Newbie Needing Help w/ Sleepyhead ?

[FoggyBrain24]

Hello All,
First off, thank you to everyone who posts / moderates / comments, I have been a lurker for a few weeks who has felt much better mentally from reading feedback from others, but have not seen much in the way of energy increases and I've been using CPAP for almost 6 months. I am hoping someone can review my SleepyHead data and let me know what jumps out at them.

Background: 33 year old male, 6', 180 lbs. I work out 4-6 times / week, and eat very healthy.

I've always thought I was someone who didn't need a lot of sleep, but over the last few years, it has caught up with me in a significant way. I've spent a disproportionate portion of the last few years caught somewhere between slightly tired to extremely fatigued. I tend to identify with fatigued more than sleepy, as if given the opportunity to fall asleep for 20-40 minutes, I do not readily fall asleep. The best comparison is that I start a majority of my days feeling like a cell phone battery that wasn't charged during the night before. I wake up @ 37% and have to figure out how to make it through my day without hitting 0. I've never actually passed out in public, but I have gotten minor anxiety attacks due to overwhelming feelings of needing to lie down. This fatigue has led to significant personal issues, and minor professional ones as well. I always noticed these were exacerbated by consuming alcohol.

November 2016 - 1st Sleep Study (No Titration)
Apnea index was 0.
AHI was 9.1 with a low desaturation of 86%.
REM AHI was 30.7 (27% of Sleep)

February 2017 - 2nd Sleep Study w/ Titration (8.0 cm)
AHI -
REM - 13.8% of sleep

I received my CPAP back in February and it was set for 4.0cm Ramp with 8.0cm night setting. It took me some time to get used to the device, but I did notice small improvements. I was using the device 5-6 times / week (was uncomfortable using it if I had a friend stay over). I have noticed considerable improvement when I focus on 7+ hours and I string together 5+ days in a row with no alcohol. When I consume alcohol, even smaller amounts (2-4 drinks), I notice that I wake up very tired. It doesn’t feel like a hangover, just more of the same fatigued feeling.

I was recently sent to a Sleep Specialist, who wasn’t the most helpful, but he ended up adjusting my prescription to AutoPap (which I ended up having to change on my own). Similar to my first few weeks with the CPAP device, I started feeling better when I would string several nights together with no alcohol and at least 7 hours of sleep, but if I only got 5 hours of sleep or slept outside my home base, I would feel exhausted. I’ve tried to tackle these items on my own but I felt the need to finally write in to this board to hold myself accountable. After some personal life stress, I've committed to focusing on getting better. I've now went 8 days with no alcohol and at least 8 hours in bed each night. I seem to be waking up more than I ever remember, some times due to leaks, other times with no explanation.

1. Per Sleepyhead, the leaks I've been dealing with are bad. I've woken up a few times having to adjust the mask due to air pressure in my eyes. It doesn't seem to leak when I fall asleep and the mask is comfortable, but it clearly moves a bit (I am a side sleeper). WISP Nasal Mask, size Large (I tried XL, moved a ton). This is what was prescribed / provided by DOM. How would you go about mitigating these risks?

I don't think I am mouth breathing, I often wake up with a very dry mouth from what I assume is leaving it closed all night.

http://imgur.com/a/uTG9u

Does anything else jump out at you?

Thanks in advance.

[Pugsy]

Go to SleepyHead/Preferences/CPAP tab and change the default red line number of 24 L/min for % of time over red line calculations to something more in line with your machine.
The 24 L/min red line is a ResMed line in the sand number and won't work on Resprionics machines.
Respironics never gives us a line in the sand because it varies from mask to mask and pressures used.

If you just have to have that statistic...change it to maybe 70 L/min
Or simply turn that statistic off.

You need to evaluate the leaks mainly by the Events graph....yeah you had some large leaks last night but no where near 52% of the night being in large leak. SleepyHead is making out like things are a LOT worse than they really are because it is using the wrong red line base number.

