Obstructive Sleep Apnea and the Adult

Perioperative Patient
Dennis L. Spence, NC, USN, PhD, CRNA, Tony Han, MC, USN,
Jason McGuire, NC, USN, PhD, CRNA, Darren Couture, NC, USN, PhD, CRNA

Obstructive sleep apnea (OSA) is a chronic condition of upper airway

obstruction during sleep. It is associated with significant morbidity and
mortality and increases the perioperative risks of surgical patients.
Thus, it is essential that perianesthesia nurses understand how to identify
and manage patients with known or suspected OSA. This continuing ed-
ucation article will review the pathophysiology of OSA, discuss the effects
of anesthesia and opioids on the sleep architecture of the OSA patients,
describe the effects of OSA on postoperative complications, review the lat-
est evidence on screening for undiagnosed OSA in the adult surgical pa-
tient, and review the perioperative management principles for patients
with OSA.
Keywords: anesthesia, obstructive sleep apnea, opioids, postoperative
complications.
Published by Elsevier Inc. on behalf of American Society of PeriAnesthesia
Nurses

OBJECTIVES—(1). IDENTIFY THE pathophysi- OSA is a chronic condition characterized by

ology of obstructive sleep apnea (OSA); (2).
Discuss the effects of anesthesia and opioids on
the sleep architecture of the OSA patients; (3).
Describe the effects of OSA on postoperative com-
plications; (4). Discuss the latest evidence on
screening for undiagnosed OSA in the adult surgi-
cal patient; (5). Discuss the perioperative manage-
ment principles for patients with OSA.
frequent episodes of partial or complete upper
airway obstruction that occur during sleep. These
frequent obstructions result in three major effects,
recurrent oxyhemoglobin desaturations, sleep
fragmentation, and increased fluctuations in intra-
thoracic pressure. Over time, these effects are in
turn associated with significant morbidity and mor-
tality.1-7 OSA is defined by an apnea/hypopnea

CDR Dennis L. Spence, NC, USN, PhD, CRNA, is the Regional
Director of Nursing Research for the Navy Medicine West
Region and an Adjunct Associate Professor, Uniformed
Services University of the Health Sciences, Daniel K. Inouye
Graduate School of Nursing, Bethesda, MD, and Staff Nurse
Anesthetist, Naval Medical Center San Diego, San Diego, CA;
CAPT Tony Han, MC, USN, is board certified in Internal Medi-
cine, Pulmonary/Critical Care, and Sleep Medicine and the
Director of the Sleep Laboratory, Naval Medical Center San
Diego, San Diego, CA; CDR Jason McGuire, NC, USN, PhD,
CRNA, is the Regional Director of Nursing Research for the
National Capital Region and an Adjunct Assistant Professor,
Uniformed Services University of the Health Sciences, Daniel
K. Inouye Graduate School of Nursing, Bethesda, MD, and
Staff Nurse Anesthetist, Walter Reed National Military Medical
Center, Bethesda, MD; and CDR Darren Couture, NC, USN,
PhD, CRNA, is the Clinical Site Research Director for the Uni-
formed Services University of the Health Sciences, Nurse Anes-
thesia Program at the Walter Reed National Military Medical
Center, Bethesda, MD, Assistant Professor, Uniformed Services
University of the Health Sciences, Daniel K. Inouye Graduate
School of Nursing, Bethesda, MD, and Staff Nurse Anesthetist,
Walter Reed National Military Medical Center, Bethesda, MD.
Conflict of interest: None to report.
Address correspondence to Dennis L. Spence, Naval Medical
Center San Diego, 34800 Bob Wilson Drive, San Diego, CA
92134; e-mail address: dennis.l.spence.mil@mail.mil.
Published by Elsevier Inc. on behalf of American Society of
PeriAnesthesia Nurses
1089-9472/$36.00
http://dx.doi.org/10.1016/j.jopan.2014.07.014

528 Journal of PeriAnesthesia Nursing, Vol 30, No 6 (December), 2015: pp 528-545

OBSTRUCTIVE SLEEP APNEA AND THE ADULT PERIOPERATIVE PATIENT
index (AHI) greater than or equal to 5 with or
without daytime sleepiness. Moderate OSA is an
AHI between 15 and 29; severe is an AHI greater
than or equal to 30. Higher rates of OSA are found
in obese patients and with older age.
In the United States, 14% of men and 4% of women
have OSA, and it is estimated that 12 to 18 million
adults have undiagnosed OSA.8,9 Patients with
severe OSA have higher mortality rates compared
with those without OSA. Young et al9 found that
65% of patients who died during the 18-year
follow-up period in the Wisconsin Sleep Cohort
Study had undiagnosed OSA (mortality
rate 5 7.9%). The incidence of undiagnosed OSA
in surgical patients has been reported as between
21% and 28%.10,11 OSA is associated with
significant comorbidities and increased risk of
perioperative complications.5-7,12 What is
alarming to nurses is that in one study, 92% of
surgeons and 60% of anesthesia providers failed
to identify patients with pre-existing or undiag-
nosed moderate-to-severe OSA.13 In community-
dwelling adults (nonsurgical patients), screening
based simply on gender or obesity tends to miss
the presence of OSA.14 Given the high prevalence
of both diagnosed and undiagnosed OSA in surgi-
cal patients, it is essential that perianesthesia
nurses have a firm understanding of OSA and
how to identify patients at risk.
The objectives of this continuing education article
are to (1) review the pathophysiology of OSA, (2)
discuss the effects of anesthesia and opioids on
the sleep architecture of OSA patients, (3)
describe the effects of OSA on postoperative com-
plications, (4) review the latest evidence on
screening for undiagnosed OSA in the adult surgi-
cal patient, and (5) review the perioperative man-
agement principles for patients with OSA.
Pathophysiology of OSA
An obstructive apnea is defined as the absence of
airflow for at least 10 seconds despite ventilatory
efforts (Figure 1). Magnetic resonance imaging of
patients with OSA has demonstrated anatomically
narrower pharyngeal airways secondary to deposi-
tion of excess adipose tissue located in the uvula,
tonsillar pillars, tongue, and lateral pharyngeal
walls when compared with matched controls
(Figure 2).22 Decreased airway size results in
529
higher airflow velocity, which lowers the intralu-
minal pressure and contributes to collapse of the
upper airway during sleep. Another mechanism
promoting airway collapse is decreased neuromus-
cular tone of the dilator muscles (muscles that
keep the airway open), which occurs during sleep,
and loss of airway dilator reflexes, which normally
activate during inspiration.
Normal sleep architecture in adults is character-
ized by alternating cycles of rapid eye movement
(REM) and non-REM sleep (three stages). The
REM periods begin 60 to 120 minutes into sleep
and become longer in duration during successive
cycles throughout the night. There are typically
three to five REM sleep cycles during the night.
Stage 3 non-REM sleep is the deepest stage and pro-
vides the physically restorative effects of sleep. It is
prominent early in the night and regulated by
homeostatic factors. REM sleep is associated with
loss of motor tone and active desynchronized elec-
troencephalogram (EEG) activity. It is regulated by
circadian factors and occurs mostly in the early
morning. OSA tends to be worse during REM sleep.
REM sleep also plays a role in mental recovery and
maintenance.23 Obstructive events have also been
found to be worse during stage 3 non-REM sleep.
During sleep, there is decreased neuromuscular
tone and compensation of airway dilator muscles
with inspiration. These factors may predispose to
airway collapse in OSA patients. During REM
sleep, there is further decrease of muscle tone
because of paralysis of skeletal muscles, sparing
the eye muscles and diaphragm.15,24 Loss of tone
of the genioglossus muscle and tensor palatini
allows the tongue and upper airway to collapse
resulting in obstructed airflow. Clinical signs
include loud snoring and witnessed apnea and/or
hypopnea. Obstructive apnea is defined as a
cessation or decreased airflow of greater than or
equal to 90% of baseline for greater than or equal
to 10 seconds and is associated with continued
or increased inspiratory effort. The definition of
hypopnea is variable, but it generally is defined
as decreased airflow of 30% to 50% that is
associated with a 3% to 4% reduction in oxygen
desaturation compared with baseline.
During obstructive respiratory events, increased
ventilatory efforts result in EEG microarousals
and may lead to significant sleep fragmentation
530 SPENCE ET AL

