The application of 5E rehabilitation management mode in the nursing of patients with aortic dissection complicated by obstructive sleep apnea.

OBJECTIVE: This study was designed to explore the effect of 5E rehabilitation mode (encouragement, education, exercise, employment, and evaluation) in patients with aortic dissection (AD) complicated by obstructive sleep apnea (OSA). METHODS: Patients with Stanford type B AD (TBAD) complicated by OSA were admitted to Guangdong Provincial People's Hospital from January 2019 to December 2020. They were randomly divided into an experimental group and a control group. After discharge, patients in the control group were given routine nursing and follow-up education, whereas patients in the experimental group were given 5E rehabilitation management mode-based nursing and follow-up education. Upon the nursing intervention, the differences in polysomnography (PSG) parameters, medication adherence, quality of life, blood pressure, and heart rate of patients between the two groups were compared. Logistic regression analysis was performed to evaluate the risk factors for the occurrence of adverse aortic events. RESULTS: A total of 89 patients were enrolled, 49 in the experimental group and 40 in the control group. After the intervention, the control of heart rate, systolic blood pressure, medication adherence, PSG parameters, and quality of life scores in the experimental group were significantly better than those in the control group (P<0.05). The incidence of adverse aortic events including aortic rupture and progressive aortic dilation in the experimental group was significantly lower than that in the control group (P < 0.05). Logistic regression analysis revealed that acute TBAD [odds ratio (OR) = 15.069; 95%confidence interval (CI), 1.738-130.652; P=0.014], history of chronic kidney disease (OR=10.342; 95%CI, 1.056-101.287; P=0.045), and apnea hypopnea index (AHI) ≥ 30 (OR=2.880; 95%CI, 1.081-9.51; P=0.036) were adverse factors affecting adverse aortic events; while 5E rehabilitation management mode (OR=0.063; 95%CI, 0.008-0.513; P=0.010) was a favorable factor for occurrence of adverse aortic events. CONCLUSION: The findings suggest that continuous nursing based on information carrier 5E rehabilitation management significantly enhanced medication adherence, improved patients' overall quality of life, and decreased the incidence of adverse aortic events in patients TBAD patients and OSA.

A Quality Improvement Project for Monitoring Surgical Patients With Obstructive Sleep Apnea.

INTRODUCTION: Patients who have obstructive sleep apnea (OSA) are at a higher risk for opioid-induced respiratory depression postoperatively. Many patients who have OSA are not given a diagnosis before undergoing surgery and may not be monitored appropriately afterward. PURPOSE: The purpose of this quality improvement project was to increase the number of preoperative patients screened for OSA and improve their postoperative monitoring through a novel OSA protocol order set through the implementation of evidence-based practices. METHODS: Screening for OSA risk is performed preoperatively using the STOP-Bang instrument. High-risk patients, as well as patients with existing OSA, are monitored postoperatively using a bundle of evidence practices to identify early respiratory compromise. If respiratory events occur, a treatment intervention will be triggered. OUTCOME: Postintervention chart reviews demonstrated 100% of the qualifying patients had OSA screening completed before surgery. The OSA protocol was ordered in 28 of the 100 charts reviewed. Patient harm may have been avoided through the implementation of the protocol's standing order for continuous positive airway pressure, which was triggered by respiratory events. CONCLUSION: It is important to identify these high-risk patients before surgery through preoperative screening. These patients should be monitored closely postoperatively to identify early respiratory compromise.

Gender as a principle of the organization of clinical sleep research.

In 2014 the National Institutes of Health required researchers to examine sex as a biological variable. While this approach is necessary to ensure adequate and appropriate female inclusion in research studies, it puts researchers at high risk for attributing their findings to biological sex differences when instead they may be more appropriately attributed to the influence and expectations of gender. In this paper, we specify how gender works as a principle of the social organization of symptoms, experiences, research, and clinical practice using obstructive sleep apnea symptomology to illustrate these patterns. We draw from psychologist Sandra Bem's account differentiating three specific mechanisms of gender: gender polarization, androcentrism, and biological essentialism.

Evidence-Based Practice: Use of STOP-BANG Questionnaire to Identify Obstructive Sleep Apnea.

