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Opioid-induced respiratory depression in patients with obstructive sleep apnea (OSA) has been the topic of many of our columns. But weve most often discussed this in relation to patients undergoing surgery. But medical patients are also at risk. In our May 6, 2014 Patient Safety Tip of the Week Monitoring for Opioid-induced Sedation and Respiratory Depression we noted a study (Herzig 2014) that showed over half (51%) of non-surgical inpatients receive opioids, often in high doses. And many nonsurgical patients also have a high risk of known or undiagnosed OSA.
Results of the OpiatesHF Study were just published (Niroula 2019). This study looked at a population known to have a high prevalence of sleep disorder breathing (SDB) those hospitalized with acute heart failure. Notice we said sleep disordered breathing rather than obstructive sleep apnea. Thats because many patients with acute heart failure may have central sleep apnea or Cheyne-Stokes breathing or obstructive sleep apnea. In the OpiatesHF Study, 54% had predominantly central apnea or Cheyne-Stokes breathing and 46% had predominantly obstructive sleep apnea.
The study looked at a sequential group of over 300 patients hospitalized with acute heart failure, who received a portable sleep study (PSS) after screening for SDB using the STOP-BANG questionnaire. The researchers then did a retrospective review of charts to assess use of opiates, need for escalation of care (defined as transfer to the intensive care unit), 30-day readmission, and length of stay.
Overall, 41.5% received opiates in the hospital, and 49.5% patients had an AHI (apnea/hypopnea index) greater than or equal to 10/h by PSS (high risk of SDB). In this high-risk group, 32% received opiates. Among those with an AHI greater than or equal to 10/h, escalation of care occurred in 26% of those who received opiates versus 4% of those who did not. Readmission within 30 days occurred in 15% of those who received opiates versus 9% of those who did not, though that difference did not meet statistical significance. Mean LOS did not differ significantly between groups.
The key finding of this study is that use of opioids in this patient population can be dangerous and should be avoided but also that careful monitoring is needed when opioids are necessary. As per our usual recommendations, that should include not just pulse oximetry but also apnea monitoring and capnography. The study also notes the utility of screening patients with the STOP-BANG questionnaire and perhaps doing a portable sleep study to further risk-stratify patients.
Apparently, opioids were most often used in these patients for comorbid conditions, like arthritis or back pain, and had often been used prior to admission. Some who were recognized to be at high risk might be considered for discontinuation of outpatient opioids and/or considered for CPAP, where appropriate based on results of a sleep study.
But the study also raises one other important issue. Low-dose opioids are often used in palliative care to reduce the sensation of dyspnea or breathlessness, and more and more patients with heart failure are in palliative care programs. The OpiatesHF Study did not specifically look at the correlation between opioid dose and outcomes, but it is known that the impact of opioids on SDB is dose-dependent. It would be of interest to see whether risk stratification (by presence or absence of SDB) is of benefit in heart failure patients receiving palliative care.
The OpiatesHF Study serves as a reminder that opioid use is common in nonsurgical patients admitted to the hospital and that many, particularly those with acute heart failure, also have sleep disordered breathing that may put them at risk if opioids are given.
Other Patient Safety Tips of the Week pertaining to opioid-induced respiratory depression and PCA safety:
Herzig SJ, Rothberg MB, Chekung M, et al. Opioid utilization and opioid-related adverse events in nonsurgical patients in US hospitals. Journal of Hospital Medicine 2014; 9(2): 73-81
Niroula A, Garvia V, Rives-Sanchez M, et al. Opiate Use and Escalation of Care in Hospitalized Adults with Acute Heart Failure and Sleep-disordered Breathing (OpiatesHF Study). Ann Am Thorac Soc 2019; 16(9): 1165-1170
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