Weve done numerous columns on obstructive sleep apnea (OSA) and particularly the risks OSA brings in the perioperative period. Therefore, we always advocate screening patients for OSA preoperatively. Though there are several tools that can be used for screening, the STOP-Bang tool is the one used most often and has been well validated.
But now a new simpler tool, the BOSTN score, has generated considerable interest (Raub 2018). The BOSTN score assigns one point for each of the following:
· Body mass index of 30 kg/m2 or greater
· Observed apnea
· Snoring that is loud
· Tiredness in the daytime
· Neck circumference of 16.5 inches or greater in females and 17.5 inches or greater in males
A score of 2 or more points indicates a high risk for OSA.
Raub and colleagues reported on their experience with use of BOSTN at Beth Israel Deaconess Medical Center (BIDMC). BOSTN is preoperatively applied by nurses at BIDMC. Patients with high OSA risk are then flagged in the medical record, and electronic decision support options are provided to clinicians.
Over 200,000 adult patients undergoing non-cardiac surgery
between 2008-2017 were evaluated. Patients with an ASA classification of 6 or
undergoing multiple surgical procedures in one day were excluded. 9.6% of these
were classified as high risk for OSA by BOSTN score and 1.5% of these required
postoperative mechanical ventilation within 7 days after surgery.
Patients with BOSTN ≥ 2 and STOP-BANG ≥ 5 showed lower odds for postoperative mechanical ventilation (aOR 0.58). Patients with BOSTN ≥ 2 were discharged earlier (aIRR 0.65) and were less frequently readmitted within 30 days (aOR 0.91).
C-statistics revealed an excellent diagnostic ability of both BOSTN and STOP-BANG for postoperative mechanical ventilation requirement and the predictive performance of the two tools was comparable.
The authors conclude that clinical implementation of the BOSTN screening, paired with a decision support system in the electronic medical record, a flag of BOSTN ≥ 2 is associated with improved respiratory complication rates and decreased hospital utilization rates.
We consider preoperative screening for OSA one the most important pieces of a good pre-op evaluation (see our August 17, 2010 Patient Safety Tip of the Week Preoperative Consultation Time to Change). The STOP-Bang score is still the gold standard but we expect to see a lot more using the BOSTN score.
Our prior columns on obstructive sleep apnea in the perioperative period and other acute settings:
June 10, 2008 Monitoring the Postoperative COPD Patient
August 18, 2009 Obstructive Sleep Apnea in the Perioperative Period
August 17, 2010 Preoperative Consultation Time to Change
July 13, 2010 Postoperative Opioid-Induced Respiratory Depression
November 2010 More on Preoperative Screening for Obstructive Sleep Apnea
February 22, 2011 Rethinking Alarms
November 22, 2011 Perioperative Management of Sleep Apnea Disappointing
May 22, 2012 Update on Preoperative Screening for Sleep Apnea
February 12, 2013 CDPH: Lessons Learned from PCA Incident
February 19, 2013 Practical Postoperative Pain Management
March 26, 2013 Failure to Recognize Sleep Apnea Before Surgery
September 24, 2013 Perioperative Use of CPAP in OSA
May 13, 2014 Perioperative Sleep Apnea: Human and Financial Impact
March 3, 2015 Factors Related to Postoperative Respiratory Depression
August 18, 2015 Missing Obstructive Sleep Apnea
June 7, 2016 CPAP for Hospitalized Patients at High Risk for OSA
October 11, 2016 New Guideline on Preop Screening and Assessment for OSA
November 21, 2017 OSA, Oxygen, and Alarm Fatigue
July 17, 2018 OSA Screening in Stroke Patients
Raub D, Nabel S, Rostin P, et al. Validation of the Boston Score, A Clinically Established Preoperative Prediction Instrument to Quantify Obstructive Sleep Apnea. 2018 Annual Meeting of the American Society of Anesthesiologists (abstract A2266).
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