RERA Questions

PEF wrote:So I wanted to see if my machine thought there were a lot of leaks. The mask fit always gave the smiley face, so I started looking at the leak rate. Other than the last few days since upping the max pressure to 8, the leak rate has averaged 7L/min. But the last 3 nights, with max pressure set to 8, it jumped up to 20L/min. It would seem that whenever I up the max pressure, I get leaks for awhile, at least until my brain gets used to the added pressure. Can anyone tell me what this means?

Where are those Leak numbers coming from? The machine's LCD? Or are they from SleepyHead or ResScan?

To say something about what these numbers mean in terms of your leaks, I need to know whether they are average, median, 90/95%, or maximum leak rate numbers. The Leak Rate shown on the detailed Sleep Quality report on the machine's LCD are 95% leak rate numbers by the way.

I am starting to wonder if the real problem is that any leaking at all is waking me up at night!

Looking at the leak rate graph inside of SleepyHead is probably the best way to determine whether leaks are a potential cause for numerous night time wakes.

Have you looked at your data in SH?

Hi Robysue. Thanks. The numbers are from the LCD menu on my machine. I looked under sleep quality, leak rate. Oh and I just realized that my type of machine is listed as a Resmed S9 Autoset For Her, but it is actually a regular Resmed S9 Autoset. Sorry. I will change that. So maybe these numbers are not really that helpful?

I have the link to download Sleepyhead, but have not accomplished it yet due to internet bandwidth problems here. I need to get to either Boquete or Panama City to do this, but I plan to as soon as I can. In fact, Pugsy was going to help me interpret the Sleepyhead data once I had it downloaded and working, but she has left the forum.

PEF wrote:Hi Robysue. Thanks. The numbers are from the LCD menu on my machine. I looked under sleep quality, leak rate. Oh and I just realized that my type of machine is listed as a Resmed S9 Autoset For Her, but it is actually a regular Resmed S9 Autoset. Sorry. I will change that. So maybe these numbers are not really that helpful?

They're very helpful. They're the 95% leak rate numbers. And that's significant.

In general summary data from the machine's LCD is great for confirming that things are on track: If the 95% Leak Rate number is always below 10 L/min and the AHI is always below 5.0 and you are getting enough sleep and feeling well, the summary data confirms that therapy really is working and that your apnea is under control.

And if you are having some kind of difficulties, the LCD summary data can be enough to help sort out whether the problem is likely something other than "ineffective therapy" (because the numbers look good, but you feel lousy) or whether the problem is that the PAP therapy needs some tweaks (because some of the numbers don't look so good, regardless of whether you feel lousy.)

But LCD summary data can only go so far. If the LCD summary data indicates that there may be a problem with leaks and/or the treated AHI, you may need more detailed data to sort out what's really going on each night. And that's where the data from SH is useful: Because it provides a very detailed picture of what goes on during the night, it can help sort out some really sticky issues in a way that summary data can't.

Let's look at the numbers. In an earlier post you write:

PEF wrote:So I wanted to see if my machine thought there were a lot of leaks. The mask fit always gave the smiley face, so I started looking at the leak rate. Other than the last few days since upping the max pressure to 8, the leak rate has averaged 7L/min. But the last 3 nights, with max pressure set to 8, it jumped up to 20L/min. It would seem that whenever I up the max pressure, I get leaks for awhile, at least until my brain gets used to the added pressure. Can anyone tell me what this means? I am starting to wonder if the real problem is that any leaking at all is waking me up at night!

When the machine's LCD showed a leak rate of 7 L/min, that meant that for at least 95% of the night your leak rate was AT or BELOW 7 L/min. The Resmed Redline for Large Leaks is 24 L/min. So on these nights we can conclude that whatever leaks you had, they were not big enough to adversely affect the quality of your therapy. Whether they were big enough to affect the way you slept is a different issue, and even small leaks that wake you up can be an issue that needs to be addressed. (But small leaks that don't disturb your sleep can be ignored.)

