New Guy

[Snoring Pastor]

Hello Everyone,

It has been a whirlwind of activity with me and OSA. Three weeks ago I went for my annual physical and told my doctor that my wife said I stop bresthing sometimes in my sleep (which I am sure is how many of us first became aware of it). Three days later I was in a sleep lab for a PSG.

Here is what they found:
Sleep Efficiency: 79%
Stage 1: 7%
Stage 2: 75%
REM: 18%
48 obstructive Apneas, 3 central Apneas, and 62 hypoapeneas in 386 minutes of sleep. AHI for night 18, 32 in REM sleep. Severe Oxygen desaturation (82%) during REM occurences.

This is all from the overview of the study - I have not recieved the study yet. I did not meet the criteria for split night, but was diagnosed. Sunday night I went for titration (I had researched machines before I went). Study kept me to o Apneas at pressure of 11 (started at 5). I woke several times and late in the night they put a chin strap to prevent mouth breathing.

The ResMed S8 Elite with integrated humidifier was the machine they brought out for me the next day. I remember from reading that this is one of the better machines so I took it.

I do not have acess to clinical menu, but through reading and experimentation I found the following info. I was able to stay on 4 hours the first night and 5 hours last night (The first night was just so bad I gave in, last night the mask was hurting below my nose when I woke up at 4 I stopped - I know - I have to push through, but I didn't feel like getting up and adjusting the mask - I would not have gone back to sleep.).

Pressure: 9.8 (I think it is 11, but it has a ramp so this number is the average I think)
Leak: 0.24 L/s
AHI: 6.5
AI: 3.6
HI: 2.9

I know even with the chinstrap i had some mouth breathing issues. I was told many to most people get over this without needing to go to full face mask. Perhaps this affected the results?

The mask is fine when I go to sleep, but begins to irritate after 4-5 hours. Given the low leak level, I'm thinking I might be able to loosen it up a bit and be more comfortable. What does other people think?

Even though I have missed out on hours in bed that I would usually have, I really have only felt exhausted at the end of the day yesterday. Unfortuanetly, being a pastor, I do lots of work at night. I do think my concentration is better. I think I need 2-3 weeks to get used to this, but I can see an improvement already.

I see many to most here have bought the card readers and software - is the Encore product OK for ResMed? I see many here use Resperonics.

Thanks for your help!

[bap40]

Welcome to the forum.. You will need to order the software for your type of machine. The encore software is only for some of the respironics products. I am sure others will respond with more info though. Good luck, Brooke

[echo]

hello pastor, and welcome to the forum!
Sounds like you have already done much homework!

For the Activa mask , I can suggest that you really loosen it up. It seals very well, but in order to do that properly it needs to be loose, unlike other masks.

For mouth breathing, many people have used tape (3M micropore, blue painter's tape). Here's a whole bunch of reading on that topic: Links to: Mouth leaks - Air Leaks - Tape - DIY Guard

As for the software& card reader - I definintely encourage you to get it, as most on this forum will. I don't use either respironics or resmed so i can't comment on which software.

Your AHI still seems a bit high. The software can help pinpoint what the problem(s) may be.

Also your leak is bit funny for the Activa. Have you programmed the Activa into the machine? If so 0.24L/s is the leak rate not including the intentional leak rate of the mask. And in that case, your leaks are pretty high. It could be the mouth breathing. You can find leak rates with your mask's manual, or here: CPAP Mask Leak rates. Note that these are the intentional leak rates for venting out the CO2.

Edit: to clarify, the intentional leak rate of the Activa at 10cm should be about 0.5L/sec (the web site is in L/minute). Therefore your value of 0.24L/s just doesn't make sense, unless the leak value you're seeing is the overall leak rate minus the intentional leak rate. On some machines you can program in the mask and it will make that calculation for you.

[Snoring Pastor]

Echo,

The mask is programmed into the machine, so I am almost 100% positive that 0.24 L/s is the net leak. Is this high?

Thank you!

[echo]

That sounds pretty high to me.
For example, normally my non-intentional leaks are in the range of 0.05 L/sec or so.

Once you get a hold of the software and the reader, you'll get a better idea of what's going on.

It could definintely be the mouth-breathing. Do you take bathroom breaks and leave the machine running? That can also skew the average leak rates.

[GuyK]

My leak rates (ResMed AutoSet II) haven't been that low...they've been more like 0.35 to 1.8 L/sec. I know those are high.

What I found is that as I adjusted, the leak rates went down, somewhat, and the AI numbers went down too.

