ROUND TWO!! APPRECIATE INPUT!!

[PaytonA]

I do not know what your dental device looks like but the only way to seal your mouth effectively is with your tongue against the back portion of the roof of your mouth. If you can not make this seal because of your dental appliance or you can not maintain it while asleep, I would say that you are not a candidate for nasal pillows or a nasal mask unless you can find another way to make this seal . That leaves you with several choices. The first would be the hated FFM. Actually I like my FFM a lot. The one that I have is technology that is 10+ years I am told but guess what, it works much better than the "higher" tech FFM that I tried first. You will suffer from some dry mouth with a FFM although you will leak less air through your mouth because the pressure outside your lips will be closer to the pressure in your mouth

Another choice would be to go with one treatment only. I would vote for PAP. I think that despite your problems the first time around, if you committed to it, you could make it work .......with patience!

Let's talk about stubbornness. It is great to be stubborn about reaching your goal. It can be self defeating to be stubborn about the path to get there. Some flexibility in methods is essential to success sometimes.

Good luck on your journey and happy papping.

Best Regards,

PaytonA

[robysue]

Last night:

AHI 7.8
Of this, (with apparent rounding errors):

.3 Obstructive --
.9 Central --
6.4 "Unknown"

Unknown apneas are scored when the machine can't tell what they are because the data from the FOT algorithm for detecting CAs is ambiguous.

Usual reason the FOT fails is largish leaks and official Large Leaks.

Is this because my lips keep blowing open? False readings?
Using nasal pillows.

If the lips are blowing open, then air is getting into your oral cavity and escaping out through the open lips. With the high "Unknown Apena Index" that points to serious leaking going on through those open lips. The Unknown events are likely REAL events that are happening when your leak rate is too high for the FOT algorithm to work. And your leak rate is too high because of the air blowing out the open lips.

You also write that your settings are:

Min EPAP=4
MAX IPAP=10
PS=3

So your EPAP ranges from 4 to 7 and your IPAP ranges from 7 to 10. Does the problem with the lips blowing open happen mainly when your pressures are 10/7 rather than when they're closer to 7/4? Also how much time are you spending at 10/7 and what do the leaks look like at 10/7?

A narrower pressure range might help, but that probably means increasing the min EPAP so that you start the night out closer to your max pressures.

A chin strap has been suggested, but my dental device already keeps my mouth shut.

The dental device may be keeping the jaw shut, but it ain't keeping your tongue up on the top of the roof of your mouth and your lips closed.

Here's the thing you need to be aware of: Tongue placement is critical when it comes to keeping the CPAP air out of the mouth in the first place. When at least the front 1/3 to 1/2 or so of the tongue is firmly pushed up against the roof of the mouth just behind the top incisors, it effectively seals off the oral cavity from the upper airway.

You can test this yourself: Put the tongue where I describe, open your mouth (while keeping that tongue firmly up on the roof of the mouth) and continue to breathe through your nose. If you start breathing through your mouth as soon as you as open your mouth, the tongue is NOT yet in the right spot. Once you are breathing through your NOSE with your mouth open, pinch your nostrils shut and you should find that it's hard to impossible to breath until you MOVE the tongue.

Once you know where that tongue needs to be to block the oral cavity, you need to train yourself to keep it there during the daytime when you are breathing through your nose. This sounds more complicated than it is: The natural tongue position for most nasal breathers is what I'm describing. And so all I'm telling you to do is to try to figure out whether your tongue does what it's supposed to naturally or whether you're doing so much (daytime) mouth breathing that the tongue has decided its natural spot is not up on the roof of the mouth.

Until you can train that tongue to stay where it belongs, it's worth trying the chinstrap. But to be honest, the chinstrap may or may not help in keeping the lips closed and that's the problem. Taping (if you're brave enough) may help.

A big problem with round one of CPAP was trying to use full face masks. I don't have too big an issue with the fit or comfort of the nasal pillows.

If you want to use nasal pillows, then you have to address the leaks coming from your lips since they are large enough to prevent the machine from accurately scoring the data. My guess is that you also had a large number of Unknown Apneas because the machine was having trouble keeping your airway properly pressurized due to the large leaks.

Should I duct tape my lips? Doesn't seem good, somehow.

Duct tape, no.

