Exhale Puff Issue

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
MMcG
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Exhale Puff Issue

Post by MMcG » Tue Oct 26, 2021 2:09 am

I've noticed from my Oscar data that I've developed an exhale puff problem, spending large parts of the night doing it sometimes. My understanding of this is that the main problem is that the CPAP machine doesn't respond to it and also can't measure other events reliably. But I still see from the wave pattern that I am inhaling during these periods - it's just the exhale wave is either very short/brief or missing completely (flat). So I'm guessing that I must still be breathing. So I have two questions. The first one is whether it's really a problem that needs to be fixed or not. If it is a problem and someone can explain why, I figure I have two options. The first is a full face mask (I don't really want to go there - it's taken me six weeks to feel reasonably comfortable with a nasal pillow). The second is "Smartflex". My Devilbiss/Intellipap machine comes with this option which I think is "bilevel", i.e. it can be programmed to reduce the pressure while exhaling. Logic suggests to me that this might reduce the urge to exhale through the mouth, but my CPAP technician is not keen on this technology. I still don't really understand why, but will talk to him about it later this week. Any guidance in the meantime would be very helpful.

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GrumpyHere
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Re: Exhale Puff Issue

Post by GrumpyHere » Tue Oct 26, 2021 4:15 am

The measurement of "exhale puff" is exclusive to Devilbiss machines.

AKA mouth leaking. AKA chipmunk cheeks.

You can deal with it via:
  • Train planting your tongue on the roof of your mouth until it’s a habit
  • Mouth taping with medical tape (Micropore, Somniflex, Coverall, Hypafix, Medipore)
  • Soft cervical collar
  • Scunci hairband / headband

Further reading:
https://www.cpaptalk.com/viewtopic.php? ... 7#p1394697

https://www.cpaptalk.com/viewtopic.php? ... 7#p1390637

SmartFlex is a comfort feature meant to help people exhale against minimum pressure level they find too high.

Your sleep tech might be not keen on it because it effectively lowers the average treatment pressure. You can compensate for it by increasing the minimum pressure.
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MMcG
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Re: Exhale Puff Issue

Post by MMcG » Tue Oct 26, 2021 7:58 am

GrumpyHere wrote:
Tue Oct 26, 2021 4:15 am
The measurement of "exhale puff" is exclusive to Devilbiss machines.

AKA mouth leaking. AKA chipmunk cheeks.

You can deal with it via:
  • Train planting your tongue on the roof of your mouth until it’s a habit
  • Mouth taping with medical tape (Micropore, Somniflex, Coverall, Hypafix, Medipore)
  • Soft cervical collar
  • Scunci hairband / headband

Further reading:
https://www.cpaptalk.com/viewtopic.php? ... 7#p1394697

https://www.cpaptalk.com/viewtopic.php? ... 7#p1390637

SmartFlex is a comfort feature meant to help people exhale against minimum pressure level they find too high.

Your sleep tech might be not keen on it because it effectively lowers the average treatment pressure. You can compensate for it by increasing the minimum pressure.
I'm still unclear as to why it's perceived as a problem?

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GrumpyHere
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Re: Exhale Puff Issue

Post by GrumpyHere » Tue Oct 26, 2021 8:09 am

You were likely titrated against plain CPAP pressure without the pressure drop on exhale.

So the lower effective pressure may not be enough to treat your apneas / hypopnoea/ flow limitations.

Whatever setting you decide for SmartFlex (1,2,3) add that amount back to the minimum pressure. That will compensate for the drop yet allow for easier breathing.
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GrumpyHere
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Re: Exhale Puff Issue

Post by GrumpyHere » Tue Oct 26, 2021 8:17 am

If you meant why mouth leaks are a problem, they can lead to dry mouth.

Before I started taping, I was waking up in the middle of the night because of dry mouth.

Leaks also leads to lower effective pressure.

With your machine, it will also stop increasing pressure if it detects excessive leaks. Read page 10 in the following manual.

https://www.devilbisshealthcare.com/fil ... 14_Web.pdf
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MMcG
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Re: Exhale Puff Issue

Post by MMcG » Tue Oct 26, 2021 11:45 am

GrumpyHere wrote:
Tue Oct 26, 2021 8:09 am
You were likely titrated against plain CPAP pressure without the pressure drop on exhale.

