Safety of restarting continuous positive airway pressure (CPAP) therapy following endoscopic endonasal skull base surgery

Abstract

ObjectivesPatients with obstructive sleep apnea (OSA) are at increased risk of perioperative and postoperative morbidity. The use of continuous positive airway pressure (CPAP) in the perioperative period may be of potential benefit. However, among patients who have undergone endonasal skull base surgery, many surgeons avoid prompt re‐initiation of CPAP therapy due to the theoretical increased risk of epistaxis, excessive dryness, pneumocephalus, repair migration, intracranial introduction of bacteria, and cerebrospinal fluid (CSF) leak. The objective of this article is to review the most up‐to‐date literature regarding when it is safe to resume CPAP usage in the patient undergoing endonasal skull base surgery.Data Sources and MethodsThis review combines the most recent literature as queried through PubMed regarding the safety of CPAP resumption following endonasal skull base surgery.ResultsRecent surveys of skull base surgeons demonstrate little consensus regarding the post‐operative management of OSA. Recent cadaveric studies suggest that approximately 85% of delivered CPAP pressures are transmitted to the sphenoid sinus. Further, at frequently prescribed CPAP pressure settings, common sellar reconstruction techniques maintain their integrity while preventing very little transmission of pressure into the sella. In small retrospective case series, patients with OSA who received CPAP immediately following transsphenoidal pituitary surgery had similar rates of surgical complications as OSA patients who did not receive CPAP in the immediate post‐operative period. Concerns of re‐initiating CPAP too early, such as the development of pneumocephalus, rarely develop.ConclusionsThere remains a paucity of objective data regarding when it is safe to resume CPAP following endonasal skull base surgery. Recent cadaveric studies and small retrospective case series suggest that it may be safe to resume CPAP earlier than is often practiced following endonasal skull base surgery.

Uninterrupted use of continuous positive airway pressure after endoscopic endonasal approach for pituitary tumors

“…CPAP users are a unique subset in this population who are particularly prone to these issues. 2 The incidence of perioperative cardiopulmonary complications increases two-to threefold with OSA, and a majority of events (>80%) occur within the first 24 h, emphasizing the need for vigilant monitoring and consideration of CPAP reinitiation at earlier timeframes. 10 Some functioning pituitary adenomas exert direct hormonal influences on body mass index (BMI), which can lead to higher incidence of OSA in this patient population.…”

“…The safety and efficacy of anterior skull base surgery has been repeatedly established; therefore, treatment teams are moving toward minimizing morbidity and maximizing functional and quality‐of‐life (QOL) outcomes. CPAP users are a unique subset in this population who are particularly prone to these issues 2 10 .…”

“…Resultant bony and/or dural surgical defects raise concern for timing of CPAP resumption given the theoretical increased risk of pneumocephalus, disruption of skull base repair, cerebrospinal fluid (CSF) leak, and epistaxis. 1,2 However, OSA patients have a higher risk of postoperative hypoxemia and cardiopulmonary complications which may be mitigated with CPAP use. 3 Reinitiation of CPAP after endoscopic endonasal approaches (EEA) to pituitary pathology lacks consensus among experts; practices vary widely and are often based on individual surgeon experience.…”

“…3 Reinitiation of CPAP after endoscopic endonasal approaches (EEA) to pituitary pathology lacks consensus among experts; practices vary widely and are often based on individual surgeon experience. 2 Few studies which have investigated this are based solely on practice pattern surveys or cadaveric models. [4][5][6][7][8] This knowledge gap is often cited as an area for future research.…”

“…An estimated eight‐million US adults rely on continuous positive airway pressure (CPAP) to treat obstructive sleep apnea (OSA), which poses a challenge for skull base surgeons in the perioperative period. Resultant bony and/or dural surgical defects raise concern for timing of CPAP resumption given the theoretical increased risk of pneumocephalus, disruption of skull base repair, cerebrospinal fluid (CSF) leak, and epistaxis 1,2 . However, OSA patients have a higher risk of postoperative hypoxemia and cardiopulmonary complications which may be mitigated with CPAP use 3 …”