How much does it leak when you open your mouth?

[Brent Hutto]

I've replaced the thread asking about downloading data to the ResScan card. Turns out you just put the card in the slot and it downloads automagically in about 30 seconds.

So here's my next question. How big a leak would you expect to see in the data if your mouth was open? I have a couple occurances where there's a big leak for 30-45 minutes, one about 0.6L/sec (36L/min) and the other over 1.0L/sec (60L/min). These big leaks end with a cluster of 10-20 second apnea events and then I wake up (probably from the apnea attack). Does that sound like the pattern of a mouth leak? BTW, these are at around 9-10cm of pressure.

[Brent Hutto]

Bump for a new question.

[Goofproof]

It says to me that your machine can't give you the needed treatment because your mouth is open.

[wading thru the muck!]

Brent,

Sounds like you hit the nail on the head. I would have said that it could have be mask leak troubles, but that is less likely with the Swift than it would be with a nasal or FF mask.

It's been my experience that the auto's do not respond well to large leaks. I think that they are not abel to get the feedback they need to respond correctly.

You also might consider that the data showing the apneic event clusters is incorrect and that the leak is what is waking you up. Seems to me to hold true that if the machine is unable to respond correctly, the data may also be incorrect.

[rested gal]

These big leaks end with a cluster of 10-20 second apnea events and then I wake up (probably from the apnea attack). Does that sound like the pattern of a mouth leak?

Yes, sure sounds like it. I think you analyzed it well, Brent. If a person is not weaing a full face mask (coving mouth and nose) mouth breathing or mouth air leaking certainly can divert treatment pressure from going where it's needed. If the treatment air is escaping out into the bedroom, it's not keeping the throat open. Throat collapses, clusters of apneas/hypopneas happen -- you wake up trying to breathe better. Yep.

[Brent Hutto]

The more I think about it, it may even be worse than that. I'd bet a nickel that I'm snoring when I get the mouth leaks. In my titration study they weren't able to stop me from snoring at 9cm but the tech saw what she thought were central apneas so she didn't go higher. The snoring kicked in at the point during the night where I had extended REM/Supine sleep and that's about the same point in the night where my "mouth leaks" (presumed) are showing up.

So I think I roll over and drop into REM, sleep for a while and then either snore my mouth open or open my mouth to snore. Unfortunately, the APAP is still cruising along at a pressure of 9.something (lower half of my range of 7-12) when the leak/apneas/awakening cycle occurs. I'm pretty sure from the sleep study that isn't nearly enough pressure to keep me from snoring.

I won't be at all surprised if my 30-day followup with the sleep doc results in a prescription of CPAP 11 or 12 rather than the APAP. On the one hand that's too bad because for much of the night I do fine down around 7 but when I arrive at snore-time I don't know that the APAP is reacting fast enough, although maybe if I fix the mouth leaks it will have a fighting chance. OTOH, I can breathe and sleep just fine at 11-ish so it's no big deal if that's what happens.

[ozij]

So I think I roll over and drop into REM, sleep for a while and then either snore my mouth open or open my mouth to snore. Unfortunately, the APAP is still cruising along at a pressure of 9.something (lower half of my range of 7-12) when the leak/apneas/awakening cycle occurs. I'm pretty sure from the sleep study that isn't nearly enough pressure to keep me from snoring.

Brent, why, in your opinion, won't the APAP algorithm respond to your first snore by raising the pressure? Respionics machines have been reported to be very snore sensitive of this forum, and I would expect yours to raise the pressure immediately. People snore when their airways start collapsing, and the automatic algorithm is supposed to catch those snores immediately. A snore, by the way, happens on inhale, and is not - necessarily - and opening of the mouth. You open your mouth either because it simply relaxes, out of habit, or because you've got an event to machine isn't handling - at which point you may start a vicious cycle of air escaping, pressure not being enough, etc.

I won't be at all surprised if my 30-day followup with the sleep doc results in a prescription of CPAP 11 or 12 rather than the APAP. On the one hand that's too bad because for much of the night I do fine down around 7 but when I arrive at snore-time I don't know that the APAP is reacting fast enough, although maybe if I fix the mouth leaks it will have a fighting chance.

In order to give the APAP algorithm a chance to treat you, you absolutely have to control those mouth leaks first - and not let a vicious cycle start.

