Management of the Hospitalized Patient With Sleep Disorder
Management of the Hospitalized Patient With Sleep Disorder
Sleep disordered breathing (SDB) frequently comes to medical attention for the first time when patients are hospitalized for diagnosis and treatment of an associated condition (eg, poorly controlled hypertension, myocardial infarction, congestive heart failure, stroke, or problems related to management of diabetes mellitus). Diagnosis of SDB is generally performed in a specialized facility, which is often inconvenient and expensive for the hospitalized patient. Expectant perioperative management of patients with sleep apnea is critical, particularly if they are previously undiagnosed. An ideal diagnostic strategy for these patients has not been defined. Continuous positive airway pressure (CPAP) is the mainstay of treatment of patients with sleep apnea. Unfortunately, it is often difficult for very ill patients to tolerate CPAP, unless it is administered with a high level of expertise.
Sleep disordered breathing (SDB), particularly obstructive sleep apnea (OSA), is a prevalent condition that is often undiagnosed. The development of obstructive apnea events is related to upper-airway anatomy and function. The relative contribution of these factors may vary widely. Obstruction most often occurs when upper-airway muscle tone is decreased relative to wakefulness. The upper airway collapses, with inspiration leading to obstructed breathing. The patient restores breathing at the expense of sleep continuity only to enter another phase of obstruction as sleep returns. This repetitive cycle of disordered breathing often produces episodic hypoxemia, increased stimulation of the sympathetic nervous system, and poor sleep quality. Other sleep-related respiratory disturbances include Cheyne-Stokes breathing and central sleep apnea (CSA), characterized by oscillation or absence of respiratory effort.
Population studies of middle-aged adults indicate that approximately 9% of women and 24% of men have SDB. It has been estimated that 5% of all adults in Western countries have undiagnosed sleep apnea. Even a relatively mild degree of OSA may be associated with adverse consequences including excess mortality, coronary artery disease manifestation, stroke, insulin resistance, and increased risk of automobile accidents. Studies have concluded that subjects with SDB are more likely to use health care resources and services before diagnosis. Therefore, incidental hospitalization of a patient with OSA may present a valuable opportunity for diagnosis. It also represents a potential challenge in management.
The impact of SDB on medical and surgical patients has not been rigorously investigated because it is largely speculative. Episodic hypoxemia and poor sleep quality may compromise recovery from medical illnesses. Furthermore, it is reasonable to assume that patients whose upper-airway patency is compromised during sleep are also at risk following administration of analgesia and anesthesia. This paper will briefly review data by which we may estimate the likelihood that OSA is present in association with commonly encountered medical conditions. Some reasonable precautions to avoid complications of SDB in medical and surgical patients will be presented. Finally, the inherent difficulties of diagnosis and treatment of a sick patient not previously known to have SDB will be discussed.
Sleep disordered breathing (SDB) frequently comes to medical attention for the first time when patients are hospitalized for diagnosis and treatment of an associated condition (eg, poorly controlled hypertension, myocardial infarction, congestive heart failure, stroke, or problems related to management of diabetes mellitus). Diagnosis of SDB is generally performed in a specialized facility, which is often inconvenient and expensive for the hospitalized patient. Expectant perioperative management of patients with sleep apnea is critical, particularly if they are previously undiagnosed. An ideal diagnostic strategy for these patients has not been defined. Continuous positive airway pressure (CPAP) is the mainstay of treatment of patients with sleep apnea. Unfortunately, it is often difficult for very ill patients to tolerate CPAP, unless it is administered with a high level of expertise.
Sleep disordered breathing (SDB), particularly obstructive sleep apnea (OSA), is a prevalent condition that is often undiagnosed. The development of obstructive apnea events is related to upper-airway anatomy and function. The relative contribution of these factors may vary widely. Obstruction most often occurs when upper-airway muscle tone is decreased relative to wakefulness. The upper airway collapses, with inspiration leading to obstructed breathing. The patient restores breathing at the expense of sleep continuity only to enter another phase of obstruction as sleep returns. This repetitive cycle of disordered breathing often produces episodic hypoxemia, increased stimulation of the sympathetic nervous system, and poor sleep quality. Other sleep-related respiratory disturbances include Cheyne-Stokes breathing and central sleep apnea (CSA), characterized by oscillation or absence of respiratory effort.
Population studies of middle-aged adults indicate that approximately 9% of women and 24% of men have SDB. It has been estimated that 5% of all adults in Western countries have undiagnosed sleep apnea. Even a relatively mild degree of OSA may be associated with adverse consequences including excess mortality, coronary artery disease manifestation, stroke, insulin resistance, and increased risk of automobile accidents. Studies have concluded that subjects with SDB are more likely to use health care resources and services before diagnosis. Therefore, incidental hospitalization of a patient with OSA may present a valuable opportunity for diagnosis. It also represents a potential challenge in management.
The impact of SDB on medical and surgical patients has not been rigorously investigated because it is largely speculative. Episodic hypoxemia and poor sleep quality may compromise recovery from medical illnesses. Furthermore, it is reasonable to assume that patients whose upper-airway patency is compromised during sleep are also at risk following administration of analgesia and anesthesia. This paper will briefly review data by which we may estimate the likelihood that OSA is present in association with commonly encountered medical conditions. Some reasonable precautions to avoid complications of SDB in medical and surgical patients will be presented. Finally, the inherent difficulties of diagnosis and treatment of a sick patient not previously known to have SDB will be discussed.