Psychiatry · Year 3 · from Psychiatry

Case 2: Obstructive Sleep Apnea

Patient Demographics

  • Age: 56 years old
  • Sex: Male
  • Occupation: Long-haul truck driver

Chief Complaint

Per wife: "He snores so loud I sleep in another room, and he sometimes stops breathing. I'm terrified." Per patient: "I'm just tired all the time."

History of Present Illness

The patient is a 56-year-old man presenting with his wife due to her concerns about his breathing during sleep. She describes loud, disruptive snoring that has progressively worsened over the past 5 years. She has observed him stop breathing for what seems like 20-30 seconds, followed by a loud snort or gasp as he resumes breathing. These episodes occur dozens of times per night. She has moved to the guest room and can still hear him snoring.

The patient reports excessive daytime sleepiness. He frequently falls asleep while watching TV, during conversations, and after meals. Most concerning, he has had 3 near-miss accidents while driving his truck in the past year due to drowsiness. He reports difficulty staying awake during long drives and uses caffeine extensively (6+ cups of coffee daily). He naps frequently when parked.

He wakes most mornings with a headache that resolves within an hour. He wakes feeling unrefreshed regardless of hours slept. He has noticed difficulty concentrating, memory problems, and irritability. His wife notes personality changes - he has become short-tempered and disinterested in activities. He denies depressed mood.

His medical history is significant for obesity, hypertension (requiring 3 medications and still not at goal), and type 2 diabetes (A1c 8.2%).

Physical Examination

Vital Signs:

  • Blood pressure: 156/98 mmHg
  • Heart rate: 82 bpm
  • BMI: 38.2 kg/m² (height 5'10", weight 266 lbs)
  • Neck circumference: 18.5 inches (>17 inches is risk factor in men)

Head and Neck:

  • Mallampati Class IV (uvula not visible)
  • Retrognathia (receding jaw)
  • Large tongue
  • Mild tonsillar hypertrophy

Cardiopulmonary:

  • Distant heart sounds
  • No murmurs
  • Clear lung fields

Screening Measures

Epworth Sleepiness Scale: 18/24 (severe sleepiness; >10 abnormal)

STOP-BANG Questionnaire:

  • Snoring: YES
  • Tiredness: YES
  • Observed apnea: YES
  • Pressure (hypertension): YES
  • BMI >35: YES
  • Age >50: YES
  • Neck >40 cm: YES
  • Gender male: YES
  • Score: 8/8 (high risk for moderate-to-severe OSA)

Diagnostic Testing

Polysomnography Results:

  • Total sleep time: 342 minutes
  • Sleep efficiency: 78%
  • Apnea-Hypopnea Index (AHI): 62 events/hour (SEVERE; normal <5)
  • Oxygen desaturation index: 54 events/hour
  • Lowest oxygen saturation: 72%
  • Time SpO2 <90%: 28% of sleep time
  • Predominant events: Obstructive apneas and hypopneas
  • Sleep architecture: Reduced REM, increased N1

Diagnosis

Obstructive Sleep Apnea, Severe (G47.33)

Diagnostic Criteria: A. Polysomnography demonstrates 5 or more obstructive respiratory events per hour AND one or more:

  • Sleepiness, nonrestorative sleep, fatigue: YES (all present)
  • Witnessed apneas, snoring, gasping: YES

OR ≥15 obstructive events/hour (AHI 62 - exceeds threshold)

Severity: Severe (AHI >30)

Associated Complications:

  • Refractory hypertension (common consequence of untreated OSA)
  • Poorly controlled diabetes (OSA contributes to insulin resistance)
  • Excessive daytime sleepiness with occupational safety risk

Treatment Plan

Urgent Occupational Safety:

  • Patient counseled that driving commercially is UNSAFE until treatment established
  • Letter provided for employer documenting need for medical leave pending treatment
  • Federal Motor Carrier Safety Administration guidelines reviewed

Primary Treatment: CPAP (Continuous Positive Airway Pressure):

  • Gold standard treatment for moderate-to-severe OSA
  • CPAP titration study scheduled to determine optimal pressure
  • Once pressure determined, auto-titrating CPAP (APAP) prescribed for home use
  • Goal: AHI <5 on therapy
  • Mask fitting session with respiratory therapist

CPAP Adherence Support:

  • Education about disease severity and treatment benefits
  • Ramp feature to increase comfort
  • Heated humidification to reduce nasal congestion
  • Mask refitting if needed
  • Follow-up at 1 week to troubleshoot early

Adjunctive Measures:

  • Weight loss: Referral to weight management program
  • Even 10% weight loss can significantly improve AHI
  • Consider bariatric surgery consultation given BMI
  • Sleep position: Sleep on side (supine position worsens OSA)
  • Avoid alcohol (relaxes airway muscles)
  • Avoid sedating medications

Medical Management:

  • Optimize blood pressure (may improve with OSA treatment)
  • Continue diabetes management

Alternative Treatments (if CPAP not tolerated):

  • Oral appliance (mandibular advancement device) - less effective for severe OSA
  • Upper airway surgery - ENT referral if anatomic issues
  • Hypoglossal nerve stimulator (Inspire) - for CPAP-intolerant patients

Follow-up:

  • Sleep clinic in 2-4 weeks for CPAP data download
  • Repeat Epworth Sleepiness Scale
  • Return to driving only with documented adherence (≥4 hours/night on ≥70% of nights) and AHI <5 on therapy

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