Adjustment phase for a Newbie CPAP user ?

[pearlr]

Hello Everyone !
I am new here and hoping to get some answers today.

DH was recently diagnosed with OSA . He went through a sleep study and his ENT doctor suggested he start using a CPAP mask.
His machine is RedMed S9 with climate control and mask is RedMed Mirage Quattro Full face. Setting is 12 cms / H2O.

He has been using the mask for a week now but is just not able to get a good nights sleep with the mask on. Lays awake for almost 2 - 4 hours with the mask on before he feels sleepy and wakes up often through the night. On a postive note - I have noticed he doesn't snore AT ALL when he has the mask on !

I am concerned that the entire reason for getting a CPAP mask is getting defeated if he's not getting a restful nights sleep . While he is getting frustrated ; he's still not ready to give up ( YET ) .

My question is firstly and more importantly - how long does it take to finally get adjusted to the mask and get a good 7 - 8 hours of sleep ?
secondly - he is starting to get a red mark on the bridge of his nose which is now raised and an angry red color. Doesn't hurt . Can he do something to avoid the mask from causing this ?

Thank you in advance.

[Guest]

Has he tried other masks yet? I went from a nasal, to full face to pillows and pillows did the trick.

Took me a few weeks to get real comfortable.

[jromano]

pearlr,

Welcome! There's no lack of answers and opinions around here... you've come to the right place!

I am concerned that the entire reason for getting a CPAP mask is getting defeated if he's not getting a restful nights sleep . While he is getting frustrated ; he's still not ready to give up ( YET ) .

Whatever he does, please don't give up!!!

My question is firstly and more importantly - how long does it take to finally get adjusted to the mask and get a good 7 - 8 hours of sleep ?

I know this probably isn't the answer you're looking for, but it varies greatly. Some adjust to the set-up the first time, while for some it can take weeks, months, years.
There are many factors at play in a complete CPAP setup. Arguably, the most important is the mask. Seal, comfort, style, etc. You mentioned that he's wearing a Quattro. Is he definitely a mouth-breather? Many people are able to use a nasal mask in combination with a chinstrap or even tape, retrain themselves to keep their mouth closed, or discover other underlying conditions for which mouth breathing is merely a symptom.
Even within only the full face mask category, there are many different types of masks and interfaces. Has your DME (Durable Medical Equipment provider) showed him some other options? Is he wearing the correct size?
A wonderful member here, Janknitz, has a blog post specifically about fitting the Quattro properly - it may provide some new information. http://maskarrayed.wordpress.com/taming ... e-quattro/

secondly - he is starting to get a red mark on the bridge of his nose which is now raised and an angry red color. Doesn't hurt . Can he do something to avoid the mask from causing this ?

CPAP therapy does not need to be painful.
Is he wearing the correct size? Has he tried different masks? Are the straps being overtightened to compensate for leaks?
You could try making a homemade mask liner from an old cotton t-shirt; cut out a piece in the shape of the mask and then a hole in the middle of that so it sits directly between the mask and your skin.
There's another wonderful forum member, Karen, who owns a business called Pad A Cheek. She makes a number of different fleece mask cozies that provide some padding between mask straps and the skin. http://www.padacheek.com/

Best of luck to you and your hubby - keep asking questions and keep us updated!
I'm sure more members will be along shortly to offer seasoned advice.

Cheers,
Jess

[Janknitz]

Most people do have an adjustment period. If his difficulty sleeping persists or gets more intense, Roby Sue will be along with a post about insomnia--but some sleep disruption is normal at first. You should see his awake time and frequency of wake ups decrease as he gets more comfortable with the machine

There are some things that will help:

1. Getting used to the mask is the most difficult thing. We recommend that your husband try wearing the mask and using the machine during the day when not trying to sleep, while doing something quiet but distracting like watching t.v., listening to music, reading, etc. This is simply to desensitize himself to the mask.
2. The mask should not be hurting his nose. I have some tips for fitting masks with air cushions in my signature ("Taming the Mirage Quattro") but before too much time goes by he should call the DME and ask for help. He may need a different mask and should be able to return this one and try out others until he finds the right mask--but don't wait too long or the DME will not be willing to swap it out. Most exchanges should be done within 30 days. If the DME won't swap it out--let us know and we can give you some hints on dealing with them. Nasal pillow masks don't touch the bridge of the nose at all, but in order to use them successfully your husband must be able to keep his mouth sealed while he sleeps. Some people use a chin strap or tape to help so that they can successfully use a nasal pillow or nasal mask.

You told us the make o fyour husband's machine, but not the model. Is it an autoset, Elite, Escape, or Escape Auto.?Hopefully it's not either the Escape or Escape Auto because those machines don't have efficacy data. If it's an Elite or Auto-set, there are ways to access the data to see if something in the machine's settings are contributing to his frequent wake ups. Often it's a simple thing that can be tweaked (with the doctor's approval) to decrease his sleep disturbances.

[robysue]

Hello Everyone !
I am new here and hoping to get some answers today.

DH was recently diagnosed with OSA . He went through a sleep study and his ENT doctor suggested he start using a CPAP mask.
His machine is RedMed S9 with climate control and mask is RedMed Mirage Quattro Full face. Setting is 12 cms / H2O.

Do let us know which particular S9 he's got. CPAPs are kind of like cars and the exact model name is important. The S9 Escape and Auto Escape are the stripped down versions (no useful efficacy data) and the Elite and the AutoSet are the upscale versions with full efficacy data.

He has been using the mask for a week now but is just not able to get a good nights sleep with the mask on. Lays awake for almost 2 - 4 hours with the mask on before he feels sleepy and wakes up often through the night. ...

While he is getting frustrated ; he's still not ready to give up ( YET ) .

