Sleep and sleep-disordered breathing in the hospitalized patient

Clinicians are becoming more aware of the risks of sleep deprivation and unrecognized sleep-disordered breathing in hospitalized patients, most importantly in those patients planning to undergo surgical procedures. Polysomnography is difficult to perform in the hospital setting, such that actigraphy or urinary metabolites of melatonin are often used as surrogate measures, and show that sleep is markedly impaired. Patients in the medical intensive care unit with sepsis or requiring mechanical ventilation may show complete absence of the normal circadian rhythm pattern, and many centers have initiated sleep-enhancement protocols. In postoperative patients, rapid-eye-movement sleep is nearly obliterated, especially in the first 1-2 days after surgery, and this appears closely related to the use of high-dose opioids. Sleep-disordered breathing is common in postoperative patients, and tools such as the Sleep Apnea Clinical Score or the STOP-BANG (Snoring, Tiredness, Observed apnea, and high blood Pressure - Body mass index, Age, Neck circumference, and Gender) questionnaires have been utilized to predict the possibility of obstructive sleep apnea (OSA) and postoperative respiratory complications. Protocols to evaluate patients that determine the need and process for positive-airway-pressure treatment in the hospital patient with OSA are being developed. An obstructive apnea systematic intervention strategy protocol to deal with patients with suspected OSA can help guide diagnostic and therapeutic decision making. Hospitals that are proactive in the development of protocols for identification and management of patients with sleep-disordered breathing are likely to be rewarded with reduced complications and costs, and the issue is sure to be incorporated in future pay-for-performance evaluations.