Sleep Breath DOI 10.1007/s11325-015-1199-6
ORIGINAL ARTICLE
Post-gastrointestinal endoscopy complications in patients with obstructive sleep apnea or at high risk for sleep apnea: a systematic review and meta-analysis Swarna Gaddam 1 & Sameer K. Gunukula 1 & M. Jeffery Mador 2
Received: 14 November 2014 / Revised: 13 May 2015 / Accepted: 15 May 2015 # Springer-Verlag Berlin Heidelberg 2015
Abstract Background Obstructive sleep apnea (OSA) is becoming increasingly more prevalent with the rise in obesity. Complications from gastrointestinal (GI) endoscopy in this patient population have been reported in several studies, but the modest complication rates from these procedures make it difficult to come to definitive conclusions based on single studies. The objective of our study was to systematically review these studies reporting the incidence of post-procedure complications in patients with OSA undergoing endoscopy to determine whether the presence of OSA increases postprocedure complications. Methods We conducted a systematic review using the Cochrane Collaboration Methodology. We searched Medline via Ovid, PubMed, Embase, and Evidence Based Medicine Reviews databases from 1950 to August 2013. We rated the quality of evidence for each outcome using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Meta-analysis was done using Review Manager Version 5.0.20. Results Our search resulted in seven eligible studies. There was no significant association between diagnosis of OSA and post-GI endoscopy complications including hypoxemia, respiratory distress, variations in blood pressure or heart rate, bradypnea, or need for significant interventions. Subgroup
* M. Jeffery Mador [email protected] 1
Department of Internal Medicine, State University of New York at Buffalo, Buffalo, NY, USA
2
Division of Pulmonary, Sleep and Critical Care Medicine, University at Buffalo and Western New York Veteran Affairs Healthcare System, 3495 Bailey Ave, Buffalo, NY 14215, USA
analysis based on the type of GI endoscopy or the type of anesthesia used did not show any significant associations either. Conclusions Obstructive sleep apnea patients and/or patients at high risk for obstructive sleep apnea do not appear to be at increased risk of adverse outcomes from GI endoscopy. Keywords Sleep apnea . Endoscopy . Complications
Introduction Obstructive sleep apnea is common in middle-aged men and women [1]. Recent systematic reviews show that sleep apnea appears to increase the risk of postoperative cardiopulmonary and neurologic complications [2, 3]. Endoscopic procedures are short and are usually performed with conscious sedation or somewhat deeper sedation, but general anesthesia and postoperative analgesics are usually not required. The residual effects on the upper airway of general anesthesia and the effects of postoperative narcotics usage are not present with endoscopic procedures. However, benzodiazepines, narcotics and propofol all can affect the upper airway, and these are the agents commonly used during endoscopic procedures [4, 5]. Thus, the purpose of this study is to determine whether sleep apnea would also increase the risk of complications from endoscopic procedures. Of the seven studies examining this issue, one study showed an increase in the proportion of patients with hypoxemia in patients at high risk for sleep apnea while the other studies showed no increase in postoperative complications in patients with sleep apnea or at high risk for sleep apnea [6–12]. Since complication rates are low after endoscopy procedures [13–18], all these studies may have been relatively underpowered to detect differences. Thus, a systematic review with meta-analysis would be useful to pool existing
Setting and period: patients who underwent elective endoscopic procedures from January 2004 to December 2009 at the University of Utah Health Sciences Center OSA group, 105 patients; 61 % males. 52.4 % received NAPS and 47.6 % received CS Non-OSA group, 110 patients; 53.6 % males. 51.8 %7 received NAPS and 48.2 % received CS Type of endoscopy: EGD or colonoscopy done under propofol sedation (NAPS) or a combination of benzodiazepine and narcotics (CS) Setting and period: Consecutive patients undergoing deep sedation for endoscopic procedures between January 2010 and December 2010 at GB Morgagni-L Pieranton hospital in Forli, Italy High-risk OSA group, 141 patients; 45 % males. Mean age 66±11 years Low-risk OSA group, 131 patients; 25 % males. Mean age 58±16 years Type of endoscopy: ERCP, EGD, colonoscopy, or both EGD and colonoscopy. Patients received deep sedation using propofol alone or in combination with benzodiazepine and/or opiate Setting and period: Consecutive patients undergoing ERCP or EUS between December 2008 and October 2009 at Washington University in St. Louis High-risk group: 100 patients; 73 % males. Mean age 60.3±12.7 years Low-risk group: 131 patients; 26.7 % males. Mean age 50.1±17.2 years Type of endoscopy: ERCP or EUS. Patients received deep sedation using propofol alone or in combination with low-dose opiate and/or benzodiazepine
Author, year: Adler et al.; 2011 [7] Study design: retrospective cohort Funding: not reported
Author, year: Cote et al.; 2010 [9] Study design: prospective cohort Funding: not reported
Author, year: Corso et al.; 2011 [8] Study design: prospective cohort Funding: not reported
Population
