Awaken tired every morning

[jessup23]

Hello: I've been using a cpap resmed s9 for about 3 yrs. now. My air leaks are high, but my numbers seem not to be bad, averaging .46 for the past year, although that can fluctuate on a daily basis from a rare 0 up to 1.00+. I usually use nasal pillows, but have also tried masks that fit around my nose. I don't breathe through my mouth. My problem is that most mornings I awaken tired. I think I begin to sleep fitfully beginning in the early morning, or at least that's when I become aware of air leaks. Should I be using a different setting or something? My pressure setting is 12.20. Thanks for any advice you can give me.

[robysue]

Hello: I've been using a cpap resmed s9 for about 3 yrs. now. My air leaks are high, but my numbers seem not to be bad, averaging .46 for the past year, although that can fluctuate on a daily basis from a rare 0 up to 1.00+.

How high is high when talking about the leaks?

Also are you using a Resmed S9 Elite, a Resmed S9 AutoSet, a Resmed S9 AutoSet for Her, or a Resmed S9 Auto Escape? It makes a difference when we're trying to figure out what the data says.

Here's the thing about leaks: If the leak rate is high enough, the AHI data can be inaccurate. In particular, when the leaks are high enough, the machine can have a hard time tracking your breathing, and if it cannot accurately track the breathing, it cannot accurately flag all the events.

More importantly, when the leaks are high enough, the machine cannot compensate for the leaking and it cannot maintain the correct pressure. Once the pressure in your airway decreases, more events are likely to happen.

You also write:

I think I begin to sleep fitfully beginning in the early morning, or at least that's when I become aware of air leaks.

Leaks that are large can be disrupting to your sleep. And it sounds like that's what's happening: You start leaking and then your sleep goes to hell in a handbasket. And you wake up tired.

You ask:

Should I be using a different setting or something? My pressure setting is 12.20. Thanks for any advice you can give me.

Without seeing any data, there's no way we can tell you about what tweaks to the settings might be worth trying.

But with the report of "high leaks" and "I become aware of air leaks", it sounds like you need to work on fixing the leaks.

How old are the masks you are using? How old are the mask cushions?

[jessup23]

Hi robysue: Thanks for your reply. I'm using a ResMed Autoset. The masks are new. I've tried stopping leaks with various pillow sizes, but nothing seems to help. This has been an ongoing problem since I've been using the cpap machine. I've tried the Pilairo and the Airfit N10, as well as sort of cloth-like mask. They all leak to about the same degree. It seems like no amount of strap-adjusting or tightening helps. Do the figures below reveal anything helpful? Thanks so much!

most recent
Average Leak Rate 14.03
90% Leak Rate 34.80
% of time above Leak Rate threshold 23.89%
Average Pressure 10.05
Min Pressure 5.14
Max Pressure 13.20
90% Pressure 11.10
Average EPAP 9.05
Min EPAP 4.14
Max EPAP 12.20

[Julie]

How do you know, when asleep (as I assume any bed partner would be) that you don't mouth breathe?

[robysue]

most recent
Average Leak Rate 14.03
90% Leak Rate 34.80
% of time above Leak Rate threshold 23.89%

Those leak numbers are "technically" within Resmed's "accepted tolerance". In other words, Mr. Green Smiley Face showed up on the short version of the sleep quality report.

But .... Resmed officially says Large Leaks are not a problem until they last 30% or more of the night. Most folks around here would beg to differ with that interpretation.

Moreover, your 90% Leak Rate is 34.80 L/min, and thats 10.8 L/min above the Large Leak definition of 24 L/min. When the leaks are that high, the machine cannot easily compensate for the leaks. So therapy may not be effective at preventing apneas. And when leaks are that high, the machine cannot easily track the breathing. So the machine may not correctly record all the events that are occuring.

And you're leaking at a rate of 34.8 L/min for at least 10% of the night. That's a lot of very large Large Leaks. If this is what your data looks like on most nights, then no wonder the leaks are waking you up and no wonder you're feeling tired in the morning.

I know you say that you don't mouth breath. But something is going on that is leading to some significant leaks. And the fix to your problem is going to involve fixing the leaks rather than tweaking the machine's settings.

It would help to look at the leak line graph in SleepyHead for several nights. You need to find out when the leaks start and how long they last. If the leak graph indicates a high probability of significant mouth breathing, you're going to need to address that potential issue. If mouth breathing turns out to not be the issue, then you're going to have to figure out what's causing the mask to become dislodged enough to trigger the Large Leaks.

You say:

The masks are new. I've tried stopping leaks with various pillow sizes, but nothing seems to help. This has been an ongoing problem since I've been using the cpap machine. I've tried the Pilairo and the Airfit N10, as well as sort of cloth-like mask. They all leak to about the same degree. It seems like no amount of strap-adjusting or tightening helps.

Which headgear on the Pilairo were you using?

