Extremely difficult to exhale, even with the machine off.

[captainsteubing]

A huge question that I have, that I don't think has been answered.  Should I be able to breathe freely wearing just the mask?  Completely disconnected from the machine, there is still a huge pressure resistance against exhaling.

Hi, 

After reading the thread there's lots of good suggestions by our friends here on the board. All I can say is that our friends here have your best interests at heart compared to the so called expert DMEs.

From my experience if you've just held the nasal pillows up to your nose and not attached to the mask it should be very much free flowing without any difficulty in exhaling. You may need to explore other mask options. 

All the best, 
Captain Steubing

[Coffee Man]

OP,

I have the same mask. There should not be an inordinate amount of resistance when you exhale.

Do you have different cushion sizes you could try to see if a different cushion fits better?

[Dormeo]

I have a lot of trouble getting enough air when my mask is on but not hooked up to the machine. As alexp mentioned, you are just getting air through your vent holes and maybe pulling some in through your mask’s hose. So what is happening when you’re not hooked up is normal.

The main focus in the comments has been on how to be more comfortable when you’re hooked up to the machine. I think you will be pleasantly surprised when you use a higher minimum pressure, EPR, and no ramp.

I hope tonight goes well for you, though it’s common to have a period of adjustment as you get used to a lot of new sensations. Keep us posted!

[OpalRose]

A huge question that I have, that I don't think has been answered.  Should I be able to breathe freely wearing just the mask?  Completely disconnected from the machine, there is still a huge pressure resistance against exhaling.

Breathing freely wearing just the mask, completely disconnected from machine?
Depends on the person and the mask.

But I know it would be very uncomfortable for me. If the electric were to go out at night, I wake up immediately. I need air!

You’ll notice you have many different recommendations for pressure, but start somewhere. Use the EPR, it will help with exhaling. If it’s also hard to inhale raise your minimum pressure.

[mesenteria]

I agree with the Cap'n, above. Masks are different, and so are their users.  But, most of us don't have any particular discomfort or difficulty using just the mask, no hose, or the mask and the hose unattached at the machine end. That is, providing the mask is appropriate for the user, in good condition (and not defective), and worn properly.  Trouble exhaling sounds like there's a problem with lung/diaphragm or the vent. When filled with water, the hose should empty easily through the vent in the hose's end, or the mask, if that's where the vent is. I just performed that very test on my own N20 to make sure surface tension didn't severely retard the flow, or impede it in my own case, and the flow was free and fast.

Kind of raises the question, though; why are you having trouble exhaling when you wear only the headgear, mask and cushion, and either do or don't have the hose attached as well?

[theoak]

The N30i has the individual holes for each nostril.

For me, once I got the holes lined up with each nostril, it was good.

It took some practice in front of a mirror, slowing tilting the cushion up and down to ensure it lined up with my nostrils. Then repeat, and repeat until I could repeat it reliably and breath reasonably easy.

I also found that having the strap low at the base of the head, almost touching the next seemed to work best for me.

I found that if the top of the cushion went past the tip of my, it would leak at the sides of my nose as the holes would move up and past my nostrils. This may depend on the shape of your nose.

Try to find the sweet spot of the nostril holes at the widest part of your nostrils.

If the N30i is too temperamental, give say give the P30i a shot as it uses the same frame.

[sheepless]

it's hard-ish to breathe in and out with my p10 nasal pillow mask when the hose is connected and the machine is off. I turn the machine on with a forceful breath when the machine is set to smartstart, so it's doable, but I wouldn't want to do it for very long. when the mask assembly is disconnected from the machine hose, it's more difficult to breath through the mask than when the machine is on but it's not too difficult. block the end of the mask assembly hose and it's possible but much more difficult to breathe. I'm not feeling any notable difference between inhale and exhale with these experiments with machine off.

masks have a vent / diffuser / exhalation port to keep us from rebreathing expelled CO2. when the mask and the machine are on, feel around for some free flowing air escaping the vent. it should be somewhat constant, perhaps increasing with increased volume of inhale. if you don't feel air escaping the vent, look for obstructions. maybe even a defect. otherwise, breathing at lower pressures, like under 10cmw, should not be difficult.

even though it isn't particularly difficult to breathe with and even against all the pressure the machine can deliver, it takes more effort to exhale against any pressure than none. exhale pressure is largely what keeps an airway prone to obstructing open. if I understand the analogy others have used, blowing through a straw in 8 inches of water is the equivalent to blowing against roughly 20cmw (centimeters of water) of pressure. it's not hard. to some degree, it's something we just have to live with and most people either aren't that sensitive to it or adapt.

make sure all your hoses and humidifier are securely connected and not leaking. check to see if your mask is venting properly. make sure it isn't leaking from anywhere but the vent. try different size cushions and play around with how you place the mask on your face and how the cushions contact your nostrils. if no difference, take the machine back to get checked out. ask the dme provider to resolve the problem by helping you with mask fit or finding a mask that works better for you.

