Respiratory System

Frame 1

It has been a slow day in the medical clinic. So far, you've treated a series of coughs and colds interspersed with regular checkups of patients with diabetes, hypertension, and dyslipidemia.

Your next patient walks in: a rather stocky man who looks exhausted. He slumps down in the chair; you introduce yourself and ask how you can help him. He runs his palm over his face and then begins:

"Nice to meet you, Doctor. My name is Joss and I'm 62. My wife dragged me here. She says that I snore really loud every night and that she can't sleep. It was either sleeping on the couch or coming here, so here I am."

Frame 2

"How long has this been going on?" you ask.

"Well, I've been snoring for many years, doctor, but according to my wife, it's only this year that it really got out of hand," he responds.

"Is anything else troubling you?" you continue.

Josh nods. "What really bothers me is that I can't seem to keep my eyes open during the day, even when talking to someone."

Frame 3

You ask Josh about morning headaches, difficulty in falling asleep, waking up multiple times during sleep, poor concentration, and mood changes. He thinks for a while, runs his palm over his face once more and says,

"Honestly doctor, the headaches and poor concentration are there all right, but about waking up in the night, I can't really tell. I could ask my wife about that though. She's right outside."

Frame 4

How do you respond?

Choice Outcome Score Continues
"No, that won't be necessary" Incorrect 0 → Frame 5
"Yes, please ask her in" Correct 1 → Frame 6

Frame 5

"No, that won't be necessary," you say.

Josh replies, "But doctor, she's the one who can tell you more. I'm asleep when this happens, so I have no idea."

You realize that he is right, and ask him to bring her in.

Frame 6

Josh returns with a middle aged lady in tow – Martha, his wife. She confirms Josh's complaints and adds:

"While he's snoring, he all of a sudden stops breathing for a while, and then he snorts loudly and continues as if nothing happened. It keeps me up all night!"

Frame 7

When you press for further information, she continues,

"Sometimes he wakes up after the loud snort, other times he just keeps on sleeping. This used to happen only about once or twice a night, but happens all the time now."

"Oh, and Doctor, I hope he has mentioned sleeping all day. His eyes seem to be shut all the time. In fact, I had to drive him here; I was scared he might fall asleep on the wheel," she finishes.

You thank Martha for her help.

Frame 8

You turn to Josh and inquire about his drinking habits and if he uses sedatives. He replies "occasionally, mainly at social gatherings", to the former; and in the negative to the latter.

A detailed medical history turns up the fact that he was diagnosed with hypertension an year ago, which is well controlled on Losartan 25 mg daily.

Frame 9

You decide to objectively assess Josh's excessive daytime sleepiness and hand him a questionnaire.

What questionnaire do you over?

Choice Outcome Score Continues
STOP-bang questionnaire. Correct 1 → Frame 12
Epworth sleepiness scale. Correct 1 → Frame 11
The sleep timing questionnaire. Incorrect 0 → Frame 10

Frame 10

You rummage through your drawer for the sleep timing questionnaire. Fortunately, while doing so, you recall that this particular tool assesses sleep quality, rather than excessive daytime sleepiness.

You grab the Epworth sleepiness scale instead.

Frame 11

Josh fills in the Epworth sleepiness scale (ESS) and hands it over to you for assessment.

You go through it and calculate his overall score be 16.

Frame 12

You hand Josh a STOP-bang questionnaire to fill in, which he does quickly.

You calculate his overall score to be 7.

Frame 13

You request to examine Josh, to which he agrees.

Josh's BMI is 33kg/m2 and neck circumference is 17.5 inches (44.5 cm). Oropharyngeal and nasal examination shows no evidence of airway constriction. Abdominal examination reveals central obesity. No other abnormal findings are present.

Frame 14

You make a probable diagnosis of obstructive sleep apnea (OSA) and ponder how to confirm the diagnosis.

Which investigation will you order?

Choice Outcome Score Continues
Multiple sleep latency test (MSLT) Incorrect 0 → Frame 15
Maintenance of wakefulness test (MWT) Incorrect 0 → Frame 16
Polysomnography Correct 1 → Frame 17

Frame 15

You request a multiple sleep latency test to confirm OSA from the sleep lab nearby.