My question is firstly and more importantly - how long does it take to finally get adjusted to the mask and get a good 7 - 8 hours of sleep ?

How long does it take to start sleeping "normally" again? That really depends on the particular CPAPer. I think that most new CPAPers are typically told by their sleep doctor, their DME, and by people on forums like this that it usually takes a couple of weeks to a couple of months. But, alas, there are some new CPAPers who take much longer than that. The trick if you land in the unlucky bunch is to somehow manage to keep on trying. And to cling to what small positive changes you do see, until your hard work starts to slowly pay off. CPAP is not a "miracle cure" for most of us; it is an on-going therapy that requires our active participation to make it work for us in our individual beds each and every night. And some nights will always be better than normal (YEAH!) and some nights will always be worse (*sigh*). The long-term goal is to get the number of GOOD nights to far exceed the number of bad ones.

Now please let me be clear: I am a rather far outlier in adjusting to CPAP: My on-going battle with CPAP induced/enhanced insomnia started on Night 3 with a disturbing dream of my being an intelligent goose being fattened up for fois gras by "forced-breathing"---having more and more air forced into my lungs and knowing this forced-breathing would continue until my lungs would pop and I'd wind up on somebody's plate in a fancy French restaurant.

However, things happen for a reason (or so we're told), and I'm now reconciled with the fact that my long and difficult adjustment period has at least allowed me to help many others avoid or get out of the CPAP & Insomnia Club. So here's hoping your hubby can avoid not joining this Club altogether. Or if he feels that he's already a member, here's hoping that his membership is very, very short.

First: The facts that hubby is still lying awake for 2 to 4 hours every night NOT sleeping AND is waking up AND is getting frustrated ARE troubling. And in my humble opinion, he may want to start addressing the insomnia NOW instead of waiting for it to get worse. Or he simply gets so frustrated with NOT sleeping that he consciously or unconsciously begins to make decisions that start to undermine his adjustment or that lead to his simply giving up altogether.

Second: If mask anxiety is an issue, then yes, have him wear the mask in the daytime as suggested by others. But if he's lying in bed for 2--4 hours and NOT TAKING the mask off at night, I rather doubt mask anxiety is the issue.

Third: As others have said---the mask should NOT be uncomfortable to the point of causing pain and sores. Get him back to the DME now for exchanging the mask for another type (if possible) or at least a good refitting of his current mask. It could be as simple as he's tightening the straps and the forehead brace too tight. If he's NOT a mouth breather, he should definitely try on a nasal pillows mask---there's no forehead brace at all. If he is a mouth breather, he may do better in a hybrid mask. But the mask is the KEY to making CPAP work long term: If the mask causes PAIN, you just won't be able to wear it night after night after night.

Fourth: I've included a long, standard post that I've written just for new CPAPers who are finding themselves lying WIDE AWAKE at night trying desperately to get (or stay) asleep with the mask on. It's full of things I've learned in my own battle as well as from reading at length both here and elsewhere about what has helped others make this difficult adjustment when the CPAP machine seems to trigger more problems than it solves. Not everything will apply to your hubby's situation, but some of it ring true to his particular situation. So if you and he read through my essay on CPAP induced insomnia, it should provide you with plenty of ideas to try as well as some guideline on just when to call in the heavy artillery and get help from the sleep doctor's office or the DME.

Best of luck,
robysue, the honorary reluctant president of the CPAP&Insomnia Club

********************
So now you're "sleeping" with the mask, only it doesn't feel like you'll ever get sleep (or stay asleep) with the mask on: Taming the CPAP-Induced Insomnia Monster

By RobySue.

INTRODUCTION
Sleeping with a six foot hose attached to your face is not exactly natural. And it's no surprise that lots of people have some trouble getting to sleep and staying asleep at the start of their xPAP therapy. After all, there's a lot to get used to:

• sensory overload triggered by the air blowing into your nose; the noise the machine makes; the sensation of the mask on your face; possible leaks waking you up, aerophagia; a dry mouth; a dry nose; skin problems triggered by the mask; a sore nose and/or sore nostrils; headaches caused by a mask being over tightened; an over awareness of your own breathing, etc. etc. etc.
  
  mask issues including properly tightening the mask (is it too tight? is it too loose?); mask leaks blowing into your eyes or onto your lips; exhaust flow from the mask bouncing off the covers and back into your eyes or onto your chest; removing the mask in your sleep; wanting to remove the mask so that you can get to sleep; worrying about leaks so much that you are not able to properly relax to get to sleep; and worrying about dislodging the mask to the point of feeling like you can't move around in bed as much as you'd like.
  
  pressure issues including a feeling that your breathing is so abnormal that you can't relax enough to fall asleep; difficulties with exhaling against the pressure; difficulties with feeling like you can't properly inhale or can't get enough air through the mask---particularly during the ramp period (if you use the ramp); feeling like the machine is rushing you to inhale when the exhale relief system is turned on; too much air in your mouth, swallowing air, aerophagia, etc.
  
  humidifier issues including rainout; congestion caused by too little or too much humidity; air feeling too warm, too wet, too cold, too dry; worrying that the humidifier may run dry.
  
  hose issues including getting tangled in the hose when you want to turn over; disliking the feel of the hose when your arms or chest bump up against it; weight of hose pulling the mask out of position; feeling tethered or trapped by the hose, etc.

And as this lengthy list makes clear: Some of us face a pretty step learning curve for learning to sleep and sleep well with a mask on our faces.

For most new CPAPers, it's only a matter of time before the problems with getting to sleep and staying asleep start to resolve themselves. And sleep begins to return to normal---in the sense of falling asleep in a timely fashion after going to bed at a decent bedtime; having few or no awakenings in the middle of the night; having no problems getting back to sleep quickly after these awakenings; sleeping through until morning and waking up feeling more rested and more refreshed than when you went to bed.

