Mouth sealed completely--AHIs go through roof

[dsm (guested yet again)]

I have to agree wholeheartedly with Rested Gals comment that epap at 8 is the most likely culprit.

I did some tests some years back where I had AHI up around 40 on a Bilevel when I set epap to 8. The AHI droped to less than 4 by merely lifting epap to 10 CMs.

DSM

Here is a link to one such chart.

http://www.internetage.ws/cpapdata/menu_0724.html

[CollegeGirl]

Holy cow. You poor thing.

Like others have said - anytime your leak rate is that bad, your data is not at all accurate. Those two days where you DID manage to get your leak rate down with the combination of solutions - THAT is much closer to accurate data. And that is NOT good. In fact...not to scare you, but...I think that is probably the WORST data I have ever seen from someone's machine when they're actually at their treatment pressure. It looks to me like either you were VASTLY mistitrated, or your DME didn't know what to do with your machine and REALLY messed up the settings.

The Respironics tech that told you "anything under 50 is acceptable" with your machine was very wrong. Acceptable leak rates are also called "vent flow rates," (you seem to at least know this much since you're referring to the "vent rate") and what that is is the measure of the amount of air that comes out of the exhalation ports of the mask in order to flush out the C02 you're exhaling (forgive me if you know any of this). Each mask has it's own particular vent flow rate, and it's different at each pressure. The higher the pressure, the higher the vent flow rate. If you look in the information that came with your mask, there may be a chart with the vent flow rate listed. The goal is to get to that rate, or very close. If the vent flow rate for your mask at your IPAP pressure is in the thirties, then you're getting very close with your combination mouth sealing method, and the data from those nights is probably fairly accurate. (The fact you're still having Large Leaks [the LL notation] makes me wonder, though it looks like you're just taking off your mask while you get up and go the restroom or something without turning the machine off first).

I would DEFINITELY be taking this data to my sleep doc ASAP as there looks to be something very, very wrong with your treatment.

Just my non-professional opinion.

[Velbor]

I have also had the experience of much higher respiratory event indices when using a nasal mask and mouth taping (and an AutoPAP), than when using the same mask without taping (leak rates are NOT sufficient to impair therapy or machine sensors) or when using a full face mask. I am still finalizing data collection and analysis; I hope to be able to post hard data about this within a few weeks.

In the meantime, one possible mechanism comes to mind: with the mouth taped, snoring, which is a trigger for most autoPAP algorithms, may be "artificially" prevented, thus impeding the machine's pre-emptive pressure response. I'm not fully convinced that this fully explains the phenomenon, but it might contribute to it.

Velbor

[johncuse48]

I am new to this forum and I have a question. I am using a Remstar Plus CPAP machine w/smart card. How can I read the information to see my AHI's.

[CollegeGirl]

John, unfortunately the RemStar Plus is not data capable. The only data it will give on your smart card is compliance data - in other words, how many hours per night you're using it. Helpful for your insurance company, but not at all helpful for you. You would need at least a RemStar Pro (or a RemStar Auto, like many of us have) to be able to see your data.

[Paul22]

My thanks to all who responded.

I talked to a Respironics tech today. He told me that the Series M respond to, and record reliably, apneas for leak rates up to 60 or 65 L/m. At 75 L/m Series M handle some, miss some. Much above 75 L/m--nothing.

Earlier I posted 4 Daily Reports--two looked horrible, two looked pretty good to me. The only difference in set-ups was that for the two horrible ones I had my lips completely sealed with a combination of dental cream and tape, for the two good ones I used a "porous dam" of over my mouth. The leak rate for the good reports was higher than that for the horrible ones--but not high enough, according to the Respironics tech, for apneas to be missed.

I had planned, in the absence of not knowing what to do, to stay with the "porous dam" until I learned more--but I will probably get enough courage to try again sealing my lips completely.

Again my thanks.

Paul22

[GumbyCT]

Paul,
I am not a Respironics tech but I do know that each machine tolerance (or calibration) could be a tad off. I am now wondering about your machine. Is it a loaner? Any way to compare it to another? Or have the pressure calibration checked?

You seem to be sensitive to even a .5cm change in pressure.

