C-FLEX TITRATION POLYSOMNOGRAM

INDICATIONS

Mr. Michael J. Ederer is a 40-year-old gentleman referred for pulmonary and sleep disorders evaluation.  Please see Mr. Ederer's history and physical dictation for details of his presentation.  Mr. Ederer's diagnostic polysomnogram revealed a moderate severity obstructive sleep apnea syndrome.  That study also revealed supine worsening of sleep-disordered breathing and intermittent hemoglobin desaturation associated with sleep-disordered breathing.  Mr. Ederer returns for a 2nd polysomnogram with the addition and titration of C-flex therapy for treatment of his obstructive sleep apnea syndrome and related problems.

DIAGNOSIS

Obstructive sleep apnea syndrome, moderate severity (327.23).

RESULTS

There were 7.9 hours of recorded time and 7.4 hours of sleep recorded.  Total sleep efficiency was normal at 94%.  A 358 minutes of sleep time recorded in the supine position and 88 minutes were recorded in the nonsupine sleep position.  Latency to sleep onset was shortened at 6 minutes, suggesting hypersomnia.  Latency to stage REM onset was prolonged at 123 minutes.  There were 17 brief awakenings for 21 minutes of awake time after sleep onset. There was a decrease in the percentages of stage III, IV, and stage REM sleep and an increase in percentage of stage II sleep.  Compared to the diagnostic polysomnogram, there was an increase in percentages of stage III and stage IV sleep.  Hypnogram revealed several awakenings and 4 short periods of stage REM sleep.

The average sleeping heart rate was 64 beats per minute.  Mild variation of heart rate was seen with events of sleep-disordered breathing and arousals. A rare PVC was seen; 41 periodic limb movements were scored, but only 2 of these events were associated with arousal and none were associated with awakening. Total PLM index was 5.5 and the PLM index with arousal was only 0.3.

Mr. Ederer was fitted with a Respironics ComfortGel, size small interface and C-flex therapy was titrated over range of pressures from 4 to 11 cm of water.  Mr. Ederer showed improvement at all C-flex pressures tested and the best results were seen at a C-flex pressure setting of 9 cm of water, 68 minutes of sleep time was recorded at this pressure setting and there were no apneas and no hypopneas scored for respiratory disturbance index of 0.  This is a marked improvement compared to the pretreatment respiratory disturbance index of 22.5.  In addition, he was able to enter a short period of stage REM sleep in the supine position at this pressure setting.  Snoring was controlled and no hemoglobin desaturations occurred at this pressure setting.  Mr. Ederer also did well at C-flex pressure settings of 7, 8, and 10 cm of water.

Mr. Ederer awakened from the study, feeling "better than usual."  He estimated that it took about 3 minutes to fall asleep and he awakened 4 times during the night, sleeping an estimated 8 hours.  His blood pressure study onset was 133/75 and 129/72 at the end of the study.

RECOMMENDATIONS

I will review these results with Mr. Ederer and recommend to begin a trial of C-flex therapy at a pressure setting of 9 cm of water with a Respironics ComfortGel size small interface or the interface of his choice. I will ask him to return in a couple of weeks to see if he was having any initial problems with C-flex therapy. 

C-FLEX TITRATION POLYSOMNOGRAM

INDICATIONS


Ms. xxxxx is a 79-year-old lady referred for sleep disorders evaluation.  Her diagnostic polysomnogram revealed combination of severe obstructive sleep apnea syndrome, disordered sleep architecture, snoring, hemoglobin desaturations, and periodic limb movement disorder.  Ms. Miller returned for a 2nd polysomnogram with addition and titration of C-flex therapy for treatment of her sleep-disordered breathing and related problems. 


DIAGNOSES

1.            Obstructive sleep apnea syndrome (327.3).

2.            Periodic limb movement disorder (327.51).

RESULTS

There were 7.4 hours of recorded time and 4.8 hours of sleep recorded.  Total sleep efficiency was reduced at 66%. There was an increase in supine sleep time compared to diagnostic polysomnogram.  2.2 hours were spent in supine sleep position and 2.6 hours were spent in the side sleep positions.  Latency to sleep onset was mildly shortened at 23.5 minutes.  There was no stage REM sleep recorded; therefore, the latency to stage REM onset was ______ 0.  There were over 30 awakenings for 127.5 minutes of awake time after sleep onset.  There was an increase in the percentage of awake time and a mild increase in percentage of stage III for sleep.  No stage REM sleep was recorded.  Hypnogram revealed frequent awakenings and difficulty maintaining sleep stages with a significant number of periodic limb movement events in the first 3rd of the study.  No stage REM sleep was recorded.

The average sleeping heart rate was 59 beats per minute.  There was an occasional PVC and PAC.  Light to moderate snoring was heard early in the study and this decreased with titration of C-flex therapy.  There were 261 periodic limb movements scored and 77 of these events were associated with arousal while 3 were associated with awakening.  Total PLM index was 54.1 and the PLM index with arousal was 16.0.  Ms. Miller was fitted with a Mirage Liberty interface with large pillows, and C-flex therapy was titrated over range of pressures from 4 to 12 cm of water and then she was placed on a trial of BiPAP therapy toward the end of the study.  It seemed to be a significant variation in her response to C-flex therapy. She did well on the C-flex pressure setting of 6 cm of water as long as she was able to avoid the supine sleep position.  There were 79.5 minutes of sleep time recorded at this pressure setting and no apneas and only 13 hypopneas scored for a respiratory disturbance index of 9.8.  This was a marked improvement compared to the pretreatment respiratory disturbance index of 33.2.  Snoring was controlled, and no significant hemoglobin desaturations occurred at this pressure setting in the 2nd half of the study.  Ms. Miller also did well at C-flex pressure setting of 12 cm of water and 89.5 minutes of sleep time recorded at that pressure setting.  There were 5 apneas and 36 hypopneas scored for a respiratory disturbance index of 27.5.  This included time in both the supine and nonsupine sleep positions.  The short trial of BiPAP therapy did not seem to significantly improve her treatment response.  The lowest hemoglobin saturation noted in the study was 84% with 96% of sleep time, had hemoglobin saturations greater than 89%, much improved compared to the diagnostic polysomnogram.

Ms. xxxx awakened from the study feeling "not rested."  She estimated it took 30 to 40 minutes to fall asleep and that she awakened many times during the night, sleeping about 3 to 4 hours.  No medication was given to help with sleep onset or sleep maintenance.  Blood pressure study onset was 158/60 and 140/70 at the end of the study.

RECOMMENDATIONS 

I will review these results with Ms. Miller, and we will discuss a trial of C-flex therapy at a pressure setting of 6 cm of water with avoidance of the supine sleep position and a Mirage Liberty interface with large pillows or the interface of her choice.  We will also discuss a possible trial of medication for periodic limb movement disorder symptoms.  If Ms. Miller's sleep does not improve with the above therapies, we may consider an auto-titration study in the home setting because of the variable response at C-flex pressures seen during this polysomnogram.