Rapid eye movement dependent central apnea with periodic leg movements
A 47-year-old man was admitted to our sleep center with snoring, witnessed apnea and day-time sleepiness. He also reported leg jerks during sleep and had a diagnosis of obstructive sleep apnea in 2003 in another hospital. He had been given Auto-CPAP therapy but his machine was disrupted and hence was admitted to renew his machine. He declared that he had day-time sleepiness while using his previous machine. His body mass index was 28.6 kg/m2 and his physical examination findings of heart and lung were normal. Ear-nose-throat examination revealed slightly larger tongue and a long uvula. Routine hematologic and biochemistrical tests revealed normal findings. The Epworth day-time sleepiness score was 24/24. Further tests were performed because of central apneas. Neurologic examination, kranial magnetic resonance imaging revealed normal findings. The eye examination was in normal ranges; there was no optic neutitis in eye examination, electrophysiologic tests (pattern visual evoked potential) were found to be normal in both sides. Echocardiologic examination revealed normal findings. Blood Borrelia Burgdoferi Immunoglobuline M (IgM) and Immunoglobuline G (IgG) levels were normal in range. Anti Cytomegalovirus (CMV) Immunoglobuline M, Anti Rubella Immunoglobuline M, Antitoxoplasma Immunoglobuline M and Herpes Simplex were negative. Anti Cytomegalovirus Immunoglobuline G and Anti Rubella Immunoglobuline G were above the normal limits.\nPolysomnography (Compumedics®, Melbourne, Victoria, Australia) was performed in Dışkapı Y. B. Educational and Research Hospital Sleep Department. The apnea-hypopnea index (AHI) was 28 and periodic leg movement index was 26. All the events were in REM stage and central apneas created most of the respiratory events; 192/192 apneas were central and 15 hypopneas were detected. Periodic leg movements followed the respiratory arousals and central apneas in REM stage [Figures and ]. His histogram demonstrated central apneas in REM stage with periodic leg movements []. Piezo electric was used as effort sensor type. The duration of oxygen saturation <90% were nearly 0 min, most of the events caused only 2% desaturation.\nMean transcutaneous carbon dioxide (TcCO2) was 35.8 mmHg (min. 32.2 and max. 45.5 mmHg). His apneas were unresponsive to noninvasive ventilator titration with continuous positive airway pressure (CPAP), bilevel positive airway pressure (BPAP) and BPAP-S/T; so servoventilator was used on the second titration night. After 2 nights’ of non-invasive mechanical ventilator titration (Weinman®, Germany), he was given servoventilator (Maximum IPAP: Inspiratuar Positive Airway Pressure: 20 cm H2O, Min EPAP: Expiratuar Positive Airway Pressure: 7 cm H2O and EEPAP: End Expiratuar Positive Airway Pressure: max 12 cm H2O). The apnea-hypopnea index in polysomnography with the servoventilator was 5,5 and periodic leg movements had disappeared.\nThe patient reported that his day-time sleepiness had also disappeared after using the device. He is still under our control periodically.