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Low spO2 levels even with low AHI
#1
So I am trying to get back in the habit of using my CPAP, even though I had a poor tolerance for it.

Been doing well for about a week on staying on CPAP (requires taking a sleep aid, and I am now exhausted in a different way than before, since I believe the CPAP wakes me up more in the middle of the night), but my charts show that my AHI is way better.

My AHI has been 3 or below most nights.  But when I added an spO2 monitor, it shows that my Oxygen levels are still not good.

Is there a link anyone can provide that talks about spO2 levels with TREATED sleep apnea?  Every link I find talks about it as a diagnostic tool to detect sleep apnea.

As a bit of background, I have a CMS50FW Oximeter, and as long as I disable wireless, I am able to link it to my CPAP results in Sleepyhead (although I had to go find an older version of sleepy head to do that).

As a bit more background, I do live at 7200ft which I believe will lower spO2 a bit anyway.  And my spO2 rates while awake aren't that great either.   I tried to talk to a new pulmonologist about it, but he didn't seem to care that my O2 rates weren't good during the day.
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#2
Once you have 4 or more posts you can link to some data that might help.  Your post raises more questions than answers.  What were the tolerance problems for CPAP, What is disrupting your sleep.  Your AHI is less than 3, but what kind of events and what are these oxygen levels.  You're using an auto CPAP at fixed pressure?  Do you have any other medical condition that might explain low SpO2?  Other data points that are relevant are minute vent, respiration rate, tidal volume.

CPAP and especially bilevel can greatly affect oxygenation and ventilation.  This video moves pretty fast and covers the most critical aspects of how CPAP and BiPAP can affect oxygenation, ventilation and other parameters.



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#3
Thanks for the interesting video. More background on my 'not tolerating' CPAP.

I was sent to several sleep studies, and they strap a mask on, and then I would proceed to stay awake all night.....
Finally someone thought, hey maybe we are wasting money on sleep studies, since we don't get any results from them. Here's 10mg of ambien to take during your sleep study.

So they get a successful sleep study, with an untreated AHI of 80 finally. I was seeing a ENT at the time, and they proscribed CPAP, at what pressure I don't remember, but I still have that machine, so I could go look it up if anyone was interested.

I think many of my tolerence issues after this point, were related to crappy DME support. You go in, they show you a wall of 10-15 masks, pick which ever you like....

So in that event of no guidance, I believe I got a nasal mask since it seemed less intrusive But of course, as soon as you apply pressure, my mouth pops open, the CPAP starts pushing serious volume of air to try to get the pressure up and I feel like I am drowning in a sea of air. (and probably not really receiving any therapeutic value either).

So ENT recommends UPPP surgery. Further sleep study shows that this drops my untreated AHI to 40. (Current pulmonologist UPPP is a waste of time, doesn't know why the ENT like it so much).

I have tried again with a different DME provider, and got a facial mask. That mask didn't fit particularly well (too large) (and until I did my own research and bought a mask out of my own pocket I didn't even realize it didn't fit). So basically anytime I moved even a little with a too large mask, I got a leak, which would wake me up.

Even with good mask fit, every time I move, the mask pulls on my face, waking me up.

At times with a full face mask, I also feel like I am getting smothered and have a lack of fresh air.

I am currently playing with a Nasal Pillow setup and a strap to keep my mouth closed. I have another strap on order, because the one I have isn't effective with my long beard, and it slips off after a while.

The nasal pillows seem less intrusive, and were working fairly well the first few nights. I switched from medium to small pillows which seemed to fit better initially, but now i seem to be having flow problems on one side or another, I may try switching back to the medium to see if that helps the fit again.

I am to the point now, where if I am really exhausted, I can eventually get to sleep while wearing a mask or nasal pillows, but there is usually a large delay. Taking a sleep aid will allow me to sleep, but still a large delay getting to sleep. I believe I do wake up several times during the night while wearing the mask.

My plan is to not take sleep aids for the rest of my life, but I hope by about 2 weeks, I will be able to tolerate having some foreign object strapped to me, tugging on me when I move, and shoving air at me all the time.
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#4
Since I need to get my post count up, here is some more background.

Pulemologist i was seeing after UPPP surgery believed that the best thing since sliced bread is Oral appliance for treating my apnea. Since I never managed to enjoy wearing a mouth guard for playing sports as a kid, or anti teeth grinding mouth guard later in life, wasn't sure about tolerance of an anti-apnea oral appliance, which at the time wasnt covered by my insurance well.

Current pulemologist believes Oral appliance is only good in moderate apnea cases... Basically all the doctors I have seen imply previous doctors are idiots.

Other health conditions.
GERD, treated with preacid.
Thyroid, treated with synthroid.
High blood pressure, treated with multiple meds, but still erratic.
I have been told that my heart muscle is thicker due to prolonged high blood pressure
Previously saw a cardiologist for shortness of breath. He did a bunch of tests, didn't find anything that interested him. His only useful advise was that there was a generic in the same class as one of my HBP meds.

Because of difficulty breathing, I had also seen an allergist, who diagnosed me as having Asthma, although I could not really see any diagnostic criteria he used to make that diagnoses. While advair seemed to make breathing easier, a rescue inhaler didn't do anything when I had shortness of breath.
Went and saw another doctor, he requested a Methacholine challenge for Ashma diagnosis. The result back was "Maybe", which he had never seen.
Switched to a pulmanologist, he requested a Methacholine challenge, and while I was somewhat close to the criteria, it has a yes/no answer, and the answer was no.
When I started seeing a new pulmanologist (other one had moved away), couldn't find my previous results, so they ordered another Methacholine challenge. Also no answer, but spO2 was low enough afterwards that they wouldn't let me leave the test when done for about 15 minutes.
New Dr also requested a new sleep study (2 night) which was going to have a $2400 copay, so I said skip that, I've had lots of sleep studies and all that comes out is a CPAP recommendation that I hadn't been able to use previously. Switched to the simpler at home sleep study (PulseOx, Nasal cannula, and band to measure your chest.) That simplier sleep study revealed an untreated AHI of 40, which is what my previous sleep clinic sleep study had also revealed.

