Question regarding mouth leak

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jnew71
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Question regarding mouth leak

Post by jnew71 » Wed Nov 19, 2014 5:43 am

So, I've been using the Swift FX nasal pillows for about a week and have had decent success with them figuring that all that is left to do now is to tweak my pressure to get optimal results. However, last night I ran into an issue and trying to figure out why. I was awakened several times last night with air billowing out of my mouth and noticed when trying to go back to sleep that my mouth kept inflating - I do use a chinstrap. I haven't really experienced that before. Pressure hasn't been adjusted in the last 4 days. The only adjustment I've made is to the humidification, changing it to classic mode as I was waking up with a dry nose every morning. I've attached my data from last night just in case - can anyone give any feedback about why my mouth kept inflating, forcing my lips to open? Thanks.

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jnew71
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Re: Question regarding mouth leak

Post by jnew71 » Wed Nov 19, 2014 8:45 am

Also have a chicken/egg question about last night's stats - not sure anyone would know. I'm wondering if the leak was caused by an increase in pressure because of all the events shown around the same time or if the events were caused by the leaks and my machine not being able to adjust enough................

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Tino2You
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Re: Question regarding mouth leak

Post by Tino2You » Wed Nov 19, 2014 10:06 am

If you use a nasal pillow and open your mouth you will get a leak. There is a trick where you place your tongue on the roof of your mouth, behind your front teeth and that will effectively block your airway in your mouth. With patience and practice, you can train your brain to keep your tongue there while you sleep. It will take a while. Even not after a couple of years, I sometimes wake up with a desert mouth. That is from the air coming out my mouth. Not pleasant. Finally, you machine is trying to maintain a pressure in your airway, when a leak occurs (as happens when your mouth is open) the pressure will increase.

Hope this helps.
-tino

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Pugsy
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Re: Question regarding mouth leak

Post by Pugsy » Wed Nov 19, 2014 10:27 am

The PR S1 machine won't try to fix a leak with more pressure.

Part of the increase in the leak line is because of the increase in pressure but not because the machine is trying to fix a leak.
The PR S1 machine reports total leak (that top leak line in SH) which is the mask's expected vent rate plus any excess leak and the vent/intentional leak rate will increase simply because of the vent rate.
More pressure always equals more vent rate. Even with zero excess leak that leak line will increase when the pressure increases because of the vent rate.

Inflated cheeks...the tongue has got lazy and dropped down and allowed air that is in the airway into the mouth.
Lips are closed...air has no where to go and cheeks inflate...we call it chipmunk cheeks.
As the tongue learns to stay in position and keep that back door to the airway closed it will become less frequent.
Highly annoying though.

The red line at 24 L/min...that's for a ResMed S9 machine and not for your machine. If you want to use the red line you can change it up to where your large leak territory is with total leak..and that's going to be up around 80 to 90 L/min. Your machine and SleepyHead 0.9.8-1 will let you know if you go into large leak territory...it shows up as LL on the events graph up by PB.

This report you show....excess leaks were minimal to none and did not negatively impact your therapy.
If you did any mouth breathing or opening of the mouth due to chipmunk cheeks...it wasn't much and sure didn't last long because it didn't show up as LL flagged time.
So in terms of therapy effectiveness...no impact but the fact that it wakes you up is another story. We want to try to eliminate anything that wakes us up.
With time and experience the tongue can normally learn to stay in position and keep that doorway closed.

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jnew71
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Re: Question regarding mouth leak

Post by jnew71 » Wed Nov 19, 2014 1:10 pm

Pugsy, if I'm hearing you correctly, the increase in pressure on my machine was due to my the actual events and not due to any leak? If that's the case, I guess I had a bad night. I went from ~3.5 AHI for the last 3 or 4 days to a 9.5 and a ton of events last night.

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grayghost4
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Re: Question regarding mouth leak

Post by grayghost4 » Wed Nov 19, 2014 1:29 pm

on the days you had 3 or 4 AHI .... did the pressure go as high as it did last night ?
I had results like you show on the posting when my pressure went that high ... I now have mine set to 7 to 9 and get much better results ... the changing pressure might be wakening you and causing all the other problems
If you're not part of the solution you're just scumming up the bottom of the beaker!

