Low AHI vs. Leaks??

[decatur11]

OK, here are three typical FL graphs. Tell me what you see and thanks so very much!

[Pugsy]

Looks pretty ugly. The middle one not so ugly.

What about your nose...can we blame any of that on nasal congestion?

If that were my report and my nose couldn't take any of the blame then I would probably try a little more pressure to see if the FLs seemed to reduce in numbers and intensity.
You saw my report...that's what it looks like with FLs are well controlled.

[decatur11]

I wondered if it would look "ugly" but had no basis for comparison but the couple I'd seen posted here. I read some earlier posts and then viewed my flow "shape." A lot of them have briefly flattened tops and, it is almost all "chairs" with the seat to the left not the right. I can see that when I have the FL's my pressure does go up, but not very much. My prescription pressure is 11 and it goes up to 12 often and to 13 if I have a big leak or breathe with my mouth open for a few minutes. Most nights I have only 2-4 events all night, though.

I do have the thing turned on that reduces pressure on exhale. Maybe I'll turn that off now that I'm more used to this and see what changes. And, yes, it could be my nose - I've started on Flonase due to the machine seeming to make the congestion so much worse, especially the mask I am using now, but need to use it more often; and, I wheeze most of the time from allergies I guess and my eyes itch and water a lot. I also have an inhaler that I only use rarely. Maybe I will experiment with combinations of these treatments to see if any change the shape or frequency of FL's. Have appointment with my FP and may get tested for allergies.

Are these FL's enough to be keeping me so tired? I know the "event" being defined as 10 seconds is, maybe not arbitrary, but a bright line that maybe is too high for me to get good rest. I also use a night guard on my teeth and have huge tori all along the inside of my lower teeth on both sides that leave very little room for my tongue; I asked the sleep doc if the tori could be contributing to the apnea but she'd never heard of that. It just seems there is less room for my tongue between both the guard in my mouth plus those tori. I know some people have them ground down but it is terribly painful.

I welcome any more observations or thoughts! Thanks so much.

[Pugsy]

Are these FL's enough to be keeping me so tired?

I don't know. Maybe. Especially if they are causing minor arousals from sleep stages.
Congestion getting worse since using the machine...perhaps play with humidifier settings. Some people need more humidity or they get similar symptoms to allergy symptoms (I am one of those) and some people get the same symptoms with too much humidity.
If you are using a lower setting...try increasing it..if you are using a higher setting then try decreasing humidity. There is no right or wrong as this is something that is personal preference and you will just need to play around with settings to see if it helps...sometimes take 2 or 3 days to see the change though depending on how bad the symptoms are.
I once dropped my setting from 4 to 1 because someone suggested it might help my AHI..bad idea. I had a really bad rhinitis thing for 3 days till my nasal mucosa get back to normal hydration.

Oh...also get something like Simple Saline and use it frequently during the day...it helps no matter what the cause for the nasal mucosa to stabilize and return to normal.

[decatur11]

Well, I have lots of ideas of things to try now. Only need to keep good enough records about what I change when and what difference it makes! Thanks very much. Maybe Robysue will take a look at my backwards chairs or FL's and offer an opinion, too.

[robysue]

decatur11,

Relatively speaking those flow limitations are not that ragged. Yes, there's a lot of "activity", particularly compared to the near-flawless example posted by pugsy, but look at the vertical axis of your flow limitation chart: Your flow limitations seldom get above 1/3 the way up the scale, indicating that the airway is remaining relatively uncompromised.

Now you might be super sensitive to anything going on with your airway. I can't remember: Did your initial sleep test say anything about you having a UARS problem? But if these were my flow limitation chart on a Resmed, I would not lose sleep over worrying about what to do about them. (Then again, pressure increases to get rid of flow limitations lead to aerophagia in my case.)

You write:

A lot of them have briefly flattened tops and, it is almost all "chairs" with the seat to the left not the right. I can see that when I have the FL's my pressure does go up, but not very much. My prescription pressure is 11 and it goes up to 12 often and to 13 if I have a big leak or breathe with my mouth open for a few minutes. Most nights I have only 2-4 events all night, though.

I'm not sure of the significance of which way the chair points. That's probably a question for Mollete. You might want to post a close up of a really good example that shows one or more of these chairs with the seat on the left and the pressure being increased at the same time in a new thread that might catch Mollete's eyes. Post both graphs along with the whole event table (which gives an idea of where in the night we're looking at the data). Only post the event graph, the close up of the wave graph, and the corresponding closes up the flow limitation graph and the pressure. But don't post all the other extraneous graphs.

I do have the thing turned on that reduces pressure on exhale. Maybe I'll turn that off now that I'm more used to this and see what changes.

Comfort is more important than obtaining the perfect flow limitation graph. If you turn EPR off, you may increase your discomfort because you may find it more difficult to exhale. Increased discomfort leads to more problems with getting a sound night's sleep, not fewer.

