Review Article Safe Use of Opioids in Individuals with Obstructive Sleep Apnea ---
-
Cynthia W. Ward, DNP, RN-BC, CMSRN, ACNS-BC
ABSTRACT:
Obstructive sleep apnea (OSA) is a chronic breathing disorder that contributes to many other health problems (Epstein et al., 2009). It is present but undiagnosed in a large percentage of the population (Adesanya, Lee, Grilich, & Joshi, 2010). Pain is recognized as a public health problem in the United States, affecting millions of people of all ages (Committee on Advancing Pain Research, Care, and Education Board on Health Sciences Policy, 2011). Because of the high prevalence of both OSA and pain, it is very likely that an individual will have both conditions. Opioid analgesics used to treat pain may cause sedation and respiratory depression by themselves. When administered to individuals with OSA, the risk for harmful respiratory events increases. This article reviews the assessment and monitoring needed to administer opioids safely to individuals with OSA and identifies best practices from a review of the literature. Ó 2015 by the American Society for Pain Management Nursing
DEFINITION OF OBSTRUCTIVE SLEEP APNEA
From the Carilion Roanoke Memorial Hospital, Roanoke, Virginia. Address correspondence to Cynthia W. Ward, DNP, RN-BC, CMSRN, ACNS-BC, 1906 Belleview Avenue, Roanoke, VA 24014. E-mail: cwward@ carilionclinic.org Received February 13, 2013; Revised May 25, 2014; Accepted May 27, 2014. 1524-9042/$36.00 Ó 2015 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2014.05.008
Obstructive sleep apnea (OSA) is a chronic disorder characterized by collapse of the upper airway during sleep and pauses in breathing. The breathing pauses last more than 10 seconds (Ankichetty, Wong, & Chung, 2011). Muscle relaxation during rapid eye movement sleep causes narrowing of the airway with partial or complete obstruction (Khan & Ali, 2008). Airway obstruction causes the individual to arouse. The cycle of obstruction and arousal may be repeated multiple of times during the night (Khan & Ali, 2008). The airway collapse causes hypoxemia and hypercapnia, leading to interrupted sleep and changes in intrathoracic pressure (Epstein et al., 2009). Although the sleep interruption is brief and not remembered by the individual, it causes strain on the cardiovascular system because of sudden increases in blood pressure and heart rate (Jigajinni, Sultan, & Radhakrishnan, 2009). Individuals with OSA may exhibit loud snoring, periods of breathing cessation, and gasping or choking and experience daytime sleepiness, morning headaches, and decreased concentration and memory (Epstein et al., 2009). Patients may describe feeling unrefreshed after sleeping and feeling sleepy during the daytime with a need for daytime naps. Nocturia and decreased libido may also be present (McCabe & Hardinge, 2011). Children may also have OSA; however, children may be of normal weight or lower than normal weight. OSA in children may manifest as behavior disorders, including hyperactivity, attention problems, or enuresis (Schwengel, Sterni, Tunkel, & Heitmiller, 2009). Pain Management Nursing, Vol 16, No 3 (June), 2015: pp 411-417
412
STOP-Bang is a tool that can be used to screen for the possible presence of OSA in individuals who have not been formally diagnosed. It consists of eight yes or no questions, with a possible score of 0 to 8. Scores of 3 or higher have been found to have a high sensitivity of identifying OSA. The components of the STOP-Bang tool are loud snoring, feelings of fatigue or sleepiness during the day, observation of cessation of breathing during sleep, being treated for high blood pressure, body mass index (BMI) greater than 35, age older than 50, neck circumference greater than 40 cm, and male gender. A comparison of the STOPBang tool to the Epworth Sleepiness Scale, the STOP tool and the 4-Variable tool found the STOP-Bang to be more sensitive in identifying individuals with moderate to severe OSA and severe OSA than the other tools (Silva, Vana, Goodwin, Sherrill, & Quan, 2011). OSA may contribute to other health conditions, including hypertension, cerebrovascular accidents, myocardial infarction, and cor pulmonale, and increase the risk of motor vehicle accidents (Epstein et al., 2009). Gastroesophageal reflux, intracranial hypertension, polycythemia, right-sided heart failure, nocturnal angina, fatigue, impaired cognition, anxiety, and depression are other possible sequelae (Khan & Ali, 2008; Moos & Cuddeford, 2006). OSA has also been shown to contribute to the development of postoperative complications, including respiratory depression and cardiac arrhythmias, and increased reintubation (Park, Ramar, & Olson, 2011). In one study, 27% of OSA patients who did not use continuous positive airway pressure (CPAP) at home required CPAP postoperatively. These patients had the highest incidence of postoperative complications, such as oxygen desaturation less than 90% (Liao, Yegneswaran, Vairavanathan, Zilberman, & Chung, 2009). Postoperative complications can create the need for intensive care monitoring and cause an increased length of hospital stay (Shafazand, 2009). OSA is diagnosed in a sleep laboratory using polysomnography, also known as a sleep study. Polysomnography is a test that measures respiratory rate, pulse, air flow in and out of the lungs, pulse oximetry, brainwaves, and limb movements during sleep (Hadjiliadis & Zieve, 2011). The result of the sleep study is reported as the apnea/hypopnea index. A diagnosis of OSA is made if there are more than 15 obstructive events during the night or more than 5 an hour (Epstein et al., 2009). Apnea is defined as the cessation of breathing for 10 seconds or more. Hypopnea is a 50% or greater decrease in airflow compared with a normal tidal volume (Moos & Cuddeford, 2006). Tidal volume is the volume of air per breath (Brashers, 2006). In hypopnea, respiratory effort is exhibited yet the airway is obstructed (Bolden, Smith, & Auckley, 2009).
Ward
TREATMENT OF OSA Treatment of all severities of OSA begins with conservative treatments such as weight loss, avoidance of alcohol, and smoking cessation (Moos & Cuddeford, 2006). The most common treatment of OSA is CPAP, which provides pneumatic splinting by passive distention to prevent collapse of the upper airway. The amount of air pressure is adjusted during polysomnography to a level to eliminate respiratory symptoms caused by obstruction (Kushida et al., 2006). CPAP use for as little as 4 hours nightly has been shown to relieve symptoms (McCabe & Hardinge, 2011). The treatment of choice for children with OSA is adenotonsillectomy (Schwengel et al., 2009). Other treatments for OSA are the use of oral appliances that reposition the mandible to prevent collapse of the upper airway or tongue retaining devices that hold the tongue in a forward position (Epstein et al., 2009). Surgery may be used if CPAP is unsuccessful or the patient cannot tolerate it. Various surgical procedures may be used, such as septoplasty, uvulopalatopharyngoplasty, mandibular maxillary osteotomy and advancement, genioglossal advancement, or tonsillectomy (Epstein et al., 2009; Jigajinni et al., 2009). Patients with severe OSA who do not respond to other treat ments may require tracheostomy (Jigajinni et al., 2009).
PREVALENCE Obstructive Sleep Apnea Obstructive sleep apnea affects 2%-4% of adults (Epstein et al., 2009) and may affect up to 5% of the general population (Khan & Ali, 2008). Other sources place the prevalence as high as 14% in men and 7% in women (Jarzyna et al., 2011). Prevalence may be as high as 78% in morbidly obese individuals (Park et al., 2011). It is believed that 1%-9% of surgical patients may be affected. Up to 80% of individuals with OSA may be undiagnosed (Adesanya, Lee, Grilich, & Joshi, 2010). OSA is most common in men and postmenopausal women (Pace, 2008). OSA occurs in approximately 1%-3% of children (Schwengel et al., 2009). Pain Pain is a common cause of physician visits and visits to hospital emergency departments. Acute and chronic pain contribute to decreased quality of life, lost work time, and impaired physical function and may lead to related psychological conditions such as depression or anxiety (Institute of Medicine, 2011). Unrelieved pain can cause harmful effects in many systems throughout the body. Cardiovascular effects can include increased cardiac workload, increased oxygen consumption by
Safe Opioid Use in Patients with Sleep Apnea
the heart muscle, and hypertension. Metabolic responses can include hyperglycemia, glucose intolerance, and insulin resistance (Pasero & Portenoy, 2011). Unrelieved pain can also lead to activation of the stress response, causing increased secretion of stress hormones by the endocrine system and suppression of the immune system (Wells, Pasero, & McCaffery, 2008). Chronic pain is pain lasting longer than the normal tissue healing time, generally 3 to 6 months. The most common location of chronic pain is low back (Johannes, Le, Zhou, Johnston, & Dworkin, 2010). Chronic pain affects more than 100 million adults in the United States each year and has an economic cost of $500 to $600 billion annually (Institute of Medicine, 2011).