It has been the experience of some member on the forum (WillSucceed, Snork1, myself) that one auto algorithm is much better for them than the other, and, coincidentally. for all three of us, the PB 420E turned out to be better than the Respironics. Research comparing various algorithms has been done, and show that the machines do indeed react differently. However, by the time it was published, the specific machines checked were mostly no longer in use.
(Here's an abstract, I did real the full paper, but can't find it now... http://erj.ersjournals.com/cgi/content/ ... t/24/4/649)

PB technique for identifying central apneas is very different from the technique other machines use, another reason you might want to try a PB before giving up on automatic treatment. Read this thread for more info:
viewtopic.php?t=514


http://erj.ersjournals.com/cgi/content/ ... t/24/4/649

O.

_________________

CPAPopedia Keywords Contained In This Post (Click For Definition): 420E, respironics, CPAP, Prescription, auto, APAP

[rested gal]

Respionics machines have been reported to be very snore sensitive of this forum, and I would expect yours to raise the pressure immediately.

ozij, my Respironics REMstar Auto with C-Flex does tick a lot of snores (or things it considers to be snores) but does not respond to them with pressure increases very often. So while the Respironics machine is sensitive to marking something as snores (a lot) for me, mine does not necessarily take action against most, if any, of the snores (or whatever it's marking as snores.)

There seems to be very little correlation between my many snore tick marks and any increase in pressure on the graphs when I use the REMstar Auto.

On the other hand, my 420E autopap seldom marks snores for me. The few times it does, my graph shows the 420E increasing pressure rather immediately and aggressively to eliminate the sneaky snore.

My REMstar Auto, even though it marks a LOT of snores for me (or a lot of "somethings" as snores) seems to ignore them for the most part.

I think the 420E identifies "real snores" better, and takes more action against them, than the REMstar does. At least for me.

[Mikesus]

Brent,

There is another possibility. There was a person on here a WHILE back that used to get clusters (not with the leak tho) And it turned out to be an issue with acid reflux. The bigger question is, are you seeing anything scored as nonresponsive in those clusters? After a large leak, I would think that the machine has already tried to compensate for the leak, and upped the pressure, so getting cluster of events AFTER the leak is a bit odd. (I could understand maybe one or two, but clusters seem to indicate something else) It could be nothing, but watch the trending, if you are seeing a lot of clusters, you might want to talk to your doc about other possible causes. (i.e. reflux, vocal cord disfunction, etc...)

-Mike

[ozij]

Respionics machines have been reported to be very snore sensitive of this forum, and I would expect yours to raise the pressure immediately.

ozij, my Respironics REMstar Auto with C-Flex does tick a lot of snores (or things it considers to be snores) but does not respond to them with pressure increases very often. So while the Respironics machine is sensitive to marking something as snores (a lot) for me, mine does not necessarily take action against most, if any, of the snores (or whatever it's marking as snores.)

There seems to be very little correlation between my many snore tick marks and any increase in pressure on the graphs when I use the REMstar Auto.

On the other hand, my 420E autopap seldom marks snores for me. The few times it does, my graph shows the 420E increasing pressure rather immediately and aggressively to eliminate the sneaky snore.

My REMstar Auto, even though it marks a LOT of snores for me (or a lot of "somethings" as snores) seems to ignore them for the most part.

I think the 420E identifies "real snores" better, and takes more action against them, than the REMstar does. At least for me.

Thanks putting me right. I somehow disregarded this important distintion.

O.

[Brent Hutto]

Brent, why, in your opinion, won't the APAP algorithm report to you first snore by raising the pressure? Respionics machines have been reported to be very snore sensitive of this forum, and I would expect yours to raise the pressure immediately. People snore when their airways start collapsing, and the automatic algorithm is supposed to catch those snores immediately. A snore, by the way, happens on inhale, and is not - necessarily - and opening of the mouth. You open your mouth either because it simply relaxes, out of habit, or because you've got an event to machine isn't handling - at which point you may start a vicious cycle of air escaping, pressure not being enough, etc.

I think the mouth opening and snoring happen either together or in a pretty short interval of time. By the time the machine could detect snores to eliminate, my mouth is leaking (maybe not wide open) and the machine may not even be able to sense the snores with a big old leak in progress. Prior to CPAP my wife's observation is that I sleep with my mouth closed and breathe through me nose until a certain point and then the snoring commences through my mouth. Maybe that's everyone's pattern, too.

