Medical Grand Rounds Clinical Vignette March 11, 2009 By Melissa Price, M.D.

Chief Complaint A 40 year-old man is brought to clinic by his wife for evaluation of heavy snoring and witnessed apneic events while sleeping for the past 2 years, worsening over the past 6 months.

History of Present Illness The patient notes that he has been overweight his “entire life.” However, over the past 2 years, he has gained an additional 20 lbs. During this time, he reports increasing daytime sleepiness, despite increasing hours of sleep. He also notes that he has difficulty arising in the morning and rarely feels refreshed.

Additional History Past Medical History: –Hypertension –Hypercholesterolemia –Diabetes –Obesity –Seasonal allergies Past Surgical History: –Denies Social History: –no smoking, alcohol or drug use –drinks 2- 3 cups of coffee each morning Family History: –Mother with diabetes –Father with hypertension Allergies: no known drug allergies Medications: –Telmisartan 40 mg daily –Metoprolol XL 100mg daily –Metformin 1000mg twice daily –Ezetimibe/Simvastatin 10mg/40 mg every evening –Mometasone nasal spray as needed Review of Systems: negative

Physical Exam General: obese male in no apparent distress Vital Signs: BP 158/88, HR 72, RR 18, T 98, 02 sat 97% on room air –Weight 300 lbs, Height 5’11, BMI 41.8 The remainder of the physical exam was normal

Laboratory Findings Basic metabolic panel and complete blood count with differential were within normal limits HbA1C- 7.8 % TSH- 3.7 mU/ml Lipid Panel- Cholesterol 153, LDL 84 EKG- sinus at 72 bpm, borderline LVH CXR- no acute cardiopulmonary pathology

Working Diagnosis Obstructive sleep apnea

Outpatient Course The patient was referred for an outpatient sleep study, the results of which are shown:

Nocturnal Polysomnography (NPSG) Severe OSA with frank apneas and oxygen desaturations down to 65% during REM sleep

Nocturnal Polysomnogram with Nasal CPAP CPAP titration of 13 relieving OSA even during REM sleep.

Nocturnal Polysomnogram Results Axis A Diagnosis: –Severe Obstructive Sleep Apnea Breathing was regular and without significant apnea once therapeutic levels of CPAP were obtained CPAP at 16 cm H20 delivered via large sized nasal mask with heated humidifier was recommended during all sleep periods

Final Diagnosis Severe Obstructive Sleep Apnea

Follow-up Recommendations for CPAP with titration, weight loss and avoidance of alcohol, sedatives, and other respiratory depressants was given. Counseling on increased risk of motor vehicle accidents and avoidance of driving and other critical tasks requiring sustained vigilance until daytime somnolence is treated After 3 months of nocturnal CPAP administration, the patient rated his sleep as “better than ever before” and refreshing His daytime somnolence resolved His wife reported no further apneic episodes