Mask or Mouth Leak?

[StuartC]

Okay, so this is my first time posting with a question.  I have a few others but I have leaks and I think I need to resolve this before anything else. 

I had been using a DS1 for 3 1/2 years up until about 3 weeks ago.  Fixed pressure of 9 cmH2O. The machine  almost never reported  any mask leaks reported until the last few weeks that I had it, but the mask was beyond old by then.  However, my wife did tell me that "the machine was making a noise".

I now have a new AS10 Elite.  Also fixed pressure, initially set to 9 cmH2O, but I have been trying at 8 cm, in part as an attempt to reduce leaks.  The machine has been consistently reporting mask leak scores in the range of 10 to 15 out of 20.

I should add that I am using, and have always used,  an Eson 2 nasal mask.  I bought a brand new one when I got the AS10.

This led me to OSCAR.  I have attached a chart from the AS10, with one from the DS1 just for reference if it is helpful (please ignore it if it is just useless history).  What OSCAR shows me is that I regularly start and end the evening with low and sporadic leaks but get large and quite consistent leaks quite suddenly about 90 minutes after going to sleep.  My thoughts are that I am going into REM and that my mouth is dropping open, making this a mouth leak rather than a problem with the mask fit.  Is this a reasonable conclusion?

I did try taping my mouth a couple of times with little success, but I was using the wrong tape so I have some better tape on order from Amazon.  I have not tried a full face mask, so your thoughts on whether this is an option would be appreciated.  I have tried a chin strap once or twice but have worked out that it is not a great one, which might explain why I thought it was a waste of time.  I have not tried a mouth guard.  I use a regular pillow, which I scrunch and maul every night, I do not have a CPAP pillow.


I do need to work this out.  I have tolerated the CPAP therapy well and have been getting very low AHIs.  But I still wake every day feeling awful.

[OpalRose]

This led me to OSCAR.  I have attached a chart from the AS10, with one from the DS1 just for reference if it is helpful (please ignore it if it is just useless history).  What OSCAR shows me is that I regularly start and end the evening with low and sporadic leaks but get large and quite consistent leaks quite suddenly about 90 minutes after going to sleep.  My thoughts are that I am going into REM and that my mouth is dropping open, making this a mouth leak rather than a problem with the mask fit.  Is this a reasonable conclusion?

StuartC,
It's easy enough to differentiate between mask leaks and mouth leaks on the graphs.  If you look at your leak rate graph, flat tops usually point to mouth leaks and if you see spikes in the graph, that is usually from mask movement.

You only have a couple spikey areas, but mostly mouth leaking.  It's not real bad, but does need to be corrected.  Your stats show you are slightly in large leak territory.  When that happens, the Cpap can't reliably detect apnea during those large leaks, regardless where it comes from.  

Another thing to consider is that a few leaks here and there won't affect much, but smaller leaks that are consistent during the night will affect your sleep quality.  

Some things to try:  mouth taping is one, also some use a "soft" cervical collar to help support their mouth/jaw from dropping open while in a deep sleep.  

Then there is always the "Tongue Suck Technique".

Tongue Suck Technique:
Place your tongue to the roof of your mouth with tip of tongue behind front teeth.  (NOT PUSHING ON TEETH).
Gently suck upwards and back.
This places the tongue in a natural position, with the back of tongue sealing the back of the throat so that if your mouth/jaw drops open while sleeping, no air will escape.

Of course, this will take time and practice.  You can practice this anywhere while finding other quicker alternatives.  

If you can't seem to control mouth breathing/leaking, you may have to try a full face mask or one of the hybrid style masks.  

Also, I think that you should be fine with keeping your pressure lower at 8cm.
Your numbers look pretty good, but how you feel is key.

[Gideon]

Pretty much what Opal said.
Your numbers appear consistently low, and your leaks are consistent and where they are into large leak territory they are barely into high leak territory. While it is never a bad idea to better manage your leaks, you don't NEED to. Work on the tongue technique, another take on it is in the Mask Primer, including some exercises. I took me months to get it down.
Your flow limits show some sign of clustering, a sign of chin tucking, but not bad enough to require correction. The Cervical collar Opal mentioned above should help with this as well.
What I mostly see is to work on the tongue technique and watch for changes.

[multicast]

It's easy enough to differentiate between mask leaks and mouth leaks on the graphs.  If you look at your leak rate graph, flat tops usually point to mouth leaks and if you see spikes in the graph, that is usually from mask movement.