BTW, my machine is a Resmed S8.

In order to give the APAP algorithm a chance to treat you, you absolutely have to control those mouth leaks first - and not let a vicious cycle start.

I agree. What I'm curious about is the chicken/egg question. If I were at higher pressure, would the snore and mouth leak not happen in the first place or conversely does the mouth leak in effect disable the treatment first and then the snores and apneas follow. It's hard to figure that out from the data recorded by the machine (especially since the Resmed S8 does not record snores). BTW, there are leaks in the data on some nights that look exactly like mouth leaks but they do not result in apnea events or awakenings and they end after 10-15 minutes.

Thanks for the pointers to the APAP internals studies. I have one or both of those in my notebook and I've definitely read the part you're talking about. The Puritan-Bennett algorithm is interesting although I surely hope I don't have to ever swap machines. Hopefully there will be a pressure setting that works well for me once I get my leakage under control. I'm going to extract a couple of these events from my Autoscan database and post the gory details to the extent I can get through them. Maybe that will shed some more light on the subject.

[Brent Hutto]

There is another possibility. There was a person on here a WHILE back that used to get clusters (not with the leak tho) And it turned out to be an issue with acid reflux. The bigger question is, are you seeing anything scored as nonresponsive in those clusters? After a large leak, I would think that the machine has already tried to compensate for the leak, and upped the pressure, so getting cluster of events AFTER the leak is a bit odd. (I could understand maybe one or two, but clusters seem to indicate something else) It could be nothing, but watch the trending, if you are seeing a lot of clusters, you might want to talk to your doc about other possible causes. (i.e. reflux, vocal cord disfunction, etc...)

Mike,

I'll post some details of a couple events if I can figure out how to zoom in one them and extract them from my Autoscan database. Maybe later today if I get time...

However, you bring up something that I am in fact concerned about. I have little doubt that once I'm getting treated as well as possible with CPAP I've got some additional issues to address. In my sleep studies I have arousals and microarousals at a rate of 80/hour even on 9cm of CPAP (residual AHI around 7). So my sleep is being fragmented badly by something (or things) in addition to OSA. I have had GERD problems in the past which appear to be completely under control with Pepcid plus elevating the head of my bed. It is certainly possible that there's still GERD there at a level that I don't notice. Once this first 30 days of APAP is done, I have followups scheduled with the sleep doctor and my internist to starting working through the usual list of sleep fragmentation suspects (medication, GERD, lifestyle, other undiagnosed comorbidities). CPAP or no CPAP I'm not going to get a whole lot better until those arousals are reduced by an order of magnitude.

POSTSCRIPT:
My Resmed doesn't record "nonresponsive" events, I would have to deduce that from the event and pressure logs. It simply stores the time that each apnea event occurs and its duration. For hypopneas, I don't even get the duration but just the event time. Snores are not recorded at all. I'm very put out by the limitations in this machine when used to monitor treatment. I expected to get detailed recording of snores and IFL (on a "rounded" versus "flattened" scale) but as I found out after I downloaded the data that information is only available with an S7 Spirit plus Reslink module. I guess I should have don't better due dilegence.

[chdurie2]

well, i don't understand the high-tech analysis but i'm not into high-tech cpap. however, the simple answer to your question is that it can leak quite a bit when your mouth is open. one easier way to tell whether you're losing a lot of efficacy because of leaks caused by open mouth is that you use a lot more water in the humidifier. these leaks can be caused by other things, but mouth open is a big leaker and will generate comparatively a lot of water running through your humidifier. this is what cpap.com rep told me.

[rested gal]

Thanks putting me right. I somehow disregarded this important distintion.

You didn't miss the distinction, ozij. In the past whenever I talked about the REMstar noting what I think are a lot of phantom snores for me, I never mentioned that it usually doesn't react to the many, many snore thingies with pressure increases.

[rested gal]

when I arrive at snore-time I don't know that the APAP is reacting fast enough, although maybe if I fix the mouth leaks it will have a fighting chance

I think that's going to be the key to good cpap treatment for you, Brent, no matter what machine you use or what type of machine. Mouth air leaks can be a real treatment-buster. (pssst.... tape...)