Constructing the Written Evidence-Based Proposal #4

Written evidence-based proposal: Final
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Abstract
In the present project, the identified problem is obstructive sleep apnoea (OSA), a serious illness that is observed in the primary care setting. A person who has this condition ceases to breath for an estimated ten seconds every hour as he or she is sleeping at night. The disorder is caused by relaxation of the muscles of the throat. About 2 percent and 4 percent of women and men respectively are affected by this disorder. Currently, patients who present with Obstructive Sleep Apnea are treated with the use continuous positive airway pressure (CPAP). In essence, CPAP therapy is poorly tolerated by patients and causes several complications such as nasal congestion, nasal dryness, conjunctivis, air leaks, facial skin abrasions, and claustrophobia. The proposed solution is to use surgical intervention to treat obstructive sleep apnoea syndrome. Surgical intervention would be carried out in the initial phase of OSA syndrome so as to reduce/prevent occurrences of complications linked to OSA. The rationale is that the proposed intervention is important since the patients will be able to tolerate it and it does not have many side effects as the current intervention, CPAP, does. The resources needed for this project include monetary resources, human resources, educational materials, as well as assessment tools.
Written evidence-based proposal: Final
1.0 Identifying a problem
1.1 Problem description
Obstructive Sleep Apnea (OSA) in adult obese men aged 40 years and older is the identified problem. Obstructive Sleep Apnea is understood as a sleep disorder wherein the individual stops to breath for about ten seconds every hour as he or she is sleeping. The cause of this condition is relaxation of the muscles of the throat; the soft tissue located in the backside of the throat collapses and then closes, and in so doing they result in blocked airways (Gutierrez & Brady, 2013). OSA affects 1.5 percent of women and 3.5 percent of men who are middle-aged. Individuals who are aged 40 years and above have a higher chance of developing this condition although people of any age could be affected, including kids (Muñoz-Hernandez et al., 2015). People who are obese are especially at risk of developing obstructive sleep apnea thanks to the extra fat that pushes against the muscles of the throat.
1.2 Setting/context and impact of problem
The setting in which the identified problem is observed is the primary care setting. People who have OSA often experience a number of symptoms which include being unusually sleepy in daytime, snoring loudly during sleep, sleep is fidgety, and periods of no breathing/silence during sleep and then followed by gasps (Victor, 2009). Currently, patients who have Obstructive Sleep Apnea are provided with costly and rather cumbersome breathing equipment which provides continuous positive airway pressure (CPAP) through a nasal mask. Adherence to this treatment might be influenced by the objective improvement in sleep apnea as well as by the patient’s subjective perception of the benefit, cost, side effects, family support or bed mate. All in all, most patients dislike CPAP therapy and adherence to it is often poor (Wolkove et al., 2008).
1.3 Gravity of the problem and its significance to nursing
At the moment, patients who present with Obstructive Sleep Apnea are treated with the use continuous positive airway pressure (CPAP). CPAP machines have a fan which blows air under pressure into the patient’s nostrils. In essence, the airflow serves as a pneumatic splint which keeps the pharyngeal airway open (Wolkove et al., 2008). The shortcomings with the current intervention are poor tolerance and ineffectiveness. Patient compliance to CPAP is generally poor. A lot of patients usually have difficulty tolerating the CPAP therapy. Patients often grumble about the rush of air pressure when using CPAP, particularly as they exhale. Researchers have reported lower rates of compliance. Long-term adherence to CPAP intervention might be challenging. Nearly 50 percent of patients would not wear the CPAP mask for a sufficient amount of time every night due to nocturnal awakenings (Victor, 2009). Other researchers have demonstrated that the use of continuous positive airway pressure was ineffective in resolving the symptoms of obstructive sleep apnea (Gutierrez & Brady, 2013). Complications associated with using CPAP include nasal congestion, nasal dryness, conjunctivis, air leaks, facial skin abrasions, and claustrophobia (Victor, 2009).
The severity of OSA disorder might vary and this condition is commonly linked to other physiologic problems including the following: reduced libido; sleep-related arrhythmias; congestive heart failure; pulmonary and systemic hypertension; morning headaches; and altered behaviour and mood for instance memory and cognitive impairment, lethargy and depression (Gutierrez & Brady, 2013). Researchers have reported that an index of at least 20, even in patients who are asymptomatic, is linked to an increased mortality rate (Muñoz-Hernandez et al., 2015). If not treated, Obstructive Sleep Apnea could result in heart disease, stroke, as well as high blood pressure. Therefore, it is of major importance for nursing staff members to use the most appropriate intervention in treating middle-aged men in the primary setting who present with Obstructive Sleep Apnea; CPAP should not be used due to poor tolerance.
