Surgical treatment of obstructive sleep apnea

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

The anesthesia care provider and circulating nurse transfer the patient to the PACU. While the patient is in the PACU, the assigned nurse provides parenteral and oxygen therapy and ensures that the patient can maintain his or her own airway. If necessary, the nurse provides the patient with airway management assistance, which may include

* performing jaw tilt;

* providing jaw thrust;

* inserting an oral airway;

* inserting a nasal airway,

* providing supplemental oxygen via ambu bag; and

* administering a reversal agent, such as naloxone.

The nurse also assesses the patient's pain status and provides medications as needed without compromising the patient's respiratory status. The nurse performs ongoing assessment of the patient. Postoperative priorities focus on adequate airway control and maintaining a systolic blood pressure below 140 mm Hg.

After phase I recovery, the PACU nurse transfers the patient to the ICU. Care in the ICU is similar to that provided in the PACU with attention focused on monitoring and managing the patient's airway, vital signs, and pain status. The nurse suctions the patient's mouth frequently, at which time he or she inspects the mouth for active bleeding, clots, or hematomas. Patients undergoing stage I surgical treatment usually are discharged from the ICU to home the next day if blood pressure is controlled, pain is properly managed, and oral hydration is greater than 1,500 mL. Patients undergoing maxillomandibular advancement usually are transferred from ICU to the surgical floor the next day and discharged from the hospital in four days. For OSA surgery to be completely successful, patients must be committed to losing or, at a minimum, stabilizing their weight as needed. Generally, patient's are instructed to continue to wear or attempt to use nasal CPAP after discharge until a postoperative sleep test has shown that OSA has been resolved; however, patients who have undergone maxillomandibular advancement are forbidden to wear CPAP because it could cause orbital or intracranial emphysema.

SURGICAL OUTCOME DATA

At follow-up office visits, patients often describe their improved quality of sleep and say they have experienced dreaming for the first time in years. The potential for resolving OSA using integrated bone and soft tissue surgery, however, is equivalent to that of CPAP therapy as measured in the sleep laboratory. The basic measures of OSA intensity are RDI and lowest oxygen saturation (ie, the lowest oxygen levels associated with airway obstruction). These measures are used to compare different treatment method outcomes. One commonly accepted definition of surgical cure is

* normalization of sleep architecture (ie, normal amount of time and frequency in stage I through IV and rapid eye movement sleep);

* relief of excessive daytime sleepiness; and

* postoperative RDI and lowest oxygen saturation equal to CPAP results, or if no CPAP results were reported, a postoperative RDI greater than 20 with at least 50% reduction in RDI. (56,57)