I read with interest the reports that Justice Antonin Scalia was found dead in bed with his CPAP neither attached to him nor even plugged in. Many of the news reports noted that: “…the chance of death from skipping a single day is tiny, and patients can and do take breaks because they have a cold, forget to take the machine on a short trip or because the masks are irritating. Typically the only immediate ill effects are snoring and possibly getting up at night gasping.”1 But oh how I wished the message was different! Given Justice Scalia's reported comorbid illnesses and his probable severe sleep apnea (I am guessing his neck circumference at least 18+ inches), the likelihood that he died of either a cardiac arrhythmia, massive stroke or pulmonary embolism is quite high. We will never know if he wore his CPAP that night, would he be alive today, however it is likely that if he had been using his CPAP that night, assuming the final event was a cardiovascular event, there would have been a reduced likelihood of a mortal event.
Reportedly, Justice Scalia's death certificate listed the cause of death as “myocardial infarction” although the county judge who completed the death certificate noted that he “died of natural causes.” No autopsy was performed and the death certificate was not released to the public (in Texas that takes 25 years). Rear Admiral Brian Monahan, Scalia's physician, did state in a letter that he suffered from “sleep apnea, degenerative joint disease, chronic obstructive pulmonary disease and high blood pressure.” What we don't know if any of these disorders were listed on his death certificate—but it is important that sleep disorders do start getting listed on death certificates. Having a sleep disorder listed is extremely valuable as these contain important data used by policy makers to prioritize public health agendas and funding health care and research2; it would also raise the level of consciousness about the seriousness of these disorders.
Sleep disorders in general and sleep apnea in particular are challenging disorders to manage as often the patient has little awareness of the problem. The patient will come to medical attention via their bedpartner or because of a comorbid condition that puts them at high risk of having OSA (e.g. resistant hypertension or stroke). We, as sleep specialists, labor to convince the patient that the disorder is serious and that the treatment is necessary. I usually show the patient the sleep study results and go over it in some detail, pointing out the dips in oxygen levels, the length of apneic and hypopneic events and the sleep disruption accompanying the sleep disordered breathing events. I try to link the symptoms they have to the sleep study results: “it is like someone shaking you awake every minute, all night long.” I wonder, did Justice Scalia's doctor do this? Did he appreciate how important it was to use his CPAP? He had it with him so he knew it was needed; he just did not wear it. Interestingly, he was also sleeping on three pillows—adding further evidence to potential breathing difficulties at night. As noted, Justice Scalia had COPD, diabetes, coronary artery disease, high blood pressure and abused tobacco—all conditions that confer risk for significant hypoxemia and increase risk for a cardiac arrhythmia.
We don't want to use scare tactics to convince our patients to use their CPAP nightly. But for patients with cardiovascular risk factors like Justice Scalia, missing their CPAP for one night could set them up for increased risk of sudden death and stroke; perhaps even taking it off early may increase the risk since REM sleep is often later in the night and the most vulnerable stage of sleep for OSA patients. It has been shown that OSA patients are more likely to die of sudden death between the hours of 12 midnight and 6 AM,3 and the more severe their hypoxemia, the higher their risk.4 Additionally patients who suffer a “wakeup stroke” are more likely to have OSA.5 And sleep apnea patients are also thought to be of increased risk for a pulmonary embolism.6 Any of these catastrophic events could have happened to Justice Scalia and all have a potential relationship to his diagnosis of obstructive sleep apnea.
When a patient asks me “is it okay to miss using my CPAP?” my response is to reiterate that whenever they don't use their CPAP, they go back to having sleep apnea—perhaps not as bad as when they were first diagnosed, but with a cumulative effect of worsening each night without it.7 And if they have all the risk factors that Justice Scalia had—missing one night may be deadly. There is much we don't know about Justice Scalia's death however a better message surrounding his lack of CPAP use that night should have been about the importance of obstructive sleep apnea as a comorbid condition—not downplaying the unknown risk of not using CPAP for one night.
Collop NA. Justice Antonin Scalia—the wrong message. J Clin Sleep Med 2016;12(5):639–640.
Cha AE, author. Did sleep apnea contribute to Justice Scalia's death? His unplugged breathing machine raises that question. Accessed 3/10/16. Available from: https://www.washingtonpost.com/news/to-your-health/wp/2016/02/24/scaliamay-have-forgotten-to-hook-himself-up-to-sleep-apnea-machine-why-that-can-be-dangerous/.
Nowels D, author. Completing and Signing the Death Certificate. Am Fam Physician. 2004;70:1813–8. [PubMed]
Gami AS, Howard DE, Olson EJ, Somers VK, authors. Day-night pattern of sudden death in obstructive sleep apnea. N Engl J Med. 2005;352:1206–14. [PubMed]
Gami AS, Olson EJ, Shen WK, et al., authors. Obstructive sleep apnea and the risk of sudden cardiac death: a longitudinal study of 10,701 adults. J Am Coll Cardiol. 2013;62:610–6. [PubMed]
Hsieh SW, Lai CL, Liu CK, Hsieh CF, Hsu CY, authors. Obstructive sleep apnea linked to wake-up strokes. J Neurol. 2012;259:1433–9. [PubMed]
Peng YH, Liao WC, Chung WS, et al., authors. Association between obstructive sleep apnea and deep vein thrombosis/pulmonary embolism: a population-based retrospective cohort study. Thromb Res. 2014;134:340–5. [PubMed]
Kohler M, Stoewhas A, Ayers L, et al., authors. Effects of Continuous Positive Airway Pressure Therapy Withdrawal in Patients with Obstructive Sleep Apnea. Am J Respir Crit Care Med. 2011;184:1192–9. [PubMed]