Six months and still struggling

[Nocibur]

...the mouth, bringing with it the high-resistance, low-pressure, and unstable mechanics of that blocked system.

Also this is incorrect, too.

Specifically, the resistance to breathing of the nose is about twice that of the mouth and nearly half the total resistance of the airways.

[Nocibur]

The act of opening your mouth often causes the tongue and soft palate to shift backward toward the throat, further narrowing the airway.

Only if you're swallowing.

[jimbud]

The act of opening your mouth often causes the tongue and soft palate to shift backward toward the throat, further narrowing the airway.

Only if you're swallowing.

Swallowing what? Air?

I do wake up with flatulence. Mostly in the morning. It gets better after a while, as the day goes along.

[Nocibur]

I do wake up with flatulence. Mostly in the morning. It gets better after a while, as the day goes along.

I can't tell you how fucking helpful your posts are.

Really, I can't.

[jimbud]

I can't tell you how fucking helpful your posts are.

Really, I can't.

Having noticed your penchant for nitpicking, here is a timely reminder for fellow Oklahoman's (among others) for you to nitpick.

Prepare for a snowstorm by
staying indoors, keeping warm with layered clothing, and having emergency supplies ready (food, water, radio, flashlights). Avoid overexertion while shoveling to prevent heart attacks. If you must travel, do so slowly, keep your gas tank full, and carry a vehicle survival kit.
Before the Storm (Preparation)

Stock Supplies: Ensure you have non-perishable food, water, flashlights, batteries, and a battery-powered radio.
Prepare Your Home: Have extra heating fuel, such as wood for a fireplace, and, if necessary, ensure you have safe, approved indoor heating equipment.
Vehicle Readiness: Keep your gas tank near full to prevent fuel line freeze-ups. Pack a winter survival kit: blankets, food, first-aid kit, and a small shove.

Hoping you are safe and warm.

JPB

[Nocibur]

Having noticed your penchant for nitpicking, here is a timely reminder for fellow Oklahoman's (among others) for you to nitpick.

Sure!! No prob!!

That would have been a great post...

yesterday!!

[jimbud]

Having noticed your penchant for nitpicking, here is a timely reminder for fellow Oklahoman's (among others) for you to nitpick.

Sure!! No prob!!

That would have been a great post...

yesterday!!

Well I'm out. After reading about Pugsy's situation with her husband's and her health I do not want to add to her aggravation on here.

At least I was able to get you to admit NOT knowing something!

Anyway, you can PM me with any questions and I will try to walk you through them.

It has been fun. Seriously.

JPB

[Nocibur]

Well I'm out.

Hey, you're the one who decided he wanted to be clever.

Not so funny now, little man.

[futoncouchsofa]

Hey there, sorry to hijack your argument, but I was wondering if anyone could help me interpret what's going on with the wave form in these screenshots.

For context, I've switched back to my X30i mask in an attempt to stop the mouth leaking/puffing that's happening when I go into REM in the mornings. I have taken the advice of people here to try to focus again on nasal breathing, and not just breathe through my mouth when I'm wearing the mask. I'm trying to breathe through my nose but I know I probably will to some extent mouth breathe.

I think what is happening is that at some point in my sleep, I am opening my mouth more and more, and that my breathing turns into mouth breathing, which precipitates an arousal. I've highlighted two screenshots from last night here that I think demonstrate that, based on my understanding of mouth exhales on a flow rate curve. But please correct me if I'm misunderstanding it.

I feel like I am sleeping better. I think it's partially because I'm using a more aggressive advancement on the mandibular advancement device and partially because I'm finding a decent pressure that has enough IPAP to stop my flow limitations while not overwhelming my system with a high EPAP. Please note that in this screenshot it says my pressure was 8/6, but it was actually 10/6 up until when I restarted sleeping with the mask around 5:22. I changed it to 8/6 at that point because it felt like the pressure was overinflating my nose and making it hard for me to breathe through my nose, and you can see that my flow limitations shot up.

I still feel like crap in the mornings but I'm hopeful that a couple of nights with uninterrupted sleep will eventually get me back to a baseline of feeling okay. And yes I know that I'm not getting a lot of sleep VOLUME; we have a one-month old at home so there's not much I can do about that, but I do try to grab a catch-up nap during the day if I can.

