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Patient Education on Sleep Apnea and Stroke

By Currents Editor posted 03-11-2022 15:19

  

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Peter J. Papadakos MD, FCCM, FCCP, FAARC, FNIV
Director Critical Care Medicine, University of Rochester

Those of us working in neurocritical care are the frontline individuals caring for ICU patients with acute stroke. This allows us a special opportunity to educate patients and families on the risks of Obstructive Sleep Apnea (OSA), both as the possible cause of a stroke and as a potential complication of a neurological event. Many patients and health care providers are totally unware of this relationship between OSA and stroke, and increasing awareness of the issue may improve outcomes on a large scale.

Obstructive Sleep Disorders are found in up to 5% of middle-aged men and woman. Due to widespread obesity, it is also a growing problem in children and young adults. The classic signs and symptoms often include loud snoring, breathing pauses, hypoxia, choking during sleep, daytime fatigue, and decreased concentration and focus. The major risk factors for OSA include obesity, male sex, and a family history of OSA. It also may contribute to other medical conditions in many patients who may be unaware that OSA can lead to other downstream issues. For example, there is a large body of evidence that OSA itself is an independent risk factor for the development of hypertension, heart disease, type II diabetes, and stroke. Although patients with OSA also often have other confounding factors such as smoking, hypertension, hyperlipidemia, and diabetes, OSA appears to exert its own impact on the risk of stroke. This is supported by a growing number of studies which have shown an increased risk of stroke with OSA that is equal in magnitude to other cardiovascular risk factors. Snoring has also been linked to direct trauma to the endothelium of the carotid artery via vibration-induced injury.

Additionally, OSA has been identified as a devastating consequence of stroke. As reported in the Journal of Sleep Medicine in 2019, OSA screening is extremely uncommon in post-stroke patients. Neuro ICU providers should be leading the way in the evaluation of OSA in this patient population. Providers need to be educated in the pathophysiology of OSA and develop a team approach. We should be able to make an early diagnosis of OSA while evaluating for other complications of stroke such as swallowing disorders. I believe that these early workups will improve the long-term health of our patients by reducing cardiovascular complications and improving blood pressure and glycemic control in our patients.

Providers should get a complete history on all stroke admissions as to the incidence of OSA. If a patient shares that they experience any symptoms of OSA, providers should ask if they have received previous diagnostic testing. If they do carry a diagnosis of OSA, providers should question whether these patients are compliant with CPAP and other prescribed treatments. In my practice I have observed that close to 25% of my pre-operative patients proudly volunteer that their CPAP machine spends the night in the closet. This is a major teaching moment for OSA education for both patients and their families. 

All post-stroke patients, and I venture to say all Neuro ICU patients, should be observed and evaluated for OSA.  We have the unique ability to provide 24/7 observation, thus making it straightforward to diagnose OSA. Some ideas to get started include:

  1. Developing an education program for bedside staff, as OSA diagnosis and treatment is not usually taught to ICU staff.
  2. Using respiratory therapists as in-house experts in the diagnosis and treatment of OSA, which is a major point in their education. They can recommend treatment such as non-invasive ventilation, while ensuring the usage of proper masks and settings.
  3. All patients diagnosed with OSA should have a sleep medicine consultation.
  4. Consider starting treatment in the ICU, then carry it forward—educate the patient and family to follow instructions on the use of CPAP/BiPAP, and that OSA treatment is as important as blood pressure and diabetes control in decreasing future complications.

By addressing this major issue on our units, we can greatly impact our patients’ health and the community as a whole. Preventing future neurologic, cardiovascular, and diabetes-related events can greatly decrease health care cost and repeat admissions. We should build bridges with colleagues in respiratory therapy and sleep medicine and develop guidelines for all OSA patients in our care. This needs to become a precept in neuromedicine and be researched and tracked as a quality measure such as other aspects of stroke care.     

Selected Readings

  1. Mark E. Dyken, Virend K. Somers, Thoru Yamada, Zong-Ying Ren, and M. Bridget Zimmerman. Investigating the Relationship Between Stroke and Obstructive Sleep Apnea. Stroke. 1996;27:401–407
  2. Mark I. Boulos, Laavanya Dharmakulaseelan, Devin L. Brown, Richard H. Swartz. Trials in Sleep Apnea and Stroke Learning From the Past to Direct Future Approaches. 2021;52:366–372
  3. Karin G. Johnson, Douglas C. Johnson. Frequency of Sleep Apnea in Stroke and TIA Patients: A Meta-analysis. J Clin Sleep Med 2010;6(2):131-137
  4. Devin L.Brown,Xiaqing Jiangb,Chengwei Lei, al. Sleep apnea screening is uncommon after stroke. Sleep Medicine. 2019; 59: 90-93

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