Certified Registered Nurse Anesthetists (CRNAs) provide care for patients with undiagnosed obstructive sleep apnea (OSA). This evidence-based practice project demonstrated that the STOP-BANG Questionnaire (SB) identified patients with OSA preoperatively and reduced hypoxemia in the postanesthesia care unit (PACU). Evidence from the literature is described; based on this evidence, a change in clinical anesthesia practice was made. Four literature databases were searched using keywords from the following PICOT (patient, intervention, comparison, outcome, time) question: Do patients (P) who have high SB scores (I) compared with patients who do not have high SB scores (C) have a higher incidence of pulmonary complications (O) postoperatively (T)? Five observational cohort studies were critically appraised. The results consistently found that patients with an SB score of 3 or greater had significantly greater postoperative pulmonary complications, including lower oxyhemoglobin saturation (SpO2) in the PACU. At the Brooke Army Medical Center in San Antonio, Texas, the SB was implemented during the preanesthesia assessment. A query of the electronic medical record identified patients with undiagnosed OSA and patients with hypoxemia (SpO2 < 94%) in the PACU. Implementation of the SB increased identification of undiagnosed OSA by 78% preoperatively and reduced the incidence of hypoxemia in the PACU.

Impact of a nurse-led limited risk factor modification program on arrhythmia outcomes in patients with atrial fibrillation undergoing catheter ablation.

BACKGROUND: We have previously demonstrated the feasibility of a nurse-led risk factor modification (RFM) program for improving weight loss and obstructive sleep apnea (OSA) care among patients with atrial fibrillation (AF). OBJECTIVE: We now report its impact on arrhythmia outcomes in a subgroup of patients undergoing catheter ablation. METHODS: Participating patients with obesity and/or need for OSA management (high risk per Berlin Questionnaire or untreated OSA) underwent in-person consultation and monthly telephone calls with the nurse for up to 1 year. Arrhythmias were assessed by office ECGs and ≥2 wearable monitors. Outcomes, defined as Arrhythmia control (0-6 self-terminating recurrences, with ≤1 cardioversion for nonparoxysmal AF) and Freedom from arrhythmias (no recurrences on or off antiarrhythmic drugs), were compared at 1 year between patients undergoing catheter ablation who enrolled and declined RFM. RESULTS: Between 1 November 2016 and 1 April 2018, 195 patients enrolled and 196 declined RFM (body mass index, 35.1 ± 6.7 vs 34.3 ± 6.3 kg/m2 ; 50% vs 50% paroxysmal AF; P = NS). At 1 year, enrolled patients demonstrated significant weight loss (4.7% ± 5.3% vs 0.3% ± 4.4% in declined patients; P < .0001) and improved OSA care (78% [n = 43] of patients diagnosed with OSA began treatment). However, outcomes were similar between enrolled and declined patients undergoing ablation (arrhythmia control in 80% [n = 48] vs 79% [n = 38]; freedom from arrhythmia in 58% [n = 35] vs 71% [n = 34]; P = NS). CONCLUSION: Despite improving weight loss and OSA care, our nurse-led RFM program did not impact 1-year arrhythmia outcomes in patients with AF undergoing catheter ablation.

Update on Research and Practices in Major Sleep Disorders: Part I. Obstructive Sleep Apnea Syndrome.

PURPOSE: The purpose of this first of two review articles providing an update on sleep disorders was to examine the pathophysiology, epidemiology, and treatment of obstructive sleep apnea (OSA). OSA is a common sleep disorder whose prevalence is similar to asthma. As with other sleep disorders, OSA has a broad impact on individuals, affecting their daily behaviors, cognitive abilities, and performance, and putting them at increased risk for accidents, mood disorders, cancer, cardiovascular disease, and hypertension. Thus, early recognition and management, much of which can be implemented by nurses, can reduce health and accident risks and improve daily functioning. METHODS: This narrative review utilized medical databases such as PubMed to identify relevant English language original and systematic review articles predominantly from peer-reviewed journals from 2012 to 2018. However, as background, findings from classic articles prior to 2012 were also included. CLINICAL RELEVANCE: OSA is a common condition with considerable impact on daily functioning and potential for accidents and serious comorbidities such as hypertension, cardiovascular disease, diabetes, and depressed mood. The impairments and comorbidities associated with OSA can be reduced through early detection, encouraging treatment, providing education about sleep and OSA, and, importantly, promoting adherence to the predominant therapy, positive airway pressure.

