Effects of CPAP Treatment for Sleep Apnea on Dysrhythmias

Introduction

Obstructive sleep apnea is a treatable and chronic disorder that has been estimated to affect over 18 million Americans. It is often characterized by either recurrent or partial closure of the upper airway. In most cases, it is dealt with using brief arousals. It has been linked with intrathoracic pressure changes. This gives rise to sleep fragmentation, increased nervous system stimulation at night. and a rise in circulating the inflammatory markers of the endothelial dysfunction (Raghuram, Clay, Kumbam, Tereshchenko, & Khan, 2014). This paper will carry an assessment of the effects of using CPAP for sleep apnea on dysrhythmias during hospitalization period in the ICU in male patients aged 40 years and above and who have suffered a myocardial infarction.  

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Studies have highlighted a connection between obstructive sleep apnea and myocardial infarction. It is estimated that over 65 percent of the patients who seek medical attention for a cardiovascular event is diagnosed with OSA (Porto, Sakamoto, & Salles, 2017). An increase in the severity of the obstructive sleep apnea has been associated with increased sleep fragmentation, which subsequently increases the risk of cardiac arrhythmias. Patients with congestive heart failure face a higher risk of sudden cardiac death from ventricular arrhythmias hence important to deal with it (Raghuram, et al., 2014).

In severe cases of obstructive sleep apnea, continuous positive airway pressure (CPAP, is used. CPAP is a treatment that aims at delivering positive pressure through a mask with an objective of maintaining the opening of the upper airways during sleep. In their study, Abumuamar, Molleyeva, Sandor, Newman, Nanthakumar, and Shapiro (2017) indicated the potential effect of improved nocturnal breathing with CPAP application on altered cardiac impulse formulation and impulse conduction, which are critical in the mechanism of cardiac arrhythmia.

The Spirit of Inquiry Ignited

Within the nursing practice, it is important to recognize the need for Evidence-based Practice (EBP). This is an aspect emphasized during the nursing education. It is an essential problem-solving approach geared towards the delivery of health care that incorporates the best evidence from studies such as patient care data with the practitioners’ experience and expertise as well as the preference and values of the patient. In reference to this research, the question of the use of the CPAP treatment regimen for patients who had suffered myocardial infarction to treat sleep apnea has severally lead to different opinions among physicians. The urge to establish a consensus on the effect of applying the CPAP treatment or not on dysrhythmias informed on the formulation and development of this research proposal. It was clear that there was a need to outline different scientific evidence based on different researches carried out on the use of CPAP for sleep apnea. The research was thereby developed with an aim of establishing whether the CPAP intervention was really necessary, to gather evidence supporting or opposing its application, describe its benefits to the patients in reference to dysrhythmias, and evaluate if not applying the intervention may have better or different outcomes.

PICOT Question Formulation 

P: Male patients aged between 40 and above who have suffered a myocardial infarction 

I: The use of a CPAP for sleep apnea

C: not using CPAP

T: Period of hospitalization in the ICU

PICOT Question 

In male patients aged between 40 and above who have suffered a myocardial infarction, how does the use of a CPAP for sleep apnea compared to not using affect dysrhythmias during their hospitalization in the ICU?

Search Strategy Conducted

The search for the evidence from different sources was carried out in medical databases such as PubMed, Cochrane Library, and TRIP database. The keywords used in the search were “CPAP for sleep apnea in patients with myocardial infarction.” Among the limiters used in the research process include trials, systematic reviews, and articles published in the last ten years. The search in the PubMed Database included the following MESH search “(effects [All Fields] AND CPAP[All Fields] AND (“sleep apnea”[All Fields] OR “sleep apnea syndromes”[MeSH Terms] OR (“sleep”[All Fields] AND “apnea”[All Fields] AND “syndromes”[All Fields]) OR “sleep apnea syndromes”[All Fields] OR (“sleep”[All Fields] AND “apnea”[All Fields]) OR “sleep apnea”[All Fields]) AND (“patients”[MeSH Terms] OR “patients”[All Fields]) AND (“myocardial infarction”[MeSH Terms] OR (“myocardial”[All Fields] AND “infarction”[All Fields]) OR “myocardial infarction”[All Fields])) AND (“2008/07/19″[PDat]. From this research process, a total of 35 relevant articles were identified from databases, with 9 articles from the PubMed database, 24 articles from the Cochrane library, and 20 articles from the TRIP Database.

Critical Appraisal of the Evidence Performed

A critical appraisal process was carried out to establish the appropriateness of the different articles identified as part of the evidence. Among the issues considered in the research process were their population, intervention, alternative intervention, outcome, and timeframe for the study. Most of the articles under consideration involved a study of a population that was undergoing CPAP treatment and were thereby considered relevant to inform on the current study. All the studies approved to be used in this study covered CPAP as the main intervention with different intervention such as ICD therapy and no CPAP treatment as alternative outcomes for comparison. The articles reviewed considered outcomes such as effects of cardiac arrhythmia and major cardiovascular outcomes such as myocardial infarction ventricular arrhythmias, and blood pressure. The level of evidence in these articles was either level I or level II evidence, which implies that the evidence can be considered reliable and valid. The articles selected as a source of evidence for this study were published in the last five years thereby enhancing their validity. The findings from these articles were relevant to practice and could be applied in practice.  

