Patient Safety / Quality

Adult obstructive sleep apnea: Taking a patient-centered approach

Like many nurses, you might frequently encounter patients with obstructive sleep apnea (OSA)—or signs and symptoms of this chronic condition. You can play a pivotal role in helping them if you recognize the hallmarks of OSA and are familiar with its treatment and follow-up.

Too often, OSA goes undiagnosed. Adults with OSA are sleep deprived and subjected to multiple physiologic insults every hour they sleep. As a group, they’re commonly overlooked—partly due to lack of education about the condition. Aftercare support of OSA patients, particularly when it comes to education, is fragmented, disorganized, and nonstandardized.

This article gives an overview of OSA, describes barriers to initial patient acceptance of and adherence to therapy, explores current approaches to follow-up education and training, and discusses potential solutions based on adult learning theories and learning options.

Incidence, risk factors, and consequences

OSA affects twice as many men as women until menopause, when the gender disparity closes. It becomes more common with age and is more prevalent in African-Americans, Native Americans, and Asians. Anatomic risk factors include a very small or receding jaw, a high arched palate and tonsillar hypertrophy, and increased neck circumference. Obesity, smoking, and alcohol use are modifiable risk factors. OSA pathophysiology is complex and includes upper-airway closure and abnormalities in upper-airway neuromodulation (the mechanism that contributes to upper-airway patency).

Long-term sequelae of OSA include hypertension, stroke, neurocognitive deficits, mood disturbances, and hormonal changes, such as increased ghrelin and decreased leptin levels (which can lead to weight gain). OSA adversely affects other medical conditions, such as diabetes, pulmonary disease, and cardiovascular disease. Conversely, such medical conditions as obesity and neurologic disorders can contribute to worsening OSA. In addition, OSA may increase the risk of motor-vehicle accidents, reduce workplace productivity, and disrupt bed-partner relationships.

Assessment and diagnosis

Clinical features of OSA include loud cyclical snoring with apneic pauses of at least 10 seconds, as well as excessive daytime somnolence. OSA typically is suspected from clinical presentation, patient history, and, as appropriate, bed-partner reporting.


An in-laboratory polysomnogram or a home sleep study is done to confirm OSA and determine its severity. In patients with OSA, these studies typically reveal apnea, hypopnea, or both, resulting in repeated oxygen desaturations, brief cortical arousals from sleep, and transient sympathetic nervous system (SNS) activation. SNS activation, in turn, causes brief increases in heart rate and blood pressure. (See Classifying OSA by clicking the PDF icon above.)

Because OSA can lead to neurocognitive deficits (especially in executive functioning), it can affect the patient’s ability to adapt to therapy. Executive functioning influences the ability to plan, execute goal-directed behavior, respond adaptively to new experiences, and draw from previous experiences. Deficient neurocognitive function may limit the patient’s ability to learn about OSA and its treatment and to carry out self-directed care at home.

Intervention

The goal of therapy is to improve or mitigate long-term consequences of OSA. Positive airway pressure (PAP)—the therapy of choice for OSA—is highly effective when used consistently over the course of the night for most nights. By maintaining a patent airway, PAP reduces apnea, desaturations, SNS arousal, and cortical sleep arousals.

PAP provides a pneumatic splint to the upper airway, maintaining an open airway. It can provide several modes of pressure delivery, including:

  • fixed (continuous) positive-
  • airway pressure (CPAP)
  • autotitration, in which pressure adjusts automatically to upper-airway changes
  • bilevel therapy, which delivers a fixed inspiratory pressure and fixed differential expiratory pressures.

Although PAP is highly effective, patients may have difficulty adapting and adhering to therapy. It can be inconvenient, the patient must learn how to use the equipment, and it may cause nasal stuffiness and claustrophobia. Some patients feel embarrassed to wear the mask. Other possible barriers to PAP therapy include lack of appropriate support and training and the need for reevaluation to ensure the patient is adhering to therapy. (See CPAP with patient interface by clicking the PDF icon above.)

Patient education

Learning to sleep with a PAP mask on and adapting to the constant flow of blowing air can be daunting. Patients must learn how to use the device, apply the mask, and keep it in place throughout the night. Also, most PAP devices have numerous software settings and buttons, which patients must learn to work in an effort to improve comfort and use.

Theoretically, the goal of education for patients with OSA has been to increase PAP adherence, which is calculated from the number of nights the patient uses PAP and nightly hours of use. Education and training techniques vary from center to center, and guidelines are lacking. Data show adherence rates of 30% and 80%, which aren’t sufficient to eliminate long-term effects of OSA and suggest that current methods of follow-up care (including education, training, and ongoing assessment) aren’t working.

