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OBSTRUCTIVE SLEEP APNEA

(OSA)

Created By: St. James Healthcare


Education Collaborative
Butte, Montana
Nursing Learning Module

To understand the challenge of OSA in a procedural


or perioperative area.

Identify risk factors that influence the planning of a


medication regime post procedure or post
operatively.

Know the ASA recommendations for OSA postprocedurally or post-operatively.

Identify three things that will change your everyday


practice.

OSA: LEARNING MODULE GOALS

1. OSA affects mostly females who are obese.


2. Patients with OSA may not be diagnosed prior to a
surgical or diagnostic procedure.
3. All professional bodies have published standard
guidelines for patients with OSA.

Care of the OSA patient may become challenging post


procedure if the medication regimen does not factor
in that patients with OSA are at greater risk of
airway compromise during analgesia and sedation.

OSA: INTRODUCTION

Suspect OSA if a patient responds positively to


screening questions about snoring and excessive
daytime sleepiness;

Be aware that @ 12 to 18 million Americans suffer


from OSA, and that the majority with moderate to
severe OSA are undiagnosed;

OSA: IMPORTANCE OF SCREENING

There is a potential increased risk of airway


compromise if OSA has not been fully evaluated prior
to medication administration of narcotics / sedation.

OSA: IMPORTANCE OF SCREENING

Diagnosis is by a sleep study - measures the number


of episodes of apnea (stops breathing for 10 seconds
or more) as well as other factors developed by sleep
medicine specialists;

The diagnosis of OSA can be :


- Mild
- Moderate
- Severe (usually requires CPAP)

OSA: DIAGNOSIS

The muscles of the pharynx relax during stages of


deep sleep, reducing the size of the airway which
does not normally cause OSA.
People with sleep apnea have airways that are
narrower and more collapsible than normal.

OSA: UNDERLYING CAUSES

Pharyngeal muscles relax and the airway obstructs;

Hypoxemia and Hypercarbia result in central nervous


system activations;

Partial arousal occurs and normal ventilation is resumed;

Sequence typically repeats several times a night, disrupting


the normal sleep cycle;

Sleep apnea is usually a chronic condition;

Episodes lasting longer than 10 seconds and occurring


more than 5 to 7 times an hour leads to serious health
problems;

OSA: CYCLE OF HYPOXIA

Hypoxia

Hypercarbia
Brain says Wake Up!
Tired During the Day

OSA: A CYCLE OF SLEEPLESSNESS

Daytime sleepiness

Impaired cognition

Anxiety / Depression

Increased risk of occupational and motor vehicle


accidents

Hypertension

Heart failure

Cardiac arrhythmias (i.e., Atrial Fibrillation)

Angina

Heart attack

OSA: MEDICAL RISKS

Patients with OSA who undergo anesthesia and/or


sedation may not have received a formal diagnosis of the
condition prior to a procedure;

In the absence of a sleep study, the possibility of sleep


apnea should be assessed based on:

physical characteristics (in particular upper body


obesity);
medical history;
interviews with patients family members regarding snoring
and sleep patterns;

Many patients that don't look like they should have OSA
(because they are not overweight with a thick neck) do in
fact have OSA;

OSA: HOW DO WE SCREEN?

Physical characteristics:
Obesity (BMI greater than 35)
Neck circumference greater than 17
inches for men or 16 inches for women
Craniofacial abnormalities
Anatomical nasal obstruction
Tonsillar hypertrophy

OSA: PHYSICAL ASSESSMENT

Investigate whether the patient has two or more of the


following observed during their sleep; or, one or more of
the following (if not observed during sleep):
Snoring loud enough to be heard through a closed
door;
Frequent snoring;
Observed pauses in breathing during sleep;
Awakens from sleep with a choking sensation;
Frequent arousals from sleep;

OSA: PATIENT HISTORY

Somnolence (one or more of the following) Frequent daytime sleepiness or fatigue despite
adequate sleep;
Falls asleep frequently in non-stimulating
environment;

OSA: PATIENT HISTORY

OSA: IMPACT OF NARCOTICS

OSA patients are more sensitive to the effects of


analgesia/sedation;

Upper airway obstruction may occur after small to


moderate doses of pain/anxiolytic medication;

Decreased muscle tone of the upper airway and


increased airway resistance;

Airway collapse;

Interferes with the survival mechanism that normally


arouses an individual during an apneic period.

OSA: IMPACT OF NARCOTICS

Male patient, age 50, with a present medical


condition of a large back wound with frequent
debridements and Wound VAC.

