Assistance needed - higher AHI with full face mask

[DreamOn]

Hi everyone,

I would appreciate any observations regarding my current situation. First, I'll give a brief background. I was diagnosed with mild OSA (moderate in supine position). I've been using straight CPAP (ResMed Elite II) for 3-1/2 months, first with a set pressure of 6 and for the last two months at pressure of 7. I no longer use EPR and no ramp.

I've been checking AHI, AI, HI, and leak rates since the beginning, and I have records for all sessions. About three weeks into therapy, I realized that I was leaking air from my mouth. My leak rate was very minor, but I wanted to see if I could eliminate it, so I started using the PAPCap chinstrap. I had zero leaks with the chinstrap until about two weeks ago, when minor leaks started showing up again. I don't believe this was due to worn mask cushion or nasal pillows, as I have been rotating between three masks (Activa LT nasal, Headrest pillows and Opus 360 pillows) and the leaks were with all of them.

I thought that perhaps I had reached a new level of sleep (even more REM?) and maybe I was relaxing my mouth open even more due to that. I didn't want to start taping my mouth if I didn't have to. It was time for my insurance company to pay for another mask, so I decided to get a full-face mask, the ResMed Mirage Quattro. I tried it for the first time last night.

I was shocked when I viewed my results this morning. So, here are two charts for comparison, the first with ResMed Activa LT nasal mask ("Activa" mask setting on machine) and the second with the ResMed Mirage Quattro full-face mask ("Mir Full" setting on machine):


JANUARY 30, 2010 (a typical night lately) - Activa LT nasal mask

AHI...................1.3
AI.....................0.1 (1 apnea)
HI.....................1.2
Leak..................0.08 L/sec
Hours.................9:40




FEBRUARY 2, 2010 (last night) - Quattro full-face mask

AHI...................5.8
AI.....................0.8 (9 apneas)
HI.....................5.0
Leak..................0.14 L/sec
Hours.................10:32



As you can see, my AHI was way up with the Quattro. The most shocking thing was the cluster of 8 apneas in the approximately 10-minute period around 3:27-3:37 a.m., which is detailed below the main chart. This may not seem like a big deal to many of you, but I usually have 0 to 2 apneas per night (AI of 0.0 to 0.2). About half of the nights I've used CPAP I've had zero apneas, and my typical AHI is 1.0 to 2.0.

Except for a one-week period, in the 3-1/2 months that I've used CPAP I have felt very good, with clear-thinking, more energy and better health. In contrast, I feel lousy today, with a slight headache and not well-rested at all. I had to readjust the mask numerous times during the night, so that accounts for last night's leak rate. I'm definitely going to have to raise the humidity with the full-face mask, and I know that it'll take some time to adjust to it. I also realize that I can't project results based on one night with the new full-face mask. It takes some time to get accustomed to changes in therapy.

Any idea why I would start mouth-leaking again after successfully using the chinstrap for several months (with zero leak rate)? Is this a common occurence? Any thoughts on why the results with the full-face mask were so much worse than with the nasal pillows and nasal mask? Has anyone experienced this much of a difference longer term? Why the cluster of apneas, which I've never had before? Any suggestions overall?

I have an appointment with my sleep doctor next week. One thing I'm going to discuss with him is raising my pressure. And I'm hoping to have more data with the full-face mask by then so I can discuss that with him too.

Thanks for any feedback!

~ DreamOn

[ozij]

DreamOn,
Those apneas -- and miserable feeling -- could both be a result of the restlessness caused by the new mask. Try to relax about it and give yourself a few more days to get used to the mask. Maybe things will iron out.

As to why mouthleaks develop -- I wish I knew... I'm having major problems with them now.

[Wulfman]

Since virtually all your apneas (except one) occurred during that one short period of time, I would suspect there was something that happened that was not related to the mask......like a sleeping position (possibly chin tucked closer to the chest?). During the other times, you may have been sleeping more soundly. I dunno......

I'd give it a few more nights and see what the reports look like

If you're one of "THOSE" types or patients that have to get their doctor's permission to change pressures ......I won't make any suggestions in that regard then.......

Theoretically, the masks shouldn't make any difference in the delivered air (pressure settings).......however, some people HAVE noticed that they may need a little more when switching to a full face mask from a direct nasal interface.

I've never tried any type of nasal mask, so I have no first-hand experience.


Den

[Ms.Snuffleupagus]

HI DreamOn,
A full face mask really does take a little bit to get used to. So, as others have said, you need a few more nights to see what will happen.

