Low daytime SPO2 and fatigue

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
vps
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Low daytime SPO2 and fatigue

Post by vps » Thu Mar 16, 2023 12:13 pm

Hello

Since March 2022 I have fatigue, frequent shortness of breath, chest tightness, low SPO2. My heart rate is 110-115 bpm even with light housework or slow walk, getting tired and sleepy after hour or two awake.

My daytime finger oxymeter readings are around 90-92% especially in the evenings. At night SPO2 drops to 84-86, despite APAP use since 2017 every night for 5-6 hours. Usual AHI is between 5 and 9, should be below 5, but it seems that's the best I can do. I had an appointment with Respiratory Consultant last year, not much advice, just continue with CPAP.
Machine is Airsence 10 Auto, FFM mask Airfit F20 is 3 month old, pressure min 9.8 max 13. Sleep still very disrupted, frequent awakenings.
CPAP data shows mainly Unclassified/Central apnea, there very few obstructive apnea events. Respiratory rate is high, around 34-36 breath per minute. My leaks are a bit high, probably because of my beard.
Cardiac stress perfusion MRI done in July 2022 detected low oxygen saturation in the heart muscle. Cardiac CT angiogram done in October detected the plaque in coronary vessels, but level is not sufficient to be deemed a critical condition. Cardiologist reckons my issues not coronary, but caused by apnea.

Can apnea cause low SPO2 during the day? My main concern is fatigue but it is probably caused by low SPO2? My respiratory appointment coming soon, any point to ask about different treatment like ASV machine?

Thanks

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palerider
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Re: Low daytime SPO2 and fatigue

Post by palerider » Thu Mar 16, 2023 12:34 pm

Please READ AND COMPLY with that first post up at the top of the forum, the one that says NEWBIES, READ BEFORE POSTING.

Then we'll be able to help you much better.

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Miss Emerita
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Re: Low daytime SPO2 and fatigue

Post by Miss Emerita » Thu Mar 16, 2023 2:58 pm

vps, I think the main thing that would be helpful is an Oscar chart. Please turn off the calendar and pie chart, and include all and only these graphs:

Events
Flow rate
Pressure
Leaks
Flow limitations
Snores.
Oscar software is available at https://www.sleepfiles.com/OSCAR/

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robysue1
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Re: Low daytime SPO2 and fatigue

Post by robysue1 » Thu Mar 16, 2023 3:01 pm

vps wrote:
Thu Mar 16, 2023 12:13 pm
Usual AHI is between 5 and 9, should be below 5, but it seems that's the best I can do. I had an appointment with Respiratory Consultant last year, not much advice, just continue with CPAP.
Machine is Airsence 10 Auto, FFM mask Airfit F20 is 3 month old, pressure min 9.8 max 13. Sleep still very disrupted, frequent awakenings.
CPAP data shows mainly Unclassified/Central apnea, there very few obstructive apnea events. Respiratory rate is high, around 34-36 breath per minute. My leaks are a bit high, probably because of my beard.
How high are the leaks? And how long are the leaks?

If you are getting the data off your machine's LCD or the MyAir app, you don't have enough data to really understand whether your leaks are large enough and long enough to affect the efficacy of your CPAP therapy. and since many of your apneas are "Unclassified", that indicates that the leaks may in fact be long enough and large enough to affect the efficacy of your CPAP therapy and/or the accuracy of the data.

Since you say that you have very disrupted sleep with frequent awakenings, my wild guess is that the CAs that are being flagged are probably not events that would be flagged on a real sleep study in a lab. Rather, they're probably normal sleep transition centrals and/or sleep-wake-junk breathing being misclassified as an apnea.

As for the high respiratory rate: Any idea what your daytime resting respiratory rate is? And have you mentioned this to any of your doctors? (Note: There's just a chance that the machine is mis-scoring your RR, but we can't possibly tell for sure without the detailed data from Oscar or SleepHQ.)

You also write:
Since March 2022 I have fatigue, frequent shortness of breath, chest tightness, low SPO2. My heart rate is 110-115 bpm even with light housework or slow walk, getting tired and sleepy after hour or two awake.
....
Cardiac stress perfusion MRI done in July 2022 detected low oxygen saturation in the heart muscle. Cardiac CT angiogram done in October detected the plaque in coronary vessels, but level is not sufficient to be deemed a critical condition. Cardiologist reckons my issues not coronary, but caused by apnea.
Has the cardiologist explained how sleep apnea might be causing your current daytime symptoms of shortness of breath, chest tightness, and low SPO2 while awake and active?
Can apnea cause low SPO2 during the day? My main concern is fatigue but it is probably caused by low SPO2? My respiratory appointment coming soon, any point to ask about different treatment like ASV machine?
I think you need to focus on possible other causes for the daytime SP02, the frequent shortness of breath, and the chest tightness. While the fatigue is easily explained by the less than great sleep, those other daytime symptoms are not.

