Documento de Consenso na Abordagem Peri-operatória do Doente com Síndrome de Apneia Obstrutiva do Sono
DOI:
https://doi.org/10.25751/rspa.18628Palavras-chave:
Apneia Obstrutiva do Sono; Cuidados Peri-operatóriosResumo
A síndrome de apneia obstrutiva do sono (SAOS) é a patologia respiratória do sono mais prevalente a nível mundial. Estima-se que tenha uma prevalência na população em geral de entre 9% a 38% e uma taxa de subdiagnóstico que pode alcançar os 90%. A prevalência de SAOS na população proposta para cirurgia é superior à população em geral, apresentando maior incidência no subgrupo da cirurgia da obesidade, podendo atingir 80% dos doentes.
A SAOS é um fator de risco independente para o aumento da mortalidade na população em geral e está associada a um aumento do risco de complicações no período peri-operatório, mais elevado nos doentes não diagnosticados. Neste grupo de doentes, destaca-se a maior incidência de complicações cardiopulmonares, maior duração de tempo de internamento e necessidade de internamento em unidade de cuidados intensivos.
O presente documento resulta do trabalho conjunto da Sociedade Portuguesa de Anestesiologia (SPA) e da Sociedade Portuguesa de Pneumologia (SPP) e visa criar um documento de consenso nacional sobre a orientação de doentes com SAOS no período peri-operatório. Para o efeito foi nomeado um grupo de trabalho constituído por oito elementos indicados por cada uma das sociedades que procedeu a revisão das publicações mais recentes de grupos de trabalho internacionais. O contexto da realidade nacional foi tido em conta na elaboração deste consenso. A sua implementação deverá adequar-se à realidade de cada unidade hospitalar.
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Referências
1. Senaratna CV, Perret JL, Lodge CJ, Lowe AJ, Campbell BE, Matheson MC et al. Prevalence of obstructive sleep apnea in the general population: A systematic review. Sleep Med Rev. 2017; 34:70–81.
2. Seet E, Chung F. Management of sleep apnea in adults - functional algorithms for the perioperative period: Continuing Professional Development. Can J Anaesth. 2010;57:849-864.
3. Singh M, Liao P, Kobah S, Wijeysundera DN, Shapiro C, Chung F. Proportion of surgical patients with undiagnosed obstructive sleep apnoea. Br J Anaesth. 2013; 110(4):629–636.
4. Olson E, Chung F, Seet E. Surgical risk and the preoperative evaluation and management of adults with obstructive sleep apnea. UpToDate; consultado em Agosto 2018. Disponível em http://www.uptodate.com/home.
5. American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology. 2014; 120:268-286.
6. Chung F, Memtsoudis SG, Ramachandran SK, Nagappa M, Opperer M, Cozowicz C et al. Society of Anesthesia and Sleep Medicine Guidelines on Preoperative Screening and Assessment of Adult Patients With Obstructive Sleep Apnea. Anesth Analg. 2016; 123:452-73.
7. Seet E, Chung F. Perioperative clinical pathways to manage sleep-disordered breathing. Sleep Med Clin. 2013; 8:105-120
8. Nagappa M, Mokhlesi B, Wong J, Wong DT, Kaw R, Chung F. The Effects of Continuous Positive Airway Pressure on Postoperative Outcomes in Obstructive Sleep Apnea Patients Undergoing Surgery: A Systematic Review and Meta-analysis. Anesth Analg. 2015;120: 1013-1023.
9. Kaw R, Chung F, Pasupuleti V, Mehta J, Gay PC, Hernandez AV. Meta-analysis of the association between obstructive sleep apnoea and postoperative outcome. Br J Anaesth. 2012; 109:897-906.
10. Hai F, Porhomayon J, Vermont L, Frydrych L, Jaoude P, El-Solh AA. Postoperative complications in patients with obstructive sleep apnea: a meta-analysis. J Clin Anesth. 2014; 26:591-600.
