Great AHI but low Oxygen - Help!

[Destitute]

Hello All,

I'm new to this forum, but I could really use some feedback.

History: 50 year old male, weight fluctuates between 270 and 295 pounds. No known heart or lung disease. Mild high blood pressure successfully treated with Azor. Depression somewhat successfully treated with Wellbutrin, but it's been pretty bad lately. Lethargy and snoring led to sleep study 3 years ago, and first CPAP. It helped the snoring and somewhat helped the lethargy. Increased lethargy and falling asleep during the day led to second sleep study about 2 years ago and a modification of CPAP settings. Still no complete relief of daytime lethargy. Lethargy increased, and third sleep study 10 months ago let to Bi-Pap. That study also showed many (>30/hr?) periodic leg movements, began treatment with Ropinerole. AHI has consistently been around 2 or under since I've had the Bi-Pap. However, lethargy has increased terribly, and Ropinerole repeatedly increased... now up to 4mg nightly without additional studies.

I frequently monitor my AHI using Encore and I also own an oximeter, but the overnight download capability no longer works. My normal daytime saturation level is 97.

With AHI so good but lethargy so bad, an overnight O2 study was ordered about a month ago, and DME finally delivered machine 2 nights ago (on a Friday). I awoke several times during the night, and after stirring for a moment and taking several normal breaths, I took a look at the oximeter. It usually read around 85 but quickly rose to the mid 90's each time... within 10 seconds or so. A review of the data in Encore show great numbers: groupereater.com/images/Capture.JPG

Questions/Comments:

1. I would imagine my O2 was actually much lower than 85 several seconds before I looked at the device, but it will probably take days to get the results of the overnight O2 study.
2. With such a low AHI, is there an apnea related medical reason why my O2 would be so low? If there is no obstruction, how could there be low oxygen?
3. Yes, I know there are many other medical conditions that lead to low O2, but why the sudden increase when I wake up?
4. My wife states that my breathing is relatively shallow and rapid... not long, deep breaths (but never has been on CPAP/BiPAP). Is that known to cause low O2? Perhaps I am not exhaling enough?
5. I know my lethargy could be caused by not getting good sleep due to the periodic leg movements, but I'm beginning to think that this is more about oxygen deprivation rather than restless sleep.
6. My depression is worsening, and I am now seeing a psychiatrist for suicidal ideation... I am just so tired of being tired. No, I have no immediate plans to off myself, but I really need help, as life like this is simply not worth living.
7. Should I park my butt in my Pulmonologist's office and refuse to leave until she orders another study, or ???

Thank you all in advance for your feedback!

[Slinky]

270 to 295 lbs doesn't tell us much. What's your BMI? Or how tall are you? Could weight be a problem? Quite often a 20 lb weight loss or gain can indicate the need for pressure change.

Until you get some answers from your medical team perhaps sleeping in a recliner WITH your PAP and mask would help. Hopefully someone here can come up w/some helpful suggestions.

[Guest]

2. With such a low AHI, is there an apnea related medical reason why my O2 would be so low?

Yes, of course. Suppose you have only 1 apnea each hour that is 150 seconds long. Your AHI will be 1.0. Do you see any reason why you may still have a low O2?

If there is no obstruction, how could there be low oxygen?

Low hemoglobin, etc.

4. My wife states that my breathing is relatively shallow and rapid... not long, deep breaths (but never has been on CPAP/BiPAP). Is that known to cause low O2?

Yes. It sounds like hypoventilation syndrome to me.

My depression is worsening, and I am now seeing a psychiatrist for suicidal ideation... I am just so tired of being tired.

Ask any of your doctors to prescribe supplemental oxygen immediately. If they won't do it, get your own concentrator and add oxygen to your nightly bipap therapy.

Caveat emptor. Someone will be by shortly to tell you why you should not follow this advice. My observation is that you need help sooner than your doctors will get around to providing it, so before you off yourself, take a stab at a solution. Even if it's wrong, you at least have tried something, and supplemental oxygen is not an irreversible choice. Depression almost always accompanies bad oxygen desats.

