DATE OF STUDY: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: This is a patient with longstanding history of sleep apnea, difficulty with treatment. The patient had a sleep study last month documenting persistent sleep apnea with an apnea index of 17 an hour, RDI of 28 an hour with O2 sats at 82%. This is in a patient with underlying atherosclerotic heart disease with evidence of reduced ejection fraction by echocardiogram.
PATIENT PROFILE: Height 62 inches, weight 219 pounds, BMI 40. Epworth sleepiness score was 6. The patient is undergoing a study with low flow oxygen to see if that is effective and then CPAP if required.
This was a study using 16 channel digital acquisition device with 6 leads of EEG, 2 leads of EOG, 1 lead of chin EMG, right and left leg EMG, body position and pulse oximetry. Thoracic and abdominal strain gauges were used to measure respiratory effort, microphone recorded snoring and nasal pressure transducer monitored air flow.
LOW FLOW OXYGEN TRIAL:
SLEEP PROFILE: The patient studied 3.2 hours, sleep time of 1.8 hours. Sleep efficiency 57%. Sleep onset 42 minutes without REM sleep. The spontaneous arousals totalled 76 with an index of 41 an hour.
SLEEP STAGES: Stage I 39%, stage II 61%.
OXYGEN PROFILE: The patient on low flow oxygen at 2 liters, baseline saturation 99%, mean sat 93%, lowest was 88%.
RESPIRATORY PROFILE: The patient slept principally right and left side with 1 obstructive apnea and 100 hypopneas and 31 RERAs producing an AHI of 55 an hour, which is worse than baseline on room air. The patient then converted to CPAP titration.
CPAP TITRATION:
SLEEP PROFILE: The patient studied 3.9 hours with sleep time of 3.3 hours, sleep efficiency 86%. Sleep onset was 7 minutes, REM latency is 183 minutes. The spontaneous arousals totalled 129 with an index of 38 an hour.
SLEEP STAGES: Stage I still elevated at 28%, stage II 57%, REM sleep 15%.
OXYGEN PROFILE: The patient studied on room air on CPAP. Baseline saturation 93%, mean sat 90%, the lowest sat was 83%.
RESPIRATORY PROFILE: The patient studied principally supine but also on the right side with CPAP with no apneas, 18 hypopneas and 51 RERAs producing an AHI of 5 an hour. A review of CPAP pressures of 4 through 11 cm shows, with the patient on a pressure of 11 cm, high sleep efficiency with 82 minutes of sleep time and an AHI of 5 an hour, but an RDI total of 7 which is a marked improvement from the lower pressures. This includes the patient sleeping right side and supine in REM sleep with very effective sleep.
CARDIAC PROFILE: The patient was in sinus rhythm throughout the study, an average heart rate awake of 80, asleep of 70 with ectopy.
LIMB MOVEMENT PROFILE: Unremarkable.
The patient studied on CPAP with a petite ComfortGel mask and with humidification and would recommend CPAP at 11 cm with moderate altitude humidifier at 4/6 and petite ComfortGel mask. Voice message has been left with the patient to discuss the results of the study. We would hope to see the patient in the clinic in a couple of weeks after starting therapy.
DIAGNOSES:
1. Obstructive sleep apnea. Intensity actually is worse with the use of low flow oxygen.
2. Sleep related hypoxemia.
3. Arteriosclerotic coronary artery disease.
4. Obesity, morbid.
PLAN: Treatment with CPAP at 11 cm with moderate altitude petite ComfortGel mask and humidifier at 4/6.