But for some new CPAPers, instead of slowly beginning to resolve themselves within the first month of therapy, these problems grow worse and worse. Eventually they may cascade into full fledged CPAP-induced (or CPAP-enhanced) insomnia: And this causes additional problems with sleep fragmentation and sleep deprivation. So in addition to the discomfort and trouble of dealing with all the physical aspects of adjusting to CPAP, these new CPAPers find themselves unable to fall asleep night after night or they wake up night after night feeling anxious, worried, angry, or simply deeply uncomfortable and desperate for sleep. Sometimes a sufferer of CPAP-induced insomnia trys to just gut it out, hoping that things will soon get better (and they don't). Other times, in the wee hours of the morning the sufferer will simply give into their baser instincts and rip the mask off (in frustration and disgust) so they "can get some sleep."

And until the sufferer of CPAP-induced insomnia starts to work on addressing both the the insomnia itself as well as the specific CPAP issues that may be triggering the insomnia, it will be very difficult to make a complete adjustment to CPAP. Moreover it may be difficult to subjectively feel any of the real benefits from CPAP until the insomnia is under control.


SIGNS THAT YOUR PROBLEMS WITH GETTING TO SLEEP OR STAYING ASLEEP WITH THE MASK ON MAY BE DEVELOPING INTO CPAP-INDUCED INSOMNIA
So how do you tell if your problems getting to sleep or staying asleep with the mask on are threatening to turn into full fledged insomnia? Here are some sure fire signs that what you are dealing with is becoming an insomnia monster:

• You've suffered from insomnia before and what you are going through feels like insomnia to you. If you've fought an insomnia beast before, you know what it feels like. Trust your instincts even if you're at the very beginning of your therapy. For me, my CPAP-induced insomnia was clearly settling in by my third night of using the CPAP machine. And I knew that it was starting to feel like my previous bouts with insomnia even though the trigger was quite different.
  
  Your problems with going to sleep or staying asleep are still around after a month of using CPAP and/or they are seriously affecting the quality of your life. This is about the standard time frame of when occasional problems with insomnia are considered to have become chronic problems. If insomnia problems have not started to resolve themselves within a month, they likely won't resolve completely on their own. You will need to do some work to tame the insomnia beast before it gets even larger.
  
  You start dreading going to bed night after night. And so you delay going to bed as long as you can.
  
  You lie in bed for what feels like hours on end unable to go to sleep (or get back to sleep) on many nights. And while you are lying in bed, you may also be focusing on just how uncomfortable the whole CPAP thing is: The mask is bothering your nose. Or the noise from the machine is keeping you awake. Or the air being blown down your throat starts to tickle the back of your throat. And so on and so forth.
  
  You consciously rip the mask off on many nights in order to finally get some sleep. Sometimes the decision is made early in the night after not being able to get to sleep for an hour or more. Other times, the decision is made much closer to dawn when you can't get back to sleep after awakening--often due to some CPAP-related issue like a leak.
  
  You feel more ALERT and AWAKE after you put the mask on for the night than you did before you masked up. And you can't seem to get yourself settled down and relaxed enough to fall asleep in a timely fashion.
  
  You start sleeping irregular hours in an attempt to get "caught up" on your sleep. Once you finally get to sleep at some ridiculous hour in the early AM, you are very reluctant to wake up and get out of bed at your normal wake up time---because you need the sleep. Only getting up late in the morning then causes more problems with getting to sleep the next night ...
  
  You worry about all kinds of things when you are in bed or preparing to go to bed: You find yourself worrying about all the CPAP stuff; worrying about how little sleep you are getting; worrying about how long you've been lying in bed trying to get to sleep; worrying about how soon morning will come; worrying about whether the CPAP is doing anything for you or not; worrying about the fact that your sleep subjectively feels much worse now than it did before you started using CPAP; worrying about the worrying itself; etc. etc. etc.

And if any of these behaviors describe what's happening to you, then here's my advice as someone who's been there and done that: Don't ignore the CPAP-induced or CPAP-enhanced insomnia. Because until you start to work on addressing both the specific issues that may be triggering the insomnia and the insomnia itself, it will be very difficult to make a complete adjustment to CPAP, and you may very well not be able to subjectively feel any benefits from CPAP until the insomnia is under control.


SO WHAT TO DO ABOUT CPAP-ENHANCED OR CPAP-INDUCED INSOMNIA?
The first thing to do if you think that CPAP-induced insomnia may be setting in is to not ignore it. Start by using standard self-help tips for all insomnia suffers. But in addition to the standard tips, be aware of how the CPAP itself may be adding to the insomnia and work on addressing those issues as well. Start dealing with the CPAP-induced insomnia by taking the following steps:

• Pay attention to your sleep hygiene. If you've never fought a battle with insomnia before, you may not be aware of sleep hygiene. But there are common behaviors that tend to aggravate insomnia (particularly once it starts) and sleep hygiene is all about replacing those behaviors with ones that will help tame the insomnia rather than feeding it. A typical set of good sleep hygiene guidelines can be found at http://www.umm.edu/sleep/sleep_hyg.htm . Read through the list and critically examine your own behaviors when you can't fall asleep to identify which of the good sleep hygiene practices may be most important to implement immediately and which you can work on over time. Sleep hygiene practices and CPAP use are discussed in more detail later.
  
  Identify specifically what kinds of things are triggering the insomnia. Write down a list of everything that you think is making it hard for you to both get to sleep and stay asleep. Write down specific things that you can identify. Keeping a sleep log for a week may help if you can't already identify which parts of CPAP are causing you to lose sleep. And start working on CPAP problems such as leaks, mask fit, masking the noise of the machine, etc.
  
