OBSTRUCTIVE SLEEP APNEA

(OSA)

Created By: St. James Healthcare

Education Collaborative
Butte, Montana

Nursing Learning Module

• To understand the challenge of OSA in a procedural
or perioperative area.
 Identify risk factors that influence the planning of a
medication regime post procedure or post
operatively.
 Know the ASA recommendations for OSA post-
procedurally or post-operatively.
 Identify three things that will change your everyday
practice.

OSA: LEARNING MODULE GOALS

1. OSA affects mostly females who are obese.

2. Patients with OSA may not be diagnosed prior to a

surgical or diagnostic procedure.

3. All professional bodies have published standard

guidelines for patients with OSA.

OSA: TEST YOUR KNOWLEDGE (True/False)

Care of the OSA patient may become challenging post
procedure if the medication regimen does not factor
in that patients with OSA are at greater risk of
airway compromise during analgesia and sedation.

OSA: INTRODUCTION
 Suspect OSA if a patient responds positively to
screening questions about snoring and excessive
daytime sleepiness;

 Be aware that @ 12 to 18 million Americans suffer

from OSA, and that the majority with moderate to
severe OSA are undiagnosed; 

OSA: IMPORTANCE OF SCREENING

There is a potential increased risk of airway
compromise if OSA has not been fully evaluated prior
to medication administration of narcotics / sedation.

OSA: IMPORTANCE OF SCREENING

 Diagnosis is by a sleep study - measures the number
of episodes of apnea (stops breathing for 10 seconds
or more) as well as other factors developed by sleep
medicine specialists;
 The diagnosis of OSA can be :
- Mild

- Moderate

- Severe (usually requires CPAP)

OSA: DIAGNOSIS
• The muscles of the pharynx relax during stages of
deep sleep, reducing the size of the airway which
does not normally cause OSA.

• People with sleep apnea have airways that are

narrower and more collapsible than normal.

OSA: UNDERLYING CAUSES

• Pharyngeal muscles relax and the airway obstructs;
 Hypoxemia and Hypercarbia result in central nervous
system activations;
 Partial arousal occurs and normal ventilation is resumed;
 Sequence typically repeats several times a night,
disrupting the normal sleep cycle;
 Sleep apnea is usually a chronic condition;
 Episodes lasting longer than 10 seconds and occurring
more than 5 to 7 times an hour leads to serious health
problems;

OSA: CYCLE OF HYPOXIA

 Hypoxia
 Hypercarbia
 Brain says Wake Up!

 Tired During the Day




OSA: A CYCLE OF SLEEPLESSNESS

 Daytime sleepiness
 Impaired cognition
 Anxiety / Depression
 Increased risk of occupational and motor vehicle
accidents
 Hypertension
 Heart failure
 Cardiac arrhythmias (i.e., Atrial Fibrillation)
 Angina
 Heart attack

OSA: MEDICAL RISKS

 Patients with OSA who undergo anesthesia and/or
sedation may not have received a formal diagnosis of the
condition prior to a procedure;
 In the absence of a sleep study, the possibility of sleep
apnea should be assessed based on:
 physical characteristics (in particular upper body
obesity);
 medical history;
 interviews with patient’s family members regarding snoring
and sleep patterns;

 Many patients that don't look like they should have OSA
(because they are not overweight with a thick neck) do
in fact have OSA;

OSA: HOW DO WE SCREEN?

Physical characteristics:
• Obesity (BMI greater than 35)

• Neck circumference greater than 17

inches for men or 16 inches for women

• Craniofacial abnormalities

• Anatomical nasal obstruction

• Tonsillar hypertrophy

OSA: PHYSICAL ASSESSMENT

Investigate whether the patient has two or more of the
following observed during their sleep; or, one or more of
the following (if not observed during sleep):

• Snoring loud enough to be heard through a closed

door;

• Frequent snoring;

• Observed pauses in breathing during sleep;

• Awakens from sleep with a choking sensation;

• Frequent arousals from sleep;

OSA: PATIENT HISTORY

Somnolence (one or more of the following)-

• Frequent daytime sleepiness or fatigue despite

adequate “sleep”;

• Falls asleep frequently in non-stimulating

environment;

OSA: PATIENT HISTORY

OSA: IMPACT OF NARCOTICS
 OSA patients are more sensitive to the effects of
analgesia/sedation;
 Upper airway obstruction may occur after small to
moderate doses of pain/anxiolytic medication;
 Decreased muscle tone of the upper airway and
increased airway resistance;
 Airway collapse;
 Interferes with the survival mechanism that normally
arouses an individual during an apneic period. 

