Removing mask unconsciously after 1–3 hours despite low leaks and good AHI

[cpapusern30i]

If anyone here can help or give advice based on this data, I would be really grateful. I have been struggling with therapy for 5 months and have been unable to keep the mask on for more than 2–3 hours a night. I remove it unconsciously during sleep. I have recorded myself with a time-lapse camera and have tried gloves, socks on my hands, etc. to prevent it.

I currently use an AirTouch N30i with a chin strap and nasal sprays to reduce nasal swelling/obstruction. I do still experience some dry mouth, possibly from after the mask is no longer on my face. I have also tried full face masks (F20, F30i, AirTouch versions), but I remove those even sooner.

My determined titration pressure was around 13.5–14, although that titration pressure was not performed during REM sleep or while supine, which is where my apnea is most severe.

I have attached last night’s OSCAR data and my settings below. Most nights, leaks appear controlled until shortly before I remove the mask. I slept over 9 hours last night, and the session with the mask on was only 36 minutes.

If anyone could help or point me in the right direction, I would really appreciate it. I honestly have not felt well rested in almost a year.

[cpapusern30i]

Attached are 4 more files:

[cpapusern30i]

Attached are my Ventilation, Exp. Time/ Insp. Time, and AHI graphs

[Pugsy]

Have you tried taping the mask straps to your face in hopes that the discomfort removing the mask will wake you up enough to stop removing the mask?

There's nothing on the reports that give a hint as to why you remove the mask prematurely that I can see.

Your brain wants it off....and you have developed a bad habit of letting the brain win.

[cpapusern30i]

Thank you for the reply. What has been confusing to me is that the removals happen even on nights where leaks seem controlled and the mask feels reasonably comfortable while awake. I have also tried multiple mask types, and the full face masks actually come off even sooner.

Last night the session was only 36 minutes despite sleeping over 9 hours. On video, I noticed myself touching/adjusting the nasal area once or twice before eventually removing the mask, although I do not remember consciously deciding to take it off before falling back asleep. I will try your method. Do you have any other suggestions?

[Pugsy]

Do you have any other suggestions?

I am sorry but you got my one and only idea. Premature mask removal is not a problem that I have ever really had. When I first started cpap therapy I probably removed the mask in the middle of the night a handful of times and didn't realize it until I saw the report.
Problems that I have experienced and worked through I sometimes can offer more thoughts but in 16 plus years I can count one hand the number of times I have done that.

Taping the straps to the face has always been what people get offered as an idea though. I have always said that to fix a problem you have to first figure out what the problem is and in this case that means figuring out why you remove the mask prematurely.

Kinda hard to figure out the "why" though. You have already tried multiple masks...... Maybe take a look at the mask I prefer to use (link in my signature line) and see if it looks interesting to you. It uses adhesive and magnets to stick to the face and maybe something totally different would break the cycle. The adhesive sticks REALLY well and the magnets attaching the hose don't come loose easily at all. At this point for you with your history I wouldn't even worry about mouth breathing because you can't keep the mask on long enough to really be effective. I would worry more about the premature removal right now and put any potential mouth breathing issue on the back burner.

[Mguitar]

I'm not an expert or anything ( I just started myself ) but it looks like you wake up, move around for a few minutes and then take the mask off. Maybe investigate why you are waking up in the first place. You don't have a flow limit around the time you wake up but maybe the machine just isn't catching it. Zoom in on your Flow Rate around the time you wake up and see if your inhale (upper part of flow rate) is flat on top or is reducing overall flow rate as time goes on.

Try taking Magnesium Glycinate and maybe L Theanine with it. It calms your CNS which might reduce arousals. You can get it at basically any store that sells vitamins (walmart, cvs, etc.).

[cpapusern30i]

I'm not an expert or anything ( I just started myself ) but it looks like you wake up, move around for a few minutes and then take the mask off. Maybe investigate why you are waking up in the first place. You don't have a flow limit around the time you wake up but maybe the machine just isn't catching it. Zoom in on your Flow Rate around the time you wake up and see if your inhale (upper part of flow rate) is flat on top or is reducing overall flow rate as time goes on.

Try taking Magnesium Glycinate and maybe L Theanine with it. It calms your CNS which might reduce arousals. You can get it at basically any store that sells vitamins (walmart, cvs, etc.).

Attached is my flowrate graph around that time: please let me know if there are any conclusions we can draw.
Thank you

[Mguitar]

That flat line bit at the start is where you stopped breathing and the machine marked it as an Obstructive Apnea. So you woke up from the OA and took the mask off.

[cpapusern30i]

That flat line bit at the start is where you stopped breathing and the machine marked it as an Obstructive Apnea. So you woke up from the OA and took the mask off.

I see, thank you for the information. Does the same pattern seem to apply to these flow rate screenshots as well? In all of these cases, the mask was eventually removed. I have been wondering whether the changes in breathing before the removal may indicate some sort of disturbance/arousal that contributed to the mask removal, rather than perfectly stable sleep followed by random unconscious removal from discomfort alone. At the same time, I understand that becoming semi-awake and interacting with the mask itself could also create irregular waveforms, so I am not sure.

I attached several additional screenshots below. Also, I changed the response setting to Soft today and managed to keep the mask on for about 4.5 hours, which is significantly longer than usual. I still woke up a few times during the night and eventually removed it while awake, but I woke up with the mask, tape, and chin strap still on.

One thing I did notice was dryness when I woke up. My climate settings are currently on Auto with the tube temperature at 78°F, but the humidifier tank itself did not feel warm in the morning. I also sleep with a fan on in the room, so I am wondering whether dryness and arousals from that may also be contributing to the awakenings/removals.