  Use a sleep log. The use of a sleep log may help you focus on which of the insomnia triggers are most critical to address and solve and which can wait. It may also help you see subtle, but positive changes in how you are feeling with the use of CPAP. And it will help you determine whether the insomnia is getting worse, stabilizing, or beginning to get better. Keeping a sleep log is not all that difficult. You can use a notebook or a spreadsheet to do it. Here's how to do it:
  
  • Every MORNING after you get up write down the following information:
    • What time you actually went to bed
    • Estimate of how long it took you to fall asleep (See Note 1 below)
    • Estimate of how many times you woke up during the night
    • Time you got up for the morning
    • Estimate of total time you slept during the night (See Note 1 below)
    • Comments on how you feel upon waking up for the day (See Note 2 below)
    • Additional comments on any wakes that you feel were disruptive or problems you had getting to sleep. They don't need to be very long or elaborate. Something like: "Woke up twice with mask leaks bothering eyes" is plenty enough detail.
    NOTE 1: The time estimates are just that: Estimates. The accuracy of these estimates is not important---what's important is your subjective feeling about how long it took to fall asleep and how long you actually slept during the time you were in bed. So don't base the time estimates on data generated by looking at a clock. Looking at the clock is a BAD idea since it tends to create worrying about how little sleep you're getting and how little time there is left before morning.
    
    NOTE 2: The comments about how good or bad you feel when you wake up are critically important. When your adjustment to CPAP starts to go better, you will likely start to see some (minor) changes in how you feel when you wake up. It might be as simple and as minor as "usual headache seems less intense this morning". For me, the first noticeable positive change due to CPAP was that I was no longer waking up with low grade pain in my feet and hands every single morning.
  Make a CONSCIOUS decision each and every night to sleep with the mask on JUST FOR TONIGHT. Yes, it's easier to sleep without the mask on---particularly at the beginning. But every time you consciously choose to sleep without the mask, you are making it that much harder to mask up the next night. Tackle the "I can't believe I have to sleep with a hose for the rest of my life" issues one night at a time.
  
  Report the insomnia to the sleep doctor's office. Ask to speak with a nurse or a PA and give them as many specific details as you can about what's causing the problems with getting to sleep and staying asleep. If all you can say is, "I can't seem to sleep with the CPAP on," they will simply say, "Give it more time." But if you can give them specific problems, that gives them something to work on.

A CLOSER LOOK AT SLEEP HYGIENE FOR CPAP-INDUCED INSOMNIA
The basic idea behind good sleep hygiene for a new CPAPer with insomnia problems is to help you teach your mind and body to make a deep triple association that

• Being in Bed = Time to Sleep = Time to Mask Up

Many insomniacs make their insomnia worse by falling into certain behavior patterns that either make it more difficult to fall asleep or more difficult to remain asleep. Good sleep hygiene practices are designed to break these behavior patterns by replacing them with behaviors that are more conductive to encouraging sleep. Many of the good sleep hygiene practices are nothing more than common sense. But some of them are counter intuitive and require some effort to implement. But they all focus on the need to teach your mind and body to make the deep association that Being in Bed = Time to Sleep.

For new CPAPers, there is the additional challenge of teaching both mind and body to make a further deep association that Time to Sleep = Time to Mask Up. And unfortunately, many newbies who find sleeping with the mask is causing them further problems with fragmented sleep and daytime exhaustion and sleepiness, choose behaviors that seriously undermine establishing the critical association that Time to Sleep = Time to Mask Up.


GOOD SLEEP HYGIENE PART 1: THE BEDROOM AND SLEEPING ENVIRONMENT
Remember the basic idea behind good sleep hygiene is to help you teach your mind and body to make a deep association that Being in Bed = Time to Sleep.

In order to make this deep connection: Do NOT use the bed for anything except sleep and sex. Lying in bed reading, watching tv, web browsing, texting, talking on the telephone, and eating are all teaching your body that the bed is NOT a special place reserved for sleep and sex. And that it is perfectly ok to be in bed and wide awake doing things that can be done in many other places in your house or apartment.

So---kick the tv and other electronic gadgets out of the bed room. Try to avoid reading in bed.

Take the time to make sure your bed is comfortable. And that the room is sufficiently dark for sleeping for your entire sleep period. If outside lights are a problem, consider getting blackout shades or learning to sleep with an eye mask.

Quietness is important as well---although it can be too quiet if you have tinnitus or if the noise of the CPAP starts to bother you. In that case a bit of white noise or soothing music played at a very low (almost inaudible) volume may help. Earplugs will make tinnitus worse and may make the noise of the CPAP machine worse if the noise is being conducted through your hose. Keep the temperature in the bedroom cool enough where you won't get hot, but not uncomfortably cold.


SLEEP HYGIENE PART 2: GOING TO BED AND GETTING TO SLEEP
The first and most important rule of good sleep hygiene is: Only go to bed when you are sleepy.

Sounds simply enough. But note that feeling sleepy is not the same as feeling tired or exhausted. It is nearly impossible to fall asleep if you are not sleepy regardless of how tired or exhausted you feel. And so it is critically important to learn to distinguish between feeling sleepy and feeling tired. Sleepiness is involves both your mind and your body. It is a positive feeling for most people. For many people, sleepiness is characterized by yawning, stretching, and the eyes getting droopy and heavy. Tiredness and exhaustion tend to be more related to how the body feels rather than how the mind feels. And being over tired or over exhausted can make it harder to fall asleep.

Other important things to keep in mind about going to bed:

Take time to establish a bed time routine. This helps both the mind and the body start to relax and feel sleepy. What your routine consists of is entirely up to you.

