The B‐APNEIC score as a reliable tool to guide clinical practice: a reply

We thank Liu and Qiu for their comments 1 on our study validating the B-APNEIC score 2. We agree that ethnicity-related craniofacial morphology represents an important anthropometric characteristic and is an independent risk factor for obstructive sleep apnoea. Future validation efforts should therefore incorporate race and ethnicity into their data collection and analytical frameworks. Regarding the study by Chan et al. 3, we wish to provide a more precise interpretation of the findings. They conducted a prospective study of 1200 patients undergoing non-cardiac surgery, stratified into mild, moderate and severe obstructive sleep apnoea groups based on pre-operative sleep monitoring 3. The primary outcome was a composite of: myocardial injury; cardiac death; heart failure; thromboembolism; atrial fibrillation; and stroke within 30 days postoperatively. As noted by Liu and Qiu, each severity category showed a distinct proportion of adverse cardiovascular events: 30% severe; 22% moderate; and 19% mild, highlighting the clinical relevance of graded risk assessment. However, these crude estimates did not account for potential confounders. Following multivariable adjustment using a Cox proportional hazards model, only severe obstructive sleep apnoea remained independently associated with the composite cardiovascular outcome 3. These findings align with the subsequent meta-analysis by Sun et al., which similarly identified severe obstructive sleep apnoea as the category associated with a significant increase in postoperative respiratory complications 4. We emphasise that peri-operative respiratory risk is multifactorial and dynamic, underscoring the necessity of sustained clinical vigilance throughout the peri-operative period. Nevertheless, we believe that adopting a risk-stratification approach focused on severe obstructive sleep apnoea is the most suitable framework for guiding peri-operative resource allocation. Our findings continue to support the utility of the B-APNEIC score in identifying patients at risk of severe obstructive sleep apnoea, consistent with current evidence showing the disproportionate peri-operative burden associated with obstructive sleep apnoea. Future studies that incorporate more ethnically diverse populations and examine postoperative outcomes across the full spectrum of obstructive sleep apnoea severity will be important for strengthening score generalisability and refining its peri-operative application.