Why Am I So Tired? A 45-Year-Old, Morbidly Obese Man Presents Worsening Fatigue

A 45-year-old Asian-Indian man with a history notable for morbid obesity (body mass index [BMI] = 52) and back pain presents with worsening fatigue over the last few years. He is a non-smoker and takes oxycodone as needed for back pain. His initial exam is notable for the following: heart rate of 92 beats/minute, blood pressure of 156/92 mm Hg, respiratory rate of 18, and pulse oximetry of 91%. Breath sounds are diminished, and there is no accessory muscle use. His heart sounds are distant, with an unremarkable exam. He has neither jugular venous distention nor lower extremity edema.

Figure 1

Figure 1

His laboratory results are as follows: normal hematology, chemistry profile, thyroid-stimulating hormone. Pulmonary function tests are notable for reduced total lung capacity, functional reserve capacity and expiratory reserve volume. His arterial blood gas (ABG) on room air shows pH= 7.32; pCO2 = 50 mm Hg, pO2 = 61 mm Hg; bicarbonate = 31. He undergoes overnight polysomnography, which shows moderate sleep apnea with apnea-hypopnea index = 20 episodes/hour with several hypopneic episodes (Figure 1).

Which of the following options is NOT recommended to manage this patient?

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