The ASPAN Obstructive Sleep Apnea in the Adult Patient Evidence-Based Practice Recommendation

The ASPAN Obstructive Sleep Apneain the Adult Patient Evidence-Based

Practice Recommendation
ASPAN OSA PR Strategic Work Team
OBSTRUCTIVE SLEEP APNEA (OSA) is associated with re-

duced muscle tone in the airway leading to frequent airway ob-

struction during sleep.1 In the United States, the incidence of

OSA is estimated to be 3% to 7% in men and 2% to 5% in

women, rising to 41% in obese individuals, and as high as

78% in the morbidly obese.2 Patients presenting to surgical ser-vices with OSA are at increased risk for the development of

postoperative complications owing to cardiovascular dysfunc-

tion and periodic sleep-associated decreases in oxygen satura-

tion and hypercarbia.3 Although awareness and diagnosis of

OSA in the surgical population has increased in the past two de-

cades, an estimated 80% of men and 93% of women who pres-

ent for elective surgery are at risk for OSA and as yet are not

diagnosed.4 Patients with untreated OSA are in higher numbersin surgical patients,5 and they have increased intensive care

admissions and hospital costs.6 The perianesthesia care of

patients with OSA is challenging but improved patient out-

comes can be achieved using evidence-based strategies for

OSA management.7

Background

OSA affects approximately 2% to 26% of the general population,

making it the most common sleep-related breathing disorder.6 In

addition to an increased mortality, OSA also has been found to in-

crease the risk of cardiovascular diseases and motor vehiclecrash. The incidence of OSA increases with age, with 7% to

62% patients aged older than 60 years having OSA.7 The use of

sleep study evaluation (polysomnography) remains the gold stan-

dard for the evaluation of patients suspected of having OSA.8 It is

encouraged for use in conjunction with medical history, family in-

terview using focused questions, and physical examination for

the preoperative evaluation of OSA.3 Patients with undiagnosed

OSA present many challenges for anesthetic management andhave an increased incidence of perioperative morbidity, postop-

erative complications, difficult intubation, have a longer length

of stay in the hospital, and a higher rate of intensive care

admission.9

Address correspondence to the ASPAN National Office, 90 Frontage Road,

Cherry Hill, NJ 08034; e-mail address: [email protected].

� 2012 by American Society of PeriAnesthesia Nurses

1089-9472/$36.00

http://dx.doi.org/10.1016/j.jopan.2012.07.003

Journal of PeriAnesthesia Nursing, Vol 27, No 5 (October), 2012: pp 309-315 309

mailto:[email protected]

http://dx.doi.org/10.1016/j.jopan.2012.07.003

aPatients with previously diagnosed OSA

should have an established plan of care

for the perianesthesia period.

310 ASPAN OSA PRACTICE RECOMMENDATION

Purpose

This practice recommendation (PR) is intended to promote peri-

anesthesia patient safety in the care of adult patients (older than

18 years) with known or suspected OSA who have received opi-

oids, procedural sedation, or general or regional anesthesia. It is

not intended to be all-inclusive. Each institution should develop

a multidisciplinary guideline to meet the needs of its patient pop-

ulation and personnel resources.

Recommendations

1. Assess and screen patients for risk factors/comorbidities asso-

ciated with OSA.

OSA risk factors/comorbidities in the adult patient are:
A. Body mass index (BMI) greater than 3010-13
B. Increased abdominal fat14

C. Cardiovascular disease

i. Hypertension2,8,10-15

ii. Resistant hypertension15

iii. Ischemic heart disease8,11,16,17

iv. Idiopathic cardiomyopathy and congestive heart fail-

ure8,17

v. Atrial fibrillation8

D. Age11,12,17,18

i. Men peak prevalence: 50 to 59 years

ii. Women peak prevalence: 60 to 64 years

iii. Men have higher risk of OSA than women until men-

opause7,11,17

E. Male gender17,19

F. Endocrine dysfunction
i. Type II diabetes20
ii. Metabolic syndrome7

iii. Altered glucose tolerance20

iv. Thyroid disease17

G. Associated hypercapnia seen in21

i. Increased BMI

ii. Restrictive chest wall mechanics

iii. Decreased overnight saturation
H. Enlargement of upper airway22
I. Stroke (history of stroke associated with increased risk of

stroke and mortality)17

J. Ethnicity: Black greater than Caucasian17

K. Lower socioeconomic status: Independent risk factor

for OSA12

2. Assess and screen undiagnosed patients for signs and symp-toms of OSA.a

OSA symptoms are as follows:
A. Daytime sleepiness8,11,23
B. Observed snoring8,10,11,23-25

