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CONTINUING EDUCATION
Caring for the Patient With ObstructiveSleep Apnea: Implications for Health Care
Providers in Postanesthesia CarePamela D. Diffee, DNP, CRNA, Michelle M. Beach, DNP, CRNA,
Norma G. Cuellar, DSN, RN, FAAN
Obstructive sleepapnea (OSA) is a sleep disorderaffecting18millionAmer-
Pamela D. Diffe
Capstone College o
caloosa, AL; Miche
dent at the Capsto
Alabama, Tuscalo
FAAN, is a Professo
ing, The University
Conflict of intere
Address correspo
of Alabama, Capst
loosa, AL 35487; e
� 2012 by Ame
1089-9472/$36.
http://dx.doi.org
Journal of PeriAnesth
icans. The prevalence of OSA is increasing due to an epidemic rise in obe-
sity, which is amajor contributing factor. The primary treatment forOSA is
continuous positive airway pressure, designed to maintain a patent air-
way for unobstructed breathing. OSA patients may experience postopera-
tive hypoventilation due to residual anesthetic, analgesic requirements,
and other comorbidities. Postoperative health care providers must be pre-
pared to assess for hypoventilation and intervene using evidence-based in-
terventions to improve outcomes. It is incumbent that the PACU nurse be
aware of and implement evidence-based clinical guidelines for patients
with OSA. Therefore, the purpose of this manuscript is to (1) describe the
physiology, comorbidities, diagnosis, and treatment of OSA; (2) identify
the effects ofanesthesia in personswithOSA; (3) discuss clinical guidelines;
and (4) describe implications for care in an effort to improve health out-
comes in persons with OSA during the perianesthesia period.
Keywords: obstructive sleep apnea, postoperative complications, contin-
uous positive airway pressure, anesthesia, continuing education.
� 2012 by American Society of PeriAnesthesia Nurses
Objectives—On completion of this activity, the
learner will be able to: (1) Describe the physiology,
comorbidities, diagnosis, and treatment of OSA,
(2) Identify the effects of anesthesia in personswith OSA, and (3) Discuss implications for care
across the perianesthesia setting.
e, DNP, CRNA, is a doctoral student at the
f Nursing, The University of Alabama, Tus-
lle M. Beach, DNP, CRNA, is a doctoral stu-
ne College of Nursing, The University of
osa, AL; and Norma G. Cuellar, DSN, RN,
r of Nursing at Capstone College of Nurs-
of Alabama, Tuscaloosa, AL.
st: None to report.
ndence to Pamela D. Diffee, The University
one College of Nursing, Box 870358, Tusca-
-mail address: diffdawglet@cox.net.
rican Society of PeriAnesthesia Nurses
00
/10.1016/j.jopan.2012.05.012
esia Nursing, Vol 27, No 5 (October), 2012: pp 329-340
OBSTRUCTIVE SLEEP APNEA (OSA), one of the
most common sleep disorders, is characterized by
airway obstruction with periods of apnea. It affects
18 million Americans1 and up to 64% of adults invarying degrees. Men are twice as likely as women
to be diagnosed with OSA,2,3 with middle-aged
obese males being the most susceptible.3 There
has been an eightfold increase in the occurrence
ofOSA, likely associatedwith the increase in obesity
in the last 10 years.4 The incidence appears to in-
crease with age, although it is reported by some to
plateau after the age of 65 years.3,5-8
In the general population, studies estimate that
nearly 80% of men and 95% of women with
moderate-to-severe OSA are undiagnosed.1,7,9-15
Surgical candidates have an even higher inci-
dence of OSA when compared with the general
population.16 This is true for all surgical specialties,
329
330 DIFFEE, BEACH, AND CUELLAR
but the occurrence varies with the specialty; for
example, more than 70% of bariatric surgical can-
didates present with OSA.17-19 Postmenopausal
women have a higher probability of having OSA
than their premenopausal contemporaries,5 and50% of nursing home residents presenting for sur-
gery exhibit symptoms of the disorder.8 Patients
with OSA have an increased risk of complications
due to comorbidities associated with OSA.20
In 2006, the American Society of Anesthesiologists
(ASA) formed a task force with the aim of examin-
ing the perioperative management of patients withOSA. This task force developed a practice guide-
line ‘‘.to improve the perioperative care and re-
duce the risk of adverse outcomes in patients
with OSAwho receive sedation, analgesia, or anes-
thesia for diagnostic or therapeutic procedures un-
der the care of an anesthesiologist.’’21 As the effects
of administered anesthetics can extend well past
the period when a patient is directly under thecare of an anesthesiologist, these guidelines have
application in several health care settings.
