The complicated patient

The complicated patient is often one of misinformation or miscommunication. 

Today was a fun day where I had a patient come in for a foIlow-up visit. I have been trying to dial in a titration and get him to wear his Herbst appliance for more than an hour and a half each night.

Yesterday we sent the patient home with a home sleep tester because I wanted to know what was happening during his 1 hour of sleep.

The patient showed up with the sleep tester and stating that the appliance does not work and can't keep it in and breath.  We downloaded the sleep study and when reviewing the patient informed me he was awake the whole time the tester was on and was goofing around the house.

The interesting part was there were oxygen desaturations and the breathing was reduced and stopped a few times even when there was activity.  How could this be? I started talking with the patient and said the only way this could be possible is with COPD.  At that moment the patient inform me he has mild COPD. 

COPD is a contra-indication for an oral appliance.  No matter what we do we can't treat him. He needs to have a BIPAP or O2 all the time.  After I explained this he then said the pulmonologist told him the same thing and that is why he hid it from me.

Now he will wear the Herbst appliance and his BIPAP, and O2 during the day.

This is why we have to keep talking to the patients and dig out the real story.  Complications are usually due to something else and not the appliance.  Keep on your toes.