11. Opperer M, Cozowicz C, Bugada D, Mokhlesi B, Kaw R, Auckley D, et al. Does Obstructive Sleep Apnea Influence Perioperative Outcome? A Qualitative Systematic Review for the Society of Anesthesia and Sleep Medicine Task Force on Preoperative Preparation of Patients with Sleep-Disordered Breathing. Anesth Analg. 2016; 122:1321-34.
12. Epstein LJ, Kristo D, Strollo PJ Jr, Friedman N, Malhotra A, Patil SP, et al; Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009; 5:263-76
13. De Hert S; Staender S; Fritsch G et al. Pre-operative evaluation of adults undergoing elective noncardiac surgery: Updated guideline from the European Society of Anaesthesiology. Eur J Anaesthesiol. 2018; 35:407–465.
14. Chung SA1, Yuan H, Chung F. A systemic review of obstructive sleep apnea and its implications for anesthesiologists. Anesth Analg. 2008;107:1543–63
15. Heinzer R, Vat S, Marques-Vidal P, Marti-Soler H, Andries D, Tobback N et al. Prevalence of sleep-disordered breathing in the general population: the HypnoLaus study. Lancet Respir Med. 2015; 3:310-8
16. R. Reis, F. Teixeira, V. Martins, L. Sousa, L. Batata, C. Santos, J. Moutinho. Validation of a Portuguese version of the STOP-Bang questionnaire as a screening tool for obstructive sleep apnea: Analysis in a sleep clinic. Rev Port Pneumol. 2015;21(2):61-8
17. Verbraecken J, Hedner J, Penzel T .Pre-operative screening for obstructive sleep apnoea. Eur Respir Rev. 2017; 26:160012.
18. Hinkelbein J1, Lamperti M, Akeson J, Santos J, Costa J, De Robertis E, et al. European Society of Anaesthesiology and European Board of Anaesthesiology guidelines for procedural sedation and analgesia in adults. Eur J Anaesthesiol. 2018;35:6-24.
19. Liao P, Luo Q, Elsaid H, Kang W, Shapiro CM, Chung F. Perioperative auto-titrated continuous positive airway pressure treatment in surgical patients with obstructive sleep apnea: a randomized controlled trial. Anesthesiology. 2013; 119(4):837-47.
20. Dawson D, Singh M, Chung F. The importance of obstructive sleep apnoea management in peri-operative medicine. Anaesthesia. 2016; 71:251–264.
21. Chung F, Nagappa M, Singh M, Mokhlesi B. CPAP in the Perioperative Setting: Evidence of Support. Chest. 2016; 149(2):586-597.
22. Nagappa M1, Patra J, Wong J, Subramani Y, Singh M, Ho G. Association of STOP-Bang questionnaire as a screening tool for sleep apnea and postoperative complications: a systematic review and Bayesian meta-analysis of prospective and retrospective cohort studies. Anesth Analg 2017; 125:1301–8.
23. Madhusudan P1, Wong J, Prasad A, Sadeghian E, Chung FF.An update on preoperative assessment and preparation of surgical patients with obstructive sleep apnea. Curr Opin Anaesthesiol. 2018;31(1):89-95.
24. Raveendran R1, Wong J, Singh M, Wong DT, Chung F. Obesity hypoventilation syndrome, sleep apnea, overlap syndrome: perioperative management to prevent complications. Curr Opin Anaesthesiol. 2017; 30(1):146-155.
25. Direção-Geral da Saúde. Orientação nº 022/2014 atualizada a 28/11/2016. Consultada em 15/08/2018. Disponível em https://www.dgs.pt/directrizes-da-dgs/orientacoes-e-circulares-informativas/orientacao-n-0222014-de30122014. aspx.
26. Joshi GP, Ankichetty SP, Gan TJ, Chung F.Society for Ambulatory Anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery. Anesth Analg. 2012; 115(5):1060-8.
27. Chung F. It may be unsafe for patients with untreated severe OSA requiring postoperative narcotic to undergo ambulatory surgery. J Clin Sleep Med. 2011 15;7(1):111-113.
