F40 Hybrid Sinus Issues

[Movieman]

I currently use the Air touch F20 mask which works, but it is big and bulky. I like the smaller design of the hybrid masks, especially for side sleeping which is why I want to switch. Over the past year tried the Evora, F30 and most recently the F40 mask. Ironically, they all seemed to be fine for a couple of weeks before symptoms started. After using the F40 for a couple of weeks, those symptoms started and my right nasal wall partially collapsed which was alarming.

Sleep doctor was no help and seemed oblivious. I saw an ENT who prescribed nasal sprays and recommended I go back to my F20 mask. It took a few weeks, but symptoms are much better now. ENT said I basically can't use the hybrid nasal or pillow masks due to deviated septum and nasal wall weakness. Doctor said some people with my problems have no issues using these masks while others can't tolerate them. ENT went over surgical options, but wouldn't recommend them just to tolerate more mask styles. Results are not guaranteed and are mixed at best. It's frustrating and I have no idea if the doctor is correct.

Has anyone had these issues using hybrid masks and found a solution that didn't require surgery? I tried more humidity and heated tube and nasal spray with no luck. I'm assuming the doc is correct, but was hoping there might be something I'm missing.

[ChicagoGranny]

I have no idea if the doctor is correct.

Generally, ENTs don't know fecal matter about CPAP.

[Movieman]

I have no idea if the doctor is correct.

Generally, ENTs don't know fecal matter about CPAP.

[robysue1]

ENT said I basically can't use the hybrid nasal or pillow masks due to deviated septum and nasal wall weakness.

How severe is the deviated septum? I ask because almost everyone has a septum with some degree of deviation, but for most people it's never a problem.

As for "nasal wall weakness", I'll be honest: I don't have the foggiest idea of what the ENT is talking about.

Doctor said some people with my problems have no issues using these masks while others can't tolerate them.

There's a truism when it comes to CPAP masks: The perfect mask for Person A is the mask from hell for Person B. And vice versa.

Meaning: We all have masks that we personally can't tolerate and we all have masks that are comfortable enough to sleep in and for which we're willing to do what it takes in order to prevent mask and/or mouth leaking.

Most people who breathe through their nose consistently can make a nasal mask or a pillows mask work because most people who consistently breathe through their nose during the daytime also breathe through their nose at night. Some people who find that their mouth pops open when the jaw relaxes are willing to use tape or a chin strap or a soft cervical collar to help minimize the mouth breathing at night. Other people cannot stand the idea of putting on even more "stuff" just to go to sleep and they prefer to just find a full face mask that works for them. (My hubby falls into that category---he could use a nasal mask if he wanted to, but he simply prefers using a full face mask.)

ENT went over surgical options, but wouldn't recommend them

Well, you've got a decent ENT who is not just trying to make money by doing surgeries that are dubious at best for "fixing" the problem they are supposed to fix. I'll give the ENT credit for that.

I currently use the Air touch F20 mask which works, but it is big and bulky. I like the smaller design of the hybrid masks, especially for side sleeping which is why I want to switch. Over the past year tried the Evora, F30 and most recently the F40 mask. Ironically, they all seemed to be fine for a couple of weeks before symptoms started. After using the F40 for a couple of weeks, those symptoms started and my right nasal wall partially collapsed which was alarming.[/b]

Question 1: Are you trying to sleep on your right side or your left side?

Question 2: When you say your "right nasal wall partially collapsed" can you tell us exactly what you mean? Do you mean the right nostril became stopped up? Do you mean the outside fleshy part of the right nostril seemed to fall towards the septum?

Question 3: What happens if you just turn over to the other side?

Question 4: Are you aware of something called the nasal cycle? Most people (even those with totally normal noses) breathe mostly through one nostril at a time. The dominant nostril automatically switches on a "schedule" that varies from person to person. (It can be as brief as 20-30 minutes or it can be as long as 8 hours or so.) In the typical nasal cycle, the non-dominant nostril typically feels congested (if we pay attention to it). For some folks who sleep on their sides, a change in the dominant nostril often results in waking up enough to realize that turning over to the other side will make breathing easier. Any chance that the symptoms you are describing as "alarming" are just you noticing the switch between dominant nostrils because you're now trying to sleep on your side? (The switch between dominant nostrils is much, much less noticeable if you are sleeping on your back or stomach, and many people with a nasal cycle don't even notice the switch unless they are lying down on their side.)

