Obstructive Sleep Apnea and Compliance Before and After Weight Loss Surgery
Sleep apnea is an important health concern which has been estimated to affect a near 18 million Americans. Of that percentage, only 10-15% are diagnosed. Of those diagnosed, CPAP compliance is estimated to be at 40-60%. A primary reason for non-compliance focuses on lack of patient education and support from sleep apnea office personnel and providers.
Sleep apnea can result from both structural and organic causes. Structural causes can be from airway obstruction due to narrowing of respiratory passages, palatine, jaw, or other facial structural abnormalities. Organic causes can be from improper brain signaling or obesity. In all of these causes, CPAP or airway devices can be indicated. For those people with a structural abnormality compounded by obesity, weight loss alone will not correct. In these individuals, lifelong CPAP may be indicated.
Sleep apnea can induce and even worsen many illnesses. Common illnesses comorbid with sleep apnea can include type 2 diabetes, high blood pressure (hypertension), heart disease, stroke, depression, memory loss, excessive day time sleepiness (hypersomnolence), irritability, and fatigue to name a few. Certain cardiac conduction abnormalities (arrhythmias) have been caused by sleep apnea. Inappropriate sleep will continue to worsen these medical problems and further compound the ability to lose weight and disrupt hormonal levels due to disruption in biorhythms and alterations in sleep required metabolic processes.
Treatment for sleep apnea can be an oral appliance, CPAP, BIPAP with or without oxygen depending on the degree of episodes and severity of oxygen saturation decline during episodes. Sleep apnea is diagnosed and managed by board certified specialist trained in the management of sleep disorders. Diagnosis is based on an overnight sleep study (polysomnography) with repeat sleep studies to determine the appropriate appliance or device and pressure needed to control symptoms. Repeated testing would be indicated following any facial or oropharyngeal surgery, facial or oropharyngeal trauma, and significant weight loss or gain.
A significant challenge in sleep apnea management is compliance with CPAP or BIPAP therapy. Patients often struggle with airway irritation, nosebleeds, anxiety, appliance leaking, and insomnia (lack of sleep) from any of these problems and noise generated from the device. Proper education on CPAP use, maintenance and monitoring is crucial to compliance. Patients should be informed on common problems that can be encountered and when to follow up.
As with any medication or appliance that is new, and adjustment time period to the airway device and machine will be needed. The two most noted challenges in literature are finding the right mask with the right fit and adjusting to the use of it at bedtime and allowing time to adjust to the pressure of the CPAP. Patients who are not given opportunity to adjust to these things will not be compliant with the machinery. Education and follow up on behalf of the sleep specialist and staff is critical to compliance. There needs to be a proper mask fit to prevent leaks and noise associated with them, prevent facial trauma and glean the best results from the therapy. Special attention should be paid to the anatomy of a person’s face when determining the best mask for use. Experts recommend trying the mask on throughout the day and getting used to its presence BEFORE using at nighttime. Common instances where this would be appropriate would be while sitting for a short period as if with reading or watching TV. The goal is to continue to build on the time used to the point where one can wear the mask for several hours. For those that have trouble with the pressure, the goal is to allow oneself a chance to fall “into the natural rhythm of breathing while using CPAP”. This also takes an adjustment period. Although the goal is to use the CPAP for an expected 6-8 hours of sleep, even a partial night of use is better than none at all.
Other issues that may cause non-compliance are dry mouth, nasal symptoms (congestion, runny nose, sneezing, sinus infections and nosebleeds), stomach bloating/discomfort, and subconscious removal of the mask at bedtime. To control for dry mouth, a chin strap or evaluation of leak is recommended. Sinus symptoms can be better controlled through heating the humidity, using a nasal saline spray or an inhaled nasal steroid (eg. Flonase or Nasonex) at bedtime may be helpful. For stomach bloating and discomfort, the pressure may be too great so following up with one’s sleep specialist will be indicated. For those who remove masks in their sleep, it is advised that the equipment is evaluated for mask fit, proper humidification and, or a chin strap if indicated.
For those patients who have had weight loss surgery, it is important to remember that sleep apnea is caused by a variety of things not just being overweight. For those that have structural abnormalities, CPAP will be needed lifelong (if surgical correction is not an option). For those with sleep apnea caused by or compounded by excess weight, improvement is noted as significant weight is lost. I tell all patients that if they start to notice an issue where the devices is causing insomnia, it could indicate that the pressure may need to change or mask may need to be re fitted or both. I advise against stopping the device unless directed by the sleep specialist. Our practice usually recommends re-testing 6 months after surgery. In some cases, earlier testing may be indicated if insomnia or intolerance arises.
In conclusion, it is imperative that insomnia and sleep issues are addressed by a medical professional, investigated and managed accordingly. Inappropriate sleep patterns can lead to serious co-morbid conditions up to death (if apnea persists long enough during sleep). Sleep apnea is a serious health condition that must be appropriately managed. Proper education and follow up is critical to compliance with therapy. Issues with the devices and equipment must individually be addressed to ensure good transition into therapy and relief from symptoms. Regular post surgical follow up is indicated for those with obesity related sleep apnea.
Kristine Vanhoose, MSN, APRN, FNP-BC
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What is CPAP? National Heart, Lung, and Blood Institute http://www.nhlbi.nih.gov/health-topics/topics/cpap/printall-index.html. Accessed June 4, 2013