[CPAP] I take my mask off every night after 1-2 hours and don't know why

[idontsleepsowell]

Hello!  My first post here, but see this forum recommended a lot on the /r/sleepapnea subreddit.

2 years ago I was diagnosed with moderate sleep apnea (I think 16 events per hour or something like that?  I'd have to look for my original paperwork).  I'm in my early 30s now and have most likely had sleep apnea for 10+ years and just didn't realize it.   I've tried various things over the last 2 years, but have never been able to get more than a couple hours of sleep while wearing my cpap machine/mask.  I've been wearing it every night for the last 2 weeks as I am trying harder to actually use the treatment instead of getting frustrated and giving up.

Some of the things I've tried so far:

• Increase min. pressure from to 6.2 (I was feeling starved for air)
  
• Change to a heated tube (Fixed issues with rainout)
  
• Turn ramp on/off.  It's currently on Auto.
  
• Tried various masks.  I'm a mouth breather and have allergies/congestion at night, so I don't think nasal pillows work very well for me.  I'm currently trying an AirFit F30 which seems comfortable enough.
  

I recently discovered Oscar and have been trying to make sense of my data, but still don't really know what I should try next.  Other than an AirFit F30, I also have been trying a full face mask (AirTouch F20).  I have a medium for the AirTouch F20 and realized I should actually use a small according to the sizing chart, so I ordered a small that I will try out.  The F30 is a medium as well which is accurate on the chart.  For either of these masks, I see a lot of "Large Leak Rate" events after the ramp-up time.

Most nights, I do not remember taking the mask off and do not know why I took it off.  The last two nights though I did remember waking up and feeling like I couldn't breathe out, like it was too much pressure.

This screenshot is from last night's oscar data:
[attachment=31602]


And the night before:
[attachment=31603]


Does anyone have any advice for me?  Or what other information would be helpful to know?


Also as a side-note - my doctor has not been super helpful other than basically telling me to keep wearing the mask every night, and that we can discuss alternative treatments if I can't acclimate to the cpap.  They haven't recommended adjusting any settings/masks/etc.

[SarcasticDave94]

Welcome to the neighborhood.

Let's try a few edits and see if this helps. One, let's try this with no Ramp. For some it can be disruptive in how it tends to hold pressures too low. Two, turn on EPR full time to 3 and increase your Min pressure to 7. This is a combo needed to give EPR room to do its thing. EPR is exhale pressure relief, it's labeled as comfort but we've seen it act on the therapy side quite effectively. BTW the way EPR works is it reduces pressure by it's set number of 1-3. This EPR setting is measured in cmH2O just like the therapy pressures are. You need at least Min 7 to allow EPR to drop 3 to absolute PAP min of 4. Just try it. If you don't like it, return it no questions asked. But I think comfort increases are going to surprise you.

Now on to the mask. Are you getting leaks and responding by going tighter? It may be an incorrect action. Rather, let's try this method of adjusting. Lie back on your bed and hold the mask on your face. Turn on PAP therapy pressures. Now adjust for leaks by finger tension only. Try to remember it and now add loose straps and gradually tighten to mimic the finger tension.

If you cannot gain reasonable control over leaks trying this, then examine the mask cushion sizing to see if it really is the right choice. Maybe you'll need another sized cushion or change make it model mask. You don't need zero leaks, just controlled to a minimal and non-disruptive level.

Lastly, don't be surprised about little doctor assistance. Most don't really help a great deal. They don't seem to have a great understanding of the several intricate Apnea and CPAP tricks. They're stuck with the basic knowledge that you use a CPAP and mask to lower AHI to 5 and compliance to meet insurance requirements. Anything much more difficult or detailed than that, these Dr. Dolittles are mostly clueless. Not so here in the Apnea Board.

OK try these changes and see if it'll get better. Report back with comments and an OSCAR. We can get you better therapy very quickly. Good luck.

[idontsleepsowell]

Thanks so much, I'll definitely give your suggestions a try!

> Now on to the mask. Are you getting leaks and responding by going tighter? It may be an incorrect action. Rather, let's try this method of adjusting. Lie back on your bed and hold the mask on your face. Turn on PAP therapy pressures. Now adjust for leaks by finger tension only. Try to remember it and now add loose straps and gradually tighten to mimic the finger tension.

I'm not sure I understood this part.  By finger tension, do you mean just hold the mask on my face without using the straps at all?  



I don't have any leaks when I go to sleep, but I think that may be because of the ramp feature.  When the pressure increases, the leaks probably start.  I'll give your suggestions a shot with my current mask, and I should be able to try my new full face mask tomorrow.

What would you consider an acceptable level of leaks?

[Geer1]

I agree with EPR recommendations, many people including myself have trouble breathing out if EPR is turned off like yours is now. 

You should also check for leaks as your data shows constant leaks even at low pressure. If your mask isn't obviously leaking there is a chance it could be your hose or humidifier. 

Put your mask on then on Airsense click my options, scroll down to bottom and select run mask fit. This will increase pressure to your max pressure (currently set at 15 cm) and allow you to look for leaks. Try laying in different positions on bed (to make sure won't leak if you change positions etc) and adjust mask until it is comfortable and doesn't leak. Also check hose/humidifier although if they are leaking will probably know once you start test.

I prefer F20 over F30 because it vents less and I found it easier to control leaks with. Everyone is a bit different though.

Edit: Imo you shouldn't have any leaks when fitting mask. If it leaks during fitting then it will leak during treatment when you start tossing and turning etc. Once I found a comfortable mask and settings my leak rate went down to nothing other than the odd momentary blip (probably me changing sleep position etc).