So the lower effective pressure may not be enough to treat your apneas / hypopnoea/ flow limitations.

Whatever setting you decide for SmartFlex (1,2,3) add that amount back to the minimum pressure. That will compensate for the drop yet allow for easier breathing.
I'm still unclear as to how excessive exhale puffing can affect titration. Do you mean that it "hides" apneas and hypopneas which would otherwise be seen, in which case my machine is underestimating my AHI's? I've read all the stuff on the Devilbiss website and it doesn't answer that question. It seems to suggest that they may resolve with use of the machine. But I have my doubts.

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GrumpyHere
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Re: Exhale Puff Issue

Post by GrumpyHere » Tue Oct 26, 2021 6:23 pm

Except for Devilbiss, everyone else calls "exhale puffs" leaks.

You're conflating lowered pressure caused by leaks vs drop caused by SmartFlex.
They both affect treatment.
Leaks are inadvertent.
Whereas the use of SmartFlex is by choice.

Leaks don't "hide" apneas and hypopneas from the machine.

Titration is the process of determinating the pressure necessary for treatment.

Leaks lowers the pressure in the airpath.

If they were present during titration, the tech may have used a higher pressure setting on the CPAP machine to compensate.
AutoAdjust tracks expiratory puffs, but does not respond.
Your machine detects leaks but does not compensate for them.
So you need to ameliorate leaks yourself via taping etc.
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MMcG
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Re: Exhale Puff Issue

Post by MMcG » Wed Oct 27, 2021 1:15 am

GrumpyHere wrote:
Tue Oct 26, 2021 6:23 pm
Except for Devilbiss, everyone else calls "exhale puffs" leaks.

You're conflating lowered pressure caused by leaks vs drop caused by SmartFlex.
They both affect treatment.
Leaks are inadvertent.
Whereas the use of SmartFlex is by choice.

Leaks don't "hide" apneas and hypopneas from the machine.

Titration is the process of determinating the pressure necessary for treatment.

Leaks lowers the pressure in the airpath.

If they were present during titration, the tech may have used a higher pressure setting on the CPAP machine to compensate.
AutoAdjust tracks expiratory puffs, but does not respond.
Your machine detects leaks but does not compensate for them.
So you need to ameliorate leaks yourself via taping etc.
I'm sorry but I still don't understand. Maybe I need a lengthy face-to-face discussion with my technician to explain all this to me. It seems to me that if the machine records that I am breathing in a regular pattern, albeit with exhaling through the mouth, then it must mean that I can't be having apneas/hymopneas while doing so. Here's a short segment from a couple of nights ago, which went on for about forty-five minutes before settling back to nasal exhaling. The pattern remained constant throughout (no events).

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GrumpyHere
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Re: Exhale Puff Issue

Post by GrumpyHere » Wed Oct 27, 2021 2:58 am

Apneas can occur on both inhalation and exhalation.

Even if no apnea is recorded (restriction < 10 sec), the airway may be restricted. Maybe constrained enough to disturb your sleep or require extra effort to breathe. Breathing through a straw takes more effort than using a pipe.

What keeps your airways open is Expiratory Positive Airway Pressure (EPAP).

You need a certain amount of EPAP to prevent respiratory problems.

On an APAP, like your machine, the minimum pressure being set is Inspiratory Positive Airway Pressure (IPAP).

If SmartFlex is not being used, EPAP = IPAP

If SmartFlex is being used then EPAP = IPAP - SmartFlex.
So the machine generates a lower EPAP. Maybe lower than necessary for an unrestricted airway. To compensate for the use of SmartFlex, you would increase IPAP.

Similarly, leaks may also lower EPAP to the level below that required for an unrestricted airway. So you want to reduce those leaks.
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MMcG
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Re: Exhale Puff Issue

Post by MMcG » Wed Oct 27, 2021 8:14 am

GrumpyHere wrote:
Wed Oct 27, 2021 2:58 am
Apneas can occur on both inhalation and exhalation.

Even if no apnea is recorded (restriction < 10 sec), the airway may be restricted. Maybe constrained enough to disturb your sleep or require extra effort to breathe. Breathing through a straw takes more effort than using a pipe.

What keeps your airways open is Expiratory Positive Airway Pressure (EPAP).

You need a certain amount of EPAP to prevent respiratory problems.