With the pressure at 8cm, the machine reported Leak rate has jumped to 20 L/min. That means on the last three nights we know that your leak rate was AT or BELOW 20 L/min for 95% of the night. Now 20 L/min is still a bit below the Resmed RedLine of 24 L/min. There's a good possibility that some of your leaks may have been over 24 L/min, but your leak rate could NOT have been that high for more than 5% of the night. Hence I know that Mr. Green Smiley Face showed up in the short version of the sleep quality report. In other words, the Resmed engineers believe your leaks on these nights are not big enough and/or long enough to adversely affect your therapy.

But leaks up around 20 L/min are a lot more likely to cause disruption to your sleep. And they're more likely to cause problems like dry mouth in the morning---particularly if the leaks were this big for substantial chunks of the night. And that's the drawback to only having the 95% Leak rate number: It's possible that you had NO leaks at all for over 80% of the night, but if your leak rate was at 20 L/min for around 6% of the night, that 95% leak number will read 20 L/min. It's also possible that you were leaking at 15-20 L/min for the whole night and that 95% leak number could still read 20 L/min.

And that's why looking at the detailed data in SH might be useful for the nights where the leak rate is eleveated: In SH you can tell if the 95% Leak Rate is elevated because of a few really bad leaks with the rest of the night being fine or whether the 95% Leak Rate is elevated because there's constant sort-of-serious leaking all night long.

You also wrote:

So I have been using only nasal masks. Since I believe that mouth breathing is responsible for some of my uncomfortable respiratory symptoms, I decided to teach myself to stop mouth breathing. So each night I use either a cervical collar or tape my mouth. When I first started, my pressure was set wide open 4 - 20. Of course, I did not know anything about CPAP at the time. After having a very difficult time falling asleep, I would wake up all night long with mouth leaks, chipmunk cheeks, etc. Mouth tape did not work, because it only stopped air from going out my mouth, not from coming into my mouth.

And quite likely because the tape kept the air trapped in your mouth, it may also have made the leak numbers look good. But chipmunk cheeks with a dry mouth in the morning (and aerophagia possibly waiting in the wings) is no way to get a really high quality sleep.

Finally I lowered the pressure to 4-6 and then I was able to sleep mostly through the night. I waited 2 months and all was pretty good, but I thought I needed more pressure.

Why? Was the AHI consistently above 5? Was there some snoring being detected?

I upped the max to 7 and the mouth leaks started again. I turned the max pressure back to 6 and all was well again.

By mouth leaks do you mean air getting into your mouth, but being trapped by the tape and/or the cervical collar? Did the 95% Leak rate go up when you increased the pressure? Did the AHI go down?

About 2 weeks later, I tried the max pressure at 7 again and this time it worked and I did not wake up with mouth leaks.

So it sounds like you learned the trick of keeping the oral cavity blocked off from the nasal one with the back of your tongue combined with nasal breathing.

I left the max pressure at 7 for about a month. Then upped the it to 8.

Why? Was the AHI consistently above 5? Was there some snoring being detected?

This time, instead of chipmunk cheeks and hissing from air escaping the corners of my mouth, I got dry mouth. I think this still means that air is entering my mouth.

Sounds like at 8 cm, the tongue got tired of "fighting" the pressure and relaxed and the air rushed into your mouth. Only this time the tape and/or the cervical collar didn't prevent you from opening your lips (slightly) and the air rushed out of the slightly opened lips. Creating leaks that were large enough to inflate the 95% Leak rate number AND cause the dry mouth.

I backed it off to 7, but am still getting dry mouth.

Sounds like the tongue has forgotten how to do its job of closing off the oral cavity from the upper airway. So now the tongue moves down out of position and that allows the air into the mouth. But at 7 cm pressure, there's not enough air is getting into the mouth to force the lips open, so you are not noticing the leaks. And the leaks may be much smaller than the ones you did notice at 8cm. But there's still enough air swirling around inside the mouth to dry it out.

I think you need to go back to whatever you were doing when you had the machine set at 4-6 when you were able to teach yourself how to keep your tongue in the right position for blocking off the oral cavity from the upper airway. Once you are doing that again consistently, then bump the pressure back up to 7 if and only if there is a real reason for doing so.

