Amy M. Sawyer RN, MScN, CS
Sleep/Pulmonary Clinical Nurse Specialist
Philadelphia VA Medical Center
VISN 4 Eastern Regional Sleep Center
Philadelphia, Pennsylvania
Sleepiness that occurs during wakeful hours of the day, low energy and mood, difficulty concentrating, and unrefreshing sleep — does this sound familiar to any of your patients? These are all symptoms experienced by patients with untreated sleep-disordered breathing.
Sleep-disordered breathing is defined as repeated interruptions of breathing during sleep that disturb sleep and cause oxygen levels to drop. Sleep-disordered breathing includes obstructive sleep apnea with well-recognized signs such as snoring, witnessed apneic events, and gasping for breath during sleep. Other types of sleep-disordered breathing include obesity hypoventilation syndrome, central sleep apnea, upper airway resistance syndrome, and Cheyne Stokes breathing during sleep. Many patients with sleep-disordered breathing do not necessarily present with the classic signs, but have more subtle symptoms of impaired daytime function and poor sleep quality. For these patients, it is essential to recognize sleep-disordered breathing as a possible additional medical problem that contributes to or complicates their other health problems.
Degenerative neuromuscular disease patients are particularly likely to fall into this category. Hence they may experience sleep-disordered breathing in addition to their primary neurological problem for which you may provide care such as wheelchairs, ambulatory aids, and commodes. Discovering sleep-disordered breathing in this patient group is often complicated by the persistent neuromuscular symptoms that may include fatigue, shortness of breath (dyspnea), and co-existent depression. Sleep-disordered breathing, a possible secondary disorder, is known to occur in this patient population and, left untreated, significantly impairs daytime function, quality of life, and may contribute to progressive neurologic symptoms.
Patients with degenerative neuromuscular diseases are at risk for sleep-disordered breathing primarily because of respiratory muscle weakness. The patient, therefore, experiences difficulty breathing or an inability to breathe when lying down with resulting increased airway collapsibility or hypoventilation. The result is sleep-disordered breathing that can be accompanied by chronic respiratory failure.
Key questions to ask your patients during routine follow-up homecare visits include:
- Do you experience difficulty breathing when lying flat?
- Has anyone observed an irregular breathing pattern when you are sleeping or napping?
- Do you snore?
- Do you fall asleep easily and/or when you don’t intend to?
- Do you feel unrefreshed on awakening in the morning?
- Do you have a headache on awakening in the morning or during the night?
- Do you have difficulty concentrating or remembering things?
- Have you lost interest in life events that have previously been important to you?
If your patients answer "yes" to one or more of these questions, they should be encouraged to discuss the problem with their medical care provider. Sleep-disordered breathing may be a "silent" contributor to daytime symptoms that may be assumed to be associated with the patient’s chronic, degenerative medical condition. Yet, because sleep-disordered breathing is a distinct and treatable disorder, further investigation of the symptoms described above is warranted in this patient population.
By simply asking a few questions that are sensitive to sleep-disordered breathing and/or chronic respiratory failure, the patient may be directed to a sleep specialist for evaluation. Depending upon the patient’s medical history and insurance coverage, the patient may go to a sleep disorders center or may have a home sleep study to diagnose sleep-disordered breathing. A sleep specialist can determine what type of diagnostic study is best for your patient. With a confirmed sleep diagnosis, nocturnal oxygen or noninvasive positive pressure therapy, either continuous positive airway pressure (CPAP) or bilevel positive airway pressure, can be prescribed and will likely greatly improve the patient’s daytime functional status and nighttime breathing comfort.
Consider Sleep-Disordered Breathing As A Secondary Disorder
In Patients With These Disorders:
Degenerative Neuromuscular Diseases
Chronic Pulmonary Disease
Diaphragmatic Weakness or Paralysis
Spinal Cord Injury/Lesion(s)
Recurrent Uncompensated Congestive Heart Failure
Cardiomyopathy
Pulmonary Hypertension
Systemic Hypertension
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In addition to patients with neuromuscular disease, homecare providers may want to investigate symptoms of sleep apnea in their bariatric wheelchair customers as well as their elderly patients: the prevalence of sleep apnea increases with age and weight.
The ASAA is extremely grateful to Ms Sawyer for volunteering to help advance the ASAA mission of seeing that all with sleep apnea are properly diagnosed and treated.
Ms Sawyer is a clinical nurse specialist in sleep medicine at the Philadelphia VA Medical Center’s VISN 4 Eastern Regional Sleep Center and a doctoral student at the University of Pennsylvania School of Nursing. Her practice and research are largely focused on sleep-disordered breathing.
