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Obstructive sleep apnea in adults

Author(s): Joy West, DNP, FNP-C; Robin M. Dawson, PhD, RN, CPNP-PC; MD Wirth, PhD; and Courtney Catledge, DNP, FNP-BC

Nurses can help improve outcomes with screening and appropriate referrals.

Takeaways:

  • Education in the primary care setting is crucial so that patients recognize obstructive sleep apnea (OSA) symptoms and are aware of risks associated with this disorder.
  • Screening with standard sleep questionnaires should be standard at primary care, cardiology, and pulmonology visits to target the millions of people who are untreated and living with life-altering symptoms, such as severe fatigue, dyspnea, chest pain, and low energy.
  • OSA is rapidly growing as obesity rates are rising. Weight loss and exercise should be encouraged to help avoid sleep interruption and eventual OSA

Obstructive sleep apnea (OSA)—breathing cessation during sleep—contributes to significant health problems, including headache, fatigue, depression, high blood pressure, stroke, heart failure, arrythmia, heart attack, and diabetes. Typical OSA symptoms may include snoring, daytime sleepiness and fatigue, morning headaches, dry mouth, sore throat, and irritability. Women are more likely to present with atypical symptoms such as insomnia, headache, anxiety, and depression.

OSA impacts quality of life and is recognized as an independent risk factor for all-cause morbidity. Although 29.4 million people in the United States have been diagnosed with OSA, according to the American Sleep Apnea Association approximately 80% are undiagnosed. Anyone can experience OSA, but it’s most commonly associated with obesity (body mass index greater than 30), making it a public health problem that continues to increase in frequency as obesity rates rise. The condition also may have a genetic component or be the result of lifestyle choices, such as smoking or alcohol use. Frequently, OSA is associated with the physiological changes of aging; it can affect people of any race or gender but is most common in Black and Hispanic men. The lower prevalence of OSA reported in women may reflect underdiagnosis as a result of atypical presentations.

Nurses can serve as a first line for OSA screening in all healthcare settings. When they understand the factors associated with risk for OSA they can ask targeted questions and make referrals to sleep disorder specialists as appropriate.

Sleep apnea and OSA physiology

Sleep apnea—central and obstructive—deprives the brain and the rest of the body of necessary oxygen, resulting in nocturnal desaturations. Central sleep apnea originates in the brain and usually is associated with neurologic disorders (such as amyotrophic lateral sclerosis), brainstem damage, traumatic brain injury, stroke, or encephalitis. Metabolic disorders (such as hypothyroidism), heart failure, and kidney failure also may trigger apneic events. Patients with central sleep apnea have the ability to breath, but their brains don’t signal the need to breath.

In contrast, obstructive sleep apnea is caused by complete or partial soft-tissue blockage of the airway. When the brain signals the need to breathe, the patient will rouse briefly with a start or snort, opening the airway. This type of apnea may occur hundreds of times during one sleep cycle, with the patient completely unaware that it’s happening.

OSA in outpatient and hospital settings

OSA is a rapidly growing concern in the outpatient setting, especially as obesity rates rise. Because patients may not know their symptoms are sleep related, they usually won’t volunteer information unless specifically asked by their healthcare provider. Consequently, providers may not connect comorbidities with a sleep disorder.

Patients with OSA have a higher incidence of hospitalization compared to those without OSA. According to a study by Shear and colleagues, two out of five inpatients, age 50 years or older, are at high risk for OSA. This study concluded that when hospitalized patients don’t understand the consequences of OSA or follow provider recommendations after discharge, they are three times more likely to be readmitted to the hospital within 30 days of discharge. Another study by Williams and colleagues found an association between healthcare provider knowledge about OSA and appropriate referral rates for further evaluation, concluding that postdischarge follow-up is imperative for timely evaluation and treatment. 

Improving outcomes with OSA screening

Many U.S. hospitals ask patients to complete a sleep questionnaire during hospitalization to determine if they should be referred to a sleep specialist after discharge. However, not all hospitals have a formal protocol for identifying at-risk patients. Appropriate OSA screening during hospitalization represents an opportunity to identify and refer patients for follow-up, potentially reducing morbidity and mortality. (See OSA screening tools.)

OSA screening tools

Several obstructive sleep apnea (OSA) screening tools are available:

  • Berlin Questionnaire
  • Epworth Sleepiness Scale
  • Four-Variable screening tool
  • Multivariable Apnea Prediction index
  • STOP-Bang tool.

