[CPAP] New forum member introduction and questions

[Jadazu]

Hello, and thank you, in advance,

I am a new member of the forum. (I wish that i had found this forum many years ago. I've spent the last few days reading many forum threads, and I've learned more about SA and PAP treatment than I've learned in 20 years of treatment by physicians. Thank you, everyone, for this forum.)

I'm 60 year old male, athletic with no underlying health problems, who has sleep apnea. I've been using CPAP and APAP machines for about 20 years. At this point, i am very frustrated with the treatment I have received from the medicos, and I'm upset with myself for not having taken more responsibility myself for my therapy.

(rant) Over those years, I've been a patient of three physicians. I've done 4 PSG's indicating that I have serious SA, with inconclusive titration measurements. Ive been prescribed and have purchased four PAP machines, the last two were a Resmed S9 Escape Auto and a Philips Respironics DreamStation Auto. (I acquired them via health insurance and prescribed DME's, and I paid about 2x the price of the machines to DME's in co-pay's...) The last two physicians said that using the auto machines would allow them to obtain the information they needed to determine the correct titration and monitor my therapy. And I've taken the SD cards from the machines to each of my annual prescription physician appointments. And now I've discovered OSCAR, and I've discovered that neither of my machines records therapeutic information!?! And I didn't like the sleep doctors very much before I discovered this... (/rant)

I've very recently purchased a Resmed 10 Airsense AutoSet and F30i mask, and have just started using them. The mask seems to fit well. I've had troubles with mouth air leaks, so I always used FF masks, and have had satisfactory fit test with them, even though I have a beard. Ive used the new machine for a few nights now, and I've been looking at the data with OSCAR, and I have a few questions about the reports. Ive been using the machine as it was delivered, auto with min of 4cm, max of 15cm, and EPR of 3cm. I hope someone will be willing to try to answer the questions that I have...    

The reports show significant time with Large Leaks. I see that the LL threshold is 25 l/min. The leak rates seem to peak at about 30l/min, and it looks like the machine is working correctly and maintaining the pressures with these leak rates. I am adjusting the mask fit to try to reduce this. when I'm awake, i can keep the leak rate low, I'm don't know what is happening when I'm asleep. Question: Since the reported mask pressures seem correct, is this high leak rate a problem that is compromising my therapy?

Next question: Is the reported Mask Pressure the measured output pressure of the machine?

The report shows Flow Limitation. I think i understand what this means; the flow rates don't change linearly with pressure changes. I guess that could be from airway restriction or changing respiratory effort. Question: Is this an important metric? Should I be concerned about this?

And, what is Minute Vent. measuring?

I'll attach some screen shots of the first nights report. I have enlarged some CA or UA events. The UA apneas seem to be diminished respiration. Question: Could these be apneas from positional obstruction?

(There is a data gap; I had the machine plugged into a new UPS power backup, but I forgot to turn on the UPS, and I slept for a while til I woke-up and turned on the machine.) 

Thank you for any responses and any help you are willing to give to me!

Jim Z


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OK, I have an attachment problem... - Moderator solved.

[staceyburke]

Welcome, you will get some great advice from some very knowledgeable people.  Let me start off with the min 4 and  EPR 3.  With this setting you are getting nothing!  The lowest the machine can go is 4.  EPR reduces the min by 1, 2 or 3 CM of pressure.  So EPR is doing nothing.  You need a min of at least 7 for the EPR to do its job.  EPR helps with flow limits.  And flow limits are just small apnea.  check out the bottom of the post for how apnea is graded. Flow limits can cause sleep interuptions.

2nd thing is the possibility of positional apnea.  Positional Apnea can NOT be helped by any cpap machine.  IF you are having Positional Apnea it is because you are sleeping in a position that is cutting off your own airway.  You would have to find out why you are in that position and stop for doing it.  You may be chin tucking which is having your chin tucking to your sternum cutting off your air.  It can happen more times while sleeping on your back.  If you are a back sleeper try side sleeping.  Or you may have to high of a pillow(s) that make it so you chin tuck.  IF it is not one of those you may need a collar to stop the chin tucking.  You can read about getting a collar in my signature at the bottom of the post.  In it shows people with and without the collar and the difference it made for them.

I will let others give you suggestions on pressures other than the min I mentioned.

Like I said there are some great people here that can and will help you.

[Sleeprider]

Three things to do: Change your pressure to minimum 7.0, and read the soft cervical collar wiki linked in my signature, and the mask primer also linked in my signature. You have large leaks all the time. Your mask either does not fit or you need a different model. With a beard, the leaks may be related to that, and I'm going to send the guy with the biggest beard I know (Gideon) to make some suggestions on that. If you can get mouth leaks under control, I'll say the Resmed Airfit P10 mask would be a silent, effective partner, but not if your jaw does not cooperate.

Your apnea, regardless of leaks occur in very consolidated clusters. This is positional apnea where your chin tucks to your chest, and it is likely the reason you have not had a successful titration evaluation. When your airway is cut-off due to positional chin-tucking, no pressure will correct that. You simply must avoid chin tucking whether it's because you use too many pillows and sleep on your back, or sleep in a fetal position on your side and tuck your chin. Our first awareness of this was a very common pattern of apnea displayed by many members here http://www.apneaboard.com/wiki/index.php...onal_Apnea and grew into the widespread use of soft cervical collars http://www.apneaboard.com/wiki/index.php...cal_Collar I use a medium down pillow and can pull it between may shoulder and jaw when the positional issue hits, but most people just sleep through the events and need a collar. There are links to some reviews in the wiki.

