New to CPAP... Some questions about the numbers...

[minelson33]

Hi all,

Complete n00b here, please indulge a few questions. I was recently diagnosed with severe obstructive sleep apnea and have been put on CPAP. I have a Resmed S9 Elite (humidified) with a Quattro full-face mask and have completed 3 nights of sleep with it on. The pressure dictated by the doctor was 12. I have a ClimateLine on the way, but have been on a Slimline normal hose.

By calling up the detailed menu, I see that my leak number has been at 16, 21, and 2 L/min for the 3 nights. This also appears to be driven to some extent by the comfort factor. More comfortable = more leaks (at least so far). I put it on pretty tight last night just to see if the leak number or other numbers would improve, but this morning I have a red outline from the mask and I feel like I've been punched in the jaw. For full disclosure purposes, I have a mustache and a goatie, so I think that is the source of my leak. Should I consider shaving? What is an acceptable number?

So, the other number, the AHI. My AHI is at 13.6, 17.5, and 14.7 for the 3 nights. All three of these are weighted fairly heavily towards the Apnea side vs Hypopnea, with the Apnea index being 11.5, 14.2 and 11.1. Looking a bit further into the data, the Apnea index is made up mostly of Obstructive, with minimal Central showing up.

With the different reports that I have seen here telling of AHI numbers that are <8 or 0, I'm wondering if I'm missing something. What is acceptable? Is there something I need to do differently to achieve a better result? Since I know how to unlock the machine and adjust settings, is there any validity to making small adjustments (to pressure perhaps) while monitoring readings over several nights to tune the setup. I'm an engineer by trade, so this sort of idea seems valid, but I don't know the ramifications of such adjustment.

Overall, I think I feel better, but I don't feel as good as I did after they had the mask on me in the sleep study. I had CPAP for 3 hours and felt like a new man afterwards...

I certainly appreciate any feedback that you may have to offer.

Thanks,
Mike

[mayondair]

Hello Mike and welcome! I do not remember how Resmed machines calculate leak, if it is subtracted from the normal mask vent rate or not so I'm sure someone else will chime in. You mask should not be so tight as to hurt, it has a cushion that should inflate with air and float on your face, look for Janknitz signature with a link to her blog and a great fitting tutorial. If you are not a mouth breather you may consider a different mask, nasal or nasal pillows so shaving may not be an issue. Mouth breathers around here have also been known to tape or use chinstraps with nasal masks. Your AHI should be below 5, most feel better when it's below 2 or 3, but nothing will be accurate until leaks are under control and you are used to sleeping with the mask, so this may take a bit to settle. You will want to look for trends not at single nights before you think about tweaking. For most I think it's a gradual improvement, not overnight success, so work on one problem at a time , you will get there soon!

[minelson33]

Hi,

Thanks for the reply! My first reaction was to think, "If my wife knew that she could keep my mouth shut with a chin strap or with tape, that would have been done long ago!!!"

So, based on your post, it seems that I should consider a different mask or should consider shaving in order to get a better seal from the mask I have. I was hoping that it wasn't normal to have to put a mask on as tight as I had it in order for it to seal. It's afternoon now and my jaw still feels worked over...

I'm still a little curious if anyone could give me an idea of what is a normal or acceptable leak number for Resmed. This will help me as I use the suggestions above to achieve a better fit.

Thanks again,
Mike

[nanwilson]

Welcome Mike
Don't shave that hair off yet, some of the "hairier" guys will chime in soon and help you out. We have a number of members with facial hair and they all use different masks, so don't dispair just yet. The quattro is not meant to be cinched down tight, it is meant to hover on your face. Read Jankintz blog about fitting the quattro or just type into the search field.. fitting the quattro,.. and you will pull up alot of discussion on the subject. Your ahi is a bit on the high side just yet, but you have just begun your journey and it takes patience to get it all right and down to acceptable levels.
Keep reading many of the discussions here and you will educate yourself.
Good luck
Nan

[mayondair]

We won't tell the wife about the tape and strap just yet . You should fill in your equipment in text in your profile, it will make it easier for others to help you. I know some Resmed models have a mask fit feature, does yours? If so use it at your full pressure without ramp for fitting. Does your machine have smiley / frowny faces for this fit feature? You might want to search the wiki on this site for leak info, all masks have a normal expected leak, I just don't know if your machine takes this into account or not, do you have soft wear? Check uncle-bob s signature for links . Patience grasshopper, there is a lot to learn Kathy

[Pugsy]

I'm still a little curious if anyone could give me an idea of what is a normal or acceptable leak number for Resmed. This will help me as I use the suggestions above to achieve a better fit.

ResMed does indeed subtract the mask intentional vent/leak rate before reporting leak so anything above 0 is excess leak.
ResMed says that anything above 24 L/min will impact therapy and probably data, so the goal is to keep the leak well below that 24 L/min number. On the ResScan software reports the 24 L/min line is red, so the goal is to keep the leak line well below the red line for the majority of the night.

[minelson33]

Thank you for the replies. I did happen upon the software today after reading the forum for some time and noted the red line on the leak chart. I have updated my equipment listings as suggested earlier after finding that little area of the site.

Thanks to all for the help so far. Night 4 approaching quickly!

Edit: Forgot to mention, thanks for the pointer to the blog regarding the mask fit. I spent about an hour with the mask this afternoon. We'll see what we get tonight!

[minelson33]

Good and bad news...