In other words, the most relevant question for moving forward is: Why did you bump the pressure up to 7 and then to 8 in the first place?

I have the link to download Sleepyhead, but have not accomplished it yet due to internet bandwidth problems here. I need to get to either Boquete or Panama City to do this, but I plan to as soon as I can. In fact, Pugsy was going to help me interpret the Sleepyhead data once I had it downloaded and working, but she has left the forum.

Yes, Pugsy's absence is quite a hole. But there are plenty of people who can help you with that if you do decide the trip to Boquete or Panama City is worth it for downloading SH.

Gosh, Robysue, I can't thank you enough! It seems that my therapy was fine and then I messed it up by trying to "improve" it. My husband told me that too.

I did not have a good reason to bump up the pressure, except to get more of a good thing. I loved the feel of actually being able to breathe really well, which without the CPAP, I can't do because my nose is always partially stuffed up and even when it is not, it just never seemed like the air got into my lungs properly. The CPAP therapy gets rid of the stuffiness in my nose and makes it feel like, for once in my life, I could really breathe well. It is hard to explain, but I have done a lot of mindfulness meditation and other exercises that often focus on the breath. My whole life I never felt I got quite the benefit from breathing the way other people did. Now I know why - I have defective plumbing. So I should have left well enough alone. All is not lost, though, because last night I slept very well wit the pressure reduced to 4 to 6 with only very slight dry mouth in the morning. So I think my tongue is learning to stay in position again. Do you agree that I should just leave the pressure at 4 - 6 and that is high enough.

On the subject of AHI. My monthly average AHI on the LCD is reported at .3. Daily, it is always below 1. I don't believe I ever had apneas, as in OSA. I am quite sure I don't have OSA, but have UARS. If I took a standard sleep test, I am quite sure that I would not be diagnosed with sleep apnea. However there is a specialized sleep test for UARS. I don't have access to this test and my doctor suggested that it would be much easier just to try CPAP and see if it worked for my symptoms. This goes back to the reason I wanted to try CPAP. I was having strange episodes of choking and waking up at night. My husband would see me choking and not even waking up. A couple of times it frightened him and he was tempted to wake me up. I would often wake up in the morning with a terrible sore throat, cough and plugged up nose, often headache. The symptoms would normally go away within a few hours of waking up, but in particularly bad clusters of these problems, my throat would be sore for months and the morning headaches would never completely go away. Long story - allergy treatment that did not help - stomach workup - I refused to take any meds for LPR (stomach acid leaking into throat). The doctors thought it was a combination of open mouth problem during deep sleep and nighttime GERD - LPR. It was like going to bed fine and then waking up with a raging cold, but it was not a cold at all. The problem would wax and wane mysteriously. This all made my insomnia much worse because I was actually afraid to go to sleep.

So after reading Dr. Park's book, I became convinced that CPAP could help. It has been a struggle, but well worth it because my symptoms are 90% gone for almost 6 months, the longest I have ever gone without some bad nightly episodes.

So I am really happy to hear your answers and I will continue with the lower pressure. I feel so much better. Before starting CPAP when my nighttime and morning symptoms were very bad, I had to take naps during the day. I would sometimes have daytime episodes where I would suddenly become so tired I needed to lie down or I felt like I would pass out. I do not need naps anymore at all.

The only problem I still have is insomnia that I have had all my life. I am really hoping that I will lose the fear of dying in my sleep that I have had all my life. This anxiety may be causing my insomnia. I actually did almost die in my sleep once about 15 years ago. We were at a party where I had too much to drink - I don't drink at all now and didn't drink much back then, but had about 3 glasses of wine that night - way too much for me. During the night, I had one of my choking episodes and started to vomit (lying on my back). I had aspirated some vomit into my lungs and never woke up. My husband heard me choking and , because he is a doctor, knew what to do. He told me later that I would have likely died if he had not heard me.

