# Management of Obstructive Sleep Apnea in Hospitalized Patients
###### Abstract  
Obstructive sleep apnea (OSA) is highly prevalent in the general population. In addition, patients with comorbid OSA are frequently hospitalized for unrelated conditions. This review focuses on managing patients with comorbid OSA in inpatient and acute care settings for inpatient providers. OSA can impact the length of stay, the risk of intubation, the transfer to the intensive care unit, and mortality. Screening questionnaires such as STOP-BANG can help with screening hospitalized patients at admission. High-risk patients can also undergo additional screening with overnight pulse oximetry, which can be used to guide management. Options for empiric treatment include supplemental oxygen, continuous positive airway pressure therapy (CPAP), auto adjusting-PAP, bilevel positive airway pressure therapy (BPAP), or high-flow nasal cannula. In addition, discharge referral to a board-certified sleep physician may help improve these patients' long-term outcomes and decrease readmission risks. OSA; SDB; OSA in-hospital; OSA CHF; auto-CPAP; inpatient sleep medicine +
Footnote †: journal: Medical  
are limited [22; 23; 24; 25; 26; 27; 28]. Understanding the management of OSA in inpatient settings is vital for inpatient providers, as a majority of the patients with OSA remain undiagnosed and are likely to present to the hospital without a diagnosis of OSA [29]. Male gender and obesity are the most significant risk factors for OSA [15]. Daytime sleepiness, snoring, and pauses in breathing are notable symptoms of OSA. A comprehensive list of signs and symptoms is described in Table 1[30; 31; 32]. These can frequently be missed in hospitalized patients due to the focus on managing the underlying illness. A retrospective chart review of 100 inpatient referrals for hospital-based PSG revealed that sleep-disordered breathing (SDB) was present in 77% of the study population [33]. While this study may have been limited by a referral bias, an increase in body mass index (BMI) was associated with an increase in the presence and severity of SDB. In this study, other common comorbid conditions included congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) in addition to OSA [33]. In a study of hospitalized patients, screening with the Berlin questionnaire revealed that 40% of patients over the age of 50 were at high risk for OSA [34]. In a prospective study of 148 patients who had a medical emergency team (MET) activation, 50% of the patients screened positive as high risk for OSA, and hypoxia was the most common reason for MET activation [35]. In another study, patients who screened as high risk for OSA had higher activation of the rapid response team (RRT). However, the number of RRT activations was lower among patients who were compliant with positive airway pressure (PAP) therapy compared to those who were non-compliant or without PAP therapy [36]. The decrease in RRT activation in those treated for OSA suggests that treatment of OSA in hospitalized settings may improve outcomes. OSA is frequently identified for the first time during the preoperative assessment of patients undergoing elective surgery [37]. OSA in the postoperative population is associated with almost double the odds of cardiac and non-cardiac complications such as respiratory failure, atrial fibrillation, hospital readmission, LOS, and ICU admission [5; 38]. OSA in the cardiac surgery population is associated with a higher incidence of postoperative major adverse cardiac or cerebrovascular events (OR 2.4) and a higher risk of paroxysmal atrial fibrillation (OR 1.94) [38; 39]. Multiple commonly seen disorders in inpatient settings are associated with comorbid OSA. Acute exacerbation of CHF is a common reason for hospitalization. SDB has been reported in up to 76% of CHF patients, with OSA present in 36% [40]. In patients admitted to the hospital with hypercarbic respiratory failure, OSA prevalence approaches 80-90% [41].