5 days into CPAP

[discusdoc]

So I received my machine last Saturday and have slept with it for 5 nights. I'm looking for any advice to deal with my current issues:

FYI, I have a ComfortGel Nasal Mask

1. Water in mask: I typically have my humidifier set to either passover mode or 1, so I'm not having trouble with water in my hose. I start to notice water in my mask leaking around the seals onto my upper lip. I assume this is condensation from my exhalations.

2. Air leaks: I have pretty minimal air leaks just a little around the right eye at times. I think I might have too large a mask. The mask sizing application on CPAP.com said a large, but it looks like I used a medium during my sleep study

3. Falling asleep: my typical sleep routine consists of lying on my back until I'm at the brink of falling asleep and then I tend to naturally turn to my side right as I'm falling asleep. I'm actually very comfortable with the mask and the pressure while lying on my back but just can not fall to sleep. I have been able to sleep some on my side although the nasal mask doesn't seem the best for this and I'm trying to avoid it. I've tried Ativan, Rozeron, and melatonin, all of which relax me and would help me sleep normally (without the mask) but still can't sleep.

It's only been 5 nights and each is better than the previous, but I wonder if a nasal pillow mask would be preferable in my case.

[DreamStalker]

1) That is right. The primary source of rainout is from exhalation. You can try to raise the room temperature if your HH is already in passover mode.

2) Yes. Finding the mask that is both comfy and leak-free is the hardest part of the treatment ... keep trying to find it.

3) Seems like you have tried all of the typical approaches. The only other regarding side sleeping is to try a different head pillow where you can hang your mask of the edge. There are PAPillows and some make their own cut-outs. I use a high-density memory foam pillow and just hang my face over the edge.

I like nasal pillow type masks myself but I'm just weird that way ... maybe you are too

[fortomorrow]

I wonder how many people use the ComfortGel nasal mask in their sleep study and then get sent home with it, unaware that there are a hundred other masks out there. I should do a survey.

I hate the ComfortGel. It's anything BUT comfortable.

[echo]

Doc -

For #1 - do you already have a hose cover? That will help a little bit with the condensation.

For #2 and #3 I would suggest trying another mask.

When I first started out, the Activa was recommended to me by forum members, and it's been my favorite mask ever since. It NEVER leaks. It's a bit heavy on the face, but with good 'hose management' it's ok. I can easily sleep on my side with it. You might want to try it. Other good side-sleeper masks include the Headrest/Aura, the NAII, or the Breeze.

As for other masks, either contact your DME or whoever your supplier is, or check out the various mask test drives and buy one yourself online.

Hose management links - this is useful info regardless of the mask you're using (keeps you from getting tangled up in your own hose Also a good hose management system will prevent the hose from pulling on the mask and causing more leaks.)

Link to Mask test drives

By the way it's great to have you on this forum! I think it's really great because (a) you're getting a jump start on your own therapy and (b) your insight as a doctor is always very welcome and useful, and you've already made some great contributions to other posts. So thank you for joining this crazy crowd I hope you stick around, even if you're not able to stop by very often.

[ozij]

Nasal Pillows masks are my favorites too.

Hose management, and the right kind of head pillow are very important.

Rainout is worse for those of us who need low pressure. I need a heated hose (http://www.sleepzone.com.au), a hose cover on to of that, and I have recently discovered that a cover for the narrow tube that leads from the main hose to the mask makes a big difference. I used to improvise that cover from tubular finger bandages, but now the one I use now is bought - giving better insulation.

O.

[Snoredog]

So I received my machine last Saturday and have slept with it for 5 nights. I'm looking for any advice to deal with my current issues:

FYI, I have a ComfortGel Nasal Mask

1. Water in mask: I typically have my humidifier set to either passover mode or 1, so I'm not having trouble with water in my hose. I start to notice water in my mask leaking around the seals onto my upper lip. I assume this is condensation from my exhalations.

As mentioned a lot of that moisture comes from exhale and condenses in the mask. If you rebreathe in a clear ziplock bag for a minute or two you will see how much that is with only a few breaths.