As for the increased AHI, I noticed that for me it can go up by quite a bit, if I am sleeping very lightly ie: when I hit the snooze button several times in the morning and I am dozing but not really sleeping. This even happens when I wear my mask when awake, reading in bed. The machine seems to misread my AHI if I am not really sleeping or if something is causing me to toss and turn (new mask??).

Re: using nasal mask/nasal pillow masks: I know you said you did not want to resort to mouth taping, but you might try it just for a couple of weeks to retrain yourself not to mouth leak. I was surprised that this worked for me and the mouth taping was short term..or so I hope. It doesn't always work but you never know.

[KatieW]

Well, I can tell you're upset, but give it a few more nights. My experiments with the Quattro are still continuing, and leaks are a big problem for me too. Plus, I just don't sleep as well, when I'm worried about leaks, and hearing leaks.

I'm just checking...you changed the Mask Setting, right?

It's a dilemma, if you bump the pressure up, you might treat some of those apneas, but then your leaks might be higher.

[JohnBFisher]

DreamOn, this is just a theory, but you might be able to test it. It is possible the Quattro Full Face Mask is pressing down on your lower jaw, causing the chin to recede more than normal. This would tend to cause the tongue to collapse into the airway more readily. One of those sports bite plates (if it is comfortable) might allow you to "keep" you lower jaw better positioned.

It's just an idea. It may be worth the money you spent on it. (aka ZIP! ) But I thought I would toss out the idea.

[DreamOn]

Thanks so much for your responses!

I went to the gym this afternoon, and I couldn't stop yawning! If nothing else, the experience last night is a reminder of how far I've come in the last few months, as far as how I feel during the day. It'll be interesting to see if I fall asleep in the early evening tonight, like I used to pre-CPAP.

Those apneas -- and miserable feeling -- could both be a result of the restlessness caused by the new mask. Try to relax about it and give yourself a few more days to get used to the mask. Maybe things will iron out.

As to why mouthleaks develop -- I wish I knew... I'm having major problems with them now.

Ozij, I'm sorry that you're having problems with mouth-leaking. I hope you figure out what (if anything) is causing that.

I will try to relax about it. I'm a patient person (most of the time, anyway). Every time I have tried a new mask it has taken several days for my numbers to settle down. I think it's an especially big change going from nasal/pillows to full-face. I wear my Activa LT nasal mask very loose, but the Quattro seems to need to be worn much tighter! But I don't feel claustrophic, so that's good. And it didn't bother my nose bridge (yet, anyway). I tried on several other full-face masks, in multiple sizes, and this one seemed to work the best.

If you're one of "THOSE" types or patients that have to get their doctor's permission to change pressures ......I won't make any suggestions in that regard then.......

I suppose I am one of "THOSE" types, to a certain extent anyway. I've been slow to make changes because (1) I have had great results since Day 1 (both in the machine numbers and how I feel) and (2) I figure I have the rest of my life to "get this right", so I'm not in a big hurry. But I am all ears for any pressure recommendations! I had an awful titration night, and felt incredibly bad the entire next day. I suspect they had to guess at the titration pressure of 6, since I didn't get many hours of sleep and not much REM at all. Results have been about the same at both pressure 6 and 7. Because I've had zero apneas about half the time and otherwise it's usually AI of only 0.1 or 0.2, I figure there may not be a whole lot of room for improvement regarding apneas. But I am a perfectionist and I want to optimize my health, so I'm open to raising the pressure to see what happens. I've never had an AHI less than 1.0, and I'd really like to see that. And it'd be great if it's possible to have zero apneas every night!

Re: using nasal mask/nasal pillow masks: I know you said you did not want to resort to mouth taping, but you might try it just for a couple of weeks to retrain yourself not to mouth leak. I was surprised that this worked for me and the mouth taping was short term..or so I hope. It doesn't always work but you never know.

Thanks for sharing that taping helped you to train yourself not to mouth leak! I am definitely open to trying mouth taping at some point, but I wanted to avoid it if possible. If the full-face mask doesn't work out, I'll either try mouth taping or just go back to the nasal/pillows mask with the PAPCap chinstrap and live with the slight leak rate.

My experiments with the Quattro are still continuing, and leaks are a big problem for me too. Plus, I just don't sleep as well, when I'm worried about leaks, and hearing leaks.

I'm just checking...you changed the Mask Setting, right?

It's a dilemma, if you bump the pressure up, you might treat some of those apneas, but then your leaks might be higher.