Has anyone had these issues using hybrid masks and found a solution that didn't require surgery?

A hybrid mask has nasal pillows that rest just inside and against the nostrils along with a mouth piece that covers the mouth. Some people's noses just don't like the feel of anything touching the nostrils. My husband is one of them---he tried my nasal pillows mask at one point and couldn't stand the feeling of the air blowing directly into his nose. He much prefers masks (both nasal and full face masks) that don't touch his nostrils. He has no nasal problems beyond some seasonal allergies caused by tree pollen.

I on the other hand have a nose that doesn't mind the nasal pillows nestled against my nostrils, but I personally cannot tolerate anything that covers the whole tip of my nose. It's not claustrophobia, at least not in the classic sense. It's that as soon as I try to put on a mask that covers the whole tip of my nose I start sneezing uncontrollably.

I point this out because it could just be that your nose really doesn't like the feel of the nasal pillows resting against your nostrils.

I tried more humidity and heated tube and nasal spray with no luck.

Here's the thing about both humidity and heat: "More" doesn't always fix problems.

More questions:

Question 1: When you take a hot steamy shower, does your nose feel more clogged or less clogged? If you feel congested during or immediately after taking a hot shower, your nose might be one that strongly prefers less humidity. And in that case, turning the humidity setting down is worth experimenting with.

Question 2: When you turned the heat up, did you just feel "hotter" while lying in bed trying to get to sleep? Do you feel like you're sleeping in a swamp? If so, turn the heat back down.

Question 3: What kind of nasal spray was recommended?

[Movieman]

How severe is the deviated septum? I ask because almost everyone has a septum with some degree of deviation, but for most people it's never a problem.

As for "nasal wall weakness", I'll be honest: I don't have the foggiest idea of what the ENT is talking about.

My septum is moderately deviated. The deviation can be seen just looking at my nose.

I was incorrect that is is my "nasal wall" is weak. It is actually my right nasal valve. It is the cartilage on the outer nostril that is weak and collapses toward the septum.

There's a truism when it comes to CPAP masks: The perfect mask for Person A is the mask from hell for Person B. And vice versa.

Meaning: We all have masks that we personally can't tolerate and we all have masks that are comfortable enough to sleep in and for which we're willing to do what it takes in order to prevent mask and/or mouth leaking.

Most people who breathe through their nose consistently can make a nasal mask or a pillows mask work because most people who consistently breathe through their nose during the daytime also breathe through their nose at night. Some people who find that their mouth pops open when the jaw relaxes are willing to use tape or a chin strap or a soft cervical collar to help minimize the mouth breathing at night. Other people cannot stand the idea of putting on even more "stuff" just to go to sleep and they prefer to just find a full face mask that works for them. (My hubby falls into that category---he could use a nasal mask if he wanted to, but he simply prefers using a full face mask.)

My nose breathing is more inconsistent. I used to mouth breathe a lot during the day, but after being on CPAP for awhile, my nasal breathing improved greatly. Still not consistently.

Question 1: Are you trying to sleep on your right side or your left side?

Question 2: When you say your "right nasal wall partially collapsed" can you tell us exactly what you mean? Do you mean the right nostril became stopped up? Do you mean the outside fleshy part of the right nostril seemed to fall towards the septum?

Question 3: What happens if you just turn over to the other side?

Question 4: Are you aware of something called the nasal cycle? Most people (even those with totally normal noses) breathe mostly through one nostril at a time. The dominant nostril automatically switches on a "schedule" that varies from person to person. (It can be as brief as 20-30 minutes or it can be as long as 8 hours or so.) In the typical nasal cycle, the non-dominant nostril typically feels congested (if we pay attention to it). For some folks who sleep on their sides, a change in the dominant nostril often results in waking up enough to realize that turning over to the other side will make breathing easier. Any chance that the symptoms you are describing as "alarming" are just you noticing the switch between dominant nostrils because you're now trying to sleep on your side? (The switch between dominant nostrils is much, much less noticeable if you are sleeping on your back or stomach, and many people with a nasal cycle don't even notice the switch unless they are lying down on their side.)