28. Carmona C, Vieira V, Marcos A, Silva Pinto JM. Recommendations for the Anesthetic Approach of the Obese Patient in Ambulatory Surgery. Rev Soc Port Anestesiol. 2017; 26:42-51
29. Memtsoudis SG, Cozowicz C, Nagappa M, Wong J, Joshi GP, Wong DT et al. Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea. Anesth Analg. 2018; 127(4):967-987.
30. Sabaté JM, Jouët P, Merrouche M, Pouzoulet J, Maillard D, Harnois F et al. Gastroesophageal reflux in patients with morbid obesity: a role of obstructive sleep apnea syndrome? Obes Surg. 2008; 18:1479-84.
31. Memtsoudis SG, Stundner O, Rasul R, Sun X, Chiu YL, Fleischut P et al. Sleep apnea and total joint arthroplasty under various types of anesthesia: a population-based study of perioperative outcomes. Reg Anesth Pain Med. 2013; 38:274-81.
32. Siyam MA, Benhamou D.Difficult endotracheal intubation in patients with sleep apnea syndrome. Anesth Analg. 2002; 95:1098-102.
33. Gupta K, Prasad A, Nagappa M, Wong J, Abrahamyan L, Chung FF. Risk factors for opioid-induced respiratory depression and failure to rescue: a review. Curr Opin Anaesthesiol. 2018;31:110-119.
34. Bernards CM, Knowlton SL, Schmidt DF, DePaso WJ, Lee MK, McDonald SB et al.Respiratory and sleep effects of remifentanil in volunteers with moderate obstructive sleep apnea. Anesthesiology. 2009;110:41-9.
35. Lam KK, Kunder S, Wong J, Doufas AG, Chung F. Obstructive sleep apnea, pain, and opioids: is the riddle solved? Curr Opin Anaesthesiol. 2016;29:134-40.
36. Mulier JP. Perioperative opioids aggravate obstructive breathing in sleep apnea syndrome: mechanisms and alternative anesthesia strategies. Curr Opin Anaesthesiol. 2016; 29:129-33
37. Subramani Y, Nagappa M, Wong J, Patra J, Chung F. Death or near-death in patients with obstructive sleep apnoea: a compendium of case reports of critical complications. Br J Anaesth. 2017; 119(5):885-899
38. Hafeez KR, Tuteja A, Singh M, Wong D, Nagappa M, Chung F, Wong J. Postoperative complications with neuromuscular blocking drugs and/or reversal agents in obstructive sleep apnea patients: a systematic review. BMC Anesthesiol. 2018 18:91.
39. Hristovska AM, Duch P, Allingstrup M, Afshari A. Efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade in adults. Cochrane Database Syst Rev. 2017;8:CD012763
40. Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG et al; American Society of Anesthesiologists Task Force on Management of the Difficult Airway.Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013 Feb;118:251-70.
41. de Raaff CAL, Gorter-Stam MAW, de Vries N, Sinha AC, Jaap Bonjer H, Chung F et al. Perioperative management of obstructive sleep apnea in bariatric surgery: a consensus guideline. Surg Obes Relat Dis. 2017;13:1095-1109
42. Sato Y, Ikeda A, Ishikawa T, Isono S. How can we improve mask ventilation in patients with obstructive sleep apnea during anesthesia induction? J Anesth. 2013;27:152-6.
43. Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics. Anesthesiology. 2009;110:891-7.
44. Meoli AL, Rosen CL, Kristo D, Kohrman M, Gooneratne N, Aguillard RN et al; Clinical Practice Review Committee; American Academy of Sleep Medicine.Upper airway management of the adult patient with obstructive sleep apnea in the perioperative period--avoiding complications. Sleep. 2003;26:1060-5.
45. Lam T, Singh M, Yadollahi A, Chung F. Is Perioperative Fluid and Salt Balance a Contributing Factor in Postoperative Worsening of Obstructive Sleep Apnea? Anesth Analg. 2016;122:1335-9.