Katie, I didn't know you were experimenting with the Quattro too! It's just amazing how similar our paths have been! Even with pulling the mask away from my face to readjust throughout the night, my leak rate of .14 L/sec with the Quattro wasn't bad at all. It was the clustered apneas that concerned me more, since I have never had a night like that since starting CPAP. I did change the machine mask setting to "Mir Full" for the Quattro, but I'm glad you asked.

DreamOn, this is just a theory, but you might be able to test it. It is possible the Quattro Full Face Mask is pressing down on your lower jaw, causing the chin to recede more than normal. This would tend to cause the tongue to collapse into the airway more readily. One of those sports bite plates (if it is comfortable) might allow you to "keep" you lower jaw better positioned.

John, that's something I hadn't thought of, and it's entirely possible! I purchased a mouth guard right before getting the chinstrap. Because the chinstrap worked so well, the mouthguard's still in the box, unused. I think I'll give it a few more nights to see if anything changes, and then try the mouth guard if results don't look better.

Thanks again to all. Your feedback is truly appreciated, and I'm open to all your suggestions! I'm going to sleep with my oximeter tonight. If there are more apneas again, like last night, it'll be interesting to see what the oxygen levels and pulse rates are. But I have a feeling I'm going to sleep better!

~ DreamOn

[DreamOn]

Yikes!!! Second night with the Quattro mask, and it's even worse than the first night!

FEBRUARY 3, 2010 (second night with Quattro full-face mask)

AHI...................9.6
AI.....................2.8 (27 apneas - vs. 9 apneas first night with Quattro and 0-2 on a typical night with nasal/pillows mask)
HI.....................6.8
Leak..................0.12 L/sec
Hours.................9:30



Contrast these results with the results posted at the beginning of this thread. Much worse!!! The first chart I had posted was a typical night with my Activa LT (AHI 1.3, AI 0.1, HI 1.2, leak 0.08 L/sec), and the second was the first-night results with the Quattro (AHI 5.8, AI 0.8, HI 5.0, leak 0.14 L/sec).

I didn't do anything different than the first night with the Quattro, except I used the straps on my PAPCap Plus, instead of the ResMed headgear, to secure the mask. I still had to wear it pretty tight on the bottom to stop the leaks. I'm wearing a size small, which comes pretty close to my eyes (as my Activa LT does). But the extra small was too small around the bridge of the nose.

Of course, this morning I feel like I was hit by a truck. Yuck!

I was going to sleep with my oximeter, but I couldn't find it when it was time to go to sleep! I had put it on top of my pillow yesterday morning, to remind me to use it at bedtime. When I went to bed it wasn't there. I think it must've been knocked off during the day because I do remember hearing something fall when I was doing something in that area during the day. I searched and searched, but couldn't find it. I'll have to do a more intensive search for it today.

I don't know how much longer I want to continue this full-face mask experiment. If I'm going to have to wear a mouthpiece too (to keep my jaw forward) it may not be worth it. It's leaking more than my Activa LT nasal and my Headrest/Opus 360 nasal pillows masks, although part of the leak numbers are readjustments while wearing the mask. I may just decide to live with the minor mouth leaks from the nasal/pillows. At least I was feeling good with those and they're comfortable to wear!

But I am still trying to remain open-minded about it. Perhaps things just aren't adjusted properly or something? I don't feel anxious wearing the mask. I don't catch myself with my neck bent down. Besides, if that was the case, you'd think I'd do that with my other masks and the constriction would show in those results too. Thoughts, anyone? I'm shocked at these bad results. Have you ever seen such a huge difference in results between various mask styles? This makes me wonder if some of the people who don't get good results from their xPAP therapy just may not be using the correct mask for them.

~ DreamOn

[Wulfman]

Hmmmmm.......maybe....er.....um.....pressure increase?

I'm still suspicious about the "clustering" of them, but I think I've thrown out all of my ideas previously.
The don't appear to be occurring during any "serious" leaking.


Den

[Muse-Inc]

Have you considered one of the hybrid-style masks? Comfort of pillows with the security of not losing therapy air when mouth breathing.

[ozij]

Your "typical night with the Activa" looks perfect to me. Those leaks are negligible -- if the mouth puffs don't wake you, you can safely ignore them.

I have been taping for many years, and tape improved my sleep for a long time. Recently I've started suffering from seal breaches (in the back of my palate) and they would cause chipmunk cheeks and wake me. My oxygenation lines were unstable too.

