Suggestions to avoid frowny face with Elite S9 and recommended maximum apneas

[CarlosSky]

I am using the Elite S9 with a humufidier and heated hose since February 2014 with mixed results. I have tried several nose masks - Eson, Breeze, Airfit, Activa LT and Mirage Soft Gel.

The Breeze gave a consistent good sleep but a congested and drppy nose. The Eson and Aitfit gave me bad results.
The Activa LT was recommended by my sleep lab in September 2013. The said it worked well for me (they used their ow CPAP).
The Mirage Soft Gel was recommended by my sleep CPAP provider.
I have been alternating the use of the Activa LT and Mirage Soft Gel with different strap adjustments. Most night they give me a good sleep a bad one usually when I get a frowny face.

When I awake after a short sleep I stay in bed with my mask on for an hour or more. I understand that the sleep result numbers can be distorted when using the mask when awake. How can I try to get back to sleep which sometimes works for me and not distort the sleep results numbers?

The results from March to June 2014 are
Sleep Quality Display
Frowny Face Avg 3 nights/month
AHI Min .7 Max 5.1 Avg 2.3/nigh
Sleep report
Leak Min 22 Max 43 Avg 29.5
AHI Min 1.9 Max 3.4 Avg 2.4
AI Min .7 Max 1.1 Avg .9
Central AI Min .3 Max .6 Avg .4

Any suggestion on how to decrease the number of frowny faces and leak?
What are the recommended maximums for the AHI, AI and Central AI?
If my AHI, AI and Central AI are within normal ranges how can the leak be so high (I read many posts with examples of leaks around 10).
Is the Sleep Report figure and average? For what period?

Thank you for your help,
Carlos

[robysue]

Welcome to the forum CarlosSky,

First let's talk about Mr. Red Frowny and his companion Mr. Green Smiley. Mr. Red Frowny shows up only when the leaks are genuinely out of control and are both large enough and long enough to adversely affect the efficacy of your therapy and the accuracy of your data.

A Large Leak is defined by Resmed to be any (unintentional) leak that is AT or OVER 24 L/min. In other words, you're loosing at least 24 L/min of air above and beyond what the mask is supposed to vent at your particular pressure.

And Mr. Frowny shows up when your leak rate is in Large Leak territory for at least 30% of the night.

For a more detailed examination of what Large Leaks are and how they affect things, see 8. Leaks in my SleepyHead guide.

So far you've tried a variety of nasal masks without much success. This may mean you need to try an alternate style of mask. This may mean you need to try an alternate style of mask. The most common cause of long, Large Leaks is probably mouth breathing. But improperly adjusted headgear can also cause a lot of large leaks.

So: First of all, review the mask fitting guidelines for your mask. If the mask you prefer uses an air cushion to form the seal, it's critically important to make sure the headgear is not too tight. Overtightening the head gear prevents the cushion from fully inflating and that leads to leaks.

Next: Is there a high probability that you are a mouth breather? If you are, then it's really important to start looking at your leak lines in either SleepyHead or ResScan so that you can determine the full scale of the problem. You already know you are seeing Mr. Red Frowny several times a month. But it's important to figure out if Mr. Green Smiley is showing up on a lot of nights where the large leaks are pushing the 30% line, but staying just below it. If multiple, long, large mouth leaks are often seen in your data, you need to figure out a way of dealing with them----regardless of who shows up in the morning on the LCD.

There are two main ways of dealing with mouth leaks:

1) Switch to a full face mask that covers the mouth as well as the nose.

2) Use a chinstrap or taping and try to train yourself to not mouth breathe.

Which approach is "best" really depends on your preferences.

Now to address some of your other questions:

When I awake after a short sleep I stay in bed with my mask on for an hour or more. I understand that the sleep result numbers can be distorted when using the mask when awake. How can I try to get back to sleep which sometimes works for me and not distort the sleep results numbers?

The easiest way I can think of requires using the SleepyHead software to analyze the data.

You can turn the machine OFF and then back ON when you wake up and decide to lie in bed for a while with the hope of getting back to sleep. This starts a new "session" in the machine's data. When you load the data into SleepyHead, you have the ability to turn individual sessions "off" and "on" by clicking on them. When a particular session is turned "off", SleepyHead ignores that data in the computation of all the statistical stuff (AHI, leak, usage, etc) and omits that session's data from all the daily graphs. One nice thing about this system is that it allows you to see how these long periods lying in bed while awake affect or distort your data.

What are the recommended maximums for the AHI, AI and Central AI?

Treatment is considered effective if the total AHI is consistently less than 5.0 night after night after night .... AND the leaks are under control.

Every one will have a bad night now and then: The aliens visit or you're sick with the flu and the AHI spikes (well above) 5 for a day (or two) and then returns to your typical AHI numbers. So it's the consistency that's looked for. If your AHI is almost always under 5.0, then the docs are happy. And they don't really care very much what the distribution of the events is as long as the total AHI is less than 5.0.

If the AHI is often above 5, then the distribution of events becomes very important. If the OA and H's are why the AHI > 5, then chances are more pressure may be needed. If the number of CAs is why the AHI > 5, the sleep doc may need to investigate the possibility of complex sleep apnea. (Complex sleep apnea seems to be a problem in about 10-15% of new PAPers.)

If my AHI, AI and Central AI are within normal ranges how can the leak be so high (I read many posts with examples of leaks around 10).

