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fluctuating oxygen saturations
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fluctuating oxygen saturations

I am a 48 year old female with a 4 year history of SOB on exertion, dry cough. I had elevated pulmonary pressures on several echoes of 45 to 50 but the RHC(2009) was normal (mean 18). PFT's have always been "low normal", no asthma, no allergies. I had a TIA last October and the MRI showed 3 previous strokes. No known cause. I started cardiac rehab two weeks ago and when I went on the treadmill, my saturations stayed below 90 and dropped as low as 83. My heart rate seemes accurate can I can only assume it was right. I am an RN in a hospital so I have checked them a few times since then since it has me quite concerned. The sats seem to fluctuate quite a bit, anywhere from 81 to 99. I wouldn't worry if I didn't get so out of breath. I really get SOB if I am talking and walking at the same time. I saw the neurologist and told him and he ordered a transesophageal echo to look for a PFO.I aksed if it was hurting me if I was in fact desaturating when walking. He did not know. Could it be hurting me? Should I be on oxygen even though know one knows what is going on and if it is even accurate?
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My first thought in reading of the combination of pulmonary hypertension, fluctuating saturations and multiple strokes (paradoxical embolization) was that you must have a PFO.  Very good of your neurologist to consider that diagnosis.  To this triad might also be added the possibility of recurrent pulmonary emboli (PE).  I suspect that you do have a PFO but it should also be remembered that vascular shunting can occur via shunts within the lungs themselves and also that hypoxemia can occur in conjunction with advanced liver disease.  Any of the preceding could be manifest as shortness of breath with exertion or even at rest.

The normal RHC PA mean pressure just might have been performed at a time when, with pressure fluctuating over time, your PAP might just have been normal at that time.  Emboli could account for fluctuating pressures as could the status of blood flow direction in the presence of a shunt.

I assume that you have no sign of intrinsic pulmonary disease to account for exercise induced oxygen desaturation or your shortness of breath.  If the assumption that you have normal lung function and no shunts within the lungs is correct, then your problem must reside in the heart, either primarily or secondary to recurrent pulmonary emboli.

I would be most interested in the results of the trans-esophageal ECHO.  My index of suspicion is so high that were the ECHO to be negative, I would urge your cardiologist to consider further testing to be sure that the ECHO result is not a false-negative.

Assuming that you, with the exception of the above, have normal cardiac function it would be highly unlikely for you to sustain any organ damage with saturations  sustained at 80% or above.  So I would doubt that supplemental oxygen during exertion would be necessary.  As to the question of supplemental oxygen, the most important measurement would oximetry during sleep.  Should you have sustained and marked oxygen desaturation during sleep, then continuous oxygen during sleep might be very beneficial.

Good luck
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