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.

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.

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.

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.

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.

An integrative review of screening for obstructive sleep apnea in commercial vehicle drivers.

Obstructive sleep apnea has been a concern for commercial vehicle drivers for several decades. An increasing body of knowledge supports the idea that insufficient sleep can affect drivers' abilities to react efficiently and expediently, leading to motor vehicle accidents. Insufficient sleep can be described as short sleep periods, prolonged driving time, and dysfunctional sleep breathing. Commercial motor vehicle drivers are required to undergo physical examinations at least once every 2 years to maintain certification. Medical examiners are encouraged to screen for obstructive sleep apnea during these biannual examinations. Current literature identifies four frequently used screening tools for obstructive sleep apnea: STOP Questionnaire, STOP-Bang Questionnaire, Berlin Questionnaire, and Epworth Sleepiness Scale. Medical examiners must determine which screening method is valid, reliable, and has sufficient evidence to support its use.

Measuring subjective sleepiness at work in hospital nurses: validation of a modified delivery format of the Karolinska Sleepiness Scale.

INTRODUCTION: Sleepiness during the work shift is common and can be hazardous to workers and, in the case of nurses, to patients under their care. Thus, measuring sleepiness in occupational studies is an important component of workplace health and safety. The Karolinska Sleepiness Scale (KSS) is usually used as a momentary assessment of a respondent's state of sleepiness; however, end-of-shift measurement is sometimes preferred based on the study setting. We assessed the predictive validity of the KSS as an end-of-shift recall measurement, asking for "average" sleepiness over the shift and "highest" level of sleepiness during the shift. METHOD: Hospital registered nurses (N=40) working 12-h shifts completed an end-of-shift diary over 4 weeks that included the National Aeronautical and Space Administration Task Load Index (NASA-TLX) work intensity items and the KSS (498 shifts over 4 weeks). Vigilant attention was assessed by measuring reaction time, lapses, and anticipations using a 10-min performance vigilance task (PVT) at the end of the shift. The Horne-Ostberg Questionnaire, Epworth Sleepiness Scale, General Sleep Disturbance Scale, and Cleveland Sleep Habits Questionnaire were also collected at baseline to assess factors that could be associated with higher sleepiness. We hypothesized that higher KSS scores would correlate with vigilant attention parameters reflective of sleepiness (slower reaction times and more lapses and anticipations on a performance vigilance task) and also with those factors known to produce higher sleepiness. These factors included the following: (1) working night shifts, especially for those with "morningness" trait; (2) working sequential night shifts; (3) having low physical and mental work demands and low time pressure; (4) having concomitant organic sleep disorders; and (5) having greater "trait" sleepiness (Epworth Sleepiness Scale). Linear mixed models and generalized linear mixed models were used to test associations that could assess the predictive validity of this format of administering the KSS. RESULTS: Greater sleepiness, as measured by higher KSS scores, was found on shifts with nurses working night shift, the third sequential night compared to the first, those with sleep disorder symptoms (especially insomnia), and in nurses with trait sleepiness on the Epworth scale. Less sleepiness (lower KSS scores) was seen in shifts with a high level of time pressure and in nurses with a biologic predisposition to be more alert in the morning (morningness trait) who worked the day shift. CONCLUSION: We found partial support for using the Karolinska Sleepiness Scale in the recalled format based on our multiple tests of predictive validity.

Occupational screening for sleep disorders in 12-h shift nurses using the Berlin Questionnaire.

BACKGROUND: The Berlin Questionnaire has been validated as a screening tool for sleep apnea in clinical samples, but no occupational studies have reported screening validity parameters for this instrument. The objectives of this pilot study were to describe the prevalence of sleep-disordered breathing symptoms in registered nurses and examine the validity of the Berlin Questionnaire to screen for sleep apnea in this chronically partially sleep-deprived group. Validity parameters for the Berlin Questionnaire are tabulated for published studies to 2012. METHODS: Twenty-one female nurses working full time 12-h shifts underwent overnight, in-laboratory polysomnography to identify sleep disorders and completed a Berlin Questionnaire. RESULTS: By polysomnogram, the prevalence of sleep-disordered breathing [Respiratory Disturbance Index (RDI) ≥ 5] was 43 %, although by the Berlin Questionnaire only 24 % were deemed high risk. The sensitivity of the Berlin Questionnaire to detect high-risk subjects (RDI > 5) was 0.33, with a specificity of 0.83, a positive predictive value of 0.60, and negative predictive value of 0.63. Berlin criterion 3 (obesity or hypertension) performed the best for predicting sleep apnea in 12-h shift nurses. CONCLUSIONS: Although the Berlin Questionnaire produced valuable data about symptoms of sleep apnea in this population, it had a high proportion of false negatives. To improve its sensitivity for screening health care workers for sleep apnea, it must better capture symptoms specific to this population. Increasing the weighting of Berlin criterion 3 items should be considered to improve its psychometric properties.

Is that snoring something to worry about? Anesthetic implications for obstructive sleep apnea.