CHALLENGES RELATED TO OPIOID USE IN PATIENTS WITH OSA Opioids are known to cause sedation and may lead to respiratory depression, particularly in opioid-na€ıve individuals and when given concomitantly with other medications causing sedation, such as benzodiazepines, sedatives, or hypnotics (American Pain Society, 2008). Opioids cause relaxation of the tongue and upper airway muscles, which may cause airway obstruction once the individual falls asleep (Macintyre, Loadsman, & Scott, 2011). The resulting weakness of upper airway muscles may exacerbate OSA. Patients who have hypercapnia and decreased respirations may still have severe pain (Wills, 2008). A major challenge is to provide adequate pain relief while simultaneously maintaining an adequate oxygen saturation and preventing respiratory depression. A long-held belief is that patients using opioids on a long-term basis become tolerant of the sedating effects of opioids and less likely to experience sedation and respiratory depression. A retrospective cohort study of patients being tested for suspected sleep apnea compared patients taking chronic opioid medications with patients not taking opioids. The apnea-hypopnea index was measured during polysomnography. The patients taking chronic opioids had significantly higher apneahypopnea indexes, increased ataxic breathing, and decreased oxygen saturation (Walker et al., 2007). The study results suggest that OSA patients receiving opioids for chronic pain management may also be at risk for adverse effects related to respiratory depression.
REVIEW OF THE LITERATURE Administration of Opioids to Individuals with OSA Regional anesthesia is recommended for use when possible in individuals with OSA having surgery
413
(Bamgbadea et al., 2009; Bolden et al., 2009; Haeck, Swanson, Iverson, & Lynch, 2009; Jigajinni et al., 2009; Khan & Ali, 2008; Moos & Cuddeford, 2006; Rudra et al., 2008; Schwengel et al., 2009). For surgeries in which general anesthesia must be used, short-acting agents provide a faster return to the baseline respiratory status (Adesanya et al., 2010; Chung, Yuan, & Chung, 2008; Jigajinni et al., 2009). Benzodiazepines cause an increased amount of effort to be needed for OSA patients to awaken from sleep. Increased length of apneic episodes may also occur because of decreased arousal response to hypoxia and hypercapnia. The use of sedatives in patients with OSA should be minimized or avoided (Ankichetty et al., 2011; Macintyre et al., 2011; Shafazand, 2009). OSA patients undergoing ambulatory procedures experienced fewer postoperative complications when undergoing peripheral procedures, when regional anesthesia was used, and when postoperative opioid use was limited (Liu et al., 2010). OSA may cause increased sensitivity to the effects of opioids, even in individuals who have used opioids for 6 months or longer. Walker et al. (2007) compared a group of individuals with OSA taking opioids for chronic pain with a group of individuals with OSA who were not taking opioids. An increased number of apnea and hypopnea episodes were associated with an increase in morphine dose (p < .001). Patients in the opioid use group also had an increased incidence of irregular or ataxic breathing (Walker et al., 2007). Patient-controlled opioid analgesia (PCA) should be used with caution and may not be appropriate (Adesanya et al., 2010; Gali et al., 2007). If PCA is used, a continuous or basal rate is not recommended (Bolden et al., 2009; Khan & Ali, 2008; Macintyre et al., 2011; Moos & Cuddeford, 2006). The use of a basal rate is associated with an increased risk of respiratory depression (Jarzyna et al., 2011). Opioids that are mu receptor agonists have the greatest risk of causing respiratory depression (Jungquist, Karan, & Perlis, 2011). Examples of mu receptor agonist opioids are morphine, codeine, fentanyl, hydrocodone, hydromorphone, oxycodone, and methadone (Pasero & McCaffery, 2011). The peak effect time of the opioid, other medications being administered at the same time as the opioid, and the patient’s level of sedation must all be taken into account to prevent respiratory depression (Jungquist et al., 2011). The body’s response to opioids is also affected by genetics. Individuals who are deficient of certain isoenzymes may be less sensitive to medications that require that isoenzyme for metabolism (Jungquist et al., 2011). Therefore opioid doses given postoperatively must be individualized and titrated to effect (Macintyre et al., 2011).
414
Opioids contribute to central nervous system depression in three ways: by depressing the respiratory drive, decreasing level of consciousness, and depressing airway muscle tone. Together these three mechanisms decrease ventilation and lead to hypoxia and hypercapnia. In postoperative patients other factors can also cause sedation, such as the administration of anesthetic or sedative medications, patient fatigue, and the presence of medical conditions such as OSA, chronic obstructive pulmonary disease, or obesity (Macintyre et al., 2011). The use of nonopioid analgesics may decrease the amount of opioids needed (Adesanya et al., 2010; Chung et al., 2008; Jigajinni et al., 2009; Khan & Ali, 2008; Rudra et al., 2008). A multimodal method combining medications with different mechanisms of action may provide better pain relief with less medication (Khan & Ali, 2008; Pasero & McCaffery, 2011; Rudra et al., 2008). Opioid analgesia and an opioid-sparing analgesia protocol were studied in 62 postoperative patients in a hospital in Australia who were assessed as being at high risk for having OSA. All the patients in the study received intravenous acetaminophen. Patients in the opioid group received morphine by PCA, whereas patients in the opioidsparing protocol group received PCA using tramadol. No significant difference was found in the number of postoperative respiratory events between the two groups (Blake, Yew, Donnan, & Williams, 2009). Monitoring Individuals with OSA Measures should be undertaken to prevent hypoxemia and hypercapnia (Adesanya et al., 2010). Hypoxemia may occur in some patients receiving opioids even during wakefulness (Macintyre et al., 2011). Hypoxemia was associated with a change in oxygen delivery, emergent CPAP application, administration of intravenous naloxone, increased intensity of care, and increased length of stay in a study of orthopedic surgery patients with OSA (Liu et al., 2011). Positioning the patient with the head elevated 30 or in the side-lying position helps to maintain airway patency (Adesanya et al., 2010; Arisaka et al., 2008; Chung et al., 2008; Khan & Ali, 2008; Rudra et al., 2008). Monitoring the respiratory rate may not be a reliable indicator of ventilatory impairment because the respiratory rate may be normal even when hypercapnia is present (Macintyre et al., 2011). Continuous oxygen saturation monitoring is recommended in OSA patients receiving opioids (Adesanya et al., 2010; Bamgbadea et al., 2009; Bolden et al., 2009; Bolden, Smith, Auckley, Makarski, & Avula, 2007; Gay, 2010; Haeck, Swanson, Iverson, & Lynch, 2009; Horlocker et al., 2009; Jigajinni et al.,
Ward
