Case Presentation on Obstructive Sleep Apnoea with Diabetic Nephropathy, Cardiomyopathy and Oral Candidiasis

1. Case Presentation on
Obstructive Sleep
Apnoea with Diabetic
Nephropathy,
Cardiomyopathy and
Oral Candidiasis
By,
Percy Arpitha. B ,
Pharm- D V yr (12Y01T0019)

2. Wards covered during my clerkship posting
– Neurology
– Endocrinology (Diabetes)
– Cardiology
– General Medicine

3. DISCUSSION
Obstructive sleep apnea (OSA) is the most common type of sleep apnea and
is caused by complete or partial obstructions of the upper airway
characterized by repetitive episodes of shallow or
paused breathing during sleep, despite the effort to breathe, and is usually
associated with a reduction in blood oxygen saturation. These episodes of
decreased breathing, called "apneas“
There are several types of sleep apnea, but the most common is
obstructive sleep apnea. This type of apnea occurs when your throat muscles
intermittently relax and block your airway during sleep. A noticeable sign of
obstructive sleep apnea is snoring.

4. DISCUSSION
Symptoms
• Excessive daytime sleepiness
• Loud snoring
• Observed episodes of breathing cessation during sleep
• Abrupt awakenings accompanied by gasping or choking
• Awakening with a dry mouth or sore throat
• Morning headache
• Difficulty concentrating during the day
• Experiencing mood changes, such as depression or
irritability
• High blood pressure
• Nighttime sweating
• Decreased libido

5. DISCUSSION
Causes
• Old age (natural or premature)
• Brain injury (temporary or permanent)
• Decreased muscle tone. This can be caused by drugs or alcohol, or it can be caused by neurological
problems or other disorders. Some people have more than one of these issues. There is also a theory
that long-term snoring might induce local nerve lesions in the pharynx in the same way as long-term
exposure to vibration might cause nerve lesions in other parts of the body.
• Increased soft tissue around the airway (sometimes due to obesity), and
• structural features that give rise to a narrowed airway.
• In adults, most individuals with OSA syndrome are obese, however, obesity is not always present.
• Adults with normal body mass indices (BMIs) often have decreased muscle tone causing airway
collapse and sleep apnea.

6. DISCUSSION
Diagnosis
Diagnosis of OSA is often based on a combination of patient history and tests (lab- or home-based).
Polysomnography
Polysomnography in diagnosing OSA characterizes the pauses in breathing. As in central apnea, pauses are
followed by a relative decrease in blood oxygen and an increase in the blood carbon dioxide. Whereas in central
sleep apnea the body's motions of breathing stop, in OSA the chest not only continues to make the movements of
inhalation, but the movements typically become even more pronounced.
Home oximetry
In patients who are at high likelihood of having OSA, a randomized controlled trial found that home oximetry(a
non-invasive method of monitoring blood oxygenation) may be adequate and easier to obtain than formal
polysomnography. High probability patients were identified by an Epworth Sleepiness Scale (ESS) score of 10 or
greater and a Sleep Apnea Clinical Score (SACS) of 15 or greater. Home oximetry, however, does not measure
apneic events or respiratory event-related arousals and thus does not produce an AHI value.

7. TREATMENT
Numerous treatment options are used in obstructive sleep apnea.
Avoiding alcohol and smoking is recommended, as is avoiding medications that relax the central nervous system (for
example, sedatives and muscle relaxants).
Weight loss is recommended in those who are overweight. Continuous positive airway pressure (CPAP)
and mandibular advancement devices are often used and found to be equally effective.
Physical training, even without weight loss, improves sleep apnea. There is insufficient evidence to support
widespread use of medications or surgery.
Physical intervention
The most widely used current therapeutic intervention is positive airway pressure whereby a breathing machine
pumps a controlled stream of air through a mask worn over the nose, mouth, or both. The additional pressure holds
open the relaxed muscles. There are several variants:

8. • Continuous positive airway pressure (CPAP) is effective for both moderate and severe disease. It is the most common treatment for obstructive sleep
apnea.
• Variable positive airway pressure (VPAP), or , also known as bilevel or BiPAP, uses an electronic circuit to monitor the patient's breathing, and provides
two different pressures, a higher one during inhalation and a lower pressure during exhalation. This system is more expensive, and is sometimes used
with patients who have other coexisting respiratory problems and/or who find breathing out against an increased pressure to be uncomfortable or
disruptive to their sleep.
• Nasal EPAP, which is a bandage-like device placed over the nostrils that utilizes a person's own breathing to create positive airway pressure to prevent
obstructed breathing.
• Automatic positive airway pressure, or automatic positive airway pressure, also known as "Auto CPAP", incorporates pressure sensors and monitors the
person's breathing.
• A 5% reduction in weight among those with moderate to severe OSA may decrease symptoms similarly to CPAP.
– Oral appliances or splints are often preferred but may not be as effective as CPAP. This device is a mouthguard similar to those used in sports to protect
the teeth. It is designed to hold the lower jaw slightly down and forward relative to the natural, relaxed position. This position holds the tongue farther
away from the back of the airway and may be enough to relieve apnea or improve breathing.
– Many people benefit from sleeping at a 30-degree elevation of the upper body or higher, as if in a recliner. Doing so helps prevent the gravitational
collapse of the airway. Sleeping on a side as opposed to sleeping on the back is also recommended.

9. Neurostimulation
– For patients who cannot use a continuous positive airway pressure device, an upper airway stimulation system that
senses respiration and delivers mild electrical stimulation to the hypoglossal nerve in order to increase muscle tone
at the back of the tongue so it will not collapse over the airway. The device includes a handheld patient controller to
allow it to be switched on before sleep and is powered by an implantable pulse generator
Radiofrequency ablation
– Radiofrequency ablation (RFA), which is conceptually analogous in some ways to surgery, uses low frequency
(300 kHz to 1 MHz) radio wave energy to target tissue, causing coagulative necrosis.
– RFA has some potential advantages in carefully selected medical settings, such as intolerance to the CPAP device.
The targeted tissue, such as tongue or palate, is usually approached through the mouth without the need for
incisions If the tongue is being targeted, this can be done from either dorsal or ventral side.
Medications
– This includes the use of fluoxetine, paroxetine, acetazolamide and tryptophan among others.

10. Demographic Data
NAME: XXX
AGE: 79 yrs
GENDER: Male
I.P. NO: 1838/16
D.O.A: 01-09-16
DEPARTMENT: General Medicine
CONSULTANT: Dr. Shivarajappa M.D

11. SUBJECTIVE
CHIEF COMPLAINTS
C/O loss of consciousness since morning
C/O SOB since 1 day

12. SUBJECTIVE
PAST MEDICAL and MEDICATION HISTORY
k/c/o
– Type II DM (Rx: inj. Human Mixtard 15u& 10u) & HTN since 35 years
– Diabetic nephropathy since 5 years (dialysis done twice)
– Type II respiratory failure since 3 months
Rx: MDI Budamate 200 (2 puffs BD)
MDI Tiova (2 puffs OD)
MDI Lavolin 50 (2 puffs SOS)
– Cardiomyopathy
– Obstructive sleep apnea (Rx: Nocturnal Bipap from9 PM to 6 AM)
– Oral candidiasis (steroid induced) Rx: Fluconazole 150mg OD

13. SUBJECTIVE
PAST SURGICAL HISTORY: Nil
ALLERGIES: Nil
PERSONAL HISTORY AND HABITS: No relevant information found
FAMILY HISTORY: Nil significant
DIET: Mixed type
APPETITE: Decreased
SLEEP: Apnea
BOWEL AND BLADDER HABIT: Constpation Rx: cremaffin 30ml H/S

