Uncomfortable night last night - SleepyHead report attached

[Pugsy]

You obviously had some symptoms prior to the home sleep study to get you to have the sleep study.
What were those symptoms?

Did you get oxygen results with your sleep study results? How low did it go and for how long? How much time spent below 88%?
A minute and a half apnea event is going to cause problems even if you don't have very many of them.

Do you feel like your sleep quality in general is worse on the cpap than without cpap...just the sleep itself and not necessarily how you feel during the day?

[Jay Aitchsee]

Char, don't drive yourself nuts and obsess over your data:

It is unlikely you have any significant central apneas. See my wave form analysis below. Most of your CA are most likely related to arousals from disturbances and would not count as "real" in a lab setting.

As far as your understanding, You are basically correct. With obstructive apnea, your breathing is obstructed, you are trying to inhale, but the airway is blocked preventing or limiting your ability until you arouse and overcome the obstruction.

With central apnea, your brain is not signaling your respiratory system to inhale. Your are essentially "holding your breath" as is normal if you wake, rollover, move, etc. These are most likely what you are seeing scored as CA - no cause for concern, especially if they are occurring in the early morning hours as your are drifting in and out of sleep, or during the night if you have been awakened and are restless for a bit. Even if you did have a few "real" central apneas it wouldn't necessarily be any cause for concern. "Real" central apneas are one way the body regulates blood gases and some real ones during the night wouldn't necessarily be abnormal.

However, you are not correct in assuming either type of apnea has to do with air entering your mouth from your throat. That has to do with the velopharyngeal sphincter (the "back door") failing to seal out the pressure from the CPAP. This is not necessarily abnormal, typically the velopharyngeal seal would not have to contend with pressure from the nasal passage as is the case with CPAP.

You may have to contend with the fact that there could be other reasons for not feeling rested. However, successful adoption of CPAP therapy will rule out one possible cause and that would be a major step. You also have to accept the fact that it takes some time for most people to adapt to the therapy and sometime before they start to feel good. You can rest assured that treatment of obstructive apnea will do your body good, even if you don't immediately feel better.

[sleepychar]

Pugsy - the symptoms that I had before the sleep study were that I was not sleeping well - sometimes, not infrequently, I was getting up almost hourly and most of the time 3-4 times a night over a 6-7 hour sleep period was usual... and, I wasn't positive, but at times I thought I was waking up with gasping breaths and that seemed to be happening more and more. I wasn't sure but it seemed real enough to me to tell my physician about it when I went in for my regular annual exam. It has been reported to me that I snore... and I was feeling very tired all the time. I had all the regular blood tests at the time of my physical and supposedly I am in very good health... I know there could be something else that could be causing my sleep issues... don't know what though. And, if I'm being honest with myself, I actually do think that for the most part I am sleeping better with the CPAP than before. It's just that I'm impatient and I guess I was hoping for a more dramatic improvement in my sleep. Like wouldn't it be great if I could sleep all the way through the night one night? That would be amazing!

Jay, thank you for your clear explanations and for your encouragement. I'm not giving up on the CPAP, I just feel like it sometimes, especially like yesterday when I felt so tired and irritable. But who doesn't have days like that, right? I'll try to stop whining so much...

[Pugsy]

Like wouldn't it be great if I could sleep all the way through the night one night? That would be amazing!

Yeah, I know that we all want that but sometimes life doesn't give us that no matter how much we want it.
First it's common to wake up during the night anyway. Like it's common to wake after a REM cycle.
Most of the time we don't remember those very brief wake ups so we think we slept all night or didn't wake up but maybe a couple of times.
The problem comes when we start remembering a bunch of wake ups so we kinda have to assume that we have some more that we don't remember.

I still rarely have one of those nights where I don't remember waking up during the night. My issues aren't cpap therapy related though so I really can't/don't expect cpap to fix those issues.
I think a lot of time people expect the cpap to fix all those other issues that people can have and they tend to thin "it isn't working" because it doesn't fix all a person's problems. They have unrealistic expectations and the "oh well, it isn't working so why bother" excuse gives them a reason to quit therapy.

What we want to do is do our best to get those other issues better managed.
I am betting that you are doing some mouth breathing even though you don't see it much on the leak graph and you don't wake up doing it. I have been there and done that myself and it takes very little to dry my mouth out. Not all mouth breathing will show up as massive leaking on the leak graph. I have an example I will put at the end of my comments here so you can see where I circled an area with known awake mouth breathing. What happened was I woke up one morning and I was mouth breathing. It was a very gentle mouth breathing without massive air rushing from my mouth. It was close to my normal wake up time so I decided that it would be a good time to continue the mouth breathing so that I could get a real good idea what the leak line looked like with known mouth breathing. My mouth was horribly dry too. See below image. I lay awake for about 20 minutes mouth breathing so that I could for sure spot it on the leak graph.

