Crit Care Nurs Clin N Am 16 (2004) 311–317
Caring for the bariatric patient with obstructive sleep apnea
Margaret M. Ecklund, MS, RNa,*, Stefan A. Kurlak, RRTb
aPulmonary Medicine, Rochester General Hospital, 1425 Portland Avenue, Rochester, NY 14621, USAbRespiratory Care, Rochester General Hospital, 1425 Portland Avenue, Rochester, NY 14621, USA
The call came from the staff nurse: ‘‘We had an nasal continuous positive airway pressure (NCPAP)
admission this afternoon from the Medical Intensive
Care Unit, and he weighs 748 lb (340 kg) and does
not fit in the bed. What do we do’’? So began the
journey of PM with the multidisciplinary team on the
step down pulmonary unit.
The care of the bariatric patient in acute care
presents many challenges, including strategies for
management of obstructive sleep apnea (OSA). The
plan of care for such patients includes a host of
strategies to manage multisystem and organizational
issues. Using a case study to highlight important
aspects of such care, this article explores the etiology
and treatment of OSA.
Case history and progress
PM, a 39-year-old male with a history of severe
obesity and a body mass index (BMI) of 91 kg/m2,
was admitted because of a fall at home secondary to
weakness from the onset of pneumonia. Because he
was unable to get up, the Emergency Medical System
(EMS) was alerted, and he was transported to the
hospital on an oversized cart.
PM lived alone and had been housebound for the
last 4 months. His weight gain worsened as his
dyspnea and depression increased, causing a further
decline in his functional status. He owned his own
business and had been working from his home.
PM’s history was significant for severe obesity,
hypertension, depression, OSA, cardiomyopathy, and
deep vein thrombosis (DVT). He had been using
0899-5885/04/$ – see front matter D 2004 Elsevier Inc. All right
doi:10.1016/j.ccell.2004.03.004
* Corresponding author.
E-mail address: [email protected]
(M.M. Ecklund).
with supplemental oxygen to treat OSA that had been
diagnosed by a polysomnogram (sleep study) the
previous year. He had also been evaluated for gastric
bypass surgery and was on a waiting list for the
procedure. Although he was knowledgeable of obe-
sity treatment strategies, his ability to control his
intake was limited.
The bariatric bed on which PM was transported
accommodated up to 500 lb (227.3 kg). Considering
his height (74 in [188 cm]), weight, and girth, the bed
was inappropriate. For example, his legs were resting
on chairs next to the bed.
The first challenge for the multidisciplinary team
was to provide PM a suitable sleep surface. The
necessary data included weight, height, girth, skin
integrity, and the ability to move independently in
and out of bed. A Barimax 2 (Kinetic Concepts,
San Antonio, TX) was selected because it accom-
modated up to 850 lb (386 kg). It was wide enough
to allow turning, had a built in scale, and a low-
pressure sleep surface. The staff coordinated PM’s
move to the new bed, and he appeared relieved once
comfortably situated.
A formal psychiatric consultation helped PM
identify his feelings about his body image and
limitations. He described feelings of despair and
frustration over lack of progress and hunger. In
addition to talking with PM, the psychiatrist recom-
mended clonazepam (Klonipin) until he improved,
and an increase in sertaline (Zoloft), which he had
been on before admission.
The evaluation of PM’s respiratory status was
done early in the admission on 4 L of oxygen with
NCPAP. An arterial blood gas (ABG) after a night on
NCPAP, demonstrated respiratory acidosis (pH 7.30,
PaCO2 66, PaO2 66, SaO2 90, HCO3 31). The team
selected bi-level ventilation with a nasal mask to treat
s reserved.
M.M. Ecklund, S.A. Kurlak / Crit Care Nurs Clin N Am 16 (2004) 311–317312
the nocturnal hypercarbia and OSA. To evaluate
nocturnal desaturation, overnight oximetry studies
were conducted. The first study on 4 L of nasal
oxygen without bi-level therapy showed significant
desaturation, with average oxygen saturation of 79%.
