What can cause sudden forced exhalation?

Question

I am a 45-year-old male. I have been having some health issues for the last five months. A month back, I was diagnosed with sleep apnea (AHI 62, oxygen saturation going down to 50 %; report enclosed). I have been trying to use a CPAP.

I have been experiencing breathlessness for the last two months- on even slight exertion, like walking for a few minutes, bending down, etc. In addition, I experience breathlessness at night while lying down.

I am told the breathlessness while lying down is due to sleep apnea. The breathlessness on exertion may be due to my coronary ischemia (I had a positive TMT and may have to undergo an angiography). Also chest physician couple of weeks back, said it is bronchoconstriction (peak expiratory flow rate at rest was 500, after walking 5 to 10 minutes was 350) and prescribed Fluorocart inhaler & Duolin inhaler as well as Deriphilin retard, and Montek.

The unresolved problem I now face is a sudden involuntary exhalation of breath. This happens more often at night; from time to time, breath exhaled in a sudden explosive spurt (involuntary) that almost throws up my body a bit (something like hiccups from the stomach). This happens many times at night and disturbs sleep. It also happens the moment I put on my CPAP (full face) mask. Earlier it was more while using the CPAP, now days it happens even without the CPAP.

Also, my wife says that even with CPAP, sometimes I am absolutely still, i.e., not breathing while sleeping.

My father is a heart patient and also has COPD, my mother used to have asthma, now cured of it. I am a non-smoker, non-drinker, and vegetarian.

In addition to the above tests, I have a normal chest X-ray and normal echo (5 months back), and a normal brain MRI (5 months back). A brain MRI was taken because I had some balancing issues, which were then diagnosed as an uncompensated vestibular lesion. I also have severe cervical spondylosis.

What could be the cause of this sudden aggressive exhalation? Also, could my breathlessness be entirely due to my lungs, in which case I need to undergo angiography?

Thank You.

Answer 1

Hi,

Welcome to icliniq.com. I have read through your query and reports (attachment removed to protect patient identity) in detail. Please find my observations below. There is a probability of parasomnia, which is defined as a sleep disorder that involves abnormal movements and features like aggressive exhalation, partial awakening, arousal with confusion, sleep terror, and related symptoms.

This problem is in addition to the obstructive sleep apnea which is there in you. Studies show that 9.5 percent of people with obstructive sleep apnea might have parasomnia. About 20 percent of patients experience improvement and decrease in episodes of parasomnia after CPAP (continuous positive airway pressure) and it is persisting even with CPAP in you.

The chest X-ray and brain MRI (magnetic resonance imaging) are normal, therefore there is no serious problem in the lungs and brain. It is understood that you have got necessary breathing tests like spirometry to rule out any abnormality in breathing volumes and therefore variation in peak expiratory flow rate for which you have been given medicine.

Angiography is an evaluation of the arteries supplying the heart. This has been asked because your TMT (treadmill test) is positive. There are two types of angiography. One is CT (computerized tomography) angiography, which is done using a CT machine and office procedure.

The other is catheterization laboratory angiography which is done in the cath lab (catheterization laboratory) and might require you to stay in the hospital for a day. Both are equally good and you might discuss with the cardiologist and then proceed with making a choice. At 45 years, getting a CT angiography is suggested. It is a low-risk procedure compared with cath-lab angiography.

Kindly help. Doing a lipid profile and cardiac enzyme test is also important.

I hope this has helped you. Thank you.

Answer 2

Hi,

Welcome back to icliniq.com.

Features involving the sudden exhalation described by you are essentially a manifestation of obstructive sleep apnea itself but recent research has shown it might be a closely associated behavior termed parasomnia. These are sleep-related disorders and require a detailed investigation including the contribution of obstructive sleep apnea. I guess your diagnosis has been made after a detailed investigation and therefore this might be an extension of your obstructive sleep apnea. Treatment wise there is a need for to the sleep hygiene with the CPAP (continuous positive airway pressure) treatment that you are taking. What do you mean by the forced exhalations with jerks even when awake? Are you completely awake or half awake? However, this need to be discussed with your doctor who made the diagnosis of obstructive sleep apnea, and then treatment might be modified as required. It is important to know if you feel sleepy in the daytime and this also requires to be treated. This is not a serious condition but might get disturbing and this is happening to you. Your doctor suspects that the peak expiratory flow rate (PEFR) findings are showing a possibility of asthma and is treating you for it. COPD also might have similar findings but there are differences between the two conditions. Diagnosis of asthma versus COPD (chronic obstructive pulmonary disease) has to be confirmed after regular follow-ups. While COPD is seen in smokers, has genetic linkage, and worsens over time. Asthma is seen in smokers and non-smokers, due to allergy and improves with medicine and might recur frequently as acute attacks of breathlessness. Although there is a strong clinical suspicion of asthma, I would like you to get evaluated for any suspected heart condition as a cause of the breathlessness. This is most important because heart problems have become common these days due to stress and lifestyle and those who are overweight. Heart problems are to be evaluated in detail and might be present without chest pain. People who have breathlessness and positive TMT (treadmill test) require proper evaluation. The risk for heart disease is calculated from multiple variables including blood serum cholesterol test, which is lipid profile and cardiac enzymes among the blood tests. There are other heart function tests like ECG (electrocardiogram), TMT, heart perfusion studies, and angiography which help in the assessment of heart disease. I hope this has helped you. Thank you.