2009; Moos & Cuddeford, 2006; Shafazand, 2009). Chung, Yuan, and Chung (2008) recommend continuous oxygen saturation monitoring in patients who are at increased postoperative risk because of OSA but not for all patients. The American Society of Anesthesiologists recommend continuous oxygen saturation monitoring in an intensive care or step-down unit (Chung et al., 2008). However, a literature review by the American Society for Pain Management Nursing found insufficient evidence to support pulse oximetry as a standard of care for all patients receiving opioid analgesia (Jarzyna et al., 2011). One should keep in mind that oxygen saturation monitoring may not be a reliable method of detecting postoperative ventilatory impairment, particularly in patients receiving oxygen (Jarzyna et al., 2011; Maddox, Oglesby, Williams, Fields, & Danello, 2008; Pasero, 2009). Patients receiving supplemental oxygen may exhibit satisfactory oxygen saturation levels even when severe ventilatory impairment is present (Macintyre et al., 2011). Supplemental oxygen is recommended for use only to treat desaturation and only for as long as necessary (Chung et al., 2008; Rudra et al., 2008). Level of sedation is an important indicator and an early warning sign of respiratory depression and should be monitored in all postoperative patients (Craft, 2010; Hutchison & Rodriguez, 2008; Pasero, 2009). Sedation manifests earlier than other respiratory effects of opioids and is not masked by supplemental oxygen use. The frequency of sedation monitoring depends on the type of opioid used and the risk factors of the individual patient (Jarzyna et al., 2011). Accurate evaluation of sedation requires that the patient be awakened for assessment (Macintyre et al., 2011). The Pasero Opioid-induced Sedation Scale (POSS) is one validated, reliable (Cronbach’s alpha 0.9) scale that includes nursing interventions based on the level of sedation assessed (Pasero, 2009). Patients who use a CPAP device should use it postoperatively (Adesanya et al., 2010; Bolden et al., 2009; Haeck et al., 2009; Horlocker et al., 2009; Jigajinni et al., 2009; Moos & Cuddeford, 2006; Pace, 2008; Rudra et al., 2008). CPAP may be beneficial if airway patency cannot be maintained with positioning (Jigajinni et al., 2009; Khan & Ali, 2008; Moos & Cuddeford, 2006). The American Society of Anesthesiologists does not have a consensus agreement regarding the use of CPAP in the presence of apnea or oxygen desaturation (Chung et al., 2008). One study of 313 patients found that oxygen desaturation occurred most often in the first 24 hours postoperatively but were not reliably prevented by the use of CPAP (Bolden et al., 2007). Capnography, the measurement of expired carbon dioxide, is recommended to help prevent hypercapnia
Safe Opioid Use in Patients with Sleep Apnea
(Haeck et al., 2009; Pasero, 2009). Supplemental oxygen may be administered concurrently. Capnography is recommended for use only in patients receiving oxygen (Hutchison & Rodriguez, 2008) or for patients in whom ventilation cannot be directly observed (Jarzyna et al., 2011). Pasero recommends capnography be used in any patient with diagnosed or suspected OSA (Pasero, 2009). When used in conjunction with ‘‘smart pump’’ technology, the PCA can be stopped automatically if capnography detects impaired respirations (McCarter, Shaik, Scarfo, & Thompson, 2010). Capnography is a more sensitive early indicator of respiratory depression than oximetry (Jarzyna et al., 2011; Maddox et al., 2008; McCarter et al., 2010; Pace, 2008). In a study of 634 patients receiving opioids by PCA postoperatively, nine had respiratory depression requiring intervention. Respiratory depression was identified by capnography in all nine of these patients. Continuous pulse oximetry was in use but the alarm had not been triggered (McCarter et al., 2010). Practical implications such as cost and outcome benefits of capnography are still being studied (Gay, 2010; Macintyre et al., 2011). The accuracy of capnography in patients using CPAP is unknown (Hutchison & Rodriguez, 2008). Because oximetry measures oxygenation and capnography measures ventilation, both are necessary for an accurate assessment of respiratory status (Maddox et al., 2008).
BEST PRACTICES FOR SAFE OPIOID USE IN PATIENTS WITH OSA The following best practices for nursing monitoring and interventions for OSA patients receiving opioids were identified based on the literature.
415
Individualize opioid doses given postoperatively and titrate to effect (Macintyre et al., 2011). Do not use a basal (continuous) dose when using PCA (Bolden et al., 2009; Jarzyna et al., 2011; Khan & Ali, 2008; Macintyre et al., 2011; Moos & Cuddeford, 2006). The use of nonopioid analgesics may decrease the amount of opioids needed (Adesanya et al., 2010; Chung et al., 2008; Jigajinni et al., 2009; Khan & Ali, 2008; Pasero & McCaffery, 2011; Rudra et al., 2008). Sedation should be monitored using a valid and reliable sedation scale (Craft, 2010; Hutchison & Rodriguez, 2008; Jarzyna et al., 2011; Macintyre et al., 2011; Pasero, 2009). The POSS scale is an example of a valid and reliable sedation scale (Pasero, 2009). Patients should be positioned either with the head up 30 degrees or on the side (Adesanya et al., 2010; Chung et al., 2008; Khan & Ali, 2008; Rudra et al., 2008). Patients who use a CPAP at home should use a CPAP after surgery at any time they are drowsy to help maintain the airway while receiving opioids. CPAP may also be of use to treat respiratory depression (Adesanya et al., 2010; Bolden et al., 2009; Haeck et al., 2009; Horlocker et al., 2009; Jigajinni et al., 2009; Khan & Ali, 2008; Moos & Cuddeford, 2006; Pace, 2008; Rudra et al., 2008; Shafazand, 2009). A continuous pulse oximeter should be used to monitor oxygenation (Bamgbadea et al., 2009; Bolden et al., 2007, 2009; Chung et al., 2008; Gay, 2010; Haeck et al., 2009; Jigajinni et al., 2009; Macintyre et al., 2011; Maddox et al., 2008; Moos & Cuddeford, 2006; Shafazand, 2009). Capnography is a more sensitive indicator of ventilation and can help prevent respiratory complications (Haeck et al., 2009; Jarzyna et al., 2011; Maddox et al., 2008; McCarter et al., 2010; Pace, 2008; Pasero, 2009)
REFERENCES Adesanya, A., Lee, W., Grilich, N., & Joshi, G. (2010). Perioperative management of obstructive sleep apnea. Chest, 138(6), 1489–1498. American Pain Society. (2008). Principles of analgesic use in the treatment of acute pain and cancer pain, (6th ed.) Glenview, IL: American Pain Society. Ankichetty, S., Wong, J., & Chung, F. (2011). A systematic review of the effects of sedatives and anesthetics in patients with obstructive sleep apnea. Journal of Anaesthesiology Clinical Pharmacy, 27(4), 447–458. Arisaka, H., Sakuraba, S., Kobayashi, R., Kitahama, H., Nishida, N., Furuya, M., & Yoshida, K. (2008). Perioperative management of obstructive sleep apnea with nasal continuous positive airway pressure. Anesthesia Progress, 55(4), 121–123. Bamgbadea, O. A., Chunga, A. S., Khalafa, W. M., Dwyerb, B. J., Alfab, J. A., & Tierney, N. M. (2009). Survey of perioperative care of adults with obstructive sleep apnoea. Eurpoean Society of Anesthesia, 26, 706–708.
Blake, D. W., Yew, C. Y., Donnan, G. B., & Williams, D. L. (2009). Postoperative analgesia and respiratory events in patients with symptoms of obstructive sleep apnoea. Anaesthesia & Intensive Care, 37(5), 720–725. Bolden, N., Smith, C. E., Auckley, D., Makarski, J., & Avula, R. (2007). Perioperative complications during use of an obstructive sleep apnea protocol following surgery and anesthesia. International Anesthesia Research Society, 105(6), 1859–1870. Bolden, N., Smith, C. E., & Auckley, D. (2009). Avoiding adverse outcomes in patients with obstructive sleep apnea (OSA): Development and implementation of a perioperative OSA protocol. Journal of Clinical Anesthesia, 21(4), 286–293. Brashers, V. L. (2006). Structure and function of the pulmonary system. In K. L. McCance, & S. E. Huether (Eds.), Pathophysiology: The biologic basis for disease in adults and children, (5th ed.) (pp. 1181–1204) St. Louis, MO: Mosby Elsevier.
