Forum has helped...but now next step to improve

[nightgagger]

Hi,
First time poster here, but have been lightly lurking on this forum for about 4 or 5 years.

I'm 59 years old and have been a loud snorer for most of my life.  It wasn't until I was married that my wife once pointed out that she thought I was gagging one night, but then never really mentioned it until she finally left the room and slept in another room....maybe a good indicator of snoring/apnea.

It wasn't until 25 years ago, on the fact that I had a sinus infection, that I went to an ENT and he additionally diagnosed that I had a deviated septum, he pointed out a large uvula, as well as tounge.  This diagnosis led me to have a in home sleep study, full PSG.  This test determined that I had loud snoring but no OA, and a few Hypopneas. The snoring was causing my sleep fragmantation at the time.

Going forward, I had a septoplasty, as well as Uvula reshaping surgery.  
This helped for a little while.  I then just put it off and sometimes had good days and bad days with sleep, grogginess, etc.

Fast forward 20 years, and gaining weight, and noticing that I would wake up in the night with sweats, and other wake up during the nights.

During the last five years, I've taken cycling as my main sport, lost about 40lbs. and currently exercise 6 days a week.  I'm an avid cyclist, so from that I'm always certain that I get a great night's sleep...but alas that hasn't been the case.  Furthermore, I do have high blood pressure and currently on medicine for that.  My physician thinks it is genetic, which seems likely as my mother who had it, and passed away from heart attack, as well as aunts and uncles are all diagnosed with high blood pressure.


Finally, I took steps for CPAP therapy almost three years ago.  My tests are attached here.

I'm on a Resmed Autosense, and Airfit nasal mask. Over the course of therapy I would notice that my AHI numbers were low, but my leak rates were high, this was using the Resmed Myair program.  I tried a chin strap, and tape, but had used 2" tape for my mouth.  This didn't really work.  I also use a mouth guard due to grinding teeth.  This was dentist prescribed and made for me.  I do have an overbite, so my jaw is a bit recessed.  Going forward, about a couple of months ago I was speaking with a fellow cyclist who is also on CPAP and he recommended going to 3M 3" tape.  I tried this and instantly my leak numbers dropped below Resmed's cutoff point, but my AHI #s were up.  Not always, but there was this inverse relationship.  
Then going by what I felt like in the morning, the results did not indicate that I was improving.

This led to a Google search and found myself back on this board, but from that I got Jason youtube channel and that opened a lot more information.  I downloaded OSCAR and have tracked my data for the past month or more.

I've tried the following from the posts and graph observations on this board:

Corflex Cervical Collar 3 1/2" - Found that it really pushes into my clavicles, sometimes uncomfortable, and pushes my chin up that the nape of my neck is uncomfortable...but works well.
Caldera Cervical Collar - Almost the same as the Corflex...a little better on the clavicles...but a bit warmer neck temps than the Corflex

3M Tape...great unless it creases, gets drool, or I don't shave for a day or two.  Leaks develop, but still the best tape
Sominix - Not good...leaks at the side of my mouth.
Lukoplast Cover Roll tape...not much better, seemed to not hold and drool took it off.

Knightsbridge Cap.  Warm and uncomfortable, didn't really help much with my mouth leaks.

And now, last night being the first night, an F30i full face mask.   I found this mask to be somewhat comfortable, obviously it was the first night, so I need to try it out to get fully comfortable, but I noticed some discomfort around the corners of my mouth.  Also small leaks waking me up during the night.  I used a cervical collar.  The Corflex still feels a bit uncomfortable, and I have ordered a 2 1/2" model to see if that improves the situation. Should be here next week.

I guess my question now is, do I need to adjust pressure, settings on the machine to optimize this F30i mask...oh and yes, I changed the setting from Nasal to FFM?

Also, I'll take in a few days of data to see a trend and may put on the Caldera collar to see what happens there as far as comfort.

And finally, the main question, how do I feel....well, tired, very tired.  I was hoping to go on a nice bike ride early this morning but due to all the leaks and waking up from them, I didn't have a good restful, continous night's sleep.

Thanks for you help.

The attachments: Sleep test.   Screenshot of just 3M tape.  No collar.
Since I can't add more than three attachments, I'll add in subsequent post.

---

Attachement #1 Best 3M tape and Collar
Attachment #2 Collar and Sominix
Attachment #3  F30i and collar

[Sleeprider]

Welcome to the forum. You are using your Autoset in fixed pressure CPAP mode with EPR at 3 for a pressure of 12/9 (inhale/exhale). Your results vary, and as I understand your post, the chart with the obstructive apnea occurred without the collar. Most nights you have substantial leaks, and event rates are good. The leaks could explain sufficient sleep disruption that you may not be getting what you need. Have you tried any other masks such as full face or hybrid? Why are you using fixed pressure?

[nightgagger]

Thanks for responding Sleeprider!

Last night was the first with a F30i, that should be the last graph in the series.

I have tried an F20 around the start of my therapy, but was very uncomfortable with it due to leakage out the sides.   I then tried it a year later and I didn't like it for the same reasons, but also how claustrophobic it felt.

I'm impressed with the F30i, it's not comfortable yet...given I've only used it one night, and will persist to improve, just like the N20 was when I started.

The pressures are what was prescribed post titration.

[Sleeprider]

The leaks need to be dealt with, but I would not hesitate to set mode to Autoset around your current setting to allow the machine to respond up or down in a narrow range. For example using Autoset mode with a minimum pressure of 10 and maximum pressure of 14 would give the machine the ability to respond to the obstructive events when they are present, and drop back when they are not. I also think you should try EPR at 3 and see what you think. EPR is considered a comfort setting but it has therapeutic application to reduce flow limitation and makes it easier to breathe both directions (inhale and exhale).

