CASE STUDIES IN SLEEP DISORDERS CLINIC

Case 1

A grossly obese 41 year old male was admitted to hospital for knee surgery. He lived alone in a small unit, was unemployed, had no interest in outdoor activities or hobbies and had very poor dietary habits. At 180 Kg, with high blood pressure and a failing heart he was not a good candidate for anesthesia. It was decided to seek the opinion of a respiratory specialist when nursing staff and fellow inpatients complained of his loud and unrestrained snoring and it was with obvious relief that he was transferred to the sleep unit. Overnight studies demonstrated severe sleep apnoea with both obstructive and central components. He was fitted with a nasal CPAP mask which greatly improved his nocturnal oxygenation but surgery was still considered too great a risk for such a patient. He was advised to continue nasal CPAP at night for the remainder of his time in hospital to familiarize himself with the procedure for home use. He was discharged from hospital following a thorough assessment of his heart disease and blood pressure, and placed on a strict weight reduction diet. The man was seen a month later in an outpatient clinic. He had reverted to his previous eating habits, put back on the small amount of weight lost during hospitalization and had discontinued the use of CPAP. He could not be convinced of its benefits and remains untreated for this serious condition.

Comment: An unmotivated patient with this sort of medical history can only expect further deterioration. It takes some time to become accustomed to CPAP, but failing that there should at least be an urgent reappraisal of one’s lifestyle.

Case 1

After many years of recurring tonsillitis in a 7 year old girl, her parents had reached the point of desperation. This first manifested itself as snoring when the child was about 18 months old but a pediatrician assured the parents that the young girl would eventually grow into her large tonsils. Sleep related snoring and occasional episodes of tonsillitis marked the early years of her life until she was 4 years old when her mother became aware of times when the child seemed to be struggling for breath. In retrospect, judging by a description of events in the following years, the child had developed OSA, the consequences of which were to disrupt the life of parents and child for a further three years. Severity of the child’s airway obstruction no doubt reflected the status of the child’s tonsils. At best there was always a degree of snoring but a common cold or any inflammation of her tonsils would guarantee a succession of traumatic nights; traumatic for the child who would awake several times a night crying and further complicated by instances of bed-wetting and falling out of bed. It was also traumatic for the parents who were anxious about their daughter’s distress at night, not to mention the considerable disruption to their own sleep. Antibiotics probably helped to minimize the duration of these episodes but it was becoming increasingly clear that prescription of these medications was not addressing the underlying problem.

For a girl of above average ability, she was not progressing as well as could be expected and frustrated teachers would report on her tiredness and lack of application. The parents finally sought help from a pediatrician with some expertise in sleep apnoea. A hospital admission and overnight studies documented airway obstruction and oxygen desaturation consistent with OSA. Tonsils and adenoids were surgically removed a month later and the results were immediately apparent. Snoring was virtually abolished and her parents no longer had to comfort a distressed child at night, indicating an improvement in sleep quality and although she still experiences occasional colds and upper respiratory tract infections, heavy snoring and complete airway obstruction has never reoccurred.

Comment: Disruption of home and school life could have been avoided with earlier detection of OSA.

*16/51/5*

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Posted on Thursday, April 23rd, 2009 at 5:50 am and is filed under General health. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.

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