Perioperative Use and Outcomes of Noninvasive Ventilation in Sleep Apnea

描述(申请人提供)：阻塞性睡眠呼吸暂停(OSA)是一种常见的疾病，其特征是睡眠期间上呼吸道反复、完全或部分崩溃，在美国至少有9%的中年女性和24%的中年男性受到影响。据报道，在接受手术的患者中，OSA的患病率从普通手术中的3%到接受减肥手术的肥胖患者中的70%不等，但OSA往往没有得到诊断，真实的患病率可能要高得多。阻塞性睡眠呼吸暂停综合征患者术后不良事件的风险增加，包括呼吸衰竭和心血管并发症，增加了对重症监护病房的需要，并延长了住院时间。OSA在非卧床环境下的长期治疗包括持续的气道正压，这是一种无创呼吸机(NIV)的形式。美国麻醉学会的指南主要是基于OSA患者并发症风险增加的知识，并根据慢性治疗的好处推断，建议所有OSA患者在手术后接受NIV并进行长时间的血氧监测。有限的证据，加上提供NIV和提供监测的成本和复杂性，可能解释了为什么80%的美国医院目前没有制定政策或协议来管理这些患者。使用一个包含来自400家美国医院的地理和结构多样化的患者记录的高度详细的数据库，我们的目标是：1)检查OSA患者在大型非心脏手术后使用NIV的情况，并确定与治疗相关的患者和医院因素；2)分析NIV治疗与OSA患者接受大型非心脏手术的术后结果之间的关联。令人感兴趣的主要结果将是出现严重的呼吸恶化，定义为插管或呼吸停止。次要结果将包括其他呼吸系统和心血管并发症、住院死亡率、住院时间和住院费用。为了限制选择偏差的威胁，我们将使用 一套强大的分析方法，包括分层Logistic回归、高维倾向得分和工具变量技术。该项目目标的成功完成将产生有关阻塞性睡眠呼吸暂停综合征患者在术后期间使用NIV的重要新知识，并将为其在常规临床环境中的有效性提供证据。这些调查结果要么将加强当前的指南建议，作为今后传播和执行研究的催化剂，要么将对这些建议提出挑战，突出需要更好的证据来指导实践。这项建议建立在我们团队在围手术期医学比较有效性研究方面的强大记录基础上，并将改善OSA患者的治疗。

DESCRIPTION (provided by applicant): Obstructive sleep apnea (OSA) is a common disorder characterized by repetitive, complete, or partial collapse of the upper airway during sleep that affects at least 9% of middle-aged women and 24% of middle-aged men in the United States. The reported prevalence of OSA among patients presenting for surgery ranges from 3% in general surgery, to 70% among obese patients undergoing bariatric procedures, however OSA is often undiagnosed and the true prevalence is likely much higher. Patients with OSA have an increased risk of postoperative adverse events including respiratory failure and cardiovascular complications, increased need for intensive care unit admission, and prolonged hospitalization. The long-term treatment of OSA in the ambulatory setting consists of continuous positive airway pressure, a form of noninvasive ventilation (NIV). Based largely on the knowledge that patients with OSA are at increased risk of complications, and extrapolating from the benefits of chronic therapy, guidelines from the American Society of Anesthesiology recommend that all patients with OSA receive NIV and have oximetry monitoring for a prolonged period following surgery. Limited evidence, together with the cost and complexity of delivering NIV and providing monitoring may explain why 80% of US hospitals do not currently have policies or protocols in place for managing these patients. Using a highly detailed database containing patient records from a geographically and structurally diverse set of 400 US hospitals, our aims are to: 1) examine the use of NIV postoperatively in patients with OSA following major non-cardiac surgery and to identify patient and hospital factors associated with treatment, 2) analyze the association between treatment with NIV and postoperative outcomes in patients with OSA undergoing major non-cardiac surgery. The primary outcome of interest will be the development of serious respiratory deterioration, defined as intubation or respiratory arrest. Secondary outcomes will include other respiratory and cardiovascular complications, in-hospital mortality, length of stay, and cost of hospitalization. To limit the threat of selection bias we will employ a powerful set of analytical methods including hierarchical logistic regression, high-dimensional propensity scores, and instrumental variable techniques. Successful completion of the aims of this project will generate important new knowledge about the use of NIV in patients with OSA in the postoperative period as well as evidence about its effectiveness in routine clinical settings. These findings will either strengthen current guide recommendations, serving as a catalyst for future dissemination and implementation studies, or alternatively, will challenge them, highlighting the need for better evidence to guide practice. This proposal builds upon our team's strong record of comparative effectiveness research in perioperative medicine and will improve the treatment of patients with OSA.