Saturday, September 8, 2012

Sleep Apnea , A mix of seemingly unrelated symptoms


 A mix of seemingly unrelated symptoms ! one Diagnosis
                                   Obstructive Sleep Apnea a Case study

72 y/o male with a recent problem of syncope and near syncope.
The symptoms started about 1 year ago  with the occasional sudden onset of nausea and a feeling that he needed to sit down. The sensations lasted about 2 minutes and would pass without any residual symptoms. There was no pain or shortness of breath.The symptoms became more frequent occurring about once a month in groups of about 3 to 4 within a 24 hours time span. The symptoms occurred when sitting , walking , eating dinner and doing hard work. One episode occurred while using a weed eater and he fell down.

 His physician ordered a  24 hour  heart monitor test  revealing an electrical conduction problem , junctional rhythm. He was referred to a cardiologist and a diagnosis of vasovagal  attacks ( fainting ) was made. He was given some exercises to do and told to discontinue his blood pressure medications amlodipine and HCTZ .


The symptoms continued 

His wife observed one episode while they were on a daily walk. He complained of the unusual nausea sensation and the urge to sit down. She observed that he was pale, sweating and unsteady on his feet . The symptoms lasted less than a minute  and they continued their walk.

The next episode occurred while driving causing him to hit a small road sign . He did have the nausea but nothing else with this episode. He felt that he just dropped of to sleep.
They discussed his long history of sleepiness when driving , some times having to stop and take a nap in less than 100 miles into a trip. The desire to sleep when driving has been very intense for many years.  Driving became a hard unpleasant chore  for years because of his struggle with drowsiness.  He always just attributed this symptoms to fatigue and long hours working. He recalled similar sleepiness dating back to his first year in college.

He saw his physician again to discuss the more severe symptoms and to discuss the question of driving safety.His physician listened to the history again , examined his neck , mouth ,weight , and suggested the idea of sleep apnea. 


    He was referred to a sleep specialist who agreed with the diagnosis and ordered a home overnight sleep test.The test was positive and confirmed the diagnosis of Obstructive Sleep Apnea. A more comprehensive in hospital overnight test was done again confirming the diagnosis.

CPAP treatment was ordered and started . The patient was amazed at how easy and comfortable  the CPAP machine was to use. He now looks forward to going to bed and sleeping soundly all night.

This was a big previously unrecognized change for him and his wife .
 He no longer keeps her awake with his snoring  . The sweating , restlessness and having to get up at 3 or 4 in the morning is also gone. He now sleeps 6 to 7 hours each night.

 His other medical problems , include mild high blood pressure and Pre-Diabetes, which started about 10 to 15 years ago.


Results of  8 months of CPAP treatment
  
     * No further vasovagal  symptoms 
     *No syncopal episodes
     * No sleepiness when driving. He and his wife have taken two road trips , totaling over 5000
        miles.  He actually enjoyed driving again.
     * His blood pressure has averaged below 140 systolic without medication. He recently restarted 
       a mild diuretic to help keep his BP below his target  goal of 130. He will  recheck his A1c test
       with his wellness exam in June.


Comment:
This case demonstrates the long unintentional delay in diagnosing sleep apnea starting with the early onset of a common everyday things such as snoring . This can be followed by a mix and gradual  addition of seeming  more unrelated things such as sleepiness while driving , mild hypertension , vasovagal symptoms , heart rhythm disturbances and Pre-Diabetes. 


Family history also needs to be considered. The above patient recalls, as a child , listening to his dads loud snoring and pauses in breathing  that seem to echo through the house. I know of another family with the father and 2 sons with obstructive sleep apnea.


I suspect that the above patients symptoms started over 20 years ago. 


Earlier Diagnosis
I believe that earlier diagnosis is possible if we pay closer attention;
         #1 to the first clue , Snoring


         #2 Make better more frequent use of the overnight home test for sleep apnea 
              and sleep specialists. 


         #3 consider family history of sleep apnea as another clue


Have fun , Be Smart-   stop snoring , live longer
David Calder, MD

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Your comments and questions are appreciated. David Calder,MD