The Airfit N10 and the Pilairo both use an air cushion to form the seal. If the headgear is too tight, the air cushion cannot fully inflate. This can cause the machine to spring leaks once the pressure increases in the middle of the night. You may need to review the mask fitting instructions. You might also want to google to see if you can find some videos that show you exactly how you need to fit the masks you are using.

Can you verify what your pressure settings are? Also are you using the ramp? The data you report indicate that your min pressure is around 5cm and the max pressure for the night was 13.2. If you fit the mask at 5cm, it's quite possible that once the pressure ramped up, the seal didn't hold---it's more difficult to seal masks at higher pressures. If you are using the ramp, you need to figure out a way to fit the mask at your full pressure. If the mask is sealed well at 13cm, it will stay sealed well at much lower pressures.

[jessup23]

Hi robysue: Thanks so much for all your helpful advice. The graphs show that I have leaks virtually all night long every night, with no particular time of night when they're low. Highs are interspersed with usually one or two periods when the leaks are low, lasting 15 to 45 min. Otherwise, the leaks zigzag up and down, but usually at a high level. I do use the ramp. When the leaks start waking me up I do readjust the mask. The Pilairo has a velcro strap that goes above my ears to the back of my head and another that goes across the top of my head.

I just thought of another problem I have, which is probably real weird, but I also have a habit of "parking' the back of my tongue against the roof of my mouth at night (daytime, too). If I do it too tightly, it seems to shut off my airway. Could this be creating such a barrier that the resmed air has no place to go except to blow out of the mask? I try real hard not to do it, but when I'm asleep, who knows?

[robysue]

Hi robysue: Thanks so much for all your helpful advice. The graphs show that I have leaks virtually all night long every night, with no particular time of night when they're low. Highs are interspersed with usually one or two periods when the leaks are low, lasting 15 to 45 min. Otherwise, the leaks zigzag up and down, but usually at a high level. I do use the ramp. When the leaks start waking me up I do readjust the mask. The Pilairo has a velcro strap that goes above my ears to the back of my head and another that goes across the top of my head.

I really need to see the Leak graph. I can't follow what you are trying to tell me.

However, if you are fitting the mask at the beginning ramp pressure, the seal may just be being blown open by the pressure once it increases up to your therapeutic level. You may need to fit the mask at full pressure.

Illustrated step-by-step instructions on what graphs to show and how to post them to the forum can be found at https://sleep.tnet.com/resources/sleepyhead/shorganize

I just thought of another problem I have, which is probably real weird, but I also have a habit of "parking' the back of my tongue against the roof of my mouth at night (daytime, too). If I do it too tightly, it seems to shut off my airway.

This is the NORMAL place for the tongue to be. When the tongue is in this position, it does block the oral cavity off from the upper airway. The upper airway is not actually blocked---air goes through the nose the way it is supposed to.

If the tongue is in this position when you have a nasal mask on, it is possible to open your mouth wide open and NOT loose any CPAP air. As in there's no air that blows down through the nose and into the mouth. All the air is going through the nose and down the airway.

[ Could this be creating such a barrier that the resmed air has no place to go except to blow out of the mask? I try real hard not to do it, but when I'm asleep, who knows?[/quote]No. If you're doing this at night, that means that you should not have any large leaks caused by opening the mouth while using a nasal mask.

[jessup23]

Hi robysue: Once again, thank you so much for your attention to my problem. I don't know how to send you the graph, or even that you would, in actuality, even want to see it. I'll start by following all your suggestions and fit my mask when the pressure is high. If that doesn't help, I'll try out a mask that will cover my nose and mouth. Hope I can solve this problem soon -- fingers crossed!

[jessup23]

Hi robysue: I think I've learned how to upload my graphs. Here's a link to it (if I've done it right): http://imgur.com/ZQFfAtj

[ChicagoGranny]

Hi robysue: I think I've learned how to upload my graphs. Here's a link to it (if I've done it right): http://imgur.com/ZQFfAtj

Your leak line is a bit nasty. Are you getting dry mouth?

Here are some basic tips on leaks --->

To reduce unintentional mask leak -

- Make sure the mask is fitted properly. (See mask manufacturer's video.)

- Make sure the headgear is adjusted properly (See mask manufacturer's video.)

- Make sure to use good hose management - the hose should not pull on the mask. Notice how your hose is positioned between machine and mask. It should be positioned to minimize any pull on the mask. Hose management is an individual practice. How it is done depends on the mask, the position of the machine, your sleeping position and other factors specific to the individual.

- If you still have problems, learn from the forum what mask liners are available.

- If your mask still has excessive leak, try other masks. Many people report trying several masks before they find one that works well for them.

Note: Links to just about all of the mask manufacturers' instructional videos can be found on the forum host's website - https://www.cpap.com/cpap-masks.php

- CG

[jessup23]

Hi ChicagoGranny: I do get some dry mouth, but most nights I'm OK or have only a little. I'm going to follow all the steps on the list you provided. I've certainly got to find a solution! Thank you very much for the information.