As others have suggested, I quickly learned that tightening the mask is not always the best way to go. Many masks (I can't say "all" because I don't really know...) depend upon "inflation" of the mask to make a good seal. For example, after several nights of higher than average leaking, I decided to tighten a set of straps that hold down the top part of the mask. Today, I woke up with a sore nose bridge, and an average leak rate that was slightly higher than it had been. I am fast coming to the conclusion that although this mask is fairly comfortable to me, the fit must not be so hot. I'm waiting for a call back from my DME-R/T to ask him about that.

For the ResMed machines, you want ResScan software (not Encore). I don't have a good suggestion where to buy it, yet. I'm still searching.

[rested gal]

Welcome to the board, Pastor.

The AHI you saw that was slightly lower than the pressure you're machine is set for, is probably because the exhalation pressure relief called "EPR" (Expiratory Pressure Relief) is turned on in your Elite. Makes it easier for you to breathe out since EPR drops the pressure a certain number of cm's each time you exhale. That pressure reduction when breathing out affects the pressure number you'll see in the data results the next day.

As Brooke (bap40) and GuyK said, Encore Pro and Encore Viewer software won't work with a ResMed machine. Encore is for Respironics machines only.

A perfect leak rate with a ResMed machine is 0.0, since that machine takes into account the expected normal amount of "intentional leak" from a mask's exhaust...if you select the right mask "setting" on your machine. I've read that any leak that stays under 0.40 is acceptable when using a ResMed machine. Your leak rate so far is "ok", but mouth breathing at times during sleep is probably what's causing it to not be zero.

A lot of this therapy is a trade-off. If you can find a way to control the suspected mouth air leaks better, fine. But if to do that, you:

1. have to give up a mask that already suits you nicely and is very comfortable and quite leak proof for most people (your Activa mask) to switch to a FF (full face mask)

2. don't want to add more to the routine (like tape, etc.)

....then you might want to keep on just as you are. You're not getting a terrible leak rate.

Personally, when using a ResMed machine with EPR turned on, I set my pressure an almost equivalent number of cm's higher than prescribed. For example, if I were prescribed a pressure of 11, and were going to use EPR at 2 (for a 2 cm drop during exhalation) I'd set the regular pressure at 12 or 13. Reason being...I want my therapeutic pressure to be well and truly in place when it's time to inhale again. But that's just what I'd do...and I'm not a doctor!

Looks like you're doing very well, Pastor. If you're sleeping well and feeling ok as is, you need to consider for yourself whether the kind of steps you could take to try to tweak your nice numbers down further are worth trying. Me...I'd do some tweaking and some taping. But that's just how I am.

[echo]

hey RG, thanks for your tempered and enlightened response
For educational purposes (for me) - where does the 0.4 L/sec "limit" come from? I guess I'm spoiled by thinking anything more than 0.1L/sec is too high

I think the pertitent question is, what's the maximum leak rate and for how long?

[rested gal]

For educational purposes (for me) - where does the 0.4 L/sec "limit" come from? I guess I'm spoiled by thinking anything more than 0.1L/sec is too high

From the Clinician Manual for the S7 Spirit (resmed)

"Generally, a leak rate of more than 0.4 L/s (24 L/min) is associated with
patient discomfort, disturbed sleep, and reduced efficacy of treatment"

More, in that same manual:

LEAK
Leak is derived by analyzing inspiratory and expiratory airflows (via the flow
sensor located in the unit). Theoretically, inspiratory and expiratory volumes
should be equal. A net airflow greater than the expected mask vent flow is equal
to the leak. Generally, a leak rate of more than 0.4 L/s (24 L/min) is associated with
patient discomfort, disturbed sleep, and reduced efficacy of treatment.


NOTES-- If the leak exceeded 0.4 L/s (24 L/min) for more than 30% of the previous session,
the following message will appear on the LCD: High leak in last session.

The Leak Alert feature, if enabled, will alert the patient when mask leak exceeds
0.7 L/s (42 L/min) for more than 20 seconds. When the leak exceeds this level, the
autotitrating algorithm ceases to perform optimally.

The leak reported in the Efficacy Data submenu (see Figure 9, The Clinical Menu
Results series, on page 40) is the 95th centile value for mask-on time for each
session, or the median 95th centile value for a selected time interval (last week,
last month, last 6 months, or last year). Non-usage days are not included in
calculations.

Also came across it here:

http://thorax.bmjjournals.com/cgi/reprint/61/3/226.pdf

On page 3, in the section "CPAP data" of this study using resmed machines:

"a 95th centile leak of 0.4 l/s was considered acceptable."

[echo]

RG- thanks!!