[Diagnosis] nocturnal hypoxemia with hypoventilation, Moderate OSA

[Bruce Reynolds]

This is a screen shot

OK thanks very much.  Judging by those results you look to be about 5'2", but IMO it's important to know weight and some of the parameters on PFT.

Also very carefully consider the results of leaks.  For example on May 18 and 19 when leaks are well controlled the nights look great.

Arbitrarily adding supplemental oxygen may or may not be a good idea as it may "do weird stuff" including altering V/Q as suggested by Jay.  On May 28 you ending up having a lot of central apneas, yet that could have also been poor sleep.

With EPR you are getting some pressure support, and IMO it's very tempting to bump that up just a bit with a bilevel device of some sort (as noted, not an ASV tho).  I believe you would qualify if we look at the RAD LCD.

[vgrando]

Thank you. I am 5'2' and weigh 170 pounds. I am finally losing weight after the COVID-19 weight gain. I know from looking at all the risk factors that this is a priority for me. Here is last night's data and some trend data. I had OA for the first 1.5 weeks, and [attachment=51272][attachment=51274][attachment=51276]after that mostly CA.

[Bruce Reynolds]

I am finally losing weight after the COVID-19 weight gain. I know from looking at all the risk factors that this is a priority for me. 

Yup, IMO that should give you the most bang for your buck.  Should put a dent in that atelectasis and gas exchange should improve (I believe several parameters on PFT are below normal, those will be good to follow).

The centrals all look to be related to disturbed sleep or sleep/wake interface.  Overall, it appears that your sleep continuity could use a little work.

[vgrando]

I agree that it appears that most but not all CA occur when I get woken up at night. Unfortunately, my mask leaking into my mouth often wakes me and I do not fall back to sleep easily. I just got a V-com. I will use it tonight. I hope it helps with the mouth leaking. 

I think things are going much better since I am on the APAP, even though it was very difficult the first three weeks. I do not understand why I stopped having OA within 1.5 weeks and then shifted to CA. I was on one liter of Oxygen up until a week ago. 

I had such a difficult time finding a mask that I could live with. I have small nares, a deviated septum, and chronic nasal congestion from house dust allergies. I had a lot of air coming out of my mouth. It woke me up all night. I was only getting 2.5 to 3 hours of sleep even though I was in bed for 7 hours! I wear both an Oura ring and an Apple watch to track my sleep.

I have been tapping my mouth for two weeks and this helps immensely with the mouth leaks. I also wear a soft collar. With a FFM I get peri-orbital edema and I felt like I could not breathe because the air pressure is too dispersed. With a nasal cradle mask or a hybrid FFM, I feel like I cannot breathe. 

I have been using the Resmed Airfit N20, mouth tape, and collar.  I breathe much better with the cap mask. But my leak rates have been high and I am getting peri-orbital edema again. But I am sleeping much better!

My first two sleep studies identified that I was desaturating all night regardless of respiratory events from 89% to a low of 76%. And that I also hypoventilated. I desaturated for 90 minutes to a low of 76 during my titration study. 

I am concerned about my low nightly oxygen levels. I wear an 02 ring and I can see that I desaturate anywhere from 50 minutes to 150 minutes if I am not on oxygen supplementation.

[Bruce Reynolds]

I'd really like to see a daytime ABG and the PFT results, but IMO you have to consider yourself as having Obesity Hypoventilation Syndrome with obstructive sleep apnea as a sidebar.

https://www.academia.edu/32755215/Recent...n_Syndrome

I am concerned about my low nightly oxygen levels.

As well you should be, but given your situation, the O2 graph you posted looks OK-- right now spending most of the time >90% with no severe desats is all you should expect. Trying to get a perfect 95%+ all night is not reasonable. See above reference and every other white paper on the subject.

[vgrando]

Thanks again! 

I must have given you the wrong impression. I am not aiming for 95% oxygen saturation, but I do not want to have oxygen desaturations below 89% from one to two hours at night. Last night was a good example of my oxygen desaturation. I desaturated below 90% for two and a half hours.  And right now my BMI is below 28.8, which does not meet the criteria for OHS.

I have intermittent low tidal volumes and slow respirations during sleep, but I cannot find any criteria for how much of this is normal. I certainly am not in REM sleep when these occur.

take care, Victoria

[Bruce Reynolds]

 And right now my BMI is below 28.8, which does not meet the criteria for OHS.

At 5'2" and 170 pounds the CDC calculator has your BMI at 31.1.  That said, IMO that shouldn't necessarily be a point of contention (i.e., @BMI 30.0 you're OHS, while @BMI 29.9 you're in the clear) if all other criteria are present.

