..back to sleep (apnea)

 I have just had my second sleep study, about which, more below. 

I have known that I have had sleep apnea for at least 5+ years, since I now qualify for a new CPAP machine and Medicare only supports you for one of these every 5 years. But I am on my second machine which suggests that I was diagnosed for this condition more than 10 years ago.

The original speculation was by my primary doc who noticed I had a large neck. Larger in that area means a higher likelihood of a collapse of the soft pallet--larger necks weigh more-- because of gravity's effect when sleeping on one's back.  Such apnea is known as obstructive apnea. There is also central apnea which is controlled by the brain, I think. The mixture of the two is called complex sleep apnea. I believe my diagnosis is the latter.

The condition is now more important to health than formerly thought. Its extreme, that is, narcolepsy, is the uncontrolled falling into sleep during the day, not good if one is driving, for example. It is now known that people who have apnea and are untreated are twice as likely to die. It is strongly correlated with heart failure, for which, as all of you know, I also have a diagnosis. It is also associated with high blood pressure and headaches upon arising. There's more, but enough.

So, I have worn a CPAP (Constant Positive Air Pressure) machine now for 10+ years whenever and wherever I sleep. It changed my life when I first started to wear one because I was immediately less fatigued during the day. Prior to that I fought sleep and fatigue during the day. The machine is positively addicting because it makes one feel better, that is, rested. But some cannot get used to having their noses and/or mouths covered. (There a variety of fixes for this, of some effect.) Suffice to say that a fair percentage of wearers discontinue use. When I was diagnosed with heart failure circa 2015, oxygen was added and I have used that since. The oxygen is safely made by a machine that strips nitrogen from air leaving an enriched output.

A variation of the CPAP machine is a BIPAP for BI-Level Air Pressure. This forces air in at one pressure and makes breathing out more difficult without extra exertion, similar to SCUBA wherein one must force air out. My machine is set at 20 psi in and 16 psi out. The BIPAP is for complex apnea. And it is this machine which is 5+ years old.

But there is a new kid on the block called an AVS for Adaptive-Servo Ventilation. This machine senses when your breathing changes and adapts by altering the pressures in and out to keep breathing regular. It was this machine and subsequent therapy by it that was the central feature of my sleep study.

A sleep study requires a night in the sleep lab, in this case, our hospital. There they put sensors on your body from your knees to your scalp. I went in this week. The technician monitors you all night. The room was comfortable but sleeping was not since I am unused to clothing (TMI!) as well as the breathing straps, etc while sleeping. But I got through it and felt fairly good upon arising. The doc's office called to say that things looked good. And I don't qualify for AVS. This appears to mean that my apnea is more obstructive than central. But I am going to get a new BIPAP machine because I am not sure how well my current one is operating and because I can.

The highlight of the results at this point was that my pulse/O2 was at or above 90% all night. In fact the medical assistant said I no longer qualified for O2 under Medicare guidelines, but since I own my oxygen concentrators I am unaffected by this outcome. She was unconcerned by continued use. Good!  Continued under-90% O2 is associated with dementia. Don't want to go there. I'm already forgetting what TV series we watched last week.

Onward....

I DON'T KNOW WHAT THE HELL HAPPENED HERE, BUT THIS WAS NEVER PUBLISHED. I MUST HAVE BEEN DISTRACTED OR HAD AT LEAST A SENIOR MOMENT. ANYWAY I AM PUBLISHING THIS BELATEDLY BECAUSE THE SAGE CONTINUES IN MY NEXT POST...

'Tis the fall season....

 Once again I am reminded by a faithful reader that I have not written in some time. Mea culpa. That fact--the omission of product--usually signifies something like 1. He's well, there is nothing to say; 2. He's at death's door and is not capable of writing; or 3. He's old--he"s forgotten; or 4. He no longer cares. or 5. Make up your own reason. Over the years that I have been baring my soul and my innards, every one of the foregoing has been true at some time. You may now think that this ever-clever amanuensis will say that it is none of the foregoing. It may be. I just don't know.

I do know that my heart has not been an issue at the forefront of my thoughts on my health, though it is never far away. I am mindful that I am in constant discomfort from my bicycle accident--resolved by getting off my feet several times per day. I am mindful that my appetite is not what it used to be. Mostly I am satisfied with child sized portions. Accordingly, my weight is pretty stable between 190-195 lbs, the lightest I have been in decades. I am mindful that my appendectomy appears related to a newly stable alimentary system, not seen in years (go figure). 

