1 of 30

Course: Medical Surgical Nursing

Topic: Obstructive Sleep Apnea

The Nurses International Community

Contact info: info@nursesinternational.org

2 of 30

COPYRIGHT

NI Privacy Policy and Terms of Use.

Contact info: info@nursesinternational.org

3 of 30

Module Goals

Learners will be able to

Describe the clinical manifestation of Obstructive Sleep Apnea.
Discuss the assessment and diagnostic findings of Obstructive Sleep Apnea.
Discuss the complications of acute Obstructive Sleep Apnea.
Describe the medical management of Obstructive Sleep Apnea.
Discuss the nursing management of Obstructive Sleep Apnea.

Contact info: info@nursesinternational.org

4 of 30

Obstructive Sleep Apnea (OSA)

Episodes of a complete (apnea) or partial collapse (hypopnea) of the upper airway with an associated decrease in oxygen saturation or arousal from sleep.
Results in fragmented, nonrestorative sleep.
Can affect anyone but is more common among older males.
Has significant implications for cardiovascular health, mental illness, quality of life, and driving safety (due to daytime sleepiness).

Slowik et al., 2022

Healthline, 2021

Contact info: info@nursesinternational.org

5 of 30

Causes of OSA

Respiratory conditions:

Obesity Hypoventilation Syndrome
Chronic lung disease
Asthma
Chronic Obstructive Pulmonary Disease (COPD)
Pulmonary Fibrosis

Endocrine conditions:

Hypothyroidism
Acromegaly

Neuromuscular conditions:

Stroke

Heart Failure
Kidney Failure
Pregnancy

Slowik et al., 2022

Contact info: info@nursesinternational.org

6 of 30

Risk Factors of Moderate to Severe OSA

Male gender
Age ≥ 50 & <65 years, Age ≥ 65 years
BMI ≥25 & <30 kg/m2, BMI >30 kg/m2
Snoring
Post menopausal status
Presence of metabolic syndrome
Excessive daytime sleepiness
Higher plasma levels of C-Reactive Protein (CRP)

Hein et al., 2017

Contact info: info@nursesinternational.org

7 of 30

Clinical Manifestation of OSA

Slowik et al., 2022

Contact info: info@nursesinternational.org

8 of 30

Clinical Manifestation of OSA (Continued)

Majority of clients are asymptomatic
Excessive daytime sleepiness and fatigue
Loud snoring
Apneic episode lasting 10 seconds or longer
Gasping
Choking
Morning headaches
Self-reported insomnia and nocturia
Breathing cessation while sleeping witnessed by bed partner

Slowik et al., 2022

Healthline, 2021

Contact info: info@nursesinternational.org

9 of 30

Clinical Manifestation of OSA (Continued)

Other symptoms include:

Hyperactivity in children
Worsening depression
Poor job and school performance
Loss of interest in sex

Healthline, 2021

Contact info: info@nursesinternational.org

10 of 30

Screening Tool for OSA: STOP-BANG Questionnaire

Snoring: Do you snore loudly?
Tired: Do you often feel tired, fatigued, or sleepy during the daytime?
Observed: Has anyone observed you stop breathing during your sleep?
Blood pressure: Do you have or are you being treated for high blood pressure?
BMI: Is your body mask index ≥ 35 kg/m2?
Age: Are you > 50 yrs of age?
Neck circumference: is your neck circumference >40 cm?
Gender: Are you male?

Slowik et al., 2022

Contact info: info@nursesinternational.org

11 of 30

What Would the Nurse Do?

Part-I

A wife complains that her husband snores loudly, is always exhausted, and wakes in the middle of the night.

The client is hypertensive and he denies use of alcohol, tobacco, or drugs.

On physical examination, the patient is afebrile, pulse 94, resps 22/min, BP 164/98. BMI is 45.

What would the nurse do?

Contact info: info@nursesinternational.org

12 of 30

Diagnosis of OSA

Polysomnography(PSG)
Electroencephalogram (EEG)
Extraocular movement/ Ocular motility examination (EOM)
Electromyography (EMG): Picks electrical activity generated during muscle movement
ECG: Records the electrical signals from the heart during the sleep
Pulse oximetry: Measures the O2 level during sleep (O2 decreases during episodes of apnea)

Slowik et al., 2022

Contact info: info@nursesinternational.org

Polysomnography: A study or test done while a client is fully asleep. A doctor will observe them sleep, record data about the sleep patterns, and may identify any sleep disorders.During the polysomnography, the technician will measure the brain waves, eye movements, skeletal muscle activity, heart rate and rhythm, blood pressure, blood oxygen level, breathing patterns, including absence or pauses, body position, limb movement, snoring and other noises. To record this data, the technician will place small sensors called “electrodes” on scalp, temples, chest, legs. Elastic belts around the chest and stomach will record the chest movements and breathing patterns. A small clip on the finger will monitor the blood’s oxygen level. The sensors attach to thin, flexible wires that send the data to a computer. At some sleep centers, the technician will set up equipment to make a video recording. This will allow to review the changes in the body position during the night. The technician will remove the sensors once the client wakes up.