[spenc938]

EPR is considered by the manufacturer to be a comfort setting.  As far as patient access to settings, Please read the article in CPAP Settings Manuals https://www.apneaboard.com/adjust-cpap-p...tup-manual   and consider that to be the stance of nearly 100% of the members and staff on Apnea Board.  We feel patients that are knowledgeable and engaged, are better able to advocate for themselves, and those that take control of their therapy are more likely to succeed and stick with it.  You are motivated, but if you let someone else command and control your settings, you are more likely to become dissatisfied and uncomfortable, resulting in failure.  Your choice.  Keep in mind as a patient you have many rights, including the right to make setting changes, accept or decline tests, treatments and follow recommendations.  Let me just say, your DME therapist is completely out of line. YOU did not have a titration test. The DME is gave you those wide open settings and is hoping they will work. They know NOTHING about your needs.

Back to EPR...go into settings and navigate the Comfort menu. https://www.apneaboard.com/resmed-airsen...setup-info   Set EPR to ON, Full-Time, and set it to 3.  My recommendation for a minimum pressure of 6.0 is because you want to have a lower exhale pressure than inhale pressure, so your current minimum of 5.0 will result in 5.0/4.0. That will be nearly imperceptible.  A pressure of 6/4 is a better start.  FWIW, if you feel better about it, call the DME and tell your therapist you're uncomfortable exhaling and are going to turn on EPR.  You don't need permission.

I read the article and completely agree about taking charge of your own healthcare being the best path to success.  I have sent the email to request the manual.  Thanks for the reassurance.  I've copied your settings and tested it out a little bit, but I'll test it more tonight.

---

Welcome to the forum,

You talked about taking control of your treatment,  this is a good place to be.
With your settings of 5 - 20 and no EPR we see that you were assigned basically wide open settings that were given with little thought.  Most of us like to provide initial settings of 6 with EPR 2 or 7 with EPR 3.  This usually helps with inhalation and allows the lowest min pressure for exhale.

We help best when we have data.  Our preferred data are the charts that OSCAR provides, so download OSCAR and post some nightly data (see my signature for links.  The Organize link indicates which charts to include.   

The DME is typically allowed to change humidifier settings, and usually the EPR settings.  They are not allowed to change any pressure settings without the doctor's permission.  Doctors are usually quick to take credit for therapy that works.

You asked about, I think, a mask on your face being "free breathing", while you can breath that way most feel that alien on their face which makes it seem harder than it is and yes, there is more restriction than breathing without a mask.  I perceived more issues with inhaling than exhaling and needed at least 10cmw to feel comfortable.  All of us are different.

I have installed Oscar and have obtained an SD card.  I'll run the machine with the card installed tonight.  I've also adjusted the settings to be closer to what you and others have recommended.

Thanks for the reassurance on the DMEs.  My experience completely gave the impression that they'll do everything they can to keep people in the dark, so that you're forced to go back to them and only them.

---

A huge question that I have, that I don't think has been answered.  Should I be able to breathe freely wearing just the mask?  Completely disconnected from the machine, there is still a huge pressure resistance against exhaling.

Hi, 

After reading the thread there's lots of good suggestions by our friends here on the board. All I can say is that our friends here have your best interests at heart compared to the so called expert DMEs.

From my experience if you've just held the nasal pillows up to your nose and not attached to the mask it should be very much free flowing without any difficulty in exhaling. You may need to explore other mask options. 

All the best, 
Captain Steubing

I do appreciate all of the suggestions and am taking steps to implement them.  I hope that I didn't give the impression otherwise.

I feel that I may need to explore other mask options.  More to come on that, in a minute.

[spenc938]

OP,

I have the same mask. There should not be an inordinate amount of resistance when you exhale.

Do you have different cushion sizes you could try to see if a different cushion fits better?

I have three different sized cushions.  They set me up with a medium.  Switching to a small-wide is a little better because it doesn't pinch my nose as much.  It's still not great though.  Still a lot of resistance even with just the mask, with no hose and no machine.  I'm not sure why it feels so much worse on the exhale.

---

I have a lot of trouble getting enough air when my mask is on but not hooked up to the machine. As alexp mentioned, you are just getting air through your vent holes and maybe pulling some in through your mask’s hose. So what is happening when you’re not hooked up is normal.