My CPAP was set to 11, with the C-flex from my last sleep clinic sleep study. Since that was from a few years ago, i switched it to the Auto Setting for a few days to see where it would self titrate to, it appears my 90% value is normally around 11, but my 95% was above that (and varied night to night) so I guess a fixed CPAP of 11 with Cflex is still a decent value.
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#5
Wow, I guess I shouldn't be surprised anymore, but the stories are amazing. ENTs think UPPP is the best thing since income was invented, and they like em, even though they have never gotten anyone off CPAP and cause crazy complications and pain. Masks are the voodoo of CPAP and if you can get it right, it makes all the difference. We have members here with truly impressive beards (Paging bonjour) and they make things work, and will give you any help they can. On nasal pillows, you went the wrong way...try the large pillow cushion. I'm serious. You will get more air and a better seal. I guess I'm assuming a Resmed Airfit P10.

Just a couple more posts and we can look at what is going on. Meanwhile stop back, say hi, and read my signature links on how to organize and post the charts. I assume you have access to your clinical settings menu on your machine?
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#6
Hi Tigerman67 and welcome to the Apnea Board.  You have caught my attention as well.  You do seem to have a lot of issues here.  We would like to offer help and support so stick with us.  Looking forward to seeing your charts.  

Rich
Apnea Board Member RobySue has posted a Beginners Guide to Sleepyhead Software here:  http://www.apneaboard.com/wiki/index.php...SleepyHead

Download Sleepyhead
Organize your Sleepyhead Charts
Post from Imgur


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#7
Welcome Tigerman67!  You certainly have been through the DME and doctor wringer!  I am impressed that you are still trying.  Kudos!

One thing about AHI: it is just a crude yardstick.  If you quit breathing for 10 seconds or 120 seconds, that is counted as the same value.  Clearly stopping breathing for 120 seconds is going to have a much more serious impact on your spO2 levels.  There is where looking at the detailed data is important.
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#8
Yes, I figured out how to access the clinical settings.  I figure I am the most motivated to get my therapy right, and a few simple adjustments will tell me a few things fairly quickly, but don't want to go too far off the beaten path. 

My nasal pillows mask is a: Swift™ FX Nasal Pillow CPAP Mask with Headgear

My full face that I have is a: Mirage Quattro™ Full Face , originally in a size large, but tended to leak into my eyes, now have a medium, which fits better, although it feels just barely big enough at the bottom. 

The chin strap I have is: Ruby-Style Adjustable Chinstrap with Extension Strap - Standard
The problem for it is it has a pocket for the chin, and the beard hair is relatively slick compared to bare skin and its fairly easy to get it to slide forward and off the chin.
I have ordered one that is wider, and looks to fit under the jaw, and less about the chin.  I think that will probably do the job.  Otherwise there is always the ace bandage if I can't make the new strap work.  
 
When wearing the full face mask, I tended to have higher AHI numbers 5-6, at least when using the Auto setting.

I'll probably switch it back to my standard CPAP settings of 11, so my comparison from night to night don't have as many variables in them.  And I need to start taking notes for myself since Sleepyhead will tell me which setting the machine is on, it won't tell me which mask I had on, or if I had any problems that night that I should remember.

My recent problems with the nasal pillows,  It generally feels like I am only getting air on one side after a while, not sure if the pillows are flexing from the weight and pull of the tube feeding them (and squeezing the opening closed on one side), or maybe I simply have had too much congestion the last few nights.
My nose is feeling a bit sore from having the pillow mask in place for the last few days (a little about my nasal passage, but more about just having something pressed up against my nose.  I may go to full face for a day or two to let the tenderness go down. 

I did see that dreamware nasal pillow setup that gets the hose out from in front, might be interesting, but I assume putting the hose in the back probably just causes different problems.  That and I am starting to have spent a bit on supplies now, and I am changing too many things at once... So I am going to just try to focus on getting to the point that I can go to sleep and tolerate the mask all night without sleep aids (which I dislike in general).  But in a few months, I might try that as a different nasal option.

For anyone considering the UPPP surgery, as sleeprider mentioned, it is very painful and long healing process, and while it can reduce your AHI number, I believe it is officially listed as having mixed results.  About the only plus is that I lost about 20lbs really quick (because you can't eat anything comfortably) but of course gained it right back. 

As an unusual aside, I normally score fairly well on Epworth sleepness scale, because I feel more fatigued than actually sleepy.  So I would love to take a nap, but I am in no danger of randomly falling asleep. 

Anyway, I think I have written a small novel so those that haven't fallen asleep from boredom, I think this puts me over the edge for being able to post the charts from sleepyhead.  I'll take a look tonight when I get home and make sure I have them organized so I can post something worthwhile.
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#9
I find that the Dreamware mask is far more comfortable, due in great part because the hose attaches at the back and top of your head. Very little pressure on your face, and that feels so much better for many of us. I previously tried the nasal wisp and P10 nose pillows. Pillows were painful and the wisp was not nearly as comfortable as the Dreamware - which is also a nasal mask, but has a very low profile as well as different hose placement.
Good luck with all this; you've been through much and may find some good direction here.
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#10
Okay here is one of my charts 


[Image: KmvAVXIl.png]
[Image: X628FJkl.png]
[url=http://imgur.com/KmvAVXI][/url]
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