July 2023 Sleep Case of the Month: Fighting for a Good Night’s Sleep

Meneena Bright MD

Sleep Medicine

Brigham and Women’s Hospital

Harvard Medical School

Boston, MA USA

A 31-year-old man presented for follow-up in the Sleep Medicine clinic. He has a past medical history of a seizure disorder and supraventricular tachycardia (SVT) and was referred after complaining of excessive daytime sleepiness. Current medications include citalopram and diltiazem. Four months prior, he was diagnosed with severe obstructive sleep apnea characterized by an apnea-hypopnea index (AHI) of 34 and an oxygen saturation nadir of 86%. The patient was initiated on continuous positive airway pressure (CPAP) therapy; however, he reported ongoing mask discomfort and difficulty with exhalation while wearing CPAP. Despite partial improvement in sleep fragmentation and daytime sleepiness, the patient reported sleeping for only 4 hours per night. The patient's sleep schedule was irregular, with bedtime ranging between 9:30 pm and 12 am, waking up at 5 am, and taking a daily nap for 4-5 hours in the morning during which he continued to use CPAP. Additionally, he described experiencing episodes of waking up from dreams, often screaming or throwing punches. A score of 15 on the Epworth Sleepiness Scale (ESS) indicated significant daytime sleepiness.

What should be done next? (Click on the correct answer to be directed to the second of five pages)

1. Begin oxygen at night
2. Begin self-titrating CPAP
3. Discontinue diltiazem
4. Neurology referral
5. Overnight laboratory polysomnography

Cite as: Bright M. July 2023 Sleep Case of the Month: Fighting for a Good Night’s Sleep. Southwest J Pulm Crit Care Sleep. 2023;27(1):1-3. doi: https://doi.org/10.13175/swjpccs027-23 PDF