Last night not any better. :(

[cindjo717]

I tightened the mask and used Burts Bee Balm on the nares.... which I thought worked very well, yet my data still showing a lot of leaking.... This is going to be an issue... I don't get it. The nasal pillows were not popping out at all, which is a good thing, I went to sleep thinking this is going to be better and woke up feeling like crap. It must be when I am sleeping the mask must move and bingo, leakage.... what to do.. I will look for a pillow today and try and cut it out , (which I will screw up for sure) in order to make a c pap pillow... This should be fun, oh JOY.

[wmcanally]

I recently changes to a Nasal pillow the Swift FX. Im a newbie on here. Been on a Cpap for a little over a week. I am using the nipple butter and so far the pillows seem to be sealing ok. The came out once last night . I rolled over and the hose got caught. I really didnt notice, but my wife did. Said she heard alot of air hissing. I was woke up ( imagine that) and adjusted and went back to sleep. I have discovered its the hardest part of this treatment , the mask sealing. I have 3 differnt mask now in my bag. I like the pillows most of the3. I hope you can get it worked out to use them. The RT at the DME told me some people just cant get them to seal due to the shaper of the nostrils. Anyway best of luck to you!!!!!!

[robysue]

cindjo717,

The screen shot doesn't show the leak curve. I can see why you're worried about those leak numbers though.

Any idea on what your expected leak is at pressures of 10-13cm? That's something that you need to take into account.


That first really awful OA cluster seems to take place about 2 1/2 to 3 hours after you went to bed. The next one (also OA) starts a bit more than an hour after the first one ends. Then there appears to be a cluster of centrals that starts about an hour or hour and half after the second cluster of OAs ends and a cluster of hypops that starts about two hours after the second cluster of OAs ends.

Any chance the clusters are REM related?

What did you sleep study say about your REM AHI vs. your NREM AHI?

It there's a chance that those nasty clusters are REM related, then slightly increasing both the EPAP and IPAP pressures might help address them. Think you're up to trying an APAP range from 11--14 instead of the 10--13 you are currently using?

[cindjo717]

Thanks for your response... they DID seal last night, my left nare it came out one time, that's it.. I don't know where the leak is coming from... I used the Burt's Bee Balm and it worked like a charm... I will try and pick up a cheap pillow and cut it out to fit my mask.. maybe because I am side sleeper.. do you sleep on your side?

[robysue]

Cindy,

I'm a side sleeper about 90% of the time. And I use the Swift FX nasal pillows mask with out much trouble. My pillow is an ancient, 20+ year old down pillows that has lost most of its feathers. It's held together by being enclosed in not one, but two zipper, mite proof pillow cases inside my normal pillow case. The pillow is super soft and super squishable. When I'm on my side, I simply squish a nest out to hold the mask and make sure the exhaust vent is not blocked. Pugsy uses a buckwheat pillow in the same way I use my old down pillow.

[wmcanally]

I start out on my back. I actually bought a CPAP pillow. It does allow for easier side sleeping. I wake up on my side and i prefer it. I just always seem to start on my back. Im going to try the Burt Bees too. Im very thankful for some good knowledgable folks on here. They have read my graphs too and gave some valuable input.

[cindjo717]

Thanks robysue, I am changing it to 11 min 14 max tonight. Here is the leak curve shot... how do I find out what the expected leak should be? Have no clue on that one!

[cindjo717]

I have the same type of pillow that you do robysue, so I don't know if making a cut out will do anything. I just can't imagine why the leak is so bad , the pillows stayed in last night.

[Pugsy]

The leaks are driving the pressure up most likely or it could be events I suppose driving pressure and pressure feeding the leak monster. Leak monster then allowing the events to sneak past the defenses. Impossible to know exactly which started it all. Nasty little circle. If they are REM related events they might be super difficult sometimes to prevent and thus driving the pressure up. Till leaks are under better control impossible to know for sure.

Intentional vent/leak rate is usually on a graph with your mask paperwork.

[2 B Sleeping Soundly]

cindjo717,

I don't know if you have seen this or not but I saw it earlier this morning at Pad-A-Cheek's. I sorry but I know nothing about your mask, but hopefully someone else here who uses the same mask or a similar hybrid would know if this leak strap will fit or not. The strap looks very light and soft... just a thought.

http://padacheek.com/PAC_AntiLeak_Strap.html

Mask & mask leaking issues seem to dominate more than a few of the Therapy struggles here. We can all sympathize with you as it can be extremely frustrating when you are so close to having it all just right and need to find that one accessory or tweak to make it work. Hang in there, before long this leak issue will all be some distant memory and sweet dreams will be yours!