Good Luck,
GumbyCT

[Paul22]

GimbyCT

The machine, a new one, was supplied about 5 months ago by the VA. Someplace around here I have a water manometer (the scale is even in cm!) that I can check the pressure with. Not particulary easy to read (it is not an inclined manometer) but should be good enough.

Something that I have not mentioned (don't understand it , either). Sometimes, generally after getting up to go to the bathroom, then going back to bed and putting on the cannulas, the air flow noise suddenly stops completely--but the machine is still switching normally between EP and IP and air is coming out the vent holes--but I can't tell by feel if the flow differs from the usuall flow. The air noise returns but the time it takes to come back varies. It might be as short as a minute, as long as our or five minutes and it does not come back as abruptly as it stopped. The occurences follow no pattern. It might happen two or three times the same night, it might not happen for two weeks. Here is the kicker--it has happened with three machines, my old VPAP II, the Respironucs M Auto (bilevel mode--not Auto), and whatever machine was used on my last titration (the RT made no comment about anything happening) Since physicists don't believe in coincidences, I have to think that it really is "in my head". the only thing common to all occurrences. But there is absolutely no physical sensation in my head when it happens. I wonder if some obstruction in my head suddenly disappeared, the vent flow and its noise drops dramatically--but there is still vent flow. ????????????? All I can say with certainty is the noise stops abruptly--and that air is still flowing--and that I have no idea what is going on.

Regards

Paul22

[Goofproof]

My thanks to all who responded.

I talked to a Respironics tech today. He told me that the Series M respond to, and record reliably, apneas for leak rates up to 60 or 65 L/m. At 75 L/m Series M handle some, miss some. Much above 75 L/m--nothing.

Earlier I posted 4 Daily Reports--two looked horrible, two looked pretty good to me. The only difference in set-ups was that for the two horrible ones I had my lips completely sealed with a combination of dental cream and tape, for the two good ones I used a "porous dam" of over my mouth. The leak rate for the good reports was higher than that for the horrible ones--but not high enough, according to the Respironics tech, for apneas to be missed.

I had planned, in the absence of not knowing what to do, to stay with the "porous dam" until I learned more--but I will probably get enough courage to try again sealing my lips completely.

Again my thanks.

Paul22

And why would you believe a Respironics Tech...... Did his lips move? Jim

[StillAnotherGuest]

The best answer would be "Get another NPSG to figure out exactly what's happening". However, lacking that, I believe that the problem and solution are still far more simple than everyone (except tech support at Respironics) makes this out to be.

The most important concept to realize is that Encore Whatever cannot determine when one is asleep.

In a review of posts:

I presently am using a Respironics Bipap Auto Series M set on 11/8 cm H2O (straight Bipap, no Auto).. My normal breathing pattern requires a longer TI than permitted by this machine. A Respironics tech told me that the TI is hardwired at 3sec, and my observations agree. I need a machine that has a longer TI, preferably 10 seconds, but I could get by on 6 sec (I also do some slow breathing exercises as part of a relaxation technique).

Some day I hope to find a full face mask that I can wear—right now am using a Nasal Aire II and have trouble with mouth breathing. If I am to use a full face mask, I will have to have a machine that transitions gradually from expiration to inspiration. The sudden transition in the few machines I have been exposed to feels like someone hitting a drum inside my face and keeps me from going to sleep.

I discovered that if I use the sealing dental cream on my lips and some tape over my lips I can get a complete seal on mouth leaks for the night—but AHIs go through the roof. Also I have trouble going to sleep and feel like I never did get fully to sleep. Using the tape only, I have no trouble going to sleep and normally sleep soundly for 5 or 6 hours—with acceptable AHIs.

And what I really do not understand is why stopping the mouth leak completely prevents my going to sleep.

If we take Paul's estimation of his actual sleep as being reasonably accurate, then the most likely explanation of those high AHIs is a breathing pattern during wake that is interpreted as a pile of apneas (physiologically, centrals at that). They are caused by a conscious breathing pattern that is unnatural (a Tinsp of > 3.0 seconds is only helpful for yoga, childbirthing and COPD (yeah, I saw that, I don't think it's pertinent, but get the PFT results)), pressure intolerance, a little compensation for wake hyperventilation, perhaps some sleep-onset central phenomenon and maybe a little CompSAS. In other words, all those events are a heap o' wake-generated garbage.

