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Background Vagal nerve stimulation (VNS) is currently used in paediatric patients with treatment resistant refractory epilepsy. There are reports of sleep disordered breathing as a common side effect in this population with limited case studies. Respiratory drive and tidal volumes are also affected with recent identification of laryngospasm during stimulation periods. Current protocols for management of sleep disordered breathing in paediatric patients with VNS therapy are not well established.Results Split study of a patient established with VNS for treatment resistant epilepsy at Evelina Children’s Hospital London showed severe OSA with altered respiratory pattern during each stimulation period during polysomnography. Respiratory polygraphy off therapy showed no residual OSA. During periods where VNS therapy was not able to be ceased with a magnet, the respiratory pattern re-emerged with severe OSA. Severe OSA from VNS therapy was more prevalent in N3 versus REM.Discussion Highlights the need to have a pre and post screening for OSA in patients with VNS implantable devices and have regular screenings for any change in sleep disturbance symptoms. Therapies including non-invasive ventilation and ENT intervention to be assessed. Further investigations for correlation of OSA from VNS during NREM versus REM are needed.