But most of all I have been thinking about falling, literally. My weird bicycle crash and subsequent testing and subsequent discovery of a crushed vertebra, started all of this. I learned about what the ER people call a "head strike"--any significant blow to the head. And how effects of such punishment may not appear immediately, ergo, don't settle that accident claim hastily. I learned that I have a shrinking brain which has a "tortuous" basilar artery. This artery feeds the brain in the area of the 8th cranial nerve which may be related to the differential hearing that I have remaining in my ears, ie, less in the right than the left. I speculate that along with sclerosis of my cranial arteries there may age related difficulties with balance owing to age and blood feed to the brain.

I began to suspect my balance was worrisome some 5 years ago and this led to the decision to sell my bass boat and stop fishing. I also started using a cane for longer distance walking, for example an hour on feet in a grocery store as opposed to walking from the car into a restaurant, though these are not hard and fast rules. I also have mistakenly assumed that keeping strong via work outs and etc would permit oneself to save oneself from a fall. I have found that there is only limited truth in this. It is true that I have saved myself from falls when I am prepared to think that I may fall. But there is no protection against most falls which happen when one is unaware. When one of those starts there is no saving yourself.

I had my most recent one of these about 10 days ago. I turned around in the house and must have stubbed a toe or otherwise caught my foot and down I went. As on the previous occasions I tried to grab a door frame but it wasn't enough and I smacked my head on the tile floor. Subsequent pain in my right knee would suggest that it hit the floor at some time as did my right shoulder which may have crashed into the door frame. There was a modest bleed at my hairline but not enough to see anyone about. My pupils did not differentially dilate. I developed a considerable goose egg. And I could not get up for a couple minutes. Jan was home and responded well. We decided to stay put and observe against headache and signs of confusion. Neither happened. But I have had a lingering tension near my mastoids which may owe to the head snapping back, then forward. I am also a bit more prone to getting a headache if I read too long. We'll keep on this, but I think all is okay.

What is not okay is the increase in frequency of these events. Starting with the bike event I have now fallen 3 times since Aug of 2020. Since I have some osteoporosis a hip being the first to hit the floor would be a disaster. But can head strikes be far behind?

Is there a walker in my (near) future?

Happy Turkey Day to all of you...

nothin' but blue skies...

 A while back I argued with the Nurse PR who is my cardiac consultant at IHC, in lieu of bringing in a cardio doc, whom they appear to save for decisions above her pay grade. She is excellent, not incidentally. The argument was about having been diagnosed as having heart failure one could thereafter not escape the condition. There is no question that I have had heart failure.  Let me stipulate that. As a part of this, the diagnosis exists in the record. But what I don't know is if  one can escape the condition. I'd like to think so, optimist that I am.

There are many measures of heart function. A couple are the synchronicity between the atria and the ventricles which can get out of sync in a variety of ways, one of which appears to be the fluttering of the atria called atrial fibrillation. I have that condition, but it is well under control, given medication for rhythm (amiodarone) and a couple circuit ablations of over-performing circuits. I also measure that rhythm daily on my Apple watch which gives me a single lead ECG. If it shows sinus rhythm then things are good.

A second set of functions appear to owe to the heart's valves which are either bi- or tri-cuspid (genetically). These can be bad by not closing sufficiently, causing leaks between chambers, called murmurs given by their sounds through the ubiquitous stethoscope. Their function can decline with age due to stiffening produced by calsification. I have some of this happening (stenosis) as well. This may be genetic but is hugely impacted by the American diet. The docs classify mine as borderline--not eligible for replacement at this time.

But the main one I want to talk about in this post is something called the ejection fraction. Inveterate readers of this blog will be familiar with this, since I have been writing about it for sometime. It is the amount of blood that the left ventricle squeezes out of the heart into the aorta upon contraction. Not all blood is moved out. Normal amounts are thought to be in the range of 50-75%, borderline amounts in the 41-50% range. It is this measure that I think of when I think of my heart's efficiency. And it is this measure about which I was thinking when I inferred that one might be able to get out of heart failure, per se, and challenged my Nurse PR.

There are a number of ways to measure the ejection fraction, the most common of which appears to be an electro-cardiogram. It will come as no surprise that I have just had one. (It's a simple in-clinic procedure)  It will also be no surprise that this was not my first rodeo with this procedure. Since 2015 I have had several.

When I was first diagnosed with heart failure in 2015, my ejection fraction was about 13%. After 2 weeks in hospital on restricted water intake, restricted diet, several cardio-versions plus medication including lots of diuretics, it rose to 35%. (This was just enough to deny me access to Medicare-funded cardiac rehab, which I had to do on my own.) And so I fell to it. Back in the gym, etc. A couple years later my ejection fraction was 50%. (For statisticians the standard error is +/- 3%.). 