1.4 Proposed solution: surgical procedure to prevent/reduce OSA complications
As the best solution to the problem, surgical operation should be carried out on the middle-aged male so as to prevent or decrease the occurrence of complications that are caused by OSA. This proposed intervention is important especially for patients who have mild or severe OSA and are not able to tolerate CPAP. Researchers have reported the efficacy of surgical interventions in preventing or decreasing the symptoms and complications associated with Obstructive Sleep Apnea. Palatal surgery: uvulopalatoplasty is a surgery which removes part of the uvula and soft palate in order to lessen sleep-disordered breathing and snoring (Victor, 2009). Radiofrequency techniques such as somnoplasy could also decrease palatal soft tissue. Uvulopalatopharyngoplasty (UP3 or UPPP) is an effectual surgical operation in reducing the symptoms and complications of Obstructive Sleep Apnea (Muñoz-Hernandez et al., 2015). Jaw surgery: patients who have maxillomandibular anatomy which serves to predispose them to airway obstruction should be advised to undergo jaw surgery. Gutierrez and Brady (2013) reported that maxillomandibular advancement surgical procedure can effectively treat OSA in as many as 95% of patients. Prior to the surgical procedure, skull and jaw radiographs are obtained in order to aid the oral surgeon in making relational measurements of the airway, teeth, and jaw. The use of the proposed solution in the treatment of Obstructive Sleep Apnea in middle-aged men is of great importance in decreasing mortality and morbidity, improving comorbid disease processes, and improving the quality of life of the patients.
2.0 Review of literature
Baradaranfar, M., Edalatkhah, M., Dadgarnia, M., Atighechi, S., Behniafard, N., Mirvakili, A., & ... Emami Meybodi, T. (2015). The Effect of Uvulopalatopharyngoplasty with Tonsillectomy in Patients with Obstructive Sleep Apnea. Indian Journal Of Otolaryngology & Head & Neck Surgery, 6729-33. doi:10.1007/s12070-014-0735-1
Summary of article: Obstructive Sleep Apnea (OSA) is the commonest type of sleep apnoea brought about when the upper airway is obstructed. The prevalence of this disorder is 2 percent in women and 4 percent in men who are middle-aged. Baradaranfar et al. (2015) assessed the efficacy of uvulopalatopharyngoplasty (UPPP) surgical operation in treating patients who had OSA syndrome. Research elements: Baradaranfar et al. (2015) conducted a prospective study. Sleep indices were assessed with the use of polysomnography (PSG) in each patient prior to performing tonsillectomy and UPPP. Research results: Baradaranfar et al. (2015) found that the use of UPPP in OSA patients could result in improvement of symptoms in 64 percent of cases. Significance to nursing and patient care: In the primary care setting, middle-aged men with OSA syndrome who are not able to tolerate continuous positive airway pressure (CPAP) therapy should be recommended for surgical intervention to treat their disorder.
Benazzo, M., Pagella, F., Matti, E., Zorzi, S., Campanini, A., Frassineti, S., & ... Vicini, C. (2008). Hyoidthyroidpexia as a treatment in multilevel surgery for obstructive sleep apnea. Acta Oto-Laryngologica, 128(6), 680-684. doi:10.1080/00016480701636884
Summary of article: Obstructive sleep apnoea syndrome is marked by frequent incidents of complete or partial obstruction of upper airway as one is sleeping resulting in a decline in blood oxygen saturation. During the 5th and 6th decades of a person’s life, 4 percent of men and 2 percent of women are affected by this disorder (Benazzo et al., 2008). The main symptoms are changes in daytime levels of performance, loud snoring and excessive daytime sleepiness. Benazzo et al. (2008) assessed the effectiveness of hyoid surgical operation in combination with oropharynx and nose surgery in treating OSAS. Research elements: in this study, 109 patients with OSAS who had undergone hyoidthyroidpexia as a treatment in multi-level surgical operation took part. Research results: hyoidthyroidpexia surgical procedure was effectual in patients who had OSAS. Significance to nursing and patient care: hyoidthyroidpexia surgical procedure can be used as an intervention in the treatment of OSAS in middle-aged male patients.
Browaldh, N., Friberg, D., Svanborg, E., & Nerfeldt, P. (2011). 15-year efficacy of uvulopalatopharyngoplasty based on objective and subjective data. Acta Oto-Laryngologica, 131(12), 1303-1310. doi:10.3109/00016489.2011.61691.
