Supreme Court Justice Antonin Scalia was nominated by President Ronald Reagan and sworn in to office Sept. 26, 1986. “The Originalist” espoused his conservative ideology and jurisprudence on the court for nearly 30 years, influencing a generation of legal thinkers with his often witty and dynamic opinions.

Known as “Nino” to friends and family, he was an avid hunter of deer, wild boar, and even alligators. He claimed he enjoyed hunting more than anything except going to church with his family. So no one was too surprised when the 79-year-old justice traveled by private plane on Feb. 12, 2016, to a southwest Texas desert ranch near the Big Bend of the Rio Grande. He was part of a group of about three dozen guests, and went out quail hunting shortly after arriving.

Scalia was a heavy pipe smoker who favored a large black Sherlock Holmes pipe. His smoking habit had been blamed for a history of shortness of breath and cough, as well as nighttime breathing problems -- sleep apnea -- that woke him up. Doctors prescribed a breathing support machine known as continuous positive airway pressure (CPAP).

The night of Feb. 13, 2016, Scalia attended a party with the other guests, but left early to go to bed. The next morning, he didn’t appear for breakfast and a planned group excursion.

Later in the morning, the resort management entered Scalia’s room to find his body face up in bed. He was lying on three pillows stacked up to elevate his head, the top pillowcase appearing to have slipped down to cover his eyes. His body was covered with sheets up to his chin, and both hands were at his sides under the sheets.

A breathing apparatus was on the table next to the bed, but it was unplugged and the switch was in the off position. A hose for the breathing machine was found on the left side of Scalia’s bed, but was not attached to him. Why was Scalia's breathing machine turned off and not even plugged in?

Solution

Scalia’s smoking habit led to severe obstructive sleep apnea (OSA) associated with chronic obstructive pulmonary disease (COPD), an inflammatory lung disorder. Given his underlying health problems and the circumstances in which he was found, it is likely that Scalia died — at the age of 79 — of either a cardiac arrhythmia, massive stroke, or pulmonary embolism. However, no autopsy was performed, because it was not requested by county or Texas state authorities, or Scalia’s family.

Usually, doctors first suspect sleep apnea when a patient’s bed partner complains of the snoring — and sometimes the sound of choking — restless sleep pattern, and multiple sudden awakenings, and even that the breathing has stopped momentarily. The poor quality of sleep in these patients often results in daytime sleepiness. An overnight “sleep study” recording the number of apnea episodes should be performed by a pulmonary specialist.

OSA often is diagnosed along with hypertension, coronary heart disease or stroke.

A CPAP machine is designed to deliver adequate uninterrupted air flow at a prescribed pressure through the tubing and mask to keep the nose and throat airways open, allowing air to reach the lungs’ air sacs (alveoli), from which oxygen enters the blood.

An apnea patient may also be vulnerable to underlying heart disease, congestive heart failure, or atrial fibrillation, which might worsen during the apnea periods, as less oxygen is available or congestive fluids accumulate in airways and lungs. Studies show that, without the CPAP apparatus turned on, apnea patients are more vulnerable to sudden death between midnight and 6 a.m., with risk rising as blood-oxygen concentration decreases.

At the time of his death, some media reports stated that apnea patients may take breaks from using their CPAP machine because they have a cold, or find the mask irritating. Some also suggested the chance of death from not using the machine just once is very small.

We’ll never know whether Scalia skipped using the CPAP entirely, or turned it off in the middle of the night — though the fact that it was unplugged seems to suggest he never had it running. The fact that he was using so many pillows to elevate his head does indicate he needed help keeping his airway open.

What we do know is that the risks apnea patients face from skipping a night of CPAP are much higher if they have underlying chronic conditions. Scalia, who also had diabetes, coronary artery disease, and high blood pressure, and was a smoker, faced higher risk for a cardiac arrhythmia, pulmonary embolism or massive stroke, all of which could have killed him with or without the CPAP. But if it was a cardiovascular event he suffered, it might not have proved deadly had he been using the CPAP machine that fateful night.

Allan B. Schwartz, M.D., is a professor of medicine in the division of nephrology and hypertension at Drexel University College of Medicine.