Subsequent studies performed on bi-level ventilation
with supplemental oxygen showed an improvement
in oxygenation and decrease in PaCO2. The studies
revealed that the most effective therapy was humidi-
fied bi-level ventilation with the following settings:
inspiratory positive airway pressure (IPAP) of 15 cm
H2O and 6 cm H2O of positive end expiratory
pressure (PEEP) or expiratory pressure (EPAP) de-
livered with 6 L of supplemental oxygen through a
nasal mask. Throughout the hospitalization, PM reli-
ably used the bi-level therapy with the addition of
humidity and nasal strips to improve nasal patency.
Mobilization in the early weeks was a challenge.
Because PM could not achieve independent sitting
balance, physical therapists worked to improve mus-
cle strength so that balance could improve and PM
could get out of bed. To help mobilize PM, an
inflatable transfer device (Hover Matt Technology,
Allentown, PA) was selected to assist with moving
PM up in bed and to reposition him as necessary.
Initially, six staff members were needed to provide
Table 1
Components of PM’s plan of care
Problem Goals
Psychosocial Ability to control aspects of care and daily
activity
Nutrition Caloric intake to meet daily energy needs;
Consistent weight loss
Respiratory SpO2 > 90%
Daytime wakefulness without lethargy
Skin integrity Healed, intact skin
Elimination Urine continence;
Bowel continence
Circulation No deep venous thromboses
Mobility Ambulation without falls
Educational Knowledge of disease process, management,
and treatment options
turning and to achieve the supine position. Until he
regained leg strength, two people were required to
move his legs for care and positioning. A sheet was
folded and placed under his legs to achieve leverage
with positioning, while his trunk was turned with a
separate lift sheet. This technique protected staff from
injury and was more comfortable for PM. He began
the daily process of getting out of bed but was re-
luctant to try any new activity if the caregivers did not
project confidence and the ability to listen to his fears
and observations.
Although a referral to skilled nursing facilities
(SNF) was initiated by the social worker once PM’s
functional state began to stabilize, the complexity and
cost of his care (noninvasive positive pressure venti-
lation [NIPPV], full assisted daily living help and
equipment rental) made acceptance impossible. An
updated referral to a bariatric surgeon was made for
gastric bypass. The care manager completed the
referral request, including the necessary cardiac,
pulmonary, psychiatry, nutritional, and social service
evaluations and the third party payer approval.
PM’s mobility improved and he lost a total of
135 lbs (61 kg). Two months after his admission,
PM was transferred directly to the hospital where his
Roux-En-Y gastric bypass surgery would be per-
Stratgies
Patient setting own goals & schedules;
Knowledge and trust of team members
Limited calorie diet, with adequate protein intake;
Diet preferences determined;
Food and intake teaching
Noninvasive bi-level ventilation at HS, with
supplemental oxygen;
Oxygen via nasal prongs daily
Local care to wounds with protective creams and
petroleum gauze [14];
Low pressure mattress;
Chair cushion & commode padding;
Turning schedule, pillowcases in skin folds
Indwelling catheter until mobile;
Assistive device to hold urinal when catheter removed;
Commode of adequate size;
Stool softener
Anticoagulation with warfarin
Progressive ambulation
Walker of adequate size;
Supplemental oxygen;
Shoes for support;
Appropriate size wheelchair
Educate about obesity and diet;
Educate about OSA
M.M. Ecklund, S.A. Kurlak / Crit Care Nurs Clin N Am 16 (2004) 311–317 313
formed. This required that specialty vendors be con-
tacted regarding PM’s weight and girth to ensure that
the proper transport equipment was available. Al-
though a freight-type transport cart was required for
ambulance transportation, PM was brought through
the hospital to the ambulance in a wheelchair to main-
tain his dignity.
PM’s bariatric surgery and recovery were success-
ful. One year later his weight is 411 lb (187 kg), he is
running his business successfully, and is an active
participant in support groups for other people con-
sidering bariatric surgery. Aspects of PM’s plan of
care are summarized in Table 1.
