Newbie with questions about REMstar Auto with A-Flex

Hi all,

I am new to CPAP and just joined this group. My hope is that I can get some questions answered here that seem to stymie my sleep technicians (they change each visit ) at Kaiser Permanente.

First some basic background: I am 49, 5'7, 138 lbs., and was diagnosed with OSA with an AHI score of 12.5 a few weeks ago. I've had problems sleeping for about 1 1/2 years now, with more frequent awakenings than is normal and mild to moderate fatigue during the day. So, not too bad a case, but still not good, of course, especially long term.

If I didn't have to sleep on my back because of a nerve condition that prevents me from sleeping on my side or stomach, sleep apnea most likely wouldn't even be (much of) a problem for me. So I was told by one the sleep techs. Not an option, unfortunately.

On the bright side, I discovered a few months ago that taping my mouth shut, eliminating mouth breathing, improves my sleep quality tremendously, except on certain days when there is marine layer (I live in Los Angeles, CA). The change in humidity seems to stimulate my nasal membranes generating just a bit more post-nasal trip, which then closes out whatever small opening is left in my throat.

Now to my questions: Kaiser gave me a REMstar Auto with A-Flex and 3 different ResMed masks (pillows, nasal, ffm) to take home for what is now my second 3-day trial. I was unable to get any sleep during the first trial because every time I was about to nod off, my mouth would fill with air and wake me up or prevent me from falling asleep. The minimum pressure was set to 5 cubic cm, and the mode was A-flex 3. Changing masks made no difference. I did not know then how to change the flex setting.

I went back to Kaiser yesterday and had them change the minimum pressure to 4 cubic cm. I tried the new, lower pressure last night with all three types oft masks and different A-Flex settings (1, 2, 3), but still couldn't get any sleep for the same reason. I tried for about 3 hours. Air would fill my mouth every time I was about to nod off. I want to say the lower pressure helped a bit, but I am not sure.

From reading one of the stickies for newbies on this forum, I would say that I feel like the machine makes me breath faster than I want. It feels like I have to keep up with the machine, which takes conscious effort, which in turn prevents sleep. Because I cannot myself turn off the flex mode, only Kaiser can do that, I haven't been able to try yet whether this makes a difference. I will go back Monday and have them turn off the A-Flex mode.

I am wondering whether the two problems I described above are related. Maybe, what is going here is that the reason my mouth fills with air is that I at some point - when I am about to fall sleep - slow down my breathing to the point where the air just has no place to go except into my mouth. In fact, I seem to recall a few instances where I noticed myself stopping to breath, not due any obstruction in my throat, but because I just didn't want/need more air. Then again, maybe the stoppage is obstructive in nature and I need more, not less pressure. I don't know.

My questions to you are: Does this sound - especially the part of my mouth filling with air - like an issue that is likely or at least possibly caused by the A-flex mode? Has anyone experienced their mouth filling with air on the REMstar Auto with A-Flex or any other machine ? What do you recommend?

Thanks a lot for your input!

Robert

You can indeed change the AFlex setting. You aren't the first to complain that the setting of 3 makes it feel like the machine is wanting you to breathe too fast. I had the same thing happen to be. It's more of a rhythm thing than the reduction in pressure since you are using 4 cm...the machine can't go lower than 4 cm.
http://aflex.respironics.com/

Go here and read how to go into the clinical set up menu and change the Flex setting so that you as a patient can alter it (it's not against the law to change the Flex setting) or even turn it off. There's also a little video.
http://www.apneaboard.com/pr-system-one ... structions
I found that a setting of 3 made if feel like was breathing too fast..almost like hyperventilating and a setting of 1 was just too slow but the setting of 2 was perfect match to my own normal respiration. Everybody is different in terms of their normal respiration pattern so each person needs to play with the settings to figure out which one is the most comfortable to them.