Implementation of an Obstructive Sleep Apnea Protocol in the Postanesthesia Care Unit for Patients Undergoing Spinal Fusion Surgery.

PURPOSE: The purpose of this project was to implement and evaluate the effectiveness of a postanesthesia care unit (PACU) obstructive sleep apnea (OSA) protocol in patients undergoing spinal fusion surgery. DESIGN: The structure of this project was a preimplementation and postimplementation design. METHODS: A convenience sample of 63 patients admitted to the PACU after spinal fusion surgery, with diagnosed or high-risk OSA, was included in protocol implementation. FINDINGS: The prevalence of diagnosed and high-risk OSA at the project implementation site totaled 74% in the spinal fusion population. The incidence of oxygen desaturations was 41% in the preimplementation group and 35% in the postimplementation group. The PACU to intensive care unit transfers were 10% in the preimplementation group and 3% in the postimplementation group. CONCLUSIONS: Protocols for surgical patients with OSA require further examination but may function as a guide for postoperative nursing care.

A Nurse-Led Limited Risk Factor Modification Program to Address Obesity and Obstructive Sleep Apnea in Atrial Fibrillation Patients.

Background Obesity and obstructive sleep apnea ( OSA ) are associated with atrial fibrillation ( AF ), yet these conditions remain inadequately treated. We report on the feasibility and efficacy of a nurse-led risk factor modification program utilizing a pragmatic approach to address obesity and OSA in AF patients. Methods and Results AF patients with obesity (body mass index ≥30 kg/m2) and/or the need for OSA management (high risk per Berlin Questionnaire or untreated OSA ) were voluntarily enrolled for risk factor modification, which comprised patient education, lifestyle modification, coordination with specialists, and longitudinal management. Weight loss and OSA treatment were monitored by monthly follow-up calls and/or continuous positive airway pressure ( CPAP ) unit downloads. Quality of life and arrhythmia symptoms were assessed with the SF -36 and AF Severity Scale at baseline and at 6 months. From November 1, 2016 to October 31, 2017, 252 patients (age 63±11 years; 71% male; 57% paroxysmal AF ) were enrolled, 189 for obesity and 93 for OSA . Obese patients who enrolled lost significantly greater percent body weight than those who declined (3% versus 0.3%; P<0.05). Among 93 patients enrolled for OSA , 70 completed sleep studies, OSA was confirmed in 50, and the majority (76%) started CPAP therapy. All components of quality of life and arrhythmia symptoms improved significantly from baseline to 6 months among enrolled patients. Conclusions A nurse-led risk factor modification program is a potentially sustainable and generalizable model that can improve weight loss and OSA in AF patients, translating into improved quality of life and arrhythmia symptoms.

Implementing Microstream End-Tidal CO2 in the PACU.

Managing patients with undiagnosed Obstructive Sleep Apnea (OSA) can be a challenge in the postoperative phase. OSA is a chronic disease defined by pauses in breathing that are repetitive during sleep that can last for one minute or longer. This can occur more than five times in an hour. As many as 80-90% of patients undergoing elective surgery have undiagnosed sleep apnea and an increased risk of respiratory complications postoperatively. Capnography is a monitoring tool that can detect increases in end-tidal carbon dioxide levels, which is a sign of respiratory decline.

Nurse vs. physician-led care for obstructive sleep apnoea: A systematic review and meta-analysis of randomized trials.