46. Tong S, Gower J, Morgan A, Gadbois K, Wisbach G. Noninvasive positive pressure ventilation in the immediate post-bariatric surgery care of patients with obstructive sleep apnea: a systematic review. Surg Obes Relat Dis. 2017;13:1227-1233.
47. Fu ES, Downs JB, Schweiger JW, Miguel RV, Smith RA. Supplemental oxygen impairs detection of hypoventilation by pulse oximetry. Chest. 2004; 126(5):1552-8.
48. Hillman DR, Chung F. Anaesthetic management of sleep-disordered breathing in adults. Respirology. 2017; 22:230-239.
49. Berry, R. Respiratory event detection by a positive airway pressure device. Sleep. 2012; 35(3).
2. Seet E, Chung F. Management of sleep apnea in adults - functional algorithms for the perioperative period: Continuing Professional Development. Can J Anaesth. 2010;57:849-864.
3. Singh M, Liao P, Kobah S, Wijeysundera DN, Shapiro C, Chung F. Proportion of surgical patients with undiagnosed obstructive sleep apnoea. Br J Anaesth. 2013; 110(4):629–636.
4. Olson E, Chung F, Seet E. Surgical risk and the preoperative evaluation and management of adults with obstructive sleep apnea. UpToDate; consultado em Agosto 2018. Disponível em http://www.uptodate.com/home.
5. American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology. 2014; 120:268-286.
6. Chung F, Memtsoudis SG, Ramachandran SK, Nagappa M, Opperer M, Cozowicz C et al. Society of Anesthesia and Sleep Medicine Guidelines on Preoperative Screening and Assessment of Adult Patients With Obstructive Sleep Apnea. Anesth Analg. 2016; 123:452-73.
7. Seet E, Chung F. Perioperative clinical pathways to manage sleep-disordered breathing. Sleep Med Clin. 2013; 8:105-120
8. Nagappa M, Mokhlesi B, Wong J, Wong DT, Kaw R, Chung F. The Effects of Continuous Positive Airway Pressure on Postoperative Outcomes in Obstructive Sleep Apnea Patients Undergoing Surgery: A Systematic Review and Meta-analysis. Anesth Analg. 2015;120: 1013-1023.
9. Kaw R, Chung F, Pasupuleti V, Mehta J, Gay PC, Hernandez AV. Meta-analysis of the association between obstructive sleep apnoea and postoperative outcome. Br J Anaesth. 2012; 109:897-906.
10. Hai F, Porhomayon J, Vermont L, Frydrych L, Jaoude P, El-Solh AA. Postoperative complications in patients with obstructive sleep apnea: a meta-analysis. J Clin Anesth. 2014; 26:591-600.
11. Opperer M, Cozowicz C, Bugada D, Mokhlesi B, Kaw R, Auckley D, et al. Does Obstructive Sleep Apnea Influence Perioperative Outcome? A Qualitative Systematic Review for the Society of Anesthesia and Sleep Medicine Task Force on Preoperative Preparation of Patients with Sleep-Disordered Breathing. Anesth Analg. 2016; 122:1321-34.
12. Epstein LJ, Kristo D, Strollo PJ Jr, Friedman N, Malhotra A, Patil SP, et al; Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009; 5:263-76
13. De Hert S; Staender S; Fritsch G et al. Pre-operative evaluation of adults undergoing elective noncardiac surgery: Updated guideline from the European Society of Anaesthesiology. Eur J Anaesthesiol. 2018; 35:407–465.
14. Chung SA1, Yuan H, Chung F. A systemic review of obstructive sleep apnea and its implications for anesthesiologists. Anesth Analg. 2008;107:1543–63
15. Heinzer R, Vat S, Marques-Vidal P, Marti-Soler H, Andries D, Tobback N et al. Prevalence of sleep-disordered breathing in the general population: the HypnoLaus study. Lancet Respir Med. 2015; 3:310-8
16. R. Reis, F. Teixeira, V. Martins, L. Sousa, L. Batata, C. Santos, J. Moutinho. Validation of a Portuguese version of the STOP-Bang questionnaire as a screening tool for obstructive sleep apnea: Analysis in a sleep clinic. Rev Port Pneumol. 2015;21(2):61-8
17. Verbraecken J, Hedner J, Penzel T .Pre-operative screening for obstructive sleep apnoea. Eur Respir Rev. 2017; 26:160012.