As for asking for an ASV machine, without a lot more data, there's no way to answer that question. A better question to ask in terms of your sleep is what might be done to help you get better quality sleep all around with significantly fewer awakenings.

So here are some questions for you to ponder:

1) Any idea on what is waking you up at night?

2) What goes through your mind when you find yourself awake in the middle of the night?

3) What do your sleep habits look like? Do you have a regular bedtime and a regular wake up time?

4) Should you get a second opinion about the heart issues?

5) Is it possible that you have a respiratory problem other than sleep disrupted breathing? In other words, is it possible you have COPD? Or asthma?
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vps
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Re: Low daytime SPO2 and fatigue

Post by vps » Fri Mar 17, 2023 7:42 am

Robysue1 and Miss Emerita, thanks for your replies. Attaching 2 of my Oscar screenshots to this post. Tried to attach yesterday to original post, but didn't work.
Update - attaching file doesn't work for some reason - file appears in Attachments but with Status Exclamation Mark in yellow triangle. When I press submit there is no file attached to post. File is only 190K, not too big
Here are 2 my Oscar screenshots on imgur - https://i.imgur.com/dhHI5Tf.png
https://i.imgur.com/hwhTESr.png
Last edited by vps on Fri Mar 17, 2023 10:06 am, edited 1 time in total.

vps
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Re: Low daytime SPO2 and fatigue

Post by vps » Fri Mar 17, 2023 8:05 am

Robysue1 here are answers to your questions:
How high are the leaks? And how long are the leaks?
Leaks are between 10 and 25 percent. I have Oscar screenshots, but unfortunately attaching files doesn't work for me. Here are 2 my Oscar screenshots on imgur - https://i.imgur.com/dhHI5Tf.png
https://i.imgur.com/hwhTESr.png
1) Any idea on what is waking you up at night?
2) What goes through your mind when you find yourself awake in the middle of the night?
Sometimes shortness of breath, sometimes feeling cold, sometimes need to go to toilet, sometimes discomfort after laying on my side. I'm light sleeper. Mind - doing meditation, thinking about pleasant moments like seaside holidays
3) What do your sleep habits look like? Do you have a regular bedtime and a regular wake up time?
Yes, sleep hygiene is ok - bedtime 11pm, wake up 7am, no mobile or TV after 9pm, last meal at 7pm, no coffee or tea in the afternoon
Last edited by vps on Fri Mar 17, 2023 10:02 am, edited 1 time in total.

vps
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Re: Low daytime SPO2 and fatigue

Post by vps » Fri Mar 17, 2023 8:52 am

Robysue1 here is 2nd part of my answers :
4) Should you get a second opinion about the heart issues?
Yes, I thought about it. My insurance has this option, however they need to inform my current cardiologist and get my data from him. This made me a bit uncomfortable as my cardiologist gets offended easily.
) Is it possible that you have a respiratory problem other than sleep disrupted breathing? In other words, is it possible you have COPD? Or asthma?
Asthma unlikely, COPD - maybe, no doctor ever tested me for it. Will ask my respiratory doc.
high respiratory rate
my daytime breathing is shallow, around 15-20 pm, with deep breath every couple of mins. I've mentioned this to doctors, but here in Ireland appointment lasts only 10-12 minutes, with lots of topics and urgent issues so breathing gets lost in discussion
Has the cardiologist explained how sleep apnea might be causing your current daytime symptoms of shortness of breath, chest tightness, and low SPO2 while awake
Probably will give some background - my age 60, male with diabetes, obesity. Cardiologist (after cardio MRI and angiogram) said that my symptoms are not coronary, most likely caused by apnea and obesity. My red blood cells and hematocrit are slightly below norm, haemoglobin at the very bottom of the norm - maybe those are contributing factors to fatigue? For the last 3 months I'm taking iron supplement and vitamins D and B complex

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Miss Emerita
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Re: Low daytime SPO2 and fatigue

Post by Miss Emerita » Fri Mar 17, 2023 11:25 am

Several quick thoughts.

