[Diagnosis] Persistent fatigue

[Expat31]

Thank you for replying so quickly, and providing what I think is exactly needed at this stage.

It does look like we are searching for that elusive "something else"

Lots to review and consider, I will come back soonest... tied  up until Friday full time.

@Barios

Hello,

Polysomnography.

This was issued on 10th February 2023. It was pre CPAP use, so of course not the situation as of today.

However there are several interesting points:-

Your BMI  at 23 kg/M2 is within the recommended band. All Ok.

Your AHI of 35.4 events is made up overwhelmingly of hypopneas (86%), which are not so significant as obstructive apneas, where the airflow is closed to the passage of air. It could be classified as "Severe Apnea Lite" (My non-medical liberty of expression).

I think your doctors were correct in the titration pressure of appoximately 7cms of water, and as a result, the AHI was quickly reduced from the pre-therapy of 35.4 to zero. AHI.

Concerning the oxymetry results, it will be better to review the latest polysomnography with the effects of the use of CPAP when they are available.

UARS - Upper Airways Resistance Syndrome, missing information?

Just to finish with your polysomnography report, I believe that  there are some important indicators that are missing from the Polysomnography report of 10th February 2023, and relate to detection of UARS (Upper airways resistance syndrome), which is the narrowing of the airways*  

They are:-

1) Flow limitations.  (Air passages restrict airflow through the nose, detected  by nasal prong sensors).

 2) RIP Phase (Respiratory Inductance Plethsmography) chest band sensors send information to computer that calculates expand how much effort is put into breathing.

 3) Paradoxical breathing. (When the diaphragm and lungs seem to be moving in different directions)

 Some studies use the RER index, which is the Respiratory Effort Arousals index. It appears in your prism report at 1 event per hour. This I understand only covers arousals that trigger an awaken only to create an RER point for  calculating the index. Micro arousals that do not provoke an awakening event are not included.

* The main difference between UARS and Obstructive Sleep apnea is how the airflow is being restricted. In sleep apnea, the airway is completely cut off (apnea) or partially cut off (hypopnea). In UARS, the airway is narrow enough to cause sleep issues, but not severe enough to meet the official diagnostic criteria for obstructive sleep apnea.
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Oxymetry going forward.

As discussed previously, an oxymètre would be a good idea. How it works is that you record during, and print the reports. This will enable you  to monitor daily. If the values are too low, you can take them to your doctor, and he will take the necessary action. I am sure after a time, you can print them from time to time.
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Summary

In summary, that "something else" may be UARS.

Let's see when you get your latest sleep report shows us.

I am sorry this is so long, as quite complicated to think about and formulate.

Let's see when you get your latest sleep report shows us, but it will most likely again miss the possibly of UARS causing you difficulties. Maybe I am quite wrong, but you never know.
 
A reasonable question to ask.

As a note of information, I am not a doctor, and not giving medical advice. My observations and opinions are derived from my previous researches, and is my best understanding and interpretation of these complex medical issues.

[Barios]

You may be right, and it is possible that what you're saying about UARS is true. However, UARS is typically treated in a similar way to traditional sleep apnea, right? So, with my CPAP therapy, I shouldn't have issues with fatigue anymore, correct? And the question that still puzzles me is why I feel even more fatigued since using the CPAP.

Regarding the oximeter, I visited my doctor, who requested an appointment for an adrenal gland scan and a thyroid ultrasound because my levels fluctuate significantly. I mentioned my blood oxygen levels to him, and he gave me an oximeter for just 5 minutes to analyze. During that time, I registered 99%. I understand it was only for 5 minutes, but he doesn't believe that is the issue.

[Expat31]

Perhaps CPAP use can treat UARS, but it depends on what is causing the narrowing of the airways. The doctor would most likely look down your throat to see what is going on.
It may mean skimming off a few centimetres from say a lingual tonsil or some other fatty tissue, but that's guesswork.

I have no idea if a CPAP can generate enough pressure to push past such narrowing.  If your CPAP is producing say 7 cms of water, that is equivalent of 6.8 millibars, which doesn't produce much motive force.

Regarding the oxymeter test at the doctor's office, this is designed to quickly identify patients who have serious oxygenation issues even being active during the day. They are perhaps candidates for use of a portable oxygen cylinder quite soon. 

We are concerned however with sleep apnea. During the night, there are of course periods of deep sleep when the body almost shuts down, and there is semi paralysis. Oxygen levels drop, and this is what needs to be focused on. Certainly levels of less than 95% would start to be abnormal, and need attention.

As mentioned in a previous post, total nightime recording is needed to properly monitor oxygen desaturation.

[Dormeo]

I am not sure why there's a continued focus on O2 sats. From a study of normal people, none diagnosed with sleep apnea, and comparisons to people with apnea and with asthma:

"Results: For the healthy patients, the mean +/- SD Low Sat was 90.4% +/- 3.1%. The mean Sat 10 was 94.7% +/- 1.6%. The mean Sat 50 was 96.5% +/- 1.5%. There was no relationship between any of the O2 Sat measures and sex, race, or obesity as measured by body mass index. However, older subjects (> 60 years of age) had lower Sat 10 (92.8 +/- 2.3) and Sat 50 (95.1 +/- 2.0) than did younger subjects. The O2 Sat of the patients with asthma was not different from the healthy subjects, but the patients with OSA had a significantly lower Sat 50, Sat 10, and Low Sat."

https://pubmed.ncbi.nlm.nih.gov/8989066/

Barios, I hope the imaging of your adrenal and thyroid glands will provide some insight into what is causing your fatigue and weakness. It can be difficult to arrive at a good diagnosis when someone has both apnea and another fatigue-causing illness, so I'm glad your doctor is paying attention.

Have you been tested for autoimmune disease, especially in the connective-tissue disease family? Anemia? B-6 and B-12 deficiency? Lyme disease?

[Expat31]

We have only one night's data pre-therapy, just one night...not much of a sample.

I think at this stage, "no stone can be left unturned".