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OBSTRUCTIVE SLEEP APNEA (OSA)

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Title: OBSTRUCTIVE SLEEP APNEA (OSA)


1
OBSTRUCTIVE SLEEP APNEA (OSA)
  • Created By St. James Healthcare
  • Education Collaborative
  • Butte, Montana
  • Nursing Learning Module

2
OSA LEARNING MODULE GOALS
  • 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
    post-procedurally or post-operatively.
  • Identify three things that will change your
    everyday practice.

3
OSA TEST YOUR KNOWLEDGE (True/False)
  • 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.

4
OSA INTRODUCTION
  • 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.

5
OSA IMPORTANCE OF SCREENING
  • Suspect OSA if a patient responds positively to
    screening questions about snoring and excessive
    daytime sleepiness
  • Be aware that _at_ 12 to 18 million Americans suffer
    from OSA, and that the majority with moderate to
    severe OSA are undiagnosed 

6
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.

7
OSA DIAGNOSIS
  • 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)

8
OSA UNDERLYING CAUSES
  • 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.

9
OSA CYCLE OF HYPOXIA
  • 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

10
OSA A CYCLE OF SLEEPLESSNESS
  • Hypoxia
  • Hypercarbia
  • Brain says Wake Up!
  • Tired During the Day

11
OSA MEDICAL RISKS
  • 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

12
OSA HOW DO WE SCREEN?
  • 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

13
OSA PHYSICAL ASSESSMENT
  • 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

14
OSA PATIENT HISTORY
  • 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

15
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

16
OSA IMPACT OF NARCOTICS
17
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. 

18
OSA Case Example
  • 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?

19
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 pre-admission 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?

20
OSA HISTORY PREVENTION
  • 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 

21
OSA OTHER SOLUTIONS
22
OSA OTHER SOLUTIONS
  • Consider the application of a high flow nasal
    cannula or mask for mild to moderate sleep apnea

23
OSA SJH POLICY
  • EtCO2 Monitoring (End-Tital CO2) with PCA
    (Patient-Controlled Analgesia)
  • Policy V-A 72
  • Reference Cards are available for monitoring
    set-up

24
OSA Modified Ramsay Scale
  • 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

25
OSA NARCOTICS MONITORING
  • 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

26
OSA PATIENT DISCHARGE
  • 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.

27
  • References
  • American Society of Anesthesiologists (2006).
    Practice Guidelines for the Perioperative
    Management of Patients with Obstructive Sleep
    Apnea. Anesthesiology 2006 104108193.
  • American Society of Anesthesiologists (2008).
    STOP Questionnaire A Tool To Screen Patients For
    Obstructive Sleep Apnea. Anesthesiology
    2008108 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 May20(5)836-7. 
  • Moos DD. (2006). Obstructive sleep apnea and
    sedation in the endoscopy suite. Gastroenterol
    Nurs. 2006 Nov-Dec29(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. 200427(3)121-124.


28
OSA TEST YOUR KNOWLEDGE (TRUE/FALSE)
  • 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.

29
Susan DePasquale, CGRN, MSN Peer Reviewed by
Cheryl Stensrud, MSN and Phil Dean, RN (2011)
  • Identify three things that will change your
    everyday practice.
  • Thank You!

May you have restful sleep happy
dreams
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