Good news first: Leak seemed OK... 95th Percentile of 3.6

Bad news: AHI of 20.6

I woke up last night with a thought... When I woke up, I almost wondered if the machine was off. I seem to remember more pressure at my face when I was in the sleep study. Could it be a bad thing that the machine backs down the pressure when I exhale? Pressure is set to 12, but EPR level is 3 (the max comfort level), which drops the level to 9 during exhale as I understand it.

<Sigh>

[Pugsy]

Bad news: AHI of 20.6

I woke up last night with a thought... When I woke up, I almost wondered if the machine was off. I seem to remember more pressure at my face when I was in the sleep study. Could it be a bad thing that the machine backs down the pressure when I exhale? Pressure is set to 12, but EPR level is 3 (the max comfort level), which drops the level to 9 during exhale as I understand it.

Yes, for some people that 3 cm drop in pressure during exhale is enough to let events sneak past the defenses.
You may need to either decrease EPR or increase pressure to compensate for it and thus have a slightly higher average pressure all night. If it were me, just starting out like you are, I would just decrease EPR in stages of 1 cm reduction to see if that helps. Disregarding nights where leak is large when evaluating the change. I have seen reports where simply reducing EPR will give marked improvement in the AHI.

[dtsm]

Pressure is set to 12, but EPR level is 3 (the max comfort level), which drops the level to 9 during exhale as I understand it.

Welcome to the forum. You are correct.

If you're initial setting is prescribed at 12, with an EPR 3, that means effective pressure on exhalation drops to 9. That 'might' be the reason for the high AHI numbers. EPR for many folks is based entirely on comfort, some prefer higher, others can do without it at all. I started at 3 but quickly reduced to 1.

I'd give myself a few more nights. Assuming your leak numbers remain under control, you would then need to consider increasing cpap pressure. The usual rule of thumb is for 1:1 ratio for EPR. So if your EPR is set to 1, you need to increase cpap pressure by 1.

Another option is after a few nights to switch to apap. Set at 12-16 and see what your 95th percentile number after a few nights. If you see it increase it is probably due to the EPR.

[TalonNYC]

Hiya:

I have the same exact setup (ResMed S9 Elite and Quattro Mirage FFM). For me, I had to shave the goatee, but left the moustache. That knocked my leak rate down to 0.0 every night. Other's advice is also very spot-on, do NOT ratchet the mask down, you'll get more leaks =)

The idea is to let the mask float on your face. It should feel tight when you put the mask on before the air is flowing, but at full pressure you should barely feel it at all.

First, turn off Ramp, then put the mask on and LAY DOWN - the FFM has a totally different fit when you are sitting up. I'd advise against using the "mask fit" feature as it fires air at you full-blast. Slowly tighten the mask until you feel no air escaping from anywhere but the air vent at the nose. Wait about 10 minutes, breathing normally. After 10 min, see if any new leaks crop up, if so, tighten slightly until they go away.

Next, try different sleeping positions, adjusting for leaks as you go.

It should be about 30 min of work total, possibly a bit longer, but should reduce your leaks a lot. Try this before shaving, as many folks report that they can use the Mirage with facial hair just fine. I have very wiry facial hair, and it seemed to be letting a lot of air out, but that's not the case for many folks.

Always remember that this is a process. It took me 3 masks and 4 weeks to get the leaks under control, but now I can swap headgear (for cleaning, etc) and get everything set back up in about 10 min flat.

Good luck!

[pap4life]

minelson..welcome sometimes our facial features are such that NO face mask is going to be the air tight interface that we hope to achieve..

Unless I overlooked it, I didn't see anyone, as yet, suggest you try the nasal pillows style. FWIW, I have a mustache (rather thick) and I could not wear any type of mask without leaks. I switched to a nasal pillows. (Resmed Swift LT) and waa-laa. NO (0) leaks.

[TalonNYC]

Unless I overlooked it, I didn't see anyone, as yet, suggest you try the nasal pillows style. FWIW, I have a mustache (rather thick) and I could not wear any type of mask without leaks. I switched to a nasal pillows. (Resmed Swift LT) and waa-laa. NO (0) leaks.

A very good point. I, myself, am in that 12% of the population where nasal-only masks won't work, but we're the minority. Most folks find they don't mouth-breathe after a few weeks of therapy, as they were only mouth-breathing because they couldn't get air at all during OSA events. If your DME has a trial program, checking out nasal pillows might not be a bad idea.

In case you were wondering about the 12% of us, there are some people who's tongue relaxes during sleep, meaning that we've either got to use a FFM or tape our mouths shut =)

[mayondair]

Mike, have you tried any other masks? Do you have any problems breathing through your nose when awake? A lot find nasal pillows more comfy, with or without tape or chinstrap. Getting the right mask is important, you need to have leaks under control, and be able to sleep with the mask all night. Getting your AHI down is the next order of business, you may want to collect a few days worth of data and then post some daily graphs.

[heiff]

Hi Mike,

I have a very heavy full beard and moustache and have had pretty good results with a nasal mask, but AMAZING results with nasal pillows. I am not generally a mouth-breather when I sleep, but even if I were, I don't think the addition of a chin strap would negate the comfort and the lack of leaks that I experience with the nasal pillows. I'd choose the pillows even if I did not have all the facial hair.

So definitely something worth thinking about - it's good to try out some other masks; if your insurance won't cover it, there are many options for snapping them up on the cheap.