Now as to the leaks waking you up and all that.
Or what to do about them.
Maybe you need a new cushion...maybe consider trying something besides the Wisp.

[FoggyBrain24]

Thanks. I changed the preference to 70 L/min.

http://imgur.com/a/uTG9u

What do you think now?

If you wake up with dry mouth, do you think that means I am breathing through my mouth?

I do like the fit of the WISP as a side sleeper, but open to changes.

[Pugsy]

70 L/min is too high of a number ....the statistic is showing 0.00% over red line and there is obviously some large leak going on.
This is where using that statistic is problematic because of the variable red line threshold.
But if we set it lower the statistic will be falsely elevated because of time where the pressure is higher and the threshold is higher.
Until your pressures stabilize more the % of time over red line statistic isn't going to be accurate.

See the total pressure line (total pressure is the mask's vent/intentional leak) which is the top pressure line....for when the pressure is up around 15 cm....no large leak flag until around 1:00 AM...then you have a lower top pressure line where there is a large leak flag
where the total pressure is maybe 10 cm. The red line moves around and makes it really difficult to get an accurate statistic.

In you case with the wide range of pressures I would just use the Events graph and eyeball the large leak time....the machine trumps the statistic.

Dry mouth usually means mouth breathing but it can mean something else and it doesn't always mean that a lot of time was spent mouth breathing. I can get a massive dry mouth from as little as 5 minutes of mouth breathing (I can sometimes spot it on the leak graph but not always). Medications can also cause dry mouth.

In general my thoughts about any leak...no matter what the cause...if it wakes me up often I want to fix it because anything that disturbs my sleep is unwanted.
Now if I sleep right through the large leak I really don't care if the leak graph shows some large leak. The amount of large leak you are showing on the graphs themselves....if I slept through those I probably would just shrug my shoulders.
Respironics machines are still fairly accurate in large leak up to around 110 total leak...

Your report overall is just plain ugly despite the low AHI. Lots of big pressure changes...which makes me think that you may be changing sleeping position often.
The 2 most common causes of pressure changes where it's obvious a pressure works sometimes quite well and other times it doesn't are REM stage sleep and sleeping on one's back instead of side or stomach.

How much of last night did you actually sleep? I see the one change in pressure and break in therapy around 1:00 AM...did you actually sleep prior to that time frame?
How much of this report usage is actually when you were asleep?
Any idea?

The VS2 snores...ugly but I don't know how to fix them...in the past they don't respond like we normally expect snores to respond...more pressure usually easily fixes snores.
See this thread for information about VS2 snores
viewtopic.php?f=1&t=155478&p=1182872#p1182872

I think more minimum pressure is needed but I have no idea how much due to the wide range of pressures.
In that case I would start small and work up...maybe go from 8 min to 9 min and see what happens.

How are you routing the hose? Is it hanging over the bed so that it rubs on something like wood or metal or is it laying across the mattress?

If you like the Wisp but it wakes you up often having to fiddle with it...then try something else.
If it used to work and the waking up fiddling with it is something new...try a new cushion.
If you like that type of mask...look at the Swift FX Nano. It's very similar to the Wisp in terms of cushion.
Any mask can be worn in any sleeping position...some just present more challenges.
I sleep primarily on my side...check out the mask I use in my profile.

[FoggyBrain24]

Thanks, understood on the threshold / statistics. I'm not sure why the pressure seems to vary so much.

As for dry mouth, I do not wake up with it each morning, only occasionally.

I agree on the leaks. The biggest issue as of late seems to be it shifting above my nose, which then leaks into my eyes. At times, I may not notice, as I also use a fabric sleep mask to provide blackness.

I do think I am changing positions a lot, but I can't really tell. I always fall asleep on my side, but I definitely shift side to side and occasionally move to my back.


How much of last night did you actually sleep? I see the one change in pressure and break in therapy around 1:00 AM...did you actually sleep prior to that time frame?
I slept from around 10-4 AM pretty soundly. Don't recall waking up @ 1 AM. Once I woke up @ 4, I couldn't really get back to sleep and then was up @ 5:55 AM.

