Combination Therapy of High-flow Nasal Cannula and Upper-body Elevation for Postoperative Sleep-disordered Breathing: Randomized Crossover Trial

Abstract

Background Low acceptance rate of continuous positive airway pressure therapy in postoperative patients with untreated obstructive sleep apnea (OSA) indicates the necessity for development of an alternative postoperative airway management strategy. We considered whether the combination of high-flow nasal cannula and upper body elevation could improve postoperative OSA. Methods This non-blinded randomized crossover study performed at a single university hospital investigated the effect on a modified apnea hypopnea index, based exclusively on the airflow signal without arterial oxygen saturation criteria (flow-based apnea hypopnea index, primary outcome), of high-flow nasal cannula (20 liter.minute-1 with 40% oxygen concentration) with and without upper body elevation in patients with moderate to severe OSA. Preoperative sleep studies were performed at home (control, no head-of-bed elevation) and in hospital (30-degree head-of-bed elevation). On the first and second postoperative nights, high-flow nasal cannula was applied with or without 30-degree head-of-bed elevation, assigned in random order to 23 eligible participants. Results Twenty-two out of the 23 (96%) accepted high-flow nasal cannula. Four participants resigned from the study. Control flow-based apnea hypopnea index (mean±SD: 59.6 ± 12.0 events.hour-1, n=19) was reduced by 14.7 (95% CI: 5.5 to 30.0) events.hour-1 with head-of-bed elevation alone (p=0.002), 10.9 (1.2 to 20.6) events.hour-1 with high-flow nasal cannula alone (p=0.028), and 22.5 (13.1 to 31.9) events.hour-1 with combined head-of-bed elevation and high-flow nasal cannula (p<0.001). Compared to sole high-flow nasal cannula, additional intervention with head-of-bed elevation significantly decreased flow-based apnea hypopnea index by 11.5 events.hour-1 (1.7 to 21.4) (p=0.022). High-flow nasal cannula, alone or in combination with head-of-bed elevation also improved overnight oxygenation. No harmful events were observed. Conclusion The combination of high-flow nasal cannula and upper body elevation reduced OSA severity and nocturnal hypoxemia, suggesting a role for it as an alternate postoperative airway management strategy.

Alternative Sleep Apnea Treatment: Comment

“…2,3 Surprisingly, this was not observed here. Conversely, oxygenation in the 30-degree head-of-bed elevation group was inferior to that in the supine position (table 2 1 ). Curiously, although the combination of high-flow nasal oxygen and 30-degree head-of-bed elevation showed additive or even synergistic effects, neither alone showed much impact on the apnea-hypopnea index.…”

“…The analysis, by Sakaguchi et al ., of the role of high-flow nasal oxygen administered postoperatively in those diagnosed with obstructive sleep apnea (OSA) in lieu of conventional continuous positive airway pressure therapy is interesting. 1 We would welcome further commentary from the authors on a few points, however.…”

Alternative Sleep Apnea Treatment: Reply

“…We thank Roy et al 1 for their relevant comments on our article. 2 As Roy et al correctly pointed out, head-of-bed elevation by 30 degrees did not significantly improve oxygenation variables such as mean nadir oxygen saturation measured by pulse oximetry (Sp o 2 ), lowest Sp o 2 , and percent time Sp o 2 < 90% in our study although, Souza’s previous study demonstrated improvement of both apnea hypopnea index (15.7 to 10.7 events/h) and lowest Sp o 2 (83.5 to 87%) in symptomatic obstructive sleep apnea (OSA) patients with only 7.5-degree head-of-bed elevation. 3 It would be easy to comment that different patient populations and study design are the cause of the difference.…”

Is Continuous Positive Airway Pressure All There Is? Alternative Perioperative Treatments for Obstructive Sleep Apnea

“…These issues provide the rationale for a study reported in this issue of Anesthesiology that considers an alternative approach to continuous positive airway pressure therapy to treat sleep disordered breathing postoperatively. 5…”

“…address this knowledge gap adroitly, and in so doing help draw attention both to these therapeutic options and, more generally, to the case for non–continuous positive airway pressure alternatives for postoperative OSA management. 5…”