Also, I am considering taping with the full-face mask. Is that a good idea? Maybe only tape part of my mouth so I can still let air out if I start to mouth breathe? I guess my thought is that if I tape my mouth I'll mouth breathe less, but then I still have the mouth part of the mask to catch my breathing when my mouth does inevitably open, usually toward the morning.

P.S. Thank you for all the nasal info/suggestions ejbpesca. I have done a lot of these things with not much help. I think I just have anatomical restriction that I'm going to eventually have to solve surgically if I want to sleep better. But for now, I'm focusing on nasal rinsing and flonase, along with trying to get the humidity as high as I can without it getting too hot int he mask. I know that some, especially on the UARS subreddit, advocate higher IPAP to deal with nasal obstruction, but I think it's too much for me to handle. I end up getting bad aerophagia and it just feels uncomfortable to breathe when the pressure support is so high.

[ozij]

Also, I am considering taping with the full-face mask. Is that a good idea?

NO NO NO. BAD idea.

Given your anatomical restrictions, you need to breathe through you mouth if your nose becomes obstructed. Taping will just make your struggle from more oxygen and wake you.
I am not a "mouth breather" but a bad "mouth leaker". I can handle taping just fine, but sometime I need an FFM - and have experience using one. I am also a light sleeper, and if I had leaks like yours my sleep would be dreadful.

When fitting your full face mask, make sure you can open your mouth without making it leak. If you use a MAD, fit you mask on after you've set the MAD. If you make changes to your MAD, you'll have to make changes to your mask fit. Use Resmed's mask fit option. Try letting your mouth drop making sure the seal is kept even when you let your mouth open.. Do all that when you're wide awake, not when all you want is just to sleep now.

Focus only on fitting to stop leaks. If the mask slips into your mouth, it may be the worng size for you. Or the wrong shape.

Then go to sleep and stop thinking about your breathing. As a matter of fact, I suggest that when you've fit the mask, just before you try to sleep, you tell yourself the following: My brain is doing its best to make sure I get the necessary oxygen. It wakes me up from sleep to make sure I get enough oxygen. I am now using two devices to keep my airway unobstructed. I will now trust my brain to handle my oxygen needs, no matter if I breathe through nosr or mouth.
Do not, repeat, not think of how you're breathing. If your brain needs more oxygen and makes you open your mouth during inhale, its doing its job - trust it. Stop struggling to control your breathing - that keeps you from sleeping.

[ejbpesca]

My attempt at taping with a full face mask failed because I needed to mouth breathe during sleep. A collar and chin strap also failed. I have come to accept that mouthbreathing is how I must breathe when in the supine position. I only mouth breathe in the supine position. I cannot avoid rolling from side to supine and the gadetry to prevent it failed. I will have clusters of apneas in the supine position, even though my pressure has hit 18. If pressure were at 8, I could have 70 events in an hour. 12-18 cm keeps AHI at a dozen per sleep session = AHI <5.

I do not think my situation is uncommon. Some manage to train themselves not to back sleep, resulting in not needing PAP therapy. It is supine sleeping that is the source of my apnea. Nightly, it is roll to back > REM sleep > jaw lowers > mouth opens > tongue falls back = Severe Apnea unless a FF mask and up to 20cm pressure keeps AHI <5.

[futoncouchsofa]

I wanted to come back with an update and get some help. I've been experimenting with higher pressure support to see if that could resolve the flat-top breathing curve flow limitations I've been seeing, and it seems to work. It also allows me to drop my EPAP to 6, which seems to be plenty to resolve my obstructive events. For the last two nights, I've had my machine set to 6 EPAP and 14 IPAP. It does feel a little strong on the inhale, but it seems that the pressure support of 8 is sufficient to stop most of the flat-top breathing curves that I've seen for many months now, so I'm very encouraged by the success of the higher pressure support. I can handle it a little bit better because the minimum pressure is lower.

But I am still having an issue later into my sleep. Especially in the mornings, when I assume I'm in REM, my nose is just unbelievably congested. It's a dry congestion, and when I take the mask off to test out my breathing, I can barely breathe through my nose at all. And yet when I put the mask on, I'm able to push through most of it and breathe OK. I'm using a P30i mask and putting an elastic headband over my mouth to prevent mouth breathing, which seems to work pretty well and means I don't necessarily need to use mouth tape.

Seems that I'm having two primary issues:

Number one is that in the earlier parts of the night, my general flow rate seems to look fine to me (most of the time), but there are intermittent periods of spikes in my breathing pattern that I can't explain. I figured these would be precipitated by some kind of flat-topped breath, but I'm not seeing that anymore now with the higher pressure support, and yet these micro-arousals persist and are fairly regular throughout the night.