Figure 1. Proposed conceptual framework for anesthesia and obstructive sleep apnea. (2) decreased; (1)
increased; (11) moderately increased; and (111) significantly increased. Framework based on understanding
of the pathophysiology of OSA and known effects of anesthetic agents, surgery, and opioids on OSA.4,7,15-21 OSA,
Obstructive sleep apnea; PACU, postanesthesia care unit; ICU, intensive care unit; REM, rapid eye movement
sleep; AHI, apnea/hypopnea index; LSAT, lowest oxygen saturation; T90 & T85, time with SPO2 less than 90% &
85%; STOP-BANG, Snoring, Tiredness, Observed apnea, high blood Pressure, Body mass index greater than
35 kg/m2, Age older than 50, Neck circumference greater than 40 cm, and male Gender; POD, postoperative day.
This figure is available in color online at www.jopan.org.

and poor sleep quality. These arousals rarely result
in complete awakening but have a negative effect
on restorative sleep and contribute to daytime
sleepiness. The arousals result in increased muscle
tone and restoration of airflow with return to
sleep. Patients are generally unaware of these
events although they may be noted by the bed part-
ner. Moderate-to-severe OSA has been demon-
strated to increase the incidence of hypertension.
It is associated with increased strokes, increased
atrial fibrillation, and reduced left ventricular func-
tion in heart failure. It is associated with hypergly-
cemia in diabetic patients, impaired cognitive
function, increased risk for automobile accidents,
and sudden cardiac death (Table 1).1-3,25-27
Polysomnography (PSG) (sleep study) is the gold
standard for the diagnosis of OSA.28,29 Attended
and unattended sleep studies are both approved
by the Centers for Medicare and Medicaid for the
diagnosis of OSA. Unattended sleep studies
typically do not record EEG data to characterize
sleep stages. OSA is defined as an AHI greater
than or equal to 5 with associated symptoms,
such as daytime sleepiness, fatigue, or impaired
cognition, or an AHI greater than or equal to 15
OBSTRUCTIVE SLEEP APNEA AND THE ADULT PERIOPERATIVE PATIENT 531

Figure 2. Comparison of normal and OSA subject airway. Volumetric reconstructions from a series of 3-mm
contiguous axial magnetic resonance images of the mandible (gray), tongue (orange/rust), soft palate (purple),
lateral parapharyngeal fat pads (yellow), and lateral/posterior pharyngeal walls (green) in a weight-matched normal
subject (top) and patient with sleep apnea (bottom), both with an elevated BMI (32.5 kg/m2). Note that the airway is
larger in the normal subject than in the apneic subject. The tongue, soft palate, and lateral pharyngeal walls are larger
in the patient with sleep apnea.22 BMI, body mass index. Reprinted with permission of the American Thoracic
Society. Ó 2014 American Thoracic Society. This figure is available in color online at www.jopan.org.

without associated symptoms. The AHI is used to equal to 15 moderate, and greater than or equal
define the severity of OSA, with an AHI greater to 30 severe OSA, respectively. It is important
than or equal to 5 indicating mild, greater than or that perianesthesia nurses understand and are

Table 1. Coexisting Diseases/Symptoms Associated With OSA

Cardiovascular Neuropsychological Endocrine/Other

 HTN  Daytime somnolence  Glucose intolerance and diabetes

 Arrhythmias:  Cognitive impairment  Obesity
B Atrial fibrillation  Accident proneness  Gastroesophageal reflux disease
B Bradycardia  Anxiety  Potential difficult airway
B Atrioventricular block  Depression
 Coronary artery disease
 Nocturnal angina
 Myocardial infarction
 Congestive heart failure
 Cerebral vascular disease
 Pulmonary HTN
 Sudden cardiac death
OSA, obstructive sleep apnea; HTN, hypertension.
532 SPENCE ET AL

able to interpret the findings of PSG studies
because the results will allow them to determine
their patients’ OSA severity, and this may have
implications for nursing management during the
perioperative period (Table 2).
Effects of Anesthesia/Opioids on OSA
Sleep Architecture
Patients with OSA have increased sensitivity to the
respiratory depressant effects of anesthetic
agents.30 Additionally, opioids and surgery have
been found to suppress REM sleep (airway
obstruction is most common during REM sleep),
yet increase the severity and duration of moderate
hypoxemia (oxygen saturations between 81% and
90%), increase the number of central apneas, and
contribute to postoperative complications
(Figure 3).5,15 However, REM sleep suppression
the first postoperative night is followed by REM
sleep rebound approximately 3 to 5 days after
surgery, resulting in possible worsening of
obstructive symptoms.19-21,31 Liao et al20 reported
that patients with OSA (AHI greater than or equal

