1385 From Rural Titration to Intubation: A Morbidity & Mortality Style Case Review

Abstract Introduction As expansion of services for rural veterans is prioritized, new clinical challenges emerge. Patients with sleep related hypoventilation disorders require complex in-lab non-invasive ventilation (NIV) titration studies. These often occur with limited in-person clinical evaluations prior to the study. We present a case of a complex rural patient in whom patient factors combined with inadequate NIV titration precipitated clinical decompensation. Report of case(s) A rural 67-year-old man with BMI of 46, severe obstructive sleep apnea (OSA), chronic hypoxia on 2 L/min oxygen, and chronic pain treated with opioids was referred to our sleep center. A split polysomnogram (PSG) in the community a baseline apnea-hypopnea index (AHI) of 69/hr and hypoxia inadequately controlled during titration up to bilevel positive airway pressure (BPAP) settings of 28/24 cmH2O. He was brought to our sleep lab for NIV titration. Patient took home dose of opioids prior to the PSG and a second dose midway through the study, with a snack. Transient central apneas were observed after sleep onset. He was initially started on BPAP 14/8 cmH2O without oxygen and was uptitrated to 26/18 cmH2O with 6 L/min of oxygen. Obstructive events resolved but he continued to hypoventilate with oxygen saturation remaining < 88% for 78% of the total sleep time. At study completion, EEG was consistent with encephalopathy, patient was difficult to arouse, prompting a rapid response. He was found to be obtunded with acute on chronic hypercarbic and hypoxic respiratory failure requiring emergent intubation. Chest imaging demonstrated a new pneumonia. He was extubated the next day to average-volume assured pressure support with improvement in his hypercapnia. Conclusion This case highlights the vulnerability of high-risk rural patients with complex cardiopulmonary diseases. Incomplete characterization of underlying physiology, combined with a challenging titration study contributed to a preventable adverse outcome prompting multidisciplinary case review. New pathways for caring for rural patients are essential, to allow for up-front diagnostics and comprehensive titration plans. Sleep lab protocols should ensure recommended metrics such as tidal volume and CO2 monitoring are implemented during NIV titrations, and the use of home meds and eating during studies should be scrutinized to prevent patient harm. Support (if any)