Obstructive Sleep Apnea

Obstructive Sleep Apnea

Patrice Fraser

Pace University Top of Form

Title:  Obstructive sleep apnea in adults

Date:  10/23/2014

Reviewer: 

FOCUSED CLINICAL QUESTION

In adults 19 years and older, what is the effectiveness of Continuous Positive Airway Pressure (CPAP) (applied via a tight-fitting mask) in improving the cardiovascular prognosis in obstructive sleep apnea (OSA) patients?

SEARCH STRATEGY

An extensive search for information from EMBASE databases, MEDLINE, National Clearinghouse Guidelines, Google Scholar, PubMED, CINAHL, Cochrane Database of Systematic Reviews, and JBI ConNECT.

CLINICAL BOTTOMLINE

OSA is a common disorder affecting persons of all age groups but prevails mostly in adults. The increasing rates of obesity seem to increase OSA prevalence rates. OSA involves repeated collapse of air passages during sleep, leading to complete or partial stoppage of breathing (apnea or hypopnea, respectively), sometimes as frequent as once in a minute. The most common OSA symptoms include daytime sleepiness and poor sleep quality, although most patients tend to be asymptomatic. OSA has been ranked a public health issue owing to the mortality and morbidity rates associated with it, attendant comorbidities (among them diabetes), and deterioration of life quality. Studies have established that prior to diagnosis, OSA patients do have high health care use, frequently visit hospital, and incur greater costs in healthcare than after diagnosis.

The inconsistent OSA definition, debates about respiratory abnormality levels that come with the disease, and the most appropriate diagnosis approach complicate OSA treatment. For instance, the apnea-hypopnea index (AHI) is a metric used to diagnose OSA and classify the severity of the disease, but no current AHI threshold exists indicating the need for treatment. The normal practice is diagnosis with OSA if one has an AHI greater than 15 events per hour or an AHI of between 5 and 14 with documented ischemic disease, stroke history, hypertension, or symptoms of longer daytime sleepiness, mood disorders, impaired cognition, or insomnia. Persons with frequent events per hour (30) are more at risk of adverse outcomes.

A PubMed review revealed that CPAP provides pneumatic splitting of the upper passage way hence is effective for the reduction of AHI. Partial reduction of pressure at expiration can supplement CPAP modes of administration. PAP application through moth, nose or oronasal interface is the most preferred treatment for OSA1. (Level I)

A Cochrane review established that although other oral appliances provide improved sleep, CPAP is more effective. Oral appliances should not serve as first treatment but should be preserved for those patients unable to tolerate CPAP. (Level I)

A Google Scholar article revealed that OSA is an independent risk factor for stroke. However, little is known about the function of CPAP on mortality in stroke patients. (Level I)

CHARACTERISTICS OF THE EVIDENCE

The evidence summary is based on a structured search of the literature and selected evidence-based health care databases. Evidence included in the summary is from:

A task force report of clinical guidelines for the evaluation, management and long-term care of obstructive sleep apnea in adults.

A systematic review of studies on oral appliances for obstructive sleep apnea

A case analysis of oral appliances for obstructive sleep apnea treatment in patients with low CPAP compliance

A study of under pressure pulmonary arterial hypertension

A study on mortality reduction effects of CPAP treatment on patients with OSA and Ischemic stroke.

PRELIMINARY NUMBER OF SOURCES IDENTIFIED

The most up-to-date articles that informed this study included three clinical practice guidelines and two research studies, which analyzed the effectiveness of Continuous Positive Airway Pressure (CPAP) applied via a tight-fitting mask to treat obstructive sleep apnea (OSA) in improving the cardiovascular prognosis in such patients

Issues I encountered

Fewer sources were available that specifically relate the application of CPAP to OSA treatment.

Accessing some of the sources in full proved difficult because most of them were in summary or review forms. The online libraries were of little help too.

Questions for Class

Should Continuous Positive Airway Pressure be adopted as the most effective way of improving cardiovascular prognosis in OSA patients?

