CompSA, Hypoventilation, PLMs, Bradycardia and Hypotension?

Muffy wrote:With the elevated CO2, the ETCO2 probably got diluted in the ASV Titration (perhaps mask leaks, and that's why they changed the mask).

Muffy

During the titration PSG I wanted to use the Mirage Liberty all night but they couldn't set this up for the ETCO2 catheter, so they put an Activa on me first and then swapped over to my preferred on completion of the ETCO2 measurement.

Well, if you calculate the pCO2 based on the -HCO3, and if your pH has normalized (you have "compensated"), then your pCO2 is 50 mmHg. Your answers to the questions about physical activity (are you a "footballer") suggest that it's not a pulmonary problem (you'd be debilitated if your pCO2 was 50 because of pulmonary problems) but I'd still consider getting that PFT.

But that leads us to a metabolic alkalosis.

Considering the obvious, are you taking a LOT of antacids?

Muffy

blizzardboy wrote:

Muffy wrote:OK, magnify 0340 to 0410 to 30 minute view.

http://users.adam.com.au/sixsome/ASV/04 ... _MV_04.JPG

Muffy

http://users.adam.com.au/sixsome/ASV/04 ... _MV_06.JPG

And you're cycling at 120.

Lemme think about this...

Muffy

Muffy wrote:Well, if you calculate the pCO2 based on the -HCO3, and if your pH has normalized (you have "compensated"), then your pCO2 is 50 mmHg. Your answers to the questions about physical activity (are you a "footballer") suggest that it's not a pulmonary problem (you'd be debilitated if your pCO2 was 50 because of pulmonary problems) but I'd still consider getting that PFT.

But that leads us to a metabolic alkalosis.

Considering the obvious, are you taking a LOT of antacids?

Muffy

No, I don't take any antacids.

My sleep doctor, whom I will see on April 30, is also a pulmonologist so hopefully he'll be right on a PFT.

In regard to exercise, well I have regularly been a vomiter after strenuous exercise, be it running, cycling, or swimming. I get clammy, sweaty and nauseous for about 5-10minutes and then I pick up again.

Then check the thyroid again.

I just don't think you're a pulmonary patient, but what the hey, I've been wrong before.

Only kidding.

Muffy

blizzardboy wrote:...he'll be right on a PFT...

BTW, tell him we need a "Complete" PFT (including an MVV) and not just a "Screener".

Muffy

Muffy wrote:BTW, tell him we need a "Complete" PFT (including an MVV) and not just a "Screener".
Muffy

Emphasis added to "we" by me.

Now that's a team approach!

kteague wrote:

Muffy wrote:BTW, tell him we need a "Complete" PFT (including an MVV) and not just a "Screener".
Muffy

Emphasis added to "we" by me.

Now that's a team approach!

It's nice to feel there's someone on your team. Not that I would know.

kteague wrote:

Muffy wrote:BTW, tell him we need a "Complete" PFT (including an MVV) and not just a "Screener".
Muffy

Emphasis added to "we" by me.

Now that's a team approach!

OK, but I think this is a critical point:

Although bb's lab work is dated, he reports an -HCO3 of 30. We can calculate the PCO2 using Henderson-Hasselbach to show:



that his pCO2 is around 50 mmHg.

Now that ETCO2 from the AdaptSV comes into question, and since it was being gathered from under a CPAP mask, even a small leak could dilute that sample significantly and give spuriously low results.

Now we (LOL) should work the hypothesis that he is in fact hypercarbic. But why? There's no reason to think that, and if his PFT is normal and he has the ability to do an MVV (total air moved in a minute) then mechanically there's no way it could happen.

So that leaves a central component as the possible culprit. But come on, look at the guy? Does he look like a central hypoventilation kind of guy?

