Caring for the bariatric patient with obstructive sleep apnea

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<ul><li><p>Crit Care Nurs Clin N Am 16 (2004) 311317Caring for the bariatric patient with obstructive sleep apnea</p><p>Margaret M. Ecklund, MS, RNa,*, Stefan A. Kurlak, RRTb</p><p>aPulmonary Medicine, Rochester General Hospital, 1425 Portland Avenue, Rochester, NY 14621, USAbRespiratory Care, Rochester General Hospital, 1425 Portland Avenue, Rochester, NY 14621, USAThe call came from the staff nurse: We had an nasal continuous positive airway pressure (NCPAP)admission this afternoon from the Medical Intensive</p><p>Care Unit, and he weighs 748 lb (340 kg) and does</p><p>not fit in the bed. What do we do? So began the</p><p>journey of PM with the multidisciplinary team on the</p><p>step down pulmonary unit.</p><p>The care of the bariatric patient in acute care</p><p>presents many challenges, including strategies for</p><p>management of obstructive sleep apnea (OSA). The</p><p>plan of care for such patients includes a host of</p><p>strategies to manage multisystem and organizational</p><p>issues. Using a case study to highlight important</p><p>aspects of such care, this article explores the etiology</p><p>and treatment of OSA.Case history and progress</p><p>PM, a 39-year-old male with a history of severe</p><p>obesity and a body mass index (BMI) of 91 kg/m2,</p><p>was admitted because of a fall at home secondary to</p><p>weakness from the onset of pneumonia. Because he</p><p>was unable to get up, the Emergency Medical System</p><p>(EMS) was alerted, and he was transported to the</p><p>hospital on an oversized cart.</p><p>PM lived alone and had been housebound for the</p><p>last 4 months. His weight gain worsened as his</p><p>dyspnea and depression increased, causing a further</p><p>decline in his functional status. He owned his own</p><p>business and had been working from his home.</p><p>PMs history was significant for severe obesity,</p><p>hypertension, depression, OSA, cardiomyopathy, and</p><p>deep vein thrombosis (DVT). He had been using0899-5885/04/$ see front matter D 2004 Elsevier Inc. All right</p><p>doi:10.1016/j.ccell.2004.03.004</p><p>* Corresponding author.</p><p>E-mail address: Margaret.ecklund@viahealth.org</p><p>(M.M. Ecklund).with supplemental oxygen to treat OSA that had been</p><p>diagnosed by a polysomnogram (sleep study) the</p><p>previous year. He had also been evaluated for gastric</p><p>bypass surgery and was on a waiting list for the</p><p>procedure. Although he was knowledgeable of obe-</p><p>sity treatment strategies, his ability to control his</p><p>intake was limited.</p><p>The bariatric bed on which PM was transported</p><p>accommodated up to 500 lb (227.3 kg). Considering</p><p>his height (74 in [188 cm]), weight, and girth, the bed</p><p>was inappropriate. For example, his legs were resting</p><p>on chairs next to the bed.</p><p>The first challenge for the multidisciplinary team</p><p>was to provide PM a suitable sleep surface. The</p><p>necessary data included weight, height, girth, skin</p><p>integrity, and the ability to move independently in</p><p>and out of bed. A Barimax 2 (Kinetic Concepts,</p><p>San Antonio, TX) was selected because it accom-</p><p>modated up to 850 lb (386 kg). It was wide enough</p><p>to allow turning, had a built in scale, and a low-</p><p>pressure sleep surface. The staff coordinated PMs</p><p>move to the new bed, and he appeared relieved once</p><p>comfortably situated.</p><p>A formal psychiatric consultation helped PM</p><p>identify his feelings about his body image and</p><p>limitations. He described feelings of despair and</p><p>frustration over lack of progress and hunger. In</p><p>addition to talking with PM, the psychiatrist recom-</p><p>mended clonazepam (Klonipin) until he improved,</p><p>and an increase in sertaline (Zoloft), which he had</p><p>been on before admission.</p><p>The evaluation of PMs respiratory status was</p><p>done early in the admission on 4 L of oxygen with</p><p>NCPAP. An arterial blood gas (ABG) after a night on</p><p>NCPAP, demonstrated respiratory acidosis (pH 7.30,</p><p>PaCO2 66, PaO2 66, SaO2 90, HCO3 31). The team</p><p>selected bi-level ventilation with a nasal mask to treats reserved.