"That's for narcolepsy, doctor; polysomnography would be a better choice for diagnosing OSA," the sleep technician advises over the phone.

Realizing that he's right, you thank him and adjust your order accordingly.

Frame 16

Just as you pencil out an order for a maintenance of wakefulness test, you feel doubtful and make a quick check for the right test.

You quickly cross out the order when the results pop out on the screen.

Frame 17

You make arrangements for Josh to undergo polysomnography in the sleep lab nearby. You also request a complete blood count, fasting plasma glucose, and lipid profile, ECG, and chest X-ray.

You also arrange for him to see you once the results are out. Both Josh and Martha thank you and take their leave.

Frame 18

Josh is back in your office three days later.

His full blood count is only significant for a hemoglobin level of 14.2 g/dL (normal: 11.5 - 17.0). His fasting plasma glucose and lipid profile are within normal parameters. The chest x-ray and ECG are also normal.

However, the polysomnography report shows that Josh has moderate OSA, with an apnea-hypopnea index (AHI) of 32 events/hour and a lowest recorded SaO2 of 76%. His AHI was highest at 38 events per hour when lying supine, and lowest at 26 events per hour when sleeping on the side. Runs of atrial fibrillation and non-sustained ventricular tachycardia were also recorded.

You look up from the reports, and start to discuss the treatment plan with Josh. You proceed to outline the importance of good sleep hygiene and weight loss in reducing his symptoms.

Frame 19

"Is that all, doctor? What about drugs?" Josh asks.

How do you respond?

Choice Outcome Score Continues
"Let's just try these out for now and reassess in a couple of weeks" Incorrect 0 → Frame 20
"No drugs for now, but you do need CPAP therapy" Correct 1 → Frame 23
"Yes, maybe we should give you a salbutamol inhaler as well" Incorrect 0 → Frame 21

Frame 20

"Got it, doctor," Josh responds. You ask him to return in a couple of weeks for reassessment.

He thanks you and takes his leave.

Frame 21

"Yes, an inhaler might help improve your symptoms", you reply, and write out a prescription for a salbutamol metered dose inhaler. You ask him to return in a couple of weeks for reassessment.

He thanks you and takes his leave.

Frame 22

A couple of weeks later, just as you are done with your shift, you see a group of paramedics rush in a patient into emergency room, wife in tow. You immediately recognize Martha, tears in her eyes.

As if in a dream, you hear the paramedics say something about a cardiac arrest.

An overwhelming feeling of guilt rushes over you. Could you have done better?

The end

Frame 23

"I'm afraid that we'll need to do more, Josh," you respond. You proceed to counsel him regarding the need for continuous positive airway pressure (CPAP) therapy during sleep, so as to help alleviate his symptoms.

Subsequently, you refer Josh back to the sleep lab for CPAP titration and education on its use. He smiles warmly and thanks you as he leaves.

Frame 24

Two weeks later, Josh is back in your office. He is visibly better, and his polysomnography parameters have improved significantly. His AHI index has dropped to 14 events/hour, with the lowest SaO2 recorded at 88%.

You let him in on the good news and he smiles and nods happily. "I'm really grateful, Doctor. I mean for starters, the Mrs. didn't move me down to the couch and that means a lot to me!"

Frame 25

"Each time I use the machine, I wake up feeling really dry in my throat and end up coughing a lot. Is there any way to prevent this?" Josh asks.

How do you respond?

Choice Outcome Score Continues
"Yes, we can switch to a mandibular advancement splint" Incorrect 0 → Frame 26
"Yes, we can adjust the CPAP machine" Correct 1 → Frame 27

Frame 26

"We could switch to a mandibular splint –" you start, but then stop as you recall that you could just humidify the air coming out of the CPAP machine.

Frame 27

"Sure there is," you say genially. "We just have to attach a humidifier to the machine and the dryness should vanish afterwards."

Josh is grateful for all your help and takes his leave, beaming.

Frame 28

Four months later, while you are out for a morning run, you meet Josh at the park with Martha.

"Hey Doctor!" he greets you cheerfully. "Thanks to you, I sleep wonderfully now! I bet I could even beat you in a quarter mile run – probably 6 months to a year from now," he adds.

You agree to the bet and bid them farewell, smiling inwardly at the improved Josh.

Well done!

The end