Remember: The point of PAP therapy is NOT a "perfect" night's sleep according to the data; the point of the therapy is to allow you to get a good night's sleep according to how you feel in the morning and how you function during the day. There's no point in chasing perfection on paper if it makes you feel worse (or even "no better") in the daytime. But it's also important to remember that PAP cannot fix anything except sleep disordered breathing, and you go on to write about a significant daytime breathing problem that could well be affecting how tired you feel during the daytime:

And, yes, it could be my nose - I've started on Flonase due to the machine seeming to make the congestion so much worse, especially the mask I am using now, but need to use it more often; and, I wheeze most of the time from allergies I guess and my eyes itch and water a lot. I also have an inhaler that I only use rarely. (emphasis added)

Yes, you need to keep track of the allergies and the wheezing. Heck, those FL might even be night time wheezing for all we know. You say you use the inhaler "only rarely." Is it possible that you need to use the inhaler a bit more frequently? In other words, check with your family doc (if s/he is the one who prescribed it) about when you should be using that inhaler as well as whether to pursue allergy testing.

But you also need to measure the effectiveness of the Flonase and the inhaler on how you feel instead of on how does the Flow limitation line look?

And for allergies, don't underestimate the power of a neti pot or a sinus rinse bottle in combination with the Flonase. They're a powerful team at keeping nasal allergies at bay.

Are these FL's enough to be keeping me so tired? I know the "event" being defined as 10 seconds is, maybe not arbitrary, but a bright line that maybe is too high for me to get good rest. I also use a night guard on my teeth and have huge tori all along the inside of my lower teeth on both sides that leave very little room for my tongue; I asked the sleep doc if the tori could be contributing to the apnea but she'd never heard of that. It just seems there is less room for my tongue between both the guard in my mouth plus those tori. I know some people have them ground down but it is terribly painful.

I know that you say you are still tired. But I'm not sure that the additional effort to try to further smooth out the FL all the way to 0 is going to have as much benefit as you hope it will. Sure, you can increase the pressure a bit and see if that helps. It might. Or it might just start a cascade of other problems: A higher pressure means more potential problems with leaks. A higher pressure can be more difficult to exhale against. And a higher pressure can mean there's more potential for problems with aerophagia. Now it could be that the leaks will stay below 24 L/min and they won't wake you up. (But if I recall, you think you're somewhat sensitive to leaks causing you to wake up or at least become restless). It could be that a higher pressure + EPR will still be comfortable to exhale against. And I don't know if you've had to battle aerophagia or not, so maybe aerophagia is not an issues. (But if you've been blessed with no aerophagia problems to date, trust me, you want to keep it that way.)

But this is important: You report that you "wheeze most of the time from allergies" and yet you "also have an inhaler that [you] only use rarely." Wheezing during the daytime can be exhausting. I wonder how much of your daytime tiredness is actually a product of the wheezing and allergies not being fully controlled rather than a symptom that there's still something seriously wrong with your sleep? Get the wheezing under control and see if that improves the daytime tiredness. That's my advice.

[ReadyforRest]

I am 5 weeks into this and have been totally tired and dragging. I'm struggling to find a mask that works and the closest I've come is the little Petite Wisp with a FP diffuser taped over the exhale port. It does not even come up to the bridge of my nose and is a little small at the nostrils but that seems to reduce the terrible swelling in my eyes and face compared to the larger Wisp and the Eson.

I'm very concerned about you using a diffuser taped over the exhale port with the Wisp mask. A diffuser is designed to be used with the Eson mask to cut down on draft and noise, but the Wisp is not designed to be used with a diffuser. The exhale port is there to take away the carbon dioxide that you exhale, so you aren't re-breathing it. If you're re-breathing carbon dioxide all night, that could be causing you to feel more tired than usual. Never cover over the exhalation port for any reason if your mask is not designed to use one. Please take that diffuser off your Wisp mask. And why are you using it? To stop the air from blowing in your eyes? To reduce the sound?

I am also concerned that you're using ... perhaps ... a smaller mask than you should be using, in an attempt to "reduce the terrible swelling into my eyes and face". Sounds like those larger masks were leaking air into your eyes. There are Pad-a-Cheek liners that can be used to create a better seal on nasal masks. Check out their website. You should always use a mask that is the correct size for you. Using a petite mask that is too small at the nostrils can cause discomfort problems that could wake you up. You need to find the right mask that is comfortable and doesn't leak as much.

You've tried several nasal masks. I started out with a nasal mask for the first week. Frankly I found it so uncomfortable over the bridge of the nose, and so loud ( Darth Vadar loud ) that it kept me awake for hours. I could not adjust to it. I then tried several different nasal pillows masks, found the one I liked best (Aloha) and never looked back. I DID test drive a couple of other full face and nasal masks, but hated them for all the above reasons and could never adjust. I found, like you, that in order to avoid leaking around the eyes, I had to keep my head in just the right position, which stressed me out, and kept me from falling asleep, and made me wake up at the least little air leak ... and they leaked a lot, around my cheeks, my eyes, the bridge of my nose, at every movement. You said you tried the Swift FX. Do you mean the Swift FX Nano nasal mask, or the Swift FX nasal pillow mask? Have you considered using a nasal pillow mask? There are many on the market. They make less facial contact, have fewer leaks, and do not blow air into your eyes at all. It might be worth a try. People new to xpap try many masks, and types of masks, before they settle on one or two that they are most comfortable with. Keep trying.