[idontsleepsowell]

Hello again!

I've made the following changes based on this thread:

• Increased min. pressure to 7
  
• Turned Ramp off completely and EPR full time to 3
  
• Switched to a smaller full face mask (AirTouch F20) and went through the fitting recommendation to make sure there are no leaks
  
• I was also prescribed an antihistamine nasal spray to help with congestion.  It does help with congestion at night, but I don't think it had any significant effect on my cpap usage.
  

With these changes, I can say the EPR is definitely more comfortable than with EPR off.  I don't feel like I have to try as hard to exhale anymore.  I'm unsure on the mask though as a couple nights I did still have a 20-30 leak, and it gets uncomfortable if I make it much tighter than it is now.  I do have facial hair that makes me wonder if it makes it more difficult to get a good seal?

Over the last week or so, I still haven't been able to wear my cpap more than an hour or so on average.  I think the max was almost 2 hours.  I also don't usually remember taking it off and don't remember the reason for taking it off.  

I'm attaching three nights of Oscar data if it helps at all.  Is my leak rate still too high?  How do I know if my pressure is correct?  Is it possible I'm having some sort of apnea that causes me to wake up and take the mask off?


   
   
   

[Geer1]

Facial hair will make it harder to seal mask. The airfit cushion is supposed to work better with facial hair (or shave if you want a reason to).

You aren't having much apnea but you do appear to have better results once pressure has increased a bit and start having more apnea before waking up and removing mask. I'd be curious what previous sleep studies showed for results as your apnea may be worse in rem sleep which usually first occurs 1.5-2 hrs into sleep. Worse breathing in rem sleep is fairly common so wouldn't be a surprise.

I would be tempted to try min pressure of 10 cm for a bit to see if that helps.

Part of PAP is getting used to it as well. Some people (myself included) have to force themselves even if it means having worse sleep at first until body adapts to it.

[idontsleepsowell]

Hello again, I thought I should update here after trying a few things.  I've managed to keep the mask on for over 2.5 hours a few days now, and almost 3 hours last night.  It may not seem like much, but it's a lot more impressive than the 30-45 minutes I was averaging before.

• I'm currently using the AirFit F30 which is a "full face" mask except your nose sits on it and the mask doesn't go over your nose.  I've been having more luck with this than the actual full face masks that go over the nose.
  
• I tried increasing the minimum pressure to 10 for a few days, but felt like it made it worse.  I didn't wear it for more than 20-30 minutes.  I don't really know if it was just harder to fall asleep with the increased pressure or if it was something else.  I'm willing to try increasing it again though.
  
• Currently my min/max is set to 8.6 - 15.0
  
• 3 out of the last 7 days I've worn my cpap for 2.5-3 hours.  The other days were anywhere from 45 to 90 minutes.
  
• I still have ERP on full-time
  
• Last night was the longest I've worn the cpap in recent memory.  In Oscar, it looks like my AHI kept going up until I took the mask off.  The pressure was also maxed out at 15 for a while.  Is this a sign that the max pressure should be increased?
  
• My fiance told me she still hears me snoring pretty loudly even with the cpap on.  I thought that that wouldn't/shouldn't happen at all?
  

Does anyone have any additional advice?  Also I'm wondering if I should adjust the temperature/humidity settings at all?  So far, I've just left them on Auto.  I don't have any rainout issues anymore and I don't particularly notice the air being too warm/cold/humid/etc, but don't know how it changes throughout the night either.

Attached are the last two nights.
   
   

[Melman]

Note the clusters of events on Saturday night. They indicate positional apnea which is usually due to tucking the chin to the chest which restricts the airway. No amount of pressure can overcome it. See this WIKI to learn more about it. http://www.apneaboard.com/wiki/index.php...onal_Apnea    There is, however, no indication of positional apnea in your chart from Friday. Do you know what you did differently with respect to sleeping position or pillow? If this happened most nights I would recommend a soft cervical collar but I think we need data from more nights to see if there is a pattern. Your Friday chart indicates that a higher minimum pressure may reduce the number of events but 2,53 is not a bad AHI and is in the range where comfort is more important than chasing numbers. If you want to try a higher pressure I suggest gradual increases and wearing the mask at the higher pressure while awake to get accustom to it.

[Dormeo]

You don't need to worry about leaks unless they bother your bed partner, wake you up, or go over 24.

You're making progress on using the mask for more of the night. Maybe the next step is to make it harder to remove it while you're unaware of what you're doing.

A couple of tricks have worked for other people. One is to put on a cap over your headgear that ties under your chin. To find one, google "medieval cap with ties." Another is to put socks or mittens on your hands. And a third is to put tape over your straps somewhere on your face so the tug on your skin will wake you up when you try to take the mask off.

[idontsleepsowell]

Apologies for the late response. I honestly have not changed a whole lot since my last post. I did change the max pressure from 15 to 16. I also changed from a heated hose back to a normal hose, and added an antibacterial filter between the machine and the hose. That was several weeks ago though and I didn't notice any immediate differences.

@Melman - Between those two nights, I am not sure what would be different. The only thing I can think of is that sometimes I put a blanket (sorta folded up) between my head and the pillow. I can never find a pillow I really like, but sleeping w/ a pillow+blanket seems to be more comfortable some nights. I also end up sleeping on my stomach a lot, but the mask is long gone by then.

I looked at the past couple of weeks and (if I understand correctly) I think there are more nights where I don't see those clusters vs nights where I do. Is there an easy way to post multiple nights' graphs at once?

@Dormeo - Thanks for the suggestions. I'm not sure how I feel about those caps, but I'll look into them