How much of this report usage is actually when you were asleep?
Any idea?
Outside of the first 20 minutes when I was reading, I slept until around 4 AM.

The VS2 snores...ugly but I don't know how to fix them...in the past they don't respond like we normally expect snores to respond...more pressure usually easily fixes snores.
See this thread for information about VS2 snores
viewtopic.php?f=1&t=155478&p=1182872#p1182872

I think more minimum pressure is needed but I have no idea how much due to the wide range of pressures.
In that case I would start small and work up...maybe go from 8 min to 9 min and see what happens.
OK, will go up to 9 min.

How are you routing the hose? Is it hanging over the bed so that it rubs on something like wood or metal or is it laying across the mattress?
No, the machine is on a shelf right next to my bed. I usually fall asleep facing it, with the hose running off the machine and next to me on the bed. When I turn, it would lay across the mattress / across me. Should I change that?

If you like the Wisp but it wakes you up often having to fiddle with it...then try something else.
If it used to work and the waking up fiddling with it is something new...try a new cushion.
Thanks. I do like the wisp, but have had mixed results as of late. I did just replace the cushion and played around with different sizes.

If you like that type of mask...look at the Swift FX Nano. It's very similar to the Wisp in terms of cushion.
Thanks, will check out what my DOM offers. Do you usually recommend just ordering new ones and seeing what works?
Any mask can be worn in any sleeping position...some just present more challenges.
I sleep primarily on my side...check out the mask I use in my profile.
Thanks, will check this out as well. I know people have different experiences on the fatigue end, but I definitely slept a lot better last night than I did the night before. I still don't feel 100%, but it was a better than average night.

[Pugsy]

Hose routing may not help the VS2 snores. If you were routing it over something hard like a headboard or metal frame where movement could create potential vibration noise that the machine might misinterpret as a snore...maybe but since you are just laying it on the bed I don't think routing will make that big of a difference BUT stranger things have happened with hose management so I am thinking it is at least worth trying and you can try without spending a bunch of money on a store bought hose management system.
See this thread for various ideas on DIY hose management projects.
viewtopic.php?t=10640
If the hose moving is pulling on the mask a bit...might also help with the leaking issues.

I am a big fan of at least trying a different mask when possible. I have tried many, many, many masks over the years and not because I was unhappy with whatever mask I was using at the time. I try different stuff to learn about my own preferences and needs. Now sometimes the only think I learn is "what a stupid idea that was" but I always learn something.

Masks come with that really big YMMV sticker. I tried the Wisp...lasted all of 90 minutes with it. That means nothing though...it's what you prefer that is important but if you haven't ever tried something else then you don't know how well you might do with a different mask.
Unfortunately mask experiments are extremely expensive unless your DME has a liberal mask swapping policy.
So we get limited by money or DME or insurance replacement allowances.

If your pocketbook permits out of pocket purchases using the return insurance available at cpap.com is a good way to experiment without breaking the bank. Some masks have free return insurance and some have it available at a small cost. Still better than eating $150 to find out the idea was a bad idea.
Watch the forum...often forum members either give away or sell at a discount their past "bad ideas". It's how I managed to experiment so much.

One idea you might consider trying.
Respironics DreamWear nasal mask...it comes in a cushion form or a gel nasal pillow form but the cushion or pillows fit on the same frame so you can buy one package and then get just a cushion or nasal pillow replacement to try the other type.
https://www.cpap.com/productpage/pr-dre ... -pack.html this is the cushion that goes under the nose

https://www.cpap.com/productpage/pr-dre ... -pack.html this is the nasal pillow version
Same frame is used with either.

Maybe having something seal under the nose might work better with tossing and turning and not leak into the eyes so much from the seal breaking at the nasal bridge area.

Just a thought.

Let's see what happens with the slight increase in the minimum. Gotta start somewhere and that's as good as any.

[FoggyBrain24]

Thanks. This is all super helpful and I know everyone appreciates all of your efforts here.