The heat function on the Humidifier is only to warm the water so the air passing over it is picked up at a greater rate. Some heat is given off by the motor in the machine but still the air moves through the machine so fast it doesn't pick up much heat from the motor. Your delivery pressure also impacts how much moisture is picked up from the humidifier. The heat function on the Humidifier was never designed to warm the incoming air, its purpose is to add more moisture to the air. If you want to warm the incoming air to the machine consider the aussie heated hose, it actually warms the incoming air to a comfort able level, it removes that raw cold feeling in your nares. Use of a pillow style mask interface will magnify that cold air feeling. That moisture can condensate and pool at the low point in the hose just like a P trap under a sink, the air pressure can blow it towards the mask where when the droplets hit you in the face they will hurt.

2. Air leaks: I have pretty minimal air leaks just a little around the right eye at times. I think I might have too large a mask. The mask sizing application on CPAP.com said a large, but it looks like I used a medium during my sleep study

Best way to size a mask is in a mirror. Hold a ruler up in the mirror and measure from the center of the pupils of the eye down to the center of the upper lip. That vertical dimension should match the nasal mask. The top of your mask weather nasal or full face should land between the eyes at the pupil level. That indention is what keeps the mask from riding up into your nares or down. That top reference point is also used to size any Full Face mask, only difference is you measure down to the indention in the chin. If you get a mask too small, it will have to ride down lower on the nose more on the bridge and leave a nice divot to wear around the next day. The cushion may ride up into your nares and cause irritation there. If too large it will ride down on the upper lip and put too much pressure against the teeth possibly even landing in the mouth.

Full face mask sizing needs to be compensated for in case your mandible drops slightly, if you size it too small the bottom of the cushion will again land in the open mouth. Sized right the top will land at the pupils (center point of the cushion) and the bottom of the cushion will land in the indention of the chin and pseudo hold the mandible from dropping.

3. Falling asleep: my typical sleep routine consists of lying on my back until I'm at the brink of falling asleep and then I tend to naturally turn to my side right as I'm falling asleep. I'm actually very comfortable with the mask and the pressure while lying on my back but just can not fall to sleep. I have been able to sleep some on my side although the nasal mask doesn't seem the best for this and I'm trying to avoid it. I've tried Ativan, Rozeron, and melatonin, all of which relax me and would help me sleep normally (without the mask) but still can't sleep.

Did you have insomnia before the machine? or is the insomnia related to use of the machine?

On avg., it takes the typical patient 4-6 weeks to get used to wearing the mask and using the machine to where they can sleep. For the new patient, a lot of that insomnia comes from the discomfort of the mask, the noise form the machine and the pressure.

While it all depends on your prescribed pressure and machine, nearly all machines today have Ramp or Auto:Ramp. This basically allows you to use a lower pressure than your prescribed pressure for a timed period. 30 minutes is usually a good time to use. If your current pressure is 10, you can set up a lower Ramp pressure of say 6.0 cm for 30 minutes. The way this works you put on your machine, it starts, you press the Ramp button, it drops from your prescribed pressure to a lower 6 cm pressure. Then after 5 minutes it increases from 6.0 to 6.5 cm, then every 5 minutes another .5 cm increase until the timer expires and/or it reaches your prescribed pressure. If it is an autopap, it does the same but instead of it being the therapy pressure it is the Minimum pressure, the autotitration mode takes over from there.

Lower pressure = Less Machine Noise = greater comfort = less insomnia.

As for a sleep aid, I have for all tense and purpose idiopathic hypersomnia, for my routine I take 3mg of melatonin. If I'm not asleep in a 1/2 hour I'll take a Tylenol PM, or a Benedryl or a Costco Sleep-Aid (Unisom).
I have a bad L4/L5 with Sciatica and if it flares up I'll go for the Tylenol. It take enteric Aspirin every night for stroke prevention. I use a 420e autopap with a starting pressure of 7.5 cm. If my sciatica gets too bad like it has recently I have to hang upside down in my inversion table for 5-10 minutes.

