title: A randomised trial of peri-operative positive airway pressure for postoperative delirium in patients at risk for obstructive sleep apnoea after regional anaesthesia with sedation or general anaesthesia for joint arthroplasty.
abstract: Previous pilot work has established an association between obstructive sleep apnoea and the development of acute postoperative delirium , but it remains unclear to what extent this risk factor is modifiable in the 'real world' peri-operative setting. In a single-blind randomised controlled trial, 135 elderly surgical patients at risk for obstructive sleep apnoea were randomly assigned to receive peri-operative continuous positive airway pressure (CPAP) or routine care. Of the 114 patients who completed the study, 21 (18.4%) experienced delirium. Delirium was equally common in both groups: 21% (12 of 58 subjects) in the CPAP group and 16% (9 of 56 subjects) in the routine care group (OR = 1.36 [95%CI 0.52-3.54], p = 0.53). Delirious subjects were slightly older - mean (SD) age 68.9 (10.7) vs. 64.9 (8.2), p = 0.07 - but had nearly identical pre-operative STOP-Bang scores (4.19 (1.1) versus 4.27 (1.3), p = 0.79). Subjects in the CPAP group used their devices for a median (IQR [range]) of 3 (0.25-5 [0-12]) nights pre-operatively (2.9 (0.1-4.8 [0.0-12.7]) hours per night) and 1 (0-2 [0-2]) nights postoperatively (1.4 (0.0-5.1 [0.0-11.6]) hours per night). Among the CPAP subjects, the residual pre-operative apnoea-hypopnea index had a significant effect on delirium severity (p = 0.0002). Although we confirm that apnoea is associated with postoperative delirium, we did not find that providing a short-course of auto-titrating CPAP affected its likelihood or severity. Voluntary adherence to CPAP is particularly poor during the initiation of therapy.
authors.affiliation: University of Rochester, Rochester, New York, USA.
authors.forename: J W
authors.initials: JW
authors.lastname: Nadler
authors.affiliation: University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
authors.forename: J L
authors.initials: JL
authors.lastname: Evans
authors.affiliation: Singapore General Hospital, Singapore.
authors.forename: E
authors.initials: E
authors.lastname: Fang
authors.affiliation: Duke University, Durham, North Carolina, USA.
authors.forename: X A
authors.initials: XA
authors.lastname: Preud'Homme
authors.affiliation: Duke University, Durham, North Carolina, USA.
authors.forename: R L
authors.initials: RL
authors.lastname: Daughtry
authors.affiliation: Duke University, Durham, North Carolina, USA.
authors.forename: J B
authors.initials: JB
authors.lastname: Chapman
authors.affiliation: Duke University, Durham, North Carolina, USA.
authors.forename: M P
authors.initials: MP
authors.lastname: Bolognesi
authors.affiliation: Duke University, Durham, North Carolina, USA.
authors.forename: D E
authors.initials: DE
authors.lastname: Attarian
authors.affiliation: Duke University, Durham, North Carolina, USA.
authors.forename: S S
authors.initials: SS
authors.lastname: Wellman
authors.affiliation: Duke University, Durham, North Carolina, USA.|Executive Vice Chair for the Langley Porter Psychiatric Institute (LPPI), University of California at San Francisco, San Francisco, California, USA.
authors.forename: A D
authors.initials: AD
authors.lastname: Krystal
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000765:Anesthesia, Conduction / Q000379:methods*; D000768:Anesthesia, General / Q000379:methods*; D019643:Arthroplasty, Replacement / Q000379:methods*; D045422:Continuous Positive Airway Pressure / Q000379:methods*; D000071257:Emergence Delirium / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D019990:Perioperative Care / Q000379:methods*; D011183:Postoperative Complications / Q000628:therapy*; D011446:Prospective Studies; D016037:Single-Blind Method; D020181:Sleep Apnea, Obstructive / Q000628:therapy*
keywords: clinical trial; mask CPAP; obstructive sleep apnoea; postoperative apnoea