Re: Newbie Qs: Leaks

Let me try to clear up some confusion about leaks when do they become a problem.
First of all..any leak that disturbs sleep is unwanted because it is disturbing sleep. Even if it is a tiny leak but because it is affecting general sleep quality and not because it is perhaps affecting the therapy.

Now let's assume that leaks are present but a person sleeps right through them and feels well rested and doing well.
ResMed says that they can compensate for leaks up to 24 L/min. So if I see leaks over 24 L/min and I have slept well and feel good and the time is brief where the leaks are over 24 L/min...I don't really care. My number one goal is good quality sleep where the OSA is well controlled and AHI is acceptable.

The farther a person goes into large leak territory the greater the chance that the therapy can be affected. The first sign of possible therapy pressure compromise is the presence of the yellow flagged events. The machine can still sense the events but it can't quite tell what category to put the event in. So it gets the "yellow unknown event" flag. My past personal experience with large leaks and my S9 machine I found that leaks at 25 to 30 L/min the machine still did a decent job of flagging whatever events I had and the yellow events started around 30 L/min. It wasn't until my leaks started hanging around 35 L/min and higher that the machine seemed to not flag any event at all. Now it's possible I didn't have any events during that time because my OSA happens to be worse in REM sleep and there's a good chance that maybe I just wasn't in a position to have many apnea events.
This is why we caution people about the "no events" nothing happening when we see some time in large leak...we don't know if there just weren't any events or if there were events and the machine missed them.

Now regarding your last night's report. The first half of the night when the tape was secure you had a lot of leaks but none that really went that far into large leak territory and/or stay there for very long. Since the tape was secure until you removed it we know that the leaks aren't from the mouth. Your mask itself is leaking. I would suggest that you look carefully at all the connections especially where the short hose attaches to the nasal pillow and make sure that there are no leaks anywhere at the connections. You had no events and even though the leak line isn't real pretty you stayed below 24 L/min for the most part and I trust the machine...you didn't have any events during that first couple of hours until around 22:30. After 23:00 we start seeing some yellow stuff...so the machine is still sensing but it's having trouble deciding what to call them..and the fact that it is sensing stuff when the prior hours had nothing to sense then we assume that the pressure is starting to become sub optimal and letting those events occur...there may be some REM component involved too..and maybe some supine sleeping.
Then it becomes obvious that you wake up often for whatever reason. With the leaks seen it could be the leaks waking you up or it could be the events waking you up.

Since that is when you removed the tape...then we assume the bigger leaks seen after 23:00 are most likely related to mouth breathing.
Even with the tape in place the first part of the night you are still having some leaks but not quite big enough or prolonged enough to seriously impact therapy itself. If you were sleeping well...I wouldn't get horribly upset about that period of time.
It is unusual though to have that much leak with mouth taped so I think maybe your fit on the nasal pillows could use some improvement. The pillows are moving (assuming that you checked all the connections and they were good) and allowing leaks.
They are big enough that most people would be having some wake ups with them but if you aren't waking up during that time frame then technically the S9 can compensate for those leaks.

See that big leak plateau right before the 0:00 time mark on top timeline? That is the worst of your big leaks as to where it went to and how long it lasted. During that time frame the leak lasted longer than it did at other times where the leak exceeded 24 L/min.
Second worst are the two columns on either side of that larger plateau leak. One on each side..fairly brief though.

The time frame beginning at the second yellow hyponea and ending at roughly where you had the 42 second obstructive is where the leak was bad enough to impact therapy....you also have several therapy breaks there...so did you sleep?
Whenever you see the yellow events...the machine was still sensing so it is probably fairly accurate at that leak level...above that the machine may lose the ability to record events but you don't spend a horrible amount of time above that level of leak.

So I do think you are having some mouth breathing but not all your leak can be blamed on mouth breathing. There's something going on with your fit...maybe try a different size nasal pillow...maybe snug up that top strap one notch...maybe try something to see what was responsible for the leaks during that time frame where we know that there wasn't any mouth breathing because the tape was in place.

If you were sleeping straight through the night and had less than beautiful leak line I probably wouldn't be concerned about 15 minutes of not so great leak but you aren't sleeping well or we wouldn't have all these breaks in therapy.
So something is waking you up and that is the first thing I would try to sort out if it were me.

Thanks for all your time, Pugsy!

I think maybe your fit on the nasal pillows could use some improvement. The pillows are moving (assuming that you checked all the connections and they were good) and allowing leaks. They are big enough that most people would be having some wake ups with them but if you aren't waking up during that time frame then technically the S9 can compensate for those leaks.

Last night I used (and have been for about a week) the Nano with the swivel hose. I went from a M to a S a few days ago, thinking I was leaking because the cushion was too big. With both sizes, I re-seat the cushion during the night whenever I feel a leak blowing on me - 5 or 6 times a night.

so did you sleep?

I haven't slept all the way through the night in forever. It's been a month on the xpap, and I decided at the outset to give it 3 months before making a decision about efficacy. It's a challenge! I do have to say that in general, I experience slightly less daytime fatigue, though, which is how I got here to start with.

There's something going on with your fit...