First, it would be very valuable to know what kind of events you are having. That means solving the leak problem. Do you breathe through your nose during the day? If yes, can you shave a tiny bit of the hair under your nose and try using a nasal pillow mask?

Second, your symptoms seem consistent with a wide range of potential problems, including some that would be quite serious (I would add pulmonary embolism to robysue1's list). You may need to be seeing both a cardiologist and a pulmonologist; ideally they would work together as a team in diagnosing and treating you.

Third, your cardiologist's prickly nature should not stand in the way of your getting the medical attention that you need. I urge you to get a second opinion. And will you have the option of going to a different cardiologist if your relationship to the current one becomes too difficult?

Fourth, I'm not yet understanding the connection your cardiologist is drawing between your symptoms and apnea. I'm also not understanding how your symptoms could be explained by obesity (which I assume has been a condition of yours for some time), given their relatively sudden onset.
Oscar software is available at https://www.sleepfiles.com/OSCAR/

vps
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Re: Low daytime SPO2 and fatigue

Post by vps » Sat Mar 18, 2023 4:11 am

Miss Emerita, thanks for your thoughts!
I've tried nasal pillows - strong airflow straight into nose is discomforting, prefer FFM, but will try nasal pillows again. I breathe mainly through nose, but if nose is blocked then through mouth so FFM suits me better.
both a cardiologist and a pulmonologist; ideally they would work together as a team
This would be great but in reality very difficult
option of going to a different cardiologist
It is possible but a bit awkward - my GP has to write referral, then waiting time even with private insurance. Also there is no way of knowing if new doctor will be better than old one.
also not understanding how your symptoms could be explained by obesity (which I assume has been a condition of yours for some time), given their relatively sudden onset
It seems doctors use obesity as universal convenient explanation for any health issues. In a way it's true, obesity has huge negative impact, but I do my best to lose weight - portion control, no junk food, walking, swimming, exercises, last meal at 7pm. Appointment with cardiologist was around 12 minutes, we've discussed my angiogram, blood tests, so he didn't go into detailed explanation, just said that my issues not coronary, likely to be related to apnea and obesity

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Re: Low daytime SPO2 and fatigue

Post by robysue1 » Sat Mar 18, 2023 8:54 am

vps wrote:
Fri Mar 17, 2023 7:42 am
Update - attaching file doesn't work for some reason - file appears in Attachments but with Status Exclamation Mark in yellow triangle. When I press submit there is no file attached to post. File is only 190K, not too big
Here are 2 my Oscar screenshots on imgur - https://i.imgur.com/dhHI5Tf.png
https://i.imgur.com/hwhTESr.png
The total storage capacity for "attached files" has been reached, and pugsy, the main moderator, does not have the proper computer permissions from the owners of the site to go in and remove the old, unneeded files posted months and years ago by posters who came, got their questions answered and their problems fixed, and then disappeared.

That's why using sites like imgur really is the preferred way to show data.
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Re: Low daytime SPO2 and fatigue

Post by robysue1 » Sat Mar 18, 2023 9:45 am

vps wrote:
Fri Mar 17, 2023 8:05 am
Robysue1 here are answers to your questions:
How high are the leaks? And how long are the leaks?
Leaks are between 10 and 25 percent. I have Oscar screenshots, but unfortunately attaching files doesn't work for me. Here are 2 my Oscar screenshots on imgur - https://i.imgur.com/dhHI5Tf.png
https://i.imgur.com/hwhTESr.png
Here's what that data looks like:

Image
Image

See all those areas with gray backgrounds? That's when your machine is flagging genuinely unacceptable large leaks that are way large enough to interfere with the efficacy of your therapy and the accuracy of the flagging of events during those times. And you're leaks are not "between 10 and 25 percent". Your largest, most unacceptable leaks are lasting for at least 10-25% of the total time you are using the machine.

You are using a Resmed 10 AutoSet: The leaks reported in Oscar are unintentional leaks and Resmed traditionally defines a large leak as any leak at or above 24 L/min. On both of the two nights you posted, your median leak rate is above 24 L/min. In other words, your leaks are in official Resmed Large Leak territory for at least 50% (half) of the night. Why Oscar is only flagging the largest of your large leaks as "Large Leaks" when it says you were in Large Leak territory for 10-25% of the night is beyond me: With those median leak numbers, we ought to be seeing a lot more gray shading than we are.