When we returned from AZ during March of 2020 I developed a persistent upper respiratory infection that lasted long enough that it weakened me. It seemed to have some of the same symptoms of COVID but was not. An ECG at that time showed that I had backslid to an ejection fraction of 35%. It was this number that I reacted to when confronted by my NPR. I thought I could regain my earlier EF and I thought she thought I could not.

During our meeting last week, she, after the consult part, called in a cardiologist, and I thought Oh shit, there's bad news coming. Actually there were high 5s when it was revealed that I regained the 50% EF I had before. Very pleasing. I had despaired when my appendicitis occurred a few weeks ago and I had to stop exercising to let my body repair. I thought that would scuttle any prior gains. Not so. 

I would like to see my next EF up one standard error--3 points--so that I am still progressing but who knows. The NPR wants more exercise than the 2, 2-hour work outs I am currently doing weekly, if only to add another aerobic session. Confounding going forward is a mal-fitting sleep apnea mask, that I have just had changed. I am closely monitoring my exhaustion level now and I think I am seeing small gains with a new mask. A sleep study is on the horizon.  Time will tell.....

Working thru it...

 It's been a while again. This time not because I don't have anything to say, but because I have procrastinated. I was going along, swimmingly,  until I wasn't. I had developed a sore abdomen (right side) that I attributed to a workout injury--you know--a muscle pull. Until it wasn't.

Appendicitis

Finally, the pain drove me to the emergency room several Sundays ago. They took pix and said I had an angry looking appendix. Come to find out, some appendicitis can be treated with antibiotics. They wanted to see if I would respond to some. So, I said give me the pills and get me outta here. They said you are going nowhere. All of a sudden things got more serious. They also asked had I taken my blood thinners (Eliquis). Answer: Yes, that very morning. So, they said if we have to operate we need to wait a couple days until the thinner is gone, otherwise, if surgery is necessary you could bleed out. Long story, two days of hospitalization and being awakened more than one likes. I was not officially a patient according to Medicare, just hospitalized for observation. Isn't that a distinction without a difference? It may be in $$. (Supposedly, the gap policy should cover this--we'll see.)

So they popped into my room on the Tuesday morning and said there's an opening in the operating suite for 2:30 this afternoon. Let's do this! So I had the operation, which was done laporoscopically. I was home by 9 pm that same evening. Unbelievable!

The result has been a relatively pain free recovery. A few extra strength Tylenols. A whole bottle of hydrocodone, unused. Of course there was pain, hence the Tylenols, but it was manageable. Two weeks after my surgery I ventured back into the gym for a light workout. I  had the second one today. All good, so far.

There have been some slight changes in heart function, that I think are temporary. An occasional A-fib reading, slightly elevated blood pressure and some edema primarily of the feet and ankles. But that is retreating in the absence of my usual diuretic. Feels to me like I am healing.

All of this is not to say that abdominal surgery at 82 is a picnic.

Hearing

Love my new hearing aids! They are blue tooth capable and come with an app that allows me to set them for different environments. Also, I can run my music through them and take phone calls and yada yada.

Heart

These guys are next up. An echocardiogram is scheduled for Sept. Hopefully I will be back in better physical health by then to see whether not there is any positive change in my heat's function.

status quo quotidian

 Wow, several months since I have updated. My condition seems appropriate to my age--maybe.

Several parameters: First, hearing

The tortuous basilar artery found in my cranial MRI may be the reason for some of my hearing changes. Nothing can be done about it. It apparently can mess with the blood supply (therefore the O2 levels) of the inner auditory canals. I have a definite difference in hearing levels in each ear. It now tricks me into looking the wrong way to locate a sound. If a sound comes from the right side I may not hear it until it gets to my left ear causing me to look that way. I will probably schedule an appointment with the USU Audiology Clinic to be fitted for hearing aids, if they think I can be helped by them. (I think I recall that not all sensorineural hearing losses are helped by amplification.) Until then, the wifey and I will still not better understand one another....and even then, who knows?

Second, heart.

Not a great deal to report which is good. My vitals are as stable as I could want them. PulseO2 in the low 90%s; resting heart rate in the low 50s; sinus rhythm all the time without any sign of A-fib, blood pressure a tad below 120/80. 

At my most recent cardio checkup a couple weeks ago I asked about getting rid of heart failure. Unfortunately, once diagnosed it is chronic. However, that doesn't appear to preclude improving one's physiology. Hence with the covid vaccination at work in my body, it is possible to return to the gym which has occurred. The little place we go only allows in 6 folks at a time (reservations only), plus masks, plus distancing, and they clean the apparatus after each use. About 6 weeks in now and one can feel new tone in the musculature. My goal is to improve my heart function sufficiently to once again approach the normal range for the ejection fraction (>50%). When last measured last year at the beginning of spring I was at 35%--but in the middle of an event. Before that I got it back to 50%+.