416
Chung, S. A., Yuan, H., & Chung, F. (2008). A systematic review of obstructive sleep apnea and its implications for anesthesiologists. Anesthesia & Analgesia, 107(5), 1543–1563. Committee on Advancing Pain Research, Care, and Education Board on Health Sciences Policy. (2011). Relieving pain in America: A blueprint for transforming prevention, care, education, and research. Washington, D.C.: The National Academies Press. Craft, J. (2010). Patient-controlled analgesia: Is it worth the painful prescribing process? Baylor University Medical Center Proceedings, 23(4), 434–438. Epstein, L. J., Kristo, D., Strollo, P. J., Friedman, N., Malhotra, A., Patil, S. P., Ramar, K., Rogers, R., Schwab, R. J., Weaver, E. M., Weinstein, M. D., & Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine (2009). Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. Journal of Sleep Medicine, 5(3), 263–276. Gali, B., Whalen, F. X., Gay, P. C., Olsen, E. J., Schroeder, D. R., Plevak, D. J., & Morgenthaler, T. (2007). Management plan to reduce risks in perioperative care of patients with presumed obstructive sleep apnea syndrome. Journal of Clinical Sleep Medicine, 3(6), 582–588. Gay, P. (2010). Sleep and sleep-disordered breathing in the hospitalized patient. Respiratory Care, 55(9), 1240–1254. Hadjiliadis, D., & Zieve, D. (2011). Polysomnography. Retrieved May 4, 2014, Retrieved from http://www.nlm.nih. gov/medlineplus/ency/article/003932.htm. Haeck, P. C., Swanson, J. A., Iverson, R. E., & Lynch, D. J. (2009). Evidence-based patient safety advisory: Patient assessment and prevention of pulmonary side effects in surgery. Part 1: Obstructive sleep apnea and obstructive lung disease. Plastic and Reconstructive Surgery, 124(4 Suppl), 45S–56S. Horlocker, T. T., Burton, A. W., Connis, R. T., Hughes, S. C., Nickinovich, D. G., Palmer, C. M., Pollock, J. E., Rathmell, J. P., Rosenquist, R. W., Swisher, J. L., & Wu, C. L. (2009). Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration. An updated report by the American Society of Anesthesiologists task force on neuraxial opioids. Anesthesioloogy, 110(2), 218–230. Hutchison, R., & Rodriguez, L. (2008). Capnography and respiratory depression: Is capnography a good way to monitor at-risk postsurgical patients? A prospective trial examines the question. American Journal of Nursing, 108(2), 35–39. Institute of Medicine. (2011). Relieving pain in america: A blueprint for transforming prevention, care, education and research. Washington, D.C.: The National Academies Press. Jarzyna, D., Jungquist, C. R., Pasero, C., Willens, J. S., Nisbet, A., Oakes, L., Dempsey, S. J., Santangelo, D., & Polomano, R. C. (2011). American society for pain management nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Management Nursing, 12(3), 118–145. Jigajinni, S., Sultan, P., & Radhakrishnan, D. (2009). Not just a patient that snores. Obstructive sleep apnoea: The perioperative concerns through the eye of the anaesthetist. Journal of Perioperative Practice, 19(11), 395–399. Johannes, C. B., Le, T. K., Zhou, X., Johnston, J. A., & Dworkin, R. H. (2010). The prevalence of chronic pain in
Ward
united states adults: Results of an internet-based survey. The Journal of Pain, 11(11), 1230–1239. Jungquist, C. R., Karan, S., & Perlis, M. L. (2011). Risk factors for opioid-induced excessive respiratory depression. Pain Management Nursing, 12(5), 180–187. Khan, F. A., & Ali, M. (2008). Perioperative management of patients with obstructive sleep apnoea: A review. Indian Journal of Anaesthesia, 52(2), 140–147. Kushida, C. A., Littner, M., Hirshkowitz, H., Morgenthaler, T., Alessi, C. A., Bailey, D., Boehlecke, B., Brown, T. M., Coleman J. Jr., Friedman, L., Kapen, S., Kapur, V. K., Kramer, M., Lee-Chiong, T., Owens, J., Pancer, J. P., Swick, T. J., Wise, M. S., & American Academy of Sleep Medicine (2006). Practice parameters for the use of continuous and bilevel positive airway pressure devices to treat adult patients with sleep-related breathing disorders. Sleep, 29(3), 375–380. Liao, P., Yegneswaran, B., Vairavanathan, S., Zilberman, P., & Chung, F. (2009). Postoperative complications in patients with obstructive sleep apnea: A retrospective matched cohort study. Canadian Journal of Anesthesiology, 56, 819– 828. Liu, S. S., Chisholm, M. F., John, R. S., Ngeow, J., Ma, Y., & Memtsoudis, S. (2010). Risk of postoperative hypoxemia in ambulatory orthopedic surgery patients with diagnosis of obstructive sleep apnea: A retrospective observational study. Patient Safety in Surgery, 4, 9. Liu, S. S., Chisholm, M. F., Ngeow, J., John, R. S., Shaw, P., Ma, Y., & Memtsoudis, S. (2011). Postoperative hypoxemia in orthopedic patients with obstructive sleep apnea. Hospital for Special Surgery Journal, 7, 2–8. Macintyre, P. E., Loadsman, J. A., & Scott, D. A. (2011). Opioids, ventilation and acute pain management. Anaesthesia & Intensive Care, 39(4), 545–558. Maddox, R. R., Oglesby, H., Williams, C. K., Fields, M., & Danello, S. (2008). Continuous respiratory monitoring and a ‘ smart’’ infusion system improve safety of patient-controlled analgesia in the postoperative period. In K. Henriksen, J. B. Battles, M. A. Keyes, & M. L. Grady (Eds.), Advances in patient safety: New directions and alternative approaches (vol. 4: Technology and medication safety). Rockville, MD: Agency for Healthcare Research and Quality. McCabe, C., & Hardinge, M. (2011). Obstructive sleep apnoea. Practice Nurse, 41(10), 36–41. McCarter, T., Shaik, Z., Scarfo, K., & Thompson, L. J. (2010). Capnography monitoring enhances safety of postoperative patient-controlled analgesia. American Health & Drug Benefits, 5, 28–35. Moos, D. D. D., & Cuddeford, J. D. J. (2006). Implications of obstructive sleep apnea syndrome for the perianesthesia nurse. Journal of Perianesthesia Nursing: Official Journal of the American Society of PeriAnesthesia Nurses/American Society of PeriAnesthesia Nurses, 21(2), 103–115, quiz 116–118. Pace, N. (2008). Sedating the patient with underlying sleep apnea. Journal of Radiology Nursing, 27(3), 107–111. Park, J. G., Ramar, K., & Olson, E. J. (2011). Updates on definition, consequences, and management of obstructive sleep apnea. Mayo Clinic Proceedings, 86(6), 549–555. Pasero, C. (2009). Administration of sedation during opioid administration for pain management. Journal of PeriAnesthesia Nursing, 24(3), 186–190.
Safe Opioid Use in Patients with Sleep Apnea
Pasero, C., & McCaffery, M. (2011). Pain assessment and pharmacologic management. St. Louis, MO: Mosby Elsevier. Pasero, C., & Portenoy, R. K. (2011). Neurophysiology of pain and analgesia and the pathophysiology of neuropathic pain. In C. Pasero, & M. McCaffery (Eds.), Pain assessment and pharmacologic management (pp. 1–14). St. Louis, MO: Mosby. Rudra, A., Chatterjee, S., Das, T., Sengupta, S., Maitra, G., & Kumar, P. (2008). Obstructive sleep apnoea and anaesthesia. Indian Journal of Critical Care Medicine, 12(3), 116–123. Schwengel, D. A., Sterni, L. M., Tunkel, D. E., & Heitmiller, E. S. (2009). Perioperative management of children with obstructive sleep apnea. International Anesthesia Research Society, 109(1), 60–75. Shafazand, S. (2009). Perioperative management of obstructive sleep apnea: Ready for prime time? Cleveland Clinic Journal of Medicine, 76(Suppl 4), S98–S103.
417
Silva, G. E., Vana, K. D., Goodwin, J. L., Sherrill, D., & Quan, S. F. (2011). Identification of patients with sleep disordered breathing: Comparing the four-variable screening tool, STOP, STOP-bang, and epworth sleepiness scales. Journal of Clinical Sleep Medicine, 7(5), 467–472. Walker, J. M., Farney, R. J., Rhondeau, S. M., Boyle, K. M., Valentine, K., Cloward, T. V., & Shilling, K. C. (2007). Chronic opioid use is a risk factor for the development of central sleep apnea and ataxic breathing. Journal of Clinical Sleep Medicine, 3(5), 455–462. Wells, N., Pasero, C., & McCaffery, M. (2008). Improving the quality of care through pain assessment and management. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality. Wills, M. H. (2008). Protecting our patients with obstructive sleep apnea during the perioperative period. The Journal of Lancaster General Hospital, 2(4), 136–139.