Except if now you figure in:

• heart rates dips into the high 40s when asleep
• blood pressure drops to 80/43 during the night
• resting blood pressure when awake is around 110/75.
• during my diagnostic sleep study I had both OSA and CSA events.
• 20mg of Fluoxetine (anectdotal evidence)
• mild depression and anxiety
• minute volume av. is 3.7l/min
• have developed acute joint pain recently. Quite odd really as each joint in my body seems to be taking its turn. The pain in any joint lasts for no more than two days, during which time it is excruciating to move, and then passes. I have had no joint repeat its pain. Neck. Shoulders. Wrists. Knees. Groin. Ankles. Knuckles. Ankles. Fingers. Toes. Feet knuckles.
• irritable
• hearing and touch sensitivity

despite prior normal lab work, I think you now have the makings of the Poster Boy for hypothyroidism. Now that might also buy an ABG at the Pulmonologist's, but if it turns out that he is hypercapnic and hypothyroid is the cause, it's going to be a heckuva lot easier to deal with that pCO2 (let the body do it)(I mean let the levothyroxine do it). Trying to beat it down with an xPAP anything would be an exercise in futility.

Muffy

If you're drawing blood for thyroid testing, tell them to also run the labs I specified before. They are probably normal, but you're going to be stuck anyway, so might as well!

NOW, let's talk about that teeny, tiny study (N=7) showing an association (just an association, not causation) between Hashimoto's Thyroiditis and OSA in euthyroid patients. It is, admittedly, a crummy study (for the aforementioned reasons), but is there something to this?

http://www.mdconsult.com/das/citation/b ... html?issn=

If so, consider having not just your TSH tested, but testing done for Hashimoto's. Actually, why not have yourself tested for Hashimoto's, if only so you'll know how closely you might need to monitor your TSH in the future. You're getting stuck anyway! (My secret plan is to have so much bloodwork drawn on you that you will be anemic by the time it's over, and then I can say, "Ah ha! See, I was right!" j/k)

SleepingUgly wrote:...have so much bloodwork drawn...

Best excuse in the world for a lotta water and a huge steak!

BBoy, I can't remember what tests SUgly recommended but these are pretty good evaluations of your thyroid system: free T3, free T4, TPO, TSH, reverse T3; something else to consider is your iodine level, many have low levels here in the US because they avoid salt (mostly iodized here) and eat very little seafood/seaweed. If I were in your shoes, I'd get a saliva test for cortisol...the kind that tests 4 times/day. I assume your blood glucose levels are 'normal' and a 2-hr provocation load of carbs showed normal insulin response?

Muse-Inc wrote:If I were in your shoes, I'd get a saliva test for cortisol...the kind that tests 4 times/day.

We want blood, saliva, oh, and while we're at it, urine (the big jug that you have to keep in the refrigerator). If we're going this far, let's rob the guy of all his bodily fluids. And lest anyone accuse us of not being thorough enough, let's throw in a stool test.

Blizzardboy, I hope you don't mind my jokes, along with my not-so-sound medical advice.

SleepingUgly wrote:...urine (the big jug that you have to keep in the refrigerator)...

Plan to do this 24-hr urine catch when you can keep the dam#ed thing in your own refrigerator! Britght red with all sorts of scary looking logos on it, is not a good thing to take and put in the office fridge by people's lunches

I hadda do the urine cortisol to rule out an adrenal tumor that might have been causing my high BP and potassium probs...idiotic doc saw horseshoe tracks and was looking for a zebra. Apnea and diuretic common causes for these probs...BP went to normal with CPAP and daily low-sodium V8 takes care of the potassium problem caused by the diuretic which I can't stop yet.

BBoy some of us have been thru all sorts of tests trying to come to an effective treatment for our SDB & its nasty side effects, I know we wish you the best in finding effective treatment.

Muse-Inc wrote:

SleepingUgly wrote:...urine (the big jug that you have to keep in the refrigerator)...

Plan to do this 24-hr urine catch when you can keep the dam#ed thing...

Almost as if by coincidence my wife and I went shopping for large rain barrels today... I kid no one about this.

Based on this thread I now consider them to be... general utility barrels instead.

P.S. Still with you, blizzardboy.

So is it better that I am currently on an Adapt SV than not?