[nightgagger]

The leaks need to be dealt with, but I would not hesitate to set mode to Autoset around your current setting to allow the machine to respond up or down in a narrow range.  For example using Autoset mode with a minimum pressure of 10 and maximum pressure of 14 would give the machine the ability to respond to the obstructive events when they are present, and drop back when they are not.  I also think you should try EPR at 3 and see what you think. EPR is considered a comfort setting but it has therapeutic application to reduce flow limitation and makes it easier to breathe both directions (inhale and exhale).

I will definitely give that a try tonight.

Thank you!

[multicast]

You are aware that you're using your machine merely as a leaf blower currently?  Considering the leakage you may not rely much on the data the machine provides.

The F30(i) is the diva of all FFM.  In contrast to adjusting other FFM, start with a position that is a bit too tight, then losen it literally millimeter by millimeter until ist fits perfectly.

The F30(i) doesn't forgive any asymmetry: you definitely need a ruler to adjust the straps and mark previous positions. It will take a week or so before the right adjustment is found. Once properly adjusted it's a cute little mask.

Alternatively you may use a nasal mask with a proper tape.  I recommend Fixomull stretch; that 3M-stuff was too weak for my mouth ant not flexible enough (all that wrinkles).

Also give APAP a try: why in the world should you use CPAP with a machine like yours?! As Sleeprider suggested, try to start from 10 to 14 with EPR; in case massive CA will occur, cancel EPR.  Also use mode "soft" from the settings; that will make the machine react less "aggressive".

[nightgagger]

You are aware that you're using your machine merely as a leaf blower currently?  Considering the leakage you may not rely much on the data the machine provides.

The F30(i) is the diva of all FFM.  In contrast to adjusting other FFM, start with a position that is a bit too tight, then losen it literally millimeter by millimeter until ist fits perfectly.

The F30(i) doesn't forgive any asymmetry: you definitely need a ruler to adjust the straps and mark previous positions. It will take a week or so before the right adjustment is found. Once properly adjusted it's a cute little mask.

Alternatively you may use a nasal mask with a proper tape.  I recommend Fixomull stretch; that 3M-stuff was too weak for my mouth ant not flexible enough (all that wrinkles).

Also give APAP a try: why in the world should you use CPAP with a machine like yours?! As Sleeprider suggested, try to start from 10 to 14 with EPR; in case massive CA will occur, cancel EPR.  Also use mode "soft" from the settings; that will make the machine react less "aggressive".

Thank you for your post Multicast!

I do like the F30(i) and last night I found that I was getting more comfortable with it.  Additionally the new settings felt more comfortable.   Not sure where the line crosses for massive CA, but there were a bit more on last night's data than previously.

The mask adjustment will have to improve due to my facial features.

I had thought I bought the Fixomull tape, one that was linked in Jason's video, which I have this exact problem....fluttering lips:

Due to the fact that I do not have four posts, I can't post a direct link, but it is on Youtube, the Lankyleft27 video posted on Jan 12, 2021, titled:

Tape mouth to improve CPAP INSTANTLY!!!

The tape recommended was this:

Due to the fact that I do not have four posts, I can't post a direct link...but it is :

Smith and Nephew/BSN Cover-Roll Stretch - 2" x 10 Yards - Hypoallergenic Pack of 2 (SG_B01F9JFBBY_US)



If this isn't the right tape, do you have a direct link to the Fixomull? 2" (5.08cm) width seem small as well, if there's a 3" (7.62cm....I wish the US would have adopted the metric system), such as the 3M tape I've used, seemed to work best out of all the 3M width sizes and my face.

Regarding EPR, should "soft" mode be used if removing EPR.

Obviously this is a lot of changes, so maybe one change and a few nights' data may be a good approach to improve my settings?  Definitely the leak issue has to be addressed.

On the attached graph, I switched from the Corflex to the Caldera cervical collar.  It's a tough call which one is better, but the back of my neck muscles seem a bit more sore with the Caldera, whereas the Corflex it's the pressure on the clavicles.

[Sleeprider]

The purpose of the collar is to resolve the clusters of obstruction that we saw before. Both collars seemed to accomplish that, so the best collar is the one you are most comfortable with. Your leaks flatten out just over the large leak threshold. I think you're still getting decent therapy, but getting the leaks taken care of will make sleep integrity better.

[multicast]

Not sure of getting you right: Do you use the F30 or the N20?  IHMO mouth taping is only useful using a nasal mask.

Im using that https://www.amazon.com/-/de/dp/B00DN6O7Q...O7QQ&psc=1 10 cm width, with great success together with the mask of my sweetest dreams, the trusty P30i.  Before applying the tape move your lips slightly inwards not only to protect the lips but for a better sealing, too.  And don't remove the tape quickly!  There will be no residues fron the tape on your face.

(Don't buy it in 5cm width, as the tape stretches fortunately only in the width-direction.  Hence having a 10cm width tape cut in 5cm length you may stretch it horizontally but not vertically, which is good as it won't stretch in the direction your mouth would open.  Just terrific.)

As you noticed, the collar is without any effect. At the moment your therapy just blows out.

[Sleeprider]

Actually, I disagree that the positive pressure therapy is ineffective at this level of leak.  It would be great if the leaks could be resolved, but the reason we know it is still effective is we can still fully visualize the respiratory flow rate. That means there is pressure between the machine's sensors and your airway.  When leaks increase to the point that positive pressure cannot be maintained, we see that respiratory flow rate significantly diminish and lose resolution. I usually observe that when leaks exceed 60-70 L/min. In this case, the 95% leak rate is less than 40 L/min. Hardly ideal, but not enough to negate therapy.  It is certainly disruptive.