Abstract
Recent obesity statistics are alarming. Forty million Americans are obese, which equates to approximately 30% of our population. Comorbid factors that accompany obesity are on the rise as well. High blood pressure, hypercholesterolemia, dyslipidemia, type 2 diabetes, osteoarthritis, and sleep apnea are some of the conditions that increase with obesity. In this editorial, I will focus on obstructive sleep apnea (OSA).
Eighteen million Americans suffer from OSA, and the morbidly obese population comprises a high percentage of that 18 million. Approximately 70% of the morbidly obese population in the United States experience OSA. Furthermore, some patients that do not meet diagnostic criteria for OSA may experience upper airway resistance syndrome (UARS), a form of sleep-disordered breathing that also leads to fragmented sleep patterns and excessive daytime sleepiness. More alarming, OSA is underdiagnosed, and as a result, many patients enter our healthcare facilities at risk for complications related to undiagnosed OSA.
When narcotics are administered to a patient with OSA, the patient is at risk for increased episodes of sleep apnea with potentially longer durations, as well as being at risk for decreased arterial oxygen saturation. The lingering sedative and respiratory depressant effects of anesthesia and narcotics may pose difficulties for airway maintenance. Thus attention to sleep apnea is critical. Given the nature of the disorder, it may be appropriate to monitor patients with OSA for several hours longer than patients without OSA after the last dose of anesthetic, opioid, or sedative is given. When narcotics are necessary, appropriate monitoring is essential, as narcotic analgesics can precipitate or potentiate apnea, which may result in cardiac arrest.
Appropriate monitoring for the patient with OSA is crucial. Patients that use C-pap or Bi-pap must have positive airway pressure (PAP) equipment at their bedside. Many facilities request that patients bring their own equipment with them when they are admitted to the hospital, as the patients are typically accustomed to using their own equipment. In the event that a patient does not bring PAP equipment, the healthcare facility must be able to procure the necessary machines, masks, and other equipment needed in a timely manner. Continuous pulse oximetry, with alarms preset at the appropriate saturation settings, must be audible to monitoring personnel. It is imperative that OSA be treated in a holistic manner, including the involvement of the patient, family members, and all nursing personnel. Whenever the patient is in bed and might fall asleep, he or she is at risk for episodes of apnea. Therefore patients and family members must be aware of existing orders that require the patient to use PAP equipment whenever sleeping. Patients that are sitting upright or standing, and who are properly monitored, are considered at low risk for episodes of apnea. However, when the patient is lying down or is otherwise in a horizontal position, sleep is always possible and therefore monitoring equipment and PAP devices must be used in order to ensure maintenance of the airway. Partnering with the patient and family can assist the nurse in ensuring that the necessary equipment is used at the appropriate times. The wording of any monitoring order is also important. “May use C-pap as at home” is quite broad and likely ineffective. An order that reads, “C-pap to be used when patient is positioned for sleep and/or sleep is anticipated” is direct and more focused.
For the surgical patient, pain management usually begins in the postanesthesia care unit (PACU), with frequent small doses of narcotics given in order to achieve satisfactory pain control. Patient-controlled analgesia (PCA) is also usually started in the PACU, with small narcotic doses and an appropriate lockout interval. When PCA is not ordered in the immediate postoperative period, patients may arrive at the acute care unit with generic pain management orders, which do not take into consideration the increased risks associated with OSA. As a result, an improper dose of narcotics may be delivered, putting the patient with OSA at risk for a serious adverse event, especially if monitored pulse oximetry has not been established and PAP equipment is not being used. Thus small PCA dosing, rather than larger, p.r.n. bolus dosing of narcotics may provide a higher level of safety.
As mentioned in the introduction, OSA is underdiagnosed. Patients with OSA enter our healthcare facilities and are as at risk for respiratory complications as the diagnosed patient. How do we, as nurses, best anticipate the potential for respiratory complications in the bariatric patient population? I believe we have to raise the awareness of this disorder. As healthcare providers, we must know the common signs and symptoms of sleep apnea (see Table 1). We must develop pathways to address the undiagnosed patient. Leaders must budget for adequate equipment, such as positive airway pressure equipment and pulse oximetry. Primary care providers must carefully screen patients in order to diagnose and treat OSA. With the rising incidence of obesity, we must all work toward prevention. In the meantime, we must assure that patients at risk for OSA are assessed and properly treated. I challenge each of you to raise awareness in your respective communities.