Answer 1: I've tried both right and left. If I sleep on my right side, my right nostril gets congested after awhile and if I lay on my left side, my left nostril starts to get clogged.

Answer 2: Apologies, I meant my nasal valve is weak, not nasal wall. Yes, fleshy outside part collapsed toward my septum. It is visibly noticeable that my right nostril is narrower than my left nostril.

Answer 3: I think answer 1 covers this one.

Answer 4: I've not heard of this, but your description fits me to a tee. I suppose the switching of dominant nostrils is what I found alarming, but only after my nasal valve was pushed toward my septum. This is something that hasn't happened before. Now, it is more difficult to breathe through my right nostril all the time when wearing the hybrid mask. I don't seem to notice it with a FFM. Although i do wake up sometimes in FFM with mouth open.

A hybrid mask has nasal pillows that rest just inside and against the nostrils along with a mouth piece that covers the mouth. Some people's noses just don't like the feel of anything touching the nostrils. My husband is one of them---he tried my nasal pillows mask at one point and couldn't stand the feeling of the air blowing directly into his nose. He much prefers masks (both nasal and full face masks) that don't touch his nostrils. He has no nasal problems beyond some seasonal allergies caused by tree pollen.

I on the other hand have a nose that doesn't mind the nasal pillows nestled against my nostrils, but I personally cannot tolerate anything that covers the whole tip of my nose. It's not claustrophobia, at least not in the classic sense. It's that as soon as I try to put on a mask that covers the whole tip of my nose I start sneezing uncontrollably.

I point this out because it could just be that your nose really doesn't like the feel of the nasal pillows resting against your nostrils.

Thanks for pointing it out. I'm not a fan of the way the hybrid touches my nostrils, but I was able to use them until this thing happened with my nasal valve.

Here's the thing about both humidity and heat: "More" doesn't always fix problems.

More questions:

Question 1: When you take a hot steamy shower, does your nose feel more clogged or less clogged? If you feel congested during or immediately after taking a hot shower, your nose might be one that strongly prefers less humidity. And in that case, turning the humidity setting down is worth experimenting with.

Question 2: When you turned the heat up, did you just feel "hotter" while lying in bed trying to get to sleep? Do you feel like you're sleeping in a swamp? If so, turn the heat back down.

Question 3: What kind of nasal spray was recommended?

Agreed more humidity does not always work. I've played around with climate line temp and humidity level.

Answer 1: My nose clears up when i take a steamy shower and shortly after too. Then during the day it may switch between getting congested and clearing up on either one or both sides. Nasal spray has improved this, but it does happen.

Answer 2: If i turn up the heat I feel hotter which is uncomfortable. Here is what I've found so far. If I use Air Touch F20, I have temp on 74 and humidity on 3. I wake up feeling not too bad, maybe slightly congested, but throat isn't dry and I find it most comfortable. If I use FFM on temp 74 and turn up humidity to 4, my mask gets droplets, but it doesn't feel swampy. I've tried these settings with the F40 hybrid, but my mouth is dry and my nose burns and gets really clogged. The other night i tried one last setting with the F40. I turned climate line on auto for both humidty and heat. That was a swamp! However, my nose felt better, still burned a bit though. I found the swamp very uncomfortable though.

Answer 3: It was recommend I use Nasonex and it works well for me. I know nasal sprays like Afrin can't be used for long term. It took a couple of weeks of using Nasonex to notice a difference.

Thanks for all the suggestions/help. I don't think there is much more i can do. It seems whatever the reason, I can't tolerate the hybrid masks either. I knew I couldn't tolerate the nasal masks/pillows as I tried them a couple of years ago. They were easier to use before this nasal valve collapse though. I hoped the hybrid would be easier to use so I could give my nose bridge a break from the irritation, but it doesn't look like it's going to work out.