Now some of your dry mouth could also be from air entering via the back door but I would bet my last dollar that if I was a fly on the wall in your bedroom at night that the mouth is coming open more than you think it is. I would suggest a one night trial with taping the lips just to see if it makes any difference or not. That way we would know for sure that you aren't doing maybe some little mouth breathing like I have circled below. I would never have thought that the actual leak response was so small. When trying to fix a problem it helps to know exactly what the cause is so that we can use the best options for the situation. I am not saying that you need to tape all the time (unless you end up electing to do that)...I am just suggesting trying it for one night, and hope the tape stays put all night, just to rule out potential mouth breathing as being a potential culprit for the mouth dryness.

What setting are you using on the humidifier and are you using a heated hose or not?

[sleepychar]

I will try taping my mouth - so one strip going up and down from just under my nose to right below my mouth? Tonight I am going to try to scunci though... then tomorrow I will try the tape.

I am using the ClimateLineAir heated hose with humidity at 7. I am thinking of notching up the humidity to 8, which is the highest level I think. I often have nasal congestion, use saline nasal spray sometimes, and the humidity actually helps with that and I wake up breathing through my nose better than when I went to sleep.

The mouth breathing thing is interesting... since I can't inhale through my mouth when the CPAP is sending air down my nose/throat. When I try to breathe in, nothing happens, I can't get any air in. Is that normal? It is a very weird sensation and was very scary the first time I experienced it. As soon as I remove the mask, then I can inhale again. That, along with the chin strap, is the reason I am doubtful I am mouth breathing. Maybe, well definitely, I am exhaling through my mouth at those times when there is air coming in from the back of my throat but I don't see how I could possibly be inhaling through my mouth as well.

[Jay Aitchsee]

I suggest, since your humidity setting is already high, you go the other way. Strange thing about humidity setting, sometimes it has the opposite effect then intended. Too much humidity can make the nose "stuffy" and encourage inhaling through the mouth, further contributing to dry mouth. If you think about it, humidity will have little effect on dry mouth with a nasal mask. The moist air is being applied to the nose not the mouth, so more humidity won't help. Many of us don't use any humidity, just letting the air blow over the unheated water in the tank - passive or pass-over humidity.

Edit: I defer to Pugsy regarding humidity setting. It's really not too good to change more than one thing at a time, anyway.

Next, think about how the air flows through the respiratory system. Normal flow is in and out through the nasal passage. Although sometimes, it is normal to breath in through the nose and out through the mouth, but we'll leave that for now. Abnormal breathing would be in through the mouth and out either through the nose or the mouth. This would only be "normal" usually under conditions of heavy exertion. Some people suffer abnormality of the nasal passage which requires inhalation through the mouth.

Inhaling through the mouth is what I call mouth breathing. Mouth breathing is likely to cause dry mouth.

The condition you describe of not being able to inhale through the mouth with the mask on is not abnormal and with practice you will be able to do it. Again, as I mentioned above, we have this velopharyngeal structure which acts as a valve to make sure stuff - air and food go the right way. When you inhale through your nose this valve directs air to you lungs and not your stomach. With the valve in that position you try to breath in through your mouth, but the CPAP pressure is holding the valve in the correct position to direct nasal air and you find it difficult. It's like trying to breath in through your nose and mouth at the same time. It's difficult, try it.

Now sometimes, the velopharyngeal structure doesn't separate the nasal passage from the oral cavity well enough and pressurized air finds its way past it into the mouth and out the lips, from the "back door", so to speak, because the pressure in the nasal passage from CPAP is higher than the atmospheric pressure at the lips. This isn't really mouth breathing, its really more like mouth leaking. Mouth leaking is what most people who try a nasal mouth suffer, although it often called mouth breathing. It's not really breathing at all, it's leaking and if it's bad enough it can cause dry mouth, and a loss of therapy. Many people find it disturbing because it feels funny and is often noisy. There are some who claim to have "taught" the velopharyngeal structure to seal properly by holding the tongue in a certain position. I think that might be possible, or it just learns on its own. My mouth leaks have improved since I started a nasal mask a year or so ago.

I think what you are experiencing is mouth leaking. Tape will stop it because once past the seal the air has no where to go. Personally, I prefer the cloth over tape because it more comfortable and it slows the leak enough for me not to be noisy or cause dry mouth. However, tape (and the cloth) will still allow air into the oral cavity and that in itself could contribute to dry mouth, though it's probably not as likely.

Full face masks will prevent loss of therapy from mouth breathing and will prevent mouth leaks by applying equal pressure to the nose and mouth, but a full face mask will not necessarily prevent dry mouth.

Chin straps may discourage mouth breathing but won't necessarily prevent mouth leaks and dry mouth.

So, the goal is to become comfortable with the therapy by trying a few things, preferably one at a time, but not to obsess or worry over it. Find what works for you and try to be patient

[Pugsy]

so one strip going up and down from just under my nose to right below my mouth?

Nope...you can still mouth breath with the strip vertical method.
Put it horizontal and cover the corners too. The vertical method is good and fairly reliable but for this one test need to have zero chance of mouth breathing occurring.

since I can't inhale through my mouth when the CPAP is sending air down my nose/throat. When I try to breathe in, nothing happens, I can't get any air in. Is that normal? It is a very weird sensation and was very scary the first time I experienced it. As soon as I remove the mask, then I can inhale again.