History: Morbidly obese, chronic back pain and


surgical incisional pain (from spine surgery). Has
been depressed, fatigued, and on long-term oral pain
medication. No history of OSA. Patient thinks he
might snore. Social situation, he lives alone.

Question: How would you screen for OSA during


your nursing admission history?

OSA: Case Example

Female patient, 25 years old, post lap chole with a common


bile duct stone removed after ERCP;

Pre-procedure: anxiety level high, c/o feeling tired all of


the time, denies sleep apnea when asked during the preadmission assessment;

Post-procedure: apneic periods observed and when patient


is more awake she finally shares with the health team that
a sleep study was recommended by her PCP to confirm
sleep apnea level and treatment plan;

Self-Reflection: What else might have been done in


addition to asking the patient whether they had sleep
apnea prior to a surgical/endoscopic procedure?

OSA: Case Example

Does the patient use a CPAP (Continuous Positive


Airway Pressure) machine at home?

Solution: If Yes, consider using the patients CPAP to


support breathing while on a pain control device or
during a procedure requiring analgesia/sedation to
keep the upper airway more open and decrease
apneic periods caused by sedation;

OSA: HISTORY & PREVENTION

OSA: OTHER SOLUTIONS

Consider the application of a high flow nasal cannula


or mask for mild to moderate sleep apnea

OSA: OTHER SOLUTIONS

EtCO2 Monitoring (End-Tital CO2) with PCA (PatientControlled Analgesia);

Policy # V-A 72;

Reference Cards are available for monitoring set-up;

OSA: SJH POLICY

Modified Ramsay Scale:

Minimal Sedation i.e. anxiolysis (1-2, rates level of


anxiety and ability to cooperate/remain tranquil)

Moderate Sedation/Analgesia (3, responds with a normal


tone of voice)

Deep Sedation/Analgesia (4 6, responsive to light tactile


or loud auditory stimulus to no response to stimulus)

Click in box to allow SJH Policy and definition of


Modified Ramsay Sedation Scale:

OSA: Modified Ramsay Scale

Current guidelines on moderate sedation for patients


with OSA undergoing certain diagnostic tests, i.e.
endoscopy or interventional radiology may be
lacking;

The American Society of Anesthesiologists (ASA)


advises use of CO2 monitoring during administration
of analgesia/sedation during the peri-operative
period;

Emergency equipment should be immediately


accessible to staff in the event of respiratory
complications;

OSA: NARCOTICS & MONITORING

Patients at risk of OSA should have someone stay


with them for 24 hours following discharge after a
procedural sedation or outpatient anesthesia;

Patients who have been diagnosed with OSA should


be encouraged to use their CPAP machine when
resting at home.

OSA: PATIENT DISCHARGE

References
American Society of Anesthesiologists (2006). Practice Guidelines for the
Perioperative Management of Patients with Obstructive Sleep Apnea.
Anesthesiology: 2006; 104:108193.
American Society of Anesthesiologists (2008). STOP Questionnaire: A
Tool To Screen Patients For Obstructive Sleep Apnea. Anesthesiology:
2008;108: 812-821.
ASGE (2009). Sedation Facts. Retrieved online 10/05/2009 at
www.sedationfacts.org...
Gazayerli M et al (2006). A correlation between the shape of the
epiglottis and obstructive sleep apnea. Surg Endosc. 2006
May;20(5):836-7.
Moos DD. (2006). Obstructive sleep apnea and sedation in the endoscopy
suite. Gastroenterol Nurs. 2006 Nov-Dec;29(6):456-63.
Ramachandran, S.K. and Josephs, L. (2009). A Meta-analysis of Clinical
Screening Tests for Obstructive Sleep Apnea. Anesthesiology. 2009; 110:
928-939.
Villegas T. (2004). Sleep apnea and moderate sedation. Gastroenterol
Nurs. 2004;27(3):121-124.

1. OSA affects mostly females who are obese.


2. Patients with OSA may not be diagnosed prior to a
surgical or diagnostic procedure.
3. All professional bodies have published standard
guidelines for patients with OSA.

OSA: TEST YOUR KNOWLEDGE (TRUE/FALSE)

Identify three things that will change your


everyday practice.
Thank You!

~ May you have restful sleep & happy dreams ~

Susan DePasquale, CGRN, MSN


Peer Reviewed by Cheryl Stensrud, MSN and Phil Dean, RN
(2011)