Table 2. Common Sleep-Disordered Breathing and PSG Terminology

Sleep Study Terms Definition
OSA A form of sleep-disordered breathing characterized by partial or complete upper airway
obstruction during sleep. Often associated with snoring, witnessed apnea, impaired
cognition, and daytime sleepiness because of reduced restorative sleep (ie, REM sleep and
stage 3 non-REM sleep)
Parameters Type of study (attended or unattended), device (ie, type 3), and parameters measured: snoring,
oral/nasal thermal sensor, nasal air pressure transducer, thoracic and abdominal respiratory
effort (using inductance plethysmography), oxygen saturation, heart rate, and body position.
For attended sleep studies, stages of sleep will be based on EEG results
AHI The number of apnea and hypopneas per hour of sleep. Used to classify OSA severity:*
Mild OSA: 5 to 14
Moderate OSA: 15 to 29
Severe OSA: $30
RDI For attended PSG, apneas, hypopneas, and RERA are added and divided by sleep time
For portable tests (home unattended), it is the number of apneas and hypopneas divided by
recording time
LSAT The lowest oxygen saturation measured during study. Also reported as minimum oxygen
saturation or nadir
T90 & T85 Total duration of measured sleep time with an SPO2 , 90% and 85%
Obstructive apnea Defined by the absence of airflow despite persistent ventilatory efforts, demonstrated by chest
or abdominal wall movements. Measured as a drop in peak thermal sensor excursion by $90%
of the baseline, lasting at least 10 seconds with continued or increased inspiratory effort.
Reported as number of events during the sleep study
Central apnea Central apnea is the absence of airflow because of the lack of ventilatory effort. Measured as a
drop in peak thermal sensor excursion by $90% of the baseline, lasting at least 10 seconds
without inspiratory effort. Reported as number of events during sleep study
Mixed apnea Includes both central and obstructive components with an initial central component followed
by the obstructive component. Measured as a drop in peak thermal sensor excursion by $90%
of the baseline, lasting at least 10 seconds without inspiratory effort in the initial portion of the
event, followed by resumption of inspiratory effort in the second portion of the event.
Reported as number of events during sleep study
Other data For attended sleep studies, the stages and total sleep time will be reported (REM and non-REM).
Cardiac data reported includes highest, lowest, and average heart rate, body position, snoring,
and ECG rhythm
PSG, polysomnography; OSA, obstructive sleep apnea; REM, rapid eye movement; EEG, electroencephalogram; AHI,
apnea/hypopnea index; RDI, respiratory disturbance index; RERA, respiratory effort-related arousal; LSAT, lowest oxy-
gen saturation; T90 & T85, time with SPO2 less than 90% & 85%.
*Centers for Medicare and Medicaid diagnostic criteria for OSA are an AHI $5 with or without associated symptoms of
daytime sleepiness, fatigue, impaired cognition, or an AHI $15 without associated symptoms.
OBSTRUCTIVE SLEEP APNEA AND THE ADULT PERIOPERATIVE PATIENT
Figure 3. Effects of remifentanil infusion on
oxygen saturations in patients with msoderate OSA.
Remifentanil is an ultra-short-acting opioid infusion.
Compared with moderate OSA patients’ baseline pol-
ysomnography, the severity and duration were signif-
icantly greater during the remifentanil infusion. SaO2,
oxygen saturation. Figure created from data pub-
lished by Bernards et al15 (Reprinted with permission
from Anesthesia Abstracts.). This figure is available in
color online at www.jopan.org.
to 5) undergoing surgery under general anesthesia
had a significantly slower recovery of REM sleep
and significantly increased AHI and oxygen desatu-
ration index on postoperative day 3 when
compared with their preoperative sleep study.
Chung et al19 found, regardless of the type of anes-
thesia (regional, monitored anesthesia care, or gen-
eral anesthesia) or surgery (minor or major), that
obstructive events (as measured by AHI) increased
in non-OSA and patients with mild and moderate
OSA on postoperative night 1. Obstructive events
peaked on postoperative night 3 in non-OSA and
in all OSA patients; in patients with severe OSA,
the AHI decreased from 45 events/hour preopera-
tively to 40 events/hour on postoperative night 1
but then increased to 65 events/hour on postoper-
ative night 3. Older patients with more severe pre-
operative OSA and higher postoperative opioid
requirements had more obstructive events postop-
eratively. An increased amount of slow wave sleep
(obstructive events occur less often during slow
wave sleep) and major surgery were associated
with decreased obstructive events postoperatively
(lower AHI). Given the frequent awakenings for vi-
tal signs and laboratory draws, it is not surprising
that major surgery was associated with reduced
postoperative obstructive events.
Dette et al21 evaluated the occurrence of REM
sleep suppression in patients undergoing total
533
knee arthroplasty under spinal anesthesia with
postoperative continuous nerve block and no
opioid administration until postoperative day 3.
They found that REM sleep decreased 8% on post-
operative night 1 when compared with the preop-
erative PSG taken 1 day before surgery (P 5 .02;
Figure 4). On postoperative day 5, REM rebound
occurred and REM sleep increased 10% when
compared with postoperative night 1 (P 5 .01).
The median number of oxygen desaturations of
greater than or equal to 4% per hour of sleep
decreased from 7.8 events/hour to 3.4 events/
hour on postoperative night 1 (presumably
because of decreased REM sleep and lack of opioid
administration) and then increased to 14.8 events/
hour on postoperative night 5. There was a posi-
tive correlation between the increase in REM sleep
between postoperative nights 1 and 5 and pain
scores at rest (r 5 0.62, P 5 .01). This suggests
that patients with more pain had a more profound
REM rebound.21 The combination of REM rebound
and opioid administration may have contributed to
the more frequent oxygen desaturations seen on
postoperative day 5. These findings are significant
because perianesthesia nurses suspect that the
greatest risk for OSA patients is in the first 24 hours.
However, these results suggest that nurses should
also be concerned about worsening obstructive
Figure 4. Percent REM sleep and ODI 4%. Results
are given as median (interquartile range). ODI 4% is
the number of oxygen desaturation events of greater
than or equal to 4%. There was a significant decrease
in percent REM sleep between preoperative night 1
and postoperative night 1 (P 5 .02) and significantly
higher percent REM sleep on postoperative night 5
when compared with postoperative night 1
(P 5 .01). REM, rapid eye movement; ODI, oxygen
desaturation index. Figure created from results pub-
lished by Dette et al21 (Reprinted with permission
from Anesthesia Abstracts). This figure is available
in color online at www.jopan.org.
534
symptoms and postoperative complications up to
72 hours and beyond when REM rebound occurs.
REM rebound may also contribute to increased