If all the new CPAP-related stuff that needs to be done before you mask up for the night is making you MORE AWAKE and LESS SLEEPY at bedtime, then do as much of the CPAP stuff early in the evening. Fill the humidifier up and put the mask, hose, and machine back together for the night around supper time. Prefit your mask in need be. Wash your face right after supper time instead of waiting until bedtime. All of this will minimize the fussing with the machine right at bedtime and minimize the tendency of taking care of the equipment waking you up right before bedtime.

Don't go to bed angry---and this includes anger directed at the CPAP or the OSA itself. It's hard to be sleepy and angry at the same time. Work out the anger and then go to bed.

Try to establish a reasonable and consistent wake up time and a reasonable and consistent bedtime. Waking up and going to bed at more or less the same time all seven days a week helps the body and mind start to get sleepy at the right time each night. It also helps the body know when to wake up and that in turn helps it sleep better during the hours that it is in bed. Pick the wake up time first---be sure it is something you can live with on both weekdays and weekends. Then count backwards by the amount of sleep you typically need to function at your best in order to determine the bedtime. While it's important to get enough sleep every night, it's also important to realize that oversleeping can leave you groggy and not at your best. Most people seem to need somewhere between 7 and 9 hours of sleep each night. If you don't know how much you need, guess that you need about 8 hours.

If you are NOT sleepy at your regular bedtime, wait until you ARE sleepy before going to bed.. Remember: You can't fall asleep if you are NOT sleepy. So if you are NOT sleepy, you don't belong in bed. If you are not sleepy at bedtime, try to do a quiet relaxing activity that will let you wind down and become sleepy. A cup of warm milk might help. A bit of bedtime reading (but not in bed) might help.

Get up at your regular wake up time regardless of how much or how little sleep you got the previous night. If it was a bad night for the insomnia, you will be tired and exhausted during the day. But sleeping late to make up for a bad night will make it harder for you to go to bed on time the next night because you will likely not be sleepy at bedtime. And that perpetuates the insomnia.


GOOD SLEEP HYGIENE PART 3: WHAT TO DO WHEN YOU CAN'T SLEEP BECAUSE OF THE CPAP
Remember: The basic idea behind good sleep hygiene is to help you teach your mind and body to make a deep association that Being in Bed = Time to Sleep.

And the basic idea of adjusting to CPAP itself is to teach your mind and body to make a deep association that Time to Sleep = Time to Mask Up.

So in dealing with CPAP induced or enhanced insomnia, the goal becomes to make a triple deep association:

• Being in Bed = Time to Sleep = Time to Mask UP

So anything that undermines this (triple) goal has to be dealt with. Common things that CPAP-induced insomniacs do that undermine this triple association include:

Lying in bed AWAKE for hours fighting with the mask. It takes time to master all the details of masking up every night. But lying in bed for hours while awake and fighting with the mask is counterproductive: It's teaching your body how to stay awake and resist the mask instead of sleeping with the mask. So allow yourself to spend about 30 minutes fighting the leaks or the mask straps or the feeling that you cannot stand to have the mask on your face. But at the end of 30 minutes, if you are not sleepy and still actively fighting with the mask, get out of bed, go into a different room and do something that will help you get your mind OFF the mask and CPAP problems and that will also help you start to relax and feel sleepy enough to try going back to bed and masking up again.

Yes, getting out of bed is counter intuitive. But it's really important: That's the only way to reinforce that being in bed is reserved for two very special biological functions: Sleep and Sex.

Consciously taking the mask off (often because of frustration about not being able to fall asleep with the mask on) and then sleeping part of the night without the mask on. The ultimate goal for the OSA sufferer is to make using CPAP a daily habit---something you don't over think and over worry about---sort of like brushing your teeth each night. (And yes, I know how ridiculous that sounds.) But every time you allow yourself to consciously fall asleep without the mask on, you are teaching your conscious mind that it does NOT really need to accept sleeping with the mask. And that in turn makes it that much harder to both mask up the next night and fall asleep with the mask on the next night.

So if you absolutely cannot stand the thought of having the hose on your nose for one more minute, it is time to get out of bed, go into a different room, and settle yourself down. This will involve dealing with the anger or anxiety you may be feeling toward the machine. You can't fall asleep if your mind is angry or over anxious. If the problem is discomfort triggered by the machine, try to think about how to solve the problem while you are out of bed. Return to bed only after you are calm enough to mask up again and sleepy enough to be in bed.

Watching the clock tick away. Wake up, look at the clock, and worry about the time, and how the clock time tells you how little sleep you have gotten so far; how little time remains for sleep before morning comes and the alarm goes off; and how difficult it will be to get through the day because of how little sleep you will have gotten during the night. This is a common behavior pattern for insomniacs; it is counterproductive because it allows your mind to continue to believe that it is OK to be in bed and be wide awake worrying about the time (and other things) instead of being asleep in bed.

For CPAP induced insomnia, watching the clock also leads to worrying about compliance time. (Have I got my four hours in for the night?) Which in turn leads to a habit of taking the mask off at the end of four (sleepless) hours and deciding to try to get a bit of (badly needed) sleep without the mask before the alarm goes off. Which in turn leads to worrying about how much harder it is to sleep with the CPAP than without it, and worrying about how much worse you feel in the daytime with CPAP than without it.

The only solution to watching the clock is to get rid of the clock! For many folks, simply turning the clock so that it faces away from the bed is enough. But if you find yourself waking up and turning the clock around to find out what time it is, you will need to move the clock away from the bed to a spot where you cannot see it from the bed when you wake up.

If you normally sleep well past dawn and you find yourself awake in the bed in the early morning and worrying about the time (and how little you have slept during the night) because the room is now light, you may need to get some black out shades for the windows so the dawn's early light doesn't give you time clues about how much or how little time you've been asleep. Black out shades will also eliminate waking up because of the morning light shining in your eyes as well.