EEG: Electrodes are attached to the scalp that will monitor brain waves before, during, and after sleep. The EOM records eye movement.

13 of 30

Complications of OSA

Hypertension
Myocardial Infarction
Cerebrovascular accident
Depression
Sleeplessness related accidents

Slowik et al., 2022

Contact info: info@nursesinternational.org

14 of 30

What Would the Nurse Do?

Part-II

The husband is reluctant to go to the specialist because he thinks that it is normal to snore and most of the people (especially males) in their community snore and are living an “everyday life.”

What would the nurse do?

Contact info: info@nursesinternational.org

15 of 30

Medical Management of OSA

Involves multiple approaches individualized to each client

Lifestyle changes:

Weight loss
Education
Avoid:

alcohol
benzodiazepines
opiates
antidepressants

Slowik et al., 2022

Contact info: info@nursesinternational.org

The treatment of OSA is a multi-pronged approach and should be individualized to each client. While treatment of moderate to severe OSA has been shown to improve clinical outcomes, there is limited or inconsistent evidence about the impact of therapy of mild OSA on neurocognition, mood, vehicle accidents, cardiovascular events, stroke, and arrhythmias.

Lifestyle Changes and Treating Underlying Medical Conditions

The importance of weight loss should be emphasized in OSA clients with overweight and obesity. Although weight loss is recommended and can often decrease the severity of obstructive sleep apnea, it is not usually curative. clients should be educated on the impact of sleep duration and their health and prioritize getting at least 7 to 8 hours of sleep per night. clients should be counseled to avoid alcohol, benzodiazepines, opiates, and some antidepressants, which may worsen their condition. For all clients, it is important to address any concomitant nasal obstruction with nasal steroids for allergic rhinitis or surgically for nasal valve collapse. For clients with lung or heart disease (such as asthma or heart failure), it is very important to optimize the treatment of these disorders.

16 of 30

Medications Used to Manage OSA

Antidepressants:

Selective serotonin reuptake inhibitor (SSRI)

Stimulants:

Modafinil
Armodafinil

Hormones Therapies:

Estrogen

Allergy and asthma drugs
Nasal decongestants
Acetazolamide

Booth, 2021

Contact info: info@nursesinternational.org

These are some of the medications that might help:

Antidepressants: Antidepressant like SSRI (selective serotonin reuptake inhibitor) make it harder to drop into REM sleep, the deep stage during which breathing problems are most likely to happen.
Stimulants: Stimulants like modafinil (Provigil) and armodafinil (Nuvigil) can help reduce daytime sleepiness, a common side effect of sleep apnea.
Hormones: Advancing age is a common risk factor for sleep apnea. Drop in the hormones (female hormones) for women in advancing age plays a part to contribute sleep apnea. In such cases, hormones therapy (estrogen) shows to ease the symptoms.
Allergy and asthma drugs: Allergy and asthma constrict the airways and getting the allergies and asthma medication relieves the symptoms and reliefs the mild apnea symptoms.
Nasal decongestants: Nasal congestion is a risk factor for obstructive sleep apnea. Therefore, nasal decongestant before bed could help keep the nasal passages open.
Acetazolamide (AZT): AZT is a drug used to treat conditions like glaucoma, epilepsy. Some research shows that AZT may help sleep apnea.

17 of 30

Medical Management of OSA (Continued)

Treating underlying medical conditions:

Nasal obstructions
Nasal valve collapse
Asthma
Heart failure

Positional therapy: sleeping at their side rather than supine
Positive Airway Pressure(PAP) therapy

Slowik et al., 2022

Contact info: info@nursesinternational.org

Positional Therapy

OSA that is more prominent in the supine position can be treated with a positioning device to keep a client on their side can be an option

Positive Airway Pressure (PAP) Therapy

Continuous positive airway pressure (PAP) is the most effective treatment for adults. Bilevel PAP (BPAP) is also better tolerated by clients who require higher pressure settings (greater than 15 cm H2O). However, despite the high efficacy of PAP in eliminating respiratory events, its effectiveness is dampened by the decreased use of treatment during sleep and inadequate adherence. Adherence to PAP among clients with OSA remains a great challenge as nearly half of clients do not adequately adhere to treatment after the first month. The American Thoracic Society published a recent statement on PAP adherence tracking systems and the optimal monitoring strategies and outcome measures in adults. It is important to standardize the PAP adherence report not only the number of hours used more than 4 hours per night (>70% of nights) but also the amount of mask leak and residual apnea and hypopnea index. However, what is the optimal goal in adherence to OSA treatment? Recent studies are looking at the utility of telemedicine adherence interventions, remote monitoring of CPAP, and more interactive features with individual clients and their families have shown to increase CPAP adherence rates.

