My journey to eliminate leak induced arousals

[PeterJohn]

Hi folks,

I would like to share my journey with you as I fine tune my CPAP therapy to treat my UARS.  My latest goal is to minimise, ideally eliminate leak induced arousals to , well, stop waking up !!  If I get too many of those within say 120-90mins before I an due to wake up, I'm fully awake and am in for a yuk day having had "only" 5-6 hours of sleep.

Firstly let me say that I read elsewhere on this forum how EPR would be great to reduce flow limitations, and wow, I can testify that it really helps and I feel more rested because of it.  I can publish evidence of that later.  My narrow nasal passages plus already large turbinates swelling during REM sleep really caused me 20 years of poor sleep until diagnosis plus CPAP plus a Nasalaid dilator came to the rescue.  

On to the current issue.  I was struggling to understand why I kept getting arousals plus Central Apneas (CA) when I had the flow limitations and RERAs sorted using CPAP+EPR, and all obstructive apneas (OA) sorted with CPAP.   It had only been 4-6 months since I resumed CPAP therapy (after a long break while I used an AveoTSD) and I had assumed I was getting treatment emergent CA.  So I tried out ASV for one night and it was terrible and did NOT eliminate any CAs.  
I was wondering, did I have RLS ? What was causing these arousals ?  I decided to try out recording my SpO2+HR (using a Nonin 3150 plus Oscar) to look for anything unusual.   Thankfully I had great Oxygen levels, very stable around 95%.  But I noticed peaks in my HR as it jumped quickly from 58bpm to 75bpm exactly when I aroused.  So I thought, OK perhaps the CA is arousing me with adrenaline which increases my HR.  But what was casing the CAs ?  Then voila !!  I found the culprit !  Mask leak !!!  I found undisputable proof of cause and effect.   I found that most leaks were followed within 2-5 seconds by an increase in HR, then within 10 seconds a CA of 10-15 seconds duration.  And sure enough others have reported that CAs follow arousals.  Not many of you will have the benefit of using a pulse oximeter to diagnose this, but in my case thankfully I can and here a pic is worth 1000 words, so check this out,

   

I have many many like the above to thoroughly convince me of the problem. that was a high leak for me as most of my arousing leaks are only 3-5 L/min per below.  Also not all leak+arousals are followed by a CA, just a noticeable pause per here

   
   So now I am looking fwd to trying out fixes, here is what I tried that so far has helped decrease the leaks. In most of the FFM scenarios below I also use a Nasalaid dilator

1. Using Nasal Mask (NM) and taping mouth shut
   
2. Using NM plus this Seatec chin and mouth strap (no mouth tape needed as it covers mouth)
   
3. Moving from NM to FFM, eliminated mouth leak
   
4. Always sleeping on my tummy with no pillow allows me to use lowest CPAP setting (as my tongue doesn't fall back) to eliminate leaks. I have somehow trained myself not to roll onto my back or sides, no need for a tennis ball.
   
5. Thinking my CAs were due to hypocapnea as the therapy flushed out too much CO2, I tried EERS per here  which is partial vent blocking plus placing a fixed leak about 10cm down from the mask per here.  Made no difference after about a week of trying that I recall.
   
6. Moving from a ResMed Quattro FX FFM to Airfit F20 FFM greatly reduced leaks.
   
7. Washing the silicone cushion in soapy water to get the oils off (each 2nd night).  Wiping oils off with a tissue on nights I don't wash it.
   
8. Washing my face with soap before bed to remove oils
   
9. Tightening the mask straps to achieve the balance between discomfort and minimal leak
   

All that fine tuning still leaves me with too many leaks !!    So next up I am going to try a foam cushion (Airtouch F20 mask) then possibly an F30i mask.  I have to be careful with the mask that there is minimal opportunity of something pressing on my nares as my nasal valves are soooo easy to collapse and that inceases FL and guarantees very fragmented sleep.  The F20 has LOTS of room for my nose/nares including the Nasalaid !  

I am reminded that the first CPAP mask by Prof. Sullivan and Dr Farrell were glued to the patient's faces !!  A few hundred people endured that, would I be game enough to try that out ?!?!

Any ideas are very welcome.  I hope what I have documented so far will help others in their journey.

[estgad]

I have a question about the graphs you provided. On the first one at 6:23:20 your flow rate flat lined, then the big spike up and to me that looks like it caused the leak. Did your machine increase the pressure for that spike up?
Were you moving, or tucking your chin?

The second thing I noticed about your flow rate leading up to that 6:23 flat line was how they have a noticeable pause after an exhale. Were these mini CA's that progressively got longer with each breath. This looks like it lead to the first increase in your HR.