SLEEP HYGIENE PART 4: ADDITIONAL RULES FOR NEW HOSEHEADS
These rules are designed to help teach your body and mind to make that deep association that Time for Sleep = Time to be Masked Up.

Never consciously go to sleep without the mask on your face. Every time you choose to consciously go to sleep without the mask on your nose, you are allowing your mind and body to continue to deny the need to learn to sleep with the hose. So don't do it.

Do NOT consciously remove the mask at night so that you can "finally get some sleep." For the same reasons as the first rule, obviously. If you are tempted to just remove the mask so you can "get some sleep," it's time to get out of bed, go to a different room, and settle yourself down. Do some kind of quiet, soothing relaxing activity to take your mind off the mask. And return to bed only after you are both sleepy enough and calm enough to face masking up again.

If you wake up without the mask on, calmly put the mask back on, turn the CPAP back on, and try to get back to sleep. Don't bother to analyze why you took the mask off in your sleep during the middle of the night. While you are fully responsible for decisions you make when you are awake, you can't control what your unconscious mind does when you are asleep. However, make notes about this behavior in your sleep log the next morning and during the daytime, try to trouble shoot the problem.

Try not to dwell on the "I have to do this forever" aspect of adjusting to CPAP. Yes, being diagnosed with OSA and prescribed a CPAP seems like a life sentence. But tackle the problem one night at a time. Each night at bedtime, make the decision just for tonight to sleep with the hose one more time. Don't worry about tomorrow night (and the following night and the night after that and so on) until that night gets here.


WHEN SLEEP HYGIENE IS NOT ENOUGH
Sometimes following the self-help guidelines is not enough to slay the insomnia beast. In general, you should seek help from your sleep doctor if your CPAP-induced insomnia:

• becomes severe enough to cause serious problems with your daytime functioning,
• is causing you to think seriously about abandoning CPAP therapy altogether because you believe you sleep better without CPAP than with it,
• is caused by serious CPAP adjustment issues, such as aerophagia or mask leaks or air getting into your eyes that you have not been able to fix or address sufficiently well on your own or with help from forum members,
• has not responded sufficiently well after using self-help guidelines for several weeks, or
• is continuing to get worse in spite of using self-help guidelines.

When you contact your doctor's office, you should ask to speak to a nurse, PA, or the doctor about the combination of CPAP adjustment problems and insomnia. This is particularly important if the doctor who is tracking your progress with adjusting to CPAP is your PCP and not a sleep specialist. If asked what the problems are, try to give the receptionist a short list of the major problems, but don't be overly vague either.

When you get a chance to talk or meet with the nurse, PA, or the doctor, be prepared to discuss the things you believe are feeding the insomnia. Include both CPAP and non-CPAP issues if the insomnia is being fed by multiple things going on in your life. Also be prepared to discuss at length what measures you've already taken to treat the insomnia---either on your own or with the advice of your PCP if you are now talking with someone in the sleep doctor's office.

If you have been keeping a sleep log, use it to refresh your memory about what issues seem to be triggering the insomnia. Bring a copy of the sleep log with you to give to the nurse, PA, or doctor at your appointment. If possible see if you can drop the sleep log by the doctor's office one or two days in advance of your appointment so that the person you are seeing has a chance to review it before the appointment. If you don't already keep a sleep log, the nurse, PA, or doctor will likely suggest that you start one.

The nurse, PA, or doctor will likely offer you a prescription for sleeping pills of some sort or suggest doing serious behavior therapy work on cleaning up your sleep hygiene, dealing with any anxiety issues, and consolidating your sleep cycles. Or he/she may suggest combining the two approaches. So you need to know how you feel about taking sleeping pills or doing behavior therapy work before you talk to your medical practitioner.

The BEST approach to therapy for CPAP-induced insomnia depends on YOU.
Different people have different comfort levels with taking daily medication and with their reactions to the commonly prescribed sleeping medications. You need to think carefully about which approach is most in line with your own preferences for your medical care. And the right choice for me may well be the wrong choice for you.

It's also important to remember that the treatment of your combination of insomnia and CPAP adjustment problems is NOT an either/or decision: Drug based treatments may be more effective with a bit of an effort to change some particularly counter productive behaviors. And even the most committed of CBT patients may need a small bit of drugs as a back up measure to prevent too many disastrous nights in a row for example.

Drug based treatment.
You may be comfortable with trying a short course of prescription sleeping pills such as Ambien, Lunesta, or Sonata. You might also be comfortable taking a supplement like melatonin on a nightly basis or an OTC sleeping pill. But at the same time, be sure to educate yourself about the pills you are using: What's the correct way to take them? How long should you expect to take them nightly---several weeks or months or permanently? How likely are they to cause rebound insomnia? When should you try to wean yourself off the pills? What's the proper way to wean yourself off them? All these are things that you will want to discuss with your specialist---even if you are using OTC sleeping pills.

And when you're given that prescription for a nightly sleeping medication, your doctor will still likely tell you to pay attention to the most basic rules of sleep hygiene: Don't watch tv or read in bed. No caffeine after lunch. Try to get up at the same time on weekends. etc. Follow the suggested rules. They will help the sleeping medication be more effective and make it easier to discontinue it when that time comes.

Anxiety and claustrophobia may still be issues even if you are taking a nightly sleeping pill. If simply using the CPAP causes the anxiety for you, you may need to do some cognitive behavior therapy to get over the anxiety of masking up. Likewise if you are claustrophobic and the mask aggravates that you may need to work on simply getting used to putting the mask on your face. The most commonly suggested thing is to drag the cpap machine out of the bedroom in the daytime and use it when you are watching tv or reading. If the anxiety or claustrophobia is severe, you may even have to start with simply holding the mask over your nose for a few minutes at a time. And in severe cases, the specialist you see may suggest a prescription anti-anxiety medication. Or formal cognitive behavior therapy or both.