-
Cynthia W. Ward, DNP, RN-BC, CMSRN, ACNS-BC
ABSTRACT:
Obstructive sleep apnea (OSA) is a chronic breathing disorder that contributes to many other health problems (Epstein et al., 2009). It is present but undiagnosed in a large percentage of the population (Adesanya, Lee, Grilich, & Joshi, 2010). Pain is recognized as a public health problem in the United States, affecting millions of people of all ages (Committee on Advancing Pain Research, Care, and Education Board on Health Sciences Policy, 2011). Because of the high prevalence of both OSA and pain, it is very likely that an individual will have both conditions. Opioid analgesics used to treat pain may cause sedation and respiratory depression by themselves. When administered to individuals with OSA, the risk for harmful respiratory events increases. This article reviews the assessment and monitoring needed to administer opioids safely to individuals with OSA and identifies best practices from a review of the literature. Ó 2015 by the American Society for Pain Management Nursing
DEFINITION OF OBSTRUCTIVE SLEEP APNEA
From the Carilion Roanoke Memorial Hospital, Roanoke, Virginia. Address correspondence to Cynthia W. Ward, DNP, RN-BC, CMSRN, ACNS-BC, 1906 Belleview Avenue, Roanoke, VA 24014. E-mail: cwward@ carilionclinic.org Received February 13, 2013; Revised May 25, 2014; Accepted May 27, 2014. 1524-9042/$36.00 Ó 2015 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2014.05.008
Obstructive sleep apnea (OSA) is a chronic disorder characterized by collapse of the upper airway during sleep and pauses in breathing. The breathing pauses last more than 10 seconds (Ankichetty, Wong, & Chung, 2011). Muscle relaxation during rapid eye movement sleep causes narrowing of the airway with partial or complete obstruction (Khan & Ali, 2008). Airway obstruction causes the individual to arouse. The cycle of obstruction and arousal may be repeated multiple of times during the night (Khan & Ali, 2008). The airway collapse causes hypoxemia and hypercapnia, leading to interrupted sleep and changes in intrathoracic pressure (Epstein et al., 2009). Although the sleep interruption is brief and not remembered by the individual, it causes strain on the cardiovascular system because of sudden increases in blood pressure and heart rate (Jigajinni, Sultan, & Radhakrishnan, 2009). Individuals with OSA may exhibit loud snoring, periods of breathing cessation, and gasping or choking and experience daytime sleepiness, morning headaches, and decreased concentration and memory (Epstein et al., 2009). Patients may describe feeling unrefreshed after sleeping and feeling sleepy during the daytime with a need for daytime naps. Nocturia and decreased libido may also be present (McCabe & Hardinge, 2011). Children may also have OSA; however, children may be of normal weight or lower than normal weight. OSA in children may manifest as behavior disorders, including hyperactivity, attention problems, or enuresis (Schwengel, Sterni, Tunkel, & Heitmiller, 2009). Pain Management Nursing, Vol 16, No 3 (June), 2015: pp 411-417
412
STOP-Bang is a tool that can be used to screen for the possible presence of OSA in individuals who have not been formally diagnosed. It consists of eight yes or no questions, with a possible score of 0 to 8. Scores of 3 or higher have been found to have a high sensitivity of identifying OSA. The components of the STOP-Bang tool are loud snoring, feelings of fatigue or sleepiness during the day, observation of cessation of breathing during sleep, being treated for high blood pressure, body mass index (BMI) greater than 35, age older than 50, neck circumference greater than 40 cm, and male gender. A comparison of the STOPBang tool to the Epworth Sleepiness Scale, the STOP tool and the 4-Variable tool found the STOP-Bang to be more sensitive in identifying individuals with moderate to severe OSA and severe OSA than the other tools (Silva, Vana, Goodwin, Sherrill, & Quan, 2011). OSA may contribute to other health conditions, including hypertension, cerebrovascular accidents, myocardial infarction, and cor pulmonale, and increase the risk of motor vehicle accidents (Epstein et al., 2009). Gastroesophageal reflux, intracranial hypertension, polycythemia, right-sided heart failure, nocturnal angina, fatigue, impaired cognition, anxiety, and depression are other possible sequelae (Khan & Ali, 2008; Moos & Cuddeford, 2006). OSA has also been shown to contribute to the development of postoperative complications, including respiratory depression and cardiac arrhythmias, and increased reintubation (Park, Ramar, & Olson, 2011). In one study, 27% of OSA patients who did not use continuous positive airway pressure (CPAP) at home required CPAP postoperatively. These patients had the highest incidence of postoperative complications, such as oxygen desaturation less than 90% (Liao, Yegneswaran, Vairavanathan, Zilberman, & Chung, 2009). Postoperative complications can create the need for intensive care monitoring and cause an increased length of hospital stay (Shafazand, 2009). OSA is diagnosed in a sleep laboratory using polysomnography, also known as a sleep study. Polysomnography is a test that measures respiratory rate, pulse, air flow in and out of the lungs, pulse oximetry, brainwaves, and limb movements during sleep (Hadjiliadis & Zieve, 2011). The result of the sleep study is reported as the apnea/hypopnea index. A diagnosis of OSA is made if there are more than 15 obstructive events during the night or more than 5 an hour (Epstein et al., 2009). Apnea is defined as the cessation of breathing for 10 seconds or more. Hypopnea is a 50% or greater decrease in airflow compared with a normal tidal volume (Moos & Cuddeford, 2006). Tidal volume is the volume of air per breath (Brashers, 2006). In hypopnea, respiratory effort is exhibited yet the airway is obstructed (Bolden, Smith, & Auckley, 2009).
Ward
TREATMENT OF OSA Treatment of all severities of OSA begins with conservative treatments such as weight loss, avoidance of alcohol, and smoking cessation (Moos & Cuddeford, 2006). The most common treatment of OSA is CPAP, which provides pneumatic splinting by passive distention to prevent collapse of the upper airway. The amount of air pressure is adjusted during polysomnography to a level to eliminate respiratory symptoms caused by obstruction (Kushida et al., 2006). CPAP use for as little as 4 hours nightly has been shown to relieve symptoms (McCabe & Hardinge, 2011). The treatment of choice for children with OSA is adenotonsillectomy (Schwengel et al., 2009). Other treatments for OSA are the use of oral appliances that reposition the mandible to prevent collapse of the upper airway or tongue retaining devices that hold the tongue in a forward position (Epstein et al., 2009). Surgery may be used if CPAP is unsuccessful or the patient cannot tolerate it. Various surgical procedures may be used, such as septoplasty, uvulopalatopharyngoplasty, mandibular maxillary osteotomy and advancement, genioglossal advancement, or tonsillectomy (Epstein et al., 2009; Jigajinni et al., 2009). Patients with severe OSA who do not respond to other treat ments may require tracheostomy (Jigajinni et al., 2009).
PREVALENCE Obstructive Sleep Apnea Obstructive sleep apnea affects 2%-4% of adults (Epstein et al., 2009) and may affect up to 5% of the general population (Khan & Ali, 2008). Other sources place the prevalence as high as 14% in men and 7% in women (Jarzyna et al., 2011). Prevalence may be as high as 78% in morbidly obese individuals (Park et al., 2011). It is believed that 1%-9% of surgical patients may be affected. Up to 80% of individuals with OSA may be undiagnosed (Adesanya, Lee, Grilich, & Joshi, 2010). OSA is most common in men and postmenopausal women (Pace, 2008). OSA occurs in approximately 1%-3% of children (Schwengel et al., 2009). Pain Pain is a common cause of physician visits and visits to hospital emergency departments. Acute and chronic pain contribute to decreased quality of life, lost work time, and impaired physical function and may lead to related psychological conditions such as depression or anxiety (Institute of Medicine, 2011). Unrelieved pain can cause harmful effects in many systems throughout the body. Cardiovascular effects can include increased cardiac workload, increased oxygen consumption by
Safe Opioid Use in Patients with Sleep Apnea
the heart muscle, and hypertension. Metabolic responses can include hyperglycemia, glucose intolerance, and insulin resistance (Pasero & Portenoy, 2011). Unrelieved pain can also lead to activation of the stress response, causing increased secretion of stress hormones by the endocrine system and suppression of the immune system (Wells, Pasero, & McCaffery, 2008). Chronic pain is pain lasting longer than the normal tissue healing time, generally 3 to 6 months. The most common location of chronic pain is low back (Johannes, Le, Zhou, Johnston, & Dworkin, 2010). Chronic pain affects more than 100 million adults in the United States each year and has an economic cost of $500 to $600 billion annually (Institute of Medicine, 2011).
