Why is my Face Swollen?

[FatBruno]

Anything looking unusual in my post above? I've been looking around the forums at other Oscar results. I rarely find anyone with the pressure I have @ 25. Most AHIs seem lower than mine. I also see a lot of leaking when the pressure builds at what appears to be REM. I am convinced my F20 Large is too big for my face now. I get a Medium in tomorrow, and I have a Philips DreamWear full mask coming in soon. We'll see what happens with that I guess.

[Miss Emerita]

FB, a couple of things strike me.

You are doing a fair amount of snoring.

You have somewhat heavy flow limitations. These may or may not be bothering you, and for now I'd suggest we leave them to one side. Later on, you could experiment with a little more pressure support, if other changes don't help you. Oh, and I should ask whether you experience nasal congestion or constriction. FLs often come from the relaxation of the tissues lining the pharynx, and those can be addressed by PS. But FLs can also appear in the nose, and PS is unlikely to help them, though addressing the nasal problem can be a boon.

You have some random obstructive apneas and then a blizzard of them starting at around 3:13, with some random ones later. Is that kind of clustering typical for you?

Clustering strongly suggests a positional issue. If you were sleeping on your sides the rest of the night but rolled onto your back, then the back-sleeping might be the problem.

And in any position, you might be getting clusters of OAs because you are tucking your chin toward your chest, which can partially constrict your airway. To deal with possible chin-tucking, the first step would be to get a low and firm pillow if you use a high pillow or several pillows. The next step would be to get a soft cervical collar. This can help you keep your head in a position that will give you a nice unconstricted airway.

I hope you soon find yourself with a mask that works well for you.

[FatBruno]

I assumed the clustering was REM sleep. After looking around the forums, it seemed to be a common issue. Most nights, I do cluster around 2 - 3am. Last night's data shows the same thing. Do you think entering REM is a culprit for the clusters?

I previously snored a lot, so I assumed that was normal? I'm not sure what the snore data should look like compared to others. My wife reports that she does not hear me even sleeping or snoring anymore, so I'm not sure what's going on there.

My wife does say I tuck my chin, so that might explain that. I do sleep on my side, but I alternate between sides. I do not like to sleep on my back and my sleep study shows that, too. I sleep almost evenly on both sides, and I flip back and forth all night, though a lot of that is due to mild hip pain. If I do sleep on my back, it's very little at all. It's possible that I'm sleeping on my back during the clusters, but I wouldn't know. I do not wake up on my back very often. That would be an extremely rare event for me. I suppose if it's a positional issue on my back, it's possible the cluster occurs on my back, and then I roll to my side. I have no idea about that. Again, is it possibly just entering REM? How would I know?

[FatBruno]

Last night's data. Seems similar to me, but I'm not sure.

[Pugsy]

Normally we have more than one REM sleep stage during the night...so if the ugly clusters were strictly REM related I would expect to see more ugly clusters.
BUT it wouldn't be impossible for the ugly cluster to be both REM related worsening OSA and a positional worsening component combination of things happening. Like maybe being in REM AND being on your back...and other parts of the night when you might have been in REM you weren't on your back.

Do you happen to have a copy of any sleep studies that might tell you if your OSA is worse in REM or not?
How did they come up with these pressure settings you were prescribed? Did you have a sleep study done in a sleep lab with cpap machine to help determine pressure needs?

I think that you probably need a little more baseline pressure (EPAP with this machine) to better prevent those ugly clusters from happening in the first place.....whatever the cause might be.
Current settings are 5 EPAP plus PS of 5 and then the machine can go up as needed...always with that 5 cm difference between inhale and exhale. While you do kiss the upper limits of your machine at times...you aren't spending all your sleep time up pushing 25 IPAP and 20 EPAP. Most of the time it's actually more in the mid to upper teens.

I don't suggest increasing PS beyond 5 at this time just to deal with flow limitations. Above 5 PS and there's an increased risk in central apneas forming. I would instead look at EPAP increase to help deal with the FLs...you need EPAP increase anyway to help prevent the ugly clusters anyway.