It's only been 5 nights and each is better than the previous, but I wonder if a nasal pillow mask would be preferable in my case.

Actually, the nasal pillow style masks are more noisy than the mask you have, you might want to try one but they won't be any quieter (they are the more noisy interface of all mask types).

Note: It takes a good 6.0 to 6.5 cm pressure (minimum) to flush out your exhaled CO2. If your starting pressure is low like 4 cm, that is the reason for all the rainout and discomfort falling asleep, when you rebreathe too much of your exhaled air the air will seem humid and stuffy. You may even wake with a headache from it. I try and use 6.5cm as the Minimum pressure I would use. Most people have difficulty at the lowest 4 cm pressure. Sometimes newbies struggle, struggle and struggle and its their pressure being too low.

[discusdoc]

I did quite a bit better last night. I like sleeping in really cold rooms (60 degrees), but cranked the thermostat up to 70 last night and didn't get any rainout in the mask. I also found that I could sleep on my side with my mask better than I had previously though.

I probably need to try some different masks, but things seem to be going in the right direction, and it has only been 6 days.

[LISusan]

Hi Discusdoc,

I got my mask last Saturday also. Last night was the longest I kept it on - from 10:30 pm - 5 am. Before cpap I fell asleep in about 10 seconds, but now I am laying there wide awake feeling this big chunk of plastic on my face. I have had a little air leakage into my right eye also, but last night, none. Everyone says it's going to take a while to get used to this, so I am trying to keep an open mind. Earlier in the week I only made it a couple of hours with the mask on, and took it off in my sleep, so I guess I'm getting better?? I am feeling exhausted during the day and am wondering when the good rested feeling will come. I'm also wondering how long you should give a mask before trying another one, and does insurance cover changes in masks??

Susan

[discusdoc]

My sleep seems to be getting better each night now. One thing I did notice was that with a pressure of 9 I would start to snore right at the brink of falling asleep and it would keep me from sleeping. Last night I raised the pressure to 10 and the snoring was less pronounced, but my AHI was 6.0 per the software. I guess I might need to up the pressure a bit more.

[echo]

Doc, just out of curiosity what was your titrated pressure?

[discusdoc]

Titrated pressure from sleep study was 9

[DreamStalker]

If you use the flex feature ... you need to raise pressure to compensate (1 to 2 cm depending on flex setting).

[LISusan]

New to this CPAP chat - what is AHI? And how are you changing your pressure yourself? Didn't the doctor recommend a level for you?

[echo]

discusdoc - basically you can do at home, with the software, what they do in the sleep clinic during the titration. Just bump up you pressure by 0.5cm or 1.0cm and stick to it for a couple of days. The idea is to titrate out apnea's, hypopnea's, snores, etc. An AHI of 6.0 isn't bad but as you have seen we aim for a much lower number still What was your snore index if the AHI was already at 6? Are your leaks under control?

LISusan - AHI stands for "Apnea Hypopnea Index". AHI = total number of apnea's and hypopnea's over the whole night, divided by the total sleep time. (It's like the average number of events per hour).
During the titration at the sleep clinic, they will find the pressure that seems right for you. However, for most people it's the first time they've used a CPAP, the masks they give you are usually crap, many people can't sleep in their ideal position because of all the wires, etc, and in general it's a very weird environment. Therefore the magical pressure number they come up with during the titration can turn out to be incorrect. Also note that we all sleep differently each night, so that number is only valid for the conditions and that night in the sleep lab. On this forum we start where the sleep clinic leaves off - and if you have your own software, you can easily track if your pressure is correct or not. In the case of Discusdoc, for example, his pressure of 9cm still gives an AHI of 6 (that's still 6 events an hour. If one apnea lasts minimum of 10 seconds, that's still 1 minute per hour NOT BREATHING). IF you have your own software, AND IF you do it carefully, it is possible to find your ideal pressure AT HOME (also called self-titatration).

Please go to the "Our wisdom" above (the Yellow Lightbulb) to start reading about Sleep Apnea. Here are a few links from there:
- CPAP definitions
- Changing your CPAP pressure settings
- Where a Newbie should start