Dr. Sagar Ramesh Makode
Cardiology
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Patient's Query
Hello doctor,
I measured my mother's oxygen via a finger oximeter. It fluctuates from the high 80s to mid-90s though the shortness of breath is not readily evident. I will have a telephone consultation with the doctor next week, but I think her heart is weakening. The other issue I noticed this last night is that her breath intake does not reach 15 cmH2O; she then quickly exhales to 12 cmH2O and then partly quickly inhales. Is this potential hypoventilation? I will try to record a video image of it.
Hello,
Welcome to icliniq.com.
Low SpO2 (saturation of peripheral oxygen) without apparent shortness of breath suggests the possibility of OSA (obstructive sleep apnea) or hypoventilation rather than the cardiac cause. Such patients tend to have chronic hypoventilation and low SpO2, so they tolerate this low saturation without developing shortness of breath. At the same time, cardiac failure patients are symptomatic at this low SpO2. So, the predominant problem is likely hypoventilation which may be obstructive or central. In patients with end-stage heart failure (with very low ejection fraction), their blood pressure persistently falls below 100 mmHg systolic. Thank you.
Patient's Query
Hello doctor,
Are there any other feasible diagnostic tests for carbon dioxide besides arterial blood gas analysis? The sleep doctor wanted the exhale pressure to increase from 10 to 12 cmH2O, and the inhale pressure to increase to 16 from 15 cmH2O. I do not know if significant hypoventilation occurred due to an AHI (apnea-hypopnea index) of 18 over the last week. I have asked an occupational therapist to keep her upper torso more propped. She is more attentive in evening when compared to morning and evening. Kindly suggest.
Hello,
Welcome back to icliniq.com.
BiPap (bilevel positive airway pressure) is helpful to our cardiac patients in the end stage. In her case, the predominant pathology is likely sleep apnea, so higher PEEP (positive end-expiratory pressure) may be helpful. So you can increase the exhale pressure to 12 cmH2O if the sleep doctor advises. Being more alert in the evening suggests the possibility of accumulation of carbon dioxide overnight due to sleep apnea, which may be getting washed out as she is awake during the day. Here, adjusting position and pressure appears to be the best possible option. In BiPap, inhale pressure is higher, and exhale pressure is lower, so it is comfortable for the patient to breathe and less cumbersome. Thank you.
Patient's Query
Hello doctor,
Her exhale pressure was changed three months back from 10 to 12 cmH2O. Her Inhale pressure has remained the same for a few years at 15 cmH2O. So it is contradictory as the sleep doctor wanted the exhale pressure to increase to lower the AHI. But on the other hand, if the exhale pressure is higher, it will be harder to breathe out. Is an arterial gas analysis that is pulled out of a vein painful? If she does retain carbon dioxide from the night, would that give them lower oxygen readings during the day using a finger oximeter? Fortunately, her AHI was always below 40 readings. But there have been several consecutive days with a high AHI. Physiotherapist declined today, referring back to the sleep clinic. My mother continues to remain confused throughout the day. She was eating less and did not have the strength to rise from the toilet this evening. Tomorrow a nurse will visit her at home.
Hello,
Welcome back to icliniq.com.
The idea of higher exhale pressure is that maintenance of high pressure will prevent the collapse of the airway during expiration, thereby reducing the obstruction to the next inspiration. However, simultaneously makes breathing a bit difficult. So the balance between the two has to be achieved. Arterial blood gases will only be taken from the artery, which will be painful compared to venous blood gases. Thank you.
Patient's Query
Hello doctor,
Does the higher numerical setting on exhale pressure remove more carbon dioxide or make it harder to do so? She got a full blood test panel done today with a urine test.
Hello,
Welcome back to icliniq.com.
Considering the predominant cause to be OSA (obstructive sleep apnea), it may reduce the obstruction and help in carbon dioxide washout. However, if sleeping is making breathing difficult, it may offset this benefit. So trial and error will give a better answer than speculation. Thank you.
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Cardiology
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