Several studies have reported conflicting findings when assessing the effect of PAP therapy on cardiovascular outcomes in clients with OSA. In a recent randomized control trial, CPAP use for a minimum of one year in clients with Acute Coronary Syndrome (ACS) and OSA (ISAACC) without excessive daytime sleepiness did not lower the incidence of cardiovascular events (defined as cardiac-related death or one or more of the following outcomes: acute myocardial infarction, non-fatal stroke, hospital admission for heart failure, and new hospitalizations for unstable angina or transient ischaemic attack). The adherence to PAP therapy was low (2.78 h/night), and follow-up was not long enough, which are significant limitations of this study. In another observational cohort study with long-term follow-up, PAP use was associated with lower all-cause mortality among clients with severe OSA around years 6–7 of follow-up. In a more recent study, clients with coronary artery disease and OSA without excessive sleepiness who exhibited higher changes in heart rate benefited more from CPAP therapy.

18 of 30

Medical Management of OSA (Continued)

Oral Appliance:

Mandibular advancements devices

Surgical treatments:

Uvulopalatopharyngoplasty (UPPP)
Maxillomandibular advancement (MMA)
Hypoglossal nerve stimulator (HNS)
Tracheostomy

Slowik et al., 2022

Contact info: info@nursesinternational.org

Oral Appliance

For clients unable or unwilling to use CPAP or those who will be unable to access electricity reliably, custom-fitted and titrated oral appliances or mandibular advancements devices (MAD) can be used to bring the lower jaw forward and relieve airway obstruction (See picture). This typically works best for candidates with appropriate dentition and mild to moderate sleep apnea. In a randomized clinical trial on 126 clients with moderate-severe OSA, 24-hour mean arterial pressure was similar between CPAP and MAD after 1-month of therapy. MAD was superior to CPAP for improving quality of life measures. More recently, another RCT demonstrated similar long-term improvement in self-reported neurobehavioral outcomes during a 10-year follow-up. The American Academy of Sleep Medicine (AASM) and the American Academy of Dental Sleep Medicine (AADSM) developed guidelines for using MAD in clients with OSA. The AASM/AADSM guidelines recommend the following:

Oral appliances can be considered rather than no treatment for adult clients with snoring (without OSA) or those with OSA who do not tolerate CPAP therapy or prefer alternate treatment.
When a sleep physician prescribes oral appliance therapy for an adult client with obstructive sleep apnea.
A qualified dentist should use a custom, titratable appliance.
A follow-up with a qualified dentist after oral appliance therapy is initiated in adult clients with OSA to assess for dental-related side effects.
A follow-up with sleep testing to confirm treatment efficacy.

Surgical Treatments

Uvulopalatopharyngoplasty (UPPP) surgically removes the uvula and tissue from the soft palate to create more space in the oropharynx. This is sometimes done in conjunction with a tonsillectomy and adenoidectomy. Nevertheless, the long-term efficacy of UPPP is very limited.

Maxillomandibular advancement (MMA) requires both the upper and lower jaws to be detached and surgically advanced anteriorly to increase space in the oropharynx. This is best for clients with retrognathia and is less successful in older clients or those with larger neck circumferences. More recently, drug-induced sleep endoscopy (DISE) has been used for preoperative planning to identify multiple levels of obstruction in these clients and candidates for surgical treatment such as MMA and hypoglossal nerve stimulator. This allows surgeons to address any nasal, soft palate, and hypopharyngeal obstructions that may be present during a single surgery.

A newer option is the implantable hypoglossal nerve stimulator (HNS), usually unilateral, although bilateral implantation has been recently reported. It works by stimulating the genioglossus (upper airway dilator muscle) during apneas resulting in tongue protrusion and relief of the obstruction. HNS effectively improves sleepiness symptoms in those with moderate to severe OSA that is not tolerating PAP treatment. Adverse events reported short- and long-term following HNS is not very common.

In extreme cases, OSA can also be treated with a tracheostomy to bypass the oropharyngeal obstruction.

19 of 30

Critical Thinking Question

A client diagnosed with obstructive sleep apnea is advised for CPAP therapy. The client's wife asks about the rationale for using CPAP to treat sleep apnea.

