Question: Transcription XXXXXXX Clinic Sleep Disorders Center at Hillcrest Hospital
6780 Mayfield Road, Mayfield Heights, OH 44124
Tel: (216)444-2165; Fax: (216)445-6205

Split Study Report

Name: XXXXXXX Date of Study: 8/5/2014 CCF#: 0000
Age: 39 (DOB: 10/4/1974) ESS: 12/24 Neck Circ.
(cm): 44.5
Height (cm): 182.9 Weight (kg): 102.1 BMI: 30.5
Referring Provider: LOUTFI ABOUSSOUAN Mailcode: FA20

Sleep history: The patient is a 39 year old male with a history of PVCs and
occasional PACs for which EPS mapping and ablation may be planned. He had
sleep apnea diagnosed after he reported symptoms of snoring, as well as
excessive daytime sleepiness present for about 10 years. He has since been on
CPAP since October 2012 and this has helped to some extent with his fatigue.
However, daytime sleepiness still persists despite the CPAP, and snoring has
not completely resolved. The patient has experienced episodes of sleep
paralysis with a sensation of being conscious on awakening yet unable to move
with sensation of a presence, and a sensation of being choked (despite CPAP
10 cmH2O), with a dream of someone choking him with a pillow. A split-night
polysomnogram study was performed. The patient endorses being a habitual side
sleeper.

Past medical history: Irritable Bowel Syndrome, Hypertension, OSA,
Palpitations
Medications: Fenofibrate, Flecainide, Atenolol, Effexor, Lorazepam
Sleep procedure: PSG w/CPAP or Bilevel PAP 4 or > addtl XXXXXXX PC (95811)

Procedure: The study was attended continuously by a sleep technologist. The
monitored parameters included: left (E1-M2) and right (E2-M1) EOG, frontal
(F3-M2 & F4-M1), central (C3-M2 & C4-M1) and occipital (O1-M2 & O2-M1) EEG,
mental and submental EMG, left and right anterior tibialis EMG, left and
right extensor digitorum EMG, single ECG waveform, snoring, continuous
airflow with thermistor, nasal pressure transducer, and PAP Interface, chest
and abdominal effort, oxygen saturation, EtCO2, and body position via video
monitoring.

Hypopnea definition: The peak signal excursions drop by =30% of pre-event
baseline using nasal pressure (diagnostic study), PAP device flow (titration
study) or an alternative hypopnea sensor (diagnostic study). The duration of
the =30% drop in signal excursion is =10 seconds. There is a greater than or
equal to 3% oxygen desaturation from pre-event baseline or the event is
associated with an arousal.

SLEEP ARCHITECTURE:
The study started at 22:27:51 and ended at 06:11:56. Total sleep time was 278
minutes resulting in a sleep efficiency of 61.1% (TRT = 455 m). There were 35
awakenings with a total time awake after sleep onset of 67.0 minutes. The
sleep latency was 79.5 minutes and the REM latency was 184 minutes. The
patient spent 27.6% of sleep time in the supine position. The sleep stage
percentages were 10.2% stage N1, 77.9% stage N2, 0.0% stage N3 and 11.8% REM
sleep. There were 181 arousals, resulting in an arousal index of 39.0. There
were 118 stage shifts.

BASELINE RESPIRATORY DATA:
This study was performed on room air. Snoring was noted. There were 81
respiratory events consisting of 0 apneas (0 obstructive, 0 mixed, and 0
central) and 81 hypopneas. The patient spent 52.1% of baseline sleep time in
the supine position. The apnea-hypopnea index (AHI) was 58.2 and the
central-apnea index (CAI) was 0.0. The supine AHI was 92.4. The off-supine
AHI was 21.0. The non-REM AHI was 58.2 and the arousal index was 76.2. The
mean oxygen saturation was 96.0%, with a minimum oxygen saturation of 93.0%.
The maximum end-tidal CO2 was 50 mmHg. The patient spent 0.4% of sleep time
with an EtCO2 above 45 mmHg and 0.2% above 50 mmHg. Cheyne-Stokes/Periodic
Breathing was not present.