Equally concerning: Even at this resolution and size of the leak graph, the flattest and lowest parts of your leak line are still in the neighborhood of 25-30 L/min. In other words, your mask is leaking all night long and your constant rate of unintentional leaks is flirting with Large Leak territory all night long.

You need to fix the leaks: Until those leaks are under control, we have to assume that your sleep apnea is under treated, as in the machine cannot reliably maintain enough pressure to splint your airway open (so you have events) AND the machine cannot reliably track your breathing at all times (so it can't detect events with great accuracy).

So the usual questions come up:

1) Are you a mouth breather?

2) Since you are using a full face mask, are you fitting the mask correctly?

3) Are you assembling the equipment correctly?

4) Does the mask cushion have a tear in it somewhere?

5) Does your hose have one or more pin-hole sized leaks or is there a tear near one of the couplings?

6) Just how busy is your beard? My husband uses a full face mask and usually has a full, usually bushy beard, but his leaks are never this bad. In fact, he usually has a really nice leak line with median leak rate almost always 0.0 L/min and the 95% leak rate usually less than 5.0 L/min. But his full face mask does have the traditional forehead support, and many that makes a difference.


vps wrote:
Fri Mar 17, 2023 8:05 am
1) Any idea on what is waking you up at night?
2) What goes through your mind when you find yourself awake in the middle of the night?
Sometimes shortness of breath, sometimes feeling cold, sometimes need to go to toilet, sometimes discomfort after laying on my side. I'm light sleeper. Mind - doing meditation, thinking about pleasant moments like seaside holidays
3) What do your sleep habits look like? Do you have a regular bedtime and a regular wake up time?
Yes, sleep hygiene is ok - bedtime 11pm, wake up 7am, no mobile or TV after 9pm, last meal at 7pm, no coffee or tea in the afternoon
So plain old sleep continuity insomnia is probably not the issue.

vps wrote:
Fri Mar 17, 2023 8:52 am
4) Should you get a second opinion about the heart issues?
Yes, I thought about it. My insurance has this option, however they need to inform my current cardiologist and get my data from him. This made me a bit uncomfortable as my cardiologist gets offended easily.
Offending one's doctor is not a good, valid reason for failing to get a second opinion. Quality doctors should not be offended by a request for a second opinion. I would speak to your primary care physician about this. I would also inform your insurance that you would like a second opinion, but you are worried the cardiologist is going to be "offended".

) Is it possible that you have a respiratory problem other than sleep disrupted breathing? In other words, is it possible you have COPD? Or asthma?
Asthma unlikely, COPD - maybe, no doctor ever tested me for it. Will ask my respiratory doc.
high respiratory rate
my daytime breathing is shallow, around 15-20 pm, with deep breath every couple of mins. I've mentioned this to doctors, but here in Ireland appointment lasts only 10-12 minutes, with lots of topics and urgent issues so breathing gets lost in discussion
First, rapid and shallow breathing is a common symptom of COPD. And COPD could easily explain the low daytime SaO2 levels.

Second, you need to think of the breathing issues as urgent so that they do get addressed. I would suggest that you call the respiratory doc's office and set up an appointment specifically for talking about the breathing problems and your low daytime SaO2 levels.

Has the cardiologist explained how sleep apnea might be causing your current daytime symptoms of shortness of breath, chest tightness, and low SPO2 while awake
Probably will give some background - my age 60, male with diabetes, obesity. Cardiologist (after cardio MRI and angiogram) said that my symptoms are not coronary, most likely caused by apnea and obesity. My red blood cells and hematocrit are slightly below norm, haemoglobin at the very bottom of the norm - maybe those are contributing factors to fatigue? For the last 3 months I'm taking iron supplement and vitamins D and B complex
So it sounds like the cardiologist can't find anything obvious wrong with your heart and he's a "plumber" that specializes in hearts and won't look at you as a "whole" person.

Yes, the obesity is an issue. Yes, the diabetes is an issue. Yes, the under treated sleep apnea is an issue. But while they can all cause daytime fatigue, none of them is a likely cause (all by themselves) for low daytime SaO2 levels. And the daytime shortness of breath and tightness in your chest are not explained by just obesity, diabetes, and your under treated sleep apnea. Something else is going wrong, and you and your docs do need to get to the bottom of it.

My advice is to make an appointment with the respiratory doctor and when you make the appointment make it clear that what you want to talk about in that 10-12 minutes you have is the daytime breathing issues and your low daytime SaO2 levels.