Anesthesia is increasingly beingperformedoutsideof
traditional operative settings in departments such as
heart catheterization and electrophysiology laborato-
ries, radiology and endoscopy suites, emergency
rooms, and brachytherapy sites. Procedures per-formed in these areas often require deep sedation,
with the patient recovered in the same area by the
procedural nursing staff. As these areas are often far
fromthecoreof surgical activity, additional expert air-
waymanagement personnelmay not be immediately
available. Perianesthesia nurses must be aware of the
treatment of postanesthesia patients with OSA. Care
providers inpostanesthesia areasmay lack awarenessof the implications of OSA for perioperative out-
comes. Therefore, the purpose of this manuscript is
to (1) describe the physiology, comorbidities, diagno-
sis, and treatment of OSA; (2) identify the effects of
anesthesia in persons with OSA; (3) discuss clinical
guidelines; and (4) describe implications for care in
the perianesthesia period.
Obstructive Sleep Apnea
One of the first descriptions of OSA was from an
1837 Charles Dickens’ novel and was referred to
as Pickwickian syndrome, in which a characterexhibited the triad features of OSA: somnolence,
snoring, and obesity.22 The earliest written article
found to medically describe these characteristics
was published in 1956 and coined the term ob-
structive sleep apnea.23 Other than Pickwickian
syndrome, the disorder has also been referred to
as upper airway apnea, but should not be confusedwith central sleep apnea, which is associated with
central nervous system dysfunction of respiratory
regulation.24
Physiology of OSA
The physiology underlying OSA typically involves
the upper airway, or pharynx. Normal activation ofpharyngealmuscle tone inanalert individual isoften
reduced during sleep cycles, when turbulent air-
flow can result in snoring.1 With severe reductions
of pharyngeal tone, the negative force of inspiration
is not sufficient to maintain patency of the pharyn-
geal lumen, and breathing temporarily stops, de-
spite persistent ventilatory effort.1 This respiratory
cessation leads tohypoxic and hypercarbic derange-ments critical enough to arouse the sleeper for
a brief period of air exchange.1 As the sleeper then
settles back into attempted rest patterns, the cycle
repeats, oftenhundredsof timesper night.1 Because
the affected individual may never achieve deep
rhythmic sleep, thehallmark symptomofOSA isday-
time somnolence.25Understandably, other reported
symptoms include frequent nocturnal awakeningsand morning headaches.4
During an OSA event, soft tissue of the nose and
pharynx collapses.26 As the pharynx is a multipur-
pose organ, it is modulated by neural and chemical
controls responsible for changing the size and stiff-
ness, depending on its purpose.26 This is accom-
plished by a change in the degree of muscularcontractionof thepharynx and airway. For example,
while eating, the contractions are used to propel
food into the esophagus for eventual digestion,
while voice tone can be affected by pharyngeal
size and stiffness during speech.26 For adequate res-
piration tooccur, a rigid andpatentpharynxmustbe
maintained. With inspiration of large tidal volumes,
such as those seenduring sleep, the trachea ispulledcaudally by pharyngeal musculature, and airway pa-
tencydependson themechanical act of breathing.26
With OSA, pharyngeal patency is diminished, as
thosewith the disorder have a structurally narrower
pharyngeal lumen and, consequently, are more
prone to collapse when these muscles are de-
pressed during sleep or under the influence of
CARING FOR PERSONS WITH OSA 331
anesthesia.26When these forces areweightedby the
addition of excess soft tissue surrounding the phar-
ynx and then compounded by the smaller tidal vol-
umes frequently seen in obese individuals, the
ability of the airway to resist collapsibility de-creases.26 During an OSA episode, apnea is abated
only when an increase in longitudinal tension of
the pharynx overcomes its potential for collapse.26
Comorbidities of OSA
OSA does not exist in isolation of other systemic
comorbidities, particularly in those who are undi-agnosed or individuals noncompliant with its
recommended treatments. Table 1 lists major sys-
tems that could be targets of OSA comorbidities
with their attendant conditions and prevalence.27
Because OSA is heavily linked with hypertension,
Table 1. Comorbidities Associated WithObstructive Sleep Apnea
Category Condition Prevalence (%)
Cardiac Treatment-resistant
hypertension
63-83
Congestive heart
failure
76
Ischemic heart
disease
38
Atrial fibrillation 49
Dysrhythmias 58
Respiratory Asthma 18
Pulmonary
hypertension
17
Neurologic First-ever stroke 71-90
Metabolic Type II diabetes
mellitus
36
Metabolic syndrome 50
Hypothyroidism 45
Morbid obesity 50-90
Surgical Bariatric surgery 71
Intracranial tumor
surgery
64
Epilepsy surgery 33
Others Gastroesophageal
reflux disease
60
Nocturia 48
Alcoholism 17
Primary open-angle
glaucoma
20
Head and neck cancer 76
Reproduced with permission from Seet and Chung.27
Copyright 2010 Elsevier.