[ozij]

How severe is the deviated septum? I ask because almost everyone has a septum with some degree of deviation, but for most people it's never a problem.

As for "nasal wall weakness", I'll be honest: I don't have the foggiest idea of what the ENT is talking about.

My septum is moderately deviated. The deviation can be seen just looking at my nose.

I was incorrect that is is my "nasal wall" is weak. It is actually my right nasal valve. It is the cartilage on the outer nostril that is weak and collapses toward the septum.

[...]
My nose breathing is more inconsistent. I used to mouth breathe a lot during the day, but after being on CPAP for awhile, my nasal breathing improved greatly. Still not consistently.
Answer 2: Apologies, I meant my nasal valve is weak, not nasal wall. Yes, fleshy outside part collapsed toward my septum. It is visibly noticeable that my right nostril is narrower than my left nostril.

A hybrid mask has nasal pillows that rest just inside and against the nostrils along with a mouth piece that covers the mouth. Some people's noses just don't like the feel of anything touching the nostrils.

The older Hybrid masks had nasal pillows.; The modern ones don't even have that - they have holes that your nose "nestles" into. Nothing entering you nostrils.

Thanks for pointing it out. I'm not a fan of the way the hybrid touches my nostrils, but I was able to use them until this thing happened with my nasal valve.

Reading your post it seems to me that this collapse is irreversible.
I find it very difficult to imagine how a mask that only touches your nose from beneath can cause this whereas a mask that sits on the bridge of you nose did not.
Which makes me wonder: Did you show both masks to your ENT?

. I suppose the switching of dominant nostrils is what I found alarming, but only after my nasal valve was pushed toward my septum. This is something that hasn't happened before. Now, it is more difficult to breathe through my right nostril all the time when wearing the hybrid mask. I don't seem to notice it with a FFM. Although i do wake up sometimes in FFM with mouth open.

Do you mean you mouth never opens when using the F40 mask?

[Movieman]

Reading your post it seems to me that this collapse is irreversible.
I find it very difficult to imagine how a mask that only touches your nose from beneath can cause this whereas a mask that sits on the bridge of you nose did not.
Which makes me wonder: Did you show both masks to your ENT?

I'm not sure I totally understand this, but yes in a way it is irreversible without surgery. My nasal valve opened up again, but my right nostril is noticeably smaller than the left now and it will be prone to collapsing back. The idea to try and keep from getting too congested so it won't do that. The ENT says the surgery isn't great, so they only do it for more severe cases. I think they insert something into nostril to make it stronger, but I guess it can have complications for some people like every surgery.

Yes, I agree. That's why I was hesitant to believe ENT. ENT said masks that sit under the nose are much like nasal pillows in that they blow air more directly up the nose than over the nose bridge masks would. Air rushing that direct into the septum can irritate the turbinates causing them to swell. The swelling leads to congestion and the congestion leads to the nasal valve collapsing back toward the septum. ENT suggested humidity and heated tube to see if that would calm the turbinates. The colder the air the more likely turbinates will get irritated. So, I switched to a heated tube, and played with heat and humidity levels to see if I could get relief, but it didn't seem to work. Even with over the nose FFM, my nostrils would be burning in the morning before switching to a heated tube. The climate line has fixed the burning sensation (74 degree and humidity 3) when using the over the nose FFM and as can be imagined my turbinates look much better now.

Do you mean you mouth never opens when using the F40 mask?

Sorry for the confusion. My mouth is always wide open when I use the F40 mask. In fact, I was ripping off the F40 at night and waking up in the morning without a mask. I guess my nose and throat was so irritated. I thought it was from leaks, but OSCAR showed very low leak levels of no more than 8. With the F20 air touch, my mouth still opens at times, but it does stay closed more. Funny thing is F20 leaks more than the F40.

[ChicagoGranny]

Air rushing that direct into the septum

In a properly operating CPAP system, air doesn't rush in. The CPAP system just creates a gentle pressure.