But there are folks who use a bit of SKINNY blue painters tape (or other kinds of tape that are EASY to rip off the skin). Usually idea is to put one or two VERTICAL strips across the lips. One piece right in the middle (where the sides of the lips are NOT covered) OR one piece on each side (where the middle of the lips are NOT covered).

[Don in Austin]

Unknown apneas are scored when the machine can't tell what they are because the data from the FOT algorithm for detecting CAs is ambiguous.

Usual reason the FOT fails is largish leaks and official Large Leaks.

If the lips are blowing open, then air is getting into your oral cavity and escaping out through the open lips. With the high "Unknown Apena Index" that points to serious leaking going on through those open lips. The Unknown events are likely REAL events that are happening when your leak rate is too high for the FOT algorithm to work. And your leak rate is too high because of the air blowing out the open lips.

The readings on the pulse oximeter looked really good, so that is encouraging.

I think I will either try light tape or without the dental device tonight.

Don in Austin

[PaytonA]

A chin strap has been suggested, but my dental device already keeps my mouth shut.

The dental device may be keeping the jaw shut, but it ain't keeping your tongue up on the top of the roof of your mouth and your lips closed.

And neither will the chin strap!

Here's the thing you need to be aware of: Tongue placement is critical when it comes to keeping the CPAP air out of the mouth in the first place. When at least the front 1/3 to 1/2 or so of the tongue is firmly pushed up against the roof of the mouth just behind the top incisors, it effectively seals off the oral cavity from the upper airway.

You can test this yourself: Put the tongue where I describe, open your mouth (while keeping that tongue firmly up on the roof of the mouth) and continue to breathe through your nose. If you start breathing through your mouth as soon as you as open your mouth, the tongue is NOT yet in the right spot. Once you are breathing through your NOSE with your mouth open, pinch your nostrils shut and you should find that it's hard to impossible to breath until you MOVE the tongue.

Once you know where that tongue needs to be to block the oral cavity, you need to train yourself to keep it there during the daytime when you are breathing through your nose. This sounds more complicated than it is: The natural tongue position for most nasal breathers is what I'm describing. And so all I'm telling you to do is to try to figure out whether your tongue does what it's supposed to naturally or whether you're doing so much (daytime) mouth breathing that the tongue has decided its natural spot is not up on the roof of the mouth.

I can not speak for all nose breathers but this nose breather DOES NOT walk around all day with his tongue plastered against the back portion of the roof of his mouth. It is definitely NOT the natural position for my tongue. Without CPAP it is not necessary to create a tongue seal in order to nose breathe as long as one's mouth is closed. If one's mouth is wide open then it may be necessary to seal with the tongue in order to nose breathe.

On the other hand, if one is trying to train oneself to keep the tongue seal at night, I agree that it would seem a good idea to try practicing it all day long while one is awake in order to develop a habit that can(?) carry over into sleep.

As I have been writing this, I have been experimenting with tongue position and breathing in order to make sure that I do not really make a tongue seal all day long in order to nose breathe. I found that I can stick my tongue out of my mouth and down as far as I am able with my mouth wide open and I am still able to nose breathe. How the heck does that work?

My workstation faces a window. I sure hope no one has been watching my facial gyrations while I was experimenting. That might just confirm their suspicions that I am Looney Tunes.

Best Regards,

PaytonA

[diamaunt]

I found that I can stick my tongue out of my mouth and down as far as I am able with my mouth wide open and I am still able to nose breathe. How the heck does that work?

because the switch is in your throat, not your tongue.

[PaytonA]

That would stand to reason but what is the "switch"?

[diamaunt]

That would stand to reason but what is the "switch"?

well, either of us can google up throat anatomy information, but since you're the one wondering you do it and tell me

[vsheline]

Unknown apneas are scored when the machine can't tell what they are because the data from the FOT algorithm for detecting CAs is ambiguous.

Usual reason the FOT fails is largish leaks and official Large Leaks.

When unintentional Leak is 30 Liter/minute or higher I think all apneas may be scored as Unknown type.

From ResScan Interpretation Guide:
Unknown AI: Index of undetermined apneas with large unintentional leaks > 0.5 L/s (30 L/min).

From ResMed white paper on the Enhanced AutoSet Algorithm:
The classifier [algorithm] labels apneas ‘unknown’ when the inadvertent leak exceeds 30 L/min or the resistance is indeterminate*.
* For example, in the scenario that the device cannot achieve the correct oscillation amplitude.
http://www.resmed.com/fr/assets/document...-paper.pdf