I really believe the the SDB is related to the problems I have had all my life, anxiety, depression, insomnia, headaches, allergy symptoms that are not allergies.
On the topic of Sleephhead - this is where I left off with Pugsy. I was going to get it up and running and show her the graphs. She was particularly interested in seeing, in my special case, what the flow limitation data showed. I think she was very curious about UARS and so am I. So I intend to do this ASAP. My husband has agreed to help.

I can't thank you enough, Robysue. I hope to be able to post my Sleepyhead data soon.

PEF wrote:Gosh, Robysue, I can't thank you enough! It seems that my therapy was fine and then I messed it up by trying to "improve" it. My husband told me that too.

Sometimes our husbands are correct. And when they are, do we listen to them???

So I should have left well enough alone. All is not lost, though, because last night I slept very well wit the pressure reduced to 4 to 6 with only very slight dry mouth in the morning. So I think my tongue is learning to stay in position again. Do you agree that I should just leave the pressure at 4 - 6 and that is high enough.

For now leave the pressure at 4-6 for at least a week or two. You may want to leave it there longer. You want to make sure your tongue learns to stay in position again before you do anything else. Re-evaluate all the data in a couple of weeks. Unless there is a reason to change the pressure settings, leave them where they are after you re-evaluate the data.

On the subject of AHI. My monthly average AHI on the LCD is reported at .3. Daily, it is always below 1. I don't believe I ever had apneas, as in OSA. I am quite sure I don't have OSA, but have UARS. If I took a standard sleep test, I am quite sure that I would not be diagnosed with sleep apnea.

Why? Waking up choking in one's sleep is much more symptomatic of classic OSA than it is UARS.

I was having strange episodes of choking and waking up at night. My husband would see me choking and not even waking up. A couple of times it frightened him and he was tempted to wake me up.

A bed partner witnessing a choking or non-breathing spell is much more symptomatic of classic OSA than it is UARS.

In UARS, the airway never collapses or even comes close to collapsing: The increased effort to breath due to very subtle changes in the airway lead to arousals before the airway is compromised enough to trigger a sense of choking.

In OSA, it is possible for the problem to be mainly hypopneas instead of full-blown apneas. In a hypopnea, the airway has collapsed enough to reduce the airflow by at least 50%. In an apnea, the airway has collapsed to the point where no air can get through---i.e. in an apnea, you really are choking.

stomach workup - I refused to take any meds for LPR (stomach acid leaking into throat). The doctors thought it was a combination of open mouth problem during deep sleep and nighttime GERD - LPR.

LPR and GERD are common co-morbidities of both OSA and UARS

This all made my insomnia much worse because I was actually afraid to go to sleep.

Being afraid to sleep is a pretty common OSA symptom as well as a UARS symptom.

The only problem I still have is insomnia that I have had all my life. I am really hoping that I will lose the fear of dying in my sleep that I have had all my life. This anxiety may be causing my insomnia. I actually did almost die in my sleep once about 15 years ago. We were at a party where I had too much to drink - I don't drink at all now and didn't drink much back then, but had about 3 glasses of wine that night - way too much for me. During the night, I had one of my choking episodes and started to vomit (lying on my back). I had aspirated some vomit into my lungs and never woke up.

This is frightening. It may be that the alcohol was why you didn't wake up. But it could also be that choking spell was caused by a full-fledged apnea.

On the topic of Sleephhead - this is where I left off with Pugsy. I was going to get it up and running and show her the graphs. She was particularly interested in seeing, in my special case, what the flow limitation data showed. I think she was very curious about UARS and so am I. So I intend to do this ASAP. My husband has agreed to help.

Yes, since you think you have UARS, the flow limitation graph is of great interest.

However, I think that you probably should be evaluated for OSA: Your husband has witnessed choking episodes in your sleep and that all by itself is a symptom of OSA.

Please note: The super low AHI at 4-6 cm of pressure does not mean that you don't have OSA. It's possible to have even moderate to severe OSA and only need a little bit of pressure to prevent the apneas. It's also possible to have mild OSA and need a fairly high amount of pressure to prevent the apneas. The amount of pressure that is needed to prevent the apneas depends more on the structure of the throat and tissues surrounding the throat rather than the frequency the upper airway actually collapses.