Obesity
Obesity is derived from the Latin word meaning
overeat. The modern definition of obesity is disease
of excess body fat. Despite common perceptions and
prejudices, obesity is a disease, not a character flaw,
cosmetic aberration, or personality disorder [1]. In the
year 2000, 38.8 million Americans were obese: an
estimated 61% of all Americans have a BMI >30 kg/
m2, according to the Centers for Disease Control
(CDC). The CDC also projects a cost of >117 billion
dollars (yearly) in health care costs for obese indi-
viduals [2].
Obesity is the result of the body consuming more
energy than it uses. It results from physiologic, social,
and cultural factors. Genes play an important role in
the regulation of body weight, and many processes in
the brain and gastrointestinal tract influence appetite.
Eating patterns are affected by satiety centers in the
hypothalamus and pituitary glands that respond to
high fat stores and hunger. Many metabolic processes
involving hormones and proteins have an impact on
obesity. In addition, dietary patterns of modern soci-
ety accompanied by more sedentary lifestyles pro-
mote weight gain and obesity [3].
Definition of obesity
The BMI (Box 1) is considered the best measure
for gauging body fat. It is a mathematic expres-
Box 1. Steps to calculate Body Mass Index(BMI) kg/m2 [4]
1. [Weight (pounds) x 703]/Height(inches)
2. Divide result by height (inches)
sion of weight adjusted for height. A BMI of 25 to
29.9 kg/m2 is considered overweight; obesity is a
BMI of 30 kg/m2 or higher. Morbid obesity is an
ambiguous term, with reference to greater than
100 pounds over the desirable weight of the individ-
ual. The National Institutes of Health consensus panel
defines severe obesity as a BMI greater than or equal
to 50 kg/m2 [3,4]. A limitation of the BMI measure-
ment is that it does not differentiate the type of weight
(fat versus muscle). Muscular individuals can be
misclassified as overweight [3].
Other measures of obesity include waist circum-
ference, waist/hip ratio, and anthropometry. A waist
measurement of greater than 31.5 in (80 cm) for
women and greater than 37 in (94 cm) for men in-
dicates health risk. The waist/hip ratio is determined
by dividing waist by hip size. The lower the ratio, the
better. Heart disease risk increases for women with
ratios greater than 0.8. Anthropometry is the mea-
surement of skin fold thickness, usually done with
forceps at the triceps. It determines how much weight
is due to muscle or fat [4].
By these definitions PM, with a BMI of 91 kg/m2,
was severely obese. He demonstrated comorbitities as
well. To understand the rationale for the treatment
plan for PM, some of the pathophysiologic processes
associated with obesity and complications are dis-
cussed in the following sections.
Physiologic processes influencing obesity
Leptin is a hormone that is released by fat cells
and the stomach and is, in part, responsible for food
intake, storage, and conversion into energy [2]. Lep-
tin is released by adipocytes, or fat cells, in propor-
tion to the size of the adipocyte cell. Adipocytes store
energy when calories are in excess and mobilize
energy when needs exceed intake. In rodents, leptin
reduces energy intake and increases energy expendi-
ture. Because this would translate to weight loss in
obese humans with high plasma leptin concentra-
tions, leptin resistance is a suggested explanation of
human obesity [3]. Leptin treatment for weight loss
has been unsuccessful except in those individuals
with leptin deficiency [5].
The inability to use insulin efficiently is also
associated with obesity. Resistin is a hormone that
is produced by fat cells and produces insulin resist-
ance [2]. If insulin is used ineffectively and hyper-
glycemia results, a host of complications can result
including impaired wound healing, infections, and
organ failure [6]. The importance of ‘‘tight’’ glucose
control was recently demonstrated in a study of
critically ill surgical patients. The investigators found
M.M. Ecklund, S.A. Kurlak / Crit Care Nurs Clin N Am 16 (2004) 311–317314
that the use of insulin infusions to attain glucose
levels less than or equal to 110 mg/dL resulted in
reduced morbidity and mortality in critically ill sur-
gical patients [6]. The study suggested that improved
glucose control can be a strategy to compensate for
the effects of insulin resistance in obese patients.
Although PM did not have diabetes, the plan of care
included weight loss and activity to compensate for
his altered metabolism and insulin use.
