Seeing more UA and CA - due to being sick or AFIB med?

[MyronH]

I hope the sleep lab data you recently got was helpful to your sleep doc but frankly, you're getting some really good reads and recommendations on your data from right here. Something I have not seen in any of your posts is a list of medications you're taking including any over-the-counter drugs and supplements. If you'll list these it would be helpful. 

Clearly, if your pulse oximetry was accurate and as you reported, there is a probability that you're experiencing acute respiratory acidosis probably as a result of increased serum levels of CO2. One of the compensatory mechanism for that, among many others, is increased respiration. You can see this on the bottom of your sleepyhead data under minute respiration and respiratory rate (not on your posted data). If your respiration ramps up dramatically following extended periods of airway obstruction, this is a nominal indication of serum acidosis (requires blood gas evaluation to confirm).

Your elevated heart rates may or may not be a response to increased levels of serum CO2. Given what we know about your medical history (A-Fib) I doubt that is what it is. Do you see a cardiologist for your A-Fib? If so, he could order an event and BP monitor for you. You activate this only when you perceive the kinds of symptoms you've already reported here. The events are monitored by telemetry and if there is something wrong, you'll get a call. Sleep restlessness will raise your BP and from the levels you've reported I don't think you are in any danger but that's not my call. Getting a 24h BP monitor is a good starting point.

A-Fib generally doesn't produce steady heart rates in the 140s - your pulse is irregular and can be thready (decreased pressure) in A-Fib. Atrial Flutter produces steady pulses > 140 bpm. The reason the ER didn't find anything is because once you were awakened, got up and cleared your airway, then got to the ER, symptoms resolved and your blood gases returned to normal - ER docs aren't going to go deep into this sort of thing once you are medically stable and you won't be admitted unless you're stable but the ER Doc has some concerns about underlying causes. Obviously they didn't, felt that you were safe to discharge to follow-up with your providers. Ask your cardiologist about Atrial Flutter.

Given what you've reported here about your tongue and the work-up your dentist undertook, it's disappointing that your sleep doc dissed him. But I'm pretty sure, he'll consider this in the sleep lab. Honestly, while obstruction measured by AHI can be done in the sleep lab, I don't think the actual cause of that obstruction can be accurately determined. That is in the scope of practice of an ENT and I think your dentist was on the right track. I'm not a sleep doc so, again, not my call. A quick search of the medical literature revealed there have been studies done to determine if tongue fat/an enlarged tongue can be an important underlying cause of OSA. Here's a link and the type of diagnostic study used to evaluate your tongue during sleep.  http://www.scielo.br/pdf/rboto/v73n5/en_a06v73n5.pdf

Bottom line is that your tongue may be a contributing cause of your OSA. At the very least, it should be ruled out as an underlying cause. I would keep pressing your providers on this issue and an oral mechanical device from your dentisy or an ENT may be appropriate therapy to treat the underlying cause. If it is your tongue dropping back and blocking your airway in any significant way CPAP isn't going to work. It could make it worse. Second, at this point, your heart issues may or may not be related to OSA. You need to have a discussion with a cardiologist about your A-Fib, increased BP at night and in bed, accelerated heart rates and symptoms you are experiencing when these occur. If your A-Fib is being managed by an Internist that is your PCP, ask him/her for a cardiology referral.

Yes I have a cardiologist, and my ENT and dentist already confirmed for the most part that I have nasal and throat obstructions. Nasal diviated septum, enlarged turbnates, and my dentist showed me my back of my throat, and little airway it has, and that my tongue is large for my mouth. He firmly thinks an appliance will help me. But those appliances are not cheap. He wants $2800 for one. My sleep doctor said the CPAP should be able to clear the airway, even with my tongue fallen to the back blocking it. 

My cardiologist is sending me a SEEQ Cardio device to wear for 2-weeks, to see if it catches the heart rythm and fast issue. I've worn these before, but they never caught anything in the past. Hopefully this time it will.

[jbuch002]

Thanks for your response. Regarding your tongue. If the Sleep Doc says your CPAP/BIPAP should clear your airway, then that's what you should go with.

I also appreciate the staggering cost of an oral appliance. I'd be reluctant too.

I like the heart monitor from your cardiologist.

On your previously reported home measurement of O2 saturation ..... getting into the low 80s is a big deal. I assume that during your in lab sleep study, there was no mention of this kind of oxygen desaturation.  If so, then I'd be wary of the accuracy of any home measurements your taking and maybe think about avoiding this while sleeping. If your anxious to begin with, this is only going to aggravate your anxiety.


