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