CHALLENGES RELATED TO OPIOID USE IN PATIENTS WITH OSA Opioids are known to cause sedation and may lead to respiratory depression, particularly in opioid-na€ıve individuals and when given concomitantly with other medications causing sedation, such as benzodiazepines, sedatives, or hypnotics (American Pain Society, 2008). Opioids cause relaxation of the tongue and upper airway muscles, which may cause airway obstruction once the individual falls asleep (Macintyre, Loadsman, & Scott, 2011). The resulting weakness of upper airway muscles may exacerbate OSA. Patients who have hypercapnia and decreased respirations may still have severe pain (Wills, 2008). A major challenge is to provide adequate pain relief while simultaneously maintaining an adequate oxygen saturation and preventing respiratory depression. A long-held belief is that patients using opioids on a long-term basis become tolerant of the sedating effects of opioids and less likely to experience sedation and respiratory depression. A retrospective cohort study of patients being tested for suspected sleep apnea compared patients taking chronic opioid medications with patients not taking opioids. The apnea-hypopnea index was measured during polysomnography. The patients taking chronic opioids had significantly higher apneahypopnea indexes, increased ataxic breathing, and decreased oxygen saturation (Walker et al., 2007). The study results suggest that OSA patients receiving opioids for chronic pain management may also be at risk for adverse effects related to respiratory depression.
REVIEW OF THE LITERATURE Administration of Opioids to Individuals with OSA Regional anesthesia is recommended for use when possible in individuals with OSA having surgery
413
(Bamgbadea et al., 2009; Bolden et al., 2009; Haeck, Swanson, Iverson, & Lynch, 2009; Jigajinni et al., 2009; Khan & Ali, 2008; Moos & Cuddeford, 2006; Rudra et al., 2008; Schwengel et al., 2009). For surgeries in which general anesthesia must be used, short-acting agents provide a faster return to the baseline respiratory status (Adesanya et al., 2010; Chung, Yuan, & Chung, 2008; Jigajinni et al., 2009). Benzodiazepines cause an increased amount of effort to be needed for OSA patients to awaken from sleep. Increased length of apneic episodes may also occur because of decreased arousal response to hypoxia and hypercapnia. The use of sedatives in patients with OSA should be minimized or avoided (Ankichetty et al., 2011; Macintyre et al., 2011; Shafazand, 2009). OSA patients undergoing ambulatory procedures experienced fewer postoperative complications when undergoing peripheral procedures, when regional anesthesia was used, and when postoperative opioid use was limited (Liu et al., 2010). OSA may cause increased sensitivity to the effects of opioids, even in individuals who have used opioids for 6 months or longer. Walker et al. (2007) compared a group of individuals with OSA taking opioids for chronic pain with a group of individuals with OSA who were not taking opioids. An increased number of apnea and hypopnea episodes were associated with an increase in morphine dose (p < .001). Patients in the opioid use group also had an increased incidence of irregular or ataxic breathing (Walker et al., 2007). Patient-controlled opioid analgesia (PCA) should be used with caution and may not be appropriate (Adesanya et al., 2010; Gali et al., 2007). If PCA is used, a continuous or basal rate is not recommended (Bolden et al., 2009; Khan & Ali, 2008; Macintyre et al., 2011; Moos & Cuddeford, 2006). The use of a basal rate is associated with an increased risk of respiratory depression (Jarzyna et al., 2011). Opioids that are mu receptor agonists have the greatest risk of causing respiratory depression (Jungquist, Karan, & Perlis, 2011). Examples of mu receptor agonist opioids are morphine, codeine, fentanyl, hydrocodone, hydromorphone, oxycodone, and methadone (Pasero & McCaffery, 2011). The peak effect time of the opioid, other medications being administered at the same time as the opioid, and the patient’s level of sedation must all be taken into account to prevent respiratory depression (Jungquist et al., 2011). The body’s response to opioids is also affected by genetics. Individuals who are deficient of certain isoenzymes may be less sensitive to medications that require that isoenzyme for metabolism (Jungquist et al., 2011). Therefore opioid doses given postoperatively must be individualized and titrated to effect (Macintyre et al., 2011).
414
Opioids contribute to central nervous system depression in three ways: by depressing the respiratory drive, decreasing level of consciousness, and depressing airway muscle tone. Together these three mechanisms decrease ventilation and lead to hypoxia and hypercapnia. In postoperative patients other factors can also cause sedation, such as the administration of anesthetic or sedative medications, patient fatigue, and the presence of medical conditions such as OSA, chronic obstructive pulmonary disease, or obesity (Macintyre et al., 2011). The use of nonopioid analgesics may decrease the amount of opioids needed (Adesanya et al., 2010; Chung et al., 2008; Jigajinni et al., 2009; Khan & Ali, 2008; Rudra et al., 2008). A multimodal method combining medications with different mechanisms of action may provide better pain relief with less medication (Khan & Ali, 2008; Pasero & McCaffery, 2011; Rudra et al., 2008). Opioid analgesia and an opioid-sparing analgesia protocol were studied in 62 postoperative patients in a hospital in Australia who were assessed as being at high risk for having OSA. All the patients in the study received intravenous acetaminophen. Patients in the opioid group received morphine by PCA, whereas patients in the opioidsparing protocol group received PCA using tramadol. No significant difference was found in the number of postoperative respiratory events between the two groups (Blake, Yew, Donnan, & Williams, 2009). Monitoring Individuals with OSA Measures should be undertaken to prevent hypoxemia and hypercapnia (Adesanya et al., 2010). Hypoxemia may occur in some patients receiving opioids even during wakefulness (Macintyre et al., 2011). Hypoxemia was associated with a change in oxygen delivery, emergent CPAP application, administration of intravenous naloxone, increased intensity of care, and increased length of stay in a study of orthopedic surgery patients with OSA (Liu et al., 2011). Positioning the patient with the head elevated 30 or in the side-lying position helps to maintain airway patency (Adesanya et al., 2010; Arisaka et al., 2008; Chung et al., 2008; Khan & Ali, 2008; Rudra et al., 2008). Monitoring the respiratory rate may not be a reliable indicator of ventilatory impairment because the respiratory rate may be normal even when hypercapnia is present (Macintyre et al., 2011). Continuous oxygen saturation monitoring is recommended in OSA patients receiving opioids (Adesanya et al., 2010; Bamgbadea et al., 2009; Bolden et al., 2009; Bolden, Smith, Auckley, Makarski, & Avula, 2007; Gay, 2010; Haeck, Swanson, Iverson, & Lynch, 2009; Horlocker et al., 2009; Jigajinni et al.,
Ward