</p></li><li><p>M.M. Ecklund, S.A. Kurlak / Crit Care Nurs Clin N Am 16 (2004) 311317312the nocturnal hypercarbia and OSA. To evaluate</p><p>nocturnal desaturation, overnight oximetry studies</p><p>were conducted. The first study on 4 L of nasal</p><p>oxygen without bi-level therapy showed significant</p><p>desaturation, with average oxygen saturation of 79%.</p><p>Subsequent studies performed on bi-level ventilation</p><p>with supplemental oxygen showed an improvement</p><p>in oxygenation and decrease in PaCO2. The studies</p><p>revealed that the most effective therapy was humidi-</p><p>fied bi-level ventilation with the following settings:</p><p>inspiratory positive airway pressure (IPAP) of 15 cm</p><p>H2O and 6 cm H2O of positive end expiratory</p><p>pressure (PEEP) or expiratory pressure (EPAP) de-</p><p>livered with 6 L of supplemental oxygen through a</p><p>nasal mask. Throughout the hospitalization, PM reli-</p><p>ably used the bi-level therapy with the addition of</p><p>humidity and nasal strips to improve nasal patency.</p><p>Mobilization in the early weeks was a challenge.</p><p>Because PM could not achieve independent sitting</p><p>balance, physical therapists worked to improve mus-</p><p>cle strength so that balance could improve and PM</p><p>could get out of bed. To help mobilize PM, an</p><p>inflatable transfer device (Hover Matt Technology,</p><p>Allentown, PA) was selected to assist with moving</p><p>PM up in bed and to reposition him as necessary.</p><p>Initially, six staff members were needed to provideTable 1</p><p>Components of PMs plan of care</p><p>Problem Goals</p><p>Psychosocial Ability to control aspects of care and daily</p><p>activity</p><p>Nutrition Caloric intake to meet daily energy needs;</p><p>Consistent weight loss</p><p>Respiratory SpO2 &gt; 90%</p><p>Daytime wakefulness without lethargy</p><p>Skin integrity Healed, intact skin</p><p>Elimination Urine continence;</p><p>Bowel continence</p><p>Circulation No deep venous thromboses</p><p>Mobility Ambulation without falls</p><p>Educational Knowledge of disease process, management,</p><p>and treatment optionsturning and to achieve the supine position. Until he</p><p>regained leg strength, two people were required to</p><p>move his legs for care and positioning. A sheet was</p><p>folded and placed under his legs to achieve leverage</p><p>with positioning, while his trunk was turned with a</p><p>separate lift sheet. This technique protected staff from</p><p>injury and was more comfortable for PM. He began</p><p>the daily process of getting out of bed but was re-</p><p>luctant to try any new activity if the caregivers did not</p><p>project confidence and the ability to listen to his fears</p><p>and observations.</p><p>Although a referral to skilled nursing facilities</p><p>(SNF) was initiated by the social worker once PMs</p><p>functional state began to stabilize, the complexity and</p><p>cost of his care (noninvasive positive pressure venti-</p><p>lation [NIPPV], full assisted daily living help and</p><p>equipment rental) made acceptance impossible. An</p><p>updated referral to a bariatric surgeon was made for</p><p>gastric bypass. The care manager completed the</p><p>referral request, including the necessary cardiac,</p><p>pulmonary, psychiatry, nutritional, and social service</p><p>evaluations and the third party payer approval.</p><p>PMs mobility improved and he lost a total of</p><p>135 lbs (61 kg). Two months after his admission,</p><p>PM was transferred directly to the hospital where his</p><p>Roux-En-Y gastric bypass surgery would be per-Stratgies</p><p>Patient setting own goals &amp; schedules;</p><p>Knowledge and trust of team members</p><p>Limited calorie diet, with adequate protein intake;</p><p>Diet preferences determined;</p><p>Food and intake teaching</p><p>Noninvasive bi-level ventilation at HS, with</p><p>supplemental oxygen;</p><p>Oxygen via nasal prongs daily</p><p>Local care to wounds with protective creams and</p><p>petroleum gauze [14];</p><p>Low pressure mattress;</p><p>Chair cushion &amp; commode padding;</p><p>Turning schedule, pillowcases in skin folds</p><p>Indwelling catheter until mobile;</p><p>Assistive device to hold urinal when catheter removed;</p><p>Commode of adequate