Cognitive Behavior Therapy for Fighting Insomnia
If prescription sleep medication is something you are not particularly comfortable with your specialist is likely to stress a cognitive behavior therapy approach to treat both the insomnia and the CPAP adjustment issues. Such approaches usually focus heavily on a collection of behaviors know collectively as good sleep hygiene as well as dealing with any anxiety issues you might have with behavior therapy: There are ways to slowly overcome anxiety that is induced by putting the mask on for example.

If you decide that you want to fight the insomnia largely through CBT rather than relying on sleeping medication, here's what you need for it to be successful:

• a great deal of patience: CBT is a long term solution---you'll see improvement over the course of weeks and months not days
• self discipline: If you cannot force yourself to do the hard work of changing your behavior (permanently) then CBT will likely not work for you.
• a desire for a drug-free or largely drug-free approach to fighting the insomnia: If you have no problems with taking sleeping medication (and many people don't), a combined plan of attack with moderate amounts of expectations of changed behavior may work far better than trying to make serious, long lasting changes in your behavior patterns.

And here's what to expect from a CBT approach to fighting insomnia:

• Strict adherence to all the standard good sleep hygiene rules, with further restrictions on things like caffeine consumption
• Keep a detailed sleep log to establish the slow, but steady progress
• (Temporary) sleep restricted schedule for several weeks to several months: Your time in bed may be artificially restricted to six hours (or less) in an effort to consolidate your sleep cycles. The time in bed will be increased only after your insomnia begins to abate in the sense of latency to sleep onset, number of night time awakenings, and estimated total sleep time.
• Gradual return to a normal sleep schedule: Once the sleep cycles are looking like they've begun to consolidate, the increase in time in bed will be done incrementally by very small amounts---in my case, the increments are 15 minute intervals. And if any problems arise, it's back to the previous bedtime until the problems resolve themselves.
• Inevitable (temporary) set backs and plateaus: There's a lot of two steps forward, one step back in the process.
• A willingness to consider some occasional use of prescription sleeping medication to prevent too many disastrous nights in a row from piling up: You may be asked to consider taking an Ambien, Sonata, Lunesta, etc. the night AFTER you've had a particularly bad night. Or possibly the night after you've had two particularly bad nights in a row. Typically you get to define what "particularly bad night" means in terms of the insomnia.
• A willingness to consider melatonin or herbal supplements that may be more acceptable to your notion of how much medication you are willing to take.

In a CBT approach, your caretaker will also spend time talking to you about how insomniacs often over estimate the time they are awake during the night and underestimate the time they are asleep. Simply knowing that you are likely drifting in and out of sleep during restless periods where you're not WIDE AWAKE enough to warrant getting out of bed is very useful in controlling the worries in the middle of the night. And this knowledge may allow you to focus more positively on the sleep you got instead of negatively on the sleep you wish you'd gotten.

If stress, anxiety and/or claustrophobia are also issues feeding the insomnia, your sleep specialist may also recommend getting CBT from a CBT specialist for learning how to better cope with those issues that go beyond the scope of the sleep specialist's training.

[Lizistired]

Along with the model fo S9, please let us know what his settings are for
Pressure,
Ramp(time and starting pressure),
EPR

[pearlr]

Thank you everyone for your replies.

We did want to try the Nasal pillow but the DME said with 12 cms / H20 Pressure it would be too much for him . Would feel like a blowdryer blowing into your nose ( her exact words ) .

Has he tried other masks yet? I went from a nasal, to full face to pillows and pillows did the trick.

Took me a few weeks to get real comfortable.

[pearlr]

His DME did try on 4 maks before he was finally ok with the Full Face Quattro. He had worn that during the sleep study as well and was ok with it then too.
Even though he he is not a mouth breather - he seems to be more comfortable with a full face mask coz a nasal mask would need a chin strap etc. But he may have to try that option out again. Thanks for suggesting.
His mask is not painful - it just leaves a red mark. Sorry for not being very clear. However its red enough to be noticeable on his face.

Thanks for the links - I will check them out.

pearlr,

Has your DME (Durable Medical Equipment provider) showed him some other options? Is he wearing the correct size?
A wonderful member here, Janknitz, has a blog post specifically about fitting the Quattro properly - it may provide some new information. http://maskarrayed.wordpress.com/taming ... e-quattro/

secondly - he is starting to get a red mark on the bridge of his nose which is now raised and an angry red color. Doesn't hurt . Can he do something to avoid the mask from causing this ?

CPAP therapy does not need to be painful.
Is he wearing the correct size? Has he tried different masks? Are the straps being overtightened to compensate for leaks?
You could try making a homemade mask liner from an old cotton t-shirt; cut out a piece in the shape of the mask and then a hole in the middle of that so it sits directly between the mask and your skin.
There's another wonderful forum member, Karen, who owns a business called Pad A Cheek. She makes a number of different fleece mask cozies that provide some padding between mask straps and the skin. http://www.padacheek.com/

Best of luck to you and your hubby - keep asking questions and keep us updated!
I'm sure more members will be along shortly to offer seasoned advice.

Cheers,
Jess

[pearlr]

His CPAP Machine is the S9 Elite.
Pressure setting is 12 cms /H20 ( inhale and exhange pressure are same )
Ramp is set at 45 mins starting at 4cms /H20

Along with the model fo S9, please let us know what his settings are for
Pressure,
Ramp(time and starting pressure),
EPR

[pearlr]

Hi !
Thank you for the tips. I will have my hubby read about "Taming the Mirage Quattro". I read it and its very helpful and detailed information !

