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Initiative Sounds the Alarm on Sleep Apnea

By Jill Clendening
February 2013

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With the use of a CPAP machine and perhaps a loving nudge from a spouse, sleep apnea is often easily controlled in the comfort of one’s own home.

But what happens when someone with obstructive sleep apnea (OSA) has to be admitted to the hospital? Substances such as narcotics and sedatives that are given for pain relief and sedation can cause shallow breathing and increased incidences of sleep apnea.

Anesthesiologists, cardiologists, respiratory therapists, sleep medicine physicians, patient safety specialists and nurses across Vanderbilt University Medical Center knew it was time for a wake up call when it came to the need to provide better care for patients with obstructive sleep apnea. They organized a task force and sounded the alarm.

When former Minnesota Vikings offensive lineman Curtis Rouse looks back over his life, he knows he’s been one heck of a lucky man.

He suffered a massive stroke in 1997 at the age of 37, and in 2005, he had a heart attack. Rouse, now a Clarksville, Tenn., resident, returned to VUMC in October with complications from congestive heart failure, and he was asked the one question that might be the key to unlocking his complicated health history.

“When they were checking me in, the nurse asked me if I had sleep apnea and if I used a CPAP (continuous positive airway pressure) machine,” he said. “I told her I did have sleep apnea, but I never used my machine because I wasn’t comfortable with it. I’ve known for a long time – since back in the ‘80s – that I had sleep apnea, because people would tell me I snored loud and that I would stop breathing, then start again. But I hated using that machine. I couldn’t sleep with it.”

Curtis Rouse is sleeping soundly after getting his apnea under control. Photo by Lauren Holland.

Curtis Rouse is sleeping soundly after getting his apnea under control. Photo by Lauren Holland.

The fact that Rouse’s CPAP machine was gathering dust concerned his cardiologist, David Slosky, M.D., who had also cared for Rouse after his heart attack. He was adamant that Rouse needed to use his CPAP machine nightly.

“We can treat people who have OSA with drugs for complications like arrhythmia, heart failure, hypertension and so on, but there’s a key here,” said Slosky. “If they’re still not getting enough oxygen while they sleep, then it’s a losing game. We know the roof is still leaking. At some point, you gotta fix the roof. We do see arrhythmias, heart failure and hypertension that get better with treatment of sleep apnea.”

Slosky’s increasing concern about patients like Rouse is mirrored all over the Medical Center campus.

A serious condition
Sleep apnea is a disorder that causes a person to stop breathing for short periods of time, and everyone can experience this at some point in life. Obstructive sleep apnea, or OSA, is a much more serious, life-threatening disorder that happens when tissue in the throat collapses, blocking air from getting to the lungs. A primary treatment for OSA is the use of a CPAP device, which blows oxygen through a face mask, forcing the airway to remain open. CPAP devices are usually prescribed after an individual completes an overnight sleep study (a polysomnogram).

In the past, patients who used a CPAP machine at home might not remember to bring it with them when they checked into the hospital. There was no process in place to guarantee that they did, or if they did, that their machines were in good shape. Hospital staff might not have even been aware that patients had OSA, leaving the serious medical condition unaddressed. Substances such as narcotics and sedatives that are given for pain relief and sedation can cause shallow breathing and increased incidences of sleep apnea. This makes the need for patients with OSA to use their CPAP machines even more critical.

“When you consider three of the risk factors for sleep apnea are being middle age, male and overweight, we have a huge population that we’re serving here,” said Roger Dmochowski, M.D., vice chair of the Section of Surgical Sciences and executive medical director for Patient Safety and Quality (Surgery). “Sleep apnea has a tremendous impact, not only on quality of life, but also on cardiopulmonary function and the body’s general overall health. It’s a huge issue, and we needed to make sure the quality of care was the best we could offer.”

Roger Dmochowski, M.D., executive medical director for patient safety and quality (Surgery). Photo by Daniel Dubois.

Roger Dmochowski, M.D., executive medical director for patient safety and quality (Surgery). Photo by Daniel Dubois.

It was time to solve the problem. Dmochowski headed a VUMC task force organized in 2011 charged with making sure patients with OSA don’t fall through the cracks when it comes to their respiratory health. The group, which included members from every specialty involved in these patients’ care, developed a new CPAP protocol, the first phase of which is now in place. Previously, an average of two patients a day were seen by respiratory therapists so they could make sure the patients were using a CPAP machine during their hospital stay, said VUMC Respiratory Therapy Director Anna Ambrose.

Now, less than a year later, more than 30 patients a day with a previous diagnosis of OSA are being seen and being provided in-hospital CPAP therapy. Special instructions are also now added to OSA patients’ charts to remind nurses to be more aware of respiratory issues. Since the program began, there have been no emergency calls to respond to OSA-related complications in this patient population, said Ambrose.

Due to the Task Force’s effort, when Rouse answered that he did have sleep apnea, a series of events were triggered. He was referred for a consultation with a Vanderbilt respiratory therapist, who came by his hospital room that same day. He was fitted with a comfortable mask and provided a CPAP machine to use while he was at VUMC that was newer than the model he had at home. If he had brought his machine in from home, the respiratory therapist would have evaluated the machine to see if it was ready to use, but Rouse said he was more than happy to try out the new machine.

“I told them I didn’t remember what the setting was, but they told me that was fine,” Rouse said. “They brought a machine in, got it set up, and I started using it the first night. I didn’t have any problem with it at all.”

Rouse is now back at home, and thanks to the consultation he received while at VUMC, his CPAP therapy has been adjusted so it is more comfortable. He reports that he is sleeping much better.

Next step
While this approach to treating those who have an existing OSA diagnosis may work for many patients, there may be some who are overwhelmed just by being in the hospital, said Beth Malow, M.D., the Burry Chair in Cognitive Childhood Development and director of the Vanderbilt Sleep Disorders Center.

“One thing we would like to build into this program is understanding which patients might need some extra help,” said Malow. “For these patients, it might be better to forgo acute treatment with CPAP and replace that with close monitoring. Then, we need to focus on getting them into a clinical setting where a physician or a nurse practitioner can work with them closely to get them to be more accepting of their treatment.”

In addition to the admission survey conducted with hospitalized patients, patients who come to the Vanderbilt Preoperative Evaluation Center (VPEC) before outpatient or elective surgery are also now being asked if they’ve been diagnosed with OSA, said VPEC Manager of Patient Care Services Russ Kunic, FNP-BC. If they do have OSA, depending on the severity, they may be recommended for surgery at the main hospital rather than at a same-day surgery center so they can be monitored more closely, said Kunic. Their OSA diagnosis is noted in their medical history, and patients are told that they must use their CPAP machines after procedures, especially if they’re taking pain medications. If VPEC’s nurse practitioners believe someone might be at high risk for OSA, they also recommend a sleep study at the Vanderbilt Sleep Center, said Kunic.

Now that the first phase of the Task Force’s protocol has proven successful, Dmochowski  says the group will address additional OSA concerns. It’s estimated that 2 percent to 4 percent of Americans have undiagnosed OSA, and the next phase will focus on identifying those patients who might be at risk for OSA. They can then be referred for a sleep study. Patients who are having difficulty using their CPAP machines consistently can also receive additional assistance.


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