Get the Clinicians manual here : http://apneaboard.com/adjust-cpap-press ... tup-manual

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Pugsy
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Re: Question regarding mouth leak

Post by Pugsy » Wed Nov 19, 2014 1:32 pm

jnew71 wrote:Pugsy, if I'm hearing you correctly, the increase in pressure on my machine was due to my the actual events and not due to any leak? If that's the case, I guess I had a bad night. I went from ~3.5 AHI for the last 3 or 4 days to a 9.5 and a ton of events last night.
Correct. The increase in pressure you see is in response to the OAs and they hyponeas that you see and the increase in the leak line itself is simply a normal response to the increase in pressure.

Last night's AHI looks to be not quite half being Clear Airway events (centrals)...and the machine would NOT respond to those at all with any pressure increase.
The machine won't/can't respond to CAs with more pressure...any pressure increase around a CA is purely coincidence because of some other pressure increase trigger (snore, Flow limitation, OA, hyponea, etc).

Your last night's report looks like a crappy night's sleep. Did you by any chance have much awake time during the night? Remember many wake ups?

The ugly part in terms of OAs and hyponeas...around 1:30 to 3:30...I wonder if maybe you were on your back during that time or maybe it was REM stage sleep (or maybe a little bit of both)...for some reason during that time frame your pressure wasn't sufficient. If you see this sort of clustering (OAs and hyponeas with a sprinkle of FLs and RERAs) fairly often then maybe a little more minimum pressure is needed.
If this ugly night is just a rare fluke or you know you spent a lot of time awake...we sort of have to ignore last night.

When evaluating pressure needs...the CAs have to be removed from the evaluation because we don't treat CAs with more pressure.
If your AHI is usually 3 to 4 and you are sleeping well and feeling decent...I would ignore last night's report...we all have bad nights from time to time.
If your AHI is usually 3 to 4 and you aren't sleeping so great and aren't feeling so great and you are seeing some clustering of OAs and hyponeas...maybe a little pressure adjustment is needed.

Again...if you are mouth breathing or leaking or opening your mouth...it would show up on the leak line if it was big enough...and yours is no where near big enough to even really show up much less be problem.
So leaks aren't an issue at least from a therapy standpoint.

Your report looks like what I would expect to see if someone says they had a "bad" night in terms of sleep itself.
If you couldn't see this report...how would you describe last night's sleep quality?

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palerider
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Re: Question regarding mouth leak

Post by palerider » Wed Nov 19, 2014 2:41 pm

jnew71 wrote:Pugsy, if I'm hearing you correctly, the increase in pressure on my machine was due to my the actual events and not due to any leak?
the machines work very hard to maintain the desired pressure level in your mask.

if you had a leak, and they increased the pressure as a result, then that would possibly be bad for your treatment.... yes?

make sense?

the machines do push more air when there's a leak to make up for the air lost in the leak, but if you hooked a manometer to your mask, and watched the actual pressure in the mask, it would be very stable, until the leak got so big that the machine couldn't supply enough extra air to keep the pressure at the desired level.

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jnew71
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Re: Question regarding mouth leak

Post by jnew71 » Fri Nov 21, 2014 5:27 am

Thanks Pugsy - I don't feel rested even when my AHI is at 3-4. I figured I needed to continue tweaking the pressure, which is what I've been doing - increasing by .5 after every 5/6 days. Still puzzled as to why I've seen such an increase in events lately - specifically the CA's which have been the primary driver in my higher AHI. In your experience, is there any reason CA's become more prevalent?

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Pugsy
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Re: Question regarding mouth leak

Post by Pugsy » Fri Nov 21, 2014 10:23 am

jnew71 wrote:I don't feel rested even when my AHI is at 3-4. I figured I needed to continue tweaking the pressure, which is what I've been doing - increasing by .5 after every 5/6 days. Still puzzled as to why I've seen such an increase in events lately - specifically the CA's which have been the primary driver in my higher AHI. In your experience, is there any reason CA's become more prevalent?
Centrals....Clear airway events. No air movement but the airway is open. Hold your breath for 15 seconds....that's pretty much what a central is...no air moving but the airway is open.
When reported by our machines they are either "real" as in would also be flagged in a sleep lab setting or not something that would be flagged in a sleep lab.