John

[Pugsy]

Intentional vent rate chart page 8 of the user guide
http://www.resmed.com/us/assets/documen ... er_mul.pdf

Looks like at a pressure of 12cm vent rate is 41 L/min

[cindjo717]

I think my leak rate is above that.... I feel like a dog chasing her tail.

[cindjo717]

Thanks 2 Be.... I will try and make one, if not I will splurge and buy it. It looks promising but won't get my hopes up. I've been shot down almost every night for a month now. I do thank everyone here for all the help.. Pugsy, I pinned that snipping tool and it works fantastic... LOVE it. If it was not for Pugsy painstakingly walking me through Sleepytime software,I don't know what I would do. It seemed so hard at first, but I am a champ now!

[robysue]

The leaks are driving the pressure up most likely

I don't think so. While an APAP will attempt to pump more air into the system in order to maintain the current pressure setting in response to a leak, that's not the same as increasing the pressure setting/level itself. Pumping more air into the system to maintain pressure is like continually pumping additional air into a bicycle tire with a slow leak. If the size of the leak starts to grow, you need to pump more air in just to keep the tire at the same current pressure, but that's not the same as increasing the pressure setting. I just wrote about this phenomenon in a different thread posted by another newbie. Click here to see my full response

According the the PR web pages about the System One Auto Algorigthm about Leak management on the System One, the Auto algorithm does NOT increase pressure in response to nasty leaks. The web page states, "Instead of falsely increasing pressure when a large leak is detected, our novel technology compensates by decreasing pressure in an attempt to re-seal the mask on the patient’s face."

And in this case, when we carefully analyze the data, we first need to know the intentional leak rate of the mask. The user guide to the Mirage Liberty can be found at http://www.resmed.com/us/assets/documen ... er_mul.pdf. According to the table for expected leak rates, the expected leak rate for the Mirage Liberty is:

• Listed as 32 L/min at 8 cm of pressure
• Appears to be about 37 L/min at 10 cm of pressure from the graph
• Appears to be about 39 L/min at 11 cm of pressure from the graph
• Listed as 41 L/min at 12 cm of pressure
• Appears to be about 42 L/min at 13 cm of pressure from the graph

And the table lists a +/- 6 L/min "error" for these figures. In other words, according to the literature, at 13 cm of pressure, Resmed believes the leak rate for the Mirage Liberty will be somewhere between 36 and 48 L/min.

Now let's re-look at the data:
[/quote]

Cindjo's leaks first start to increase noticeably around 1:00 right at the time there appears to be a couple of hypopneas. It also appears that the PR's hunt-and-peck algorithm also kicks in right around 1:00. In other words, the machine is thinking, "It's time to increase pressure a tad to see if the inspiratory part of the wave form is better with or without a small increase in pressure. The hunt-and-peck algorithm is what's behind those green spikes in the Pressure graphs between 12:15 and 1:00. Each of those times, the machine concluded the wave form did not improve and hence dropped the pressure right back down to 10cm. At 1:00, either because of the hypops or because of an improvement in the wave form, the machine decides to leave the pressure at around 11cm.

From 1:00 to 1:30, the leak rate continues to increase, but except for the hunt-and-peck algorithm and/or response to the 1:00 hypopneas, there is no real increase in pressure between 1:00 and 1:30. Indeed, about 1:20, the System One decreases the pressure back to 10, possibly in response to the increasing leak rate. But at around 1:25, there are some flow limitations and an OA or two. So the machine increases the pressure (back up to about 11.5) in response to these events. The leak is just above 47 L/min, which is at the top end of the "expected leak rate range" for the mask at this point.

More flow limitations occur around 1:40 and machine raises the pressure first to 12.5 and then to 13cm. At this point the leak rate also rise from about 47 L/min to a minute or two long spike at about 53 L/min before dropping back down to the 40-45 L/min range, which is where the leak rate stays for most of that really bad first cluster of OAs. It's not until 2:00 until the leak rate suddenly jumps up and then stays above the 50 L/min line. And it's also about 2:00 when that first cluster seems to end. It could be the leak is now bad enough to affect the quality of the data, but a leak rate of 55 L/min is only about 13 L/min above the expected leak rate of 42 L/min and only about 7 L/min above the top range of the "acceptable leak range" of 36-48 L/min.

And note that the first bad cluster of events starts right around 1:40. And at this time, the machine is either already at 13cm (maximum) pressure or it immediately raises the pressure from 12.5 to 13 cm at the start of the cluster. And since the machine is already at maximum pressure when OAs start to pile up in this cluster, it can't raise the pressure any more. Hence the problem with that first cluster of events seems to be insufficient pressure to deal with them, instead of genuinely horrid leaking of the sort that says "All bets are off" concerning the accuracy of the data.