size;</p><p>Stool softener</p><p>Anticoagulation with warfarin</p><p>Progressive ambulation</p><p>Walker of adequate size;</p><p>Supplemental oxygen;</p><p>Shoes for support;</p><p>Appropriate size wheelchair</p><p>Educate about obesity and diet;</p><p>Educate about OSA</p></li><li><p>M.M. Ecklund, S.A. Kurlak / Crit Care Nurs Clin N Am 16 (2004) 311317 313formed. This required that specialty vendors be con-</p><p>tacted regarding PMs weight and girth to ensure that</p><p>the proper transport equipment was available. Al-</p><p>though a freight-type transport cart was required for</p><p>ambulance transportation, PM was brought through</p><p>the hospital to the ambulance in a wheelchair to main-</p><p>tain his dignity.</p><p>PMs bariatric surgery and recovery were success-</p><p>ful. One year later his weight is 411 lb (187 kg), he is</p><p>running his business successfully, and is an active</p><p>participant in support groups for other people con-</p><p>sidering bariatric surgery. Aspects of PMs plan of</p><p>care are summarized in Table 1.Obesity</p><p>Obesity is derived from the Latin word meaning</p><p>overeat. The modern definition of obesity is disease</p><p>of excess body fat. Despite common perceptions and</p><p>prejudices, obesity is a disease, not a character flaw,</p><p>cosmetic aberration, or personality disorder [1]. In the</p><p>year 2000, 38.8 million Americans were obese: an</p><p>estimated 61% of all Americans have a BMI &gt;30 kg/</p><p>m2, according to the Centers for Disease Control</p><p>(CDC). The CDC also projects a cost of &gt;117 billion</p><p>dollars (yearly) in health care costs for obese indi-</p><p>viduals [2].</p><p>Obesity is the result of the body consuming more</p><p>energy than it uses. It results from physiologic, social,</p><p>and cultural factors. Genes play an important role in</p><p>the regulation of body weight, and many processes in</p><p>the brain and gastrointestinal tract influence appetite.</p><p>Eating patterns are affected by satiety centers in the</p><p>hypothalamus and pituitary glands that respond to</p><p>high fat stores and hunger. Many metabolic processes</p><p>involving hormones and proteins have an impact on</p><p>obesity. In addition, dietary patterns of modern soci-</p><p>ety accompanied by more sedentary lifestyles pro-</p><p>mote weight gain and obesity [3].</p><p>Definition of obesity</p><p>The BMI (Box 1) is considered the best measure</p><p>for gauging body fat. It is a mathematic expres-Box 1. Steps to calculate Body Mass Index(BMI) kg/m2 [4]</p><p>1. [Weight (pounds) x 703]/Height(inches)</p><p>2. Divide result by height (inches)sion of weight adjusted for height. A BMI of 25 to</p><p>29.9 kg/m2 is considered overweight; obesity is a</p><p>BMI of 30 kg/m2 or higher. Morbid obesity is an</p><p>ambiguous term, with reference to greater than</p><p>100 pounds over the desirable weight of the individ-</p><p>ual. The National Institutes of Health consensus panel</p><p>defines severe obesity as a BMI greater than or equal</p><p>to 50 kg/m2 [3,4]. A limitation of the BMI measure-</p><p>ment is that it does not differentiate the type of weight</p><p>(fat versus muscle). Muscular individuals can be</p><p>misclassified as overweight [3].</p><p>Other measures of obesity include waist circum-</p><p>ference, waist/hip ratio, and anthropometry. A waist</p><p>measurement of greater than 31.5 in (80 cm) for</p><p>women and greater than 37 in (94 cm) for men in-</p><p>dicates health risk. The waist/hip ratio is determined</p><p>by dividing waist by hip size. The lower the ratio, the</p><p>better. Heart disease risk increases for women with</p><p>ratios greater than 0.8. Anthropometry is the mea-</p><p>surement of skin fold thickness, usually done with</p><p>forceps at the triceps. It determines how much weight</p><p>is due to muscle or fat [4].</p><p>By these definitions PM, with a BMI of 91 kg/m2,</p><p>was severely obese. He demonstrated comorbitities as</p><p>well. To understand the rationale for the treatment</p><p>plan for PM, some of the pathophysiologic processes</p><p>associated with obesity and complications are dis-</p><p>cussed in the following sections.