WITHDRAWAL FROM PAP: CAN'T LIVE WITH IT, CAN'T LIVE WITHOUT IT

SESSION TITLE: Sleep Disorders Case Report Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/10/2023 09:40 am - 10:25 am INTRODUCTION: Hypoglossal nerve stimulation (HNS) for the treatment of obstructive sleep apnea (OSA) in patients who have failed PAP therapy for one reason or another is now an acceptable and proven alternative to treat OSA in this population. HNS requires a sleep titration a few months after placement and device activation. During this time, stimulation voltages are slowly increased to achieve optimal tongue protrusion at night. As sleep apnea is not controlled during the adjustment phase, sometimes patients are encouraged to continue using PAP therapy especially if their sleep disordered breathing was severe. We present a case of a patient who failed PAP therapy, elected for HNS placement, then failed his HNS titration study because of withdrawal of PAP therapy during the HNS titration night. CASE PRESENTATION: A 55 yo man with sleep disordered breathing of several years presented to sleep clinic for worsening daytime sleepiness after non-compliance with PAP therapy. A sleep study revealed an AHI suggestive of severe obstructive sleep apnea-hypopnea syndrome worse in the supine position and REM sleep. CPAP in all positions failed to improve his symptoms and required BiPAP-S at a pressure of 17/13 to be effective. However, patient found BiPAP caused even more night-time awakenings due to prone sleeping, poor mask fit despite multiple interfaces, and development of facial wounds from the masks. The patient underwent successful HNS evaluation and was implanted and activated 1 month post implantation. As he had severe REM sleep associated apnea hypopnea events with daytime symptoms, he was advised to continue his BiPAP-S therapy but with lower pressures. He complied. The voltage was increased weekly to 1.5 volts and BiPAP decreased down to 10/7 from original settings of 20/15. Subsequently, an HNS sleep titration study was completed without PAP therapy, however the study was suboptimal. Patient could not sleep during the titration study without the use of his BiPAP. Hypopneas persisted during REM sleep and non-REM sleep and HNS up titration was associated with arousals. Patient required reinitiation of his BiPAP-S at the low settings combined with HNS device to provide adequate sleep and treatment of sleep disordered breathing with a more prolonged home trial to up titrate HNS and wean off PAP therapy. DISCUSSION: The more severe the sleep apnea, the more PAP dependence may occur for sleep. This is also evident when a patient complains of poor sleep if PAP device breaks. This case highlights the importance of stopping PAP therapy in advance of an HNS titration study. Ironically, the patients PAP adherence to ensure that the HNS device was successfully titrated led to his dependence on PAP therapy. CONCLUSIONS: While it is reasonable to ask patients to use PAP therapy until they are optimized with regard to the HNS voltage, there may be benefit to having patients come off PAP therapy completely several nights before titration is considered. Hence, we postulate that there could be a withdrawal effect from PAP therapy affecting HNS titration study in terms of patient's ability to sleep, sleep architecture and severity of sleep disordered breathing. REFERENCE #1: Heiser C, Steffen A, Strollo PJ Jr, Giaie-Miniet C, Vanderveken OM, Hofauer B. Hypoglossal nerve stimulation versus positive airway pressure therapy for obstructive sleep apnea [published online ahead of print, 2022 Jul 2]. Sleep Breath. 2022;10.1007/s11325-022-02663-6. doi:10.1007/s11325-022-02663-6 DISCLOSURES: No relevant relationships by Vichaya Arunthari No relevant relationships by Justin Call No relevant relationships by Brendon Colaco No disclosure on file for Clinton Colaco No relevant relationships by Mantavya Punj