this letter. REFERENCES
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