It's normal to have a few "real" centrals that would be noted in a sleep lab study but they aren't cause for alarm.
Sleep onset centrals are normal and not cause for alarm unless someone is having a truckload of them causing drops in O2 levels or they keep bouncing us out of sleep so that we have trouble actually falling asleep.
This can happen at any time during the night where we wake up briefly and thus have to go through another sleep stage transition from awake to asleep.

Awake breathing is not nearly as regular as asleep breathing and often we will pause our breathing and not realize it. The machine doesn't know if we are awake or not..it just measures the air flow. These machines can and will flag awake breathing pauses and most usually they get flagged as central. These are what I call the "not real" centrals because in a sleep lab setting they would be omitted from sleep apnea AHI numbers or evaluation.
jnew71 wrote:is there any reason CA's become more prevalent?
For some people who start cpap therapy it's the cpap pressure that causes centrals because of an instability in breathing with O2 and carbon dioxide exchange. It's actually carbon dioxide levels in our blood stream that trigger the need to breathe response. People tend to think this is related to higher cpap pressures but it can just as easily be caused from pressures as low a 5 cm...it's any pressure and not just higher pressures. When we see this happen it's called complex sleep apnea. It takes more than 2 or 3 centrals per hour to make this diagnosis though and/or to be a problem.

Is this what is happening with you? I doubt it. Odds are what you are seeing are either sleep onset centrals or awake/semi awake breathing being flagged by mistake (we call those SWJ Sleep/Wake/Junk). Complex Sleep Apnea isn't all that common and depending on what you read maybe happens to 10 or 15% of the people who start cpap therapy.

If your AHI is 3 to 4 and primarily (50% or more) CA...there's no need to increase the pressure. You won't bring the CA index down with more pressure. We don't fix centrals with more pressure with your machine. A different machine is needed and even if all your AHI was central in nature 3 or 4 per hour doesn't normally dictate a need to change to that machine.
When you change the pressure it is possible that the change itself is causing maybe more SWJ which would include CAs. That's why when we see a report with numerous CAs we ask people if they slept well during the night or if they woke up a lot. Before worrying about centrals we have to try to figure out if the centrals are "real" or not.

If you don't feel rested...first evaluate hours of sleep and sleep quality and not just the AHI number.
If you are having multiple awakenings for any reason (lip flutters or whatever) we can't expect to feel very rested even with a nice low AHI. If we only are getting 6 hours of sleep we can't expect to feel very rested.

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jnew71
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Re: Question regarding mouth leak

Post by jnew71 » Fri Nov 21, 2014 5:26 pm

Pugsy wrote: When you change the pressure it is possible that the change itself is causing maybe more SWJ which would include CAs. That's why when we see a report with numerous CAs we ask people if they slept well during the night or if they woke up a lot. Before worrying about centrals we have to try to figure out if the centrals are "real" or not.
So, how do I know if the CA's or the flags are being caused by my waking up or if my waking up is caused by CA's?

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Pugsy
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Re: Question regarding mouth leak

Post by Pugsy » Fri Nov 21, 2014 5:56 pm

jnew71 wrote:So, how do I know if the CA's or the flags are being caused by my waking up or if my waking up is caused by CA's?
We don't know. We can't tell for sure with the data that is available to us.
We can sometimes get sort of an idea by looking at the wave form flow rate graphs zoomed way in to see each breath.
All we can do is try to eliminate or reduce the awakenings that could be related to OSA stuff and see if the centrals reduce along with the reduction of the OSA related stuff.

What you can do, if you have the presence of mind to do it in the middle of the night. is each time you wake up reach over and push the button to turn the machine off and then right back on again.
This will enable you to be able to easily spot a known awake time and then you can look to see if anything happened right before you woke up.
The therapy break can easily be spotted on the graphs when you zoom in.
Then you compare it to any events you see preceding or following that therapy break.

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