If it were my report....I would add 1 cm increase in EPAP minimum to 6 and see what happens.
Often when the minimum baseline pressure gets up to a more optimal level the machine may not need to go as high.
The higher minimum helps PREVENT the collapse in the first place so then the machine doesn't need to go quite so high to try to kill what is happening.
Prevention is always better than trying to fix after the fact.

[FatBruno]

I'm not sure, but here's what my sleep results showed. This was an at-home study.

[Pugsy]

Your home sleep study was what we call a Type 3 sleep study....it didn't measure sleep status so there's no way to know if your OSA is worse in REM or not.

You would have needed a Type 2 sleep study which does measure sleep status...similar to what is done in a sleep lab setting.

For details on the various home sleep studies..read this.
http://freecpapadvice.com/home-sleep-tests

Now all that said...I have always felt that it didn't really matter if it was REM related or supine related or whatever related...just adjust the machine so it can optimally deal with whatever and be done with it and sleep in whatever position a person wants to sleep in. It's not always so easy to change primary sleep position anyway.

Interesting to note that per your sleep study...side sleeping was a lot worse than sleeping on your back at least in terms of OAs but you had a significant number of hyponeas when supine.
And look at the hyponea numbers when on your side...either side.
What we don't know is how much time you might have actually spent on your back to get such a lower AHI. Maybe it's a lower AHI because minimal time was spent on your back.
Normally supine sleeping will worsen OSA. You may be the exception or maybe you just didn't spend all that much time asleep on your back.

At any rate my advice doesn't change. Increase the minimum EPAP a little bit and see if preventing the whatever caused events gives you a more improved/lower AHI.
Start with small increase and give it several nights for your body to adjust and then maybe try another small increase.
I am thinking 8 or 9 minimum EPAP is going to be needed but I don't like big changes for several reasons.
Main one is big jumps can be a problem with comfort and someone not being able to sleep. Gotta sleep first for any of this stuff to matter.
Another reason is sometimes smaller actually works out better than what is initially thought.
So adjusting is easier going with slow increases and sometimes people get lucky and smaller increase actually works out great.

Are you using the mask fit feature on your machine when you fit your mask at the beginning of the night?
If not...you need to because it will deliver a higher pressure than what you are starting out at.
Obviously what seals well at 5 EPAP and 10 IPAP isn't going to seal so great when EPAP is 10 and IPAP is 15.

[FatBruno]

Well, I will probably give it one more night because I am getting two things in the mail today:

1. a Medium ResMed AirFit F20 (not the Large I have now which I think is too big)
2. a PadTheCheek Mask Liner

I'll upload new data tomorrow to see if much has changed. Then I will try to go to 6 EPAP as you recommend.

I suspect the back position is just not where I sleep and that's why there isn't much data. I've always been a side sleeper, and I've always switched sides throughout the night -- even as a child.

With respect to the home sleep study: as I've mentioned in a prior post, I have panic attacks and generalized anxiety. My MD suggested a lab sleep study, and I pushed for a home sleep study. Ultimately, I decided to get a home sleep study on my own accord and against my doctor's advice. Truth be told, I really hate my MD for so many other reasons, and I'm trying to find someone new. I actually canceled my last appointment with him because I really don't want to go back at all. That's an entirely different story and unrelated to my sleep apnea. But I'm simply mentioning the anxiety that I have in sleeping in a lab. I realize the results might be better, but there's an excellent chance I'd have a panic attack or not be able to really sleep at all in a lab. I take Lexapro for my anxiety.

I have used the mask fit feature, but only a few times and certainly not every night before bed. I'm gathering from your post that I should be, so I guess that I will.

I'm going to look at the cervical collar you mentioned because I do know that I tuck my chin. I sleep always in a fetal position on my side curled up. I'm thinking I might be constricting my own airway doing that.

[Pugsy]

I can understand wanting to find a different doctor....I have fired several in my life just because I didn't like them for whatever reason.

I didn't mean to knock your home study....it was more than enough to get a reliable diagnosis in your situation.
The fact that it didn't measure sleep status would be more of an issue if your numbers were maybe borderline for making the diagnosis.

Proceed at your own pace...yes make use of that mask fit feature more consistently...give the cervical collar a try because it might just work and would be an easy fix. Sleep in whatever position you want to sleep in because trying to alter positions sometimes will create additional falling asleep problems and just remember that sleep is your number one priority.
Without sleep none of this matters.

