Dados do Trabalho

Título

Challenge of continuous positive airway pressure therapy adaptation: a case report

Introdução

Despite the technological development in the last years, the adaptation of continuous positive airway pressure (CPAP) therapy continues to pose difficulty in many cases for the treatment of obstructive sleep apnea (OSA).

Objetivo

To report a case of difficult adaptation of CPAP in a patient using oronasal mask interface.

Métodos

Clinical and demographic data were collected in the patient’s medical chart; the patient agreed to have his case reported.

Resultados

A 66 years-old male patient with polycythemia secondary to a severe obstructive apnea (apnea-hypopnea index [AHI] of 57.4 per hour) presented with persistent symptoms of excessive daytime sleepiness and high residual AHI, despite initiation of CPAP therapy with nasal mask. The symptoms deprived his ability to work, as he utilized a chainsaw in his job. Complaints of oral air leakage in the middle of the night were, leading to maladaptation and did not ameliorate despite the use of chinstrap. Oronasal interface was successful in improving patient’s adherence, but yet he continued to suffer with the initial complaints. Increase in therapeutic pressure did not result in a better control, even with a trial of higher levels using a bi-level ventilator. AHI reported by the CPAP algorithm widely varied over the nights, with mean residual levels of 15-20/hour (mainly obstructive events). Polysomnography CPAP titration was not available. Patient denied intermittent use of alcohol or any medicine that could interfere with OSA. He used to sleep in a hammock, in semi-lateral decubitus position. Eventually, after a throughout evaluation, the healthcare team noticed that, in order to avoid even minimal air leak of the mask, patient used to force the bottom strap of his mask as much as possible, which probably was contributing to tongue drop during sleep and to worsen the obstructive events. After orientation to a permissive - but controlled – air leak of the mask, patient evolved with improved control of AHI and his symptoms.

Conclusões

Adaptation of CPAP represents yet a challenge for clinicians. Mask interface and adaptation parameters must be selected depending on individual aspect of patients in treatment. Although nasal mask is usually considered the first one interface choice, oronasal may be better for some cases. Especial attention to details of the flow generator, trachea and mask interface is imperative, particularly when treating patients with difficulty in adaptation.

Palavras -chave

obstructive sleep apnea; continuous positive airway pressure