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“Doc, Can You Order a Sleeping Pill?”
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A7281 - “Doc, Can You Order a Sleeping Pill?”
Author Block: J. Bishara1, W. Kareem2, E. Valladares1, Z. Borok3, T. C. Hammond4; 1Internal Medicine, Keck Hospital of USC Sleep Disorders Center: and USC SleepHUB, Los Angeles, CA, United States, 2Pulmonary Critical Care, Keck Medicine of USC, Los Angeles, CA, United States, 3Univ of Southern California, Los Angeles, CA, United States, 4Pulmonary, Critical Care Sleep Medicine, Keck School of Medicine of USC, Los Angeles, CA, United States.
INTRODUCTION
Intolerance of continuous positive airway pressure (CPAP) occurs in 25-50% of patients with obstructive sleep apnea (OSA). Hypnotics are often ordered to address early issues of CPAP comfort, but merit careful prescribing. As patient portals proliferate, physicians commonly receive electronic requests for medications, including hypnotics. However, not all patients are appropriate candidates for these medications. We report a case of a patient with acute inflammatory demyelinating polyradiculoneuropathy (AIDP) and newly diagnosed OSA, who was immediately intolerant of CPAP and placed an electronic request for a “sleeping pill” to improve adherence.
DESCRIPTION OF THE CASE
A 56-year-old male who underwent subtotal thyroidectomy for thyroid cancer several months’ prior presented to the sleep clinic “for CPAP equipment”. Shortly after surgery, he developed progressive lower extremity weakness and dyspnea and was diagnosed with AIDP. Spirometry showed moderate restrictive lung disease ((forced vital capacity 57% predicted) and abnormal maximum ventilatory volume (51% predicted)). Witnessed apneas developed post-operatively. Polysomnography showed mild OSA (apnea-hypopnea index [AHI] 8, AHI 66 in rapid eye movement sleep). CPAP was titrated to 12 cmH2O, but the patient never received the equipment.
Records were reviewed at a scheduled sleep clinic follow up and CPAP 12 cmH2O ordered. One week later, he initiated CPAP, but felt claustrophobic and requested “a sleeping pill.” Fortunately, the sleep fellow recalled the complexity of his case and advised him to return to sleep clinic later that day for re-evaluation.
On arrival, the patient was visibly dyspneic with a respiratory rate of 38 breaths/minute and resting oxygen saturation of 94%. Peak flow was 150 liters/minute (25% predicted). Due to concern for impending respiratory failure, he was admitted to the hospital. Room air arterial blood gas (ABG) showed pH 7.41, PCO2 57 mmHg, PO2 79 mmHg with serum bicarbonate of 32 mE/dL. Vital capacity was 1.99 liters. With sleep, ABG worsened to 7.30/75/131 and bilevel positive airway pressure (BiPAP) was applied at a setting of 16 cmH2O/6 cmH2O with a rate of 20. ABG stabilized and he tolerated BiPAP well with significant improvement in dyspnea. He was discharged home on these settings and did not require a sleep aide.
NOVELTY AND IMPORTANCE
Electronic medical records have changed the way physicians and patients communicate, but careful consideration of even seemingly simple medication requests can have important implications and must be considered carefully. Indiscriminate ordering of hypnotics in this patient without additional evaluation could have resulted in serious complications.
Author Block: J. Bishara1, W. Kareem2, E. Valladares1, Z. Borok3, T. C. Hammond4; 1Internal Medicine, Keck Hospital of USC Sleep Disorders Center: and USC SleepHUB, Los Angeles, CA, United States, 2Pulmonary Critical Care, Keck Medicine of USC, Los Angeles, CA, United States, 3Univ of Southern California, Los Angeles, CA, United States, 4Pulmonary, Critical Care Sleep Medicine, Keck School of Medicine of USC, Los Angeles, CA, United States.
INTRODUCTION
Intolerance of continuous positive airway pressure (CPAP) occurs in 25-50% of patients with obstructive sleep apnea (OSA). Hypnotics are often ordered to address early issues of CPAP comfort, but merit careful prescribing. As patient portals proliferate, physicians commonly receive electronic requests for medications, including hypnotics. However, not all patients are appropriate candidates for these medications. We report a case of a patient with acute inflammatory demyelinating polyradiculoneuropathy (AIDP) and newly diagnosed OSA, who was immediately intolerant of CPAP and placed an electronic request for a “sleeping pill” to improve adherence.
DESCRIPTION OF THE CASE
A 56-year-old male who underwent subtotal thyroidectomy for thyroid cancer several months’ prior presented to the sleep clinic “for CPAP equipment”. Shortly after surgery, he developed progressive lower extremity weakness and dyspnea and was diagnosed with AIDP. Spirometry showed moderate restrictive lung disease ((forced vital capacity 57% predicted) and abnormal maximum ventilatory volume (51% predicted)). Witnessed apneas developed post-operatively. Polysomnography showed mild OSA (apnea-hypopnea index [AHI] 8, AHI 66 in rapid eye movement sleep). CPAP was titrated to 12 cmH2O, but the patient never received the equipment.
Records were reviewed at a scheduled sleep clinic follow up and CPAP 12 cmH2O ordered. One week later, he initiated CPAP, but felt claustrophobic and requested “a sleeping pill.” Fortunately, the sleep fellow recalled the complexity of his case and advised him to return to sleep clinic later that day for re-evaluation.
On arrival, the patient was visibly dyspneic with a respiratory rate of 38 breaths/minute and resting oxygen saturation of 94%. Peak flow was 150 liters/minute (25% predicted). Due to concern for impending respiratory failure, he was admitted to the hospital. Room air arterial blood gas (ABG) showed pH 7.41, PCO2 57 mmHg, PO2 79 mmHg with serum bicarbonate of 32 mE/dL. Vital capacity was 1.99 liters. With sleep, ABG worsened to 7.30/75/131 and bilevel positive airway pressure (BiPAP) was applied at a setting of 16 cmH2O/6 cmH2O with a rate of 20. ABG stabilized and he tolerated BiPAP well with significant improvement in dyspnea. He was discharged home on these settings and did not require a sleep aide.
NOVELTY AND IMPORTANCE
Electronic medical records have changed the way physicians and patients communicate, but careful consideration of even seemingly simple medication requests can have important implications and must be considered carefully. Indiscriminate ordering of hypnotics in this patient without additional evaluation could have resulted in serious complications.
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