A SURGICAL PROTOCOL FOR SLEEP DISORDERED BREATHING

SUMMARY A treatment philosophy has been formulated for medical and surgical management. The goal is to treat all patients for cure and to direct management in a logical manner by systematic evaluation and objective studies. The patients are counseled and educated concerning their syndrome. Choices in treatment medically and surgically are reviewed and the patients and family are exposed to the options and risks of each to include the possible outcome of no treatment. A staged surgical protocol is suggested to avoid unnecessary surgical or overaggressive intervention. A commitment to follow-up is absolutely essential. The patient is at risk for developing a life-threatening problem if proper follow-up and objective studies are not done. Certainly not all patients will comply, however, a vigorous attempt to discharge this responsibility will place the burden back on the patient and their family. It would not be proper to leave this discussion without a working definition of cure in this protocol (Table 4). Cure is defined as normal by subjective and objective study. We have used the results of CPAP titrations on the second night to compare surgical results in those who have undergone this medical treatment. For those who have not used CPAP, an RDI of 20 and/or a 50% reduction in RDI is used, that is, if the initial RDI is 26 then after treatment it must be 13 to qualify as a responder. If the RDI is 80 before treatment, it must be 20 or less after surgery. In addition, oxygen saturation must be equal to or greater than 90% (with only a few dips below 90%). Normal sleep architecture post- operatively is now included. The subjective or objective assessment of EDS must also be evaluated. The RDI of 20 was selected as a cutoff because most patients do not experience EDS below this level, and mortality figures have been associated with an RDI of 20.33 With the new data on UARS, that is, EDS with normal RDIs, these criteria may need to be adjusted in the future. Also there are selected cases now of OSAS that have EDS at lower levels than 20 and each case must be evaluated for a responder status individually. An oxygen saturation of 90% was selected because this is the upper limit of the oxyhemoglobin curve and a medically acceptable level. The clinical outcomes of this suggested protocol have been presented on a large number of patients.83 Those who wish to establish their own guidelines or ignore previously published protocols will surely be frustrated at best. Not until you have personally done 200 to 300 cases with follow-up will you really start to appreciate what constitutes success and failure in the surgical treatment of OSAS. Those who persist and are up to the challenge in understanding sleep medicine will be rewarded by a grateful patient and family. The future direction in sleep medicine and surgery will by necessity be focused on developing centers of excellence for integrated diagnosis and treatment. It is likely that only those who have previously availed themselves of contributions in sleep education and science will participate at these centers. We hope that this number will be many. The future of sleep medicine and our vast pool of undiagnosed patients depend on it.