[Treatment] But I'm a MOUTH BREATHER!

[Sam Wallis]

I am using a Dreamwear with gel cushions and like it alot.  The P10 was very comfortable, but I toss and turn so much I was getting wrapped up in the hose and jerking my CPAP off the nightstand, so the Dreamwear with the hose on top is much better for me.  I am a mouth breather by day but at night the pressure from CPAP seems to keep my nasal airways open enough to let me survive.  That said, if you absolutely can't get air through your nose, try one one the hybrid full face masks such as the Amara View or the new Dreamwear full face mask.

[paperboy]

After several years of getting bad advice from my doctor, DME supplier and sleep techs I finally decided to do my own research.  This is what I have discovered. About 50% of patients can’t use a nose or nose/mouth mask.  The problem is often that the air gets pushed in from the mask thru the nose, but then comes out the mouth (open mouth sleeper), often with a lot of mask leaks.  This is because the soft palate in some people is floppy at the back of their throats.  As long as they remain upright, the baggy palate remains down towards the tongue and passage to the nasal cavity remains open.  But upon reclining, the palate falls towards the back of the throat and acts like a flap valve. Air comes in from the nose, but then the palate blocks air flow out thru the nose and forces the mouth open when sleeping. This was my problem.

If you have this condition you need to use a mouth mask called the Oracle 452 Oral CPAP Mask.  It looks and works like a SCUBA mouth piece.  There are two silicone ovals, one covers the outer lips and one covers the inner lips.  It is kind of hard to describe.  Just look for a YouTube video.  These two supports keep the mouth and lips gently closed and sealed around the mouth to prevent leaks. The mask has a very simple and comfortable strap that fits around the back of the neck.  I have not needed to keep it tight, just not excessively loose.

You must use a humidified system because your mouth will dry out without it.  I usually run the humidifier on the high side.  Even so, sometimes my mouth dries out.  So I keep a squeeze bottle of water at the bedside.  If my mouth dries out a night, I can easily dislodge the mask from my mouth without removing it entirely, take a swig of water to moisten my mouth, put the mask back in and I am back to sleep in less than a minute.

A couple of other tricks.  Use the nose plugs (it comes with sm, med, lg sizes).  Air can sometimes slip past the floppy palate and come out the nose.  When this occurs, the nose plugs can get blown out when you are sleeping.  If you awaken, it is hard to find the plugs in your sheets somewhere.  So I tie a 12 inch piece of string to the bridge of the nose plugs and the other end of the string to the connection between the neck strap and the mask.  If I blow the plugs out I can easily find the string near my cheek, retrieve the plugs and put them back in without having to turn on the light or even removing my mouth piece.

The Oracle has a pressure relief valve near the connection to the air hose.  During humidification, water will condensate on this valve and drip on me, which wakes me up.  So I wrap masking tape around it to seal it up to keep it from leaking.  There is a second, filtered area nearer to the mask that allows you to exhale. So blocking this valve does not present a problem.

With a humidified system, I found that condensation will collect in the air hose if it droops between you and the machine.  When water accumulates in that low area, it often gurgles loudly and wakes me up.  So I tent the air hose over the head of my bed so the condensate either drips back to the machine or drips towards me.  This eliminates the loud gurgling. This can occur with any humidified system and any mask.

Finally, I started wearing a soft cervical collar. They can be purchased on-line for about $15 without a prescription. This does two things. First it keeps my mouth gently closed. I tried using a chin strap but found it uncomfortable and it also forced my jaw shut which causes me to grind my teeth and bite down hard on the mouth piece which is not necessary to keep the mask in.  So I started using a soft cervical collar.  Secondly, it keeps my head in the sniffing position which is the optimum position to maintain an open airway.  Many people tuck their chins after they fall asleep.  This tends to occlude the airway and makes the CPAP less effective.  Try this as a test.  Close your mouth and tip your head up slightly like you are ‘sniffing’ home baked cookies.  Then take a large breath through your nose.  Next tip your chin down close to your chest (like in a fetal position that many sleepers assume after losing consciousness).  Take another deep breath thru your nose.  You will probably notice that it is harder to suck the air in because your airway has been partially occluded. Chin straps may keep your mouth closed, but they don’t stop your chin from tucking into a fetal position which partially obstructs the airway. Chin straps also tend to pull your jaw (and tongue) back towards your skull which further obstructs the airway. This is another reason people fail their CPAP treatments.

Many doctors, DME suppliers and sleep techs have never heard of the Oracle mask so you are going to have to educate them.  They are not expensive; about $70.  So if you are a mouth breather unsuccessfully using CPAP, try the Oracle and soft cervical collar.  What do you have to lose?

Disclaimer:  I do not work for Fisher & Paykel and have received no money or consideration for writing this.  I am an operating room RN, so I know a little bit about proper airway maintenance when patients are asleep or recovering from anesthesia.