On an APAP, like your machine, the minimum pressure being set is Inspiratory Positive Airway Pressure (IPAP).

If SmartFlex is not being used, EPAP = IPAP

If SmartFlex is being used then EPAP = IPAP - SmartFlex.
So the machine generates a lower EPAP. Maybe lower than necessary for an unrestricted airway. To compensate for the use of SmartFlex, you would increase IPAP.

Similarly, leaks may also lower EPAP to the level below that required for an unrestricted airway. So you want to reduce those leaks.
[/quote

I scanned all forty-five minutes and the wave pattern barely changed. So it appears to me that I was just breathing in through the nose and breathing out through the mouth. If I had any apneas/hypopneas during that period, the wave pattern would have surely changed. I know what hypopneas and apneas look like on the breathing graph, because I get some of each at times. Thanks for the feedback anyway. This is a steep learning curve for me and it doesn't help when one is tired from insufficient sleep!

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GrumpyHere
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Re: Exhale Puff Issue

Post by GrumpyHere » Wed Oct 27, 2021 9:04 am

It is up to you as to WHEN you want to deal with mouth leaks.

It is generally agreed that they reduce the efficacy of CPAP treatment.

Hopefully you will have a smooth path forward in adapting to CPAP.

Good luck and don’t give up.
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Pugsy
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Re: Exhale Puff Issue

Post by Pugsy » Wed Oct 27, 2021 9:14 am

Tape your mouth shut for one night only. Make sure it is solidly taped and that it can't come loose...and doesn't.
Then look at your reports to see if the exhale puff index reduces or not...or if any leak numbers change.

Even if you are doing some mouth breathing it doesn't always mean that everything in terms of therapy is in the toilet.
If sleeping good and feeling good...I would let a little mouth breathing slide.
Below is an example of some mouth breathing...circled in red...known mouth breathing because I woke up mouth breathing and had a bit of time and decided to continue mouth breathing so I could see exactly what it did to the leak rate.
As you can see...barely did anything and well within the machines ability to compensate.
Don't ask what the big leak earlier in the night was from...I slept through it....most likely mask movement.
I don't care...slept through it and it didn't disturb my sleep.

Sometimes when trying to get perfect leak numbers or stats we end up creating a worse problem in terms of sleep quality.
The cure is sometimes worse than the disease kind of thing.

Image

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MMcG
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Re: Exhale Puff Issue

Post by MMcG » Thu Oct 28, 2021 3:21 am

Pugsy wrote:
Wed Oct 27, 2021 9:14 am
Tape your mouth shut for one night only. Make sure it is solidly taped and that it can't come loose...and doesn't.
Then look at your reports to see if the exhale puff index reduces or not...or if any leak numbers change.

Even if you are doing some mouth breathing it doesn't always mean that everything in terms of therapy is in the toilet.
If sleeping good and feeling good...I would let a little mouth breathing slide.
Below is an example of some mouth breathing...circled in red...known mouth breathing because I woke up mouth breathing and had a bit of time and decided to continue mouth breathing so I could see exactly what it did to the leak rate.
As you can see...barely did anything and well within the machines ability to compensate.
Don't ask what the big leak earlier in the night was from...I slept through it....most likely mask movement.
I don't care...slept through it and it didn't disturb my sleep.

Sometimes when trying to get perfect leak numbers or stats we end up creating a worse problem in terms of sleep quality.
The cure is sometimes worse than the disease kind of thing.

Image
Strangely, I hardly did any exhale puffing last night and slept fairly well. Must have been the threat of taping my mouth! :D I'm hoping that it will resolve without resorting to such measures. Thanks. I really appreciate all the helpful feedback.

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MMcG
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Re: Exhale Puff Issue

Post by MMcG » Fri Oct 29, 2021 7:54 am

The "problem" appears to be resolving by itself. The percentage time in "exhale puff" has been 5% or less now for a number of nights in a row. I still suspect that the Devilbiss software is misinterpreting my breathing pattern. Why? Well I tried to breath like that while awake with the pressure at 6 and it was very uncomfortable. I doubt that I could have slept through forty-five minutes or more at 7-8, as I was recorded as doing last week, without being awoken.

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Mask: AirFit™ N10 Nasal CPAP Mask with Headgear
Additional Comments: My machine is sold in Europe as Devilbliss Blue Auto Plus Automatic