Obstructive sleep apnea (OSA) is a chronic disease that is underdiagnosed. It is characterized by repetitive pauses in breathing during sleep that can last for several seconds and can subsequently cause hypoxia-related complications. This apnea can lead to significant medical problems, daytime somnolence, cognitive impairment, decreased work productivity, and an increased risk of motor vehicle crashes. Patients having diagnostic procedures or surgeries in which sedation or anesthesia will be received should be evaluated for OSA to prevent or reduce postoperative complications. The Berlin Questionnaire and the STOP-BANG Questionnaire are useful tools that can be used preoperatively to identify patients at risk for surgical complications. If patients who have OSA or who are at risk for having OSA are identified before surgery, anesthesia providers can take action to prevent perioperative complications. Guidelines published by the American Society of Anesthesiologists provide helpful anesthetic considerations for patients with OSA undergoing surgery in an effort to decrease morbidity and mortality. While research into the effects of surgery and anesthesia in patients affected by OSA is ongoing, compliance with these recommendations, along with vigilance, will help ensure that many patients with OSA can be managed safely during their surgical experiences.

[Screening for sleep-disordered breathing during cardiac rehabilitation]. / Le dépistage des troubles respiratoires du sommeil en réadaptation cardiaque.

Sleep-disordered breathing may take the form of apnoea or hypopnoea. These conditions have physiological consequences on the cardiovascular function. Night staff in cardiac rehabilitation departments must therefore be able to organise themselves to screen for risks of sleep-disordered breathing, with collaboration between medical and paramedical staff.

The early postoperative course of surgical sleep apnea patients.

OBJECTIVES/HYPOTHESIS: Recent guidelines from the American Society of Anesthesiologists recommended postoperative monitoring for most patients undergoing surgery for obstructive sleep apnea (OSA). These guidelines, however, are largely based on retrospective literature and expert opinion. The appropriate level of postoperative monitoring remains controversial. Our objective was to prospectively document the early postoperative course of patients undergoing OSA surgery. STUDY DESIGN: Prospective cohort study. METHODS: One hundred twenty-one patients (age 43.9 + or - 13.5 years, 79.8% male) with sleep-study proven OSA (apnea-hypopnea index 31.9 + or - 22.7) who were undergoing surgery for OSA at our tertiary care center were recruited from 2007 to 2009. Outcome measures were: 1) incidence of respiratory complications requiring nursing intervention, 2) level of postoperative blood oxygen saturation divided into three groups: mean oxygen saturation in recovery room (SpO2(recovery)), mean oxygen saturation in step-up unit (SpO2(step-up)), and lowest oxygen saturation over the 24 hour period (SpO2(minimum)). These results were then compared to the benchmark literature. RESULTS: The overall incidence of nursing intervention in response to a respiratory complication (3.4%) was significantly less than expected (P < .002). Mean SpO2(recovery) was 92.9 + or - 3.2%, SpO2(step-up) was 95.9 + or - 1.6%, and SpO2(minimum) was 92.8 + or - 3.1%. No variables were identified as being predictive of any of the outcome measures. CONCLUSIONS: The incidence of respiratory events requiring intervention in the early postoperative course of OSA patients was low (3.4%). Routine postoperative inpatient monitoring may not be required in many cases.

Surgical treatment of obstructive sleep apnea.

THE PRIMARY TREATMENT for obstructive sleep apnea (OSA) has been continuous positive airway pressure (CPAP) therapy, but the minimum acceptable number of hours of nightly CPAP use remains unclear. INTEGRATED SOFT TISSUE and bone surgery may be a viable alternative for patients who have rejected CPAP as a treatment option. Formal sleep testing has shown that surgery and CPAP therapy are equally successful at resolving OSA. REPEAT SLEEP TESTING conducted several years after patients have undergone combined soft tissue and bone surgery has demonstrated consistent and reliable surgical results. Patients with OSA should be offered surgery as an alternative to life-long CPAP treatment or as an option when CPAP therapy has not been successful.

Obstructive sleep apnea in head and neck cancer patients post treatment ... something to consider?

Obstructive sleep apnea (OSA) occurs due to enlarged tissue such as tonsils, base of tongue or palate, pharyngeal space narrowing, or decreased muscle tone of the pharyngeal dilator muscles. Treatments for head and neck cancer may cause physical changes resulting in OSA. Based on recent anecdotal experience and limited research available looking at the incidence of OSA in post treatment head and neck cancer patients, assessment for signs and symptoms of OSA by otorhinolaryngology nurses seems warranted. Prompt diagnosis and treatment of OSA in the patient with head and neck cancer may significantly improve the person's health and quality of life.

Uso del CAP: un desafío de enfermería / Use of the Continuos Positive Airway Pressure: a challenge to nursing

El síndrome de apnea onstructiva del sueño (SAOS) afecta al 4 por ciento de hombres y al 2 por ciento de mujeres (Capa, Fernández & Moreno, 1998; Chokroverty, 1999; Strohl & Redline, 1996), el tratamiento de elección es un dispositivo que ejerce una presión continua positiva de aire (CPAP), que evita colapso de la vía aérea superior. Se realizó una investigación de tipo descriptiva, retrospectiva y transversal cuyo objetivo es conocer cuáles son los factores que influyen en el uso del CPAP, percibidos por las personas con diagnóstico de SAOS que acuden al Centro Medico del Sueño de la Pontificia Universidad Católica de Chile (CEMS) entre mayo 1998 a septiembre del 2000. El universo estuvo constituido por 375 personas requirientes de CPAP, conformándose una muestra de 130 personas contactadas por vía telefónica. En términos generales el uso del CPAP es aceptado por la población en estudio, sin embargo,ésta posee necesidades educativas que requieren ser satisfechas para lograr un mayor uso del CPAP, las que deben ser cubiertas por un equipo multidisciplinario donde la enfermera cobra un rol importante