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Abstract Introduction It’s always challenging to diagnose central sleep apnea (CSA) in related to chronic opioid use. Report of case(s) A 66 years old male with a significant history of myasthenia gravis, obstructive sleep apnea, depression, and asthma. Initial home sleep apnea test (HSAT) AHI: 65. However he could not tolerate PAP therapy and eventually underwent an oral device. The repeated HSAT AHI while on oral appliance was 30.3. Due to poor compliance, he has been off both treatments for a few years until he was seen in our clinic with excessive daytime sleepiness (EDS), fatigue, loud snoring and witnessed gasping events. His Epworth scale was 24. His medications were remarkable for fentanyl 150 mcg patch daily for chronic pain. His BMI is 28. A new in-lab polysomnography (PSG) showed AHI of 57.9 with mild central apnea index 5.1. BIPAP 20/16 was recommended under titration. The patient declined PAP therapy and surgery. Subsequently, he underwent tracheostomy and his symptoms were much improved. However he was still having residual EDS. A repeated PSG was done with his tracheostomy with AHI: 107 but all the apnea and hypopnea events were central in origin. The study showed a very irregular and ataxic breathing without Cheyne-Stokes breathing. His ECHO shows an ejection fraction of 51%. All other blood work up was unremarkable. It was believed that his central apnea had been induced by chronic opioid use based on Morphine Milligram Equivalents (MME). Prevalence of CSA in patients taking chronic opioid is 24%. CSA due to opioids is associated with abnormal breathing patterns (ataxic, biot and/ or cluster). The morphine equivalent daily dose (MEDD) or Morphine Milligram Equivalents (MME) is strongly associated with the severity of sleep breathing disorders (SBD) predominantly CSA. Studies have shown that ataxic breathing during NREM was more frequent at MED ≥ 200. Our patient's fentanyl dose of 150 mcg patch equals 360 MME which puts him at an extreme risk of CSA. Conclusion It’s important to calculate MME among patients with opioid to avoid risk of inducing central sleep apnea. Support (if any) None
Alsaggaf et al. (Sat,) studied this question.