The cheeks puffing out thing....that happens all the time and with all machines. We call it chipmunk cheeks. Air goes up the nose and starts down the airway but gets diverted into the mouth and with lips shut the cheeks inflate. Highly annoying.
The trick to preventing this from happening is tongue placement so that the air can't enter the mouth. Play around with keeping your tongue planted in the roof of your mouth and that generally closes the door and the air can't sneak into your mouth.
Easy to do while awake but sometimes not so easy to keep doing when we go to sleep. The tongue gets lazy and drops down and opens the doorway. Practice breathing through your nose with the tongue in the roof of the mouth during the day and try to create a habit so the tongue will want to stay in place even when asleep.
Chipmunk cheeks isn't related to AFlex or even a certain brand of machine. It happens to people using all different brands with all sorts of exhale relief options and/or eve not using any sort of exhale relief.

If you didn't tape your mouth then most likely the chipmunk cheeks would force the mouth open to expel the pressure in the mouth but with the tape in place it becomes difficult to get the air out of the cheeks so we wake up.

Pugsy, thanks a lot for the super-fast and helpful reply. I'll reading the instructions on how to turn off the flex mode momentarily.

Good to know that the puffy cheeks are common and not related to the flex mode. I do generally pay attention to keeping my tongue pressed against the top of my mouth, but apparently my tongue drops when I fall asleep. I suppose that otherwise I may not be experiencing OSA in the first place, or at least much less.

Thanks again,

Robert

I was able to turn off the flex mode. Already feels a lot better. We'll see tonight ..

Robert

4 cm is the lowest pressure your machine can deliver.
Many folks complain they feel there suffocating at 4 cm. Many folks require 6-10 cm minimum to avid the feeling of suffocation. You should check that out, perhaps this afternoon while you are learning about the various adjustments that can be done.
What are the current minimum and maximum settings on your machine? Is it set wide open, 4-20. If so the chipmunk cheeks may be caused by runaway pressure increases. Since you have nothing else to do all weekend, why not read about Sleepyhead software and install it on your computer. Then you can look at whatever data may have been collected by your machine, share that here to get help deciphering what it says. Maybe it will provide the key to unlocking successful therapy.

So I just tried to take a nap with the A-Flex mode turned off. It definitely feels a lot more "normal" and I think I should be able to get used to sleeping in the off mode.

However, the "puffy cheek" problem still persisted and I couldn't fall asleep because of it (using a ffm, which I find most comfortable). I think you are right, Pugsy, and my tongue drops down blocking my air way.

So, now I am confused: I thought that this blockage - i.e., obstructed breathing due to tongue drop or otherwise - is precisely what CPAP/APAP is supposed to overcome. If the machine works only, or at least works best, if the airway is not obstructed, I don't understand why anyone would be using it.

What am I missing?

Thanks for bearing with me.

Robert

I never get puffy cheeks and I use a nasal pillow mask and I pretty much keep my mouth totally shut all night.
In fact for me to get the chipmunk cheeks I have to make a very specific movement at the back of my throat to allow the air to enter the mouth from the airway. Keep practicing while awake...maybe while watching TV.

I had lots of issues with air leaking from my mouth for a week or so, but I think I learned to keep my toungue planted on the roof of my mouth to prevent it. I think it still happens a little but no longer wake up to deal with it. It's pretty annoying, but maybe it will solve itself over time.
Jim

OK, thanks for the additional comments. So, I'll try to work on that loose to tongue of mine

When the tongue is on the roof of the mouth, it seals off the mouth from the airway so that you don't get chipmonk cheeks. If the tongue isn't up there it doesn't close off the airway, it merely allows some of the pressurized air to fill your mouth. This won't be as much of a problem in a full face mask. Your mouth will have airflow and feel pretty dry because of it, but the pressure splinting open your airway will be maintained. Not so in a nasal or pillow mask, where the air will flow out of your mouth and you'll lose effective pressure, or if taped, fill up like a balloon.

I suggest you stick with a full face mask while you are learning to keep your tongue up on the roof of your mouth. Practice every day, all day, unless you are speaking or eating. Once your tongue will stay up there all night you can try the nasal and nasal pillow masks with a better chance of success.