Other complications of obesity
Complications of obesity can be categorized into
weight related complications, metabolic obesity, and
organ-related obesity [1]. Weight-related complica-
tions include degenerative joint disease, respiratory
compromise, skin changes, and intraabdominal
pressure compromise (varicose veins, hemorrhoids).
Metabolic obesity presents with neurohormonal
and behavioral symptoms (stress intolerance, seden-
tary lifestyle, or use of tobacco, alcohol, or drugs),
substrate overload (type 2 diabetes, dyslipidemia,
cholelithiasis), and thrombogenic manifestations.
Organ-related pathology includes presence of adipose
tissue, liver fibrosis, and kidney dysfunction [1]. PM
experienced a number of weight and metabolic com-
plications, including respiratory compromise, skin
breakdown, and sedentary lifestyle. One of the most
serious complications was OSA, which will be dis-
cussed further.
Obstructive sleep apnea
Definition
OSA occurs when there is partial or complete
upper airway collapse during sleep. During periods
of OSA, episodes of oxyhemoglobin, desaturation,
and transient nocturnal arousals and awakening create
sleep disturbances resulting in daytime sleepiness [7].
OSA, recognized over 30 years ago, is measured in
terms of obstructive apnea and hypopnea episodes
per hour of sleep resulting in an apnea-hypopnea
index (AHI). Central sleep apnea is characterized by
repeated episodes of apnea or hypopnea resulting
from deceased neural output to responding motor
neurons without airflow obstruction. One out of every
five adults with a mean BMI of 25 to 28 kg/m2 has at
least mild OSA, whereas 1 of every 15 has mild sleep
apnea. One interesting fact regarding OSA is that
most patients with OSA snore, but most individuals
who snore do not have frank OSA [8]. The preva-
lence of OSA can be predicted from increased neck
circumference, hypertension, habitual snoring, noc-
turnal gagging, and choking [7].
The modifiable risk factors of OSA are over-
weight and obesity, alcohol consumption, tobacco
use, nasal congestion, and estrogen depletion in
menopause. Weight loss is the single most significant
factor in reducing OSA [7]. Undiagnosed OSA with
or without symptoms is independently associated
with increased likelihood of hypertension, cardiovas-
cular disease, stroke, daytime sleepiness, motor ve-
hicle accidents, and diminished quality of life [7].
For PM, it was essential that the team treat his
OSA effectively. Based on overnight oximetry re-
sults, bi-level support with nasal mask was selected.
Mechancial ventilation for obstructive sleep apnea
Mechanical treatments for OSA in the category of
NIPPV include continuous positive airway pressure
(CPAP) and bi-level ventilation. The most common
treatment for OSA is NCPAP. The difference between
NIPPV systems is that bi-level ventilation uses dif-
ferent pressures on inspiration and expiration, where-
as NCPAP operates with one continuous level of
pressure during both inspiration and expiration. The
decision to choose one system over the other in part
centers on the amount of pressure needed to keep
the airways open and whether nighttime hypoventi-
lation is present with apnea episodes. In situations in
which high levels of pressure are required, mean
airway pressures can be lowered using bi-level sys-
tems versus CPAP systems and potentially making
the patient more comfortable. The amount of CPAP
required to eliminate apnea and maintain oxygenation
commonly ranges from 5 to 20 cm H2O pressure [9].
Another choice in NIPPV for treating OSA is a bi-
level device that cycles between an IPAP and EPAP
(or PEEP). The inspiratory phase can be initiated by
the patient or by the backup rate programmed into
the device. The backup rate delivers a set number of
breaths in the event of apnea. With bi-level devices,
the difference in pressure between the inspiratory and
expiratory phases dictates the resulting tidal volume.
Bi-level settings are generally expressed as inspira-
tory pressure over expiratory pressure (ie,10/5) and
generally require a pressure difference of 5 cm H2O
between settings. Breaths on the bi-level system are
similar to pressure supported breaths on conventional
ventilators. Increasing the inspiratory pressure while
maintaining the same level of expiratory pressure
yields an increase in expected tidal volume. For
example, increasing the settings from 10/5 to 15/5
results in a higher level of support on inspiration.