Never had this tiredness before CPAP.

It's normal for us to feel tired during the adjustment period of getting used to cpap therapy. You are only at the 5 week mark. It can take as much as 3 months (or more, it's all individual) to get settled in and get most of the bugs out. However, if you're more tired than you were before, there are things that you can be doing right now to help you get a better night's sleep. I found that my xpap therapy got more effective as I added things to my treatment that made it work better. They were: getting on autopap (not cpap), finding the most comfortable mask, getting leaks under control including keeping my lips closed, getting a hose holder, using a shaped or contoured pillow, finding the right EPR setting for me (1), not sleeping on my back.

My hands and arms are sore up from holding my head just right on my pillow (side sleeper always) or the mask where my head rests on my hands with mask between them. If I could relax a little maybe I would not be dragging so.

You should run, don't walk, to buy a contour-style pillow for side-sleeping. Find one that is comfortable, is the right thickness for you (every person is different and likes a different thickness, so really do your research into which one will suit you best). This can make a big difference to you being able to relax, fall asleep, and stay asleep all night without being tense and stressed out from using your arms to hold your head in the right position. I use the cpapmax https://www.cpap.com/productpage/cpapma ... oduct.html. I place it on another pillow to make it thicker. Or the Contour pillow https://www.cpap.com/productpage/contou ... cover.html or something else that appeals to you. There are cut-outs for your mask when you sleep on your side. A regular pillow pushes against the mask, and can dislodge it from your face, causing leaking and discomfort. My sleep got much better when I started to use a cpap pillow.

Buy a hose holder. There are several on the market. It lifts the hose up away from your body, allows you freedom to move around in bed without getting wound up in the hose, and takes away the worry that the hose will wake you up when you turn over.

I am getting AHI below 1 or 2 (in fact, with all masks I've used ever since night #1) but the leaks or sometimes mouth breathing wake me up frequently. I presume I am so tired because I cannot get a good night's sleep, maybe only two since I started. I think I can sleep with this mask finally, getting used to it a little. But, there are lots of leaks showing on Sleepyhead and some that may be mouth breathing. Someone here said not to worry about leaks so much if you are getting good AHI and sleeping. Can folks confirm that? Maybe I'll sleep better if not worrying so about leaks. Advice or help or confirmation that leaks are not such a big deal when AHI is below 2?

You are getting great numbers, especially for just starting out at this. It took me many months to get my numbers down to where yours are. And yours have been there from the start, so you should feel good about that. Which means that other things are making you not sleep well. Let's face it. Wearing a mask attached to a hose, blowing air down your throat all night WILL make you not sleep well, or have an interrupted sleep all night, until you get used to it. Give it more time.

Everyone is different. Some people have little sensitivity to leaks. They can sleep right through them. Others have great sensitivity and any little leak will wake them up. Your numbers are great, so your leaks aren't negatively effecting them. However if your mouth is falling open (blubbering lips) and air is escaping from it, that can wake you up and be irritating. If it happens often during the night, it isn't good for your sleep, and you need to fix the problem right away.

Most masks allow your mouth sag and your lips to open, causing leaks. Nasal masks (and nasal pillow masks), while smaller and less bothersome, DO have this negative side-effect. I always use a chinstrap to keep my mouth closed. But chinstraps don't really hold your chin up very well, and they don't keep your lips closed. I've made one that covers my mouth too, and keeps my lips closed all night. It works like a charm. Many people here use tape to keep their lips closed. There are many topics here that you can search for that information. Find a way to keep your lips closed at night, by whichever means feels most comfortable to you.

[NateS]

though I cannot imagine it, get one of those pillows

decatur11, I would just like to say that I was very skeptical of the cpapMax pillow when I saw it and squeezed it with my hands in the store, but I overcame my reluctance and bought it; I'll tell you that even though it looked and felt weird - too small; too chunky, etc. - now I look forward to leaning back and laying my head down on mine at night. It feels great to relax and sleep on! My neck and head feel wonderful lying on it! Regardless of whether I am lying on my back or my side. And it is much less likely to interfere with my mask when side-sleeping, compared to a conventional pillow.

Best wishes, Nate

[decatur11]

Thanks to everyone who has been so helpful. I understand a lot more of what Sleepyhead is telling me. I need to take a methodical approach to this, record what changes I make and not make too many changes at once or too quickly. There may be another mask or two to try - I guess a lot of folks are in continual search so that seems OK.
The Flonase doesn't seem to help much; I think Nasonex worked pretty well for me in the past so maybe I'll see about switching to that. I am set up with the nasal saline. Will start making notes so I can be organized when I see my FP in a few weeks. Next on the list: pillow for side sleeping.