Sleep Disorders: Student/Resident Case Report Poster - Sleep Disorders |

Less Is More: Sleep Disordered Breathing and Medication FREE TO VIEW

Brendon Colaco, MBBS; Meghna Mansukhani, MD
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Mayo Clinic, Rochester, MN

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):1289A. doi:10.1016/j.chest.2016.08.1403
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SESSION TITLE: Student/Resident Case Report Poster - Sleep Disorders

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Opioids and benzodiazepines can worsen or precipitate sleep disordered breathing (central and obstructive), sleep-related hypoxemia/hypoventilation and result in periodic or erratic breathing patterns.

CASE PRESENTATION: A 62 year old woman with a history of chronic headache/back pain, anxiety, lacunar infarction, cerebral amyloid angiopathy, hypertension, Hashimoto’s thyroiditis and diabetes mellitus was referred to the sleep clinic. She was diagnosed with OSA of unknown severity over 10 years ago. She underwent 3 follow up polysomnograms (PSG) and was on bi-level PAP in the spontaneous mode at 25/20 cm water pressure with supplemental oxygen bled in at 4 L/min at the time of presentation. In the same time interval, dependence on opioid/benzodiazepine medication had escalated. She complained of severe daytime sleepiness, falling asleep in conversation and at meals with an Epworth Sleepiness Score of 17. She had ongoing issues with imbalance,falls, cognitive impairment and chronic pain. BMI was 33. PSG revealed an AHI of 25, RDI of 37 and central apnea (CA) index of 4/hour. On CPAP, AHI was 32 and CA index 28. On Bi-Level PAP in the spontaneous mode, AHI was 81, mostly CA. On adaptive servoventilation (ASV) at maximal EPAP, AHI was 28 with persistent CA. She was prescribed CPAP at 10 cm water as most obstructive events appeared to be eliminated at this pressure, with the understanding that it was crucial to her therapy and symptoms to decrease the use of opioid/benzodiazepine medications. Over the next 2 months, she successfully decreased diazepam from 20 to 5mg daily, oxycodone ER from 240 to 80mg and short-acting oxycodone from qid to a once daily dose. Subsequent PSG showed elimination of most sleep disordered breathing/hypoxemia on CPAP at 12 cm water and no evidence of hypoventilation on arterial blood gas.

DISCUSSION: Prior research has shown a dose-response relationship between opioid/benzodiazepine medications and sleep disordered breathing but this varies depending on the type of drug. It can be challenging to control sleep disordered breathing in these patients. Although difficult, we have to encourage patients to decrease/discontinue these medications safely in tandem with optimizing PAP therapy.

CONCLUSIONS: CPAP therapy alone was sufficient in our complex patient after significantly decreasing opioid and benzodiazepine medications.

Reference #1: Webster LR, Choi Y, Desai H, Webster L, Grant BJ. Sleep-disordered breathing and chronic opioid therapy. Pain Med. 2008 May-Jun;9(4):425-32

Reference #2: Correa D, Farney RJ, Chung F, Prasad A, Lam D, Wong J. Chronic opioid use and central sleep apnea: a review of the prevalence, mechanisms, and perioperative considerations. Anesth Analg. 2015 Jun;120(6):1273-85.

Reference #3: Mason M, Cates CJ, Smith I. Effects of opioid, hypnotic and sedating medications on sleep-disordered breathing in adults with obstructive sleep apnoea. Cochrane Database Syst Rev. 2015 Jul 14;7:CD011090.

DISCLOSURE: The following authors have nothing to disclose: Brendon Colaco, Meghna Mansukhani

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