Date of Award

January 2025

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Melissa Knauert

Abstract

The prevalence of Obstructive Sleep Apnea (OSA) in the general adult population has been estimated to be between 9-17% in women and 25-30% in men. However, the prevalence of OSA among medical intensive care unit (MICU) patients is unknown. A 2015 systematic review by Knauert et al demonstrated the associations of OSA with many chronic diseases commonly seen in MICU patients (for instance, hypertension, type II diabetes mellitus, and congestive heart failure). This same review also shed light on the gaps in knowledge surrounding OSA, including underdiagnosis, undertreatment, and lack of research. Given the overall prevalence of OSA and the prevalence of common comorbidities among MICU patients, we hypothesize that OSA is highly prevalent in this population. Furthermore, prior studies of hospitalized patients with OSA have established the link between untreated OSA and increased morbidity and in-hospital complications, but as yet, none has focused on MICU patients with OSA. We hypothesize that OSA often goes unrecognized and unmanaged or incorrectly managed in the MICU. Moreover, we hypothesize that patients whose OSA goes untreated in the MICU will face worse outcomes during and after hospitalization. The overall objective of this study was to investigate the prevalence of OSA among patients in the MICU, the identification and treatment of OSA by MICU teams, and the impact of OSA on MICU patients’ short- and long-term outcomes.This observational study combined retrospective and prospective methods. We abstracted chart data from 750 consecutive patients admitted to the MICU on either of YNHH’s campuses (York Street and St. Raphael’s) between June and October of 2022. Patients admitted for allergic desensitization or medication titration only were excluded from analysis. Patients admitted to YNHH MICU for less than 48 hours or with significant stays in other units prior to MICU admission were included for prevalence data only. We collected demographic information, evidence of prior OSA diagnosis, past medical history, hospital course, OSA recognition, OSA management, and outcomes. Evidence of prior OSA diagnosis included OSA in the problem list, documentation of sleep studies, current orders for PAP therapy, non-ventilatory OSA treatment, documentation of surgical intervention, prior referrals to sleep medicine, or mention of OSA diagnosis in notes. Rater’s confidence in a patient’s OSA diagnosis was classified as “high confidence” (eg. Sleep study scanned into medical record), “low confidence but probable” (eg. Patient report of OSA history but no sleep study found), or “high clinical suspicion but not diagnosed” (eg. Repeated referrals to sleep medicine but no diagnostic testing performed). Data were analyzed in STATA. 255 patients (34.5% of total sample) had evidence of preexisting OSA in their charts. Of these, 32.2% were marked “high confidence”, 27.8% were marked “low confidence but probable”, and 40.0% were marked “high clinical suspicion but not diagnosed.” We found that 17% of patients who were adherent to their home PAP therapy for OSA had no mention of OSA in their MICU treatment plans. 20% of patients adherent to home PAP were given no PAP therapy during their MICU stays and had no rationale given for this treatment decision by providers. Exploratory analysis of outcomes demonstrated that patients with OSA experienced significantly longer intubation periods but a significantly lower mortality rate than those without. We found that OSA was indeed highly prevalent in this population, impacting over a third of MICU patients. We also found that a nontrivial portion of these patients with evidence of OSA were not officially diagnosed with OSA at the time of hospitalization but rather suspected to have OSA by numerous providers. We hope that these findings will serve as the foundation for increased investigation into the role OSA plays in the MICU.

Comments

This is an Open Access Thesis.

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