The second issue is that more toward the morning, it seems that my nose is blocking up really badly and that I am getting more classic-looking flow limitations. So I'm trying to figure out how to solve for both of these things. I do have an X30i mask, which I could try tonight to see if maybe that helps with the flow limitations I'm getting closer to the morning that are likely caused by the nasal congestion. But as many of you know, breathing through the mouth is not the best and potentially could cause more problems and also dries me out, which also could wake me up, so I'm not really sure what the best solution to that is.

Maybe the solution is to raise the pressure support even more, but I'm wondering if I'll be able to tolerate something over 8 for the entire night. I do have the V-COM device, which I could maybe use to slow down the inspiratory flow, so maybe that's a good option for me. But I'm also thinking about ASV because maybe what I need is something that adjusts the pressure support dynamically throughout the night so that I'm not getting pressure support of like 10+ early in the night when I don't need it. It seems that my nose closes up later in the night/early morning, possibly something to do with laying down for a long time and blood engorging my nasal blood vessels or something like that. For the earlier part of the night, I don't really know if there's something I can do. 

Doctors have suggested some medication to lower my arousal threshold, like Quviviq, so I'm considering something like that. But at the same time, I would prefer to try to find a solution with the machine and avoid drugs. I also know that there are potential other solutions long-term re: my nasal breathing, but I've already tried many of them like steroid nasal sprays and saline rinses and allergy nasal sprays. I also had a turbinate reduction and deviated septum repair in May of 2025. I can breathe through my nose during the day now, but still have these issues at night. I have not really found much relief from any medications/sprays. I'm open to trying them again in the future, but I'm trying to be stepwise about this and focus on the PAP therapy first and see if I can get as much as I can out of that before making other changes.

I should note that in the last two nights when I've been using higher pressure support, I've woken up feeling better than I have in the recent past. But I still don't feel very good, so I don't want to give the impression that it's kind of been resolved. But at the same time, I have to note that the higher pressure support is definitely doing something. The question is, how much higher can I go without blowing myself up? And is that really the solution? Maybe a slightly higher EPAP might help stabilize things?

My hope is that people can look at my waveform data and help me understand what I'm looking at. It's just very confusing to me, these sort of frequent ragged breaths that I see and the waxing/waning breathing pattern. I just don't really understand what's causing this and what it all means and how to resolve it. I have been operating under the assumption that if I resolved the flat-top breaths that this would take care of itself, but it doesn't appear to have happened.

Maybe I have loop gain? I don't really understand it completely, but I've been reading a bit more about it recently and it seems to maybe match what is going on with me.

By the way, I don't think the cluster of OAs I had were real OAs. I think I was awake during that time.

I'm attaching main screenshot from OSCAR. Zoomed in images here: https://imgur.com/a/FRjRvgf

[futoncouchsofa]

Whoops I missed up the overall screenshot

[ejbpesca]

Are you using PS 8 due to respiratory issues other than OSA? If so, I understand, but if not, isn't 8 too high? ASV machines are used for those with mixed apneas of OA and Centrals. I have been studying the use of a bilevel machine for simple OSA. Most suggestions for PS to address FLs are not over PS 4.

I do not think getting smooth, round waveforms across an entire sleep session is realistic. PS is not for forcing your body to not breathe erratically between sleep stage changes, wake to sleep/sleep to wake, change of position, scratch an itch, flinch, react to a dream, etc. Use it sparingly unless you have COPD or another issue other than OSA.

The congestion you are experiencing could be from tissues swelling due to a sleeping position. Some get it on the down side of the nose when side sleeping. Some get it when sleeping on their back. It could be a non-allergic rhinitis due to PAP therapy. You can push through it because the pressure is holding the tissues open.

Changing the humidity level may help, up or down. Nasal rinsing may help. The only sure-fire way I know to unstop a swollen nasal passages is Afrin or other sprays with the same roto router decongesting chemical. I use them occasionally without consequences. 1/2 a spray does it for 12 hours...for me. YMMV

With FLs being of concern, have you considered Vauto mode that gives a FL 95% score?

[tlohse]

6 months is a long time to be struggling. Maybe you should go back to your doctor and reevaluate your issues. I’ve been a cpap user since 2013 and not once have I really had problems. I was always able to connect with my team and have been pretty successful with this.