The main focus in the comments has been on how to be more comfortable when you’re hooked up to the machine. I think you will be pleasantly surprised when you use a higher minimum pressure, EPR, and no ramp.

I hope tonight goes well for you, though it’s common to have a period of adjustment as you get used to a lot of new sensations. Keep us posted!

Thanks for the support.  I have implemented the settings changes and am eager to try it out again.

---

A huge question that I have, that I don't think has been answered.  Should I be able to breathe freely wearing just the mask?  Completely disconnected from the machine, there is still a huge pressure resistance against exhaling.

Breathing freely wearing just the mask, completely disconnected from machine?  
Depends on the person and the mask.  

But I know it would be very uncomfortable for me.  If the electric were to go out at night, I wake up immediately.  I need air!

You’ll notice you have many different recommendations for pressure, but start somewhere.  Use the EPR, it will help with exhaling.  If it’s also hard to inhale raise your minimum pressure.

Even without the hose and machine, just the mask, the exhale still has a lot of resistance.  I feel like kind of a dummy, but it is what it is.

I have enabled EPR and done some of the other settings changes.  I'll report back tomorrow.

[spenc938]

I agree with the Cap'n, above. Masks are different, and so are their users.  But, most of us don't have any particular discomfort or difficulty using just the mask, no hose, or the mask and the hose unattached at the machine end. That is, providing the mask is appropriate for the user, in good condition (and not defective), and worn properly.  Trouble exhaling sounds like there's a problem with lung/diaphragm or the vent. When filled with water, the hose should empty easily through the vent in the hose's end, or the mask, if that's where the vent is. I just performed that very test on my own N20 to make sure surface tension didn't severely retard the flow, or impede it in my own case, and the flow was free and fast.

Kind of raises the question, though; why are you having trouble exhaling when you wear only the headgear, mask and cushion, and either do or don't have the hose attached as well?

Just the mask, no machine and no hose, is pretty difficult to exhale.  Even with just the 3 inch wide cushion, there is still a lot of resistance.  I'm not convinced that this type of mask is going to work for me.

---

The N30i has the individual holes for each nostril.

For me, once I got the holes lined up with each nostril, it was good.

It took some practice in front of a mirror, slowing tilting the cushion up and down to ensure it lined up with my nostrils.  Then repeat, and repeat until I could repeat it reliably and breath reasonably easy.

I also found that having the strap low at the base of the head, almost touching the next seemed to work best for me.

I found that if the top of the cushion went past the tip of my, it would leak at the sides of my nose as the holes would move up and past my nostrils.  This may depend on the shape of your nose.

Try to find the sweet spot of the nostril holes at the widest part of your nostrils.

If the N30i is too temperamental, give say give the P30i a shot as it uses the same frame.

I went and practiced in front of a mirror just now and it did noticeably help.  Thank you for the suggestions.

---

it's hard-ish to breathe in and out with my p10 nasal pillow mask when the hose is connected and the machine is off.  I turn the machine on with a forceful breath when the machine is set to smartstart, so it's doable, but I wouldn't want to do it for very long.  when the mask assembly is disconnected from the machine hose, it's more difficult to breath through the mask than when the machine is on but it's not too difficult. block the end of the mask assembly hose and it's possible but much more difficult to breathe.  I'm not feeling any notable difference between inhale and exhale with these experiments with machine off.

masks have a vent / diffuser / exhalation port to keep us from rebreathing expelled CO2.  when the mask and the machine are on, feel around for some free flowing air escaping the vent.  it should be somewhat constant, perhaps increasing with increased volume of inhale.  if you don't feel air escaping the vent, look for obstructions.  maybe even a defect.  otherwise, breathing at lower pressures, like under 10cmw, should not be difficult.

even though it isn't particularly difficult to breath with and even against all the pressure the machine can deliver, it takes more effort to exhale against any pressure than none.  exhale pressure is largely what keeps an airway prone to obstructing open.  if I understand the analogy others have used, blowing through a straw in 8 inches of water is the equivalent to blowing against roughly 20cmw (centimeters of water) of pressure.  it's not hard.  to some degree, it's something we just have to live with and most people either aren't that sensitive to it or adapt.  

make sure all your hoses and humidifier are securely connected and not leaking.  check to see if your mask is venting properly.  try different size cushions and play around with how you place the mask on your face and how the cushions contact your nostrils.  if no difference, take the machine back to get checked out.  ask the dme provider to resolve the problem by helping you with mask fit or finding a mask that works better for you.

Thanks for the tips.  I'm still working with it and am implementing the suggestions here.