You didn't say anything about your prescription and supplemental meds and if you don't want to share that it's fine. The reason that I asked is that I was trained to look at the simple things behind a symptom first and before looking for the Zebras (more complex causes). Medications and their side effects are important. For example, if your'e using any OTC supplements, these can interact with your prescribed medications producing the kind of symptoms (racing heart) that you've described. I'd recommend you take everything you are putting into your mouth to a pharmacist and have him check for interactions. It's very common when you are seeing multiple Docs that an RX can be given by one Doc will interact with an RX from another Doc. It's not intentional or negligent but it happens because prescribers don't always know your entire medication list, including supplements for a lot of different reasons. I can do this for you using a software program I have. Your call.

Your SleepyHead data posts need to be presented differently. At the top should be Event, followed by Flow Rate, Pressure, Leak Rate, Snore, then Flow Limit. There is a link that I don't have that shows you how to arrange these and get them to fit in a screen shot. I'll defer to one of the Advisory Members to provide that to you.

[Sleeprider]

Well I got the results from the sleep study. They said after titrating me again, I had ZERO OA and ZERO CA. It seems like every sleep study I have done, I have zero CA, but when I get home, my machine shows a couple CA a night.

They used a Respironics machine, and I told the tech I really liked how it felt, compared to my ResMed. But she said at the same pressure settings, I shouldn't notice much difference. They switched me to BIPAP in middle of the night just to test that too.

My doctor is ordering a BIPAP for me to try at home for two weeks. In the meantime, he has changed my APAP pressures to 7-14. He said I could also try a constant pressure of 9, but i dont think that would be enough to clear most of my OA's.

Last night, I set my machine to 7-14, with EPR3, as instructed. Slept for about 5-1/2 hrs, and woke up feeling a little "jittery". Like I was going to have a panic attack or something. I took my prescribed clonazepam and went back to sleep for a couple hours.

Checked my logs this morning. AHI 4.35. During the first 5-1/2 hours, had (3) CA's. According to my doctor assistant, AHI <5 is good, and she was not concerned about the CA's. She had no explanation what caused me to feel "jittery". But this feeling I've had in the past, especially when they had me on a constant higher pressure.

During one of my CA's, I see that my Resp.Rate didn't go down to 0. Does that mean this was a false flagged CA, and I was still breathing?

Myron, first the Resp. Rate is a time averaged breaths per minute, so a 10 second CA is not going to significantly change the overall breath rate for that period, however there is a clear dip just to the right of the green line which marks when the CA occurred.  So that event briefly reduced your resp rate, tidal volume and minute vent. In your case, the CA events are really nothing to be concerned with.  You still have a lot of OA. Part of the reason is you "listened" to your doctor's recommendation for pressure, but didn't "understand" that he is not accounting for the reduction of 3-cm in exhale pressure.  With EPR at 3, your real pressure is 7/4 to 14/11.  Your charts don't tell us what the pressure was when the OA events occurred, but you really need to up the minimum pressure if you're going to use EPR 3.   It is EPAP (exhale pressure) that prevents the next obstructive apnea, and yours needs to be higher.

[MyronH]

Great info SleepRider. Thanks. I just don't understand why Sleep doctors don't think EPR makes any difference, besides "comfort". I've had two sleep doctors and an assistant tell me that EPR is all about comfort, and doesn't affect anything else. 

My sleep doctor did mention, I could put my machine on a constant pressure of 9, which he got that number after reviewing my sleep study. So maybe I could put my range from 9-14 then? Or just minimize the EPR to 2 or 1 or off also?

As far as I know, during the sleep study, they were using some type of EPR, because when i was awake, it definitely felt like EPR was enabled. Whatever they call it on the Respironics.

My Meds:
Multaq (for AFIB), Bystolic 2.5mg (for HBP), L-Thyroxine, Atorvastatin 20mg. I also take Fish Oil, and a baby aspirin at night, but Cardiologist may be switching me back to Xarelto, due to my Factor Five clotting disorder, and previous history of DVT/PE. My CHAD/VASC score is only 1 though.

[jbuch002]

Myron, Multaq is an excellent anti-arrhythmic with a very good safety profile. It does not interfere with anything else you are taking. Bystolic, a Beta Blocker, is an antihypertensive and is also commonly prescribed to prevent A-Fib from becoming A-Flutter. No interactions there either. Your thyroid medications, LevoThyroxine is fine, no interactions there. Same with Atorvastatin. If you have had recurrent DVT or PE, you absolutely should be on an anticoagulant and there's not much evidence that Aspirin at 325mg daily is effective in clot prevention so, I get your cardiologist thinking you should be on a novel anticoagulant like Xaralto. Your CHAD/VASC score of 1 indicates for paroxymal, not chronic A-Fib, considering A-Fib alone, you don't need anti-coagulation but the DX of Factor Five clotting disorder changes that calculus.