all related associations with cardiovascular disease
may be present. A noncompliant left ventricle with
congestive heart failure can occur.5,9,10,13,14,28-33
Of significance is that 40% to 50% of patients with
heart failure also have OSA.1 The most commonarrhythmias associated with OSA are vagal brady-
cardia and atrial-ventricular block as well as atrial
fibrillation.1,5,8,28,29 Higher incidences of pulmo-
nary hypertension, right ventricular hypertrophy,
cor pulmonale and polycythemia occur when
compared with those without OSA. In extreme
cases, cardiomyopathy may occur, resembling
that seen with pheochromocytoma or chroniccocaine use.34 When coupled with arrhythmias
and myocardial infarction, which frequently occur
during sleep, thismayexplain the associationswith
sudden death seen in this population.4,29
In untreated OSA, the episodic fluctuations of hy-
poxemia and hypercarbia produce a physiologic
stress response in the individual, which ultimatelycascades into systemic derangements. Vascular
inflammation and atherosclerosis have been linked
to the stresses induced by the hypoxia-reoxy-
genation episodes of OSA.1,5,7,10,30 The resulting
increase in catecholamines activates the renin-
angiotensin-aldosterone axis, leading to sodium re-
tention and further increases in vasoconstriction
with the possibility of renal failure.1,2,7,32,34
Other affected organs include the cerebrovas-
cular, endocrine, gastrointestinal, and pulmonary
systems. Increased intracranial pressure can be
present, and may be linked to stroke, frequent
impaired cognition, and depression.6,8,13,14,25,31,
33,35-37 Metabolic irregularities have been connec-
ted to OSA, with higher rates of diabetes mellitusand hormone suppression demonstrated.1,5,15,19,
27,32,36 These irregularities have also been
determined to have a strong association with
stroke.38 The increase in intrathoracic pressures
necessary to overcome an apnea episodemaybe re-
sponsible for the common symptoms of gastro-
esophageal reflux.7,14,25,28 This can culminate in
asthma and chronic obstructive pulmonarydisease (COPD) from passive aspiration of acidic
stomach contents during sleep.27,34,35
Diagnosis of OSA
In undiagnosed individuals, abnormalities of the
head, face, or mouth such as those seen in patients
332 DIFFEE, BEACH, AND CUELLAR
with Down syndrome, muscular dystrophy, or cra-
niosyntosis may be used as clues for the possible
presence of OSA.21 Also, those complaining of
chronic nasal stuffiness or possessing tonsil hyper-
trophymay be candidates for anOSA evaluation.9,21
OSA severity appears to positively correlate not only
with obesity, but also with neck circumference.21 A
body mass index higher than 35 kg/m2 coupled
with a neck circumference greater than 40 cm
may serve as a marker for the existence of OSA.21
Withmale gender and agemore than 50 years added
to the list of variables, studies have implicated
a greater than 90% likelihood for patients havingmoderate-to-severe OSA.16 The Mallampati classi-
fication can be used as a visual aid to determine
a relationship between the size of the tongue and
pharyngeal structures, including visualization of
soft palate, fauces, uvula, and anterior/posterior
pillars.39
The diagnosis of OSA begins with a patient screen-ing. The interviewer begins with questions di-
rected toward symptoms such as snoring and
daytime somnolence.2 The interview should then
progress toward physical evaluation for obesity,
chin recession, and neck circumference, as well
as determination for the existence of comorbid-
ities such as hypertension.2 If the screening reveals
positive results for the likelihood of OSA, a morecomprehensive sleep history and physical exami-
nation should be performed, with consideration
for a sleep study, or polysomnography (PSG).2
OSA is clinically diagnosedbyPSG.2,4,17 Patients are
monitored during sleep and physiologic signals are
measured. These signals are chin electromyogram,
electroencephalogram, electrooculogram, airflowoxygen saturation, respiratory effort, and electro-
cardiogram.17 A PSG technologist monitors for
technical adequacy, patient compliance in com-
pleting the study, and relevant patient behaviors.17
The frequency of obstructions is reported as an ap-
nea/hypopnea index.17 Confirmation of an OSA di-
agnosis is made if the number of obstructive events
on PSG is greater than 15 events/hour or greaterthan 5 events/hour in a patient complaining of
any of the following: unintentional sleep during
wakefulness; daytime sleepiness; unrefreshing
sleep; fatigue; insomnia,waking up breath holding,
choking, or gasping; or if the bed partner describes
breath holding or loud snoring during the patient’s
sleep. Severity is scored as mild for events $5 and