Pretty normal really. I am the same way because that's when I say I have to work hard consciously to let air enter my mouth so that I can mouth breathe.
But that's while we are awake and there's no guarantee that we do that when we are asleep.

The only reason I am suggesting taping at this time is to make absolutely sure that mouth breathing isn't contributing to the dry mouth. Since the dry mouth is waking you up...we want to fix it but in order to have the best chance of fixing it we need to try to figure out exactly what is causing it.
So...totally eliminate any chance of mouth breathing happening so that we can concentrate on some other solution.

I am like you...the humidity helps with any congestion I might have and I often find that the nose is a lot clearer in the morning than it was when I went to bed. For this reason I use maximum humidity available. We joke about it...I laugh and tell people if I could snort water I would be the happiest.
You can try increasing the humidity to 8. I don't know that it will help but it won't hurt.

Right now for you in your situation the main problem seems to be the dry mouth causing wake ups.
Anything that causes wake ups is unwanted. We will try to come up with some ideas to reduce the dry mouth so it doesn't wake you up so much....but first rule out mouth breathing..hence the taping. It's the only way to know with 100% certainty that the dry mouth is coming from the air coming in the back door and not the exchange in and out the front door (through the lips).

[Pugsy]

I suggest, since your humidity setting is already high, you go the other way. Strange thing about humidity setting, sometimes it has the opposite effect then intended. Too much humidity can make the nose "stuffy" and encourage inhaling through the mouth, further contributing to dry mouth.

I don't suggest lowering humidity because she says this and isn't complaining of nasal congestion and in fact breathes better in the AM with more moisture.
Now if she was complaining of congestion during the night or in the morning and the taping of the mouth proves mouth breathing...then yeah, reduction in moisture.
But I agree that increasing is unlikely to add enough moisture to make the mouth feel better but it won't hurt to try.

the humidity actually helps with that and I wake up breathing through my nose better than when I went to sleep.

[sleepychar]

Thanks - Scunci test tonight. I'll update tomorrow...

[sleepychar]

I tried the scuncii last night. That lasted for just under 3 hrs. Woke up, removed scuncii, back to sleep with no chin strap, no scuncii, just mask. Woke up about an hour later with a gush of air out my mouth so I think at that point my mouth must have dropped open in my sleep. Finally put chin strap in place, mask in place, and back to sleep. So far I think the chin strap is my best bet. I don't think I'm going to try the tape over my mouth because there is no question in my mind that air is coming into my mouth from my throat and I don't see how taping my mouth is going to help that. At this point, I'm going to continue with the chin strap and mask and hope my body will somehow adjust to be able to start blocking air coming into my mouth from my throat. That did seem to stop for a little while right after I started using the chin strap and I'm not sure why it started up again. I may try one of the aids to moisten my mouth but I want to discuss with my dentist first. I am using other mouthwash for dental issue and not sure how everything will interact. So for now, that's what's happening. Hopefully this is just a rough patch and I will be able to post an "I'm doing great" message in the not too distant future...

[Pugsy]

Okay. Do as you think best.
The taping idea wasn't necessarily meant to help but instead to answer a question so you could best address the problem but since you think you already know the answer for sure I will bow out and let you sort it out.

[sleepychar]

Thanks so much, Pugsy, for the time you spent thinking about this and trying to help. I do appreciate it and I always look at your comments to other people's posts and find them really helpful. I'm just going to give it a bit more time I guess and see what happens...

[Sleeprider]

Sleepychar, one feature I noted in your posted graph is an unusually low average tidal volume of about 200 mL. If you are a particularly small person, this would make some sense, or perhaps you're not ventilating as well as you should at night, in spite of low numbers of apnea events. Pressure support is known to help with this, but your pressure are already quite low. I note you are using EPR of 2.0. The low tidal volume and minute vent may not be an issue. When you have more comfortable night, or increased pressure, do you observe any increase in those numbers?

[Jay Aitchsee]

So far I think the chin strap is my best bet
...At this point, I'm going to continue with the chin strap and mask

Yes, you should continue with what makes you feel comfortable. As I said before, one of the biggest challenges is just getting used to the therapy. Hopefully, with a little more time, things will improve.

Let your health care provider know you aren't doing as well as you'd like. When is your follow up appointment?

Here's a graphic to help visualize mouth leaks:

[Jay Aitchsee]

Sleepychar, one feature I noted in your posted graph is an unusually low average tidal volume of about 200 mL. If you are a particularly small person, this would make some sense, or perhaps you're not ventilating as well as you should at night, in spite of low numbers of apnea events. Pressure support is known to help with this, but your pressure are already quite low. I note you are using EPR of 2.0. The low tidal volume and minute vent may not be an issue. When you have more comfortable night, or increased pressure, do you observe any increase in those numbers?

Interesting observation, Sleeprider. I would agree that a tidal volume of around 200 could be low. However, that is a median value and not an average. So it could be skewed quite a lot. A better representation might be the Volume Graphics, but I don't think she's posted any.