Hypoxemia: pulse oximetry
ORIGINAL ARTICLE
Post-gastrointestinal endoscopy complications in patients with obstructive sleep apnea or at high risk for sleep apnea: a systematic review and meta-analysis Swarna Gaddam 1 & Sameer K. Gunukula 1 & M. Jeffery Mador 2
Received: 14 November 2014 / Revised: 13 May 2015 / Accepted: 15 May 2015 # Springer-Verlag Berlin Heidelberg 2015
Abstract Background Obstructive sleep apnea (OSA) is becoming increasingly more prevalent with the rise in obesity. Complications from gastrointestinal (GI) endoscopy in this patient population have been reported in several studies, but the modest complication rates from these procedures make it difficult to come to definitive conclusions based on single studies. The objective of our study was to systematically review these studies reporting the incidence of post-procedure complications in patients with OSA undergoing endoscopy to determine whether the presence of OSA increases postprocedure complications. Methods We conducted a systematic review using the Cochrane Collaboration Methodology. We searched Medline via Ovid, PubMed, Embase, and Evidence Based Medicine Reviews databases from 1950 to August 2013. We rated the quality of evidence for each outcome using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Meta-analysis was done using Review Manager Version 5.0.20. Results Our search resulted in seven eligible studies. There was no significant association between diagnosis of OSA and post-GI endoscopy complications including hypoxemia, respiratory distress, variations in blood pressure or heart rate, bradypnea, or need for significant interventions. Subgroup
* M. Jeffery Mador [email protected] 1
Department of Internal Medicine, State University of New York at Buffalo, Buffalo, NY, USA
2
Division of Pulmonary, Sleep and Critical Care Medicine, University at Buffalo and Western New York Veteran Affairs Healthcare System, 3495 Bailey Ave, Buffalo, NY 14215, USA
analysis based on the type of GI endoscopy or the type of anesthesia used did not show any significant associations either. Conclusions Obstructive sleep apnea patients and/or patients at high risk for obstructive sleep apnea do not appear to be at increased risk of adverse outcomes from GI endoscopy. Keywords Sleep apnea . Endoscopy . Complications
Introduction Obstructive sleep apnea is common in middle-aged men and women [1]. Recent systematic reviews show that sleep apnea appears to increase the risk of postoperative cardiopulmonary and neurologic complications [2, 3]. Endoscopic procedures are short and are usually performed with conscious sedation or somewhat deeper sedation, but general anesthesia and postoperative analgesics are usually not required. The residual effects on the upper airway of general anesthesia and the effects of postoperative narcotics usage are not present with endoscopic procedures. However, benzodiazepines, narcotics and propofol all can affect the upper airway, and these are the agents commonly used during endoscopic procedures [4, 5]. Thus, the purpose of this study is to determine whether sleep apnea would also increase the risk of complications from endoscopic procedures. Of the seven studies examining this issue, one study showed an increase in the proportion of patients with hypoxemia in patients at high risk for sleep apnea while the other studies showed no increase in postoperative complications in patients with sleep apnea or at high risk for sleep apnea [6–12]. Since complication rates are low after endoscopy procedures [13–18], all these studies may have been relatively underpowered to detect differences. Thus, a systematic review with meta-analysis would be useful to pool existing
Setting and period: patients who underwent elective endoscopic procedures from January 2004 to December 2009 at the University of Utah Health Sciences Center OSA group, 105 patients; 61 % males. 52.4 % received NAPS and 47.6 % received CS Non-OSA group, 110 patients; 53.6 % males. 51.8 %7 received NAPS and 48.2 % received CS Type of endoscopy: EGD or colonoscopy done under propofol sedation (NAPS) or a combination of benzodiazepine and narcotics (CS) Setting and period: Consecutive patients undergoing deep sedation for endoscopic procedures between January 2010 and December 2010 at GB Morgagni-L Pieranton hospital in Forli, Italy High-risk OSA group, 141 patients; 45 % males. Mean age 66±11 years Low-risk OSA group, 131 patients; 25 % males. Mean age 58±16 years Type of endoscopy: ERCP, EGD, colonoscopy, or both EGD and colonoscopy. Patients received deep sedation using propofol alone or in combination with benzodiazepine and/or opiate Setting and period: Consecutive patients undergoing ERCP or EUS between December 2008 and October 2009 at Washington University in St. Louis High-risk group: 100 patients; 73 % males. Mean age 60.3±12.7 years Low-risk group: 131 patients; 26.7 % males. Mean age 50.1±17.2 years Type of endoscopy: ERCP or EUS. Patients received deep sedation using propofol alone or in combination with low-dose opiate and/or benzodiazepine
Author, year: Adler et al.; 2011 [7] Study design: retrospective cohort Funding: not reported
Author, year: Cote et al.; 2010 [9] Study design: prospective cohort Funding: not reported
Author, year: Corso et al.; 2011 [8] Study design: prospective cohort Funding: not reported
Population
Hypoxemia: pulse oximetry
