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RECOGNITION AND MANAGEMENT OF

OBSTRUCTIVE SLEEP APNEA: STRATEGIES TO

PREVENT POST-OPERATIVE RESPIRATORY

FAILURE

Peggy Hollis MSN, RN, ACNS-BC March 9, 2017

DEFINITION

Obstructive sleep apnea is a disorder

characterized by repetitive episodes of apnea

or reduced inspiratory airflow due to upper

airway obstruction during sleep.

PATHOPHYSIOLOGY

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BACKGROUND AND SIGNIFICANCE

• 80% of patients with OSA have never

been diagnosed

• 22% of adult surgical patients have

OSA

• 7 % of patients have moderate to

severe OSA

• Patients with OSA are 8 times more

likely to have postop hypoxemia

PERIOPERATIVE RISK

• 44% of patients with OSA have postop

complications (attributable to adverse

respiratory events)

• General anesthesia exacerbates OSA

by causing:

Upper airway collapse

Blunted arousal from sleep

Depressed ventilation

PERIOPERATIVE RISK

• Respiratory failure

• Cardiac arrhythmias

• Delirium

• Death

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PERIOPERATIVE RISK

• Vulnerability to airway

obstruction can last for days

ISSUE PROBLEM

In CY 2010 the postoperative respiratory

failure rate at SMMC was 17.96/1000 pt.

elective surgery days and in CY 2011 the

rate was 18.17/1000 patient elective

surgery days

Post-operative Respiratory Failure PSI-11

Mechanical Ventilation for 96 consecutive hours or more - zero or more days after the major operating room procedure code Mechanical Ventilation for less than 96 consecutive hours or undetermined - two or more days after the major operating room procedure code Re-intubation - one or more days after the major operating room procedure code

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PICO

In adult surgery patients does OSA

risk identification and stratification

combined with use of a

management protocol reduce the

occurrence of post-operative

respiratory failure?

LITERATURE SEARCH

OVID Medline was searched from 1996-2012

using the keywords obstructive sleep apnea

and perioperative risk or post-operative

complications.

SYNTHESIS OF LITERATURE

Reference: 1st Author, year, level of evidence

Supports risk screen and prevention bundle

Does not support risk screen and prevention bundle

Chung, S. (2008) Level of evidence V +

Olson, E. (2012) Level of evidence V +

Farney, R. (2011) Level of evidence VI +

Gali, B. (2009) Level of evidence IV +

Joshi, G. (2012) Level of evidence VII (or weak I) +

Kaw, R. (2012) Level of evidence V +

Meoli, A. (2003) Level of evidence VI +

O’Gorman, S. (2013) Level of evidence II (weak) +

Vasu, T. (2012) Level of evidence V +

Gross, J. (2006) Level of evidence VII +

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CLINICAL PRACTICE GUIDELINES

• AASM-American Academy of Sleep

Medicine (2003)

• ASA- American Society of

Anesthesiologists (2006)

• ACCP-American College of Chest

Physicians (2010)

Time to Get With the Guidelines

CURRENT CONDITION (2010)

Patients admitted for elective

surgical procedures without OSA

screening, risk stratification or risk

mitigation strategies.

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ROOT CAUSES

• No systematic method for screening and

identifying patients at risk for OSA

• No bundled protocol for management of

patients to mitigate risk

• No clear definition of “respiratory precursor

event” – Triggers for ventilatory support.

• No plan for longer observation of day

surgery patients.

RECOMMENDATION

All patients will be screened for risk of

OSA prior to admission. Those

determined to be “at risk” will be

identified with a unique wrist band and

management protocol orders will be

initiated. Identification of at risk patients

combined with risk mitigation strategies

will reduce the rate of postoperative

respiratory failure.

SMART GOAL

We will appreciate a 25% reduction

in postoperative respiratory failure

by the end of calendar year 2012.

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Plan/ Integration

PREOPERATIVE EVALUATION

• Based on history and physical exam

• Screening questionnaire that asks

about snoring, daytime sleepiness,

BMI and neck circumference.

• Screening is done prior to surgery

RISK SCREEN

Chung, F. (2008)

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PREDICTIVE VALUE OF STOP-BANG

Negative predictive value = 100%

Sensitivity = 83-100%

Specificity = 60-100%

DEFINITIONS

Apnea- cessation of airflow for >10 secs

Hypopnea- Reduction in airflow <50%, with

desaturation ± arousal

Apnea Hypopnea Index (AHI)- number of

apneas and hypopneas per hour of sleep

PREDICTIVE VALUE

Farney, RJ. et al. (2011). The STOP-Bang equivalence model and prediction of severity of obstructive sleep apnea: Relation to polysomnographic measurements of the apnea/hypopnea index. The Journal of Sleep Medicine, 459-465B.

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INTRAOPERATIVE MANAGEMENT

• Premeds with sedatives or analgesics

discouraged

• Consider regional anesthesia

• Monitor oximetry and capnography

• Maintain positive airway pressure

• Follow ASA guidelines for difficult

airway

• Pre-oxygenate with mask 3 minutes

PACU MANAGEMENT

• Order “RT to eval. and treat”

• HOB at 30 deg. (unless prohibited)

• Keep patient lateral rather than supine

• Keep SaO2 >89%

• Use CPAP/BiPAP

• Referral to Sleep Center

PACU MANAGEMENT

Respiratory event

RR < 8 min.

Apnea > 9 secs.

SaO2 < 88% on 3 l/min. via NC

Interventions for respiratory event

RT to initiate APAP therapy

Anesthesia to determine disposition

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SDS MANAGEMENT

Keep patient 3 hours longer than a

normal stay.

FLOOR MANAGEMENT

• Sign on HOB – ZZZzzz

• Notify Pharmacy – Caution inputs

• Transition from IV to oral analgesics ASAP

• PCA should be only on demand

• Utilize CPAP/BiPAP

• Continuous pulse oximetry

• Place near nurses station

• Hourly assessment

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FLOOR MANAGEMENT

CPAP/BiPAP should be used:

When asleep

When level of sedation is >/= 2

Sedation scale

1=wide awake

2=Drowsy

3=Dozing intermittently

4=Mostly sleeping

5=Only awakens at when aroused

ADVISING PATIENTS OF RISK

Outcomes/ Check

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PSI-11 TREND – POSTOPERATIVE

RESPIRATORY FAILURE

ACT

• Expand screen to all inpatients to be

done with admission history

• Optimization of EMR to include

screening, orders and interventions

• Increase referrals to Sleep Center for

at risk patients to improve population

health

SUMMARY

• Obstructive sleep apnea is

a high-risk condition with

serious morbidity

• Identification of at risk

patients combined with

use of an evidence-based

prevention bundle will

improve patient outcomes