18. Hinkelbein J1, Lamperti M, Akeson J, Santos J, Costa J, De Robertis E, et al. European Society of Anaesthesiology and European Board of Anaesthesiology guidelines for procedural sedation and analgesia in adults. Eur J Anaesthesiol. 2018;35:6-24.
19. Liao P, Luo Q, Elsaid H, Kang W, Shapiro CM, Chung F. Perioperative auto-titrated continuous positive airway pressure treatment in surgical patients with obstructive sleep apnea: a randomized controlled trial. Anesthesiology. 2013; 119(4):837-47.
20. Dawson D, Singh M, Chung F. The importance of obstructive sleep apnoea management in peri-operative medicine. Anaesthesia. 2016; 71:251–264.
21. Chung F, Nagappa M, Singh M, Mokhlesi B. CPAP in the Perioperative Setting: Evidence of Support. Chest. 2016; 149(2):586-597.
22. Nagappa M1, Patra J, Wong J, Subramani Y, Singh M, Ho G. Association of STOP-Bang questionnaire as a screening tool for sleep apnea and postoperative complications: a systematic review and Bayesian meta-analysis of prospective and retrospective cohort studies. Anesth Analg 2017; 125:1301–8.
23. Madhusudan P1, Wong J, Prasad A, Sadeghian E, Chung FF.An update on preoperative assessment and preparation of surgical patients with obstructive sleep apnea. Curr Opin Anaesthesiol. 2018;31(1):89-95.
24. Raveendran R1, Wong J, Singh M, Wong DT, Chung F. Obesity hypoventilation syndrome, sleep apnea, overlap syndrome: perioperative management to prevent complications. Curr Opin Anaesthesiol. 2017; 30(1):146-155.
25. Direção-Geral da Saúde. Orientação nº 022/2014 atualizada a 28/11/2016. Consultada em 15/08/2018. Disponível em https://www.dgs.pt/directrizes-da-dgs/orientacoes-e-circulares-informativas/orientacao-n-0222014-de30122014. aspx.
26. Joshi GP, Ankichetty SP, Gan TJ, Chung F.Society for Ambulatory Anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery. Anesth Analg. 2012; 115(5):1060-8.
27. Chung F. It may be unsafe for patients with untreated severe OSA requiring postoperative narcotic to undergo ambulatory surgery. J Clin Sleep Med. 2011 15;7(1):111-113.
28. Carmona C, Vieira V, Marcos A, Silva Pinto JM. Recommendations for the Anesthetic Approach of the Obese Patient in Ambulatory Surgery. Rev Soc Port Anestesiol. 2017; 26:42-51
29. Memtsoudis SG, Cozowicz C, Nagappa M, Wong J, Joshi GP, Wong DT et al. Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea. Anesth Analg. 2018; 127(4):967-987.
30. Sabaté JM, Jouët P, Merrouche M, Pouzoulet J, Maillard D, Harnois F et al. Gastroesophageal reflux in patients with morbid obesity: a role of obstructive sleep apnea syndrome? Obes Surg. 2008; 18:1479-84.
31. Memtsoudis SG, Stundner O, Rasul R, Sun X, Chiu YL, Fleischut P et al. Sleep apnea and total joint arthroplasty under various types of anesthesia: a population-based study of perioperative outcomes. Reg Anesth Pain Med. 2013; 38:274-81.
32. Siyam MA, Benhamou D.Difficult endotracheal intubation in patients with sleep apnea syndrome. Anesth Analg. 2002; 95:1098-102.