sympathetic activity and is speculated to
contribute to postoperative cardiac events.32
OSA and Postoperative Complications
OSA is associated with an increased incidence of
difficult intubation, postanesthesia care unit
(PACU) length of stay, unplanned intensive care
unit (ICU) admission, and respiratory, pulmonary,
and cardiovascular complications during the peri-
operative period.5-7,33 Gupta et al5 conducted
one of the first studies on postoperative complica-
tions in OSA patients undergoing total knee arthro-
plasty. The incidence of postoperative
complications in OSA patients was 39% vs 18% in
the control group (P 5 .001); serious complica-
tions, such as ICU admission, cardiac events, or
need for intubation, were also significantly higher
in the OSA group (24% vs 9%, P 5 .004). Hospital
length of stay was approximately 2 days longer in
OSA patients (P 5 .03). What is significant to
nurses is that approximately one-third of OSA pa-
tients experienced complications between 24
and 72 hours after surgery. REM rebound occurs
between 48 and 72 hours after surgery; therefore,
these findings suggest that nurses should be con-
cerned about the occurrence of complications in
OSA patients up to 72 hours after surgery. It is
important to note that this study included patients
who had surgery between 1995 and 1998. The
awareness of the perioperative implications of
OSA was much less during this period. However,
results of this study highlight the importance of
communication between perianesthesia and
medical-surgical nurses on patients’ comorbidities
during patient handoffs.
Gali et al33 examined the relationship between
recurrent PACU respiratory events and OSA. At
their institution, OSA patients who experienced
recurrent PACU respiratory events during the
90 minutes after admission had to be admitted
overnight to their intermediate care unit with
continuous pulse oximetry monitoring for up to
48 hours. Recurrent events included bradypnea
(less than eight respirations), apnea greater than
or equal to 10 seconds, oxygen desaturations
less than 90% despite being on nasal cannula
oxygen (three episodes needed for yes), and
SPENCE ET AL
pain-sedation mismatch (Richmond Agitation
sedation scale score indicating moderate or
deep sedation or unarousable, plus a pain score
greater than 5; only one episode needed for an
yes). Gali et al33 found that patients who were
at high risk for OSA and experienced recurrent
PACU respiratory events were 13 times more
likely to experience a postoperative complication
(ie, unplanned ICU admission, need for respira-
tory therapy, continuous positive airway pressure
[CPAP] therapy, electrocardiographic changes).
This is one of the few published studies that
examined PACU respiratory events as predictors
of postoperative respiratory complications in
OSA patients. It provides evidence demonstrating
the usefulness of a PACU protocol that may help
perianesthesia nurses identify which patients
may need a higher level of care postoperatively.
Hwang et al34 examined the association of sleep-
disordered breathing (OSA) with postoperative
complications. At their institution, a two-step
screening process to identify patients at risk for
OSA was completed on all patients. If patients
had at least two clinical features of OSA, they
were selected for a home nocturnal oximetry
study before surgery (eg, snoring, excessive day-
time somnolence, witnessed apnea, or crowded
oropharynx). They calculated the oxygen desatu-
ration index greater than or equal to 4%; mild
OSA was defined as 5 to 20, moderate 20 to 40,
and severe greater than 40 events per hour from
the oximetry studies. They then evaluated the inci-
dence of postoperative complications, such as
hypoxemia, need for oxygen therapy, atelectasis,
or adverse events affecting a major organ system
that required further monitoring or diagnostic
testing. Hwang et al34 found that patients with an
oxygen desaturation index greater than or equal
to 5 (suspected OSA) were 7.2 times more likely
to experience a postoperative complication (95%
confidence interval [CI], 1.5 to 33, P 5 .012).
The most common complication was hypoxemia.
This study was novel in that it demonstrated a stan-
dardized preoperative screening process that
incorporated that oximetry testing could identify
patients at risk for OSA-related complications.
Liao et al35 found that patients with OSA had a
higher incidence of coexisting diseases, difficult
intubation (OSA vs non-OSA: 20% vs 10%,
P 5 .003), and were almost two times more likely
OBSTRUCTIVE SLEEP APNEA AND THE ADULT PERIOPERATIVE PATIENT
to experience a postoperative complication such
as hypoxemia (44% vs 28%, P , .01). A concern
for nurses was that most complications occurred
after the patients were transferred to the ward
when monitoring was less frequent (25% vs
16%). These results highlight the importance of
an ensuring information about the patient’s OSA
history communicated to ward nurses during pa-
tient handoffs and suggest that patients with OSA
may need a higher level of monitoring for respira-
tory complications postoperatively (ie, continuous
pulse oximetry [SPO2] or end-tidal carbon dioxide
[ETCO2]).
In the largest study to date, Memtsoudis et al6
examined more than three million records of US
patients undergoing general and orthopaedic sur-
gery (ie, total knee and hip arthroplasty). Mem-
tsoudis et al6 confirmed that patients with OSA
are at high risk for experiencing serious postoper-
ative pulmonary complications (aspiration pneu-
monia, adult respiratory distress syndrome,
postoperative intubation, pulmonary embolism,
and aspiration). Memtsoudis et al6 found that the
prevalence of diagnosed OSA almost doubled be-
tween 1998 and 2007 (prevalence: general surgery
1.7%; orthopedic surgery 2.5%); this could be
because of increasing obesity and/or awareness
of the problem. They also found that patients
with OSA tended to be older and sicker (ie, higher
American Society of Anesthesiologists [ASA] class).
It is important to point out that the study only
examined patients with diagnosed OSA; therefore,
the results may underestimate the true incidence
of OSA in these populations. However, it does indi-
cate that OSA prevalence is higher in orthopaedic
patients undergoing joint replacement. The results
also suggest that OSA may be associated with se-
vere postoperative pulmonary complications.
In a follow-on study, Memtsoudis et al36 compared
neuraxial anesthesia alone, to a combination of
neuraxial anesthesia plus general anesthesia, to
general anesthesia alone and found that 16% to
18% of OSA patients undergoing total knee and
hip arthroplasty (N 5 30,024) experienced a major
complication; however, complication rates were
lower in those who received neuraxial anesthesia
alone or combined with general anesthesia when
compared with general anesthesia alone. Other in-
vestigators have also determined that patients with
OSA have higher rates of in-hospital mortality
535
(odds ratio [OR], 1.9; P , .02), pulmonary embo-
lism (OR, 2.1; P 5 .001), and increased costs
($61,044 vs $58,813, P , .01) after total joint ar-