I've got moderate OSA (diagnostic AHI = 23), but I have a very low pressure range: My EPAP goes from 4-6cm and my IPAP goes from 6-8cm. That's all the pressure I need to prevent most of my apneas.

I hope to be able to post my Sleepyhead data soon.

Please do try to post that Sleepyhead data.

Yes, I would like to be evaluated for OSA. It is certainly possible that the low pressures took care of it. I did not know that OSA could be cured by low pressures - I always assumed they would have to be high. Interesting. I am not able to get a sleep test here, but could get one if I go back to the US for a time. I wanted to get a home sleep test done, but couldn't figure out how to get the machine back. I can easily receive things here but sending anything out is either unreliable or too expensive.

The really good news is that I have not had any problematic acid events at night anymore - no choking, no acid sore throat or waking up with a horribly stuffed up nose. I am so grateful for this. No more nighttime hot flashes or morning headaches.

My husband and I are going to work on get Sleepyhead up and running.

I have had 2 really good nights. I got to sleep within 30 minutes. With the pressure set back to 4 to 6, I have had no more mask leaks. Both nights the leak rate was 3L/min. The AHI was something like .1. I did not have any problems with dry mouth. The reason I still use the tape is so I can relax more. I don't need the tape to stop mouth leaks, but I am very aware and mentally vigilant for my lower lip to not drop as I fall asleep. If I feel it drop, I will often wake up because I am afraid I will get mouth leaks. The tape prevents my lower lip from dropping. Of course, now I know that it is my tongue position that matters, not the lower lip. But I still just feel better having the tape on. I am confident that I can do without the tape soon.

I have a question about the pressure. I noticed that, when I have the pressure set to 4 to 6, the machine reports the average pressure at 5.8. When I changed the max pressure to 7, the machine reported average pressure at 6.8. Could this mean that I would do better with the pressure set higher until the nightly pressure does not rise to close to max? I also thought I felt a little better with the max pressure set at 7, until I ruined the whole thing by upping it to 8. What do you think?

I am very happy that I started CPAP therapy. It has done me a lot of good already. Thanks to everyone on this forum.

PEF wrote:Yes, I would like to be evaluated for OSA. It is certainly possible that the low pressures took care of it. I did not know that OSA could be cured by low pressures - I always assumed they would have to be high.

The pressure needed to control the apnea is not directly correlated with the severity of the apnea.

The reason I still use the tape is so I can relax more. I don't need the tape to stop mouth leaks, but I am very aware and mentally vigilant for my lower lip to not drop as I fall asleep. If I feel it drop, I will often wake up because I am afraid I will get mouth leaks. The tape prevents my lower lip from dropping.

That's a perfectly good reason to continue the taping for the time being. You want to do anything you can that encourages or allows you to fall asleep in a reasonably quick fashion.

I have a question about the pressure. I noticed that, when I have the pressure set to 4 to 6, the machine reports the average pressure at 5.8. When I changed the max pressure to 7, the machine reported average pressure at 6.8. Could this mean that I would do better with the pressure set higher until the nightly pressure does not rise to close to max? I also thought I felt a little better with the max pressure set at 7, until I ruined the whole thing by upping it to 8. What do you think?

Maybe, maybe not.

Flow limitations are probably the thing that is driving the pressure increases and the tendency of the machine to stay at or near the max pressure setting. If the machine scored flow limitations are real flow limitations, a bit more pressure may reduce the flow limitation activity and allow you to feel better. If the machine flow limitations are due to something going on in your nose (as opposed to your upper airway) or if they're due to nasal congestion, then the machine is probably going to just raise the pressure to the max in an effort to fix a problem that just doesn't respond to increased pressure.

If you had no dry mouth problems, no aerophagia, and the leaks were ok with a max pressure of 7 and you think you slept better with the max equal to 7cm, then it's reasonable to increase the pressure back up to 7cm. You can always back it back down if you wind up having one or more of these problems after you increase the max pressure to 7cm.