That's been my feeling all along. I've used the FX pillows (S and M) and the Nano with the new hose (S and M). The pillows never feel sealed to me unless I scrunch them all the way up into my nares, which isn't my understanding of how they are supposed to work and isn't very comfortable. The M Nano seemed huge, and the S is more comfortable but still leaks. My DME didn't even take the mask out of the plastic (and I was there 3 hours) - maybe I should go back to the sleep center and have them fit me. My next thought was to try cannulas (Nasal Aire). I've also thought about how to seal the Nano to my face. Gel liner, pad-a-cheek liner, tegaderm? But since the Nano has to inflate, I'm not sure that will work either.

I would suggest that you look carefully at all the connections especially where the short hose attaches to the nasal pillow and make sure that there are no leaks anywhere at the connections.

I've felt around when it's inflated, and only feel air at the vent. But, maybe I should swap out the swivel hose for the one that came with the pillows, and see if that makes a difference.

The toughest part is that I cannot seem to correlate any changes I make to my AHI, which was 4.6 last night, and 1.5 the night before.

Thanks for your support, Jean

Jeannh wrote:The toughest part is that I cannot seem to correlate any changes I make to my AHI, which was 4.6 last night, and 1.5 the night before.

Don't worry about those numbers. We don't sleep the same each night and some variation is to be expected at times.
Even now after all this time I might have a really low AHI one night and the very next night a much higher AHI and changed nothing and leaks well controlled both nights.

Here's my AHI for the last 7 nights starting with last night
3.48 with only 0.46 being CA
3.27 with only 0.36 being CA
0.44 with no CAs at all
1.39 with only 0.23 being CA
0.63 with only 0.13 being CA
2.61 with only 0.52 being CA
2.58 with only 0.12 being CA

On Oct 3 my AHI was 4.32 with CA of 1.65

On Sept 23 my AHI was 7.02 with CA of 1.28

So even I have AHIs all over the place. A while back I went past 8.0 AHI for one night.
Long term for a year...it all averages out to a little less than 2.0.

Until you have less wakeups don't worry so much about the numbers because I suspect you are having some awake/semi awake events getting flagged and that totally messes up the AHI picture anyway.

For now just concentrate on doing what you need to do to reduce the wakeups and if the leaks are factor then work on them.
Maybe try a size larger in the nasal pillows so you can get a better seal without having to snug up the straps.

The Nasal Aire II prongs...I have tried them and I ended up being an in between size. They aren't nearly as forgiving when it comes to size and fit. One size (I forget which it was) was too small and inflated the prongs wouldn't quite seal but the next size up was too big because when inflated it hurt like a son of a gun. Let me check my stash to see if I have an old one you can have just to try. Save you some money. Short on time right now but will try to go through the stash later to see if I have enough parts to complete a mask.

OK - I tried the Nasal Aire II for its leak-free reputation. For me - the issue is the big hoses. I cannot even keep headgear on, so the big hoses over the ear was a deal-breaker for me. Thank you, cpap.com for having return insurance!

- Unbelievably (to me, anyway), I tape and am perfectly used to it.
- I use the Bella Loops, covered with Karen's pad-a-cheek cozies/covers.
- No issues with my ears using the Loops.
- That means my choices are the Swift FX or the Nano.

The Nano blows the house down if I don't wear the Small, Waiting for a gel nose bridge and pad-a-cheek cover to try and stop the leaks. For the Swift FX cushions, I think I finally figured out the "hovercraft" positioning, but need a M to accomplish it. After almost a week of that (which seemed quieter and blew no outside air) my AHI is finally in the 1-3 range.

I still leak continuously, every night all night, but generally under 24l/min, so I'm going to call that good enough while I wait for more continuous sleep, which is getting better very slowly. Still have a dry mouth problem, but will post that in a separate thread.

Cross your collective fingers, Jean

I have on cpap about the same amount of time as you and also working on "leaks" with the Swift FX and Bella Loops. For me, the weight of the hose in a downward orientation pulls the pillows away and breaks the seal. If I rotate the short hose 180 deg so it essentially goes over my head, I get a better seal. Finding the right hose position makes the flow of air quieter-and presumably fewer leaks. I also tuck the long hose between pillow and headboard to stay in place.

Good luck -

For me, the weight of the hose in a downward orientation pulls the pillows away and breaks the seal.

This one, I solved. I got the cheapest hose hanger I could find - from Amazon - http://www.amazon.com/gp/product/B0034C ... UTF8&psc=1. It was easy to install, and works like a dream. I can flop from side to side with no impact on the mask. The other thing I do to seal the pillows a bit is to put a tiny bit of Lansinoh lanolin on my nares. You can find it on the baby aisle at Target or Walmart.

I've now also had luck with a Nano nasal cushion. If you already have the Swift FX, you need only the 'assembly kit', available from our sponsor, https://www.cpap.com/productpage/resmed ... y-kit.html. Remember that if you want to take advantage of the return insurance (which I have a bunch of times, and it is totally hassle-free), you need to buy the whole mask, https://www.cpap.com/productpage/resmed ... dgear.html.

Note that while I need a M in the cushions, I needed a S in the Nano (which means a for-her). You can use the Bella Loops with both. YMMV. Good luck! Jean

PS - Post your equipment in your profile - lots of smart people here can speak directly to your setup!