throplasty.37
In contrast, Mokhlesi et al38 examined 91,028
(OSA 5 33,196 vs non-OSA 5 57,832) patients un-
dergoing bariatric surgery and found that diag-
nosed OSA was associated with a 0.34 times
lower odds of in-hospital death (OR, 0.34; 95%
CI, 0.23 to 0.50). Patients with OSA were 4.4 times
more likely to require emergent tracheal intuba-
tion and mechanical ventilation (95% CI, 3.97 to
4.77), 14 times more likely to require postopera-
tive CPAP (95% CI, 12.1 to 16.5), and atrial fibrilla-
tion was more common (OR, 1.3; 95% CI, 1.1 to
1.4). A significantly higher proportion of patients
in the OSA group required emergent intubation
and mechanical ventilation on the day of surgery
or the first postoperative day as compared with
non-OSA patients (90% vs 63%, P , .001). Out-
comes were much worse in non-OSA patients
who required emergent intubation. In this study,
bariatric patients with OSA were intubated earlier
in the postoperative period compared with non-
OSA patients, and thus their prognosis was better.
The reason for the lower in-hospital mortality may
have been because providers and nurses taking
care of bariatric patients with OSA were more vigi-
lant and had guidelines (ie, use of CPAP, use of
pulse oximetry) for their postoperative manage-
ment. It is possible some of the patients in the
non-OSA group may have had undiagnosed OSA.
As can be seen from this review of the literature,
virtually every one of these studies found higher
rates of postoperative complications in patients
with OSA. The most common complication was
respiratory, especially hypoxemia. This is not sur-
prising given that patients with OSA are more sen-
sitive to anesthetic agents and postoperative
opioids and thus are more likely to experience
hypoxemia and worsening of their obstructive
symptoms. However, serious complications were
reported. A limitation of the studies reviewed is
that most were retrospective and thus prone to
bias. Conducting large prospective trials, including
randomized controlled trials, are difficult to com-
plete, and very large sample sizes are needed to
detect differences in serious complication rates
(ie, in-hospital mortality). Despite these limita-
tions, the overwhelming evidence demonstrates
536
that known or suspected OSA, especially when
moderate to severe, increases the risk of perioper-
ative complications. These results suggest that
OSA (known or suspected) may require a higher
level of care postoperatively.
Preoperative Screening for OSA
Given the high rate of postoperative complications
associated with OSA, it is essential that health care or-
ganizations support protocols and that nurses as well
as others on the perioperative team participate in the
development and implementation of protocols for
identifying patients with diagnosed and undiagnosed
moderate-to-severe OSA to enable implementation
of perioperative OSA risk reduction precautions
(Table 3).39-42 Current recommendations suggest
that patients suspected of having moderate-to-
severe OSA with comorbidities suggestive of long-
standing OSA (uncontrolled hypertension, heart fail-
ure, arrhythmias, cerebrovascular disease, morbid
obesity, and metabolic syndrome) and in need of ma-
jor elective surgery should be referred for preopera-
tive PSG and possible treatment with CPAP
therapy.39,40,43 Patients with suspected or known
mild OSA typically do not always require
preoperative CPAP and can be managed with OSA
risk reduction precautions (Table 3). CPAP is the
treatment of choice for OSA because it helps stent
the airways open during sleep and reduces nocturnal
hypoxemia and AHI, decreases daytime sleepiness,
and improves comorbidities such as hypertension
and obesity.44 Unfortunately, it is difficult for many
patients with suspected OSA to obtain a sleep study
to confirm the diagnosis and become compliant pre-
operatively and postoperatively with CPAP.10,43
Without validated easy-to-use questionnaires, sur-
geons and anesthesia providers may not always
identify patients with OSA. Singh et al13 found
before implementation of a screening question-
naire (Snoring, Tiredness, Observed apnea, high
blood Pressure, Body mass index greater than
35 kg/m2, Age older than 50, Neck circumference
greater than 40 cm, and male Gender [STOP-
BANG]) for OSA that 92% of surgeons and 60% of
anesthetists failed to identify patients with pre-
existing or undiagnosed moderate-to-severe OSA.
This study highlights the importance of educating
providers and nursing staff and having protocols in
place to screen for undiagnosed OSA preopera-
tively.
SPENCE ET AL
Table 3. OSA Risk Reduction Precautions
 Identify patients with known or suspected OSA (use
STOP-BANG score $3) (consider moderate to severe
OSA if score $5)
 Minimize preoperative sedation
 Prepare for possible difficult airway
 Minimize use of long-acting opioids.
 Nonopioid techniques preferable. Consider multi-
modal analgesic techniques and regional anesthesia
when possible
 Use short-acting inhaled or intravenous anesthetics
(ie, desflurane, sevoflurane, propofol)
intraoperatively
 Ensure patient is fully conscious and cooperative and
has full reversal of neuromuscular blockade before
extubation
 Use the nonsupine position for recovery
 Resume CPAP therapy in patients with OSA
 Consider initiating CPAP postoperatively if noncom-
pliant with preoperative CPAP, or if patient has severe
OSA, or experiences recurrent PACU respiratory
events
 Consider extended care in a monitored bed with
continuous ETCO2 and/or SPO2 for moderate-to-
severe OSA if postoperative opioids required and/or
for recurrent PACU respiratory events
 Educate surgeon, patient, and family of how to
monitor for respiratory events postoperatively
OSA, obstructive sleep apnea; SPO2, pulse oximetry/
oxygen saturation; STOP-BANG, Snoring, Tiredness,
Observed apnea, high blood Pressure, Body mass index
greater than 35 kg/m2, Age older than 50, Neck circum-
ference greater than 40 cm, and male Gender; CPAP,
continuous positive airway pressure; ETCO2, end-tidal
carbon dioxide.
Note: OSA risk reduction precautions based on pub-
lished research, guidelines, and expert opinion.39-41
In recent years, the STOP-BANG questionnaire
(eight yes-no questions; greater than or equal to 3
high-risk OSA) has become one of the most com-
mon validated instruments used and studied
in the preoperative period to identify patients
at high risk for OSA.7,17,45 The questionnaire
contains four questions and four clinical
characteristics of OSA (Snoring, Tiredness,
Observed apnea, high blood Pressure, Body mass
index greater than 35 kg/m2, Age older than 50,
Neck circumference greater than 40 cm, and
male Gender). The questionnaire is a self-report
and forced choice (yes/no) questionnaire that
OBSTRUCTIVE SLEEP APNEA AND THE ADULT PERIOPERATIVE PATIENT
can be completed in less than 1 minute. A score
greater than or equal to 3 is considered high risk
for OSA. It was based on the Berlin Questionnaire,
consensus of a group of anesthesiologists, sleep
specialists, and literature review. Other question-
naires validated in surgical populations include