Tachycardia, the kind you are experiencing, can be associated with anxiety. The Cardiac monitor that has been ordered for you will reveal how likely the tachycardia you are experiencing at night is related to an underlying uncontrolled arrhythmia. My guess at this point is that it's not and your heart rate increases secondary to anxiety. There are other ways to deal with anxiety other than Benzodiazapines like Klonopin. Benzos are nice and they work but you might benefit from a longer acting SSRI like Lexapro or Celexa that has less downsides than Benzos. I'll defer to whoever is your PCP and probably prescribed these for you. But ask.

The thing I get most worried about with folks who complain of palpitations and racing heart are users of decongestants containing pseudoephedrine (e.g. Sudafed and a whole bunch of cold and lfu meds), coffee addicts (> 3 cups in 2-3h), folks who use energy drinks like Red Bull and a bunch of other products heavily marketed to energize you, Gensing users and occasionally those who partake in "natural or homeopathic medicines." All of these supplements have cholenergic effects and concomitant potential to increase sympathetic tone and accelerate your heart rate. Nicotine will do this too. If you're not using any of these products then your tachycardias are not due to them.

Looks tome like your medications are fine ..... as long as your not using any of the other stuff I mentioned above.

[ajack]

A sleep lab will only count a CA when there is an O2 desaturation. Otherwise they ignore it. It doesn't matter.
Normally at home, the machine will mark more events than there really are. It can't tell if there is an o2 desaturation. If you are concerned, you can get a spo2 recording o2 meter called cms50f for $60-80. It's not needed, but you might like the feedback.

I would use auto and by your chart with 3cm EPR, I too would raise the minimum, I would guess with the median pressure at 9.8, 10 would be a good starting point. This epr 3 may give more CA, where the body waits for the co2 level to build up again, triggering you to breathe. It all should settle down within 12 weeks.
I would lift the maximum pressure more, I'd want at least 2-3cm above the 95% pressure reading. 16 or more would be suitable. to get it out of the way.
The 95% pressure reading, is often used for setting a fixed pressure, when auto titrated.

[MyronH]

thanks. Nope not using any caffeine , except for maybe one cup of coffee in morning. It's just weird the tachycardia presents itself only during my sleep. I dont see how I can have an anxiety/panic attack in my sleep. When I wake up, I don't remember any bad dreams, and most of the time don't feel panic, just the crazy racing heart and high blood pressure.

One doctor did mention Lexapro, but it and all the antidepressants have major interactions with Multaq. They can all cause long QTc. So I'm staying away from them. Plus before I was on Multaq, I was on Sertraline(Zoloft), and Buspirone and those did nothing for me.

Cardiologist did mention they may put me back on Xarelto, depending on results they get from the SeeQ cardiac monitor. I have an AliveCor Kardia device to detect afib. Every time I've used it, it's been normal. Only time I've been in AFIB was last year in the hospital, and that's when my cardiologist just put me on Multaq. I feel he did so too soon, because it was just one episode, and we don't know what triggered it. I may have not ever had another AFIB episode again in my life. It could've been triggered by tachycardia though, since for several nights before, I kept having racing heart issues at night. Then that one night, woke up in AFIB.

[MyronH]

This is my WORST night yet! I set the EPR from 3 to 2 to see if that would help with CA's. Not sure why I had so many leaks last night. But look at how long the events were! I had an Unclassified Apnea lasting 49 seconds long!

I am wondering why at HOME I'm having so many long apneas. But during the sleep study they said they titrated me and had no apnea's for the rest of the night. 

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[Walla Walla]

The one unclassified event you showed a closeup on was obstructive. Your main problem at this point is the leaks. Until you get them under control nothing else is going to matter. Your not getting useful treatment with those high leaks.

[Sleeprider]

The breathing ahead of your firs and second OA have strong flow limitation characteristics with flattened peaks. The UA also has obstructive appearance to me and a lot of FL following the flag. I think this was mainly obstructive and could be positional. By the end of the sequence your pressure is 11.7/9.7. You seemed comfortable with EPR 3, and I think if you set your minimum pressure at 9 or 10 that should work fine. Consider a comfortable fitting soft cervical collar for the positional issues. I think your airway is getting cut off from chin-tucking.