,15, moderate for events $15 and #30, and se-
vere for events.30/hour.2,25
Treatment of OSA
OSA is a complex disorder with wide-ranging treat-
ment recommendations. Conservative approaches
include lifestyle modifications such as weight loss
for those who are obese, cessation of smoking, es-
trogen replacement for postmenopausal women,
and a decrease in alcohol consumption.5,14,40
Supportive treatment options include noctur-
nal oxygen use and pharmacologic therapy forcomorbidities, such as antihypertensives to treat
increased blood pressure.14 Adding continuous
positive airway pressure (CPAP) during sleep
with or without oxygen therapy may lessen symp-
toms in those with moderate-to-severe OSA.2 In se-
vere cases not responsive to CPAP and supportive
measures, surgical interventions including trache-
ostomy and maxillofacial reconstruction may berecommended.2,40
CPAP applied nasally, orally, or via a combination
interface during sleep is the preferred treatment op-
tion for theOSApopulation.1,5,6,10,12,29,31,41-44 CPAP
pressurizes air generated from an adjustable fan
driven system delivered by a hose and snug-fitting
facial mask, which is worn during sleep.2 The pur-poseofCPAP is tomaintain thepharyngeal lumenpa-
tency for air exchange.45 CPAP alone may also
improve comorbid conditions with OSA such as hy-
pertension, metabolic anomalies, atherosclerosis,
and inflammation.30 Of interest is that the American
Association of Sleep Medicine task force identifies
CPAP as the treatment of choice for all OSA patients,
regardless of severity, and recommends that it beoffered to all who have been diagnosed.2
The economic impact of the untreated OSA patient
is significant. The cost is estimated in the billions of
dollars per year.46 The use of CPAP in managing
OSA patients has proven to be the most
cost-effective use of health care resources.45 In pa-
tients with severe OSA, the incremental cost-effectiveness ratio of CPAP was found to be
$3,354 US dollars per quality-adjusted life years
(QALYs). This is lower than the commonly ac-
cepted threshold of $50,000 per QALY.46 Evaluat-
ing medical costs that relate to OSA treatment has
practical implications. Health policy decision mak-
ing is financially driven and current research
CARING FOR PERSONS WITH OSA 333
justifies the cost-effectiveness of CPAP in the treat-
ment of the OSA patient.47
Effects of Anesthesia in PersonsWithOSA
Intravenous hypnotics, analgesics, narcotics, and
inhalational gases produce respiratory depression
in a dose-dependent fashion in normal individ-
uals.1,17,33,35,40,41,48-52 In persons with OSA, they
may produce airway obstruction out of propor-tion to the level of sedation.7,17,19,21,49,50,53,54
Anesthetic agents predictably blunt or abolish the
usual defense mechanisms available to overcome
airway obstruction in normal individuals. These
mechanisms are critical to the OSA patient who
is vulnerable to airway collapse during natural
sleep devoid of anesthetic influence.17,41,53,55 The
transition period from a controlled airway tospontaneous breathing is an unstable period,
particularly in the person with OSA.56
Complications for the OSA patient are often first
encountered in thepostoperativephase,when resid-
ual anesthetics continue to exert their respiratory
effects without the presence of indwelling airway
devices.11,53 Most airway emergencies occurduring the first 24 to 48 hours postoperatively. This
occurs because of preoperative sleep deprivation
and rapid eye movement sleep rebound coupled
with postoperative analgesic requirements.26 When
compared with a control group, persons with OSA
have a 24% increase in serious postoperative respira-
tory complication rates. This may result in longer
hospital stays, reintubations, cardiac events, and un-planned intensive care unit days.10
Postoperative CPAP
A major factor influencing effectiveness of postop-
erative CPAP therapy is whether or not the patient
with OSA is using it at home as recommended be-
fore surgery. Data suggest that the compliance ofpatients using their prescribed CPAP preopera-
tively is important to its effectiveness postopera-
tively.37 This may be due to the possibility that
CPAP use before a surgical procedure places OSA
patients in a more optimal hemodynamic state
before surgery, thus providing carryover protec-
tion afterward.36,48 Higher rates of postoperative
complications have been reported in OSA pa-tients who are not compliant with their at-home
CPAP use.35 Liao et al35 state that patients noncom-
pliant with prescribed CPAP are at increased risk
for episodes of oxygen desaturation postopera-
tively, and thus more at risk for reintubation.34,49
Furthermore, preoperative home CPAP use may
