28
AASMMembershipSectionsNewsletter
■
Issue #5
AmericanAcademy
of SleepMedicine
She completedherMDandMPHTM
at TulaneUniversity, and her training
in Internal Medicine, Pulmonary&
Critical Care, andSleepMedicine at
theUniversity of MarylandSchool
of Medicine. Her research interests
include ambulatorymodels of sleep
care, health access, peri-operative
risk related to sleep disordered
breathing, and the relationship
betweenPTSD and sleepapnea.
She is amember of theVASleep
Network steering committee,
a groupof VAsleep providers
working together topromote high
quality clinical care, to standardize
programmatic processes, and to
developmultisite collaborative sleep
research. Aself-proclaimed foodie,
oenophile, and craft beer enthusiast,
her other interests include full and
half marathons, yoga, and travel.
ChadHagen, MD
Dr. Hagen isDirector of theOregon
Health andScienceUniversitySleep
DisordersProgram. Hemaintains
a busy academic sleep clinical
practice, teaches residents and sleep
medicine fellowswhile continuing
research related to sleep disordered
breathing syndrome definition and
diseasedetection. ■
Testing:
Ferritinnormal at 254ng/mL
Split -night polysomnogramdidnot
split to treatment as theAHI calculated
usingAASMhypopnea ruleB (CMS-4%-
AHI)was less than20. TheCMS-4%-AHI
requires a4%desaturation for the inclusion
of hypopnea. For the entirenight, both
theCMS-4%AHI and the rateof 4%
desaturations per hourwereboth1.8. There
werenoobstructive apnea, no central or
mixed apnea and theminimumoxygen
saturationof 88%. The apneahypopnea
index calculatedusingAASMhypopnea
ruleAwas 17which includehypopnea
with either a3%desaturationor an arousal.
PLM indexwas 38 andPLM indexwith
arousalwas 12.
Question1
Basedon these results,whatmost likely
causedhis apnea, loud snoring, non-
restorative sleep, excessivedaytime
sleepiness, Epworth scoreof 15, restless leg
symptoms,morningheadaches, drowsy
driving, anddozingoff atwork?
A. Periodic limbmovement disorder
B. B.Restless leg syndrome
C. Obstructive sleep apnea
D. Narcolepsy
E. Stress
Question2
What is themost rational first treatment
recommendation?
A. Dopamine agonist or gabapentin
B. Iron replacement
C. CPAP
D. Stimulant or alertingmedications
E. Weight loss
TreatmentCourse
Although theAHI-4%-CMSwas 1.8, his
AHI followingAASMhypopnea scoring
ruleswasmuchhigher at 17, indicating
significant arousal from sleepdue to
OSAHS. This amount ofOSAHS appeared
likely to contribute tohis presenting
symptoms ofwitnessed apnea, loud snoring,
non-restorative sleep, excessivedaytime
sleepiness, Epworth scoreof 15, restless leg
symptoms,morningheadaches, drowsy
driving, anddozingoff atwork - thusCPAP
was initiated. Hewasnever treatedwith
hypnotics, dopamine agonists, gabapentin,
iron supplementation, or other sleep related
medications at any timeover his courseof
treatment
Outcome
Hewas observedduring titration to
havenormal sleep andbreathing laterally
atCPAPof 9 cmH20, andnormal sleep
andbreathing supineonce increased to11
cmH20. He took approximately2weeks
to accommodate toCPAP therapy, and
was thereafter compliant andbenefiting
from treatmentwithCPAP in automode
fromminimumpressureof 9 tomaximum
pressureof 11 cmH2O.His averageCPAP
usewas 6hours 33minutes pernight
withgreater than90%of nights>4hours.
Objectively, flow reductionswith arousal
at a rateof 17per hourwere reduced to<
5per hourwithCPAP titration andflow
changeswere reduced to0.8per hour as
estimatedbydatadownload fromhisCPAP
machine. Subjectively, hisEpworth score
reduced from15 to6, he reported resolution
ofmorningheadaches, sleep complaints,
complete resolutionof restless leg
sensations, andhiswife reported resolution
of snoring andpauses inhis breathing. He
reported significant improvements in ability
to stay awake and alert throughout theday,
no longer dozedoff atwork, andhadno
further incidents of drowsydriving.
