Stick Out Your Tongue and Say Ahhh

A 51-year-old male with obstructive sleep apnea and a history of smoking eventually benefited from nasal CPAP therapy after sleep specialists made a surprising discovery during the patient’s sleep study.

The Sleep Center at Spartanburg Regional Medical Center in South Carolina is a hospital-based facility that performs sleep testing on five patients each night of the week. To monitor these five patients, we staff three technologists who are accredited by the American Academy of Sleep Medicine and have been providing care in the field of sleep medicine for 18 years. We thought we had seen just about everything ... until recently.

A 51-year-old male was directly referred to our facility by one of our center’s neurologists. The patient’s history included severe neck pain, headaches, episodes of waking up gasping, disorientation, snoring and daytime sleepiness, and fatigue. The patient’s medications included diclofenac sodium and misoprostol (Arthrotec); venlafaxine hydrochloride; doxepin; diazapam; and lansoprazole. He was 6'7" tall, weighed 175 pounds, and reported a history of smoking 60-plus packs of cigarettes per year. This man drove himself to our center and was tested as an outpatient.

Our center’s protocol for testing included standard electroencephalographic derivations: C3-A1, C4-A2, O1-A2, O2-A1; ground; LOC; ROC; and submentalis electromyography (EMG). Airflow monitoring was done via nasal/oral thermistor. We monitored a lead II electrocardiograph and used a snore microphone. Respiratory effort of thoracic and abdominal excursions was assessed via piezo crystal respiratory effort belts. Oxygen saturation was monitored via pulse oximetry. Finally, anterior tibialis EMG was monitored via snap electrodes. The patient was monitored throughout the night via audio and video recording with infrared illumination. The patient was very cooperative and accommodating to the paraphernalia of testing.

With all of our patients, two presleep assessments are performed to establish the patient circumstances for the evening. The first is completed by the patient (or by the guardian if the patient is a child), which covers the previous night’s sleep, day’s activities, medications, and patient’s current feelings of fatigue and sleepiness. The technologist also performs a presleep assessment, which includes noting the patient’s demeanor, special needs, overall appearance, as well as any pain the patient may be experiencing. We ask about vision and hearing needs as well as if the patient normally wears or sleeps with dentures.

The Sleep Study
Lights-out was uneventful at 10:15 pm with our patient supine. Sleep onset occurred in 32 minutes. The patient began snoring loudly, and the snoring was noted with the patient in both side and supine position. Mild apneas were demonstrated and associated for the most part with arousal. There was also quite a bit of coughing. Approximately 3 hours into the study, there was a baseline drift in our patient’s SaO2 into the 85% to 88% saturation range. Per protocol, supplemental oxygen was administered via nasal cannula at 2 LPM. When applying the cannula, the technologist noted that the patient was somewhat less responsive than expected, but as he had been so soundly asleep, she thought that might be usual for him. She left the room but began watching him via the video monitor very closely. He awakened a few moments later for a trip to the restroom and was observed to be somewhat wobbly but did converse with the technician appropriately. The patient quickly returned to sleep, and the supplemental oxygen elevated saturation into the low 90% range. The patient was now supine, and the snoring worsened.

We have often told our staff to be especially mindful of sudden change, as often it is the sudden shift that proves most dangerous. Fortunately, intuition that makes a technician a true polysomnographic technologist sounded the alarm on this patient that evening. She noted that the patient’s breathing began sounding “wet,” with gagging and gurgling sounds. The snore had changed pitch to a more flappy, heavier sound. His heart rate began to elevate dramatically, and PVCs were noted. The technologist entered the room and attempted to arouse the patient without success. The study was terminated, and a “Code 3” for respiratory crisis was called.

Our center is located near the intensive care areas, so the hospital’s Code Team arrived in less than 2 minutes. The respiratory care staff positioned to intubate the patient when suddenly he awakened and began to vomit. His airway was suctioned, and his breathing returned to a more normal rate. Intubation was not performed, and the patient’s heart rate remained quite elevated. The patient was transferred to our neuro intensive care unit for more intensive monitoring and further evaluation.

Now for the excitement
A few hours later in the morning, the patient’s sleep and pulmonary physician, Wilson P. Smith, MD, was examining the patient when he noted something shiny and blue in the patient’s mouth. The patient reported that the object was a piece of glass he “slept with each night to keep his mouth wet.” Apparently our patient had served in the military, and a trick many soldiers used when marching and in situations when they wanted to add moisture in their mouth was to put a pebble on their tongue to increase saliva production. A side effect of this patient’s medication was dry mouth, so he regularly slept with a piece of glass in his mouth—it was smoother and cleaner than a rock. That morning Smith saw the patient’s replacement glass.

After a review, our physician believed the glass might have been a large component in the previous night’s respiratory crisis. Due to his anxiousness over sleep testing, the patient reported having taken more diazepam than was his usual dose. That, combined with his apnea, sleeping supine, and the glass slipping to the back of the airway, led to the respiratory episode. Needless to say, the patient was advised not to continue sleeping with glass in his mouth.

Once stabilized, the patient was discharged from our hospital, to which he returned 2 weeks later for another study. On that night, medications were closely monitored, apnea was documented, and nasal continuous positive airway pressure (CPAP) was administered with successful resolution of the patient’s obstructive sleep apnea. He now uses CPAP at home.

Conclusion
With each test, we learn, and now, prior to testing, we ask each patient to stick out his tongue and say “ahh.” This case brings to light concerns we had not previously considered. We had thought of foreign-body obstruction in children, but other than for dentures we really had not considered it as a regular assessment in all patients. Today, we must consider tongue, lip, and nose piercings and their associated adornments and jewelry as well as surgical alteration and bifurcation of the tongue. We must also remember to check out jewelry-studded teeth, as well as dentures, bridges, and other orthodontics to see if they might become dislodged or fall back into and compromise the airway.

We also confirmed that the special intuition of a good polysomnographic technologist is invaluable in quality patient care, safety, and sleep testing.

Shari Angel Newman, RPSGT, is manager of the Sleep Center at Spartanburg Regional Medical Center, Spartanburg, SC.

Acknowledgement
Special thanks to Wilson P. Smith, Jr, MD, PA, ABSM, medical director of the Sleep Center of Spartanburg Regional Medical Center (SRMC), and Kelly Hallman, SRMC staff technologist.