offer carryover protection through the first post-operative day despite CPAP not actually being
administered during the postoperative course.50
Some studies suggest CPAP’s effectiveness in main-
taining airway patency may allow the use of more
systemic analgesics.7,41
Dissenting opinions exist regarding CPAP’s
efficacy. Chung et al18 state that there are norandomized controlled studies on this topic,
thus no existing evidence to support the belief
that CPAP reduces cardiopulmonary risk for pa-
tients with OSA perioperatively. Passannante
and Tielborg57 also claim a lack of evidence for
the theory that CPAP decreases postoperative re-
spiratory complications. This lack of evidence
may be a contributing factor to the underuseof CPAP in the perioperative management of
OSA patients.34
Clinical Guidelines
The ASA’s Clinical Guidelines for the Perioperative
Management of Patients with Obstructive Sleep
Apnea were developed using a systematic analysis
of current literature, synthesis of expert opinion
with open forum commentary, and inclusion of
clinical feasibility data.21 Recommendations ad-
dress the areas of preoperative evaluation and
preparation, intraoperative management, andpostoperative management.21 Postoperative man-
agement will be discussed separately, as health
care personnel employed in areas removed from
the operating room are frequently without the im-
mediate presence of an anesthesia provider and
are therefore in an optimal position to affect
more favorable outcomes for patients with OSA.
Preoperative Evaluation/Preparation
Preoperative evaluation and preparation should be
performed by the anesthesia provider to help de-
termine the existence of diagnosed and more im-
portantly, the possibility of undiagnosed OSA.
Ideally, the surgeon will refer the patient with
a strong suggestion of OSA for anesthesia evalua-tion far enough in advance to allow optimization
of their comorbidities before the day of surgery.21
334 DIFFEE, BEACH, AND CUELLAR
A perusal of the medical record and past anes-
thetics can help the provider determine the pres-
ence and/or severity of OSA and comorbidities.21
Interviewing the patient similar to the initial
screening done for determining the need for PSGof OSA patients helps reveal those who may have
been undiagnosed.21 Using a screening question-
naire such as that used by Chung et al16 may prove
helpful. The usual detailed physical examination of
the airway should include not only mouth open-
ing, chin-to-hyoid distance, and Mallampati classifi-
cation39 but also tongue volume, tonsil size, neck
circumference and nasopharyngeal characteris-tics.21 Sleep studies can also be used as indicators
in guiding an anesthesia provider’s preoperative
preparation.21 If the patient is previously undiag-
nosed, the determination must now be made
whether to proceed with the planned surgical pro-
cedure or seek further consultation. Referring the
patient for further OSA evaluationwith PSG testing
may result in recommendations for preoperativeCPAP therapy or use of nighttime mandibular ad-
vancement devices.21 Additionally, the provider
may address the need for preoperative weight
loss with the obese patient.21 Further determina-
tions can also be made regarding the safety of
proceeding with a surgical procedure on an outpa-
tient basis, especially in OSA patients with comor-
bidities.21
Intraoperative Management
For intraoperative management of this population,
the anesthesia provider should take into consider-
ation the respiratory side effects of intraoperative
medications.21 Their decisions on anesthetic
choice will be affected by the type and duration
of the operative procedure. Anesthetic effects
will extend into the recovery phase for the OSApatient.21 For this reason, the use of local anes-
thetics, peripheral nerve blocks, spinal or epidural
anesthesia, and light-to-moderate sedating medica-
tions are usually chosen over general anesthesia,
when possible.21 Even for procedures not requir-
ing general anesthesia, capnography is recommen-
ded intraoperatively to help detect for the
potential of unrecognized airway obstruction.21
Procedures requiring deeper planes of anesthesia
will usually require an airway management device
such as intubation to allow unobstructed ventila-
tion to occur. Deep sedation is typically avoided
in this population.21 Plans for extubation
require a fully awake patient breathing adequate
tidal volumes who has been fully reversed of
all neuromuscular-blocking medications and posi-
tioned in a lateral, semiupright, or other nonsupineposition in preparation for the postoperative
phase.21
Postoperative Management
If regional anesthetic techniques were not per-
