Case study

Case Study

Robert’s PSG

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Robert, a 45-year-old chronic pain patient, presented at MemorialCare with complex sleep apnea (CSA) superimposed on obstructive sleep apnea (OSA). Robert has a history of chronic long-term long-acting opiate use for chronic pain. He had recently gone through an extensive workup for a chronic intermittent fever of unknown origin (FUO). With a BMI of 39, Robert fit the profile of an OSA patient. Consequently, he was scheduled for a split-night sleep study toward the end of his evaluation. Robert’s PSG showed an AHI of about 63 (14 central apneas, 29 mixed apneas, 20 obstructive hypopneas).

Failure to stabilize with CPAP or bilevel

During the second half of Robert’s study, he failed to stabilize with continous positive airway pressure (CPAP) up to 11 cm H2O. Subsequently, he awakened after only seven minutes of bilevel treatment. On a second night, Robert was introduced again to bilevel treatment with the following results:

Success with VPAP Adapt SV™

  • Spontaneous mode bilevel: AHI increased to 107/hr (85% centrals).
  • Spontaneous-timed mode bilevel: AHI was 99/hr with apparently mostly obstructive events.
  • Spontaneous-timed bilevel with entrainment of oxygen at up to 2 L/min: AHI was 62/hr with mostly obstructive events.

Following the unsatisfactory results with CPAP and bilevel, Robert was introduced to VPAP Adapt SV, a new adaptive servo-ventilator available for the treatment of CSA. Because of the low sleep efficiency Robert had experienced previously, we gave him temazepam 30 mg (a benzodiazepine) at bedtime. We started VPAP Adapt SV with the default pressure settings at 8/5 with the following results:

  • Robert fell asleep in 0 minutes and slept a total of 461 minutes.
  • Phenomenally high sleep efficiency of 99.5%.
  • REM latency was a scant 7.5 minutes.
  • Remarkable REM rebound—5 REM periods comprising a 37% REM rebound.
  • Only ONE scoreable hypopnea was noted during the entire night.
  • There were NO apneas.
  • Only a few RERAs.
  • Sleep was unbelievably consolidated with a total arousal index of 6/hr.

Subjectively, the patient’s clinical response was very good. He indicated sleep quality was ‘much better than usual.’ Robert was subsequently initiated on VPAP Adapt SV for the treatment of his CSA.

Stephen E. Brown, MD
Medical Director
MemorialCare Sleep Disorders Center
Long Beach Memorial Medical Center