What methods are your institutions using to improve cardiovascular prognosis in OSA patients?

Can patients effectively administer CPAP on their own?

What challenges have your institution encountered while using CPAP?

Top of FormKeywords

Obstructive sleep apnea (OSA); cardiovascular prognosis; Continuous Positive Airway Pressure (CPAP)

Best Practice Recommendation (in order of the references below)

Physical examination can suggest high risk and should include respiratory, neurologic, and cardiovascular systems. One should pay specific attention to signs of the airway narrowing, presence of obesity, or the presence of other disorders, which can lead to OSA development or its consequences. Features to be evaluated, which may suggest OSA presence (Grade A) include larger neck circumference (>16 inches in women, >17 inches in men), body mass index ≥30 kg/m2,the presence of retrognathia, macroglassia, lateral peritonsillar narrowing, elongated/ enlarged uvula, tonsillar hypertrophy, nasal abnormalities (turbinatehypertrophy, valve abnormalities, deviation, polyps), high arched palate, a Modified Mallampati score (3 or 4), and/or overjet.

There is increasing evidence, which suggests that oral appliances improve sleep disordered breathing and subjective sleepiness compared to a control. CPAP is more effective in the improvement of sleep-disordered breathing than oral appliances (Grade A). The difference in the symptomatic response between the two treatments is insignificant, although it is impossible to rule out an effect and favor either therapy. Until more definitive evidence is discovered on the effectiveness of oral applications in relation to CPAP (long-term complications and symptoms), it is more appropriate to recommend oral application therapy to patients suffering from mild symptomatic OSA and those patients who cannot tolerate CPAP therapy.

There are no correlations between oral appliances (potential predictors of OSA) and the response to mandibular advancement devices.

Long-term CPAP treatment in ischemic stroke and moderate/ severe OSA is linked to a decrease in excess risk mortality.

OSA, as with other complex diseases, it is important for critical and progressive care nurses to give patients emotional and education assistance. It is imperative for OSA patients to be very active in communicating problems to health care providers and cooperate with them in managing the disease. OSA comes with crucial lifelong patient responsibilities, which require intensive patient education and including their families.

References

Epstein, L. J., Kristo, D., Strollo, P. J. Jr., Friedman, N., Malhotra, A., Patil, S. P.,

Ramar, K., Rogers, R., Schwab, R. J., Weaver, E. M., and Weinstein, M. D. (2009). Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine: Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med, 5(3), 263-276. Retrieved October 1, 2014 from National Guideline Clearinghouse. >> HYPERLINK “http://www.guideline.gov/content.aspx?id=15298&search=continuous+positive+airway+pressure” http://www.guideline.gov/content.aspx?id=15298&search=continuous+positive+airway+pressure (Level I)

Lim, J., Lasserson, T. J., Fleetham, J. and Wright, J.J. (2014). Oral appliances

for obstructive sleep apnoea. Cochrane Database of Systematic Reviews, 12(10). Retrieved October 1. 2014 from Cochrane Database of Systematic Reviews. >> HYPERLINK “http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004435.pub3/abstract” http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004435.pub3/abstract (Level I)

Marchese-Regona, R., Manfredini, D., Mion, M., Vianello, A., Staffieri, A., and

Guarda-Nardini, L. (2014). Oral appliances for the treatment of obstructive sleep apnea in patients with low C-PAP compliance: a long-term case series. Cranio 32(4), 254-259. Retrieved October 1, 2014 from PubMED. >> HYPERLINK “http://www.ncbi.nlm.nih.gov/pubmed/25252763” http://www.ncbi.nlm.nih.gov/pubmed/25252763 (Level III)

Martínez-García, M. A., Soler-Cataluña, J. J., Ejarque-Martínez, L., Soriano, Y.,