formed preoperatively, the anesthesia provider
may choose to perform them postoperatively for
the purpose of avoiding the respiratory depressant
side effects of systemically administered analge-sics.21 If anesthetic localization is not possible
or effective, systemic opioids can be used via
patient-controlled analgesia (PCA) or titrated in in-
cremental intravenous doses.21 With PCA, basal in-
fusions should be used with caution, if at all, and
nonsteroidal anti-inflammatory drugs or transcuta-
neous electrical nerve stimulation can be used as
analgesic alternatives or adjuncts.21 Caution is ad-vised against the combined administration of opi-
oids and benzodiazepines, as this can present an
increased risk for airway obstruction in OSA
patients.21
The ASA recommends the use of continuous pulse
oximetry measurements along with supplemental
oxygen for this population postoperatively.21 Inaddition, CPAP should be instituted as soon as pos-
sible, especially for those using it preoperatively,
unless the surgical procedure contraindicates its
use.21 The nonsupine position should be contin-
ued throughout the recovery process, and supple-
mental oxygen therapy should be provided until
the patient obtains his or her preoperative baseline
saturation levels in room air.21 Strong consider-ation should be given to continuing pulse oxime-
try measurements after postanesthesia care unit
(PACU) discharge for inpatients.21 This may neces-
sitate transfer to a bed in a critical care area, step-
down, or telemetry unit.21 If these areas are not
available, attendance by a trained professional ob-
server in the patient’s room is necessary to observe
for oxygen desaturation and impending airwaycompromise.21 Continuous pulse oximetry read-
ings should be used until the patient can maintain
his or her oxygen saturation levels above 90%
during sleep.21
CARING FOR PERSONS WITH OSA 335
Outpatient Surgical Procedures
For patients undergoing outpatient surgical proce-
dures, the ASA recommends an additional 3-hourobservation period for OSA patients compared to
those without the disorder, before leaving the facil-
ity.21 For postoperative patients who have had an
episode of airway obstruction or hypoxemia, con-
tinued monitoring is recommended for a median
of 7 hours, breathing room air in an unstimulating
environment.21
Implications for Postanesthesia HealthCare Providers
Nursing personnel caring for patients with OSA in
the PACU face several challenges, few of which
have been addressed in the literature. Seasoned
health care personnel working in these settings
possess experience in caring for differing patient
populations, including the OSA population. They
may have experienced the difficulties and frustra-tions encountered while trying to ease a patient’s
postoperative pain, while having to weigh treat-
ment against the possibility of compromising the
patient’s unsecured airway. Some may have felt
forced to discharge the patient from PACU care
with inadequate pain control. Opioids given for
pain relief may have brought on sleep apnea epi-
sodes, resulting in a longer postoperative observa-tion stay.
Written guidelines for the perioperative care of the
OSA patient are intended to provide a safe transi-
tion for this population from surgical procedure
through the recovery phase.21 Procedures are in-
creasingly being performed in specialty areas out-
side the operating room. When these proceduresrequire anesthesia administration, anesthesia pro-
viders are often not immediately available during
the entire recovery period. Therefore, it is inher-
ent that nursing care providers have protocols in
place to guide decision making.
Although the ASA’s clinical guidelines for care of
the patient with OSA were written in 2006, thereis still much work to be done to fully implement
these guidelines into practice.35 One report identi-
fied that only 63% of OSA patients who were com-
pliant with home CPAP received postoperative
CPAP in the acute care setting.35 The ASA guide-
lines recommend extended oxygen saturation
monitoring postoperatively for the OSA patient.35
This may be restrictive in some settings, such as
ambulatory care surgery centers, which typically
do not have the option for extended hours with
the potential for an unexpected overnight stay.Strictly following the guidelines would limit
much of an ambulatory surgery center’s client
base. As the incidence of obesity continues to in-
crease in the general population, OSA patients
will continue to seek surgical services. Under the
ASA’s recommendations, ambulatory surgery cen-
ters would not be an option for them. This may
explain, in part, the institutions’ hesitancy inadopting the guidelines without reservation.
