This unfortunate man in his early fifties developed severe sleepiness and sleep attacks after age 40. He had fallen down due to sleep attacks while standing and had broken his wrist when toppling out of a chair during another sleep attack. He had caused a serious sleep-related highway crash. He snored loudly and had acted out violent dreams, striking his wife and falling out of bed.
While only mildly overweight, he is diabetic. He had been treated with medications since the early 1990's for an enlarged heart and abnormal heart rhythms.
Of greatest significance is the fact that he had undergone repeated back surgeries with development of severe scarring in the spinal canal and incapacitating chronic pain. In 1995, a morphine pump was implanted in his low back and he also required multiple additional drugs by mouth that could also depress his drive to breathe.
During his first overnight recording at our Center in 2003, he demonstrated over seventy episodes of breathing abnormality per hour with precipitous drops in blood oxygen levels. After elimination of upper airway obstruction with positive airway pressure, he had severe central pauses in breathing, unresponsive to bilevel PAP with a back-up breathing rate (BiPAP-ST®). Fortunately, both his subjective sleep quality and daytime alertness were improved since he was no longer having to struggle to overcome upper airway collapse all night. He also required supplemental oxygen to address persistent drops in his oxygen levels.
His back problems worsened and his pain medications were increased: with resulting increases in the levels of carbon dioxide (CO2) in his blood. Chronically elevated CO2 levels can also act much like narcotics and suppress our drive to breathe--in severe cases, even to the point of triggering respiratory arrests.
In the summer of 2006, we obtained an exciting new treatment for central and obstructive sleep apnea (adaptive servo-ventilation or ASV) such that we performed another overnight recording--both to try to control his central apneas and to see if we could eliminate supplemental oxygen. Oxygen therapy in patients with persistently high CO2 levels can cause further elevations in those elevated CO2 levels: our key reason for hoping that ASV would eliminate the need for home oxygen in this severely ill patient.
We found that ASV nearly eliminated his central apneas and improved his blood oxygen levels to the point that we could discontinue home oxygen: with some improvement in his high CO2 levels during sleep. He also reported feeling better once on ASV.
Tragically, he was hospitalized for a heart attack in January 2009 and underwent placement of a cardiac pacemaker and defibrillator. He was put back on oxygen during his hospital stay. To make matters worse, the dosages of his narcotic pain medications were increased again.
Hence, we recommended that he undergo two more overnight recordings. During the first, we found that his sleep apnea was much worse, as anticipated--with markedly increased CO2 levels even when using ASV without supplemental oxygen.
During the second night, we substituted AVAPS for ASV. This newer technology, a variant of bilevel PAP, permits the physician to increase the patient's depth of breathing in order to increase blood oxygen levels and lower CO2 levels.
His response was dramatic. When on his final AVAPS settings, without supplemental oxygen, he showed completely normal breathing and blood oxygen levels: without any significant elevations in CO2 levels!
COMMENTS: AVAPS has proved to be an ideal treatment for this particular patient. He has been far more alert and energetic than we had ever seen him, and he reports feeling the best that he had in a long time.
AVAPS was developed specifically for management of a number of serious medical conditions that lessen the depth of breathing with consequent drops in oxygen levels and potentially dangerous buildups in CO2 levels. These include restricted breathing due to spine deformities such as kyphoscoliosis and from severe obesity, chronic lung disease and weakness of the muscles used in breathing from such disorders as post-polio syndrome and various forms of muscular dystrophy.
AVAPS is an exciting new approach that helps many patients enjoy improved oxygen levels and reduced CO2 levels, a safer and more direct approach than chronic oxygen therapy when effective.
If this patient's story reminds you of your own--or that of a loved one--please do not hesitate to contact us at flamenco@netexp.net with any questions that you may have. We are here to help.
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