Summary of article: Browaldh et al. (2011) evaluated the symptoms and recordings of sleep apnoea in patients who had obstructive sleep apnoea fifteen years following uvulopalatopharyngoplasty (UPPP) in comparison to previous follow-ups and baseline. At the moment, mandibular retaining devices (MRDs) and continuous positive airway pressure (CPAP) are the major treatments for OSAS. Research elements: the study was a prospective, non-randomized intervention study that included fifty patients who had undergone UPPP between the year 1985 and 1988, with 49 years as the median age. Research results: there was a noteworthy and stable reduction in median oxygen desaturation index 4 percent values over the 15-year period. Significance to nursing and patient care: uvulopalatopharyngoplasty (UPPP) surgical operation can be employed in primary care as an alternative to CPAP in the treatment of OSA syndrome in 40-60 year old men.
Chisholm, E., & Kotecha, B. (2010). Oropharyngeal surgery for obstructive sleep apnoea in CPAP failures. European Archives Of Oto-Rhino-Laryngology, 264(1), 51-55. doi:10.1007/s00405-006-0139-2
Summary of article: Chisholm and Kotecha (2010) reported that OSA takes place whenever there are recurring occurrences of incomplete or total obstruction of a person’s upper airway as one sleeps. In the United States, in excess of twelve million persons have sleep apnea and 1 in twenty-five men and one in fifty women who are middle-aged have this disorder. CPAP is to some extent an effective management for severe and moderate obstructive sleep apnoea (OSA), but it is poorly tolerated. Chisholm and Kotecha (2010) studied the role of laser-assisted uvulopalatoplasty (LAUP) in patients who had severe to moderate OSA and would not bear CPAP. Research elements: Every participant went through dynamic sleep nasendoscopy in order to establish the anatomical level of blockage and their appropriateness for the procedure. Study subjects were 20. Research results: LAUP is a valuable and effectual instrument for managing OSA and reducing its severity in patients who bear CPAP therapy. Significance to nursing and patient care: laser-assisted uvulopalatoplasty surgical intervention can be utilized in reducing the severity of obstructive sleep apnoea in patients who are not able to tolerate the CPAP therapy.
Göktas, Ö., Solmaz, M., Göktas, G., & Olze, H. (2014). Long-Term Results in Obstructive Sleep Apnea Syndrome (OSAS) after Laser-Assisted Uvulopalatoplasty (LAUP). Plos ONE, 9(6), 1-6. doi:10.1371/journal.pone.0100211
Summary of article: Goktas et al. (2014) noted that OSA syndrome is the most widespread sleep-related breathing sickness. They described OSAS as a serious ailment. OSAS prevalence in women is about 8.2 percent and in men it is about 4 percent. In their study, Goktas et al. (2014) examined lasting outcomes of treatment in patients who had OSAS and they assessed laser-assisted uvulopalatoplasty (LAUP) as a surgical intervention. Research elements: a total of 25 patients took part in the study. Patients who had formerly undergone laser-assisted uvulopalatoplasty (LAUP) surgical operation were invited by the authors were invited for follow-up appointments. Research results: the findings of their study revealed that LAUP is effective in reducing apnea-hypopnea-index (AHI) score of patients who have obstructive sleep apnoea syndrome. Significance to nursing and patient care: laser-assisted uvulopalatoplasty (LAUP) could be used as a surgical intervention in managing OSA syndrome in adult men.
Itasaka, Y., Miyazaki, S., Yin, M., Shibata, Y., Tanaka, T., & Ishikawa, K. (2009). Effectiveness of surgical treatments for obstructive sleep-related breathing disorders: Upper airway pressure analysis. Sleep & Biological Rhythms, 3(3), 114-121. doi:10.1111/j.1479-8425.2005.00181.x
Summary of article: According to Itasaka et al. (2009), people who have OSA syndrome might experience persistent events of hypopnoea and apnoea in the night as they sleep. The recurring sleep disruptions could make the individual to feel very tired during the day. In treatment of obstructive sleep-related breathing ailments, surgical or non-invasive therapies, in combination or separately, are employed and this depends on the severity as well as causes of symptoms. Surgical operation involving nasal surgery, uvulopalatopharyngoplasty (UPPP), tonsillectomy and uvulectomy are carried out depending on the stenotic or obstructive sites in the upper airway (Itasaka et al., 2009). Research elements: in this study, 72 patients with snoring or OSA underwent polysomnography as well as concurrent upper airway andintraesophageal pressure monitoring using a multi-sensor pressure catheter. Research results: Their findings revealed that the usefulness of a surgical intervention could be verified by the concurrent monitoring of upper airway as well as intraesophageal pressure in polysomnography. Significance to nursing and patient care: a number of surgical interventions could be performed depending upon the obstructive sites in the upper airway. Some of these surgical procedures are nasal surgery, uvulopalatopharyngoplasty (UPPP), tonsillectomy and uvulectomy.