REM-Time REM AHI NREM-Time NREM AHI Total-Time Total AHI
Supine 0.0 m -- 43.5 m 92.4 43.5 m 92.4
Off-Supine 0.0 m -- 40.0 m 21.0 40.0 m 21.0
Total 0.0 m -- 83.5 m 58.2 83.5 m 58.2

POSITIVE AIRWAY PRESSURE THERAPY:
During the second part of the study, CPAP titration was initiated at 01:35:21
and ended at 06:08:03. The patient did not have difficulty falling back
asleep. Snoring was eliminated at a CPAP setting of 10 cmH2O. There were 17
respiratory events consisting of 0 apneas and 17 hypopneas. The mean oxygen
saturation during the study was 97.0%, with a minimum oxygen saturation of
95.0%. The patient spent 0.0% (0.0 min) of sleep time with an oxygen
saturation below 90%. Cheyne-Stokes/Periodic Breathing was not present.
Supplemental oxygen was not administered. A Fisher Paykel simplus mask
without chin strap was used during the titration study.

PAP SUMMARY:

By Time:

PAP O2 TST %Sup SupAHI REM RAHI CAI HI AHI ArIdx Nadr AvgSaO2
05 0 37.5m 0% -- 0.0m -- 0.0 1.6 1.6 12.8 96% 97%
06 0 28.5m 0% - 4.0m 30.0 0.0 6.3 6.3 29.5 95% 96%
07 0 28.0m 93% 25.4 28.0m 23.6 0.0 23.6 23.6 55.7 96% 97%
09 0 57.0m 13% 8.0 1.0m 60.0 0.0 2.1 2.1 16.8 97% 98%
10 0 44.0m 0% -- 0.0m -- 0.0 0.0 0.0 13.6 97% 98%

MOVEMENT DATA:
Elevation in chin/upper-limb/lower-limb EMG tone during REM sleep was
present. On arousal was noted where the patient moved his legs, but not
obviously in a way to suggest a dream enactment. There were 244 periodic
limb movements during sleep, resulting in a PLM-index of 52.6. Of these, 24
movements were associated with arousals, resulting in a PLM-arousal index of
5.2.

ECG DATA:
The average heart rate during sleep was 59 beats per minute, with a range of
50 to 80. During wake, the heart rate ranged from 48 to 87 beats per minute.
The following arrhythmias were observed: premature ventricular contractions
(PVC) up to 6 per minute prior to the titration phase of the study.

OTHER NOTABLE FINDINGS:
Experience to PAP therapy as stated by the patient on the morning after sleep
questionnaire: Medium.

Reported that he remembered a dream in which he was kicking a friend who was
attacking him.

ICSD DIAGNOSIS:
Obstructive Sleep Apnea Syndrome [327.23]

IMPRESSION:
1. Severe obstructive sleep apnea.
2. At a PAP setting of 10 cmH2O, the apnea-hypopnea index and the arousal
index were normalized. At this setting, snoring was eliminated and the oxygen
saturation was maintained above 97%.
3. Frequent periodic limb movements resulting in arousals from sleep were
observed and may be contributing to the patient?s sleep complaints.
4. There were limb movements after respiratory arousal in REM sleep. Of note,
pseudo-REM Behavior Disorder risk should be considered from medication (here;
Effexor) or from the obstructive sleep apnea.
5. Abnormal sleep architecture likely due to respiratory events, PAP
titration, limb movements, medications, and first night effect.

RECOMMENDATIONS:
CPAP 10 cmH20 with humidification, with off-supine sleep preferred. A Fisher
Paykel simplus mask without chin strap was used during the titration study.

INTERPRETING PHYSICIAN:
XXXXXXX Moul, M.D.
I attest that I have performed epoch by epoch review of the entire raw data.

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Report Digitally Signed By: XXXXXXX MOUL M.D. (8/9/2014 3:12:44 PM)                
General Information
Collected:

8/5/2014 10:27 PM
Resulted:

8/9/2014 3:12 PM
Ordered By:

Loutfi S Aboussouan, MD
Result Status:

Final result

What would your opinion be concerning this study? How can this be treated and what are the implications for those crazy percentages for n1,n2,n3, and REM stages and the numerous arousals? I am considering an ablation due to PVCs and my EP called for this study to be done. Could this be making the PVCs worse since they went down after titration? May have had this for 7-10 years before diagnosis. Thank you sir.