During the last week I decided to let myself have mouthleaks, intentionally; I try to leave a small crack in the tape. The results are as follows:
Expected: I wake up during the night with my cheeks stuck to my gums, and feeling dry to my very tonsils (!).

Somewhat unexpected: Despite those unpleasant awakenings, I feel that my sleep is more restful, and most nights -- and days --are better. Apparently those mouth puffs against the tape were very disruptive of my sleep.

Surprising: My AHI is better, I'm getting some 0 AI nights, and lower HI overall

Truly amazing: My oxygen line is often far more stable (at 95%) during leaks, than it gets when I tape. Furthermore, the A's and H' often appear when I close my mouth. And no, most mouth openings are not a response to a H or A

I'll report this on a separate thread when I've tried a FFM or two -- but I wanted you to know that my personal experience in leaks shows that they far from being as harmful to therapy as I thought. For me at this point, they seem to be beneficial. This it true of me -- I'm not saying how true it may be for others, but I am saying that Muffy has often noted we are over-concerned with mouth leaks.

O.

[KatieW]

Ozij, that is so interesting. I have noticed that a small amount of leak, makes no noticeable difference to my AHI, and I wonder if it even improves it. Or maybe it just doesn't matter.

My January average Leak Rate was .06 liters/second; and efficacy averages were AI 3.1, AI .2, HI 2.9. (I'm very happy with that, and feel great.)

Last night my Leak Rate was .12 liters/second; AHI 2.3, AI 0, HI 2.3.

Looking back, on my 3 other O AI nights in Jan., the Leak Rates were: .08, .10, .08.

I guess I better stop obsessing about the numbers.

[DreamOn]

Thanks so much to everyone who has responded! It is so interesting to learn what others have tried and how it's working for them. I have gained so much from you sharing your experiences, and from your suggestions.

Have you considered one of the hybrid-style masks? Comfort of pillows with the security of not losing therapy air when mouth breathing.

Muse, I have tried the Liberty hybrid, and that one didn't work for me, but I am interested in the hybrid mask that you're using. Unfortunately, my DME doesn't carry it, so insurance wouldn't pay for it. I may decide to try it in the future, though.

Your "typical night with the Activa" looks perfect to me. Those leaks are negligible -- if the mouth puffs don't wake you, you can safely ignore them.

Yes, I do get very good results with the nasal and nasal pillows masks -- in both "the numbers" and the way I feel during the day. My mouth leaks are always very minimal with them when I use the chinstrap. My leak line was absolutely flat, at zero, for several months and then the slight mouth leaks came back, so that made me curious what kind of results I would get from a full face mask. I thought that perhaps I would switch between the mask styles to give myself a break from the chinstrap once in a while.

Based on your results, ozij, when I'm finished with the full face mask experiment, maybe I'll try the nasal and pillows masks without the chinstrap to see how that affects my AHI (particularly AI).

Now, for my results from last night (third night of Quattro use, and some time with the Activa LT)....

February 4, 2010

AHI...................1.4
AI.....................0.2 (2 apneas! - vs. 27 apneas second night with Quattro, 9 apneas first night with Quattro, and 0-2 apneas on a typical night with nasal/pillows masks)
HI.....................1.2
Leak..................0.06 L/sec
Hours.................9:44 (6.25 hours using Quattro and 3.5 hours using Activa LT)



As you can see, the first part of the night I used the Quattro. The only change I made from the previous night was to raise the humidity from 2.0 to 2.5. Sleep was very restless, but only 2 apneas! Much, much better than the previous two nights with the Quattro, when one night I had 27 apneas and the other night 9 apneas! The major leak around midnight was because the hose popped off the humidifier. I have no idea how that happened either, as I'm hooked up via a hose suspension system so there's no tension there! Despite that major leak and others around the second apnea, as well as mask adjustments during the night, the leak rate of 0.06 L/sec was surprisingly low!

I had intended to sleep the entire night with the Quattro, but after 6.25 hours I couldn't take it anymore. I felt like I was waking up constantly and didn't feel rested at all. I was even tempted to sleep without any mask for the rest of the night, but I resisted that urge and put on the Activa LT and PAPCap chinstrap. Sleep with the Activa LT was much more restful. I remember several dreams during that period when I woke up, so I probably got some good (needed!) REM time.

