Urgent advice needed - In hospital - Lots of CA's and respiratory feels depressed

[MyronH]

I got admitted to the hospital a couple days ago for blood clots in my lungs. They have been giving me Lovenox injections blood thinner. I was on my last night here to go home, when suddenly I developed a lot of CA's and feel like I'm stopping breathing at night, whenever I go to sleep. 

It happens almost immediately when I go to sleep, my SPO2 drops to 80's also and their oxygen sensor beeps and wakes me up.  I try going back to sleep but same thing happens. The nurses don't seem concerned and said i need to talk to the doctor.

I had NO sleep last night. It takes me awhile each time to fall to sleep, then suddenly it wakes me up with low oxygen warning.

I'm not sure what is going on, my NORMAL AHI is almost always <1. 

I'm on Multaq, Bystolic, and now the blood thinner. My oxygen when awake is 94%+. 
But when i doze off to sleep it immediately goes to 80's and I have CA's!

Please do you have any thoughts on what I can say to the hospital doctor to run tests on me while I'm here?
I don't want to go home in this condition!

I have the head of bed slightly raised just like I have at home. And the first nights here at the hospital I slept okay with 
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[Hojo]

You need to be talking more with your doctors, especially a Pulmonologist (lung doctor), having a pulmonary emboli is nothing to take likely and I'm sure they will be watching you.  If you have too many CA's then they may want to consider an ASV to get you over this hump.

[tedvpap]

Some medicines cause CA so ask your doctor.

Explain to your doctor that your sleep apnea has been well controlled (AHI<1).  Now it is unacceptable.

The pulmonary embolism could significantly impacting your lung efficiency so your PAP treatment may need to be adjusted.

[Sleeprider]

I think consult with your physicians. If you are prone to anxiety, the sleep onset centrals may be amplified by an anxious response, awakening and additional centrals. You are in a stressful environment and hopefully things will return to normal when you are back home. Good luck, get well.

[Fats Drywaller]

MyronH: I sympathize & empathize. What follows is mostly futures, not immediate, which is all I can contribute, sorry!

I had a DVT and a PE a number of years ago, had no idea what was happening until I went to the ER and was diagnosed, came pretty close to snuffing it, but they pulled me through and yes, it was the Lovenox (heparin) that did it. I assume they've got you on oxygen, and if not, maybe you should be? IIWY, I would quiz/grill the docs about everything and insist on answers to all relevant questions including the CPAP-related things. If you're given a resident doc who seems vague or confused or clueless, then insist on talking to an attending instead! You are the customer, and the customer is always right, and you deserve straight and complete answers from at least one doctor who knows WTF he or she is doing.

The futures: Probably when you go home you'll be put on further Lovenox (subcutaneous injections, self-administered) for some number of weeks, followed by six months of Coumadin (a.k.a. Warfarin), like 5 or 10 mg/day. After that, I highly recommend staying on low-dose aspirin, 81 mg/day, forever. It works wonders. At first, immediately after ending the six months of Coumadin, I didn't know about that and I had disturbed sleep with bad circulation in extremities, but a clueful doc told me about it and said "Take it" and I started the 81 mg/day and have not stopped since. I could immediately feel the difference in circulation during sleep. You might encounter a doctor here & there who pooh-poohs an aspirin regimen for anything, but that's nonsense and most likely the doc is merely annoyed that there's no profit in it for the drug companies and therefore for the sleazy docs who are on the take from the drug companies. (Low-dose aspirin costs about two cents per pill if you buy generic or house-brand and stay away from the big brand names.)

BTW, a bit of trivia: the name "Warfarin" seems scary & repulsive at first glance, especially since the drug is also a rat poison (make 'em bleed to death, ugh, how horrible and inhumane), but it turns out that the name has nothing to do with warfare; it's from the acronym of "Wisconsin Alliance Research Foundation".

Best of luck and best of treatment to you.