Well, in my case it's just the other way round: "flat" leaks are always mask leaks, the spiky ones are always mouth leaks.  I know that for sure because I tape my mouth thoroughly.

[StuartC]

Thanks for the replies.  I had not considered a collar and will look into getting one to try.  I do see some advertised in a local pharmacy, but will do  a bit of research first to confirm that is the correct type.  I do not see any in the online CPAP stores, so I hope so.

[OpalRose]

StuartC,
This link may help on choosing a collar.
http://www.apneaboard.com/wiki/index.php...cal_Collar

Also, a very good wiki article on understanding leaks:
http://www.apneaboard.com/wiki/index.php...Head#Leaks

[StuartC]

Thank you.  That does help.

[Phil7]

Try this.  I had a rough night last night, where I got a work call 1 hour after I fell asleep.  I was using a P10 pillow last night, and I think I might have over-tightened the strap on it.

Otherwise (the interesting part), I mouth taped last night.   I used a cut strip of 4" BSN Medical Roll tape.  You can actually breath through that tape, if you put it on loose.  However, I normally push the tap down above my upper lips and hold my lips firmly together before pressing the bottom of the tap down (stretching the tape before pressing the bottom part down so it's good and tight, holding the lips together firmly).   When I woke up (both times), my lips were still firmly pressed together, where I could not draw any air.

Yet, I had 4 large leak events last night, that's should not have been able to come from a mouth leak.    This was an unusually bad leak rate night for me. I was using a P10 mask, which I sometimes have issues with. I also may have had the headgear strap too tight.

[StuartC]

I got a collar yesterday and used it last night.  It definitely reduced the leaks, to the point where MyAir gave me 20 out of 20.  So, thanks for the suggestion.
 
Still some leakage that I will chip away at but, as you can see since I have also got hold of an O2ring in the last few days, other issues to look at first.  I have some things to test, only one per night, and then I will probably open a separate topic with a more relevant description to make it easy for others for whom this topic holds no interest.

For the record, I have removed pressure from the attached chart because it is constant 9 cm H2O (IPAP) with EPR of 2 (i.e. EPAP = 7).  I have also removed snore because there is nothing shown.  Both graphs are spectacularly boring and unhelpful, especially compared to SpO2 and pulse rate!

[Phil7]

The best solution for mouth leaks is a boil and bite mouth guard.   They're uncomfortable, an absolute pain in the butt, and can easily lead to horrid stiff jaw issues in the morning.  Cervical collars are also a complete pain in the butt, uncomfortable and can lead to trouble sleeping.

The only good solution is mouth taping.   And, I mean mouth taping where your lips are firmly pressed together.   Due to medical establishment insurance practices, any sleep lab or clinic will always say that mouth taping is absolutely evil and should never been done.  I actually had a sleep clinic tech tell me that I should absolutely never mouth tape because of the bad risk that you could asphyxiate at night if you vomit in your sleep (I kid you not).  I could actually visualize the moronic corporate training, for insurance coverage purposes, behind that.   Personally, I'm over 50 and once probably came close to dying, or a hospital stay, in college when I chugged 20 shots of tequila in 5 seconds.   Yet, I've never once thrown up in my sleep.  I've actually never heard of anyone vomiting while asleep.


This is the best mouth taping option I've found, after trying many options.   Cut a piece off, press down on above your upper lip and stretch the tape down tight while holding your lips firmly pressed together.   You should not be able to draw air.  If you go any looser, you can actually breath throw the fabric mesh.    Some would say there's a risk of re-breathing if a power outage occurs.   The theory being you can slip further into sleep from a carbon dioxide build up.   But, all masts have vent holes as well.  I'm not worried myself.  Not enough to buy a new battery backup anyway.

BSN Medical Cover Role
https://www.amazon.com/Cover-Roll-Stretc...B07KPPRYSW

Just try proper (can't drawn any air at all) mouth taping one night, or part of a night, to see what the leak rate difference looks like for yourself.  It's worth an experiment.   And, if you're paranoid about a full proper mouth taping job, just cut a little slit in the tape at first (mouth taping paranoia training wheels).   Hell, if you're supper paranoid, you could go as far as to wear something like an $100 Wellue O2Ring, which can be set with a "wake up" ring vibration alarm, to wake you up if your O2 level drops below a specific level (decent preset value that you can change).

Edit - I forgot to say if you mouth tape with BSN Medical Cover role, before pressing down the corners, crimp (or twist) them for grab points to pull the tape off easily. Otherwise the corners are hard to get up. At least crimp one corner. I crimp all 4, for 4 grab point options when I'm half asleep and waking up.