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SummaryObstructive sleep apnoea-hypopnoea (OSAH) causes excessive daytime sleepiness, impairs quality-of-life, and increases cardiovascular disease and road traffic accident risks. Continuous positive airway pressure (CPAP) treatment and mandibular advancement devices (MAD) have been shown to be effective in individual trials but their effectiveness particularly relative to disease severity is unclear.A MEDLINE, Embase and Science Citation Index search updating two systematic reviews to August 2013 identified 77 RCTs in adult OSAH patients comparing: MAD with conservative management (CM); MAD with CPAP; or CPAP with CM. Overall MAD and CPAP significantly improved apnoea-hypopnoea index (AHI) (MAD −9.3/hr (p < 0.001), CPAP −25.4 (p < 0.001)). In direct comparisons mean AHI and Epworth sleepiness scale score were lower (7.0/hr (p < 0.001) and 0.67 (p = 0.093) respectively) for CPAP. There were no CPAP vs. MAD trials in mild OSAH but in comparisons with CM, MAD and CPAP reduced ESS similarly (MAD 2.01 (p < 0.001); CPAP 1.23 (p = 0.012).Both MAD and CPAP are clinically effective in the treatment of OSAH. Although CPAP has a greater treatment effect, MAD is an appropriate treatment for patients who are intolerant of CPAP and may be comparable to CPAP in mild disease.

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There is now a growing body of evidence suggesting that MADs are a clinically and cost-effective treatment for OSA; and in some cases, patient preference may make them a better option than CPAP. Further work needs to continue to refine MAD therapy in order to optimize treatment response and compliance, whilst retaining a pragmatic and cost-effective approach that is relevant to clinical practice and sustainable in the longer term.

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Introduction and objectivesObstructive sleep apnoea (OSA) is common and can be associated with adverse health outcomes. There are conflicting data for the impact of undiagnosed OSA on the outcome of surgical procedures but at least some results suggest an association with worse outcomes. EuroSCORE risk model was developed to calculate the risk of mortality after cardiac surgery. We evaluated the prevalence and impact of undiagnosed sleep apnoea (SA) on postoperative outcomes in cardiac surgery.MethodsPatients undergoing coronary artery bypass grafting with or without cardiac valve surgery were screened for the presence of SA, prior to surgery, with the STOPBANG questionnaire and overnight oximetry. SA was defined as a 4% oxygen desaturation index (ODI) of ≥5/hr. A Weibull model was used to analyse lengths of stay (LoS) in intensive care unit (ICU). Complications in ICU were dichotomised and analysed with binary logistic regressions. Parsimonious models were obtained using a combination of step-wise regression and manually removing predictors that did not reach the 5% significance level.Results122 subjects were included in final analysis of which 57 (47%) had a new diagnosis of SA. Of those, 45 (79%) had mild SA and 12 (21%) had moderate/severe SA. There was no simple relationship between OSA as measured by ODI and LoS in ICU. The most significant predictor for ICU LoS was developing complications at ICU (p < 0.001). The independent predictors associated with increasing likelihood of developing major organ complications following cardiac surgery were EuroSCORE, ODI and intravenous opioid analgesia (IOA). When patients with mild and moderate SA received IOA, predicted probability of complications rose 2.4 and 1.4 times respectively (Figure 1).Abstract S28 Figure 1Predicted probabilities and 95% CI of suffering a complication at ICU as ODI increases for individuals with average EuroSCORE (5) and with or without IOAConclusionWe found a high prevalence of undiagnosed sleep apnoea in our cohort. EuroSCORE, SA and the administration of intravenous morphine were found to be independent risk factors for developing post-operative complications. This risk has increased when patients with SA received intravenous morphine.

Introduction and objectivesQuestionnaires to assess the risk of obstructive sleep apnoea (OSA) prior to surgery could reduce the need for screening sleep studies. STOPBANG questionnaire is user friendly and was previously validated in a general surgical population. A high risk of OSA has been defined as a score of ≥3 and low risk as a score 0–2. We aimed to validate the STOPBANG against nocturnal oximetry in a population undergoing major cardiac surgery and assessed its prognostic value for postoperative outcomes.MethodsPatients were screened for high risk of OSA with the STOPBANG questionnaire. The presence of sleep apnoea (SA), prior to surgery, was assessed with overnight oximetry. SA was defined as mild with a 4% oxygen desaturation index (ODI) of 5–14/hr, moderate with ODI of 15–29/hr and severe ODI ≥30/hr. Predictive performance of STOPBANG against nocturnal oximetry was assessed for diagnosis of mild and moderate SA by assessing the area under curve receiver operating characteristic (AUC-ROC) and sensitivity and specificity were calculated. A multiple-logistic regression model was used to assess association of STOPBANG and post-operative outcomes.ResultsThe AUC-ROC for mild SA was low 0.57 (95% CI = 0.47–0.67). Good performance was observed for moderate SA with AUC-ROC 0.82 (95% CI = 0.69–0.95) (Figure 1) but specificity of STOPBANG at the conventional cut of value of ≥3 for moderate SA was very low at 5% whilst sensitivity was 100%. The best predictive STOPBANG cut-off value for moderate SA was ≥6 with sensitivity and specificity of 75% and 77% respectively. Assessing predictive value for severe SA was not possible due to the lack of severe SA cases in our cohort. STOPBANG was not found to be an independent predictor of worse post-operative outcomes.Abstract S27 Figure 1ROC curves for STOPBANG to predict ODI ≥5 and ODI ≥15ConclusionPredictive performance of STOPBANG in our patient cohort at the conventional cut off value was poor. The probable explanation is that the cardiac surgical population is preselected as male, older and most suffer with hypertension. Thus the majority will score as high risk for OSA. STOPBANG had no prognostic value on worse postoperative outcomes in our study, which again contrasts with the findings in general surgical cohorts.