</p><p>Physiologic processes influencing obesity</p><p>Leptin is a hormone that is released by fat cells</p><p>and the stomach and is, in part, responsible for food</p><p>intake, storage, and conversion into energy [2]. Lep-</p><p>tin is released by adipocytes, or fat cells, in propor-</p><p>tion to the size of the adipocyte cell. Adipocytes store</p><p>energy when calories are in excess and mobilize</p><p>energy when needs exceed intake. In rodents, leptin</p><p>reduces energy intake and increases energy expendi-</p><p>ture. Because this would translate to weight loss in</p><p>obese humans with high plasma leptin concentra-</p><p>tions, leptin resistance is a suggested explanation of</p><p>human obesity [3]. Leptin treatment for weight loss</p><p>has been unsuccessful except in those individuals</p><p>with leptin deficiency [5].</p><p>The inability to use insulin efficiently is also</p><p>associated with obesity. Resistin is a hormone that</p><p>is produced by fat cells and produces insulin resist-</p><p>ance [2]. If insulin is used ineffectively and hyper-</p><p>glycemia results, a host of complications can result</p><p>including impaired wound healing, infections, and</p><p>organ failure [6]. The importance of tight glucose</p><p>control was recently demonstrated in a study of</p><p>critically ill surgical patients. The investigators found</p></li><li><p>M.M. Ecklund, S.A. Kurlak / Crit Care Nurs Clin N Am 16 (2004) 311317314that the use of insulin infusions to attain glucose</p><p>levels less than or equal to 110 mg/dL resulted in</p><p>reduced morbidity and mortality in critically ill sur-</p><p>gical patients [6]. The study suggested that improved</p><p>glucose control can be a strategy to compensate for</p><p>the effects of insulin resistance in obese patients.</p><p>Although PM did not have diabetes, the plan of care</p><p>included weight loss and activity to compensate for</p><p>his altered metabolism and insulin use.</p><p>Other complications of obesity</p><p>Complications of obesity can be categorized into</p><p>weight related complications, metabolic obesity, and</p><p>organ-related obesity [1]. Weight-related complica-</p><p>tions include degenerative joint disease, respiratory</p><p>compromise, skin changes, and intraabdominal</p><p>pressure compromise (varicose veins, hemorrhoids).</p><p>Metabolic obesity presents with neurohormonal</p><p>and behavioral symptoms (stress intolerance, seden-</p><p>tary lifestyle, or use of tobacco, alcohol, or drugs),</p><p>substrate overload (type 2 diabetes, dyslipidemia,</p><p>cholelithiasis), and thrombogenic manifestations.</p><p>Organ-related pathology includes presence of adipose</p><p>tissue, liver fibrosis, and kidney dysfunction [1]. PM</p><p>experienced a number of weight and metabolic com-</p><p>plications, including respiratory compromise, skin</p><p>breakdown, and sedentary lifestyle. One of the most</p><p>serious complications was OSA, which will be dis-</p><p>cussed further.Obstructive sleep apnea</p><p>Definition</p><p>OSA occurs when there is partial or complete</p><p>upper airway collapse during sleep. During periods</p><p>of OSA, episodes of oxyhemoglobin, desaturation,</p><p>and transient nocturnal arousals and awakening create</p><p>sleep disturbances resulting in daytime sleepiness [7].</p><p>OSA, recognized over 30 years ago, is measured in</p><p>terms of obstructive apnea and hypopnea episodes</p><p>per hour of sleep resulting in an apnea-hypopnea</p><p>index (AHI). Central sleep apnea is characterized by</p><p>repeated episodes of apnea or hypopnea resulting</p><p>from deceased neural output to responding motor</p><p>neurons without airflow obstruction. One out of every</p><p>five adults with a mean BMI of 25 to 28 kg/m2 has at</p><p>least mild OSA, whereas 1 of every 15 has mild sleep</p><p>apnea. One interesting fact regarding OSA is that</p><p>most patients with OSA snore, but most individuals</p><p>who snore do not have frank OSA [8]. The preva-</p><p>lence of OSA can be predicted from increased neckcircumference, hypertension, habitual snoring, noc-</p><p>turnal gagging, and choking [7].</p><p>The modifiable risk factors of OSA are over-</p><p>weight and obesity, alcohol consumption, tobacco</p><p>use, nasal congestio...</p></li></ul>

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