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How Dangerous Is Obstructive Sleep Apnea During Surgery?

“There’s meaning in thy snores.” — Shakespeare

Theodore Dalrymple


July 2, 2013 - 9:00 am


Shakespeare, on the whole, was in favor of sleep – at least if the opinions of his characters are any guide to his own opinion. “He that sleeps feels not the toothache,” says the Gaoler in Cymbeline. Sleep, says Macbeth:

… knits up the ravell’d sleave of care

and is:

The death of each day’s life, sore labour’s bath,

Balm of hurt minds, great nature’s second course,

Chief nourisher in life’s feast.

By contrast, not to sleep is a torment. Shakespeare must have known insomnia, for in Sonnet XXVII he says:

Weary with toil, I haste me to my bed…

But then begins the journey in my head…

And keeps my drooping eyelids open wide,

Looking on darkness which the blind do see.

Shakespeare also knew that “there’s meaning in thy snores,” though perhaps not the meaning that doctors now attach to them. They often mean obstructive sleep apnea (OSA), when sleep, which should be “death’s counterfeit,” becomes death’s possible harbinger, in the form of heart attacks and strokes.

According to a recent article in the New England Journal of Medicine, between a fifth and a quarter of the American population suffer from OSA, and this poses a risk, whose magnitude is not precisely known, to patients undergoing surgical procedures. The reason the magnitude is not precisely known is that it is difficult to control for obesity: not all people who are fat have OSA, and not all people who have OSA are fat, but there is a strong correlation, almost certainly a causative one. What the authors of the article call “the epidemic” of OSA – yet another epidemic of a non-contagious risk factor – is really an “epidemic” of obesity. A higher proportion of patients undergoing surgery than in the rest of the population have OSA: not surprisingly, 80 percent of patients being operated on for their obesity have it. All in all, perhaps 10 million operations are performed in America annually on people with OSA.


If OSA poses a risk to patients undergoing surgery, what should surgeons and anaesthesiologists do to reduce it? The trouble is that nobody knows yet. There are various suggestions such as that patients should undergo screening for ASO before operation and that they should be more closely monitored than others, and for longer, after operation. People with ASO who would otherwise be day cases should be admitted overnight. Perhaps they should receive treatment beforehand such as positive airway pressure therapy (PAP). But no one knows for how long they should receive it or even whether it would reduce postoperative risk. All that is really known is that something must be done.

That something is sure to be expensive, and one of the reasons something must be done is the threat of legal action. Doctors and hospitals might be held responsible for post-operative complications in patients with OSA if they did nothing to try to prevent them, even if it is not known scientifically what exactly they should have done to prevent them. This seems to me completely mad: first the sentence, then the verdict. What would be prevented by preventive treatment, therefore, are not medical complications but legal ones.

The authors conclude their article as follows:

Until we can better identify patients who are at risk and evidence-based interventions that improve outcomes… institutions should, at the very least, address the issue of OSA and develop protocols that take into account the need for heightened awareness as well as locally available resources.

This is a pure example of the something-must-be-done-ism that is epidemic – I use the term loosely or metaphorically – in political life. And what must be done is always to spend more and drive up costs.


image courtesy shutterstock /  Claudio Divizia / Paul Vasarhelyi

Theodore Dalrymple, a physician, is a contributing editor of City Journal and the Dietrich Weismann Fellow at the Manhattan Institute. His new book is Second Opinion: A Doctor's Notes from the Inner City.

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All Comments   (8)
All Comments   (8)
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Seems to me that the "blame the obesity epidemic" train is out of control. Yes there is a correlation between OSA and obesity, but there is also a lot of info detailing the biological consequences of the lack of quality sleep of which weight gain is but one.
Considering much of the research being done currently, I suspect that obesity is far more often a symptom than a cause.
1 year ago
1 year ago Link To Comment
Many of the patients in our hospital undergo empirical CPAP/BiPAP titration, meaning that they are found to obstruct and are given an approximate level of CPAP/BiPAP to alleviate the worst of it. Then they are referred to the sleep lab for more formal testing and treatment.

Obviously, you haven't read enough, haven't explored what the American Academy of Sleep Medicine says, etc.
1 year ago
1 year ago Link To Comment
Thank you for the warning. I'm going to call my doctor and tell him, as I have surgery scheduled for the end of the month, and have apnea.
1 year ago
1 year ago Link To Comment
Who said we should first kill all the lawyers? :-)

I say that in jest, but with a bit of healthy cynicism as well. Just how much does the sure threat of lawsuits every time a procedure does not go perfectly increase the cost of US health care? I suspect much more than we know or are told.

Vultures perform a healthy service in nature. I'm not so sure about their brethren the personal injury and medical malpractice trial lawyers.
1 year ago
1 year ago Link To Comment
I have OSA and I have surgery - relatively minor - thank goodness. It will involve an overnight stay and I will take my CPAP machine which I know as a matter of objective testing reduces the incidences of actual airway blockage from 30 per hour to 3.5 - anything below 5 considered normal. I'm not sure it is much ado about nothing, but I will want the surgeon and the anesthetist to know about it! On the other hand, I know that it is true we Americans try to fix everything by passing a law and agree with Gridley that leads to increased costs. We also pathologize everything - the DSM does not get smaller. I see my OSA as just another hazard on the way. It makes no sense to individually pass a law for every tree beside the road to make it illegal to drive into it for the purposes of committing suicide. And then sending out workmen - I mean workpersons - to post signs to that effect for each oak, and maple and pine. Gadzooks!
1 year ago
1 year ago Link To Comment
"This is a pure example of the something-must-be-done-ism that is epidemic – I use the term loosely or metaphorically – in political life. And what must be done is always to spend more and drive up costs."

In political life, the solution is to pass a law.....any law. But that amounts to the same thing as spending more, and driving up costs.
1 year ago
1 year ago Link To Comment
unless it's the surgeon, this isn't a problem. truly much ado about nothing.

it is a tale told by an idiot. full of sound and fury, signifying nothing.
1 year ago
1 year ago Link To Comment
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