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Dont Ignore the Score:
An Obstructive Sleep Apnea
Linda Lakdawala DNP, RN, CPAN
The learner will understand the:
need for a surgical obstructive sleep apnea screening
process of implementing an evidence-based practice
sleep apnea guideline in a shared leadership
Iowa Model of Evidence-Based Practice process.
Personal Interest and focus Passion nursing excellence
PACU Nurse assessment process Self discovery vulnerable sleep apnea patient
How can we be sure patients are safely cared for?
Capstone project: Doctorate Nursing Practice
Goal: promote best practice for nurses to screen
patients for obstructive sleep apnea
Obstructive sleep apnea (OSA): common
condition caused by decrease in upper airway size
and patency during sleep
Apnea: cessation of airflow 10 seconds
Hypopnea: airflow > 10 seconds + 30% airflow
+ at least 4% oxygen desaturation
Polysomnography: Apnea Hypopnea Index (AHI) AHI 5-14/hr. mild
AHI 15-30/hr. moderate
OSA Cycle: Path to Comorbidites
Individuals with OSA are aroused repeatedly
from deep sleep by hypoxemia and
Cycle: Permits breathing to resume
Flow Diagram Pathophysiology of OSA / Sedation
Why a Screening Tool
PA Safety Advisory Board: >250 cases
poor patient outcomes
The Joint Commission: Direct Impact
Issue: Safety initiative anesthesia and
National Clearinghouse: safer outcomes
with implementation of guidelines
ASA Task Force: meta analysis: guidelines
for care of perioperative OSA patient
Focus: patients heart and lung history
Little emphasis on sleep
Patients with unremarkable
medical history developed unexpected
postoperative respiratory complications
2-26% U.S. adult population: OSA
80-90% unaware of having OSA
PICO Prevention Question
For patients in the perioperative area
receiving anesthesia, sedation, or
intravenous opioids, does the use of a
screening tool to identify patients with
obstructive sleep apnea, (OSA) reduce the
risk of complications of OSA compared with
those OSA patients who did not have a
Population of Interest: Perioperative patients receiving
anesthesia, sedation or intravenous opioids.
Intervention: Develop screening tool and guidelines for
perioperative nurses to safely monitor patients with
obstructive sleep apnea (OSA).
Comparison: Evidence-based practice (EBP) nurse
assessment screening tool for OSA versus current method which is no definitive screening tool.
Outcome: An EBP screening tool for assessment of OSA
will be used throughout the perioperative area.
________________________ Berlin Questionnaire____________________________Questions Answers Scoring
Category 1 Items 1,4,8,10: category 1: positive: Sum 2
1. Do you snore? Yes(1), no(0) dont know(0) category 2: positive: Sum 2
2. If yes, how loud is it? Item 2: category 3: positive item 10
3. How often do you snore? Slight louder than breathing (0) is yes or if BMI > 30kg/m2
4. Has snoring bothered others? As loud as talking (0)
5. Has anyone noticed that you louder than talking (1) High risk of OSA: 2 or more
quit breathing during sleep? very loud heard in categories scored as positive
adjacent rooms (1)
Category 2 Items 5,6,7,9:
6. How often do you feel tired nearly every day (1)
Or fatigued after sleep? 3-4 times a week (1)
7. During your waking time, 1-2 times a week (0)
do you feel tired, fatigued, 1-2 times a month (0)
or not up to par? never or nearly never (0)
8. Have you ever nodded off or
fallen asleep while driving?
9. If yes, How often does this occur?
10. Do you have high blood pressure?
Abrishami, A., Chung, F. (2010)
The American Society of Anesthesiologists Checklist
Questions Answers Scoring
Category 1: Predisposing Physical Characteristics all items: yes/no If items in category
1. BMI 35kg/m2 1 are positive, category
2. Neck circumference > 43cm/17 inches (men) or 1 is positive.
40 cm/ 16 inches (women) If items in Category 2
3. Craniofacial abnormalities affecting the airway are positive, category 2
4. Anatomical nasal obstruction is positive.
5. Tonsils nearly touching or touching the midline If +items in category
Category 2: History of Apparent Airway 3 are positive,
1. Snoring (loud enough to be heard through closed category 3 is positive.
door) High risk of OSA: 2
2. Frequent snoring more Categories
3. Observed pauses in breathing during sleep scored as positive.
4. Awakens from sleep with choking sensation Low risk of OSA: 1
5. Frequent arousals from sleep or no categories Category 3:
Somnolence scored as positive.
1. Frequent somnolence or fatigue despite adequate
2. Falls asleep easily in a nonstimulating environment
3. Parent or teacher comments child appears sleepy
during the day, is easily distracted, is overly
aggressive, or has difficulty concentrating*
4. Child often difficult to arouse at usual awakening
* Refers to pediatric patients Gross et al. (2006)
American Sleep Apnea Association Snore Score
Are you a loud and/or a regular snorer? Yes No
Have you ever been observed to gasp or stop breathing
during your sleep? Yes No
Do you feel tired or groggy upon awakening, or do you
awaken with a headache? Yes No
Are you often tired or fatigued during the wake time hours?
Do you fall asleep sitting, reading, watching TV, or driving? Yes No
Do you often have problems with memory or concentration? Yes No
The Epworth Sleepiness ScaleUse the scale to choose the most appropriate number for each
0 = would never doze or sleep
1 = slight chance of dozing or sleeping
2 = moderate chance of dozing or sleeping
3 = high chance if dozing or sleeping
Situation Chance of Dozing
Sitting and reading _____
Watching TV _____
Sitting inactive in a public place _____
Being a passenger in a motor vehicle
for an hour or more _____
Sitting and talking to someone _____
Sitting quietly after lunch (no alcohol) _____
Stopped for a few minutes in traffic
while driving _____
Total score (add up the scores) ________
STOP-Bang OSA Scoring Model
Answer Yes or No to each question and place an X in the corresponding column.
1. Snoring: Do you snore loudly (louder than talking or loud enough to be heard
through closed doors?) ___ ___
2. Tired: Do you often feel tired, fatigued, or sleepy during the daytime? ___ ___
3. Observed: Has anyone observed you stop breathing during your sleep? ___ ___
4. Blood Pressure: Do you have or are you being treated for high blood pressure? ___ ___
5. Height: ____ft. ____in. Weight: _____lbs. BMI Calculator____BMI > 35? ___ ___
6. Age: > 50 yr. Old? ___ ___
7. Neck Circumference: > 17 in. or 40 cm.? ___ ___
8. Gender: Male gender ___ ___
Total for Yes: ___
The patient is at high risk for OSA if they answered yes to three or more items.
The patient is at low risk for OSA if they answered yes to less than three items.
Chung et al. (2008)
Iowa Model Algorithm for OSA Screening Tool
Trigger for EBP: Need to improve current care of OSA patients.
Organizational Priority: Promote excellence in patient safety outcomes.
Team Formation: Linda Lakdawala: PACU RN, Quality Director, Chief Anesthesiologist, Informatics Nurse, Critical Care Advanced Practice Nurse.
Evidence Gathered: Highest level literature review.
Research Base Critiqued and Analyzed.
Iowa Model Process
Sufficient Evidence Gathered: ASA Task Force (2006)
Pilot Change: STOP-Bang Screening Tool (Chung et al,
2008) One month pilot for orthopedic patients
Decision: Incorporate Tool as preoperative assessment and
postoperative physician order set.
Widespread Implementation with Monitoring of
Outcomes: Educational competency for periope