And maybe someone will have better advice for you than this. There is always hope.

[Slinky]

Guest's suggestion regarding buying an oxygen concentrator sounds wise. Look for a 5L DeVilbiss, a 5L Invacare, Respironics makes one ..... check at cpapauction.com Sometimes they have a used one offered for sale. I'm not sure if cpap.com sells oxygen concentrators or not but you can check their website. You should be able to find a brand new one somewhere in the region of $500-$700, give or take (don't give much more than that). And, of course, a good lightly used one should be able to be found at considerably less than that. (There are also 3L oxygen concentrators but there's not much savings in cost). It just takes some careful online shopping. Good luck and God bless.

[DoriC]

Can you tell us what machine you have, your titration, what pressure ,what mask you're using? Humidifier setting? Do you use exhalation relief? Does your data show leaks? Do you have arousals during the night? Lots of questions but your answers may be helpful.

[zeeclass]

I'm new to apnea but not to other medical conditions. A few things come to mind.

First of all, have you had a complete blood workup, including hemoglobin, glucose levels, cholesterol, thyroid levels, and vitamin/mineral levels, especially magnesium and B vitamins? Being hypothyroid can make you feel very lethargic, foggy, and depressed. Your TSH level should be below 3.0.(I feel best when mine is around 1.0).

Do you take any supplements besides the drugs you mentioned in your post?

Do you get regular exercise?

Are you considered overweight?

Do you get short of breath when you exert yourself or walk up the stairs?

Have you ever felt faint after exertion or standing up quickly?

Have you been evaluated for asthma or a lung problem by a Pulmonologist?

Have you had a cardiac study done by a Cardiologist?

What major diseases run in your family?

Here's what I'm wondering: Are you deficient in something? Do you have a heart or lung irregularity that has been confirmed or denied by a test? Are you taking something that is causing you to feel so lethargic? Do you eat enough omega 3's, particulary high EPA omega 3's (high EPA omega 3 helps depression).

I'm also wondering when this lethargy began. Can you remember a time when you didn't feel this way? If so, what was different back then?

[jazzer4]

I can't help much with your question, sorry, but I can tell you Wellbutrin "may" be the cause of the leg movements...it was with me.

It took about 2 months to totally get out of my system but after that my legs were fine, just like before the Wellbutrin.

[archangle]

Welcome to the board. Please go into your profile under User Control Panel and enter your equipment so we can see what equipment you're using. We may be able to give you some better suggestions then.

Two nights is not enough to expect any improvement from your new machine.

[ozze_dollar]

I think we can cut through the technical stuff here. LOSE 30KG and you will improve out of sight.I think so many people underestimate the problems over weight can cause.

[Slinky]

And too many over estimate the value of weight loss to eliminate sleep apnea.

[gpap]

I have the same problems. No real cause has been found. The pulmonologist thinks a little fluid builds up at night.... 2 liters of oxygen takes care of it. AHI runs < 2 all night every night. Sleep doc likes the graphs.

[GumbyCT]

AHI has consistently been around 2 or under since I've had the Bi-Pap. However, lethargy has increased terribly, and Ropinerole repeatedly increased... now up to 4mg nightly without additional studies.

I frequently monitor my AHI using Encore and I also own an oximeter, but the overnight download capability no longer works. My normal daytime saturation level is 97.

Leg movements were already mentioned, so I'll talk about your AHI. A low AHI can be the result of mouth breathing or mask leaks. Both can cause the machine not to detect events and also result in a lower pressure not sufficient to keep your airway open.

If you post some of your daily graphs (along with the machine settings) the fine people here can offer other thoughts to help.

Good Luck

[emma_chase]

This is a really old thread, but I just wanted to comment that there is a new trend to assess severely obese people for Adult ADHD.

Adult ADHD Assessment is being done at some bariatric clinics.

Please Google "Adult ADHD + Obesity" for more scientific articles on the topic.

If the OSA is at the point where you are feeling suicidal, then that is a life interfering situation.

I hope you are able to find help for your situation.

Emma (Psychiatrist's wife)