Positional therapy in a patient with refractory treatment-emergent central sleep apnea
Recommended Citation
Jaziri M, Palmer W, Tovar M. Positional therapy in a patient with refractory treatment-emergent central sleep apnea. Sleep Med 2022; 100:S266-S267.
Document Type
Conference Proceeding
Publication Date
12-1-2022
Publication Title
Sleep Med
Abstract
Introduction: Treatment-emergent central sleep apnea (TE-CSA) is a condition characterized by central respiratory events that can arise with the use of positive airway pressure (PAP) therapy during treatment of obstructive sleep apnea (OSA). It is usually transient in nature and resolves after continuous PAP therapy most of the time. In cases of persistent TE-CSA, adaptive servo-ventilation (ASV) is a common treatment as it affords a backup respiratory rate to support central apneas, and studies have shown ASV’s ability to improve the apnea-hypopnea index (AHI) in patients with TE-CSA. While worsening sleep apnea in the supine position is a known phenomenon in OSA and central sleep apnea (CSA), worsening positional TE-CSA is rarely reported and to date poorly understood. Positional therapy is a strategy that has been shown to be effective in treating both OSA and central sleep apnea (CSA) but has not been established as a treatment option for TE-CSA. We are presenting a rare case of persistent positional TE-CSA that was refractory to standard treatments and only improved after adding positional therapy. Case report: This is the case of a 60-year-old woman with symptomatic moderate obstructive sleep apnea who experienced progression to treatment-emergent central sleep apnea (TE-CSA) after initial treatment with positive airway pressure (PAP) therapy. A prolonged trial with continuous PAP (CPAP) or bilevel PAP (BPAP) was not possible because the patient experienced periods of pressure intolerance and adaptive servo-ventilation (ASV) was pursued. However, ASV titration revealed a persistent and positional preference for central respiratory events. She was fitted for a mandibular advancement device and had serial home sleep studies with device adjustment that continued to reveal inadequate control of her apneic events. After having used CPAP for 72 days, BPAP for 26 days, ASV for 78 days, and a mandibular advancement device, the patient was evaluated for HGNS therapy. Her HGNS titration re-demonstrated persistent central events with a supine AHI of 43.4 and a lateral AHI of 2.9, indicating a strong positional component of her refractory TE-CSA. Positional therapy was initiated with good control of the patient’s apnea with HGNS use during lateral sleep and resolution of the patients reported sleep related symptoms. Conclusions: The final improvement in our case of TE-CSA resulted from positional therapy in concert with HGNS. The patient’s successful lateral sleep therapy for positionally exacerbated TE-CSA demonstrates the benefit of a well-known sleep apnea treatment for this rarely described condition. Positional therapy continues to be invaluable in treating various forms of sleep apnea and may be effective for patients with positional TE-CSA who are refractory to other common therapies.
Volume
100
First Page
S266
Last Page
S267