What would be best from the response of the nurse?

“It is a positive air pressure that holds the airway open.”
“It creates negative air pressure holds prevents airway collapse.”
“It delivers pure oxygen to facilitate effective respiration.”
“It is the only device that cures the sleep apnea of your husband.”

Contact info: info@nursesinternational.org

20 of 30

Nursing Management of OSA

Plays a role in identification and referral of sleep apnea.

Watch for the typical and atypical symptoms of OSA.
Suggest referrals to sleep specialists.

Observe sleeping patterns.
Elevate head of bed.
Prepare the CPAP machine if recommended as treatment.
Instruct in the handling of oral breathing devices/nasal.

West et al., 2020

Nurses International Committee, 2022

Contact info: info@nursesinternational.org

21 of 30

Nursing Management of OSA

Education:

Maintain a healthy weight
Engage in regular exercise
Limit alcohol consumption
Smoking cessation
Avoid the supine position during sleep

West et al., 2020

Nurses International Committee, 2022

Contact info: info@nursesinternational.org

22 of 30

What Would the Nurse Do?

A client who is a known case of obstructive sleep apnea has undergone Maxillomandibular Advancement (MMA) surgery. Which of the following findings of prescribed medication would concern the nurse?

Paracetamol 750 mg PO q8h after food
Fentanyl SOS for pain management
Ceftriaxone 500 mg IV every 12 hours
Zofran 8 mg PO q8h

Contact info: info@nursesinternational.org

23 of 30

Red Flags

Self-awakenings, sleep disturbance.
Unexplained fatigue or daytime sleepiness.
Morning headaches.
Apnea (stopping of breathing) in sleep (told by others).
Irritability and other personality changes.

Contact info: info@nursesinternational.org

24 of 30

Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

Contact info: info@nursesinternational.org

25 of 30

Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may affect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

Contact info: info@nursesinternational.org

26 of 30

Cultural Considerations: Examples

Obstructive sleep apnea is often viewed as a type of insomnia, an age-related phenomenon, and as being caused by certain bedtime activities.
Some believe that it is caused by certain foods.
In Nepal, most of the people believe snoring and obesity have a relationship but are not aware that it is a medical condition that needs treatment.

Shaw et al., 2012

Contact info: info@nursesinternational.org

27 of 30

Cultural Considerations: Examples

There are certain cultures that believe that apnea and snoring are caused due to a strange environment, being watched while they sleep, and evil spirits.
In South Asian countries like Nepal, India, Bangladesh, women are shy to tell their provider that they snore which makes it difficult to seek medical help.

Shaw et al., 2012

Contact info: info@nursesinternational.org

28 of 30

References

Agency for Healthcare Research. (2020). Health Literacy Universal Precautions Toolkit, 2nd Edition. https://www.ahrq.gov/health-literacy/improve/precautions/tool10.html

Booth, S. (2021, June 21). Sleep Apnea: Can Medications Help With Sleep Apnea? https://www.webmd.com/sleep-disorders/sleep-apnea/sleep-apnea-can-medications-help

Healthline. (2021, October 21). Obstructive Sleep Apnea. https://www.healthline.com/health/sleep/obstructive-sleep-apnea

Hein, M., Lanquart, J. P., Loas, G., Hubain, P., & Linkowski, P. (2017). Prevalence and risk factors of moderate to severe obstructive sleep apnea syndrome in insomnia sufferers: a study on 1311 subjects. Respiratory research, 18(1), 135. https://doi.org/10.1186/s12931-017-0616-8

Contact info: info@nursesinternational.org

29 of 30

References

Slowik, J. M., Sankari, A., Collen, J.F. (2022, June 28). Obstructive Sleep Apnea. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459252/

Shaw, R., McKenzie, S., Taylor, T., Olafiranye, O., Boutin-Foster, C., Ogedegbe, G., & Jean-Louis, G. (2012). Beliefs and attitudes toward obstructive sleep apnea evaluation and treatment among blacks. Journal of the National Medical Association, 104(11-12), 510–519. https://doi.org/10.1016/s0027-9684(15)30217-0

West, J., Dawson, R. M., Wirth, MD., Catledge,C. ( 2020). Obstructive sleep apnea in adults. https://www.myamericannurse.com/obstructive-sleep-apnea-in-adults/#:~:text=In%20the%20outpatient%20setting%2C%20nurses,to%20sleep%20specialists%20if%20indicated

Contact info: info@nursesinternational.org

30 of 30

Please go to

My Learning Experience

to provide feedback on your experience.

Thank you, and come back soon!

Contact info: info@nursesinternational.org