The easiest to administer is the STOP-Bang Tool, a screening questionnaire that asks simple questions about:

  • Snoring
  • Tiredness and sleepiness during the day
  • Observed cessation of breathing during sleep
  • Blood Pressure abnormalities
  • Body mass index (BMI)
  • Age
  • Neck circumference
  • Gender.

The total score identifies whether the person is at low, intermediate, or high risk for OSA, and which patients would benefit from a referral after discharge.

What nurses can do

In the outpatient setting, nurses can play an instrumental role in improving patient outcomes when they know the typical and atypical symptoms of OSA, suspect OSA as a factor in common disorders, ask targeted questions to assess sleep, and suggest referrals to sleep specialists if indicated. Nurses also can educate patients about the lifestyle changes they can make to increase their quality of life. OSA, in many cases, can be improved or even avoided by maintaining a healthy weight, engaging in regular exercise, limiting alcohol consumption, smoking cessation, and avoiding the supine position during sleep.

In the inpatient setting, nurses spend more time with patients than any other healthcare professional, placing them in a unique position to initiate OSA screening, suggest referrals, and improve outcomes. Nurses in a variety of specialty areas (including medical-surgical, intensive care, cardiac care, and labor and delivery) should consider taking a proactive approach to OSA screening. When patients are identified as moderate to high risk, a referral to a sleep specialist should be advised at discharge. (See Nurse-led QI project.)

Nurse-led QI project

In a quality improvement (QI) project conducted in a 225-bed community hospital in rural South Carolina, nurses working on a 42-bed medical-surgical floor implemented the STOP-Bang assessment tool in a patient population age 50 years and over and/or with a BMI of 28 or greater.

A 4-week pre-implementation chart review showed that 181 of the patients met criteria for OSA referral, but only 16% received a referral on discharge. At 4 weeks’ postimplementation, a chart review showed that 177 patients met criteria for further OSA evaluation and 130 (73%) were referred to a sleep specialist at discharge. No differences were found in referrals by race, ethnicity, or gender.

This project yielded a 57% increase in the number of referrals, demonstrating that a simple nurse-led initiative has tremendous potential for improving OSA-related evaluations in this population.

After the referral is made, nurses should inform the patient about next steps. The sleep specialist will conduct a complete sleep assessment, including a history and physical. Diagnostic procedures may include home sleep testing or polysomnography (sleep study). (See OSA diagnostic testing.)

OSA diagnostic testing

Polysomnography (a sleep study) is recommended for patients with comorbidities such as significant heart disease, moderate-to-severe chronic obstructive pulmonary disease, stroke, or severe insomnia. This standard diagnostic test, usually administered at a sleep center or hospital, monitors and records:

  • breathing patterns
  • oxygenation levels
  • body positioning and movements
  • heart rate
  • snoring
  • brain activity (with an electroencephalogram).

If apneas are detected, the technician may evaluate the effect of continuous positive airway pressure (CPAP) on the patient’s apneic episodes.

Nurses can relieve some of the anxiety associated with this testing by explaining to patients what to expect, including the use of scalp sensors, cardiac monitors, and CPAP devices.

Nurses can help improve outcomes for patients with OSA in all settings when they recognize symptoms, ask the right questions, make referrals, and provide patient education. For additional information and online resources, see Useful OSA links.

Useful OSA links

Learn more about obstructive sleep apnea (OSA) at these online resources:

Joy West is a nurse practitioner at Carolina Cardiology Associates in Lancaster, South Carolina. Robin M. Dawson is an assistant professor and director of the Smart Start Nursing Program at the University of South Carolina College of Nursing. MD Wirth is an assistant professor at the South Carolina College of Nursing. Courtney Catledge is the BSN program director at the University of South Carolina Lancaster College of Nursing.

References

Chung F, Abdullah HR, Liao P. STOP-Bang Questionnaire: A practical approach to screen for obstructive sleep apnea. Chest. 2016;149(3):631-8.

Shear TC, Balachandran JS, Mokhlesi B, et al. Risk of sleep apnea in hospitalized older patients. J Clin Sleep Med. 2014;10(10):1061-6.

Watson NF. Health care savings: The economic value of diagnostic and therapeutic care for obstructive sleep apnea. J Clin Sleep Med. 2016;12(8):1075-7.

Williams NJ. Nunes JV, Zizi F, et al. Factors associated with referrals for obstructive sleep apnea evaluation among community physicians. J Clin Sleep Med. 2015;11(1):23-6.

Wimms A, Woehrle H, Ketheeswaran S, Ramanan D, Armitstead J. Obstructive sleep apnea in women: Specific issues and interventions. Biomed Res Int. September 6, 2016. hindawi.com/journals/bmri/2016/1764837/

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