2009; Moos & Cuddeford, 2006; Shafazand, 2009). Chung, Yuan, and Chung (2008) recommend continuous oxygen saturation monitoring in patients who are at increased postoperative risk because of OSA but not for all patients. The American Society of Anesthesiologists recommend continuous oxygen saturation monitoring in an intensive care or step-down unit (Chung et al., 2008). However, a literature review by the American Society for Pain Management Nursing found insufficient evidence to support pulse oximetry as a standard of care for all patients receiving opioid analgesia (Jarzyna et al., 2011). One should keep in mind that oxygen saturation monitoring may not be a reliable method of detecting postoperative ventilatory impairment, particularly in patients receiving oxygen (Jarzyna et al., 2011; Maddox, Oglesby, Williams, Fields, & Danello, 2008; Pasero, 2009). Patients receiving supplemental oxygen may exhibit satisfactory oxygen saturation levels even when severe ventilatory impairment is present (Macintyre et al., 2011). Supplemental oxygen is recommended for use only to treat desaturation and only for as long as necessary (Chung et al., 2008; Rudra et al., 2008). Level of sedation is an important indicator and an early warning sign of respiratory depression and should be monitored in all postoperative patients (Craft, 2010; Hutchison & Rodriguez, 2008; Pasero, 2009). Sedation manifests earlier than other respiratory effects of opioids and is not masked by supplemental oxygen use. The frequency of sedation monitoring depends on the type of opioid used and the risk factors of the individual patient (Jarzyna et al., 2011). Accurate evaluation of sedation requires that the patient be awakened for assessment (Macintyre et al., 2011). The Pasero Opioid-induced Sedation Scale (POSS) is one validated, reliable (Cronbach’s alpha 0.9) scale that includes nursing interventions based on the level of sedation assessed (Pasero, 2009). Patients who use a CPAP device should use it postoperatively (Adesanya et al., 2010; Bolden et al., 2009; Haeck et al., 2009; Horlocker et al., 2009; Jigajinni et al., 2009; Moos & Cuddeford, 2006; Pace, 2008; Rudra et al., 2008). CPAP may be beneficial if airway patency cannot be maintained with positioning (Jigajinni et al., 2009; Khan & Ali, 2008; Moos & Cuddeford, 2006). The American Society of Anesthesiologists does not have a consensus agreement regarding the use of CPAP in the presence of apnea or oxygen desaturation (Chung et al., 2008). One study of 313 patients found that oxygen desaturation occurred most often in the first 24 hours postoperatively but were not reliably prevented by the use of CPAP (Bolden et al., 2007). Capnography, the measurement of expired carbon dioxide, is recommended to help prevent hypercapnia
Safe Opioid Use in Patients with Sleep Apnea
(Haeck et al., 2009; Pasero, 2009). Supplemental oxygen may be administered concurrently. Capnography is recommended for use only in patients receiving oxygen (Hutchison & Rodriguez, 2008) or for patients in whom ventilation cannot be directly observed (Jarzyna et al., 2011). Pasero recommends capnography be used in any patient with diagnosed or suspected OSA (Pasero, 2009). When used in conjunction with ‘‘smart pump’’ technology, the PCA can be stopped automatically if capnography detects impaired respirations (McCarter, Shaik, Scarfo, & Thompson, 2010). Capnography is a more sensitive early indicator of respiratory depression than oximetry (Jarzyna et al., 2011; Maddox et al., 2008; McCarter et al., 2010; Pace, 2008). In a study of 634 patients receiving opioids by PCA postoperatively, nine had respiratory depression requiring intervention. Respiratory depression was identified by capnography in all nine of these patients. Continuous pulse oximetry was in use but the alarm had not been triggered (McCarter et al., 2010). Practical implications such as cost and outcome benefits of capnography are still being studied (Gay, 2010; Macintyre et al., 2011). The accuracy of capnography in patients using CPAP is unknown (Hutchison & Rodriguez, 2008). Because oximetry measures oxygenation and capnography measures ventilation, both are necessary for an accurate assessment of respiratory status (Maddox et al., 2008).
BEST PRACTICES FOR SAFE OPIOID USE IN PATIENTS WITH OSA The following best practices for nursing monitoring and interventions for OSA patients receiving opioids were identified based on the literature.
415
Individualize opioid doses given postoperatively and titrate to effect (Macintyre et al., 2011). Do not use a basal (continuous) dose when using PCA (Bolden et al., 2009; Jarzyna et al., 2011; Khan & Ali, 2008; Macintyre et al., 2011; Moos & Cuddeford, 2006). The use of nonopioid analgesics may decrease the amount of opioids needed (Adesanya et al., 2010; Chung et al., 2008; Jigajinni et al., 2009; Khan & Ali, 2008; Pasero & McCaffery, 2011; Rudra et al., 2008). Sedation should be monitored using a valid and reliable sedation scale (Craft, 2010; Hutchison & Rodriguez, 2008; Jarzyna et al., 2011; Macintyre et al., 2011; Pasero, 2009). The POSS scale is an example of a valid and reliable sedation scale (Pasero, 2009). Patients should be positioned either with the head up 30 degrees or on the side (Adesanya et al., 2010; Chung et al., 2008; Khan & Ali, 2008; Rudra et al., 2008). Patients who use a CPAP at home should use a CPAP after surgery at any time they are drowsy to help maintain the airway while receiving opioids. CPAP may also be of use to treat respiratory depression (Adesanya et al., 2010; Bolden et al., 2009; Haeck et al., 2009; Horlocker et al., 2009; Jigajinni et al., 2009; Khan & Ali, 2008; Moos & Cuddeford, 2006; Pace, 2008; Rudra et al., 2008; Shafazand, 2009). A continuous pulse oximeter should be used to monitor oxygenation (Bamgbadea et al., 2009; Bolden et al., 2007, 2009; Chung et al., 2008; Gay, 2010; Haeck et al., 2009; Jigajinni et al., 2009; Macintyre et al., 2011; Maddox et al., 2008; Moos & Cuddeford, 2006; Shafazand, 2009). Capnography is a more sensitive indicator of ventilation and can help prevent respiratory complications (Haeck et al., 2009; Jarzyna et al., 2011; Maddox et al., 2008; McCarter et al., 2010; Pace, 2008; Pasero, 2009)
REFERENCES Adesanya, A., Lee, W., Grilich, N., & Joshi, G. (2010). Perioperative management of obstructive sleep apnea. Chest, 138(6), 1489–1498. American Pain Society. (2008). Principles of analgesic use in the treatment of acute pain and cancer pain, (6th ed.) Glenview, IL: American Pain Society. Ankichetty, S., Wong, J., & Chung, F. (2011). A systematic review of the effects of sedatives and anesthetics in patients with obstructive sleep apnea. Journal of Anaesthesiology Clinical Pharmacy, 27(4), 447–458. Arisaka, H., Sakuraba, S., Kobayashi, R., Kitahama, H., Nishida, N., Furuya, M., & Yoshida, K. (2008). Perioperative management of obstructive sleep apnea with nasal continuous positive airway pressure. Anesthesia Progress, 55(4), 121–123. Bamgbadea, O. A., Chunga, A. S., Khalafa, W. M., Dwyerb, B. J., Alfab, J. A., & Tierney, N. M. (2009). Survey of perioperative care of adults with obstructive sleep apnoea. Eurpoean Society of Anesthesia, 26, 706–708.
Blake, D. W., Yew, C. Y., Donnan, G. B., & Williams, D. L. (2009). Postoperative analgesia and respiratory events in patients with symptoms of obstructive sleep apnoea. Anaesthesia & Intensive Care, 37(5), 720–725. Bolden, N., Smith, C. E., Auckley, D., Makarski, J., & Avula, R. (2007). Perioperative complications during use of an obstructive sleep apnea protocol following surgery and anesthesia. International Anesthesia Research Society, 105(6), 1859–1870. Bolden, N., Smith, C. E., & Auckley, D. (2009). Avoiding adverse outcomes in patients with obstructive sleep apnea (OSA): Development and implementation of a perioperative OSA protocol. Journal of Clinical Anesthesia, 21(4), 286–293. Brashers, V. L. (2006). Structure and function of the pulmonary system. In K. L. McCance, & S. E. Huether (Eds.), Pathophysiology: The biologic basis for disease in adults and children, (5th ed.) (pp. 1181–1204) St. Louis, MO: Mosby Elsevier.
