1186 Phrenic Nerve Stimulation to Improve Central Sleep Apnea and Quality of Life in Palliative Patients: A Case Report

Abstract Introduction Central sleep apnea (CSA) is a devastating disease and occurs in approximately 40% of patients with a history of stroke, neurological conditions, and heart failure(Joseph et.al). Typical symptoms include disrupted sleep or paroxysmal nocturnal hypoxemia. The gold standard for diagnosis is polysomnography and treatment is typically positive airway pressure (PAP)(Ishikawa et. al). REMEDE stimulates the phrenic nerve transvenously, providing innovative therapeutic alternatives for patients who cannot tolerate PAP therapies(Joseph et. al). Report of case(s) A 77-year-old male with history of advanced Parkinson’s disease (PD) established with palliative care, was referred to the sleep clinic for additional management of severe central sleep apnea refractory to bilevel positive airway pressure (Bilevel PAP ST). Despite initial Bilevel PAP settings of 22/18 cm of water with a backup rate of 12 bpm, the patient faced difficulties using his machine. His apnea hypopnea index (AHI) remained in the moderate range at 18 events/hour despite PAP therapy. Attempts to adjust pressure settings, implement acclimation measures, and mask changes proved unsuccessful. Due to persistent symptoms and poor quality of life (QoL), the patient was subsequently considered for phrenic nerve stimulation, meeting inclusion criteria. Six months post-implantation, he experienced significant improvement in his reported QoL (improved mood, less sleepy during the day with improved Epworth Sleepiness scores), confirmed from his wife. Unfortunately, he passed away 11 months after implantation due to PD-related complications. Conclusion Phrenic nerve stimulation emerges as a novel and effective treatment for CSA, particularly for patients intolerant to Bilevel PAP therapy. This case study highlights the positive impact of phrenic neuromodulation on QoL and sleep improvement, even in patients with palliative conditions and advanced neurodegenerative diseases. Even in patients with end-stage Parkinson disease neurosurgery to replace deep brain stimulation generators is low risk(Carlson et. al). Moreover, nutrition and swallowing can be difficult in end stage Parkinson disease and there is a role for percutaneous endoscopic gastrostomy (PEG) tube to also improve QoL(Schindler et. al). We assert that methods aimed at enhancing sleep, albeit invasive and surgical, should be considered viable options for patients categorized as palliative or terminal, with the overarching goal of improving their remaining days(Lilley et. al). Support (if any)