Why Aren't Doctors Paying More Attention to Oxygen Levels?

[LoQ]

AHI is not everything:

http://www.hopkinsmedicine.org/Press_re ... 17_09.html

low blood oxygen levels during sleep are “a particularly worrisome sign,” citing the factor as the single biggest predictor of death in people with sleeping disorders.

[emphasis mine]

[elena88]

That is a very interesting article, thanks for posting it.

elena

[snnnark]

Perhaps in light of this study, more emphasis will be placed on gathering O2 data with the CPAP. My wish is that Intellipap would speak to Contec and get together with them. Most people here have Contec oximeters and they are FDA approved. Either that or Nonin need to reduces its prices.

[M.D.Hosehead]

Perhaps in light of this study, more emphasis will be placed on gathering O2 data with the CPAP. My wish is that Intellipap would speak to Contec and get together with them. Most people here have Contec oximeters and they are FDA approved. Either that or Nonin need to reduces its prices.

All XPAP machines should have integrated oximetry monitors.

Also, the article cited by LoQ strongly suggests that we should be using 90% or even higher as a critical value for desaturation, rather than the conventional 88%.

[LoQ]

Also, the article cited by LoQ strongly suggests that we should be using 90% or even higher as a critical value for desaturation, rather than the conventional 88%.

At 90%, things start to go bad pretty quickly from there. The article says this about the doctors' standards:

“Our goal is to achieve normal breathing patterns during sleep and maintain blood oxygen levels as close to normal as possible,” says Punjabi, who points out that the medical standard is to always maintain blood oxygen levels in the range of 95 percent or above.

Seems to me that if you have a precipice, why walk right up to it? 88-90% is the precipice. Why not put your fence back from that a bit? Note that if you decide that keeping the patient above 90% is sufficient, very small changes can cause the patient to fall off the cliff.

Choosing 95% as the minimum acceptable gives 5% more "runway" when something goes wrong, and 95% is often very achievable. M.D.Hosehead, have you not suggested 95 or 96 percent in your previous posts? I remember thinking at the time that you were very smart to pick that number.

[torontoCPAPguy]

Hello? Anyone out there? Is this not what I have been hollering for weeks and months now? Work with your blower's numbers but keep close track of your SpO2 because THAT is the single biggest indicator of what is going on inside you? Low SpO2 = Skyhigh BP = stroke, aneurism, heart attack, poor organ function, lack of REM sleep, etc., ad nauseum.

I will just get up on my soapbox for a moment here....

THE MOST IMPORTANT SINGLE NUMBER THAT YOU NEED TO BE RECORDING AND WATCHING CLOSELY IS BLOOD OXYGEN SATURATION!

Over and out.

Oh. Just one other thing. Just saw a top pulmonologist and am scheduled for three pages of tests next week or so. I took in ALL of my blower data as well as my SpO2 graphs. Guess what she did? Threw the blower data back in my file folder and poured over the SpO2 graphs and then, after a cursory examination, ordered up three pages of every imaginable test known to man and mouse in the hospital ASAP, including a baseline arterial blood gas workup (I HATE those).

[torontoCPAPguy]

BTW
I use the Contec CMS50E pulse oximeter. It is accurate, reliable and small (fingertip only); the new models have both USB and Bluetooth. They will run for 24 hours on a single charge of their lithium battery (charger included) and record as much data (SpO2 and pulse rate). I use a piece of blue painters' masking tape to ensure it does not move or fall off at night. I record pretty much every night... it is the first thing I do before retiring so that we can see my SpO2 before APAP and afer APAP/O2. Laying down and resting my SpO2 is generally 92% and rises to 97% with 3L/M O2 being infused into 12-16 cmH2O APAP pressure and breathing normally (not deep breathing nor rapid breathing). My SpO2 drops marginally into the 93-95% range on entering what I assume to be REM sleep and shallow breathing. Sometimes my pulse rate zooms up for a minute to about 85 or so but returns to my normal at-sleep pulse rate in the low 60's rapidly. I don't even want to mention what things were like before.... my SpO2 prior to APAP was down into the 50's!!! After APAP it still dropped into the 70's on entering what I assume to be REM... and only when O2 was infused did it remain above 90% ALL THE TIME. And that is the key. Anything below 90%, according to every MD I have spoken to and a couple of Paramedics as well is considered RESPIRATORY DISTRESS and warrants immediate oxygen.

Please, please, please pay attention to your SpO2 and your BP (I went out and bought an Accutor automatic BP machine - top of the line hospital grade). Your SpO2 drops; your BP skyrockets.

He died peacefully in his sleep.

[LoQ]

Hello? Anyone out there?

Calm down. A number of us have been saying this, though perhaps not with the same level of excitability that you bring to the discussion. You're not the only one here concerned about oxygen.

arterial blood gas workup (I HATE those)

Why do you hate them? I had one a couple of months ago and it was a piece of cake. I suppose that for a person who gets anxious about needles, just the thought of sticking one into your wrist might make the process seem bad, but actually, it doesn't hurt worse than a vein draw from the elbow. I didn't think it hurt at all, frankly. Lancing my finger for a glucose test hurts a LOT worse than that did!