[Ron AKA]

That oral mask is an interesting concept. Thanks for posting about it. I however would like to suggest another consideration in mask selection. I have not tested a lot of masks compared to some others. My list includes the AirFit P10 pillows mask, the Mirage FX nasal mask, the Mirage Quattro full face mask, and most recently the AirFit F20 full face mask. I found the Mirage FX uncomfortable and gave up after a couple of hours. The Mirage Quattro was the same. And I simply could not get it to stop leaking. The F20 lasted longer, and I nearly made it through 4 full nights. I say nearly because I took it off last night about 7 hours into the sleep. It is going back in the box. I could get it to stop leaking even when sleeping in the side position. The problem was that it was not comfortable. Sounds crazy, but I would wake up with an itchy nose, and you can't scratch it. You have to take the mask off. That wakes you up and you end up staring at the ceiling for 30 minutes or so trying to get back to sleep.

So the consideration I would suggest making is sleep quality. Can you get a good continuous sleep with the mask on, or are you up all through the night adjusting and fiddling with the mask? Are leaks waking you up? I sure find they do when they blow in my eyes, or when the mask is making noises like a cow farting. So, I am now back to my original AirFit P10. Yes it leaks. But the leaks are not annoying and don't often wake me up. Yes, I sometime let air out of my mouth, and SleepyHead doesn't like it. But, again I do not often wake up with it, and only know about it when SleepyHead tells me. And I can scratch my nose, and rub my eyes with it on. 

Those are my thoughts on this seemingly endless search for the perfect mask. I just want one that lets me sleep!

[Sam Wallis]

Regarding the Oracle mask - tried it, didn't like it. First reason: It keeps your mouth slightly ajar, and that made me nuts, because I couldn't seem to swallow without taking it out of of my mouth. Reason number two, very annoying: It puffed my cheeks out so I looked and felt like a blowfish. Reason number three: I was constantly aware that air was being forced into me under pressure. For some reason, those three things together kept me from being able to sleep with the Oracle.

What I did like though, it stayed in place quite nicely without even using the head strap. At the time I was using it, my nose was so congested I didn't even need the nose plugs. The congested nose was the pitts, the not needing nose plugs was nice.

Having been a scuba diver, I really didn't mind the mouth piece in my mouth.

If you cannot use another mask, you may give the Oracle a try. Just because I could not get to sleep while wearing it does not mean that it may not be a great mask for you.

[djensen9367]

I am also a mouth breather, I tried several pillow and nasal masks but my left nostril plugs up about 70% of the time and it just isn't worth the hassel. I tried the Amara View and it work pretty good but felt a little obstructive. The they came out with the F20, it worked great, plenty of air,cool and great numbers. I prefer the airtouch (foam liner). Only thing I don't like is when I get an itch, doable but a little hassle. Now I am trying the Dreamwear full face, it works well numbers wise but can also feel like I am not getting enough air flow like the Amara View. I will keep working with it as I like being able scratch an itch.

The others are right about pressure. I was prescribed 8 fixed but they set auto to 4-15.
4 is definitly to low, starved for air. Went fixed at 8 and all was well. Have since changer to auto at 8-15, not a problem since.

Anyway, everyone likes to preach nasal stuff, some of us just can't do it and rather than do nasal when i can breath thru my nose and switch to full face when I can't I just stick to full face and have been ore than happy and 97% of the time MyAir Web reads 100%. Can't get much better than that. I also use sleepy head and everything looks great there also.

Hope this helps

[gregger]

I'm a "part time" mouth breather. I prefer to breathe through my nose but a lot of time my nasal passages are too constricted to let it happen. As a result of my CPAP therapy I'm now exploring whether that's due to an allergic response (although I rarely have itchy/runny nose or eyes) or...what. (I do have a deviated septum but so does a huge percentage of the population). 

At night I always slept with mouth hanging open and snoring loudly. Enter CPAP, very recently. I tried the Dreamwear Nasal Cushion and loved the way it fit, and still love it. I was very surprised to find that I could keep from breathing in or out of my mouth intuitively with my tongue...that is, without really giving it a thought.

More recently, problems set in when my nasal congestion increased, so I added a Dreamwear Full Face Mask. In their nasal cushion I use a medium, so first tried a medium in the FFM. It felt too small around my mouth and too leaky at the corners. Fortunately my DME felt I'd need a large and included one with the medium, and yes, it does fit more comfortably. But as others have noted, getting this thing to stop leaking--in either size--is a challenge.

What I find odd is that my AHI numbers are either bad or worse with an FFM! I may be one of those "soft palate" people discussed above, for whom CPAP delivery via mouth just doesn't work with a normal FFM. I also wake with a totally dry mouth several times a night regardless of the humidity setting. With so much air blowing into my mouth that my cheeks puff out, why SHOULDN'T I have a totally dried out mouth? Not good for gums and teeth, btw...

Right now I'm clinging to Flonase and whatever else can help me use my beloved Dreamwear nasal cushion. Agree with the others: Get that min. pressure up to 6 or 8 or you feel like you're suffocating, and turn ramp to OFF. (I do use AutoRamp with the FFM, though.)