416
Chung, S. A., Yuan, H., & Chung, F. (2008). A systematic review of obstructive sleep apnea and its implications for anesthesiologists. Anesthesia & Analgesia, 107(5), 1543–1563. Committee on Advancing Pain Research, Care, and Education Board on Health Sciences Policy. (2011). Relieving pain in America: A blueprint for transforming prevention, care, education, and research. Washington, D.C.: The National Academies Press. Craft, J. (2010). Patient-controlled analgesia: Is it worth the painful prescribing process? Baylor University Medical Center Proceedings, 23(4), 434–438. Epstein, L. J., Kristo, D., Strollo, P. J., Friedman, N., Malhotra, A., Patil, S. P., Ramar, K., Rogers, R., Schwab, R. J., Weaver, E. M., Weinstein, M. D., & Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine (2009). Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. Journal of Sleep Medicine, 5(3), 263–276. Gali, B., Whalen, F. X., Gay, P. C., Olsen, E. J., Schroeder, D. R., Plevak, D. J., & Morgenthaler, T. (2007). Management plan to reduce risks in perioperative care of patients with presumed obstructive sleep apnea syndrome. Journal of Clinical Sleep Medicine, 3(6), 582–588. Gay, P. (2010). Sleep and sleep-disordered breathing in the hospitalized patient. Respiratory Care, 55(9), 1240–1254. Hadjiliadis, D., & Zieve, D. (2011). Polysomnography. Retrieved May 4, 2014, Retrieved from http://www.nlm.nih. gov/medlineplus/ency/article/003932.htm. Haeck, P. C., Swanson, J. A., Iverson, R. E., & Lynch, D. J. (2009). Evidence-based patient safety advisory: Patient assessment and prevention of pulmonary side effects in surgery. Part 1: Obstructive sleep apnea and obstructive lung disease. Plastic and Reconstructive Surgery, 124(4 Suppl), 45S–56S. Horlocker, T. T., Burton, A. W., Connis, R. T., Hughes, S. C., Nickinovich, D. G., Palmer, C. M., Pollock, J. E., Rathmell, J. P., Rosenquist, R. W., Swisher, J. L., & Wu, C. L. (2009). Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration. An updated report by the American Society of Anesthesiologists task force on neuraxial opioids. Anesthesioloogy, 110(2), 218–230. Hutchison, R., & Rodriguez, L. (2008). Capnography and respiratory depression: Is capnography a good way to monitor at-risk postsurgical patients? A prospective trial examines the question. American Journal of Nursing, 108(2), 35–39. Institute of Medicine. (2011). Relieving pain in america: A blueprint for transforming prevention, care, education and research. Washington, D.C.: The National Academies Press. Jarzyna, D., Jungquist, C. R., Pasero, C., Willens, J. S., Nisbet, A., Oakes, L., Dempsey, S. J., Santangelo, D., & Polomano, R. C. (2011). American society for pain management nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Management Nursing, 12(3), 118–145. Jigajinni, S., Sultan, P., & Radhakrishnan, D. (2009). Not just a patient that snores. Obstructive sleep apnoea: The perioperative concerns through the eye of the anaesthetist. Journal of Perioperative Practice, 19(11), 395–399. Johannes, C. B., Le, T. K., Zhou, X., Johnston, J. A., & Dworkin, R. H. (2010). The prevalence of chronic pain in
Ward
united states adults: Results of an internet-based survey. The Journal of Pain, 11(11), 1230–1239. Jungquist, C. R., Karan, S., & Perlis, M. L. (2011). Risk factors for opioid-induced excessive respiratory depression. Pain Management Nursing, 12(5), 180–187. Khan, F. A., & Ali, M. (2008). Perioperative management of patients with obstructive sleep apnoea: A review. Indian Journal of Anaesthesia, 52(2), 140–147. Kushida, C. A., Littner, M., Hirshkowitz, H., Morgenthaler, T., Alessi, C. A., Bailey, D., Boehlecke, B., Brown, T. M., Coleman J. Jr., Friedman, L., Kapen, S., Kapur, V. K., Kramer, M., Lee-Chiong, T., Owens, J., Pancer, J. P., Swick, T. J., Wise, M. S., & American Academy of Sleep Medicine (2006). Practice parameters for the use of continuous and bilevel positive airway pressure devices to treat adult patients with sleep-related breathing disorders. Sleep, 29(3), 375–380. Liao, P., Yegneswaran, B., Vairavanathan, S., Zilberman, P., & Chung, F. (2009). Postoperative complications in patients with obstructive sleep apnea: A retrospective matched cohort study. Canadian Journal of Anesthesiology, 56, 819– 828. Liu, S. S., Chisholm, M. F., John, R. S., Ngeow, J., Ma, Y., & Memtsoudis, S. (2010). Risk of postoperative hypoxemia in ambulatory orthopedic surgery patients with diagnosis of obstructive sleep apnea: A retrospective observational study. Patient Safety in Surgery, 4, 9. Liu, S. S., Chisholm, M. F., Ngeow, J., John, R. S., Shaw, P., Ma, Y., & Memtsoudis, S. (2011). Postoperative hypoxemia in orthopedic patients with obstructive sleep apnea. Hospital for Special Surgery Journal, 7, 2–8. Macintyre, P. E., Loadsman, J. A., & Scott, D. A. (2011). Opioids, ventilation and acute pain management. Anaesthesia & Intensive Care, 39(4), 545–558. Maddox, R. R., Oglesby, H., Williams, C. K., Fields, M., & Danello, S. (2008). Continuous respiratory monitoring and a ‘ smart’’ infusion system improve safety of patient-controlled analgesia in the postoperative period. In K. Henriksen, J. B. Battles, M. A. Keyes, & M. L. Grady (Eds.), Advances in patient safety: New directions and alternative approaches (vol. 4: Technology and medication safety). Rockville, MD: Agency for Healthcare Research and Quality. McCabe, C., & Hardinge, M. (2011). Obstructive sleep apnoea. Practice Nurse, 41(10), 36–41. McCarter, T., Shaik, Z., Scarfo, K., & Thompson, L. J. (2010). Capnography monitoring enhances safety of postoperative patient-controlled analgesia. American Health & Drug Benefits, 5, 28–35. Moos, D. D. D., & Cuddeford, J. D. J. (2006). Implications of obstructive sleep apnea syndrome for the perianesthesia nurse. Journal of Perianesthesia Nursing: Official Journal of the American Society of PeriAnesthesia Nurses/American Society of PeriAnesthesia Nurses, 21(2), 103–115, quiz 116–118. Pace, N. (2008). Sedating the patient with underlying sleep apnea. Journal of Radiology Nursing, 27(3), 107–111. Park, J. G., Ramar, K., & Olson, E. J. (2011). Updates on definition, consequences, and management of obstructive sleep apnea. Mayo Clinic Proceedings, 86(6), 549–555. Pasero, C. (2009). Administration of sedation during opioid administration for pain management. Journal of PeriAnesthesia Nursing, 24(3), 186–190.
Safe Opioid Use in Patients with Sleep Apnea
Pasero, C., & McCaffery, M. (2011). Pain assessment and pharmacologic management. St. Louis, MO: Mosby Elsevier. Pasero, C., & Portenoy, R. K. (2011). Neurophysiology of pain and analgesia and the pathophysiology of neuropathic pain. In C. Pasero, & M. McCaffery (Eds.), Pain assessment and pharmacologic management (pp. 1–14). St. Louis, MO: Mosby. Rudra, A., Chatterjee, S., Das, T., Sengupta, S., Maitra, G., & Kumar, P. (2008). Obstructive sleep apnoea and anaesthesia. Indian Journal of Critical Care Medicine, 12(3), 116–123. Schwengel, D. A., Sterni, L. M., Tunkel, D. E., & Heitmiller, E. S. (2009). Perioperative management of children with obstructive sleep apnea. International Anesthesia Research Society, 109(1), 60–75. Shafazand, S. (2009). Perioperative management of obstructive sleep apnea: Ready for prime time? Cleveland Clinic Journal of Medicine, 76(Suppl 4), S98–S103.
417
Silva, G. E., Vana, K. D., Goodwin, J. L., Sherrill, D., & Quan, S. F. (2011). Identification of patients with sleep disordered breathing: Comparing the four-variable screening tool, STOP, STOP-bang, and epworth sleepiness scales. Journal of Clinical Sleep Medicine, 7(5), 467–472. Walker, J. M., Farney, R. J., Rhondeau, S. M., Boyle, K. M., Valentine, K., Cloward, T. V., & Shilling, K. C. (2007). Chronic opioid use is a risk factor for the development of central sleep apnea and ataxic breathing. Journal of Clinical Sleep Medicine, 3(5), 455–462. Wells, N., Pasero, C., & McCaffery, M. (2008). Improving the quality of care through pain assessment and management. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality. Wills, M. H. (2008). Protecting our patients with obstructive sleep apnea during the perioperative period. The Journal of Lancaster General Hospital, 2(4), 136–139.