the Berlin Questionnaire46 and the ASA OSA
Checklist.41
Chung et al17 using PSG found that the odds of
having any degree of OSA (AHI greater than or
equal to 5), especially severe OSA (AHI greater
than or equal to 30), increased as the STOP-
BANG score increased. The sensitivities for a
score of greater than or equal to 3 on the STOP-
BANG with an AHI greater than or equal to 5
(mild OSA), greater than or equal to 15 (moderate
OSA), and greater than or equal to 30 (severe
OSA) were 83.6%, 92.9%, and 100%, respectively
(sensitivity refers to the true positive rate; the
percentage of patients correctly identified as hav-
ing that level of OSA severity).10 At a cutoff score
of greater than or equal to 3, the STOP-BANG has
a fairly high false-positive rate (low specificity);
however, using a cutoff score of greater than or
equal to 5 was 74% specific for severe OSA
(AHI greater than or equal to 30) and at greater
than or equal to 7 the specificity was 96% (spec-
ificity refers to the true-negative rate; the percent-
age of patients who are correctly identified as not
having that level of OSA severity).17 Patients with
a STOP-BANG score of 5 were 10 times more
likely and a score of greater than or equal to 7
were 15 times more likely to have severe OSA.
These results suggest that a score of 5 or more
may be a better cutoff score for identifying pa-
tients with moderate-to-severe OSA. The implica-
tion for nurses is that if a patient is classified as
being at low risk (STOP-BANG score less than
3), there is a low probability of moderate-to-
severe OSA. In contrast, nurses can be fairly confi-
dent if a patient has a high score (greater than or
equal to 5) that the patient has moderate-to-
severe OSA. Chung et al17 suggest using a STOP-
BANG score of greater than or equal to 3 in
populations with high prevalence of moderate-
to-severe OSA (ie, bariatric surgery) but to use a
score of greater than or equal to 5 in surgical pop-
ulations with lower prevalence rates. The Berlin
questionnaire and ASA OSA Checklist have
between 79% and 89% sensitivity for moderate-
to-severe OSA.47 However, both these question-
537
naires take a longer time to complete, and scoring
is more complicated than the STOP-BANG.
STOP-BANG and Perioperative Outcomes
Use of the STOP-BANG by perianesthesia nurses
has shown value in identification of patients at
risk for undiagnosed OSA. In an evidence-based
practice project, Lakdawala45 found that imple-
mentation of a comprehensive program for
educating nurses, creating standard OSA order
sets and guidelines, and use of the STOP-BANG
for screening surgical patients improved patient
safety by increasing the identification of patients
with undiagnosed OSA. Lakdawala45 found that
before implementation of the STOP-BANG the
documented incidence of undiagnosed OSA was
3%, and after implementation of the STOP-BANG
that the percentage of patients at high risk for
OSA increased to 17%. Unpublished work by the
lead author on this article found at Naval Hospital
Okinawa after implementation of the STOP-BANG
that the incidence of undiagnosed OSA increased
from 5% to 21% (P , .05) and the frequency of
anesthesia consults for suspected OSA increased
from 5% to 25% (P , .05). Overall, these inci-
dences of undiagnosed OSA are consistent with
previous investigations.10,11 These findings are
important because they demonstrate how a
simple screening tool such as the STOP-BANG
can improve the perianesthesia nurse’s ability to
identify patients with undiagnosed OSA. Nurses
can then implement risk reduction strategies
(Table 3). However, the workload on preoperative
nurses may increase because more patients may
require anesthesia consultation preoperatively.
Nurses should work with their medical and surgi-
cal staff to develop screening processes that are
efficient but that ensure patient safety.
The STOP-BANG questionnaire is predictive of
postoperative complications. Vasu et al7 found
that surgical patients undergoing major inpatient
surgery who were identified as high risk for OSA
based on the STOP-BANG (greater than or equal
to 3) were 11.3 times more likely to experience a
postoperative pulmonary complication. Chung
et al47 found that the patients classified as being
at high risk for OSA (STOP-BANG score greater
than or equal to 3) were three times more likely
to experience a postoperative complication such
as oxygen desaturation (95% CI, 1.20 to 7.53).
538
Taken together, these results demonstrate that the
STOP-BANG is useful in screening and predicting
the severity of undiagnosed OSA and may be help-
ful in identifying which patients may be at risk for
postoperative complications. Both the Society for
Ambulatory Anesthesia39 and the American Soci-
ety of PeriAnesthesia Nurses48 recommend use of
the STOP-BANG in surgical patients.
The STOP-BANG is routinely administered preop-
eratively at many large academic medical centers
and at Department of Defense Military Treatment
Facilities; however, the information obtained
from the STOP-BANG is not consistently used to
guide intraoperative and postoperative care. The
reason for this multifaceted implementation of a
protocol to screen and develop protocols for pa-
tients for OSA must be seen as a priority for the or-
ganization and requires multidisciplinary team
who can incorporate the tool into existing work-
flow and documentation, educate staff, and track
compliance and ensure sustainment. Use of the
Iowa model of evidence-based practice may help
nurses when implementing screening programs
at their institutions.
Additionally, many providers and nurses believe
further evidence is needed to demonstrate that a
higher score on the STOP-BANG is predictive of
worsening postoperative sleep apnea parameters
and clinical outcomes after surgery to justify
providing a higher level of care. This evidence is
critically important because subjecting OSA pa-
tients to unnecessary higher level of care (ie,
extended postanesthesia unit stay, ICU admission,
continuous respiratory monitoring with SPO2,
ETCO2) results in significantly increased costs.42
Postoperative Management of OSA
Patients
In 2014, the ASA updated their guidelines for the
perioperative management of OSA patients.41
Recently, the Society for Ambulatory Anesthesia39
and the American Society of PeriAnesthesia
Nurses48 published guidelines. All three organiza-
tions acknowledge that most recommendations
are based on lower levels of evidence. Postopera-
tive concerns addressed in these guidelines
include postoperative analgesia, oxygenation and
ventilation, patient positioning, and monitoring.
Health care providers, nurses, patients, and their
SPENCE ET AL
families need to be aware that patients with OSA
are at risk for respiratory depression after surgery
or ambulatory procedures in which anesthetic
agents have been administered. They also need to
be made aware that obstructive symptoms, espe-
cially in patients with moderate-to-severe OSA,
may worsen 3 to 4 days after surgery when REM
sleep rebounds.19-21,30 There is limited literature
that has compared analgesic techniques on