My plan at this point is to keep trying the Quattro at least through the weekend. I have an appointment with my sleep doctor next week on Friday. I'm also planning to see the RT that day. I'm using a small Quattro. I did try on extra small, but it seemed a tad too small near the nose bridge. But, depending on results over the next few days, I may switch for an extra small Quattro or try the small FullLife mask, which seemed to fit me well.

I found my oximeter. It had been knocked off my pillow into an open drawer! I used it last night, but unfortunately, when I switched masks I also absent-mindedly turned off the oximeter. I did restart recording after donning the Activa LT, but it apparently overwrote the data from the time with the Quattro. Oximeter results with the Activa LT were unremarkable. I'm going to use it again tonight with the Quattro because I'm very curious about oxygen and pulse levels with that mask, especially when/if I do have apneas.

Have a happy weekend, everyone! And thanks again for your very generous help!

~ DreamOn

[Hawthorne]

Ozij - sorry you are having dry mouth issues now that you are leaving gaps in the tape. The good news is that you are getting better therapy, it seems!

I have always been able to manage mouth leaks with just a piece of 1" tape vertically across the middle of my lips (which would be similar to your "gap in the tape"). I still get a bit of chipmunk cheeks (not every night) but the data is always excellent (AHI below 1 almost always) and leak rate almost spot on (almost always none over the expected vent rate for my pressure) with my SwiftLT mask.

I use Biotene mouthwash every night at bedtime and it seems to deal with any dry mouth issues for the most part, even when I do have a bit of "puffing". Are you using something like this or "Biotene Oral Balance Gel"? It sounds like you therapy is going very well except for the dry mouth thing. Of course, dry mouth is not good for general oral health so none of us should leave it unattended but I wonder if a FF mask is the answer.

I have little experience with FF masks (have only tried mine for napping a few times) and I get an even drier mouth with a FF mask than I do with my current minimal taping and nasal pillows. I don't even need a FF mask when I have a cold so it is just there.

Maybe we are overly concerned about mouth leaking. When I had my last sleep study, I took tape but the tech asked me not to use it. I was using my own mask but it was a Comfort Curve at that time. She said she could get the humidity high enough to deal with mouth breathing. I've never used a very high humidifier setting (actually pass over most of the year and about 2 at this time of year in Canada) but I did not wake up with a dry mouth after that sleep study and was not using Biotene at that time. I really don't have any idea what the humidity setting was during the study.

I'd rather not use a FF mask because I do find it "mouth drying" and I am not very comfortable with a FF mask at all. I get a really red mark on my nose bridge (not idea what that would become if I used it all night most nights). I also have a Hybrid but find it finicky to adjust, for me. I don't use my card during naps so don't know if the data is worse or not. A nap would probably not show enough to tell me if it affected the data much.

Maybe a FF mask and higher humidity would help you - or maybe just higher humidity and use your current mask - maybe no taping----.

I'm going to see if I get any different therapy with no taping and maybe a little more humidity. If I am awakened in the night by dry mouth, I can get a swish of Biotene easier or put a bit of "Oral Balance" in my mouth without the tape on!

I feel I am away off topic on this thread now and am just "thinking out loud" so will stop!

Sorry DreamOn! I don't think I was much help with your situation!!!

[DreamOn]

I don't mind the side-conversations at all, Hawthorne! I learn new things, and your comments were helpful because it made me think more about humidity.

With my nasal and nasal pillows masks, I have found that I can't have the humidity any higher than 1.5 or I get moisture in the mask (from breathing, not rainout from the hose). So that's the humidity setting that I used with the Quattro the first night. Well, the air was blowing COLD and my mouth was very dry. And, although my lips weren't chaffed, they felt "crusty" during the first night I used the Quattro. That crusty feeling did go away when I wiped off my lips in the morning, but it felt weird during the night. (I do use lip balm or calendula ointment on my lips with any mask type.)

So the second night I bumped the humidity up to 2.0. Still the same feeling on my lips and in my mouth. But last night, at humidity of 2.5, I didn't feel either sensation. So I do think that, at least for me, the proper humidity is very important with a full face mask. Tonight I'm going to try 3.0 with the Quattro and see what happens.

I have another question for you all. Drooling. I'm not sure, but when my mouth leaks returned with the nasal/nasal pillows masks, I think I may have been drooling too, before I was asleep. (What an attractive picture that paints!) Although that's something I have done in the past, it isn't the case all the time. Why do we drool anyway? I'm just thinking that maybe there's a connection between drooling and the return of mouth leaks. More relaxed/deeper sleep perhaps? Thoughts anyone?

~ DreamOn