C. Snoring under sedation26,27

ASPAN OSA PRACTICE RECOMMENDATION 311

D. Dry mouth or sore throat8,11,24

E. Morning headache8

F. Fatigue or malaise8,10

G. Apnea reported by sleeping partner8,11

H. Restlessness11

I. Drowsiness with driving23

J. Awakening unrefreshed after sleep11

K. Nocturia11

bPositive screenings should initiate com-

munication with the patient, physician

providers.

3. Incorporate the use of standardized screening tool to identify

patients at risk for OSA.b

The use of the Berlin Questionnaire (BQ) is well established in the

OSA literature; however, there has been limited application of the

BQ in the perianesthetic patient. Tools specific to the perianes-

thetic population of patients have been suggested by the Ameri-

can Society of Anesthesiologists (ASA),3 but their use has

limited supportive data.

Currently, two recommended tools exist and include:
cFor more information regarding the
STOP-Bang tool, visit http://www.stop

bang.ca/, the official STOPBang Question-

naire Website.

A. STOP-BANGc,5,6,28

B. ASA OSA checklist6 (snoring, tired, observed with ap-

nea, high blood Pressure, body mass index greater

than 25 Kg/m2, age greater than 50 years old, neck cir-

cumference greater than 40 cm and male gender)

4. Initiate postanesthesia management of the patient with diag-nosed or suspected OSA. Phase I and II management includes:

dPain management background:

� OSA patients are at risk of respiratory

depression postoperatively owing to

decreased pharyngeal activity

� OSA patients are sensitive to opioids and

sedatives

� Health care providers need to have

heightened awareness in this patient

population

A. Routine monitoring and the addition of capnography

when available3

B. Positioning the patient with OSA in a lateral, lateral re-

cumbent, or sitting position; avoid placing the patient

in supine position unless clinically indicated28-30

C. Providing continuous positive airway pressure (CPAP)/

bilevel positive airway pressure (BPAP) as prescribedearly in the postoperative course to reduce respiratory

effort and may reduce other complications3,31,32

D. Individualizing pain managementd plan of care based on

severity of OSA, type of procedure, and need for opi-

oids33-35

E. Advocating for the use of multimodal approach

(using medications from different categories, such

as nonsteroidal agents, acetaminophen, tramadol,clonidine, COX2 inhibitors, ketamine, gabapentin,

and dexmedetomidine)9,34-37

F. Advocating for the use of regional anesthesia for pain

control (epidural, nerve blocks)3,36

G. Initiation of careful titration of opioids, if needed3,38-40

H. Noting that if patient-controlled analgesia is used, a basal

opioid infusion is not recommended3,33

I. Considering the use of nonpharmacologic comfortmeasures41

J. Patient may require extended monitoring in the immedi-

ate postoperative period38

http://www.stopbang.ca/

http://www.stopbang.ca/

eDesaturation occurs when the percentage

of oxygen delivered to the tissues (SpO2)

drops with changes in carbon dioxide

levels, pH, body temperature, and hemo-

globin. Hypoxemia is defined as an SpO2

of 90% and severe hypoxemia when the

SpO2 is 75%.49

fA hypoxemic event is defined as a sus-

tained decline in SaO2 requiring interven-

tion for improvement (ie, stimulation or

supplemental oxygen).

gAdherence with treatment was reported to

be dependent on ongoing layers of infor-

mation in educational programs, written

instructions, equipment demonstration,

and timely trouble shooting of encoun-

tered problems.48 An obstacle encountered

for the implementation of educational pro-

grams is the lack of psychological pre-

paredness required for behavioral

change.45 If adequate education is not

given, it can cause fear, anxiety, and non-

adherence.47

Negative messages emphasiz-

ing the consequences of untreated OSA

resulted in greater adherence.47


5. Plan for patient discharge with diagnosed or suspected OSA:

Phase I Postanesthesia Care Unit (PACU).