[Movieman]

Air rushing that direct into the septum

In a properly operating CPAP system, air doesn't rush in. The CPAP system just creates a gentle pressure.

I hear ya Granny. Machine works fine. I’m not sure I agree pressure is gentle at least to me. Lol.

ENT is just saying airflow is more direct with under the nose masks which is a problem for some people. Too bad I didn’t think to say that.

[ChicagoGranny]

airflow is more direct with under the nose masks

This has been said multiple times on this forum. I've never been able to understand it.

No matter which of the two styles of masks being used, there is the same air pressure under the nose. The speed of the airflow is controlled by the rise and fall of the user's diaphragm.

[ozij]

Think of a garden hose.
Think of what happens to the force of the spray if you cover half the hose with your finger.
Nasal pillows masks, for sure have an upper part that is narrower than your nostrils' opening, and therefore the air flow coming out is indeed stronger and more irritating, than when you simply breathe in through your nostrils.

I see what the ENT means.

Funny thing is F20 leaks more than the F40.

That simply says something about the mask's ability to seal properly. It has nothing to do with your open mouth per se. In other words: An open mouth in a well-fitting well-sealed mask doesn't cause leaks.

[ChicagoGranny]

Think of a garden hose.
Think of what happens to the force of the spray if you cover half the hose with your finger.
Nasal pillows masks, for sure have an upper part that is narrower than your nostrils' opening, and therefore the air flow coming out is indeed stronger and more irritating, than when you simply breathe in through your nostrils.

This is a faulty analogy. CPAP machines have sensors that adjust to control the pressure at their hose connection. The pressure of a garden hose is controlled by the input side of the water source and is not adjusted when a finger is held over it.

The CPAP machine controls the pressure at the mask.The rise and fall of the user's diaphragm controls the airflow.

Think about a ResMed mask with the hose connection on top. When one side of the mask is completely cut off (as may happen when side-sleeping), the pressure at the mask is unchanged. By the OP's thinking, the airflow would what, double? If it did, these top-connection masks would not be on the market.

[Movieman]

Think of a garden hose.
Think of what happens to the force of the spray if you cover half the hose with your finger.
Nasal pillows masks, for sure have an upper part that is narrower than your nostrils' opening, and therefore the air flow coming out is indeed stronger and more irritating, than when you simply breathe in through your nostrils.

I see what the ENT means.

Funny thing is F20 leaks more than the F40.

That simply says something about the mask's ability to seal properly. It has nothing to do with your open mouth per se. In other words: An open mouth in a well-fitting well-sealed mask doesn't cause leaks.

Yep, I agree. My mouth open may have something to with large leaks on occasions I turn on my back due to jaw drop. On my side that doesn’t happen. F40 does seal better for me than the F20, but the F20 leaks not bad as long as I sleep on my side.

[Movieman]

airflow is more direct with under the nose masks

This has been said multiple times on this forum. I've never been able to understand it.

No matter which of the two styles of masks being used, there is the same air pressure under the nose. The speed of the airflow is controlled by the rise and fall of the user's diaphragm.

I'm not sure I can explain it well, but I'll try. If I set my CPAP to 7cm fixed pressure, the machine will always deliver that pressure no matter what mask I use which is what I think you're saying. Now, if you take that 7cm of pressure and disperse it through a smaller mask opening, the force of that air will be greater than if you disburse it through a bigger mask opening. Keep in mind the difference is minimal.

I have a friend who switches between a nasal mask and an over than nose FFM. When he uses his nasal mask, his pressure never goes above 10cm. When he uses his FFM, his pressure can go up to 12cm keeping in mind his mask leak rate is around the same in both masks. His doctor said that it is not uncommon because with a bigger FFM you lose a bit of the pressure being delivered by the machine. The machine is still delivering the same pressure, but the effectiveness is a bit less when pushed through a bigger opening.