Karataylý-özgürsoy, S., & Demireller, A. (2012). Hyoid suspension surgery with UPPP for the treatment of hypopharyngeal airway obstruction in obstructive sleep apnea. ENT: Ear, Nose & Throat Journal, 91(8), 358-364.
Summary of article: According to Karataylý-özgürsoy and Demireller (2012), OSA is usually characterized clinically by recurrent occurrences of hypopnea and apnea as the individual is sleeping. OSA is a grave ailment which has been implicated in accidents involving motor vehicles, too much daytime hypersomnolence, in addition to functional impairment. Furthermore, this illness is linked to cardiovascular mortality and morbidity secondary to cardiac arrhythmia, high blood pressure, cerebrovascular disease, myocardial infarction, as well as congestive heart failure. OSA’s prevalence in men is 4% and 2% in women aged from 30 years to 60 years (Karataylý-özgürsoy & Demireller, 2012). Research elements: Karataylý-özgürsoy and Demireller (2012) carried out an observational, prospective study of twenty patients – 2 women and 18 men – who were aged 15 years to 52 years. Each of the patient had undergone UPPP and hyoid suspension surgery in one session. Research results: surgical operation – uvulopalatopharyngoplasty (UPPP) and hyoid suspension surgery – was in fact effective in 90% of the patients, hence supports proposed solution. Significance to nursing and patient care: in the treatment and management of OSA syndrome, hyoid surgery and UPPP surgery could be considered as the primary treatment in middle-aged patients.
Lundkvist, K., Januszkiewicz, A., & Friberg, D. (2009). Uvulopalatopharyngoplasty in 158 OSAS patients failing non-surgical treatment. Acta Oto-Laryngologica, 129(11), 1280-1286. doi:10.3109/00016480802654380
Summary of article: Obstructive Sleep Apnoea Syndrome (OSAS), as Lundkvist, Januszkiewicz and Friberg (2009) stated, is an ordinary illness. The prevalence of OSAS is two percent in women whilst it is four percent in men. The main symptoms of this disorder are daytime sleepiness, snoring noisily, in addition to non-refreshing sleep. OSAS is strongly linked to cardiovascular diseases like stroke and high blood pressure, and early death, and diabetes type two. Research elements: this was a prospective, randomized study that included 19 women and 139 men with a median of 45 years who has undergone UPPP. Research results: Their findings revealed that 88 percent of the patients who underwent the surgical procedure were happy. The surgical procedure UPPP was found to be safe and effective. Significance to nursing and patient care: since UPPP is both a safe and effective procedure, it can be employed in treatment and management of OSA syndrome in middle-aged men who have this illness.
Park, C. Y., Hong, J. H., Lee, J. H., Lee, K. E., Cho, H. S., Lim, S. J., & ... Kim, H. J. (2014). Clinical Effect of Surgical Correction for Nasal Pathology on the Treatment of Obstructive Sleep Apnea Syndrome. Plos ONE, 9(6), 1-7. doi:10.1371/journal.pone.0098765
Summary of article: Park et al. (2014) pointed out that OSA is essentially a sleep disorder that is common and is marked by airway collapse at several levels of upper airway, which bring about airflow cessation or decrease. OSA might bring about hypoxemia as one sleeps at night or vascular injury because of free oxygen radicals. Moreover, OSA can cause neurocognitive, endocrinologic and cardiovascular diseases if there is no proper diagnosis treatment. Research elements: a total of 25 participants who had decreased patency of nasal cavity as well as narrowing of retropalatal or retroglossal airways were diagnosed with obstructive sleep apnoea and gone through nasal surgical operation like turbinoplasty or septoplasty to correct nasal pathologies. The effect of the surgical operation on nasal patency was measured by calculating minimal cross-sectional area with the use of acoustic rhinometry. Research results: surgical intervention of nasal pathology helps to improve nasal airway patency; it reduced the severity of OSA in 56% of the study participants. Significance to nursing and patient care: nasal pathology surgery could be used as an effective intervention for the management and treatment of OSA syndrome in adult male patients.
Richard, W., Kox, D., de Herder, C., van Tinteren, H., & de Vries, N. (2009). One stage multilevel surgery (uvulopalatopharyngoplasty, hyoid suspension, radiofrequent ablation of the tongue base with/without genioglossus advancement), in obstructive sleep apnea syndrome. European Archives Of Oto-Rhino-Laryngology, 264(4), 439-444. doi:10.1007/s00405-006-0182-z
Summary of article: Richard et al. (2009) examined the surgical outcomes of a multi-level surgical procedure...