A more significant problem with leaks occurs between 2:30 and 3:00 when the pressure is at 11cm and the leak rate is right around 55 L/min. The expected leak rate at 11cm of pressure is somewhere between 33 and 45 L/min. And so this leak is somewhere around 16 L/min above the expected leak rate (39 L/min) and a good 10 L/min above the top end of the "expected/acceptable leak rate range" for the mask at 11 cm and roughly 22 L/min above the bottom of the that expected leak rate range. About 2:50, the machine drops the pressure from 11 cm to 10cm, perhaps in an effort to reseal the mask. And sure enough, the leak rate plummets from 55 L/min to 36 L/min. But with the decrease in pressure, comes the start of the next nasty cluster of events, which starts just at 3:00 with a flow limitation (or two) and a RERA (or two) followed by a large cluster of OAs. And after the flow limitation and the RERA, the pressure is first increased to 11, then to 12 and then to 13. And the leak rate increases from 36 L/min to about 42 L/min over the same period of time. Not an alarming increase in leak rate, given the intentional leak rates for the mask at 11--13 cm of pressure.

The odd and unexplained thing is: Whey did the System One decrease the pressure back down to 12 cm at about 3:10 when the cluster of events still seems to be going on?

So my take on the leak problems, the pressure increases and the first two clusters is this: The increase in pressure is driven by the cluster of events and not the leak. The pressure increase might be the root of the leak OR it could be the leak is a mouth leak OR it could be Cindjo moved around in bed and dislodged the mask. My best guess is that it is some combination of the three. And as to why the clusters themselves happened? Well it could simply be that 13 cm of pressure was not enough to keep Cindjo's airway open on this particular night (maybe REM? may supine sleep?). No doubt the large unintentional leak of 10-20 L/min added to the problems: The machine had to increase air into the system (but not the pressure setting), and there's evidence that leaking may have been large enough at two points to make the machine decrease the pressure in order to reseal the mask. And the second time this happened, the decreased pressure undoubtedly contributed to the number of events in the second cluster.

Leak monster then allowing the events to sneak past the defenses.

Or, since the pressure is maxed out during that first nasty cluster, it could simply be there's not enough pressure to deal with the (REM?) clusters to begin with. Moreover the second nasty cluster starts RIGHT AROUND the time the leak is resolved at around 3:00 and the leak rate during that cluster doesn't seem to be as bad.

[Pugsy]

Or, since the pressure is maxed out during that first nasty cluster, it could simply be there's not enough pressure to deal with the (REM?)

I didn't say that the leaks for sure drove the pressure up. I said it was "most likely". I still think it does impact the pressure to some degree.
All of what you said is true per theory. But APAPs can cause runaway pressure in some instances. Stop the leak and runaway pressures stop. Been there myself and have seen it on hundreds of reports from others. viewtopic.php?f=1&t=67883&p=631376&hili ... mb#p631376
Very easy to spot.

My point is that until the leaks are removed as a possible complicating factor in the clusters, we just don't know for sure. I wouldn't want to advise increase pressure until leak is minimized if it were me. I see no reason to go there unless it is proven to me that leak does not contribute to need for more pressure. But that is just me and others sure have the right to look at things differently. I am the first to say that we can't see who exactly caused the problem. My crystal ball is a bit fuzzy as to who came first.

For Cindi's problem I suspect that it is probably a combination of contributing factors. I just prefer to go back to the basics when looking at reports. Take leak out of the equation and then evaluate. My gut also tells me that a higher minimum is needed for the clusters so I agree there and if it were my report I would have done that a long time ago but when it comes to advising someone else I tend to be more conservative and would prefer to see leak line more stable before such a recommendation. Just me and the way I am. I figure if I am going to err I prefer it to be on the side of caution. Despite what Avi says about me, I am very cautious when it comes to other people's reports and my ideas.

I do see your point though Robysue and in part I agree but I have to respectfully disagree regarding leaks and runaway pressure and as you probably realize...I don't really care what Respironics says. Call me pigheaded if you wish..won't be the first time someone has said it. And I am sure it won't be the last.

So can we both just respectfully agree to disagree with each other on this issue? I won't attempt to change your mind because I know it is just as deeply entrenched as mine is.

All I really wanted here was to see a report with clusters and maxed out pressure with a stable leak line.
From this single report I can't tell enough to easily recommend more pressure. Perhaps there were other reports with a more stable leak line. I have no problem at all with your suggestion to increase min and max.
Personally, like I said, I think more minimum will be needed. So no argument from me on that suggestion.
I just wasn't comfortable making the suggestion based on this report. You were and that is fine.