Surgical treatment of obstructive sleep apnea

AORN Journal, Sept, 2005 by Wayne Colin, Susan Duval

INEFFECTIVENESS AT REDUCING NOCTURNAL OBSTRUCTIVE BREATHING EVENTS. Continuous positive airway pressure therapy is ineffective when it fails to reduce the frequency of nocturnal obstructive breathing events to normal range. For some patients, CPAP therapy may be ineffective, which warrants prompt referral for a surgical opinion. Many patients are intolerant of airway pressures that are elevated or escalating and discard the treatment. When CPAP fails to improve (34) or worsens excessive daytime sleepiness, either the treatment or the diagnosis of OSA should be questioned, and surgery should be considered.

BEHAVIORAL, PHYSICAL, AND MECHANICAL INTOLERANCE. Surgery is a viable option when CPAP has proven to be intolerable because of behavioral difficulty, interface problems between the mask and facial skin, or airway problems induced by CPAP pressure. Behavioral unwillingness to use CPAP is observed in patients who

* are unable to sleep when using CPAP,

* experience anxiety,

* experience claustrophobia or a sense of suffocation,

* have a bed partner who refuses to adjust to the inconveniences of the therapy,

* have no access to electricity,

* inadvertently remove the mask during sleep, or

* travel frequently. Interface problems with the CPAP mask and its contact with facial skin can include

* allergy,

* air leakage,

* facial pain,

* skin ulceration, or

* topical infection. Airway difficulties may include

* dry nose,

* nasal obstruction,

* problems with upper airway infection, (35)

* rhinorrhea, and

* sore throat or aerophagia. (36)

CONTRAINDICATIONS FOR CPAP THERAPY. Use of CPAP therapy is not medically appropriate for all people. Positive airway pressure treatment is contraindicated for those who have had a skull-base injury or surgery with cerebrospinal fluid leak because of the increased risk of contracting pneumocephalus (37) or bacterial meningitis. (38)

WHEN SURGERY SHOULD BE CONSIDERED

Surgical modification of the upper airway may be the treatment of choice for some patients, especially people who are not exceptionally obese. Children and young to middle-aged adults may strongly prefer a surgical solution for their apnea rather than relying on lifelong CPAP therapy. People who clearly exhibit a discrete anatomical deformity that narrows the airway should be considered for surgery early in treatment to avoid chronic CPAP treatment. Examples of isolated anatomical distortion that are readily amenable to surgery include small upper or lower jaw, small chin, large tonsils, or nasal obstruction. People who have had a tracheotomy for OSA should be evaluated carefully. Some are potential candidates for one or more surgical procedures to expand the upper airway, with the goal of removing the tracheotomy tube.

PREOPERATIVE ASSESSMENT

Constant vigilant assessment of the patient's needs is necessary to provide optimal outcomes. The preoperative nurse performs an assessment, which includes taking a thorough individual and family history. Before surgery, the nurse questions the patient about the length and severity of OSA and any history of CPAP therapy. Following are common questions that nurses should ask to assess the degree of compliance with CPAP.