Division of Sleep Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford Hospital and Clinics, Stanford, California.
Green Button, Stanford Center for Biomedical Informatics Research, Stanford, California.
JAMA Otolaryngol Head Neck Surg. 2021 Apr 1;147(4):329-335. doi: 10.1001/jamaoto.2020.5179.
The efficacy of surgical treatments for obstructive sleep apnea (OSA) is variable when considering only the Apnea Hypopnea Index as the treatment end point. However, only a few studies have shown an association between these procedures and improved clinically relevant outcomes, such as cardiovascular, endocrine, and neurological sequelae of OSA.
To evaluate the association of surgery for OSA with clinically relevant outcomes.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used the Truven MarketScan Database from January 1, 2007, to December 31, 2015, to identify all patients diagnosed with OSA who received a prescription of continuous positive airway pressure (CPAP), were 40 to 89 years of age, and had at least 3 years of data on file. Data were analyzed September 19, 2019.
Soft tissue and skeletal surgical procedures for the treatment of OSA.
The occurrence of cardiovascular, neurological, and endocrine complications was compared in patients who received CPAP alone and those who received surgery. High-dimensionality propensity score matching was used to adjust the models for confounders. Kaplan-Meier survival analysis with a log-rank test was used to compare differences in survival curves.
A total of 54 224 patients were identified (33 405 men [61.6%]; mean [SD] age, 55.1 [9.2] years), including a cohort of 49 823 patients who received CPAP prescription alone (mean [SD] age, 55.5 [9.4] years) and 4269 patients who underwent soft tissue surgery (mean [SD] age, 50.3 [7.0] years). The median follow-up time was 4.47 (interquartile range, 3-8) years after the index CPAP prescription. In the unadjusted model, soft tissue surgery was associated with decreased cardiovascular (hazard ratio [HR], 0.92; 95% CI, 0.86-0.98), neurological (HR, 0.49; 95% CI, 0.39-0.61), and endocrine (HR, 0.80; 95% CI, 0.74-0.86) events. This finding was maintained in the adjusted model (HR for cardiovascular events, 0.91 [95% CI, 0.83-1.00]; HR for neurological events, 0.67 [95% CI, 0.51-0.89]; HR for endocrine events, 0.82 [95% CI, 0.74-0.91]). Skeletal surgery (n = 114) and concomitant skeletal and soft tissue surgery (n = 18) did not demonstrate significant differences in rates of development of systemic complications.
In this cohort study, soft tissue surgery for OSA was associated with lower rates of development of cardiovascular, neurological, and endocrine systemic complications compared with CPAP prescription in a large convenience sample of the working insured US adult population. These findings suggest that surgery should be part of the early treatment algorithm in patients at high risk of CPAP failure or nonadherence.
仅以呼吸暂停低通气指数作为治疗终点来考虑，手术治疗阻塞性睡眠呼吸暂停（OSA）的疗效是不同的。然而，只有少数研究表明这些手术与改善与临床相关的结果之间存在关联，例如 OSA 的心血管、内分泌和神经后遗症。
评估 OSA 手术与临床相关结果的关联。
设计、设置和参与者：本回顾性队列研究使用 Truven MarketScan 数据库，从 2007 年 1 月 1 日至 2015 年 12 月 31 日，确定所有被诊断为 OSA 的患者，他们接受持续气道正压通气（CPAP）的处方，年龄在 40 至 89 岁之间，并且至少有 3 年的档案数据。数据分析于 2019 年 9 月 19 日进行。
用于治疗 OSA 的软组织和骨骼手术。
比较单独接受 CPAP 和接受手术的患者发生心血管、神经和内分泌并发症的情况。使用高维倾向评分匹配来调整模型中的混杂因素。使用对数秩检验的 Kaplan-Meier 生存分析比较生存曲线的差异。
共确定了 54224 名患者（33405 名男性[61.6%]；平均[SD]年龄，55.1[9.2]岁），其中包括接受单独 CPAP 处方的 49823 名患者队列（平均[SD]年龄，55.5[9.4]岁）和 4269 名接受软组织手术的患者。中位随访时间为索引 CPAP 处方后 4.47（四分位间距，3-8）年。在未调整的模型中，软组织手术与心血管（风险比[HR]，0.92；95%置信区间[CI]，0.86-0.98）、神经（HR，0.49；95% CI，0.39-0.61）和内分泌（HR，0.80；95% CI，0.74-0.86）事件的减少相关。这一发现在调整后的模型中得以维持（心血管事件的 HR，0.91[95% CI，0.83-1.00]；神经事件的 HR，0.67[95% CI，0.51-0.89]；内分泌事件的 HR，0.82[95% CI，0.74-0.91]）。骨骼手术（n=114）和同时进行骨骼和软组织手术（n=18）在发展全身并发症的发生率方面没有显著差异。
在这项队列研究中，与 CPAP 处方相比，OSA 的软组织手术与心血管、神经和内分泌全身并发症的发生率降低相关，在大型便利的美国成年工作人群中进行的大型便利样本中。这些发现表明，在 CPAP 治疗失败或不依从风险较高的患者中，手术应成为早期治疗方案的一部分。