However, I am still easily fatigued, so perhaps not progressing as much as I think. I had to start back at 10 min on the recumbent bike and 5 min on the arm bike, and at about 50% of the weight I was lifting before last spring. I am now at 21 min on the recumbent (on the way to 30 min), and 11 min on the arm bike (on the way to 15 min), and about 2/3 of the weight of last year. I am content with my progress.

Third, apnea.

I am sleeping well, Usually get through the night (7-8 hrs) without rising or awakening for long periods. Still need a post lunch siesta of about an hour. Don't seem to be awakening with O2 starvation. unless I fall asleep in a recliner without my mask and O2. This suggests that the mask and O2 are doing their jobs. But I am not falling asleep when I don't want to.

So, on balance, nothing to complain about...

sailing onward (not obliviously).....

Here are the general results of my brain MRI:

Hey, Hey, Hey: no tumor (acoustic neuroma); instead there is age-related brain atrophy and a couple places where the report seems to mean changes due to ischemia--in other words the results of insufficient oxygen. There is a basilar artery that is described as tortuous (full of twists and turns) and it is apparently near to the auditory nerve. I'll find out what implications this has for my future in an April consult with the ENT guys. 

On the COVID front some quick acting neighbors (bless them) let us know when Bear River Health had several hundred doses remaining after having done all the medical and first responder types. We got an appointment and our innoculation last week. It was efficiently handled in our car. Now, one hopes for the timely availablility of the second dose, which is problematic elsewhere in the country.

All for now....

If it isn't one thing...

 Happy New Year to my several readers. No apology for not posting sooner as I have just concluded a good holiday run of eating well, bingeing on Netflix and Prime and NFL, reading and having our little family together.

A summary update: 

Not working out yet. Still afraid of small spaces with strangers nearby--even masked strangers. But, our regional health center will begin taking reservations for COVID-19 innoculations toward the end of this week via their website. Then we'll see how much delay there is at that point. I am ready to get back to working out as soon thereafter as possible. (Utah still has one of the highest positivity test rates in the country.)

My vitals are consistently good with few exceptions: my resting HR is in the low 50 bpm. My pulse/O2 is in the low 90%s. I am sleeping through most nights getting 8 hours with a 1-hr afternoon nap. My blood pressure is at or slightly below the norm of 120/80. 99% of the time my heart is in normal sinus rhythm. (There were 2 exceptions last week where I got AFib readings on the insurrection days.) My diuretic (Lasix) usually only needs to be taken every 3rd day, meaning I am building up fluid at a slower rate. All good. But:

Every winter I get an ear pain related to swallowing which I interpret as a failure of the eustachian tube to clear with a change in pressure.  (Think of clearing your ears after descending in an airplane, or rather not being able to.) Usually, some throat lozenges or a spray will take care of it. This winter it has been more pronounced. I have also felt as though I am carrying more residual mucous in my head leading to the condition. In any case I scheduled an appointment with my regular physician. He and a helper noted considerable ear wax and tried to clear the outer canals. They were unable to complete the task so sent me onward to an ENT guy in the same clinic who completed the task.

Soon thereafter I noted a phenomenon in my right ear: it was echoing sounds from my right hand on the piano, on the telephone, on the TV and in conversation. This is called monaural diplacusis. It was enough to lead me to get an audiological work up at the university's audiology clinic. There they found a considerable difference in my hearing levels in my ears. The left ear shows a typical age related hearing loss with mild loss in the lower frequencies and a falloff to the moderate/severe category in the higher frequencies. However, the right ear shows a severe to profound loss in the lower frequencies rising until it pairs with the left ear in the higher frequencies--an inverted U or V pattern. The audiology clinician thought this outcome had clinical significance and referred me back to the ENT guys.

Apparently these symptoms lead to the possibility of an acoustic neuroma which is a (usually benign) tumor growing in the inner ear canal on the myelin sheath. (I believe said canal is post-cochlear and enters the skull as the 8th cranial nerve.)  So, an MRI is about to be scheduled and we'll go from there.

Here is Wikipedia:

It is better called vestibular schwannoma (the latter are the type of cells involved).

True incidence is rare (20 or so per million) but may be rare only because it wasn't identified.with earlier MRI technology.

Symptoms: unexplained unilateral hearing loss, tinnitus, and disequilibrium. (So I have two of three, now.)

More to come, surely....