A Patient’s Narrative: Living with Undiagnosed Obstructive Sleep Apnea

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This patient narrative describes the treatment of a patient diagnosed with moderate Obstructive Sleep Apnea (OSA); the patient developed other preventable diseases had OS, diagnosis occurred. A diagnosis of Generalized Anxiety Disorder (GAD; was given when the patient first sought medical assistance. OSA, underlining illness, wasn’t discovered until performing a sleep study as part of a routine procedure for the patient’s treatment of Traumatic Brain Injuries (TBI). The late diagnosis resulted in abnormal heart rate issues leading to a surgical procedure on the patient’s heart. It’s not normal for the human body to require energy drink’s to function. This patient relied on these drinks along with caffeine tablets.

The patient is a service member in the Army with 26 years of service. A 43-year-old Male with, BMI of 24, Body Fat, 5%, an avid marathon runner, 23 marathons over the past 15 years, and a high level of physical fitness. The patient complained of daytime fatigue increasing over the past ten years but assumed it was part of life. In September 2016, while deployed, he sought care from a theater medical clinic in Kuwait for bruxism (teeth grinding), Restless Leg Syndrome (RLS), and daytime sleepiness. Diagnosed with General Anxiety Disorder (GAD) and referred to Behavior Health (BH) initiated a treatment plan consisting of pharmacological and psychotherapeutic approaches of a low dosage of sertraline HCL with a gradual increase to 100MG and  Cognitive Behavioral Therapy (CBT). The patient discontinued the medication on his own due to no results and increased fatigue. 

The patient suffered TBIs in March and December of 2017 during airborne training events. The patient described these events as “a blessing in disguise,” as it led to a mandatory sleep study as part of his treatment, bringing to light the reason for his increased fatigue. 

Since the diagnosis of OSA, the patient has undergone multiple approaches to relieve the symptoms. CPAP treatment with multiple masks was trialed, along with various levels of pressure. The patient complained of aerophagia (air in the stomach). The patient was fitted with a Mandibular Advancement Device (MAD), trialed for a few months with no success. A Drug-Induced-Sleep-Endoscopy (DISE) noted the following using the Dr. Eric Kezirian VOTE classification: 

With mandibular advancement device in place: 

• Velum 60 percent in AP dimension, 
• Oropharynx 30 percent in sagittal dimension, 
• Tongue base 50 percent, 
• Epiglottis 70 percent and sagittal collapse pattern and supraglottic with 50 percent obstruction at the arytenoid mucosa level.

Without mandibular advancement device in place: 

• Velum palate 70-80 percent in AP dimension, 
• Oropharyngeal collapse roughly 30-40 percent mostly unchanged, 
• Tongue base 70 percent obstructive in AP dimension, 
• Epiglottis 90-100 percent obstructive in the sagittal pattern. 
  

In January 2020, an epiglottopexy was recommended to address an omega-shaped epiglottis with a collapse. The patient contacted multiple clinics throughout North and South Carolina in search of a provider willing to perform the procedure. UNC-Chapel Hill agreed to conduct the procedure; however, after a second DISE, the provider determined that the Inspire ® hypoglossal nerve stimulator would be the best option due to the patient’s structure’s epiglottis. However, the patient was sent to Walter Reed National Medical Center as Humana Military would not cover the Inspire device.  

As of October 2020, the patient utilizes the Inspire device; effectiveness is still unknown; the patient didn’t fit OSA patients’ typical characteristics. Low BMI and over-all healthy lifestyle. The lack of an early diagnosis caused severe life-altering impacts on the patients’ well-being. 

March 2019 patient underwent an atrial ablation to address paroxysmal atrial fibrillation. The patient is an overall healthy individual and avid runner; atrial fibrillation is assumed to be correlated to the unresolved OSA.

Cardiologist post-op advice recommended a return to BH and emphasized the importance of a resolution to the OSA. BH recommended anti-depressants. The patient was prescribed Fluoxetine, which was ineffective, then Duloxetine. Pseudo-resistance during treatment and medication increased fatigue; psychotherapy subsided the symptoms. Fatigue had greatly intensified to the point that the patient required a mix of Nuvigil and Concerta to be able to function at work. Without this medication, the patient would fall asleep driving into position. From March to October 2020, severe neurological issues increased to include decreased cognition, stress, anxiety, irritability, high sensory sensitivity. Brain Zaps greatly intensified. All of these symptoms are associated with Duloxetine consumption, detox, hypoxia, and hypercapnia. 

The patient requested assistance from his primary care provider to be informed that symptoms would subside once OSA was resolved. The patient possessed previous knowledge of brain plasticity and proven methods to increase cognition. The patient started a strict daily cognitive workout consisting of mindfulness, CBT, and problem-solving exercises. This enabled the mental balance needed for work. Determining what was currently causing the symptoms would take a slow detox with detailed journaling.  

Cymbalta is currently causing severe symptoms as the patient is undergoing a detox of this medication. The Brain Zaps and increased RLS caused by the Cymbalta has made the trial of the Inspire device to be difficult. The stimulation created by the Inspire device intensifies the headaches associated with the Cymbalta detox. The patient has not utilized the device successfully and expects to once the Cymbalta detox has been completed. The amount of unnecessary suffering and additional diseases this patient has undergone is directly related to the medical provider’s lack of knowledge in the field of sleep medicine

About Post Author

Chris Pierce

chris.pierce23@gmail.com

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