Most people do have an adjustment period. If his difficulty sleeping persists or gets more intense, Roby Sue will be along with a post about insomnia--but some sleep disruption is normal at first. You should see his awake time and frequency of wake ups decrease as he gets more comfortable with the machine

There are some things that will help:

1. Getting used to the mask is the most difficult thing. We recommend that your husband try wearing the mask and using the machine during the day when not trying to sleep, while doing something quiet but distracting like watching t.v., listening to music, reading, etc. This is simply to desensitize himself to the mask.
2. The mask should not be hurting his nose. I have some tips for fitting masks with air cushions in my signature ("Taming the Mirage Quattro") but before too much time goes by he should call the DME and ask for help. He may need a different mask and should be able to return this one and try out others until he finds the right mask--but don't wait too long or the DME will not be willing to swap it out. Most exchanges should be done within 30 days. If the DME won't swap it out--let us know and we can give you some hints on dealing with them. Nasal pillow masks don't touch the bridge of the nose at all, but in order to use them successfully your husband must be able to keep his mouth sealed while he sleeps. Some people use a chin strap or tape to help so that they can successfully use a nasal pillow or nasal mask.

You told us the make o fyour husband's machine, but not the model. Is it an autoset, Elite, Escape, or Escape Auto.?Hopefully it's not either the Escape or Escape Auto because those machines don't have efficacy data. If it's an Elite or Auto-set, there are ways to access the data to see if something in the machine's settings are contributing to his frequent wake ups. Often it's a simple thing that can be tweaked (with the doctor's approval) to decrease his sleep disturbances.

[svarney]

I have been on CPAP since the end of April. It took a few days to get comfortable with the mask I had. I did develope a sore on the bridge of my nose and put up with it until last week. I talked with my doctor and he wanted me to try the nasal pillows and I love it. My pressure is set to auto ramp up to 11 after 10 minutes of use. If he has the unit that will ramp up you may want to suggest to set the time out alittle so he can get comfortable in bed. Have him try the nasal pillows it should work for him. Just have him stick with with it.

[robysue]

Thank you everyone for your replies.

We did want to try the Nasal pillow but the DME said with 12 cms / H20 Pressure it would be too much for him . Would feel like a blowdryer blowing into your nose ( her exact words ) .

LOL. There are lots of people here who use nasal pillows with pressures that are at this level or even higher. If the pillows are properly fitted and placed, you notice far LESS breeze with them than with either a nasal mask or a FFM. Tell that DME to let your hubby try the pillows and see for himself whether they work for him.

Even though he he is not a mouth breather - he seems to be more comfortable with a full face mask coz a nasal mask would need a chin strap etc.

If he's NOT a mouth breather, then why would he need the chin strap with a nasal mask? That makes no sense at all.

As for the bump just being RED, but not painful. There simply should NOT be a RED bump at all if the mask is fit correctly. A red bump is indicating the mask is putting too much physical pressure in one concentrated spot. If the bump is not painful now, who's to say it won't become painful in the future? And why should your hubby have to go through life with a big red bump on his nose? It's hard enough to get used to this therapy without a constant reminder every time you see yourself in the mirror.

[pearlr]

Robysue :

The mask was 100% covered by Insurance and we could get any mask. My husband is not a mouth breather but he does get seasonal allergies; so after discussing various scenarios and options with the DME we all came to the conclusion that a full face would be the best bet. Incase he gets allergies / nasal congestion - the nasal mask would not help since he WOULD end up breathing though his mouth.
Also, the thought of wearing a mask every night was a lot to handle - and to add to that a Chinstrap seemed like too much would be going on...so we opted for the Full face.

[pearlr]

Since our mask was covered by Insurance , I am not sure if it can be "exchanged".

Thank you everyone for your replies.

We did want to try the Nasal pillow but the DME said with 12 cms / H20 Pressure it would be too much for him . Would feel like a blowdryer blowing into your nose ( her exact words ) .

LOL. There are lots of people here who use nasal pillows with pressures that are at this level or even higher. If the pillows are properly fitted and placed, you notice far LESS breeze with them than with either a nasal mask or a FFM. Tell that DME to let your hubby try the pillows and see for himself whether they work for him.

[Janknitz]

We did want to try the Nasal pillow but the DME said with 12 cms / H20 Pressure it would be too much for him . Would feel like a blowdryer blowing into your nose ( her exact words ) .

I don't know where these DMEs get their information--it certainly isn't from users who have to sleep with this stuff. The nasal pillows (Swift FX and LT, at least) are rated up to 20 cm and people use them comfortably with BiPaps delivering even higher pressures. You really, honestly, and truly do NOT feel the pressure in your nose, other than a pleasant coolness, unless you have severe sinus issues. The nasal pillow masks must be fit properly, however. Some DME's don't ahve a clue what they are doing and insist the user cram them up the nose. Nasal pillows rest against the outside of the nostril, NOT in it, and the headgear should be fairly loose. They are extremely comfortable, and because there is so little surface area that has to seal, they are much easier to seal than other types of masks. I have a fitting guide for nasal pillows as well ("Swift FX Fitting Guide").

That said, I'm mostly a Quattro user lately (need to change my signature!). I've had a series of upper respiratory infections with asthmatic bronchitis, and the FF mask works better for that because of lingering sinus issues and cough. The FF mask gives me a lot of relief at night. Despite all my hints and tips, leaks continue to be an issue, but not so much that they interfere with getting good therapy from the machine. I'm coming to the conclusion that it's almost impossible to have no leaks with the Quattro, but it is possible to manage the leaks--at least with an auto machine--and still get good therapy. BUT, it is a very hard mask for beginners.

That red bump indicates pressure and it will get worse over time. It's worth considering trying nasal pillows, if for no other reason thatn to give that area some pressure relief. Just learn to take whatever the DME says with a grain of salt.