I will adjust the minimum pressure to 9. I will also see if I can route the hose a bit differently so it stays out of the way.

I will reach out to my DME and see exactly what insurance covers. It's pretty amazing how little follow up they do. I have a GP who is great, but he referred me to ENT, who then referred me to Sleep / Pulmonologist. Between those 3 and the DME, no on follows up at all, but I've been nagging them a bunch to ensure it gets better every day.

I've had so many fatigued days both before and after, it seems like if you can just make 1% progress each day, you should be better in no time, provided you make it a priority.

[FoggyBrain24]

I have adjusted my minimum pressure to 9. I also took a few minutes to re-read all the mask fitting suggestions, as to get it working right from the start.
I slept pretty soundly from around 10 pm until 4 AM, but then woke up a few times.

When I woke up, I did notice some air escaping from the top part of my Wisp mask and then I cannot seem to get it to stop. I'm not sure if that is what woke me up. I can see that event on the Leak Rate map around 4:15 AM. I do see the pressure spike up around 14-15 at this time, but it didn't seem to affect me earlier in the night (12:30 AM / 16 pressure). Does a range of 7 seem like a lot for certain masks to remain in place?

http://imgur.com/a/uTG9u

Any other things that jump out? When I did get out of bed around 7 AM, I noticed the humidifier was empty, so perhaps that played a role?
I do think I should point out that I do have a beard in case anyone views that as relevant. My mouth was pretty dry when I woke up as well.

I am hoping to set up a fitting with my DME next week, but in the meantime, can anyone give some suggestions as to how to create a liner for the WISP mask that will hopefully help for the next few days?

Should I keep all as is, or should I go up to 10.0 on min pressure?

Thanks again in advance!

[Pugsy]

Your max pressure was 15 and yes fitted at 9 cm probably isn't going to fit so great at 15 cm.

Have you used the "Mask Fit" feature on your machine? It will let you try to fit at a higher pressure to better anticipate what you are going to hit later in the night. If you haven't tried it...might be worth trying.

Mask liners...generally we say lay the mask cushion down on an old T shit and draw around it about 1 inch from the outer edge.
Cut it out on that line and then cut out an opening in the middle for the nostrils or mouth if using a full face mask.

A beard shouldn't really impact a nasal mask so much unless it is fairly bushy on the upper lip. Do look at a nasal pillow mask...sits a bit more securely at the nostril and less chance of upper lip hair impacting things and of course less chance of having a leak at the nasal bridge area since it isn't involved with nasal pillows.

You may be doing some mouth breathing but if you are it's not horrible in terms of affecting therapy.
To try to do a full face mask with a beard will present even more challenges in terms of leaks and there's no guarantee it will fix the dry mouth anyway.

I still don't know what to make of the VS2 snores. They aren't normal and I don't know if it means something weird is going on with the machine or something else.
Still showing a few more of the regular snores than I would like to see...so if they are still there after a couple more nights I would try another 1 cm increase in minimum.

If the leaks weren't waking you up I don't know that I would worry too much about them.
The dry water chamber could have caused a wake up if for no other reason than it might stink a bit.

I suspect the rather dramatic change in pressure needs are when you roll over onto your back. You might investigate trying something to stay on your side in an effort to better keep the pressure needs reduced and thus lessen pressure changes impacting the seal.
I don't advocate doing something that causes pain or wake ups as a way to stay on one's side...just seems kinda stupid to add something to wake us up more when what we are wanting is to wake up less. For that reason I suggest building some sort of wall that is comfortable and if you lay against it you won't have discomfort. I use a buckwheat hull pillow up against my back when I am wanting to try to stay on my side. It won't move out from under me as easily due to the weight and if I roll against it I find that it actually offers a nice comfortable support to my back.

If those are REM stage sleep increases we can't do anything about them. When you see your doctor next get a copy of your sleep study to see if your OSA is worse in REM sleep or not.

