clinics in surgery clinical image · chief complaints were frequent awakenings from sleep, snoring...
TRANSCRIPT
Remedy Publications LLC., | http://clinicsinsurgery.com/
Clinics in Surgery
2017 | Volume 2 | Article 15261
Patient with Chronic Pain and Sleep Disturbance
OPEN ACCESS
*Correspondence:Susmita Chowdhuri, Department of Sleep Medicine, John D. Dingell VA Sleep Wake Disorders Center and
Wayne State University, 46446 John R, Detroit, MI, USA,
E-mail: [email protected] Date: 17 Mar 2017Accepted Date: 15 Jun 2017Published Date: 29 Jun 2017
Citation: Abbas H, Edward S, Mukkavilli V,
Anees F, Saleeby K, Chowdhuri S. Patient with Chronic Pain and Sleep
Disturbance. Clin Surg. 2017; 2: 1526.
Copyright © 2017 Chowdhuri S. This is an open access article distributed under
the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work
is properly cited.
Clinical ImagePublished: 29 Jun, 2017
Abbas H, Edward S, Mukkavilli V, Anees F, Saleeby K and Chowdhuri S*
Department of Sleep Medicine, John D. Dingell VA Sleep Wake Disorders Center and Wayne State University, Detroit MI, USA
Abbreviations AHI: Apnea/Hypopnea Index; ASV: Adaptive Seroventilation; BPAP: Bilevel Positive Airway
Pressure; CAI: Central Apnea Index; CPAP: Continuous Positive Airway Pressure; CSA: Central Sleep Apnea; qd: Daily; P. Flow: Pressure Transducer Flow; PO: Oral; RE: Respiratory Event; T. Flow: Thermistor Flow; EEG: Electroencephalogram; EOG: Electrooculogram; EKG: Electrocardiogram; OA: (red bars): Obstructive Apnea; OH: (green bars): Obstructive Hypopnea; CA: (blue bars): Central Apnea; Thorax/Abdomen: Thoracic and Abdominal Respiratory Inductance Plethysmography; SaO2: Oxygen Saturation via Pulse Oximetry
Clinical ImageA 62-year-old gentleman was referred to the sleep clinic for evaluation of sleep apnea. His
chief complaints were frequent awakenings from sleep, snoring and gasping. Past medical history: hypertension and COPD. Medications: Lisinopril PO 10 mg qd, Symbicort inhaler BID and methadone 55 mg PO qd.
BMI: 29, Oropharyngeal exam: Mallampati score IV, lateral narrowing, no tonsillar hypertrophy or macroglossia, normal nasal turbinates; otherwise unremarkable exam 2D echocardiogram: ejection fraction 65% (Figure 1).
Q1. What is the likely diagnosis?
Q2. What is the next step in the management?
Answer 1. Central sleep apnea (CSA) is due to medication or substance (narcotic or opioid induced CSA) (ICSD-3).
PSG showed: AHI: 24.5/h, CAI: 20.3/h.
Answer 2. Patient underwent titration but continuous positive airway pressure (PAP) alone, CPAP plus oxygen and bilevel PAP with oxygen did not eliminate central apnea (CA) (Figure 2). ASV alone was ineffective but addition of oxygen to ASV reduced central apneas. Patient was also advised to taper and stop methadone (Figures 2 and 3).
Figure 1: PSG was performed.
Chowdhuri S, et al., Clinics in Surgery - Otolaryngology
Remedy Publications LLC., | http://clinicsinsurgery.com/ 2017 | Volume 2 | Article 15262
Figure 2 and 3: Patient was also advised to taper and stop methadone.
References1. The International Classification of Sleep Disorders - Third Edition (ICD-
3).
2. Javaheri S, Malik A, Smith J, Chung E. Adaptive pressure support Servoventilation: a novel treatment for sleep apnea associated with use of opioids. J Clin Sleep Med. 2008;4(4):305-10.