[Treatment] Low AHI but dizziness and fatigue with spikes of low O2 levels

[John94]

Hi all, I was hoping to get more clarity on some issues I am seeing in OSCAR and with my O2 ring that I suspect could be affecting my treatment negatively.

Background: roughly 30yo, generally healthy prior to covid but went from 26->33 BMI during covid (2021-2022 timeframe). Late last year my company returned to office and I found myself having almost no energy outside of work, and had a few bouts of (new to me) severe anxiety/vertigo/panic attacks. Heart + TSH + basic bloodwork fine; finally diagnosed with severe apnea with pAHI = 30, pRDI = 40 via WatchPat test a few months ago.

I've been using my ResMed 11 Autoset for roughly two weeks now, with an average sleep time of 6.5 hours. I have managed to adjust relatively quickly, and my AHI has averaged slightly below 1. I am waiting on more tests (ferritin, etc) to see if those could be the causes of my bouts of anxiety/dizziness/fatigue, but I am hoping the APAP eventually takes care of it...

With the caveat that it has only been ~2 weeks, and that it can take 2-3 months to see improvement (please correct me if I am wrong), I continue to feel mostly exhausted, with bouts of severe fatigue and anxiety/dizziness on random days for reasons unknown to me. It is a coin flip between being very tired but able to go to work and exhausted to the point of barely being able to leave my home. Two things stand out:
1. My O2 ring shows dips into the 80s; these dips are not consistent with movement, and match up with events in OSCAR.
2. My Dr turned off the ramp function after the first night, but I still feel like my breathing is slightly labored, and that I need to breathe a little more deeply than usual to get oxygen. This feeling is mild, and I am able to go to sleep relatively quickly.

My questions are:
1. What to make of these O2 drops? I saw a member say they are often due to movement, but there is no movement detected during these periods by the O2 ring, and they line up with what (to my novice eyes) look like non-positional apnea events in OSCAR. Due to file limits, I cannot attach the latter part of my O2 chart which shows fairly consistent peaks below 90%.
2. I feel like I should increase my pressure, but my doctor said that everything looked great (and according to AHI, it does). Based on my median pressure throughout the night, wouldn't a 6-7 min be more appropriate?
3. Anything else my charts could point at which would explain the lack of improvement?

I have attached 3 charts: a general chart of the night, 1 of my 2 O2 ring charts, focused on a low O2 dip, and a 3-minute OSCAR chart focused on the same low O2 dip time. Let me know if I should attach the O2 chart where I see more consistent peaks below 90%.

Thank you very much in advance, and for all that you do for the sleep apnea community!

[staceyburke]

I’m not sure if this will be helpful but your settings are NOT allowing you to use EPR.

The way the machine works is the LOWEST pressure it can go is 4. Yourmin is set to 5 with EPR (exhale pressure relief) is set at 3. So min 5 - EPR 3 = 4 because 4 is the lowest it can go.

So if you want to use EPR 3 then you have to increase min to 7. Min 7 - EPR 3 = 4.

[Sleepy Quixote]

@John94

Like Stacey says, taking full advantage of EPR will reduce that feeling of labored breathing at the beginning, most people (adults) feel air starved below a minimum of 6 or 7. Looking at your flow limits I'd recommend starting with a minimum of 7 for a good place to start. Good on the doc for turning off ramp, no therapy happens during ramp its just wasted potential efficacious treatment time.
Your take on the spo2 is the same as I have read, others here have much more experience with following desats than I, so maybe someone will chime in on that part.

[Jay51]

Concerning your overall SPO2 at night, it doesn't look bad IMO.  Average of 95 all night is normal.  You have a few drops down to 88 or so.  They all look like short "spikes".  They could have possibly come from the device slipping on your finger, etc.  Or they could be coming from something else.  You only have one area of concern IMO when you have about 4 or 5 spikes close together (and your pulse spikes pretty high there also).  I do not know what could be causing this.  The rest of the spikes downward later in the night look like isolated events and don't even cause your heart rate to increase.  Your heart is obviously working harder with the clusters of spikes, but this may be an isolated issue.  (Track your SPO2 for several more nights or even a week or more to see if you have any more clusters of spikes; or if your downward spikes are in isolation (and look at heart rate chart to see how much they are affecting you). 
From what I have read, spikes into the low 90's are not too big of a concern.  When they start spiking below 90 and even 88; and you start getting more and more of them, they probably need to be looked at more closely.  Try using your best investigative techniques to determine what caused/causes "clusters" of the spikes like you had in your SPO2 data.

[John94]

Thank you both for your replies.

I gave it another go tonight with the O2 ring, and have attached three files: the second part of yesterday's (7-29 to 7-30) O2 graph (with the consistent values under 90%), today's (7-30 to 7-31) OSCAR chart, and today's O2 graph (again, showing consistent values under 90%). 

I cannot help but feel like this is a big part in why I am not seeing any improvement; I'll also say that the two times I woke up (~4:20am and ~6:40am) I felt slightly out of breath, and had to take very intentional, large breaths when putting the mask back on to feel like I was getting enough oxygen. This feeling is present most nights, but today was more 'acute' than normal.

I'll try setting the starting pressure to 6 tonight and see whether that alleviates the shortness of breath feeling. As for the O2 ring, I'll keep wearing it for the near future; hopefully someone can chime in on what I am seeing. Even given the ~3% variance with these consumer sensors, I would think these charts are pretty indicative of an issue...?

---

Jay51, thanks for your reply. I was writing my update as your posted; perhaps these new charts I've added could shed more light on the issue?

For the spikes you mentioned from the O2 chart in my original post, that was likely my getting up to use the restroom right before starting the CPAP (I wore the ring a little before going to bed to get used to it).

[maka12]

hi
From what I've been told by the doctor and have read online, the spikes i have similar to yours are only a real  concern if the stay constantly low for a extended period of time , yours shoot back up and your average over the night is 95% which is good. how long are they staying  low for, can you zoom in on them, it should tell you, try sleeping with a wedge pillow, that's what i do, feels i can breathe better when using it.

[John94]

Replying to add that the heart rate spike in my original O2 graph, and the large two spikes in tonight's O2 graph, correlate with me waking up and walking to the restroom, so I am not overly worried about those.

It appears that the purported periods of low oxygenation do not cause my HR to climb much (although there are occasional spikes above 70). I'm fairly young and have not had respiratory/cardiac issues before, so I am inclined to look at other causes before lung function issues.

As of now I would assume either 1. The sensor really is getting a terrible read on my finger somehow; or 2. There is some issue with my being unable to get enough oxygen during the evening, whether due to wrong pressures or something else.

I'll keep wearing the O2 ring to get a better sense of what is an outlier and what is not.

[Jay51]

Your OSCAR looks pretty good.  These 2 SPO2 charts look worse than the other one you posted.  Maka12 makes some good points.  It would probably be best to show copies of these to your Dr.(s) to see what they think.  Also, if your total time below 88% is greater than 5 minutes according to Medicare, that qualifies a person for supplemental oxygen.

[PamVT41]

Are you tucking your chin?  Your flow limits don't look that bad.  I had a similar problem.  I had a 0.0 apnea yet my O2 dropped when I shifted positions in the night.  I have eliminated leaks for the most part but If I lie on my back my chin tucks into my chest and narrows my windpipe so there's less O2  getting through.  If you get a soft cervical collar and wear it at night that should keep your chin from tucking.  Also elevate your bed with a low slant bed wedge so your torso is up somewhat.  Air can flow in and out better.