[FoggyBrain24]

In red:

Have you used the "Mask Fit" feature on your machine? It will let you try to fit at a higher pressure to better anticipate what you are going to hit later in the night. If you haven't tried it...might be worth trying.
I have not used it, but I did come across when viewing all of the settings. I will try that tonight. Would you say to use the highest pressure, so 16?

Mask liners...generally we say lay the mask cushion down on an old T shit and draw around it about 1 inch from the outer edge.
Cut it out on that line and then cut out an opening in the middle for the nostrils or mouth if using a full face mask.
Thanks, will try this.

A beard shouldn't really impact a nasal mask so much unless it is fairly bushy on the upper lip. Do look at a nasal pillow mask...sits a bit more securely at the nostril and less chance of upper lip hair impacting things and of course less chance of having a leak at the nasal bridge area since it isn't involved with nasal pillows.
Will look @ this once I hear from my DME.

You may be doing some mouth breathing but if you are it's not horrible in terms of affecting therapy.
To try to do a full face mask with a beard will present even more challenges in terms of leaks and there's no guarantee it will fix the dry mouth anyway.
Thanks.

I still don't know what to make of the VS2 snores. They aren't normal and I don't know if it means something weird is going on with the machine or something else.
Still showing a few more of the regular snores than I would like to see...so if they are still there after a couple more nights I would try another 1 cm increase in minimum.
Thanks. My DME did ask about these and suggested a raise in pressure could help. I do have the CPAP on a shelf that could have a slight vibration, could that potentially explain this? I will be traveling this weekend and could place it on another level item to see if that has an effect.

If the leaks weren't waking you up I don't know that I would worry too much about them.
The dry water chamber could have caused a wake up if for no other reason than it might stink a bit.
I did not notice any smell at all.

I suspect the rather dramatic change in pressure needs are when you roll over onto your back. You might investigate trying something to stay on your side in an effort to better keep the pressure needs reduced and thus lessen pressure changes impacting the seal.
I don't advocate doing something that causes pain or wake ups as a way to stay on one's side...just seems kinda stupid to add something to wake us up more when what we are wanting is to wake up less. For that reason I suggest building some sort of wall that is comfortable and if you lay against it you won't have discomfort. I use a buckwheat hull pillow up against my back when I am wanting to try to stay on my side. It won't move out from under me as easily due to the weight and if I roll against it I find that it actually offers a nice comfortable support to my back.
OK. I do have several pillows, I could try this tonight and if it helps, I can look into a buckwheat pillow.

If those are REM stage sleep increases we can't do anything about them. When you see your doctor next get a copy of your sleep study to see if your OSA is worse in REM sleep or not.
I have a copy of my 2 sleep studies now, is there an easy way to post the full files besides IMG? I do believe this may be the issue. REM and Supine.

Thanks again for all of your help.

[Pugsy]

You might put something under the machine to see if it helps with the VS2 stuff....like a towel or mouse pad to absorb any potential vibration/noise issues.

Increasing the pressure won't fix the VS2 snores. More pressure only fixes the snores related to the airway collapsing stuff.
That's why you don't see pressure increases with the VS2 snores and you only see increases with the other VS snores which aren't nearly as numerous. There's something else causing the VS2 snores.
Can you put the machine lower and have something under it?

When you do the mask fit thing let the machine try what it thinks is a good pressure. I am thinking around 12 or 13 might be a good compromise. I think the machine will likely use a 90% pressure number.

If you have a copy of your sleep study just look for REM AHI and supine AHI and compare those numbers to non REM and/or side sleeping numbers. It's usually fairly easy to spot.
Like for me my non REM AHI was 12 and in REM it was 53.
Supine vs side was not much different. So mine is worse only in REM.
But some people get the double whammy....worse in both REM and supine sleeping.
We can't control REM so not much we can do and if you do have the double whammy might as well let the machine sort it out and sleep in whatever position allows you to sleep the best. Remember the number one goal is more/better sleep.

[FoggyBrain24]

You might put something under the machine to see if it helps with the VS2 stuff....like a towel or mouse pad to absorb any potential vibration/noise issues.
Thanks, will try this tonight.