This looks like a timing issue on the breathing. Can you look into the cycle, trigger, timin & timax settings? (I have a bipap so those are the settings on my machine that effect timing of the inhale & exhale)

The second graph too, several significant pauses in the inhale then that big spike up in the flow rate and then the leak.

[Jay51]

Here are some tips from our Wiki:     Mask Primer

• Mask leak solutions
  

[Benjamin]

I just joined ApneaBoard and after browsing some of the pages I am very glad I did - this is a great resource! So then I decided to check out Today's Messages and found yours right away because I had a major problem with a leaking mask. Finally, when I went for a sleep test, the tech put on the AirFit 20 FFM non-magnetic (since I have an ICD) and wow it worked great. I gather you tried that one too with some success but I'll tell you what I did. Firstly, it uses foam around the edge which seems to let it mold better to my face. Secondly, I started to use a chin strap to keep my mouth closed. Thirdly, I found that if I tighten both the headgear and the chinstrap as much as possible it gets the the foam snug and succeeds in keeping my mouth closed - a big problem for me since I kept waking up with a dry mouth. The tight chinstrap solved that problem. The advice you get from the supplier is "don't tighten it too much" but I am just ignoring that since (a) the pressure doesn't bother me and (b) the tight fit works best. Hopefully the tightening won't be a problem for you.
This is the only info I can give you, I can't address the many other issues you raised.  Best of luck!
(BTW - As a new member I'm not too sure about the rules on posting the identification of supplies ,but I thought I could include the mask reference since you had it in yours.)

[PeterJohn]

Thankyou J51.
estgad, let me check my other graphs and data before I comment on your observations.
Benjamin, thanks for the mask suggestion. I can't see where the Airfit F20 has foam on the cushion, it looks all silicone to me. I wonder if you mean the Airtouch F20 which certainly has a full foam cushion. The masks that we shouldn't tighten to much are the ones with silicone cushions as that defeats the self sealing method using the CPAP pressure. The Airtouch F20 with memory foam probably can be tightened without negative consequences besides discomfort. I think I will try that mask.
It seems your use of a chinstrap isn't to minimise leak but to minimise mouth dryness, which is still good in itself.

[PeterJohn]

I have a question about the graphs you provided.  On the first one at 6:23:20 your flow rate flat lined, then the big spike up and to me that looks like it caused the leak.  Did your machine increase the pressure for that spike up?  
Were you moving, or tucking your chin?  

The second thing I noticed about your flow rate leading up to that 6:23 flat line was how they have a noticeable pause after an exhale.   Were these mini CA's that progressively got longer with each breath.  This looks like it lead to the first increase in your HR.

This looks like a timing issue on the breathing.  Can you look into the cycle, trigger, timin & timax settings?  (I have a bipap so those are the settings on my machine that effect timing of the inhale & exhale)

The second graph too, several significant pauses in the inhale then that big spike up in the flow rate and then the leak.

your keen eye might have picked up on the root cause being something other than a mask leak. The leaks might be phantom and incorrectly deduced from a large inspiratory flow.
 It might not be a timing issue on the breathing because I am basically using fixed CPAP with a very tiny (~0.4cmH2O) range on the Autoset just to give me sense of when it wants to increase the pressure.  I'm not letting it g beyond that tiny range as that tends to arouse me too if it is too much too suddenly.  I checked and pressure is not increasing at the onset of leak.  I use EPR=3 and there are no other options I know of.  CPAP is different to BiLevel and doesn't have the cycle, trigger, timin & timax  settings.     It is possible the sequence of events is actually:

1. I have a sudden large peak flow which either causes a legit. leak, or is incorrectly misinterpreted as leak by the flow generator
   
2. if a phantom leak then whatever caused the flow change is also causing  HR increase plus arousal plus CA.
   
3. if a legit leak then the leak could still be arousing me.
   

attached are some more plots of this phenomenon to see what can be elucidated
   

[G. Szabo]

What if the culprit is not leak, but the position changes? 
You change position , which requires some physical effort. Then, simultaneously, three things happen: your breathing pattern changes, your leaks increase, and your HR changes. 
Look at #4. The HR started changing before the leak.

[estgad]

Can you do another screen shot showing the following graphs:
flow rate
pressure
flow limit
resp rate
insp time
exp time
leak rate

This would help to show the breathing patterns happening before, during and after these events you are having.

This morning as I looked at the last screen shot it made me think about my own breathing pattern.  Even during the day I will be going along taking normal breaths, and then I have to take a deep breath.  And most of the time it is a deep mouth breath.  When I first lay down to go to sleep this happens a lot, and several of those deep breaths are big yawns.  I have noticed on my data that when I take these deep breaths that it can produce a leak.

[Benjamin]

How embarrassing, yes you are correct, I am using the AirTouch 20 cushion.

[estgad]

You have nothing to be embarrassed about, that is the purpose of this board for the shared community experiences and knowledge.