Case Studies in Sleep Medicine

Lifestyle/Occupation: Married, one son. Electronics sales professional. 

 

Referred for: Loud snoring and nonrestorative sleep.

 

Past Medical History: Hypertension, hypercholesterolemia, seasonal allergies.

 

Previous Surgical History: None.

 

Sleep History: Albert reports excessive daytime sleepiness. He reports feeling “very sleepy in the afternoon, unable to stay awake after lunch, feeling groggy when I wake up, I don’t sleep well.” He reports a history of snoring, loud enough to disrupt domestic tranquility. His wife does not report observing apneic episodes during his sleep but he has, on occasion, awakened choking and gasping. He awakens frequently and gets up to urinate twice a night. He naps daily but does not feel refreshed. He has had some difficulty maintaining alertness during meetings and is concerned that his productivity at work has gradually fallen off over the past two years. On workdays he goes to bed at midnight and gets up at 8:30 am. On weekends he usually goes to bed at 12:30-1 am, and sleeps until 9:30-10:00 am. Epworth Sleepiness Scale score is 16, consistent with moderately severe excessive daytime sleepiness. 

 

Medications: Benicar, Amlodipine, Lipitor, Rescon-MX, alprazolam, aspirin.

 

Physical Examination: Height: 72 inches, Weight: 208 lbs. Body Mass Index (BMI): 28.2 (mildly overweight). Oropharynx: uvula, soft palate not visible without use of tongue depressor (Mallampati palate position Class III), Class I dental occlusion.

 

Treatment History: Used alprazolam intermittently to facilitate sleep onset and maintenance, finds that he falls asleep more readily with alprazolam but still wakes up tired. Has gained 20 lbs. in the past five years; trying to lose weight but no success. 

 

Initial Diagnostic Impression: History and symptoms strongly suggestive of obstructive sleep apnea.

Diagnostic Evaluation: One overnight polysomnography, first segment diagnostic evaluation, second segment CPAP trial.

 

Findings: No apneas and 56 hypopneas were observed in the diagnostic portion of the recording, yielding an Apnea + Hypopnea Index (AHI) of 48.9/hour, consistent with severe obstructive sleep apnea. O2 desaturations to 83% were observed. Apneas, hypopneas, snoring and arousals were relieved with CPAP at 8 cm H2O.

 

Treatment Plan: CPAP at 8 cm H2O, with a heated humidifier and nasal mask.

 

Treatment Goals: 1) Improve daytime alertness. 2) Improve sleep continuity, reduce nighttime awakenings. 3) Reduce or eliminate need for benzodiazepine medication (alprazolam) to facilitate sleep onset. 4) Reduce risk for cardiovascular morbidity.

Outcomes: Sleep continuity greatly improved with CPAP at 8 cm H2O. Sleep efficiency (sleep time over time in bed) = 96.2%. No apneas or hypopneas observed with CPAP at 8 cm H2O. Snoring abolished. O2 saturation averages 97.8%. No O2 desaturations below 96%. Patient rates the quality of his sleep as “good,” reports feeling more rested than usual upon awakening with CPAP. Patient reports improved alertness, “feels great” upon awakening in the morning with CPAP. Sleeps through the night. No more nighttime awakenings. Discontinued use of alprazolam. No snoring with CPAP. Spouse’s sleep improved. Marital harmony restored. Concentration, productivity at work improved.