A fragmented approach

The current approach to OSA patient education is fragmented. While general standards exist, there’s little agreement on which techniques yield the best results. A common approach is to have patients watch a video before a sleep study and give them written material about OSA on their first visit to the clinic. The sleep specialist or respiratory therapist reviews the condition with the patient before or after the sleep study.

For the sleep study, a titration method is used to obtain the optimum PAP pressure required to eliminate apnea, hypopnea, arous¬als, and oxygen desaturation. Before this study, the technologist demonstrates to the patient how to use the equipment, places a mask on the patient’s face, and has an informal discussion about OSA. After confirming optimal pressure, the sleep specialist formulates a prescription and sends it to a durable medical equipment (DME) provider for setup and training. The patient goes home to provide self-care and may or may not return to the sleep center.

Although DME providers often have the burden of care, few standards or consistent methods exist for providing patient information, conducting training, and providing follow-up care. Due largely to this lack of consistency, clinical outcomes vary greatly.

Traditionally, many sleep clinics have relied heavily on DME companies to provide most of the education and PAP training to patients. But in some cases, these companies aren’t reimbursed for this task, which limits follow-up opportunities for patient learning. Although the American Academy of Sleep Medicine provides clinical guidelines for care of OSA patients and recently outlined a process for DME accreditation standards, little information on patient education is included. Nested within the guideline is a one-paragraph statement on patient education, which describes topics to discuss (results, risks, and therapy) and notes that a multidisciplinary approach should be adopted. Although the guideline states that brochures, videos, handouts, and websites can be used to provide this education, it doesn’t elaborate further.

In one study, researchers reported differences in the perceived informational needs of CPAP users and clinical staff; study results showed a mismatch between what healthcare professionals believe patients need to know and what patients believe they need to know to use this therapy successfully.

Education is crucial to patients’ adherence to OSA therapy. But a more robust initial teaching plan is needed, along with concentrated follow-up of the patient’s knowledge, self-efficacy, and ability for self-care.

New patient education models

OSA education should use an intra¬disciplinary approach. Although few nurses work in sleep centers, many nurses, regardless of their specialty, can be instrumental in ensuring that patients diagnosed with OSA understand the condition and have confidence in their ability to use the therapy. Nurses working in a home-care environment are in a unique position, because PAP devices typically are located at the bedside. This provides an opportunity to examine the PAP device and mask and to discuss PAP use and good sleep hygiene. The nurse also should ensure that the patient understands how to clean the PAP machine properly. In an acute-care facility, the nurse should ask the patient about signs and symptoms related to OSA and provide appropriate referrals, if needed.

For hospital patients, the nurse should encourage PAP use during the hospital stay and provide education about the serious health risks of OSA and adequate adherence to PAP therapy. Respiratory therapists may be good adjunct educators in this regard.

Be aware that sleep-deprived patients may be unable to retain information unless they’ve had some treatment. This presents a quandary and requires assessment of the patient, current standards for learning, individual planning to optimize outcomes, implementation, and outcome measurement. Caregivers who understand barriers to learning in OSA patients and apply adult learning theories can better serve these patients.

Research indicates the need for new patient-education models for OSA—models based on varying learning techniques to help patients understand the condition and adapt to therapy. Not only do patients need to understand OSA, but they also must be trained in the skills required to use PAP and associated therapies. Healthcare educators need to elicit the patient’s beliefs when assessing learning needs, because the patient’s opinion of what he or she needs to learn may differ from the provider’s.

Teaching methods for OSA patients include face-to-face sessions with the provider, group education, viewing a video with a “learning sheet” on which the patient can write down key learning points, and hands-on experience with the PAP machine. Additional techniques that have proven to be helpful include motivational interviewing and the teach-back method.

Assessing effectiveness of interventions

Objective measures are available to assess whether OSA interventions are working. You can obtain measures of adherence and effective therapy by downloading data from the PAP device. These measures include mask leak, time on therapy (usage), and effectiveness of therapy based on numbers of residual apnea and hypopnea events. Also useful are subjective measures of daytime sleepiness using such tools as the Epworth Sleepiness Scale (ESS). While not specific to OSA, the ESS is a validated, self-administered tool that assesses daytime sleepiness. It asks questions that measure a patient’s level of daytime sleepiness. For each question, the patient indicates the likelihood that he or she would fall asleep in a particular situation. The higher the score, the sleepier the patient. A total score below 10 is considered normal; a score of 24 indicates severe sleepiness. You can use this objective and subjective information to assess treatment compliance and efficacy, track patient progress, and evaluate learning outcomes in OSA patients. (See Using the Epworth Sleepiness Scale by clicking the PDF icon above.)