Evidence Integrated with Clinical Expertise and Patient Preferences to Inform a Decision and Practice Change Implemented

Among the evidence presented, it was observed that the impact of CPAP treatment on the frequency and severity of cardiac arrhythmia was affected by a number of factors such as duration of CPAP application, compliance level with the prescribed treatment, the initial severity level of obstructive sleep apnea, and cardiological pathology (Mollayeva, Sandor, & Shapiro, 2017). These factors should be considered when implementing CPAP treatment in patients. Comparison of the application of CPAP treatment on patients and treatment with no CPAP indicated that treatment group with CPAP treatment had a 1.5 percent combined occurrence of death, myocardial infarction, coronary revascularization, and stroke events in comparison to the group with no CPAP where combined incidence of the above outcomes was 11.4 percent (Qi et al., 2016). Patients with obstructive sleep apnea placed on CPAP treatment are indicated to have an escalation to more permanent forms of atrial fibrillation in comparison to those with no CPAP treatment (Holmqvist et al., 2015).

Outcome Evaluated

The study by Pecker (2016) indicated that the incidence of the primary endpoint did not differ significantly between patients who received CPAP treatment versus those who did not receive. Another study by McEvoy (2016) indicated that CPAP significantly reduced snoring and daytime sleepiness and improved quality of life and blood. The positive effect of the application of the CPAP treatment was asserted by Qi et al. (2016), who indicated that CPAP treatment leads to a significant reduction in systolic blood pressure in patients with hypertension. Important factors that were found to affect the effectiveness of the CPAP treatment as identified by Abumuama et al. (2017) include the duration of CPAP application, compliance with treatment, baseline severity of OSA, and cardiac pathology. The study by Holmqvist et al., (2015) revealed that patients with OSA CPAP treatment were less likely to progress to more permanent forms of AF as compared to patients without CPAP.

Project Dissemination

The project will be disseminated with an aim of reaching every relevant stakeholder. Among the important stakeholders are the primary care physicians. The project may be disseminated through publishing in the medical journals. The results may also be presented in relevant workshops, and conferences.

Conclusion

The research discussed above was developed with an aim of establishing whether the CPAP intervention was really necessary, to gather evidence supporting or opposing its application, describe its benefits to the patients in reference to dysrhythmias, and evaluate if not applying the intervention may have better or different outcomes. The literature was acquired for PubMed, Cochrane Library, and TRIP databases. The analysis of evidence indicated that the impact of CPAP treatment on the frequency and severity of cardiac arrhythmia was affected by a number of factors such as duration of CPAP application, compliance level with the prescribed treatment, the initial severity level of obstructive sleep apnea, and cardiological pathology. CPAP treatment was found to be effective. CPAP treatment was found to have positive outcomes in the reduction of snoring and daytime sleepiness, improved quality of life and blood, and reduction in systolic blood pressure.

References 

Abumuamar, A. M., Mollayeva, T., Sandor, P., Newman, D., Nanthakumar, K., & Shapiro, C. M. (2017). Efficacy of continuous positive airway pressure treatment in patients with cardiac arrhythmia and obstructive sleep apnea: what is the evidence? Clinical Medicine Insights: Therapeutics, 9, 1179559X17734227.

Holmqvist, F., Guan, N., Zhu, Z., Kowey, P. R., Allen, L. A., Fonarow, G. C., … & Holmes, D. N. (2015). Impact of obstructive sleep apnea and continuous positive airway pressure therapy on outcomes in patients with atrial fibrillation—Results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). American heart journal, 169(5), 647-654.

Porto, F., Sakamoto, Y. S., & Salles, C. (2017). Association between Obstructive Sleep Apnea and Myocardial Infarction: A Systematic Review. Arquivos Brasileiros de Cardiologia108(4), 361–369.

Raghuram, A., Clay, R., Kumbam, A., Tereshchenko, L. G., & Khan, A. (2014). A Systematic Review of the Association between Obstructive Sleep Apnea and Ventricular Arrhythmias. Journal of Clinical Sleep Medicine: JCSM: Official Publication of the American Academy of Sleep Medicine, 10(10), 1155–1160.Qi, Y., Cai, M., Zhang, H. M., Yang, L. R., Qin, F., Liang, E. P., … & Zou, Y. B. (2016). Impact of long-term continuous positive airway pressure treatment for patients with obstructive sleep apnea syndrome. Zhonghu Xin Xue Guan bing za zhi44(2), 144-149

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