[torontoCPAPguy]

Thanks LoQ for your reassurance; I think the arterial blood gas draw really depends on the person taking it. While in critical care (and awake) I had three arterial taps in my right arm and veinous taps all the way up my other arm and across my chest (all supposedly well taped down). One of the arterial taps came loose while I was comotose and I almost bled out.... the hospital mattresses are plasticized in these parts and the blood pooled so there was no sign to a nurse sitting at the foot of my bed. Only three months later did I receive a letter advising that I had received whole blood products, etc. When they moved me to a medical room they removed the taps... and it really depended on who was taking the blood and from where as to the level of discomfort. Funny thing is that it was the student nurses that seemed to be the best at painless withdrawals for some reason. In fact, I was fortunate to have a student nurse take my arterial blood at night and I barely awoke.

I would stand on top of the tallest mountain and use the largest PA system to get folks to realize that SpO2 (SaO2) is so much more 'urgent' than the numbers that your blower is pumping out. It is so very easy to fall into a false sense of security when you have an AHI under 1.0 but plummeting SpO2 at times during the night.... it kills. THIS we learned while I was in critical care and comatose; the family was told to gather as my BP was so high that they did not believe I would last the night. But, being here to tell the tale, I don't just jab folks in the ribs and mention it.... I tend to holler it. I was on SpO2 monitor 24/7 while in hospital as a result of acute pneumonia as a result of H1N1 and can tell you that the nurses all came running whenever the SpO2 dropped below about 88% - I couldn't understand what the big deal was (when I was awake) as I felt fine. But they would then watch my BP (I was on an Accutor automatic BP system) like a hawk, etc., and the doctor would request blood gases (fortunately mostly through one of the arterial taps).

[M.D.Hosehead]

Choosing 95% as the minimum acceptable gives 5% more "runway" when something goes wrong, and 95% is often very achievable. M.D.Hosehead, have you not suggested 95 or 96 percent in your previous posts? I remember thinking at the time that you were very smart to pick that number.

Thanks and right back atcha. I just pulled that number out of the air, and was interested to see that Dr Punjabi uses 95% as his treatment goal.

I like your analogy of the precipice. When they make the movie, it will be a cliffhanger.

I wanted to know more about what they found about desats, so tracked down the article here:

http://www.plosmedicine.org/article/inf ... ed.1000132

Turns out the study was of heart patients with untreated SDB. They found:

1. that SDB correlates with increased risk of death, and the more severe the SA, the higher the risk of death. No surprise there.

2. independent of all other risk factors, men aged 40-70 who spent more than 2.7% of the night at less than 90% saturation had 1.8 times the mortality from all causes.

However, TST90 was a significant predictor of mortality in men less than 70 y in age, even after adjusting for age, race, smoking status, BMI, systolic and diastolic blood pressure, AHI, prevalent hypertension, diabetes, and cardiovascular disease. Compared to the first three quartiles (TST90≤2.70%), younger men in the fourth quartile (TST90>2.70%) had an adjusted hazard ratio of 1.83 (95% CI: 1.31–2.52) for mortality. In older men and women of both age categories, TST90 was not associated with mortality.

3. The study did not assess sublethal damage such as dementia.

4. The study design cannot indicate whether treating SDB or eliminating desats reverses the risk. Nevertheless, Dr Punjabi shoots for 95% sat all night, and I think it makes sense for me to do the same.

[LoQ]

Thanks, M.D.Hosehead, that was interesting.

Which brings me back to the persistent unanswered question, what is the danger of supplemental oxygen at night for people who cannot maintain their daytime SpO2 levels when they sleep?

[GumbyCT]

Thanks, M.D.Hosehead, that was interesting.

Which brings me back to the persistent unanswered question, what is the danger of supplemental oxygen at night for people who cannot maintain their daytime SpO2 levels when they sleep?

That question scares me.

IF you can't maintain I'd say that something IS wrong. But then I'm not a doctor. Sleeping in an O2 tent will do nothing for people who hold their breath. But remember, I'm not a doctor and I can't multi task either. You know like sleep AND breath.

EDIT - repairing a tpyo for those who can figure it out.

[LoQ]

That question scares me.

IF you can maintain I'd say that something IS wrong. But then I'm not a doctor. Sleeping in an O2 tent will do nothing for people who hold their breath.

This is probably because my brain is foggy, but I really have no idea what you are saying here.

Why is my question scary?

What do you mean when you say, "IF you can maintain I'd say that something IS wrong." What does that mean? How can anything be wrong with being able to maintain saturation during sleep? Are you saying that if a person stays saturated while asleep, then there is something wrong with them? That is what a literal reading of your comment would mean.

You say, "Sleeping in an O2 tent will do nothing for people who hold their breath." What are you talking about? Many people in this forum have related that they are still tired even though they have adequate PAP therapy. And some of them have further indicated that supplemental oxygen at night helps them. Are you disputing their claims or what?

[LoQ]

Or, if you don't mind me adding to the question: is there a danger?

I don't mind at all, and in fact, I like your question a lot better.

So what about it, folks? Is there a danger that applies to the vast majority of sleep apnea patients who would feel better if they use supplemental oxygen at night?

[LoQ]

EDIT - repairing a tpyo for those who can figure it out.

I hardly think those who can figure it out need for you to repair it. It's those of use who can't tell if you understand our questions from what you have said who need for you to clarify.