Conversely, if both the inspiratory and expiratory
M.M. Ecklund, S.A. Kurlak / Crit Care Nurs Clin N Am 16 (2004) 311–317 315
pressures are increased the same amount, there will
be no difference in the pressure gradient and therefore
an increased tidal volume is not expected [10]. The
fundamental difference between CPAP and bi-level
ventilation is that in CPAP the levels remain constant,
whereas in bi-level, the levels of pressure vary on
inspiration and expiration. The point to be empha-
sized is that NIPPV treats but does not cure OSA
[11]. These methods of noninvasive ventilation are
delivered through a variety of devices.
Noninvasive interface devices: selection and
considerations
In treating OSA, one of the prevalent issues the
health care professional faces is patient compliance,
specifically, wearing the interface device consistently.
Interface devices are masks or pillows used to deliver
NIPPV to the nose or mouth. Therefore, in addition to
providing the optimal settings for the patient, every
effort is made ensure comfort. The use of nasal
masks, full-face masks, and nasal pillows are all con-
sidered. Allowing the patient to have a variety of
options contributes to compliance [11]. An adequate
face seal is important. Because the bi-level devices
compensate for leaks, some leak is acceptable. It is
important to prevent leaks around the eyes and avoid
resting the nasal mask on the lip. Different headgear
may be used to ensure a snug fit without causing
undue pressure. Skin breakdown at the bridge of the
nose is a risk with nasal and full-face masks. Vigilant
assessment by respiratory therapists and nurses helps
prevent the development of this complication. Pre-
vention strategies include mask repositioning, appli-
cation of hydrocolloid dressings, or padding with
gauze dressing. Selection of a full-face mask is done
cautiously because aspiration is possible if the patient
vomits and cannot remove the mask before doing so.
Patients with decreased mental status and those
unable to remove the mask if needed are poor can-
didates for full-face mask ventilation. Collaboration
among care providers can help determine risk, strate-
gies for nasogastric tube use, or decisions regarding
feeding. In general, because of the potential for as-
piration, patients should not consume oral intake
while on NIPPV. It is important that the nurse and
respiratory therapist collaborate in care planning so
that ventilator-free times are provided for eating and
other activities. Alternate oxygen delivery devices
may be required during periods off the NIPPV.
Another factor to consider is humidity because
positive airway pressure can result in the airways be-
coming dry and uncomfortable. A simple humidi-
fication system can make the difference between
patient compliance and noncompliance. The addition
of a flow-by humidification system to the NIPPV will
reduce the drying effect of the continual gas flow. PM
found that he was more comfortable when humidity
was used and that nasal strips helped with nasal
patency. As with PM, it is important to remember that
compliance with NIPPV is often related to comfort.
NIPPV interface devices include nasal mask, full-
face mask, or nasal pillows. All interface devices
have a leak port with a single limb circuit to allow
exhalation [11].
Evaluating noninvasive positive pressure ventilation
Evaluation of the effectiveness of NIPPV is ac-
complished with a combination of patient reporting
(ie, daytime sleepiness) and physical and laboratory
data. Arterial blood gases provide information related
to PaCO2 levels and are especially helpful to deter-
mine the effectiveness of therapy during sleep. Pulse
oximetry helps identify desaturation episodes and
may be used continuously throughout the sleep
period or intermittently, as the patient condition
requires. More subtle signs of effectiveness over time
can be resolution of right-sided heart failure symp-
toms, including decreased peripheral edema. Once
NIPPV requirements are determined, qualification for
approval of insurance coverage is sought [11]. Many
insurers adhere to the Medicare approval process,
which dictates an algorhythmic approach to diagnosis
and therapy requirements. A formal sleep study may
be necessary to qualify for reimbursement.
Other therapeutic treatment options for obstructive
sleep apnea
Other treatments for OSA are generally catego-
rized into three groups: behavior modification and
medical and surgical treatments. The least invasive of
the treatments is behavior modification, beginning
with the obvious benefit of weight loss followed by
avoidance of alcohol and sedatives and altering sleep
positioning. Switching from supine positioning to
lateral positioning can reduce obstruction symptoms.