OSA: IMPACT OF NARCOTICS

• Male patient, age 50, with a present medical
condition of a large back wound with frequent
debridements and Wound VAC.

• History: Morbidly obese, chronic back pain and

surgical incisional pain (from spine surgery). Has
been depressed, fatigued, and on long-term oral pain
medication. No history of OSA. Patient thinks he
might snore. Social situation, he lives alone.

• Question: How would you screen for OSA during your

nursing admission history?

OSA: Case Example

 Female patient, 25 years old, post lap chole with a
common bile duct stone removed after ERCP;
 Pre-procedure: anxiety level high, c/o feeling tired all of
the time, denies “sleep apnea” when asked during the pre-
admission assessment;
 Post-procedure: apneic periods observed and when patient
is more awake she finally shares with the health team that
a “sleep study” was recommended by her PCP to confirm
sleep apnea level and treatment plan;
 Self-Reflection: What else might have been done in
addition to asking the patient whether they had “sleep
apnea” prior to a surgical/endoscopic procedure?

OSA: Case Example

 Does the patient use a CPAP (Continuous Positive
Airway Pressure) machine at home?

 Solution: If Yes, consider using the patient’s CPAP to

support breathing while on a pain control device or
during a procedure requiring analgesia/sedation to
keep the upper airway more open and decrease
apneic periods caused by sedation; 

OSA: HISTORY & PREVENTION

OSA: OTHER SOLUTIONS
Consider the application of a high flow nasal cannula
or mask for mild to moderate sleep apnea –

OSA: OTHER SOLUTIONS

• EtCO2 Monitoring (End-Tital CO2) with PCA (Patient-
Controlled Analgesia);

• Policy # V-A 72;

• Reference Cards are available for monitoring set-up;

OSA: SJH POLICY

Modified Ramsay Scale:

• Minimal Sedation – i.e. anxiolysis (1-2, rates level of

anxiety and ability to cooperate/remain tranquil)

• Moderate Sedation/Analgesia (3, responds with a normal

tone of voice)

• Deep Sedation/Analgesia (4 – 6, responsive to light tactile

or loud auditory stimulus to no response to stimulus)

Click in box to “allow” SJH Policy and definition of

Modified Ramsay Sedation Scale:

OSA: Modified Ramsay Scale

 Current guidelines on moderate sedation for patients
with OSA undergoing certain diagnostic tests, i.e.
endoscopy or interventional radiology may be
lacking;
 The American Society of Anesthesiologists (ASA)
advises use of CO2 monitoring during administration
of analgesia/sedation during the peri-operative
period;
 Emergency equipment should be immediately
accessible to staff in the event of respiratory
complications;

OSA: NARCOTICS & MONITORING

 Patients at risk of OSA should have someone stay
with them for 24 hours following discharge after a
procedural sedation or outpatient anesthesia;

 Patients who have been diagnosed with OSA should

be encouraged to use their CPAP machine when
resting at home.

OSA: PATIENT DISCHARGE

References –
 American Society of Anesthesiologists (2006). Practice Guidelines for the
Perioperative Management of Patients with Obstructive Sleep Apnea.
Anesthesiology: 2006; 104:1081–93.
 American Society of Anesthesiologists (2008). STOP Questionnaire: A Tool
To Screen Patients For Obstructive Sleep Apnea. Anesthesiology:
2008;108: 812-821.
• ASGE (2009). Sedation Facts. Retrieved online 10/05/2009 at
www.sedationfacts.org...
 Gazayerli M et al (2006). A correlation between the shape of the epiglottis
and obstructive sleep apnea. Surg Endosc. 2006 May;20(5):836-7. 
 Moos DD. (2006). Obstructive sleep apnea and sedation in the endoscopy
suite. Gastroenterol Nurs. 2006 Nov-Dec;29(6):456-63.
 Ramachandran, S.K. and Josephs, L. (2009). A Meta-analysis of Clinical
Screening Tests for Obstructive Sleep Apnea. Anesthesiology. 2009; 110:
928-939.
 Villegas T. (2004). Sleep apnea and moderate sedation. Gastroenterol
Nurs. 2004;27(3):121-124.
1. OSA affects mostly females who are obese.

2. Patients with OSA may not be diagnosed prior to a

surgical or diagnostic procedure.

3. All professional bodies have published standard

guidelines for patients with OSA.

OSA: TEST YOUR KNOWLEDGE (TRUE/FALSE)

Identify three things that will change your
everyday practice.

Thank You!

~ May you have restful sleep & happy dreams ~

Susan DePasquale, CGRN, MSN

Peer Reviewed by Cheryl Stensrud, MSN and Phil Dean, RN
(2011)