There is very little empirical evidence to guide this sec-

tion of the OSA-PR.

� The patient should not have signs of desaturatione when

left undisturbed in the Phase I PACU

� Anticipate extended PACU stay42,35

6. Plan for patient discharge with diagnosed or suspected OSA:

Phase II PACU.

� Room air oxygen saturation (SpO2) should return to base-line3,33

� No evidence of hypoxia or obstruction when patient is

left undisturbed for 30 minutes3,33

� Patients should be observed while asleep and unstimu-

lated, to establish that their room air SpO2 remains at

baseline3

� Anticipate a minimum observation period of 2 to 6

hours33,43

� Outpatients should be observed on average 3 hours lon-

ger than non-OSA counterparts before discharge to

home3

� With each hypoxemicf and/or obstructive event, moni-

toring should continue for 7 hours after last episode3

� If there is no requirement for high-dose oral opioids post-

operatively, the patient may be discharged to home35

� Consult with anesthesia/surgeon for appropriateness ofdischarge for patients requiring oral opioids for painman-

agement at home43

� If no problems in the Phase II PACU, the patient may dis-

charge to home.44 Discharge criteria include, but are not

limited to:

��

�

Return to baseline level of consciousness44

Oxygen saturation should be greater than 94% or at

baseline for at least 2 hours before discharge43

Able to use CPAP on returning home44

7. Provide discharge education to patients with suspected/diag-

nosed OSA.g

There is very little empirical evidence to guide this sec-

tion of the OSA-PR.

� Patients should be educated about their continued risk

for respiratory compromise for 1 week postoperatively

� Patients being discharged with CPAP therapy should be

reminded that the use of CPAP therapy is crucial during

the first postoperative week42,46

� To prevent oversedation, patients need to be taught the

risks of taking more than the prescribed dose of pain or

sedating medications, including over-the-counter medi-cations, during this high risk recovery period


� Patients need to have a responsible adult caregiver with

them overnight after discharge; this should be emphasized

with the patient

� Patients should be encouraged to sleep on their sides, in

prone, or sitting position3

� Responsible caregivers should be taught how to apply theCPAP therapy before discharge to home

Acknowledgments

Strategic Work Team Members

SQAD #1: Questions 1 to 6

– Coleader: Dina Krenzischek, PhD, RN, CPAN, FAAN

– Coleader: Kim Noble, PhD, RN, CPAN

– Amy Dooley, MS, RN, CPAN

– Laura Kling, MSN, RN, CNS, CPAN, CAPA

– Kim Kraft, BSN, RN, CPAN

– Jan Lopez, BSN, RN, CPAN, CAPA

– Cecilia Reyes, BSN, RN

– Kyra Stewart, RN, CPAN


– Leader: Daphne Stannard, PhD, RN, CCRN, CCNS, FCCM

– Cynthia Beane, RN, RNLC, CPAN

– Debbie Sandlin-Leming, RN, CPAN

– Renee Smith, BSN, MS, RN, CPAN, CAPA

– Marie Wiegert, BSN, MAN, RN, CPAN, CAPA


– Leader: Barbara Krumbach, MSN, RN, CNS, CPAN

– Theresa Clifford, MSN, RN, CPAN

– Stephanie Kassulke, MSN, RN, CPAN

– Ellen Poole, PhD, RN, CPAN, CNE

– Linda Ziolkowski, MSN, RN, CPAN


– Leader: Kathy DeLeskey, DNP, RN, CPAN, CNE

– Linda Beagley, BSN, MS, RN, CPAN

– Deborah Bickford, BSN, RN, CPAN

– Maureen McLaughlin, MS, RN, CPAN, CAPA

– Candace Taylor, BSN, RN, CPAN

– Karen Wessels, MSN/Ed, RN, CPAN


– Leader: Sarah Brynelson, BSN, MS, RN

– Kathy Daley, MSN, RN, CNS, CCRN-CMC-CSC, CPAN

– Susan Russell, BSN, RN, JD, CPAN, CAPA

– Ellen Sullivan, BSN, RN, CPAN

– Tracy Underwood, BSN, RN

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Documents

The ASPAN Obstructive Sleep Apnea in the Adult Patient Evidence-Based Practice Recommendation