Román-Sánchez, P., Illa, F. B., Canal, J. M. M., and Durán-Cantolla, J. (2009). Continuous Positive Airway Pressure Treatment Reduces Mortality in Patients with Ischemic Stroke and Obstructive Sleep Apnea. American Journal of Respiratory and Critical Care Medicine, 180(1), 36-41. Retrieved October 1, 2014 from Google Scholar. >> HYPERLINK “http://www.atsjournals.org/doi/abs/10.1164/rccm.200808-1341OC” l “.VCxWpN69-IU” http://www.atsjournals.org/doi/abs/10.1164/rccm.200808-1341OC#.VCxWpN69-IU (Level I)

Weber, C., Silver, M., Cromer, D., Kaminski, S., Wirick, T., and Vallejo, J. (2011).

Under Pressure: Pulmonary Arterial Hypertension . . . A Mother’s Struggle. Critical Care Nurse, 31(4), 87-94. Retrieved 1 October, 2014 from CINAHL Database. >> HYPERLINK “http://ccn.aacnjournals.org/content/31/4/87.full” http://ccn.aacnjournals.org/content/31/4/87.full (Level II)

Recommended Practice

CPAP treatment

EQUIPMENT

CPAP machine

CPAP humidifier

CPAP mask

PREPARATION OF PATIENT

Put patient on the machine for a few nights

Predict patient compliance with the device by using

Built-in smart cards

Communication modem

Web-based system

Record the hours of machine use and the interface usage

PROCEDURE (IMPROVING COMPLIANCE)

Early and Continuous education (Level I)

Education should be conducted by the physician, the sleeping partner and the spouse of the patient

This makes the patient have a better “first impression” of CPAP hence getting ready for its use

Education should cover CPAP advantages and disadvantages

Initiation of CPAP therapy (Level I)

CPAP starts after the couple of nights trial

Upon producing the device patient should know

what it is

how to do titration

why the device is being used

what to expect throughout the nights

Issues related to leaks, swallowing, talking and mouth-breathing should be clarified

Assure patient to keep in touch in case any mechanical problems arise

Immediate Individual Follow-up (Level I)

Call patient several times in the first week to discuss the therapy

Encourage the patient

Monitoring Compliance and Efficacy (Level I)

Check compliance 3 to 6 months following its initial setup

Assess usage of equipment (use and application hours)

Check the device settings

Ensure good condition of interface (masks, pillows, etc)

Discuss the assessment results

Reinforce the need for adherence

Correct anything that could affect compliance

Long-term Support (Level I)

Annual visit to the clinic is necessary to assess the usage of the device

Changes in patient body conditions (e.g. weight loss/ gain) could warrant pressure alterations in the device

Choice of Interface/ Mask Fit (Level I)

The pillows and nasal masks should be of correct size

Nasal pillow is essential for patient with claustrophobia

Oronasal mask essential for patient with persistent mouth leak or nasal congestion

Replace broken headgear/ supply tube/ interface immediately

Nasal Congestion, Steroids/ Antihistamines (Level I)

Difficulty in breathing creates compliance difficulty

Nasal sprays with antihistamines essential for patient with congestion

Group Support (Level I)

Gather CPAP patients for support

Support groups help to:

share tips of coping with CPAP

discuss health effects of CPAP

explore CPAP effect on sleep partner relationship

reinforce CPAP education

bear each other’s burden

REFERENCE

Marchese-Regona, R., Manfredini, D., Mion, M., Vianello, A., Staffieri, A., and

Guarda-Nardini, L. (2014). Oral appliances for the treatment of obstructive sleep apnea in patients with low C-PAP compliance: a long-term case series. Cranio 32(4), 254-259. (Level III)

OHS LOGOS: (Mark an X beside the logos to be included)

X Patient Information

X Wash Your Hands

X Standard Precautions

Take Care With Sharps

X Clinical Competency

X Back Care Manual Handling

Spills Are Hazardous

X Resident Education

X Maintain Electrical Safety

Cytotoxic Chemotherapy

Radiation Hazard

X Safety Testing