14. OBJECTIVE
Date 1st 2nd 3rd
Temp (°F) - - -
B.P(mm of Hg) 140/9
0
150/9
0
130/9
0
P.R(beats/min) 80 82 90
R.R(cycles/min) - 20 -
General examination System examination
Date 1st 2nd
CVS S1S2+ S1S2+
RS Bil. Crepts + Ronchi +

15. OBJECTIVE
TEST 3rd Normal range
S. Sodium 123 135- 145 mmol/l
S. Potassium 3.2 3.5- 5.5 mopl/l
S. Chlorides 84 98-105 mmol/l
Electrolytes
Blood sugar tests
Date 3rd Normal value
Blood sugar (Fasting) 153 60- 110mg/dl

16. ASSESMENT
Based on subjective and objective evidence the patient is a
known case of Diabetes, Hypertension, Type II respiratory
failure, Cardiomyopathy, Diabetic Nephropathy,
Obstructive sleep apnea and oral candidiasis and newly
diagnosed to have worsening symptoms and
Dyselectrolytemia

17. PLANNING
S.
no
Brand
name
Generic
Name
Dose ROA Freq Duration of Therapy
1. Inj. Lasix FUROSEMIDE 20mg+20mg IV STAT/
BD
1-9-16 to 3-9-16
2 Inj.
Hydrocortisone
HYDROCORTISONE 100mg IV STAT/
SOS
1-9-16 to 3-9-16
3 Inj. Tazomac PIPERACILLIN+
TAZOBACTUM
4gm+500mg IV OD 1-9-16 to 3-9-16
4 Inj. Pantop PANTOPRAZOLE 40mg/2ml IV OD 1-9-16 to 3-9-16
5 Inj. 3%Nacl SODIUM CHLORIDE 3gm/100ml IV OD 1-9-16 to 3-9-16
6 Inj. Kcl POTASSIUM CHLORIDE 1.5gm/10ml IV OD 1-9-16 to 3-9-16
7 Ta. Telsartan TELMISARTAN 40mg PO BD 1-9-16 to 3-9-16

18. PLANNING
S.
no
Brand
name
Generic
name
Dose ROA Freq Duration of Therapy
8 Inj. Glycopyrollate GLYCOPYRROLATE 0.2mg/ml IV OD 2-9-16 to 3-9-16
9 Tab. Febrex plus CHLORPHENERAMINE+
PARACETAMOL+
PHENYLEPHRINE
2mg+
500mg+
10mg
PO BD 2-9-16 to 3-9-16
10 Tab. Livisiz M L-CETRIZINE+
MONTELUCAST
5mg+
10mg
PO OD 2-9-16 to 3-9-16
11 Tab. Doxoril DOXOFYLLINE 400mg PO ½ tab
BD
2-9-16 to 3-9-16
12 Inj. Human Mixtard INSULIN 30/70 S/C BD 2-9-16 to 3-9-16

19. PLANNING
S.
no
Brand
name
Generic
name
Dose ROA Freq Duration of Therapy
13 Inj. Mucomix N-ACETYL CYSTEINE 100mg/ml INL BD 2-9-16 to 3-9-16
14 Neb. Duolin Budecort SALBUTAMOL+
IPRATROPIUM BROMIDE+
BUDESONIDE
2mg+
500mcg+
200mcg
INL TID 3-9-16

20. Pharmacist Intervention
Drug –Drug Interactions
GLYCOPYRROLATE x POTASSIUM CHLORIDE (CONTRAINDICATED): concurrent use
may result in risk of gastrointestinal lesions.
FUROSEMIDE- HYDROCORTISONE (MODERATE): result in hypokalemia
INSULIN- TELMISARTAN (MODERATE): increased risk of hypoglycaemia
POTASSIUM CHLORIDE- TELMISARTAN (MODERATE): result in hyperkalemia

21. Thank
You