Please be aware that the Lexapro has some rather ugly side effects....research them just so that you are aware that some of your daytime symptoms could possibly be related to medication side effects.
It also has been known to mess with sleep stages and even inhibit REM sleep in some people. All of those type of meds can do that as a side effect.

[FatBruno]

Thanks very much for all the advice! I'm very intrigued by the neck brace because I really think there's something to that. I will definitely try it!

[Miss Emerita]

Not to pile on too much gear here, but....

Given the hypoxea measured in your sleep test, you might want to try using a recording oximeter to see how your O2 sats are doing. Several of those devices are compatible with Oscar, meaning you can see the night's data in a graph that will allow you to correlate what your O2 is doing with everything else (pressure, events, FLs, snores, respiration, etc.) Click on Oximetry Wizard on the Welcome page to see the list.

I hope the increase in your EPAP that Pugsy has recommended, plus a soft cervical collar, will help you with the OAs, plus maybe even the snores and FLs.

Keep us posted, would you?

[FatBruno]

Would a ResMed Oximetry Module work? I have a regular Oximeter at home, but obviously that is something I would put on when I'm awake. Does the ResMed Oximetry Module work with Oscar, and do I need to attach anything else to my body to make it work?

[FatBruno]

Last night seemed worse in certain ways. First of all, I got my new Medium F20. It's too small. After putting on the Medium mask and the PadTheCheek mask liner, I could NOT breathe out of my nose. It just pinched my nose too much. I tried adjusting it several ways and I cut a larger whole in the mask liner. None of it worked. I spent an hour last night running Mask Checks on my machine on both the Large and Medium masks, with and without the liner. I did not see any kind of improvement in mask leakage with the liner. So, I ended up sleeping with the Large mask again and the liner.

The results show not only a higher AHI, but a lot more leaks. I want to say the mask might have been even tighter than usual, because I could not get a good result from the mask check without tightening it.

I want to point out that I'm running it at max pressure here. How many of you are doing the same? Everyone says don't over-tighten it, but I am telling you it leaks like crazy (esp. into my eyes) unless I do. I don't know how to get around this, and I've tried now two sizes. The Large is too big; the Medium is too small. I seem to be between sizes or something. I'm going crazy trying to find a solution.

The type of apneas seemed to differ. I tried to keep my chin not curled up, but I have no idea how successful I was doing this in the middle of sleeping. At one point, I woke up thinking it was time to get up, and I took my mask off. You will see that gap in the data below. Then I tried to put the mask on and it felt like the liner was laying on my mouth, so I took it off again briefly to try and adjust it. I got so frustrated sitting up in bed playing with all this equipment. I'm not sure what to think anymore, but it's all very annoying.

Tonight I will try raising the EPAP to 6.0 I guess. I'm not sure what else to do. What do you guys think?

[Pugsy]

Time to accept the fact that your facial structure just doesn't play nice with this full face mask.
Move on to another mask of some sort.

You are NOT running at max pressure all night. Yes, some of the time you come close but it's NOT happening all night.
Quit worrying about it....it is what it is for now and there's a good chance with a more optimal minimum pressure that higher attained ceiling might get lowered. You need more minimum EPAP anyway....use it and see what happens.

As for comparisons...there are people who start out with minimum pressures of 20 cm all night long and they can go up to 25 and some machines will even go to 30 cm....there are a lot of people using pressures all night way above what you are using.
I have a friend that needs a minimum of 17 cm to deal with her OSA....so she starts out the night at 17 cm minimum EPAP.
You are starting out the night at 5 cm EPAP. There are lots of people using, successfully, much higher pressures all night long without major leak problems.

Yes...higher pressures do present additional challenges but these challenges can be met.

Don't you have a nasal mask to try? Try it....did you know that sometimes people can get by with less pressure using a nasal mask than they might need with a full face mask? Sometimes as much as 3 or 4 cm less pressure.
No guarantees but the possibility alone should convince someone to at least try a nasal mask of some sort.
What do you have to lose? And if you are worried about mouth breathing being an issue...cross that bridge if/when you come to it.

[FatBruno]

How is this "excellent"?