Medical options include medications; however, phar-
macologic therapy has not shown definitive improve-
ment in symptoms [12].
Dental appliances can treat OSA. The mandibular
positioning appliance attaches to one or both dental
arches (the maxilla and mandible). The appliance
facilitates the forward advancement and downward
rotation of the mandible. The tongue retaining device
works by holding the tongue anteriorly while the
M.M. Ecklund, S.A. Kurlak / Crit Care Nurs Clin N Am 16 (2004) 311–317316
patient is sleeping. These devices are specifically de-
signed for each patient [12].
Surgical treatment for OSA is usually reserved for
when other treatments have failed. The most common
surgery is palatal surgery in which the airway is
modified so that it is located above the base of the
tongue. Uvulopalato-pharynoyoplasty surgery has
been successful in reducing snoring but has not
demonstrated efficacy in reducing episodes of ap-
nea-hypopnea [12].
Bariatric surgery options
Surgery is reserved for cases of extreme obesity
(BMI >40 kg/m2) or obese patients with BMI >35 kg/
m2 if comorbities are present. The gastric bypass or
Roux-en-Y is the most commonly performed gastric
bypass procedure in the United States. It can be done
either laparoscopically or via open incision. The
upper portion of the stomach is stapled to create a
reservoir of approximately 10 to 30mL. The reservoir
connects directly to the jejunum in a Roux-en-Y man-
ner. By restricting the stomach capacity and bypass-
ing the stomach and proximal small intestine, caloric
quantity is reduced and nutritional absorption is
limited. Weight loss is averaged at 60% to 70% of
excess body weight up to one year after the surgery.
Mortality rates are 1.3% to 1.5% in contrast to higher
rates in the 1980s. Complications associated with
gastric bypass include wound infection, incisional
hernia, peritonitis with anastamosis leak, vitamin
and mineral deficiencies, and osteoporosis [3,13].
Rigorous selection of appropriate patients is done
by surgical centers to ensure patient understanding of
weight loss and postoperative commitment to suc-
cess. Failure of nonsurgical methods of weight loss,
absence of endocrine abnormality contributing to
severe obesity, and psychological stability, with the
absence of drug and alcohol abuse, are all standard
criteria for surgical consideration. A complete preop-
erative assessment is completed before surgery ac-
ceptance. Active peptic ulcer disease is an absolute
contraindication. The incidence of cholelithiasis is
15% to 25% in severely obese patients, therefore
screening of patients who have their gall bladder
intact is recommended, with cholecystectomy sug-
gested with surgical intervention. A limited diet is
resumed within 1 day postoperatively, with gradual
increase to a pureed diet for 4 weeks. Postoperative
follow up with the surgical team and a nutritionist
assists the individual to ensure adequate protein and
caloric intake [13].
PM was a candidate for the laparoscopic approach
Roux-En-Y procedure as determined by the preopera-
tive evaluation data. PM’s procedure was performed
without complications and his recovery was unevent-
ful and proceeded as planned.
Summary
Caring for the bariatric patient requires a compre-
hensive approach that extends beyond airway man-
agement. The case of PM highlights additional issues
related to the care of the obese patient with OSA.
Critical issues include skin care, mobilization, nutri-
tion, and psychologic support. Although obesity is
common and more bariatric patients are likely to be
hospitalized for related complications, few evidence-
based guidelines exist to direct care. The selection
and efficacy of bariatric equipment and techniques
for mobilizing these patients have yet to be deter-
mined scientifically.
Care for the bariatric patient is complex and
requires coordination and skill. The advanced prac-
tice nurse is uniquely prepared to take a lead role.
Without doubt, comprehensive and systematic atten-
tion to the many details of the plan of care are critical
if good outcomes such as those attained by PM are to
be realized. At the core of the care is the importance
of establishing trust and maintaining the individual’s
dignity. In the case of PM, the multidisciplinary team
partnered with him to achieve his goals for weight
loss and a return to health and a productive life.
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