[Mguitar]

The first one looks like another OA but the other two look like post arousal CA’s. Basically you “wake up”, breath deeper and then when you drift back to sleep you stop breathing so your co2 levels get back in sync. You do this while awake too you just don’t realize it. If you take a few deeper breaths while awake you will pause your breathing for a second to stabilize. Keep in mind the machine won’t pick up every disturbance. The threshold for an event is static and if you miss it by a second then it won’t flag it.

Look at the breaths on your first pic, some of those peaks are flat which signals a partially blocked airway.

[Pugsy]

You are zooming out way too much with your snippets. You need to be able to see more of what went on before.

I disagree with the first example shown. I don't believe it is an OA...the 3 spikes in air flow immediate to the sort of flat line point to an arousal......so arousal came first then the most likely holding of your breath then the large leak.

When you see those big spikes those indicate big breaths or gulps of air. Usually means some sort of arousal either awake or semi awake.

When you see flat lines of any real duration that means no air is moving....most like some sort of apnea or almost apnea.
Remember anything flagged has to last at least 10 seconds to earn a flag.
9 seconds of flat line won't earn a flag....gotta be at least 10 seconds duration.

Asleep breathing is very regular and smooth.
Here below are a couple of examples of both asleep and arousal breathing. Also remember you may or may not remember the arousal.
I circled the asleep breathing in red....anything not in the circle I wasn't asleep.



same time frame but just zoomed out more

[cpapusern30i]

You are zooming out way too much with your snippets. You need to be able to see more of what went on before.

I disagree with the first example shown. I don't believe it is an OA...the 3 spikes in air flow immediate to the sort of flat line point to an arousal......so arousal came first then the most likely holding of your breath then the large leak.

When you see those big spikes those indicate big breaths or gulps of air. Usually means some sort of arousal either awake or semi awake.

When you see flat lines of any real duration that means no air is moving....most like some sort of apnea or almost apnea.
Remember anything flagged has to last at least 10 seconds to earn a flag.
9 seconds of flat line won't earn a flag....gotta be at least 10 seconds duration.

Asleep breathing is very regular and smooth.
Here below are a couple of examples of both asleep and arousal breathing. Also remember you may or may not remember the arousal.
I circled the asleep breathing in red....anything not in the circle I wasn't asleep.



same time frame but just zoomed out more

Interesting, I figured there was probably something going on with arousals.

I attached screenshots from both my diagnostic and titration studies since that will probably give more context than just the OSCAR flow rate snippets. One thing I found especially interesting is that the titration report says the AHI dropped to 0 at 14 cmH2O, but looking at the pressure table, that pressure was reached during neither REM nor supine sleep. Since my untreated study showed much worse hypopnea activity while supine, I am wondering whether 14 cmH2O is not necessarily the true maximum pressure I may need in more vulnerable sleep stages/positions.

The studies also showed a pretty high respiratory arousal burden with mainly hypopneas rather than obstructive apneas, no PLMS, and fairly strong positional worsening.

If you get the chance to look through the screenshots, I would really appreciate your thoughts on what you think may actually be driving these repeated arousals and irregular breathing patterns before mask removal. I am wondering whether it seems more like residual flow limitation/hypopnea instability, pressure transitions, EPR effects, REM/supine instability, or simply semi-awake arousal breathing itself.

I do also have ADHD, although it has improved substantially over time and I only require a very small Ritalin dose now, so I am not sure how much that would realistically contribute here compared to the respiratory findings.

You have already been extremely helpful, thank you again.

[cpapusern30i]

You are zooming out way too much with your snippets. You need to be able to see more of what went on before.

I disagree with the first example shown. I don't believe it is an OA...the 3 spikes in air flow immediate to the sort of flat line point to an arousal......so arousal came first then the most likely holding of your breath then the large leak.

When you see those big spikes those indicate big breaths or gulps of air. Usually means some sort of arousal either awake or semi awake.

When you see flat lines of any real duration that means no air is moving....most like some sort of apnea or almost apnea.
Remember anything flagged has to last at least 10 seconds to earn a flag.
9 seconds of flat line won't earn a flag....gotta be at least 10 seconds duration.

Asleep breathing is very regular and smooth.
Here below are a couple of examples of both asleep and arousal breathing. Also remember you may or may not remember the arousal.
I circled the asleep breathing in red....anything not in the circle I wasn't asleep.



same time frame but just zoomed out more

Interesting, I figured there was probably something going on with arousals.

I attached screenshots from both my diagnostic and titration studies since that will probably give more context than just the OSCAR flow rate snippets. One thing I found especially interesting is that the titration report says the AHI dropped to 0 at 14 cmH2O, but looking at the pressure table, that pressure was reached during neither REM nor supine sleep. Since my untreated study showed much worse hypopnea activity while supine, I am wondering whether 14 cmH2O is not necessarily the true maximum pressure I may need in more vulnerable sleep stages/positions.

The studies also showed a pretty high respiratory arousal burden with mainly hypopneas rather than obstructive apneas, no PLMS, and fairly strong positional worsening.

If you get the chance to look through the screenshots, I would really appreciate your thoughts on what you think may actually be driving these repeated arousals and irregular breathing patterns before mask removal. I am wondering whether it seems more like residual flow limitation/hypopnea instability, pressure transitions, EPR effects, REM/supine instability, or simply semi-awake arousal breathing itself.

I do also have ADHD, although it has improved substantially over time and I only require a very small Ritalin dose now, so I am not sure how much that would realistically contribute here compared to the respiratory findings.

You have already been extremely helpful, thank you again.

[cpapusern30i]

These are the last three screenshots of my titration study, I will be sending my diagnostic study now as well.
Thank you very much once again