outcomes after surgery in OSA patients; however,
the work by Memtsoudis et al36 suggests that neu-
raxial anesthesia is associated with less complica-
tions. Experts believe that the use of regional
anesthesia (ie, epidural or peripheral nerve
blocks—single shot or continuous) and multi-
modal analgesia protocols that minimize opioids
reduce the likelihood of postoperative complica-
tions. If patient-controlled analgesia is used, basal
rates should be avoided in OSA patients, and if
available, continuous ETCO2 should be used.49
The use of postoperative oxygen in OSA patients
should be administered as needed; however, it
should be discontinued when patients are able to
maintain their baseline oxygen saturations. It is
important to point out that oxygen therapy may
mask or delay recognition of hypoventilation and
life-threatening hypercarbia. Mehta et al50 in a
meta-analysis of nonsurgical OSA patients found
although supplemental oxygen improved oxygen
saturation, it may also increase the duration of
apnea-hypopnea events possibly through suppres-
sion of the hypoxic respiratory drive. This poten-
tial problem may be exacerbated in surgical
patients who have had anesthesia and are receiving
opioids or other sedatives postoperatively.
There is limited literature from the perioperative
setting on patient positioning after surgery in OSA
patients. The nonsurgical literature suggests the
sitting or lateral or sitting position reduces obstruc-
tive symptoms.51 Experts recommend that during
the postoperative recovery period when possible,
a nonsupine position should be used.39,41,48
The 2014 ASA recommendations41 state that the
literature was insufficient to offer guidance on the
most appropriate type of postoperative monitoring
in OSA patients (ie, pulse oximetry, continuous
ETCO2, telemetry, duration, or location [stepdown
unit or ICU]). However, they do recommend that
continuous monitoring should be maintained as
OBSTRUCTIVE SLEEP APNEA AND THE ADULT PERIOPERATIVE PATIENT
long as the patient is at increased risk for respiratory
depression. The exact duration of monitoring
needed is unknown. The duration of monitoring
may vary from institution to institution because of
differences in patient comorbidity, surgical proce-
dures performed, resources, and staff experience.
As was described previously, Gali et al33 used a
PACU protocol that was based on recurrent respi-
ratory events to guide the type of monitoring and
location of admission that perianesthesia nurses
may find useful. Bolden et al52 reported on 428
OSA patients at their institution and found that ep-
isodes of significant oxygen desaturation occurred
both with oral and intravenous opioids most
commonly during the first 24 hours. As a result,
they developed a protocol at their institution that
requires all patients with known or suspected
OSA who receive postoperative intravenous opi-
oids to be admitted for 24 hours with continuous
pulse oximetry to ensure adequate oxygenation
and the absence of significant apnea.53 For ambula-
tory patients, if postoperative opioids are required,
patients with moderate-to-severe OSA are moni-
tored similarly for up to 23 hours.52 For ambula-
tory procedures that require no postoperative
opioids, OSA patients are monitored in the PACU
for at least 3 hours or until physically assessed
and discharged by the attending anesthesia pro-
vider. Patients must maintain an oxygen saturation
of greater than 94% on room air before discharge.
Although they did not specifically report out-
comes in OSA patients, Taenzer et al54 described
implementation of a patient surveillance system
that included heart rate and pulse oximetry with
nursing notification of violation of alarm limits
via wireless pagers. They found that the number
of rescue events in surgical and nonsurgical
patients (ie, rapid response team calls) decreased
from 4.4 6 2.9 to 1.9 6 1.7 per 1,000 bed days
(P , .05) with an estimated cost savings of $1.48
million dollars because of decreased ICU transfers.
These results provide compelling evidence that
perianesthesia nurses can use to justify implemen-
tation of patient surveillance systems for OSA
patients at their institutions.
Patients with a low respiratory rate may maintain an
oxygen saturation greater than 90%, yet still develop
life-threatening hypercarbia. As a result of sentinel
events, both the Joint Commission and the Anes-
539
thesia Patient Safety Foundation recommend contin-
uous monitoring of oxygenation (ie, SPO2) and
ventilation with continuous ETCO2 in patients
receiving opioid therapy (ie, patient-controlled anal-
gesia). Use of continuous ETCO2 is preferable
because it will detect respiratory depression earlier
than pulse oximetry.49,55 Currently, there is limited
published evidence evaluating the efficacy of
continuous ETCO2 on outcomes after surgery in
OSA patients. However, given OSA patients are
more sensitive to respiratory depressive effects of
anesthetic agents and opioids, and their risk of
respiratory complications in unmonitored
settings,35,56 it makes sense that this technology
may help reduce complications in OSA patients.
However, it is acknowledged that hospital
administrators may request further evidence to
support the purchase of additional monitors.
Further research is needed on the effect use of
continuous ETCO2 and alarm fatigue in nursing staff.
CPAP or bilevel PAP is the main treatment for
OSA. It is recommended that OSA patients on
CPAP therapy bring their devices on the day of
surgery and use them postoperatively, unless con-
traindicated by the surgical procedure. However,
there is limited evidence to support instituting
CPAP or noninvasive positive pressure ventilation
in patients who have not previously been treated
with these modalities. Liao et al57 randomized 177
OSA patients with an AHI greater than 15 to auto-
titrated CPAP, which was started 3 days before
surgery or routine care and found that CPAP
significantly reduced postoperative AHI; howev-
er, less than 48% of patients used the CPAP for
more than 4 hours per night. Reasons for nonad-
herence included postoperative pain, nausea
and vomiting, and patient’s changing their minds.
Other investigators have found similar low adher-
ence rates.43 Perianesthesia nurses should keep
these findings in mind when developing care
plans that promote CPAP adherence for OSA pa-
tients postoperatively.
Conclusion
OSA is a common comorbidity seen in surgical
patients that increases their risk of perioperative
complications. This article has provided a compre-
hensive overview and some practical tips that
perianesthesia nurses can use to guide the periop-
erative management of patients with known or
540
suspected OSA. Readers are encouraged to
examine their policies and procedures at their in-
stitutions to see if changes can be implemented
to improve outcomes in OSA patients.
Acknowledgment
The Uniformed Services University of the Health Sciences,
4301 Jones Bridge Road, Bethesda, MD 20814-4799, is the
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randomized controlled trial. Anesthesiology. 2013;119:837-847.
542 SPENCE ET AL

