Sleep Apnea and Combined Cardiopulmonary Disease

A 68-year-old male with moderate chronic obstructive pulmonary disease (COPD) and obesity suffers an inferior wall myocardial infarction. He recovers from the acute event; 6 weeks later, he is left with chronic systolic congestive heart failure (CHF) with an ejection fraction (EF) of 25% and paroxysmal atrial fibrillation (PAF). He is managed medically at the time with aspirin, statin therapy, antiplatelet therapy, and low-dose beta-blockers. He is slowly improving and tolerating these medications, but his wife complains that the patient is always tired, often sleepy. He has a history of loud snoring with nocturnal choking and gasping sensations that pre-date his recent cardiac events, but his fatigue is worse. His heart rate and blood pressure are on the lower end of normal range, and he is mildly orthostatic. On physical examination his lungs are clear, and there is no pedal edema. He has quit smoking, is taking his medications and eating healthier, and is motivated to improve his health.

Based on the above, his cardiologist orders an overnight sleep study (his COPD and CHF preclude a home sleep apnea test), and the results of the diagnostic portion indicate severe obstructive sleep apnea (OSA), with an apnea-hypopnea index of 61.3 events/hour and oxygen desaturations down to 63% on room air. Episodes of PAF are again noted. The sleep technologist applies continuous positive pressure therapy (CPAP) during the second half of the study and at 7 cm H20 most of the obstructive events improve. However, at 8 cm H20, he exhibits more desaturations now associated with dramatic episodes of central sleep apnea (CSA), similar to Cheyne-Stokes respiration patterns. The technologist is unable to find an “ideal” CPAP pressure.

Which of the following statements describes the most appropriate medical management?

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