July 2023 Sleep Case of the Month: Fighting for a Good Night’s Sleep

Meneena Bright MD

Sleep Medicine

Brigham and Women’s Hospital

Harvard Medical School

Boston, MA USA

A 31-year-old man presented for follow-up in the Sleep Medicine clinic. He has a past medical history of a seizure disorder and supraventricular tachycardia (SVT) and was referred after complaining of excessive daytime sleepiness. Current medications include citalopram and diltiazem. Four months prior, he was diagnosed with severe obstructive sleep apnea characterized by an apnea-hypopnea index (AHI) of 34 and an oxygen saturation nadir of 86%. The patient was initiated on continuous positive airway pressure (CPAP) therapy; however, he reported ongoing mask discomfort and difficulty with exhalation while wearing CPAP. Despite partial improvement in sleep fragmentation and daytime sleepiness, the patient reported sleeping for only 4 hours per night. The patient's sleep schedule was irregular, with bedtime ranging between 9:30 pm and 12 am, waking up at 5 am, and taking a daily nap for 4-5 hours in the morning during which he continued to use CPAP. Additionally, he described experiencing episodes of waking up from dreams, often screaming or throwing punches. A score of 15 on the Epworth Sleepiness Scale (ESS) indicated significant daytime sleepiness.

What should be done next? (Click on the correct answer to be directed to the second of five pages)

1. Begin oxygen at night
2. Begin self-titrating CPAP
3. Discontinue diltiazem
4. Neurology referral
5. Overnight laboratory polysomnography

Cite as: Bright M. July 2023 Sleep Case of the Month: Fighting for a Good Night’s Sleep. Southwest J Pulm Crit Care Sleep. 2023;27(1):1-3. doi: https://doi.org/10.13175/swjpccs027-23 PDF 

January 2023 Sleep Case of the Month: An Unexpected EEG Abnormality

David M. Baratz, MD¹

Ken Cooper, RPSGT²

¹Pulmonary Associates

Scottsdale, AZ USA

²Cobre Valley Regional Medical Center

Globe, AZ USA

A 46-year-old woman was referred because of snoring, observed apnea, and daytime hypersomnolence. Her Epworth Sleepiness Scale was 9 out of 24. She was slightly overweight but otherwise her physical examination was normal. An overnight polysomnography was requested but denied by her insurance company.

What should be done at this time? (Click on the correct answer to be directed to the second of six pages)

1. An at home sleep study
2. ENT referral
3. Reassurance
4. 1 and 3
   
5. All of the above

Cite as: Baratz DM, Cooper K. January 2023 Sleep Case of the Month: An Unexpected EEG Abnormality. Southwest J Pulm Crit Care Sleep. 2023;26(1):1-4. doi: https://doi.org/10.13175/swjpccs056-22 PDF

July 2022 Sleep Case of the Month: A Sleepy Scout

Christine S. Fukui MD

Honolulu, HI USA

History of Present Illness:

A 25-year-old African American man complaining of excessive daytime somnolence. He was a US Army Ranger scout who received a traumatic brain injury (TBI) from an improvised explosive device attack in Afghanistan which resulted in a loss of about ¼ of his visual field. He said he slept well at night and there was no history of snoring. There was no history of any parasomnias.

PMH, SH, FH:

Other than the traumatic brain injury there was no significant PMH. His most recent brain scan showed only the remnants of his brain injury which resulted in an intracerebral hemorrhage which was managed conservatively. He was single. He did not smoke and had only moderate alcohol intake. There was no significant FH of sleep apnea.

Physical Examination:

Other than the visual field loss his physical examination was unremarkable.

What should be done next? (Click on the correct answer to be directed to the second of five pages)

1. Brain MRI
2. Electroencephalogram (EEG)
3. PSG (polysomnography) sleep study
4. Repeat CT of head
5. All of the above

Cite as: Fukui CS. July 2022 Sleep Case of the Month: A Sleepy Scout. Southwest J Pulm Crit Care Sleep 2022;25(1):1-3. doi: https://doi.org/10.13175/swjpccs027-22 PDF