Now with that said, my buddy told me that he can use any mask and he feels no difference in pressure or his nasal breathing. If I use the under the nose mask, I can immediately tell the pressure feels greater in my nostrils. It's also harder for me to breathe through my nasal passages, but doable at first. Forget about pillows or nasal masks, as I feel like I'm suffocating in them immediately. I feel nothing of the sort with an over the nose FFM. Now, add in APAP and say I have an apnea in under the nose mask and my pressure kicks up, I will awaken with burning nostrils after using the mask a few days. Then it takes a couple of weeks after switching masks for my nostrils to feel better. I hoped a heated tube would help, but it didn't.

Do I get these symptoms because of a deviated septum or nasal valve issues, or a combination of them both? who knows. I've gotten feedback from people with deviated septum who can use any mask without issues while others suffer like me. . It's frustrating because my nose bridge gets irritated especially in the winter with over then nose FFM, which is why I wanted to use the hybrid mask at least some of the time.

[robysue1]

Now with that said, my buddy told me that he can use any mask and he feels no difference in pressure or his nasal breathing. If I use the under the nose mask, I can immediately tell the pressure feels greater in my nostrils. It's also harder for me to breathe through my nasal passages, but doable at first.

Most of our noses have not read any physics texts about how you maintain air pressure in a semi-closed system. And as a result, how we perceive the air being blown into the semi-closed pressurized system comprising the CPAP machine's blower unit, the hose, the mask, our nose (and mouth if using a FFM), and our upper airway often does not correspond to what a physics text would tell us is going on.

And when it comes to how our noses and mouths perceive what's happening with how our CPAP is maintaining the pressure, our subjective perception is far more important than what the physics books say is happening.

And this definitely affects the choice of mask for any individual CPAPer: Some people (and you are one of them) perceive any air flow directly into the nose that is not strictly from their own breathing as irritating. Other people don't. Some people (I'm one of them) perceive air flow on the outside of the nose as both irritating and too cold (if the tube is unheated) or too hot (if the tube is heated). Other people don't.

Forget about pillows or nasal masks, as I feel like I'm suffocating in them immediately. I feel nothing of the sort with an over the nose FFM. Now, add in APAP and say I have an apnea in under the nose mask and my pressure kicks up, I will awaken with burning nostrils after using the mask a few days. Then it takes a couple of weeks after switching masks for my nostrils to feel better. I hoped a heated tube would help, but it didn't.

Again, the facts are: Your nose didn't read a physics text book on how pressure is maintained in a semi-closed system and what your nose is (subjectively) feeling is far more important than what physics says about maintaining pressure in semi-closed systems.

In other words: Your nose turns out to be irritated when air (needed to maintain the pressure in the semi-closed system) is blown directly into your nose rather than into a mask that externally covers both your nose and mouth. The physics of what's actually happening in that semi-closed system is totally irrelevant: Your nose knows it gets irritated. And your nose takes a substantial time to heal. And your nose is the nose that has to be reasonably happy in order for you to keep using your CPAP night after night.

Now, it's a shame that a heated hose didn't help persuade your nose that it could deal with the way a nasal pillows mask or a nasal mask feels to your nose. But your nose is your nose, and you can't really change how it reacts to what it perceives is going on when you put your mask on and go to sleep with the machine each night.

Do I get these symptoms because of a deviated septum or nasal valve issues, or a combination of them both? who knows. I've gotten feedback from people with deviated septum who can use any mask without issues while others suffer like me.

As I said before, it's not just folks with physical problems (like a deviated septum) that sometimes can't tolerate a nasal pillows mask or a nasal cradle mask. Some people's noses just don't like all the air being blown into the semi-closed pressurized system to go directly into the nostrils. Other people's noses don't mind that happening, but may object to having their whole tip being in the breeze because the whole tip is covered by a mask.

. It's frustrating because my nose bridge gets irritated especially in the winter with over then nose FFM, which is why I wanted to use the hybrid mask at least some of the time.

So perhaps the answer is to try to find a way to protect the nose bridge from becoming irritated. Have you ever considered using a mask liner designed for your full face mask? That might help protect the bridge of your nose.

Padacheek sells a mask liner for both the Resmed F20 and F40 full face masks. Here are the links:

Padacheek mask liner for F40
Padacheek mask liner that fits Resmed AirFit F10, AirFit F20, and Air Touch F20 masks