Case H3.98

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Posted by Stuart Holtby MD ABSM on March 03, 1998 at 19:33:24:

In Reply to: Welcome to the Part 2 Forum posted by Sandman on February 22, 1998 at 22:34:48:

Case H3.98 is a 32 year old man who presented 98Mar2 with severe daytime drowsiness: Epworth 16/24; falls asleep at long street lights; at his computer at work; between courses at meals. He has snored since he was a teenager, and his wife of 5 years says he has had apneas since the last 2 years. He does not drink excessively and his weight has been stable. He is restless at night. He has no other sleep or general history. On exam he weighs 95 kg and is 172 cm. He has a shallow posterior oropharynx and a largish tongue, but no other findings aside that his BP is 162/92 L arm supine.
A polysomnogram shows sleep onset central apneas, and then very fragmented sleep with continous obstructive apneas and hypopneas with desaturations into the 60's.
He was started on CPAP after the first hour of collection and did well for an hour on 8 cm, then began to have OA's again. Increases in CPAP to >9cm lead to severe mouth leaks not controlled with a chin strap. A change to a full face mask failed because of leaks around the mask. A switch to BiPAP 8/4, escalated gradually to 16/10 failed, in part because he could not adapt to breating on the system and couldn't sleep.
QUESTION:
Discuss management in detail.

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