Patients presenting for surgery with an underlying
diagnosis of OSA require a tailored anesthetic man-
agement strategy. Because they are at an increased
risk for postoperative complications, current rec-
ommendations include a prescreening to determine
OSA severity preoperatively.8,41 If OSA is diagnosed,the anesthetic plan may include regional and/or
local anesthesia as warranted by the surgical site,
procedure and patient presentation.8,55 If general
anesthesia with airway manipulation is required,
minimal opioids should be given and complete
reversal of neuromuscular blockade accomplished
before considering extubation and transitioning
care into the postoperative phase.34 Opioids shouldbe given judiciously in the PACU and oxygen satura-
tion monitored continuously.8
CPAP plays a critical role in decreasing risks for
hypoxemia, atelectasis, pneumonia, and cardiac
complications in persons with OSA.4,6,41,49,52
Sources recommend that patients with OSA
receiving heavy sedation or general anesthesiareceive immediate administration of CPAP with
oxygen saturation monitoring postoperati-
vely.9,25,28,34,50,55
The ASA has identified a deficiency in literature
evaluating effects of pain control measures, admin-
istration of supplemental oxygen, optimum pa-
tient positioning, and efficacy of monitoringsystems for the patient with OSA in the postopera-
tive setting.21 Recommendations are based on
a synthesis of expert opinion. By establishing prac-
tice guidelines/recommendations as opposed to
a standard of practice, recommendations can be
amended as evidence becomes available with fur-
ther research in the field. Guidelines/practice
336 DIFFEE, BEACH, AND CUELLAR
recommendations invite creative initiative in find-
ing ways to perform patient care that do not neces-
sarily conform to traditional practice, but result in
good patient outcomes.
Summary
There is an increase in the prevalence of OSA in
this country. The underlying diagnosis of OSA in-
creases a patient’s risk for postoperative complica-
tions. Unfortunately, most patients with OSA
present for surgery undiagnosed of the condition.
CPAP is the most effective means of treating OSA
pre- and postoperatively, yet few facilities havea postoperative protocol in place to insure its
use. More research is needed to increase
evidence-based knowledge in caring for persons
with OSA in the postanesthesia period.
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338 DIFFEE, BEACH, AND CUELLAR
Caring for the Patient With Obstructive Sleep Apnea: Implications for HealthCare Providers in Postanesthesia Care
.86 Contact Hours
Purpose of the Journal of PeriAnesthesia Nursing: To facilitate communication about and deliver
education specific to the body of knowledge unique to the practice of perianesthesia nursing.
Purpose/Goal: The purpose of this educational activity is to review the care of the patient with obstructivesleep apnea in the perianesthesia setting.
Target Audience: The primary audience for JOPAN includes nurses in perianesthesia settings: ambulatory
surgery, preadmission testing, postanesthesia (Phases I, II, III), and painmanagement. Additionally, the Jour-
nal provides information of interest to professionals practicing in office-based settings, operating rooms,
medical/surgical and critical care nursing, and all areas where sedation/analgesia is utilized. Facilities and
settings of care delivery vary and therefore it is the practice, not the location that determines the focus.
Article Objectives: (1) Describe the physiology, comorbidities, diagnosis, and treatment of OSA. (2) Iden-
tify the effects of anesthesia in persons with OSA. (3) Discuss implications for care across the perianesthesia
setting.
Accreditation
American Society of Perianesthesia Nurses is accredited as a provider of continuing nursing education by
the American Nurses Credentialing Center’s Commission on Accreditation.
Accreditation does not imply that ASPAN or ANCC-COA approves or endorses any product included in the
activity. Additional provider numbers: Alabama #ABNP0074, California #CEP5197, Florida 50-114.
Registered nurse participants can receive .86 contact hours for this activity.
Non-endorsement of Products: Accreditation refers to recognition of continuing nursing educationactivities only and does not imply ASPAN or Commission on Accreditation approval or endorsement of
any commercial product.
Disclosure: All authors and planning committee members of nursing continuing education activities are
required to disclose (1) any significant financial relationships with the manufacturer(s) of any commercial
products, goods, or services and (2) any unlabeled/unapproved uses of drugs or devices discussed in the
educational activity. Such disclosures will be printed in the educational activity. Any conflicts of interest
must be resolved prior to the development of the educational activity.
Planner and Author Disclosure: The members of the planning committee for this continuing nursingeducation activity do not have financial arrangements, interests, or affiliations related to the subject matter
of this continuing education article.