I think the only data that you should consider as valid and interface set-up that is effective are those that come out of a night that you think you actually slept for the great majority of the night.

SAG

[mindy]

Interesting series of comments.

On this forum we sometimes seem to be, imho, very focused on leaks. I was told that the machine can compensate for leaks *up to a certain point* and what that point is varies depending on who is giving the info. I was told up to about 70 was ok, now I'm hearing 50. I've seen with my own data that large leaks (as defined by the Respironics M-Series Auto with AFlex) result in no recording of apneas and think I can reasonably assume that means no little or no therapy.

During a normal night for me, I switch around my sleeping position periodically. At those times my nasal mask (and FFM, too) may leak a bit more for a very short time. I can't imagine those couple of minutes at a time with a leak rate of perhaps 40-50 is going to seriously affect my therapy - especially since I have mild apnea. I could be wrong.
I suspect that some of those people who have gorgeous leak rates may not be serious "tossers and turners".

In any case, my philosophy is to try "reasonable" measures to reduce leaks but I don't go crazy about it. It works for me.

Mindy

[Hawthorne]

As to Mindy's point - I think that the amount a person moves at night has a great deal to do with leak rates. It may have more to do with it than mask fit for some people, maybe more to do with it that mild mouth breathing.

I am one who hardly moves at all for the whole night and my leak line is great. It is right on or very very near the manufacturers vent rate almost always ( a "gorgeous" leak rate) no matter which mask I am using. I'm far from a serious "tosser and turner"! I do tape (because I used to wake up with a dry mouth) but just one strip of tape (1" wide) vertically across the middle of my lips does the trick for me. My diagnoses was severe sleep apnea 6 years ago.

[rested gal]

The more I look at the Encore Pro data from the two "good" nights, I've changed my mind about saying raise the EPAP.

I think I'd just keep going with the porous tape and the present EPAP/IPAP settings.

[Paul22]

Thanks to all for the responses. Below are two Daily Reports--machine setings and mask were the same for both.

The machine is a Respironics Auto Series M. Its settings are;

Therapy Mode Bilevel
BiFlex Setting 1
IPAP 11.0
EPAP 8.5
Ramp Time 0

Nasal Aire II Extra large cannula Factory published vent rate ~35 L/m@10 cm H2O

The wide difference in reports is evident. Subjectively I slept better the night of the first report and felt Ok the next day. I didn't feel quite so good the day after the second report, but I didn't feel too bad, either--did not feel sleepy and tired all day. When I went to the gym that afternoon, their oximeter gave me an O2 reading of 96%.

FWIW, my sleeping pattern and digestive system were permanently altered by a close encounter with a shark after my ship was sunk off Okinawa by a kamakazi back in WW II. For me a good nights sleep is 3 to 5 or so hours of deep, uninterrupted sleep followed by 3 or 4 hours of in and out sleep, very restful and peaceful, with lots of dreams.

Right now, I am debating with myself over two options:

Option 1. Make no changes in settings but sleep on my side instead of on my back.

Option2: Change IPAP to 12.5 cm and EPAP to 10.0 cm.

Paul22

[GumbyCT]

Paul, Sleeping position can make a big difference. Keep a log of any changes you make and the results (how you feel is prob most important).

Reading this will help -
For Acronyms & Definitions
http://www.sleepnet.com/definition.html

Watching this will help -
http://www.resmed.com/en-au/clinicians/ ... 40x380.swf

Start at the Yellow Lite bulb - Our Collective Wisdom found at the top of the page at http://www.cpaptalk.com
our-collective-cpap-wisdom.php
new-cpap-user.php

Watching this will help -
http://www.resmed.com/en-au/clinicians/ ... 40x380.swf
http://www.resmed.com/en-us/patients/un ... 40x380.swf
http://www.nbc.com/Saturday_Night_Live/ ... -2/742141/

take a breath, put on your reading glasses and get comfy
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Good Luck,
GumbyCT