AIM: To evaluate the effectiveness of nurse-led care for obstructive sleep apnoea compared with physician-led care. BACKGROUND: The incidence of obstructive sleep apnoea is increasing worldwide. There is a need for cost-effective care models to ease off the pressure on tertiary care centres and divert care to the community. DESIGN: Systematic review and meta-analysis. DATA SOURCES: We searched major electronic databases (MEDLINE, EMBASE, AMED, British Nursing Index, CINAHL, HMIC, PsycINFO, Health Business Elite and the Cochrane Central Register of Controlled Trials CENTRAL) from inception till December 2016 using a structured search strategy for all randomized trials evaluating nurse-led treatment interventions for adults with obstructive sleep apnoea compared with physician-led ones. We screened relevant articles against a predefined inclusion criterion. We applied no search limitations. REVIEW METHODS: We assessed the risk of bias as per Cochrane recommendations. We calculated weighted mean difference with 95% confidence intervals for continuous outcomes and used a random-effects model to meta-analyse data. RESULTS: We screened 309 articles and only four studies met our inclusion criteria. All studies used continuous-positive airway pressure as the main treatment strategy with similar compliance rate in both comparison groups. The scores of the Epworth Sleepiness Scale, the SF-36 questionnaires for vitality, physical function and the SF-36 mental health were all similar between the two groups. There was a significant heterogeneity in all meta-analyses (I2  > 92%). CONCLUSION: Nurse-led care for adults with obstructive sleep apnoea is non-inferior to physician-led care. More research is needed to standardize nurse-led interventions and evaluate their long-term effectiveness and cost-effectiveness.

Balancing task focus and relationship building: asking sleepy patients about traffic risk in treatment initiation consultations.

BACKGROUND: The use of traffic risk assessment questions is an understudied area in nursing research. Obstructive sleep apnoea is associated with an increased risk of traffic accidents. Therefore, traffic safety authorities demand adherent continuous positive airway pressure use. Nurses act as coaches to achieve treatment adherence, but they are also obliged to act as state agents by prohibiting obstructive sleep apnoea patients from drowsy driving. OBJECTIVE: To examine how nurses and obstructive sleep apnoea patients manage traffic risk assessment questions in the relation-building context of treatment initiation consultations. METHODS: To study, in detail, the actual practice of risk assessment, we used conversation analysis of 19 video-recorded initial treatment consultations with nurses and recently diagnosed obstructive sleep apnoea patients. ETHICS: The study received ethical approval from the Central Ethical Review Board in Linköping (registration number 214/231-32) and follows the ethical guidelines for qualitative research. RESULTS: Patients influence how nurses phrase questions about traffic risk by taking a stance to daytime sleepiness prior to the risk question. Nurses ask traffic risk questions in a way that assumes that driving is unproblematic if patients have not previously indicated problems. It may pose a significant problem when nurses, by accepting patients' prior stance when asking about traffic risk, orient to relationship building rather than task focus. CONCLUSION: To clarify the difference between their two potentially conflicting roles, nurses need to refer to existing laws and official guidelines when they raise the issue of risk in treatment initiation consultations. Nurses should also ask risk assessment questions in a problem-oriented communicative environment. Traffic risk assessment is sensitive yet important, as obstructive sleep apnoea is a highly prevalent problem causing excessive sleepiness. It is essential to acknowledge nurses' double roles with regard to coaching continuous positive airway pressure treatment and assessing traffic risk.

The effects of integrated nursing education on quality of life and health-related outcomes among obstructive sleep apnea patients receiving continuous positive airway pressure therapy.

PURPOSE: This study sought to examine the effects of a nursing education program on quality of life and sleep disturbance among obstructive sleep apnea (OSA) patients receiving continuous positive airway pressure (CPAP) therapy. METHODS: This study was a randomized controlled trial with an intervention group consisting of a nursing education program. The intervention group received the instruction of the CPAP nursing education program, and the control group received routine care. Data was collected for both groups before the intervention (pre-test), on the 7th day measurement after the intervention, and on the 30th day measurement after the intervention. RESULTS: The results showed, first, that the intervention group reported a significantly reduced level of disturbance from wearing CPAP compared with that of the control group after the intervention (ß = -1.83, p = .040). Second, the Calgary sleep apnea quality of life index (SAQLI) total scores significantly improved after the intervention (ß = 1.669, p = 0.014). Also, symptoms of the SAQLI sub-items were improved and significantly different (ß = 5.69, p = 0.007) after the intervention in the intervention group. CONCLUSIONS: According to the results of the study, the disturbance from wearing CPAP, the total score of the SAQLI and the symptoms of the SAQLI were significantly improved after the nursing education intervention. Therefore, an adequate nursing education program is recommended for the initial period of CPAP use among OSA patients.