Obstructive Sleep Apnea and the Adult Perioperative Patient

1.5 Contact Hours

Purpose of the Journal of PeriAnesthesia Nursing: To facilitate communication about and deliver
education specific to the body of knowledge unique to the practice of perianesthesia nursing.
Outcome of this CNE Activity: To enable the nurse to implement strategies to promote optimal care
for diagnosed and undiagnosed OSA patients.
Target Audience: All perianesthesia nurses.
Article Objectives: (1) Identify the pathophysiology of OSA. (2) Discuss the effects of anesthesia and
opioids on OSA patients sleep architecture. (3) Describe the effects of OSA on postoperative complications.
(4) Discuss the latest evidence on screening for undiagnosed OSA in the adult surgical patient. (5) Discuss
the perioperative management principles for patients with OSA.
Accreditation
American Society of Perianesthesia Nurses is accredited as a provider of continuing nursing education by
the American Nurses Credentialing Center’s Commission on Accreditation.

Additional provider numbers: Alabama #ABNP0074, California #CEP5197, Florida 50-114.

Registered nurse participants can receive 1.5 contact hours for this activity.
Disclosure: All planners and authors of continuing nursing education activities are required to disclose any
significant financial relationships with the manufacturer(s) of any commercial products, goods or services.
Any conflicts of interest must be resolved prior to the development of the educational activity. Such disclo-
sures are included below.
Planner and Author Disclosure: The members of the planning committee for this continuing nursing
education activity do not have any financial arrangements, interests or affiliations related to the subject mat-
ter of this continuing education activity to disclose.
The author for this continuing nursing education activity does not have any financial arrangements, inter-
ests or affiliations related to the subject matter of this continuing nursing education activity to disclose.
Verification of Participation: Verification of your participation in this educational activity is done by hav-
ing you complete the registration form and submit the form along with the posttest and evaluation form to
the ASPAN national office.
Requirements for Successful Completion: To receive contact hours for this continuing nursing educa-
tion activity you must submit the posttest and evaluation form to the ASPAN national office and achieve a
minimum grade of 80% on the posttest.
Commercial Support/Sponsorship/Unrestricted Educational Grant: No commercial support, spon-
sorship or unrestricted educational grant has been received for this educational activity.
OBSTRUCTIVE SLEEP APNEA AND THE ADULT PERIOPERATIVE PATIENT
Directions: The multiple-choice examination
below is designed to test your understanding
of Obstructive Sleep Apnea and the Adult
Perioperative Patient according to the objec-
tives listed. To earn contact hours from the
American Society of PeriAnesthesia Nurses
(ASPAN) Continuing Education Provider
Program: (1) read the article, (2) complete the
posttest by indicating the answers in the test
Posttest Questions
1. Severe OSA is defined as an AHI:
a. Greater than or equal to 5
b. Greater than or equal to 15
c. Greater than or equal to 30
d. Greater than or equal to 20
2. Factors that may predispose patients to have
OSA include all the following EXCEPT:
a. Increased tone of the genioglossus muscle
during REM sleep
b. Narrower pharyngeal airways secondary
to excess adipose tissue
c. Higher airflow velocity and lower intralu-
minal upper airway pressure during sleep
d. Decreased neuromuscular tone of the
dilator muscles during sleep
3. After surgery, opioids have been found to
a. Decrease the severity and duration of
moderate hypoxemia
b. Decrease the number of central apneas
c. Reduce postoperative complications
d. Suppress REM sleep
4. With regard to the sleep architecture of the
OSA patient, which of the following state-
ments is TRUE?
a. REM sleep decreases on postoperative
night 1
b. The combination of REM rebound and
opioid administration may contribute to
postoperative oxygen desaturation
c. REM sleep rebound approximately 3 to
5 days after surgery
d. All the above
5. In the immediate postoperative period, what
nursing action(s) would you consider most
beneficial to decrease the risk of oxygen de-
saturation in the patient with OSA?
a. Provide supplemental oxygen as needed
b. Position the patient supine
543
grid provided, (3) complete the evaluation
form, and (4) tear out the page (or photocopy)
and submit postmarked before September 30,
2017, with check payable to ASPAN (ASPAN
member, $12.00 per test; nonmember, $15.00
per test) and return to ASPAN, 90 Frontage
Road, Cherry Hill, NJ 08034–1424. Notification
of contact hours awarded will be sent to you
in 4 to 6 weeks.
c. Use a basal rate for patient-controlled
analgesia
d. Administer long-acting opioids
6. Which of the following are the most com-
mon type of postoperative complication
experienced by patients with OSA?
a. Cardiovascular complications
b. Neurological complications
c. Respiratory complications
d. All the above
7. Patients who are at high risk for OSA are __
times more likely to experience PACU respi-
ratory complications.
a. 2
b. 6
c. 9
d. 13
8. Which of the following are NOT clinical
characteristics of patients with OSA?
a. Snoring
b. Low blood pressure
c. Tiredness during the day
d. Observed apnea during sleep
e. Male gender
9. Which of the following scores on the STOP-
BANG suggests the patient is at high risk for
OSA?
a. 1
b. 2
c. $3
10. Which of the following interventions
should nurses consider to reduce risk
in patients with known or suspected
OSA?
a. Use long-acting opioids
b. Position the patient in the supine position
c. Avoid CPAP therapy postoperatively
d. Use multimodal analgesic techniques
when possible
544 SPENCE ET AL

OBSTRUCTIVE SLEEP APNEA AND THE ADULT PERIOPERATIVE PATIENT

ANSWERS

W010917 Please circle the correct answer

1. A. 2. A. 3. A. 4. A. 5. A.
B. B. B. B. B.
C. C. C. C. C.
D. D. D. D. D.

6. A. 7. A. 8. A. 9. A. 10. A.
B. B. B. B. B.
C. C. C. C. C.
D. D. D. D. D.
________________________________________________________________________________________

Please Print
Name__________________________________Nursing License No./State____________________________
Address__________________________________________________________________________________
City_______________________________State_______________________Zip_________________________
ASPAN Member #__________________________________________________________________________

E-Mail____________________________________________________________________________________
OBSTRUCTIVE SLEEP APNEA AND THE ADULT PERIOPERATIVE PATIENT 545

Evaluation Form
Use the following Likert scales to address the questions
below: 1 5 Low 4 5 High Low High
1. The objectives for this educational activity were met. 1 2 3 4
2. The content was relevant to my nursing practice. 1 2 3 4
3. Learner paced was an appropriate format for the content. 1 2 3 4
4. This educational activity was free from commercial bias. 1 2 3 4
5. The planner and presenter disclosure information was 1 2 3 4
included in the accreditation information for this educational
activity.
6. Identify the amount of time required to complete this educational activity (read the article, take the test and
complete the evaluation form):
a. Over 120 minutes
b. 91-120 minutes
c. 61-90 minutes
d. 30-60 minutes
e. Under 30 minutes
7. How will the knowledge gained through this educational activity change your practice?

8. Additional comments

Test answers must be submitted before September 30, 2017 to be eligible for contact hours.