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Persistent Sleepiness in Obstructive Sleep Apnea

Case Editor - Kamyar Afshar

Reviewed By Sleep and Respiratory Neurobiology Assembly

Submitted by

Nader Mina, MD

Fellow

Pulmonary, Critical Care and Sleep Medicine

Wayne State University

Detroit MI

Anan Salloum, MD

Assistant Professor of Medicine

Pulmonary, Critical Care and Sleep Medicine

Wayne State University

Sleep-Wake Disorders Center, John D. Dingell VA Medical Center, Detroit MI.

Susmita Chowdhuri, MD, MS

Associate Professor of Medicine

Pulmonary, Critical Care and Sleep Medicine

Wayne State University

Sleep-Wake Disorders Center, John D. Dingell VA Medical Center, Detroit MI.

Submit your comments to the author(s).

History

This is a 48 year-old female with a history of hypertension who presented to the sleep clinic with snoring, fatigue, daytime sleepiness, frequent nocturnal arousals, and morning headache. Her Epworth Sleepiness Scale (ESS) score was 17.

Review of her sleep habits revealed that her bedtime was around 10 pm, with sleep latency of 20 minutes, 2 nocturnal arousals without difficulty falling back asleep, and a final awakening around 8 am.

The patient denied any history of smoking or alcohol or recreational drug use, but had been consuming about 48 ounces of caffeine daily to stay awake. She denied using any sedating medications.

Physical Exam

Exam was significant for BMI of 38 kg/m2, oropharyngeal exam revealed Mallampati class IV, and mildly enlarged tonsils. The cardiovascular and respiratory examinations were normal.

The patient underwent a split-night polysomnography (PSG) study confirming the diagnosis of obstructive sleep apnea (OSA), with an apnea-hypopnea index (AHI) of 76.4/hour, minimum oxygen saturation of 87% and sleep efficiency of 57.7% during the baseline portion of the study. Figure 1 presents the hypnogram from the polysomnography study. 

Figure 01

Figure 1: The hypnogram represents the split-night PSG study with an initial diagnostic portion followed by titration with continuous positive airway pressure (CPAP): On the respiratory event channel, the green and red bars represent hypopneas and obstructive apneas, respectively. Respiratory events channel: numbers indicate duration of event in seconds. clock time is indicated on the top border of the figure. Body position channel: B: back, R: right, L: left, S: side. SaO2; oxygen saturation. Heart: heart rate. Treatment: numbers indicate CPAP setting (cm H2O).

Subsequently, the patient was prescribed continuous positive airway pressure (CPAP) therapy.  

Question 1

During the subsequent clinic visits, the patient continued to complain of daytime sleepiness with an ESS score of 18.

What should be the next step in the management of this patient?


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