Telemonitoring of CPAP therapy may save nursing time.

PURPOSE: Telemonitoring might enhance continuous positive airway pressure (CPAP) adherence and save nursing time at the commencement of CPAP therapy. We tested wireless telemonitoring (ResTraxx Online System®, ResMed) during the habituation phase of the CPAP therapy in obstructive sleep apnea syndrome (OSAS). METHODS: In total, 111 consecutive OSAS patients were enrolled. After CPAP titration, patients were followed with the telemonitoring (TM, N = 50) or the usual care (UC, N = 61). The TM group used fixed pressure CPAP device with and the UC group similar device without wireless telemonitoring. Patients and study nurses were unblinded. The evaluated end-points were hours of CPAP use >4 h/day, mask leak <0.4 L/s, and AHI <5/h. Nursing time including extra phone calls, visits, and telemonitoring time was recorded during the habituation phase. CPAP adherence was controlled in the beginning and at the end of the habituation phase and after 1-year of use. RESULTS: TM and UC groups did not differ in terms of patient characteristics. The average length of the habituation phase was 4 weeks in the TM group and fixed 3 months in the UC group. Median nursing time was 39 min (range 12-132 min) in the TM group and shorter compared to that of 58 min (range 40-180 min) (p < 0.001) per patient in the UC group. Both treatment groups had high CPAP usage hours (>4 h/day) and the change in usage at the end of the habituation phase did not differ between the groups (p = 0.39). Patients in both groups were equally satisfied with the treatment protocol. CPAP adherence (6.4 h in TM vs. 6.1 h in UC group, p = 0.63) and residual AHI (1.3 in TM vs. 3.2 in UC group, p = 0.04) were good in both groups at 1-year follow-up. CONCLUSIONS: Wireless telemonitoring of CPAP treatment could be relevant in closing the gap between the increasing demand and available health-care resources. It may save nursing time without compromising short- or long-term effectiveness of CPAP treatment in OSAS.

Clinical outcomes in a high nursing ratio ward setting for children with obstructive sleep apnea at high risk after adenotonsillectomy.

BACKGROUND: In 2012 clinical management of children having adenotonsillectomy (AT) for suspected obstructive sleep apnea (OSA) at our tertiary centre changed based on previous research: children with severe obstructive sleep apnea (OSA) at increased risk of post-operative respiratory adverse events (AE) identified using home overnight oximetry or polysomnography (PSG) were managed post-operatively in a high nurse/patient ratio unit in the ward (high acuity unit, HAU) rather than in the intensive care unit (ICU) as previously. OBJECTIVES: To examine the post-operative respiratory AE post AT in HAU. METHODS: A retrospective audit was performed of children having AT on the HAU list from Oct 2012-Sept 2014, identifying clinical information, pre-operative testing for OSA and post-operative course. RESULTS: 343 children underwent elective adenotonsillectomy at our tertiary centre in the study period, of whom 79 had surgery on the HAU list (16F; median age 4.2year (range 1.2-14.7); median weight-for-age centile 77.9% (IQR 44-98.7%)). 75 had moderate/severe OSA by oximetry (n=44) or PSG (n=31) criteria. 77 of 79 children had oxygen therapy in the recovery room (median 20min, IQR 15-40min). 18 (23%) had at least one AE outside the recovery room, which were observed (n=2) or treated with oxygen therapy (n=14) or repositioning (n=2). Obesity increased the risk of an AE (10/25 obese vs 8/54 non obese, p=0.01), as did the presence of a major comorbidity (5/9 with comorbidity vs 13/70 without, p=0.03). There were no admissions from the HAU to ICU. 63 patients (83%) stayed only one night in hospital (median 1d, range 1-5d). CONCLUSIONS: In a cohort of children with known moderate-severe OSA, post-operative AE after AT were all managed in the HAU. Post-operative care in HAU provides safe and effective care for high-risk children post-AT, minimizing admissions to ICU.