The thing about long, large leaks is that they can seriously affect the accuracy of the data: When the leaks are over 24 L/min for any length of time, the machine can have problems accurately detecting the breathing, and when the machine can't accurately detect the breathing, it becomes extremely difficult for the machine to score events.

And then there's also this to consider: Apneas don't cause large leaks. You can have a truly horrendous AHI because the pressure is too low and have a perfect leak line.

But large leaks can allow more events to happen because the machine can't maintain the needed pressure AND it may not be able to score those events because it can't follow the breathing. I talk about this in 8. Leaks.

[trish6hundred]

Hi CarlosSky,
WELCOME! to the forum.!
Hang in there for more responses to your post and best of luck to you with your CPAP therapy.

[CarlosSky]

Thank you for prompt response.

I would appreciate an answer to the two questions that were not answered

What are the recommended maximums for the AI and Central AI?
Is the Sleep Report figure and average? For what period?

Carlos

[robysue]

What are the recommended maximums for the AI and Central AI?

If the total AHI < 5.0, it doesn't really matter what the distribution of events is. In other words, all of the following are equally acceptable in terms of efficacy of therapy:

• AHI = 4.0, AI = 4.0, CAI = 4.0 (So HI = 0.0 and OAI = 0.0)
  
• AHI = 4.0, AI = 4.0, CAI = 0.0 (So HI = 4.0 and OAI = 4.0)
  
• AHI = 4.0, AI = 3.0, CAI = 2.0 (So HI = 1.0 and OAI = 1.0)
  
• AHI = 4.0, AI = 1.0, CAI = 0.0 (So HI = 3.0 and OAI = 1.0
  
• AHI = 4.0, AI = 0.0, CAI = 0.0 (So HI = 4.0 and OAI = 0.0)
  

In other words, you need all of AI, OAI, CAI, and HI to be less than five individually, but you also need:

• HI + OAI + CAI < 5

Is the Sleep Report figure and average? For what period?

It depends on what Sleep Report figures you are talking about. Some are averages and some are 95% numbers.

As for the period, that depends on what period you've selected in the menu. The default view shows figures based on one night's data, but you can switch to look at numbers for 1 week, 1 month, 3 months, 6 months, and 1 year time periods as I recall.

You might find Data available on the ResMed S9's LCD useful for understanding how the numbers that show up on the Sleep Report on the S9's LCD are computed and what they mean.

[Sleepster]

The Breeze gave a consistent good sleep but a congested and drppy nose.

Hi Carlos, did you try adjusting the humidifier settings to help with the congestion? Sometimes just going back to a mask after awhile can work.

I suspect your problem is not the mask itself, but instead a problem called mouth-leaking. Have you noticed pressurized air hissing out of your mouth when you wake up in the middle of the night?

I would try a simple fix, which is a chin strap. These are an easy remedy for this very common problem. They come in all shapes and sizes and you should be able to get one from your equipment supplier.

Good luck and keep us posted.

[zonk]

Any suggestion on how to decrease the number of frowny faces and leak?

Simple answer, better mask fit, good mask fit is essential for effective treatment
I've used both SoftGel and Activa LT, both cushions fit on the same frame and different size cushions fit on the same frame too
Activa LT is lighter and works better for me, the key is not to overtighten, loose is better
Chinstrap helps keeps mouth closed and minimize mouth leaks
Leak 24 L/m considered okay, lower is better but not the end of world if goes higher for short time, practice makes perfect

Everyone is different, I need slightly higher temp setting otherwise get congested, for others might be the opposite is true

If using Ramp, normally start at a lower pressure, mask seal might be good at lower pressure but might not be so good once pressure increase to set pressure. Mask-fit feature is good idea, you can test and adjust mask seal, it goes on for 3 minutes

[CarlosSky]

Thank you for your prompt replies.

I have been using a CPAP for 20 years. I have been tested at a sleep lab yearly and never found to breath by my mouth. Nonetheless. Based on my recent problems I decided to try a chin strap in the last two nights and now my sleep is better.

I used the pillow for 17 years and was frequently congested. I did try increasing the temperature even tried with my current Elite S9 machine which has a humidifier, heated hose and allows me to set an specific temperature. After using nasal masks, using the pillows for one night made me extremely congested... so I decided to continue with the nasal mask. With the nasal mask I had many weeks when I slept well. However, occasionally and recently I did not. For me the result of poor sleep is that I feel very out of sorts the next day not just sleepy. I will continue to try to make the nasal mask work well.

I will interpret the sleep report in my computer. After I reach consistent results or if I encounter problems I will post result here.

Carlos

[CarlosSky]

My sleep is now better.

Actions I took are
I increased my Clonazepam PLM medication by .25mg.
I changed my mask to the AirFit.
I increased the temperature in the S9 humidifier to 30C. This decreased my congestion (drippy nose the next morning) but not eliminated it.
I place a small portable heater besides my bed and set it to 27C. This has almost eliminated my nose congestion of the next day. I am still trying different options since I would like to eliminate the need to carry a portable heater when I travel.
I bought a new chin strap (although I was not told I needed one when last tested at a sleep clinic in September 2013) and use it.
The leak of the S9 has decreased to 9 from around 30. I will further experiment with this since I prefer not to use a chin strap if I do not need one.
I see a happy face every day and other indices are within normal limits.

Carlos