Increasing the pressure won't fix the VS2 snores. More pressure only fixes the snores related to the airway collapsing stuff.
That's why you don't see pressure increases with the VS2 snores and you only see increases with the other VS snores which aren't nearly as numerous. There's something else causing the VS2 snores.
Can you put the machine lower and have something under it?
Yes, can try this as well.

When you do the mask fit thing let the machine try what it thinks is a good pressure. I am thinking around 12 or 13 might be a good compromise. I think the machine will likely use a 90% pressure number.
OK, will do.

If you have a copy of your sleep study just look for REM AHI and supine AHI and compare those numbers to non REM and/or side sleeping numbers. It's usually fairly easy to spot. Like for me my non REM AHI was 12 and in REM it was 53.

Comment from the doctor "OSA occurs only during Supine Sleep."
60% in Supine position, Supine AHI 14.3
Non-Supine AHI 1.1
REM AHI 30.7
non-REM AHI 1.0

Supine vs side was not much different. So mine is worse only in REM.
But some people get the double whammy....worse in both REM and supine sleeping.
We can't control REM so not much we can do and if you do have the double whammy might as well let the machine sort it out and sleep in whatever position allows you to sleep the best. Remember the number one goal is more/better sleep.
Since we have a similar situation with much higher REM AHI, my understanding is there isn't much you can do to positively increase sleep architecture? I've been using a Fitbit with sleep tracking. Although I'm not sure how accurate the data is (although the below link seems to believe they are getting better), I do notice that my % of REM sleep seems low compared to the expectation (which would jive with me going to sleep study after complaining about brain fog and extreme fatigure). It does seem to improve slightly as a % when I am diligent about all of this. My REM seems low compared to normal benchmarks.


[url]https://www.sporttechie.com/fitbit-stud ... -calories/

[Pugsy]

You've got the double whammy if you are on your back but not so much so if on your side.
Then if you hit REM when on your back...big double whammy.

I don't know how accurate the regular FitBits are for gauging sleep stages. Now the newer one with Heart rate and specific algorithm for determining sleep stages is reportedly more accurate but you have to be using one of the higher end Fitbits or get an older higher end model upgraded via software upgrade.
I had a regular FitBit...and it wasn't particularly accurate since all it used was an accelerameter.
I haven't yet bought the higher end newer model that supposedly is more accurate and uses pulse rate and whatever other magic to determine sleep stages. Always something else I would rather spend $180 on.

See if you can stay off your back if at all possible and see what that does to the pressure needs.

[FoggyBrain24]

I don't know how accurate the regular FitBits are for gauging sleep stages. Now the newer one with Heart rate and specific algorithm for determining sleep stages is reportedly more accurate but you have to be using one of the higher end Fitbits or get an older higher end model upgraded via software upgrade.
I had a regular FitBit...and it wasn't particularly accurate since all it used was an accelerameter.
I haven't yet bought the higher end newer model that supposedly is more accurate and uses pulse rate and whatever other magic to determine sleep stages. Always something else I would rather spend $180 on.

I would recommend checking the below fitbit out. I know it's $150, I asked for it for Christmas from my family.

For now, you would recommend keeping the minimum @ 9 or should I try moving up to 10?



https://www.amazon.com/Fitbit-Charge-Fi ... S24EM?th=1

[Pugsy]

I would recommend checking the below fitbit out. I know it's $150

That looks like the one I have been eyeing. Looks like the price has dropped a little since I last looked.
I recently bought a new AirSense 10 AutoSet for Her instead.
Maybe later I will try the FitBit. My sleep quality has been in the toilet for quite a while and I don't need a FitBit to tell me that little detail. My issues are totally unrelated to sleep apnea or my therapy and until I get those issues improved upon I just have a hard time spending the money on something just to confirm what I already know.
Plus I wasn't real happy with the fact that my first FitBit up and died on me. Makes me a bit leery about spending more money on one.