The author for this continuing nursing education activity does not have financial arrangements, interests, or
affiliations related to the subject matter of this continuing education article.
Off-Label Use of a Commercial Product: The author will not be discussing any off-label use of equip-
ment, products, etc in this continuing nursing education activity.
Verification of Participation: Verification of your participation in this educational activity is done by
having you complete the registration form and submit the form along with the post test and evaluationform to the ASPAN national office.
Requirements for Successful Completion: To receive contact hours for this continuing nursing educa-
tion article, a minimum grade of 80% must be achieved on the post test.
CARING FOR PERSONS WITH OSA 339
Directions: The multiple-choice examination be-
low is designed to test your understanding of
Caring for the Patient With Obstructive SleepApnea: Implications for Health Care Pro-viders in Postanesthesia Care according tothe objectives listed. To earn contact hours
from the American Society of PeriAnesthesia
Nurses (ASPAN) Continuing Education Provider
Program: (1) read the article, (2) complete the
posttest by indicating the answers in the test
grid provided, and (3) tear out the page (or pho-
tocopy) and submit postmarked before October
31, 2014, with check payable to ASPAN (ASPAN
member, $12.00 per test; nonmember, $15.00per test) and return to ASPAN, 90 Frontage
Road, Cherry Hill, NJ 08034–1424. Notification
of contact hours awarded will be sent to you in
4 to 6 weeks.
Posttest Questions
1
1. Women are twice as likely to develop OSA
than men.
A. True
B. False2. The most likely contributor to the increase
in the incidence of OSA is:
A. Hypertension
B. COPD
C. Sedentary lifestyle
D. Obesity
3. The triad features of OSA include all of the
following except:A. Gasping
B. Somnolence
C. Obesity
D. Snoring
4. The hallmark symptom of OSA is:
A. Obesity
B. Difficulty sleeping
C. Daytime somnolenceD. Memory lapses
5. OSA is clinically diagnosed via PSG.
A. True
B. False
6. The preferred treatment for OSA patients is:
A. Maxillary reconstruction
B. Apnea monitoring
C. CPAP applicationD. Tracheostomy
7. Patients with OSA have up to a 50% risk for
airway complications postoperatively.
A. True
B. False
8. Detailed physical examination of the airway
should include all of the following except:
A. Mouth openingB. Nares diameter
C. Tonsil size
D. Neck circumference
9. General anesthesia is the preferred anesthe-
sia technique for the OSA patient.
A. True
B. False
0. ASA recommends at least a ____ hourobservation before discharge for ambulatory
surgery patients.
A. 2
B. 3
C. 4
D. 5
Caring for the PatientWith Obstructive Sleep Apnea: Implications for Health CareProviders in Postanesthesia Care
ANSWERS
W011014 Please circle the correct answer
1. A. 2. A. 3. A. 4. A. 5. A.
b. B. B. B. B.
C. C. C.
D. D. D.
6. A. 7. A. 8. A. 9. A. 10. A.
B. B. B. B. B.
C. C. C.
D. D. D.
________________________________________________________________________________________
Please Print
Name__________________________________Nursing License No./State____________________________
Address__________________________________________________________________________________
City_______________________________State_______________________Zip_________________________
ASPAN Member #__________________________________________________________________________
EVALUATION: Caring for the Patient With Obstructive Sleep Apnea: Implications for Health Care Providers
in Postanesthesia Care
(SD, strongly disagree; D, disagree; ?, uncertain; A, agree; SA, strongly agree) SD D ? A SA
1. To what degree did the content meet the objectives? 1 2 3 4 5
a. Objective # 1 was met 1 2 3 4 5
b. Objective # 2 was met 1 2 3 4 5
c. Objective # 3 was met 1 2 3 4 5
2. The program content was pertinent, comprehensive, and useful to me. 1 2 3 4 5
3. The program content was relevant to my nursing practice. 1 2 3 4 5
4. Self-study/home study was an appropriate format for the content. 1 2 3 4 5
5. This educational activity was free from commercial bias. 1 2 3 4 5
6. The planner and author disclosure information was included in this educational
activity.
1 2 3 4 5
7. Identify the amount of time required to read the article and take the test:
Under 30 min 30-60 min 61-90 min 91-120 min over 120 min
Test answers must be submitted before October 31, 2014 to receive contact hours.
340 DIFFEE, BEACH, AND CUELLAR
Recommended