And that said, looking at PFT might clarify if you're OHS or Overlap Syndrome.

And THAT said, that's probably academic as xPAP treatment approach is the same.

[Bruce Reynolds]

I have intermittent low tidal volumes and slow respirations during sleep, but I cannot find any criteria for how much of this is normal.   I certainly am not in REM sleep when these occur.

Without PSG there's no way of knowing whether or not you're in REM.  There may be clues and devices that would cause you to suspect you are in REM, but that's about it.

"Normal" is relative.  You need to figure out where you need to be.  For instance, if daytime ABG shows your pCO2 to be like 55 mmHg, it makes no sense to set up a device with parameters that would blow your pCO2 down to 40 mmHg at night.

[vgrando]

At 5'2" and 170 pounds the CDC calculator has your BMI at 31.1.  That said, IMO that shouldn't necessarily be a point of contention (i.e., @BMI 30.0 you're OHS, while @BMI 29.9 you're in the clear) if all other criteria are present.

And that said, looking at PFT might clarify if you're OHS or Overlap Syndrome.

And THAT said, that's probably academic as xPAP treatment approach is the same.

I have lost more weight, which has lowered my BMI. It is a moving target!

I had a recent PFT, which was normal. I am going for a Cardiac, Pulmonary exercise test at the end of the month.

As I mentioned, I do not have cardiac or pulmonary disease except for mild bilateral atelectasis. 

But I have been having daytime drops in my oxygen to as low as 85% with severe fatigue. I thought the new fatigue that I have been experiencing is because the APAP interrupted my sleep. For the first month, I was only getting about 3 hours of sleep a night. The drops in oxygen are random. I had COVID, maybe this is part of the Brain Fog in long COVID.

Moreover, I have an abnormally low body temperature of 96 F, and low blood pressure (usually 90/60). I am on thyroid meds.
My blood work repeatedly shows elevated red blood cells and HCT and occasional high C02. I am insulin resistant diabetic.

Without PSG there's no way of knowing whether or not you're in REM.  There may be clues and devices that would cause you to suspect you are in REM, but that's about it.

"Normal" is relative.  You need to figure out where you need to be.  For instance, if daytime ABG shows your pCO2 to be like 55 mmHg, it makes no sense to set up a device with parameters that would blow your pCO2 down to 40 mmHg at night.

I track my sleep with an Oura ring and my Apple watch. They report the same levels of REM sleep, which is usually less than 30 minutes. In my titration study, my REM sleep was 100 minutes. 

My baseline C02 was 39 mmHg and I went to 49 mmHg during the study.

I disagree with normal being "relative." IMO there should/needs to be some parameters to judge my nightly hypoventilation,  low Tidal volume,  and desaturations. Otherwise, how can they possibly treat me? 

My goal is to have my oxygen above 90% when I sleep.  At my age, I do not need my vital organs being deprived of oxygen while I sleep, especially since new research is showing how sleep issues affect the brain's white matter. So, I guess it is not a risk I am willing to take!  

Moreover, a recent study  Sleep Apnea’s Deep Impact on Gene Activity" on mice showed:

1. "In the study, nearly 16% of all genes in the lungs were affected by intermittent hypoxia, with significant changes also seen in the heart, liver, and cerebellum."

In my in-lab sleep study, they reported that  "Patient also had significant nocturnal hypoxemia with the lowest oxygen
saturation being 83.00 % and 22.61 minutes before they put me on oxygen." During the titration study,  my oxygen went to a low of 76% and below89 for 92 minutes. So, I think what I am having now could be considered significant. And yes, the APAP has greatly improved my nightly desaturation. But in my opinion, it is not sufficient. 


Thank you for your time and concern! Victoria

[vgrando]

This video, I think explains my concerns: https://www.youtube.com/watch?v=SUrOsb-lgR0

One of your old posts keeps popping up when I try to reply to you. I deleted it but thought that I might address some of your questions.

Before I was put on an APAP machine, in my at-home study. I desaturated for 420 minutes. I started to desaturate immediately basically, the whole time I was asleep. And the desaturation was not connected to respiratory events. 

In the in-lab study, I started to desaturate immediately to a low of 76% and they waited 25 minutes before starting me on supplemental oxygen. 

I certainly think that there is more going on with me having low oxygen than either obstructive or central apneas can explain. 

I think it is connected to my hypoventilation, from slow breathing and low tidal volumes. 

 I wear a soft collar and I do not sleep on my back.  


Take care, Victoria