The reason you need to change your minimum pressure to 7.0 is that you are using EPR at 3. That's great and very comfortable, but do the math. The minimum pressure you machine produces is 4.0 cm, so if your minimum is 4, you don't get any EPR, but at 7, you get the benefit of inhale at 7.0 and exhale at 4.0, and that changes the game. Your Airsense 10 Autoset can keep up with your needs, but I expect once you correct leaks and positional issues, we may narrow in on some better settings. Standby for Gideon.

[mesenteria]

Jadazu, am I ever glad you came to this site.     You could use some help, obviously, and you have just received the Gold Standard.

I'm sure you'll see the reasoning and agree to try anything suggested at this point.  What I caution is to not expect permanent changes right away, and to not rely on the first night's data as an indication of where you'll be in two weeks.  Sleeprider has given you his best solid assessment, and you really ought to try what he suggests....for about three nights to see how you settle in.  From there, we'll bracket the settings to see if we can get you dialed in quickly and feeling much better about your condition, your experience, and your equipment.

Hang in there...we'll get you sorted out one way or another.

[Gideon]

   

Have a beard, so do I.  That is me in my Amara View FFM(Hybrid) backup mask (which I haven't needed in years.  I now use the ResMed P10 Pillow mask exclusively.
On the leak issue, before you can handle (meaning get away with) a Large leak such as you have, you MUST have a VERY LOW AHI before you can even think of allowing a small large leak.  In short, you need to have so few events that missing an odd one or two wouldn't make a difference.  If you had none of the UA's WITHOUT the large leak consistently (no events there), you may be able to tolerate a large leak a bit above the threshold.  The UA's here are telling us that you are currently nowhere near thinking about this.  

Read the Mask Primer regarding mask fit and leaks.

Why the Amara view?  For me, it was fit and avoiding a lot of the beard and stash.  The nose is sealed with a 'flap with a hole in it sealing the bottom of the nose not quite like a pillow mask but close.  The rest of the seal was around my mouth where my beard is the thinnest.

Because of mouth breathing, I started with an FFM,  Then went to a nasal mask, specifically the ResMed Mirage Activa Nasal mask.  A nice mask that allows for about a half inch movement in any direction without a leak. That's great, isn't it? Not if you are a mouth breather and I was.  The initial solution was taping. Now with a full beard and stash (I think that covers full) how the h did I do it?  Tape will not hold your mouth shut, no way, no how, unless you are wrapping your head in a very heavy-duty tape. A small hint, DON'T. The way to tape, especially with a beard and stash is as if you were putting on chapstick.  You are taping the lips, to stop minor mouth breathing, not to keep the jaw closed.  While doing this I was also learning the tongue technique.  

from the Mask Primer, my experience with it.

Tongue Trick. 

1. Place the tongue on the roof of the mouth, Practice during the daytime. The idea is to train the tongue that this is a good place to be, does not happen overnight, but it works for some. The tongue trick is where you want to be, but it takes a lot of time and some people just cannot get it.
   
2. Place the tongue on the roof of your mouth and breathe with your mouth shut. Breathing thru your nose, right?
   
3. Now leaving the tongue where it is open your mouth, you should still be breathing thru your nose.
   
4. Now that you have that down, move your tongue, breathing thru your mouth right?
   
5. OK, put your mask on, under pressure, and repeat the above. Expect to need to turn your machine off when you start to repeat.
   
6. Add talking while under pressure, It takes a while to get any of this down. It took me months.
   

The exercises above are to help you understand the positions that cause the issue and how to correct it. For all this to become automatic will take a while.

[Jadazu]

Thank you, each and all of you, for the replies!

The next steps for me:

I've ordered two soft cervical collars to try. I''m a side sleeper and use soft pillows. I realize now that my sleeping posture is not very regular, I'm probably moving my head around a lot. I've also purchased a firmer pillow, to try to start from a better foundation.

I am going to increase the min pressure to 7cm. I now see the issue with low min pressure and EPR.

Mask wise, I've been using full face masks since about 2017. Prior to that, I used nasal masks, but I could not stop mouth leaks. The tongue trick was what the therapists I was going to said would work. It did at first, but I can no longer do it consistently. Until I found this forum, I had only heard rumors or anecdotes about lip taping. The question that immediately came to my mind was that of safety. I see now that the answer is, yes, it is safe to do. (I've searched, and read the threads about it) I've ordered two rolls of stretch bandage tape, and I am going to try it. (Also, I've re-adjusted the F30i mask that I have. Last night I only had one short instance of LL reported.) Thinking about this, I anticipate that I will need a chin strap to make the taping work.

I will proceed with this, solve the leak problem, and look for improvements.

Again, I will say a big "Thank You!" to all of you forum participants. In 20 or so years of treatment, no one had ever said anything to me about sleeping postural problems with airway maintenance. And I feel a little stupid about it as I was a firefighter and EMT for many years, and head alignment is the first aspect of airway maintenance...

[Gideon]

I understand, former Firefighter, Heavy Rescue, EMT, Advanced First Aid Instructor and CPR Instructor here.

I will remind you that here the purpose of the collar is not as rigid as it was as an EMT, mostly it is just to keep the chin from tucking, not to immobilize the neck (just restrict it a little bit).

[Jadazu]

Thank you, Gideon.

I’ve got one of them now, and I’m trying and ‘testing’ the compliance of the collar vs my perceived breathing effort...