33. Gupta K, Prasad A, Nagappa M, Wong J, Abrahamyan L, Chung FF. Risk factors for opioid-induced respiratory depression and failure to rescue: a review. Curr Opin Anaesthesiol. 2018;31:110-119.
34. Bernards CM, Knowlton SL, Schmidt DF, DePaso WJ, Lee MK, McDonald SB et al.Respiratory and sleep effects of remifentanil in volunteers with moderate obstructive sleep apnea. Anesthesiology. 2009;110:41-9.
35. Lam KK, Kunder S, Wong J, Doufas AG, Chung F. Obstructive sleep apnea, pain, and opioids: is the riddle solved? Curr Opin Anaesthesiol. 2016;29:134-40.
36. Mulier JP. Perioperative opioids aggravate obstructive breathing in sleep apnea syndrome: mechanisms and alternative anesthesia strategies. Curr Opin Anaesthesiol. 2016; 29:129-33
37. Subramani Y, Nagappa M, Wong J, Patra J, Chung F. Death or near-death in patients with obstructive sleep apnoea: a compendium of case reports of critical complications. Br J Anaesth. 2017; 119(5):885-899
38. Hafeez KR, Tuteja A, Singh M, Wong D, Nagappa M, Chung F, Wong J. Postoperative complications with neuromuscular blocking drugs and/or reversal agents in obstructive sleep apnea patients: a systematic review. BMC Anesthesiol. 2018 18:91.
39. Hristovska AM, Duch P, Allingstrup M, Afshari A. Efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade in adults. Cochrane Database Syst Rev. 2017;8:CD012763
40. Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG et al; American Society of Anesthesiologists Task Force on Management of the Difficult Airway.Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013 Feb;118:251-70.
41. de Raaff CAL, Gorter-Stam MAW, de Vries N, Sinha AC, Jaap Bonjer H, Chung F et al. Perioperative management of obstructive sleep apnea in bariatric surgery: a consensus guideline. Surg Obes Relat Dis. 2017;13:1095-1109
42. Sato Y, Ikeda A, Ishikawa T, Isono S. How can we improve mask ventilation in patients with obstructive sleep apnea during anesthesia induction? J Anesth. 2013;27:152-6.
43. Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics. Anesthesiology. 2009;110:891-7.
44. Meoli AL, Rosen CL, Kristo D, Kohrman M, Gooneratne N, Aguillard RN et al; Clinical Practice Review Committee; American Academy of Sleep Medicine.Upper airway management of the adult patient with obstructive sleep apnea in the perioperative period--avoiding complications. Sleep. 2003;26:1060-5.
45. Lam T, Singh M, Yadollahi A, Chung F. Is Perioperative Fluid and Salt Balance a Contributing Factor in Postoperative Worsening of Obstructive Sleep Apnea? Anesth Analg. 2016;122:1335-9.
46. Tong S, Gower J, Morgan A, Gadbois K, Wisbach G. Noninvasive positive pressure ventilation in the immediate post-bariatric surgery care of patients with obstructive sleep apnea: a systematic review. Surg Obes Relat Dis. 2017;13:1227-1233.
47. Fu ES, Downs JB, Schweiger JW, Miguel RV, Smith RA. Supplemental oxygen impairs detection of hypoventilation by pulse oximetry. Chest. 2004; 126(5):1552-8.
48. Hillman DR, Chung F. Anaesthetic management of sleep-disordered breathing in adults. Respirology. 2017; 22:230-239.
49. Berry, R. Respiratory event detection by a positive airway pressure device. Sleep. 2012; 35(3).
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2019-12-28
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Almeida, A. L., Santos, A., Teixeira, F., Drummond, M., Órfão, R., Moreira, S., Sousa, S., & Taleço, T. (2019). Documento de Consenso na Abordagem Peri-operatória do Doente com Síndrome de Apneia Obstrutiva do Sono. Revista Da Sociedade Portuguesa De Anestesiologia, 28(4), 238–248. https://doi.org/10.25751/rspa.18628
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