While waiting for the appointment with the respiratory doctor to take place, you should also figure out why your leaks are so darn high when using the CPAP machine. Start by carefully inspecting all your equipment far away from daytime. You're looking for very small holes and/or very small tears. If the place that set you up with the equipment has any respiratory therapists on staff who actually know something about CPAPs, it may be worth calling them to see if you can meet with a respiratory therapist to help trouble shoot the equipment. But if you are more inclined to be a do-it-yourselfer, then you can get a lot of help trouble shooting those leaks here.

Let us know if you want our ideas on what to do about the leaks.
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vps
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Re: Low daytime SPO2 and fatigue

Post by vps » Sun Mar 19, 2023 4:27 am

Robysue1 thanks for your help.
let us know if you want our ideas on what to do about the leaks.
Yes, your ideas will be greatly appreciated!
1) Are you a mouth breather?
Mainly nose breather, but when nose is blocked (often!) I'm mouth breather.
Since you are using a full face mask, are you fitting the mask correctly?
Using fit test on machine to check. It's difficult for me to achieve 100 percent green face - it feels like exhaled air stays in my mask and I inhale warm and humid exhaled air. So usually fit is a compromise between green and red, with green majority.
3) Are you assembling the equipment correctly?
yes, no leaks in joints
4) Does the mask cushion have a tear in it somewhere?
No, cushion is 3 month old
5) Does your hose have one or more pin-hole sized leaks or is there a tear near one of the couplings?

No can't see any faults
forehead support
never tried those masks
First, rapid and shallow breathing is a common symptom of COPD. And COPD could easily explain the low daytime SaO2 levels.
Second, you need to think of the breathing issues as urgent so that they do get addressed. I would suggest that you call the respiratory doc's office and set up an appointment specifically for talking about the breathing problems and your low daytime SaO2 levels.
Yes, going to talk about these issues during upcoming appointment. What test is good for COPD diagnosis? My GP regularly checks my breathing and lungs with stethoscope. Cardiac MRI would have picked up if there was serious lungs issue. ECG also done last year. Spirometry wasn't done for a while, will buy spirometer myself
sounds like the cardiologist can't find anything obvious wrong with your heart and he's a "plumber" that specializes in hearts and won't look at you as a "whole" person
Yes that's the problem - narrow formal approach and brushing me off to another consultant. It seems most doctors like this.
But if you are more inclined to be a do-it-yourselfer, then you can get a lot of help trouble shooting those leaks here.
Would prefer to deal with leaks myself, respiratory consultant has no technician to check machine

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ozij
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Re: Low daytime SPO2 and fatigue

Post by ozij » Sun Mar 19, 2023 6:57 am

vps wrote:
Sun Mar 19, 2023 4:27 am
- it feels like exhaled air stays in my mask and I inhale warm and humid exhaled air. So usually fit is a compromise between green and red, with green majority.
"warm and humid" comes from your Climateline / Humidity settings. It's not exhaled air.

You have to disable Climateline = Auto and then set the temperature and the humidity separately.

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vps
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Re: Low daytime SPO2 and fatigue

Post by vps » Sun Mar 19, 2023 8:33 am

warm and humid" comes from your Climateline / Humidity settings. It's not exhaled air.
You have to disable Climateline = Auto and then set the temperature and the humidity separately.
I don't have Climateline, it's just hose without any heating. My humidifier tank is empty to reduce humidity.

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Re: Low daytime SPO2 and fatigue

Post by ozij » Sun Mar 19, 2023 9:00 am

vps wrote:
Sun Mar 19, 2023 8:33 am
warm and humid" comes from your Climateline / Humidity settings. It's not exhaled air.
You have to disable Climateline = Auto and then set the temperature and the humidity separately.
I don't have Climateline, it's just hose without any heating. My humidifier tank is empty to reduce humidity.
My apologies - I can see in this image https://i.imgur.com/dhHI5Tf.png that your humidifier is off.

I'm trying to undersand your "sometimes red sometimes green" statement. Are you intentionally letting your mask leak to "let out the hot humid air"?
Are you really using an antibacterial filter as it says in the image?

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Additional Comments: Machine: Resmed AirSense10 for Her with Climateline heated hose ; alternating masks.
And now here is my secret, a very simple secret; it is only with the heart that one can see rightly, what is essential is invisible to the eye.
Antoine de Saint-Exupery

Good advice is compromised by missing data
Forum member Dog Slobber Nov. 2023