The Prevalence and Clinical Features of Hypertension in Patients With Obstructive Sleep Apnea Hypopnea Syndrome and Related Nursing Strategies.

BACKGROUND: Obstructive sleep apnea hypopnea syndrome (OSAHS) is a common sleep-related breathing disorder. Hypertension is frequently a concomitant disorder in patients with OSAHS. PURPOSE: This study investigates the prevalence and clinical features of hypertension in patients with OSAHS and explores the related nursing strategies. METHODS: Three thousand six hundred seven patients were included in this study. Subjects were divided into four groups that were categorized according to apnea-hypopnea index (AHI) scores as follows: control group (control, n = 354) with AHI < 5, mild OSAHS (mild, n = 658) with 5 ≤ AHI < 15, moderate OSAHS (moderate, n = 753) with 15 ≤ AHI < 30, and severe OSAHS (severe, n = 1842) with AHI ≥ 30. Blood pressure (BP) values were measured at four time points (daytime, evening, nighttime, and morning). The prevalence of hypertension and BP values in the different groups were compared at four time points. Finally, the nighttime-to-daytime mean BP (MBP; RN/D) and morning-to-evening MBP (RM/E) ratios were calculated. RESULTS: The prevalence of hypertension in the control group, mild group, moderate group, and severe group were 22.32%, 34.65%, 39.04%, and 55.37%, respectively. AHI positively correlated with the prevalence of hypertension (r = .191, p < .001). The daytime, nighttime, evening, and morning MBP rose as AHI increased. The ratios of nighttime-to-daytime MBP (RN/D) and morning-to-evening MBP (RM/E) increase with the severity of the illness (F = 9.821 and 18.957; p < .001). The daytime BP correlates significantly with AHI and lowest oxygen saturation (LSaO2; systolic BP, r = .195 and -.206; diastolic BP, rs = .248 and -.251, p < .01). Daytime MBP increases gradually in small fluctuations concurrent with increases in AHI until 61-65. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: OSAHS is an independent risk factor for hypertension. Patients with OSAHS have a significant increase in nighttime and morning BP, which means they lose normal BP diurnal rhythm. Therefore, nurses should take necessary measures based on the clinical features of hypertension in patients with OSAHS to minimize the risk of cardiocerebral vascular incidents.

Sleep quality and adverse outcomes for patients with acute myocardial infarction.

AIMS AND OBJECTIVES: This study aimed to analyse the relationship between the worsening of clinical outcomes (cardiovascular death, recurrent cardiovascular ischaemic events and stroke) and sleep quality, daytime sleepiness and risk for obstructive sleep apnoea syndrome in patients admitted to cardiac care units due to an acute myocardial infarction. BACKGROUND: There is evidence that sleep disorders can contribute to the worsening of cardiovascular diseases. DESIGN: This is a descriptive study with follow-up. METHODS: Data collection was conducted in a large university hospital in Brazil from October 2013 to March 2014. Patients admitted with acute myocardial infarction provided data about sleep quality, daytime sleepiness and risk factors for obstructive sleep apnoea syndrome by answering specific questionnaires. Clinical data were obtained from medical charts. Data were analysed with descriptive statistics and multiple logistic regression models. RESULTS: The worsening of clinical outcome occurred in 12·4% of patients and was independently associated to poor sleep quality. CONCLUSION: Poor sleep quality, excessive daytime sleepiness and high risk for obstructive sleep apnoea syndrome were frequent in hospitalised patients with acute myocardial infarction and affect negatively the process of recovery. RELEVANCE TO CLINICAL PRACTICE: It is important to evaluate sleep quality and sleep disorders, aiming at preventing and reducing unfavourable outcomes of cardiovascular disease, particularly for acute myocardial infarction patients.

Postoperative management of patients with obstructive sleep apnea: implications for the medical-surgical nurse.

Obstructive sleep apnea (OSA) affects up to 7% of Americans, and those undergoing surgery are at risk for complications. Medical-surgical nurses should be knowledgeable regarding this common disorder and understand how to screen effectively and monitor patients with OSA.