[Diagnosis] Any clues in OSCAR data as to why so many leaks and high AHI?

[PhoebeAnn]

I thought my problem (have to refill humidifier 2 times during the night) was most mask fit, so I posted the problem here: http://www.apneaboard.com/forums/Thread-...#pid341511. The experts told me I had many more problems than that, and to start a new thread, so here we go.

Would appreciate someone who knows a lot more about this than I taking a look at the last 2 nights' OSCAR charts to see if there are any obvious things I can change to reduce leaks and maybe lower AHIs. My doctor has made no comments at all since I started, and my DME supplier this time was a pump-and-dump who gave me several masks to try. None of them worked at all, for several reasons. I've tried multiple masks and chinstraps, but have always reverted to a simple P10 mask (given to me at first titration) until recently, when chinstraps itched and kept me awake, and don't keep my mouth closed anyway. I switched to an N30 (given to me at last titration) and will soon try a P30.  I've always been a side sleeper and a mouth breather, but can use the tongue trick easily as long as I'm awake, but sometimes I'm pretty sure I revert to mouth-breathing when sound asleep. There seems to be a pattern of a period of no leaks, I get up to pee, put the mask back on, and the next period may be leaky (or not). Lately when I remove the mask in the morning, it is noticeably more difficult to breathe. Last night, I slept with a cervical collar on, suggested by Dormeo in the referenced thread.

Background: Was put on CPAP following Dx of apnea found during telemetry collected following triple bypass in December 2017. Switched to BiPAP folllowing Dx of ALS 1/24/20; CPAP history:

First                      Last                      Days         AHI         FL            Machine                           Pressure Relief     Mode                 Pressure Settings
03/18/20              03/22/20              5              6.91        0              Auto BiPAP (700X110)    None                   Fixed Bi-Level     EPAP 8.0 IPAP 13.0 (cmH2O)
03/11/20              03/17/20              7              2.29        0              Auto BiPAP (700X110)    None                   Fixed Bi-Level     EPAP 8.0 IPAP 12.0 (cmH2O)
03/04/20              03/10/20              7              2.18        0              Auto BiPAP (700X110)    None                   Fixed Bi-Level     EPAP 6.0 IPAP 10.0 (cmH2O)
01/31/19              02/24/20              358          6.27        0.25         Auto CPAP (500X110)    None                   APAP (Variable)   Min 8 Max 12 (cmH2O)
04/29/18              01/30/19              277          8.27        0              Auto CPAP (500X110)    None                   CPAP                  Fixed 8 (cmH2O)

[Gideon]

You were asked to start a new thread because your chart posts revealed treatment issues other than leaks and thus to not hijack the OPs thread.

Leaks:  22 Mar,  These are mostly mouth leaks.  A soft Cervical collar will help with these.  
21 Mar, these are a combination of mouth leaks (flat tops on the leak chart) and mask seal leaks (many peaks on the leak chart) The Cervical collar will help with the mouth leaks.

As I said in the other thread the P10, because it is so light and small and held on with little strap tension need to have the CPAP hose supported so that the mask is not pulled by the weight of the main CPAP hose.

Another cause of the seal leaks is age.  I find I need to change my pillow nose piece (large) several times a year.  I do this when I see an increase in leaks and my leak rate always dramatically drops when I do.  

Also you are showing significant clustering of obstructive events which typically means you are tucking your chin.  A Soft Cervical Collar really helps this as well.

If you are using a collar you may need to adjust it or perhaps get a different size,

[PhoebeAnn]

We've tried many masks and chinstraps and we're still looking for the right combination to seal well, be comfortable, and be quiet to everyone in the area. I'm beginning to think you only get to choose 2 out of 3.

As far as being quiet, we're finding that "quiet" is a different thing for the user and bedmate. Last night I wore a Dreamware full-face mask for a couple hours before giving up (up to about 11:30 in the OSCAR screenshot)  because it was so noisy and uncomfortable, and switched to a P30i, which is quiet and comfortable for me, but requires a chinstrap, which itches. My wife thought the Dreamware mask was quiet, but the P30 (or, more likely,  my mouth)  kept her awake.

The Dreamware seems to seal well, but it sounds like it's leaking most of the time, and is very susceptible to displacement (which generates more noise) as I thrash around. Further, the mask gets its air from overhead; the air flowing in the tubes (which run right by my ears) and exhausting into the mask is very noisy. OTOH, the air flowing the same way in the P30 is very quiet, but my mouth opens up and allows huge leaks.

Finally, my question: I'm wondering if anyone has seen (or used) something like a mouthguard they use in sports, only formed to seal the mouth's airway. Some are designed to address sleep apnea, but those say expressly that they keep the airway open.

[Dormeo]

Before you try other solutions, do see what happens when you use a cervical collar, as Bonjour has suggested.

About itchy chin strap: can you use a piece of old t-shirt or other soft fabric to make a little barrier between your skin and the chinstrap?

[PhoebeAnn]

I used the cervical collar several times with no effect. But I think I've solved the mask problem. The neoprene (?) mask seal doesn't seal against a beard. I tried a ResMed F20 AirTouch last night (the AirFit uses a neoprene seal, the AirTouch uses a foam seal) and it sealed nicely. Unfortunately, the mask is too small, and during the night it creeps upward, exposing the mouth, at which time it leaks like a sieve. I eventually wake up, pull the mask back down, and go back to sleep.  You can see from the OSCAR graph where this happened last night. I should have a Large mask Wednesday for the final (I hope) test.

The original problem (using way too much water) remains, but may be a machine problem. This morning, as I removed the reservoir for cleaning, I noticed the tray underneath was wet - very wet. I can't believe the reservoir is leaking, but for some reason, water is coming out of the reservoir and ending up in the tray (and, much to my wife's dismay, all over the wooden nightstand on which the machine sits). Or there may be a problem with the humidification system in general. This machine was billed as a used machine (I don't know how used), so who knows what problems I've inherited? Whatever, I have to refill the reservoir every 3 or 4 hours. And my mouth feels like the Gobi Desert in the morning.