An opportunity to better your patients’ lives

As a nurse, you need to understand the current model of care and education for OSA patients and important nursing implications. You’re in an optimal position to identify signs and symptoms in patients who haven’t been evaluated and diagnosed.

With patients already diagnosed with OSA, don’t assume they’ve received adequate training. Remember that they have a chronic illness and may require multiple learning opportunities and interventions. By using a multidisciplinary approach, you have a valuable opportunity to affect the lives of millions by identifying at-risk patients, evaluating learning needs, promoting patient-centered educational opportunities, and promoting optimal patient outcomes.

Selected references

Aloia MS, Arnedt JT, Stepnowski C, et al. Predicting treatment adherence in obstructive sleep apnea using principles of behavioral change. J Clin Sleep Med. 2005;1(4):346-53.

Billings DM, Halstead JA. Teaching in Nursing: A Guide for Faculty. 4th ed. St. Louis, MO: Elsevier Saunders; 2012.

Brostrom A, Stromberg A, Ulander M, et al. Perceived informational needs, side-effects and their consequences on adherence—a comparison between CPAP treated patients with OSAS and healthcare personnel. Patient Educ Couns. 2009;74(2):228-35.

Canessa N, Castronovo V, Cappa SF, et al. Obstructive sleep apnea: brain structural changes and neurocognitive function before and after treatment. Am J Respir Crit Care Med. 2011;183(10):1419-26.

Epstein LJ, Kristo D, Strollo PJ Jr., et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009;5(3):263-76.

Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991;14(6):540-5.

Lo JC, Groeger JA, Santhi N, et al. Effects of partial and acute total sleep deprivation on performance across cognitive domains, individuals and circadian phase. PLos One. 2012;7(9):e45987.

Olsen S. Smith S, Oei T, et al. Health belief mod¬el predicts adherence to CPAP before experience with CPAP. Eur Respir J. 2008;32(3):710-7.

Punjabi NM. The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc. 2008;5(2);136-43.

Quan SF, Chan CS, Dement WC, et al. The association between obstructive sleep apnea and neurocognitive performance—the apnea positive pressure long-term efficacy study (APPLES). Sleep. 2011;34(3):303-314B.

Redecker NS, McEnany GP. Sleep Disorders and Sleep Promotion in Nursing Practice. New York: Springer; 2011.

Smith CE, Mayer LS, Metsker C, et al. Continuous positive airway pressure: patients’ and caregivers’ learning needs and barriers to use. Heart Lung. 1998;27(2):99-108.

Smith I, Nadig V, Lasserson TJ. Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines for adults with obstructive sleep apnea. Cochrane Database Syst Rev. 2009;(2):CD007736.

Weaver TE, Sawyer AM. Adherence to continuous positive airway pressure for obstructive sleep apnoea: Implications for future interventions. Indian J Med Res. 2010;131:245-58.

Robyn Woidtke is the director of education at Florida International Sleep School in Fort Myers, Florida.

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5 thoughts on “Adult obstructive sleep apnea: Taking a patient-centered approach”

  1. TKrupski says:

    This is a wonderful synopsis which presents the key points with concise practical relevance.

  2. Pat Moxley says:

    Nice…

  3. RWoidtke says:

    Kent:
    Thank you for your comments. I agree with your assessment regarding oral appliances and effectiveness for OSA. Thank you for bringing up a very important therapeutic approach. I chose to focus on PAP because of word limits. I can also state that there are also emerging therapies such as the Winx and Provent. Also, implantables to stimulate the hypoglossal nerve are in clinical trials right now. Surgery remains an option for some as well.

  4. Kent Lauson says:

    Is a very good article as far as it goes, but the author should talk also about the night time use of oral appliances to advance the mandible which can be very effective in mild to moderate OSA. Other advances in Functional Facial Orthopedics have shown great promise in changing that narrow upper jaw and recessed lower jaw to more ideal, thus reducing or eliminating OSA. These are procedures used by a limited number of dental professionals.

  5. dkbarnp says:

    As an NP in a sleep clinic, this article should be read by every nurse: hospital, home health, office, skilled or nursing facility. I graduated from a BSN program in the late 1970’s. There was no diagnosis of sleep apnea then. How many people who “died in their sleep” are likely from undiagnosed sleep apnea or its complications? ALL nurses with patient contact can ask the questions, suggest screening &/or treatment.

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