[pholynyk]

Thank you, Fats, for pointing out that Lovenox is heparin. After my bypass last year I was given heparin for three weeks, and the nurses had me self-administer several times so I would know how to do it. One thing I leaned the hard way is that it is almost painless if into the roll of fat below the belly button, but somewhat painful above. Be warned... Thankfully I did not need to continue it after I left the hospital.

[MyronH]

Fats, 
I had a DVT/PE back in 2015, and at that time they put me on Xarelto for 6 months, then a baby aspirin 81mg. Well, here I am again with a DVT/PE, because I also have "Factor V Leiden" gene mutation that makes me more susceptible to clots. My hematologist initially had my on 81mg aspirin, saying they thought that was all that was needed. Now they are going to put me on Xarelto or similar medicine for rest of my life.

My O2 is fine during the day, always 93%+. But even this morning, if I lay down and try again to take a nap, the damn O2 Alarm they have me wearing goes off and shows my O2 dropping to 80's.

This O2 drop happened in the past once or twice, and I went to the ER, and they sent me back home and said to go see my sleep doctor. My sleep doctor looked at the "summary" of my BIPAP machine and said everything was okay. He claimed the CA's were normal transitions into sleep. But last night those CA's were a lot and clustered. That is NOT normal! 

I told the nurses what happened but they said to wait for the doctor. I'm almost 99% certain he will just tell me to go see my sleep doctor. I don't feel comfortable going home in this condition and it is another two nights until Monday until i can contact my sleep doctor.

[Fats Drywaller]

I had a DVT/PE back in 2015, and at that time they put me on Xarelto for 6 months, then a baby aspirin 81mg. Well, here I am again with a DVT/PE, because I also have "Factor V Leiden" gene mutation that makes me more susceptible to clots. My hematologist initially had my on 81mg aspirin, saying they thought that was all that was needed. Now they are going to put me on Xarelto or similar medicine for rest of my life.

Yikes! I'm sorry to hear it. I mean not about the drug itself (that's a recent one that I have no experience with, and I've read that great things are expected of it); of course I hope that works fine and prevents further clotting. I mean about the condition in general. That's tough luck.

I can't help with the CPAP details, so I'll bow out and hope that the experts here can clear it up for you.

Edited to add: I doubt that a sleep doctor will be able to help, as you said. What does a pulmonologist say? And if the docs who are treating you aren't taking the O2 problem seriously, why not?

[ardenum]

I have 3 heavy hitters for you.

1. Blood markers for Hypoxia

HIF1 (HIF-1α and HIF-1β) and HIF-2 proteins are a more reliable blood hypoxia markers that will be present for up to 24h(HIF1) and 2-3 days(HIF-2) after cell hypoxia. Ask them to do it. If the levels are in range, you can rest assured those initial dips are harmless.

Link Removed, instead search Novusbio website for Hypoxia information.

2. Brain (brainstem) perfusion SPECT scan.

https://www.ncbi.nlm.nih.gov/pubmed/8931538

Sudden rise in continuous(during the whole night) Central Apnea would suggest a worsening of an existing Heart Failure or hypoperfusion of the Brainstem, which is responsible for autonomic breathing. In your case with your history of clots, it might indicate a clot in one of the supplying basilar arteries or the vertebral arteries. If that were the case an addon to the heparin would be an tPA IV (tissue plasminogen activator)

3. If the hypoxia markers are fine tell the nurses to turn off the alarm so you can fall asleep.

On the light note. My sat% sometimes dips to 70 for a few seconds when I fall asleep. How much it drops is a marker of tiredness that day for me.

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[DeepBreathing]

He claimed the CA's were normal transitions into sleep.

That can often be the case, but looking at your chart you don't experience any CAs until an hour after you lie down. There are a couple of mask-off events in that time so you may not have been sleeping deeply if at all, but these don't look like transition CAs to me. Docs need to learn to look at the details.