Large Leaks

Here's a good example of what I meant by the machine essentially working as a fixed pressure machine because the leaks were so bad it didn't know it was supposed to increase the pressure. Note that once the leaks got really bad shortly after hour 1 that the machine essentially became a fixed pressure machine.
Note the pressure change shortly before 7 hour mark....leaks were no longer in large leak territory and the machine was able to sense and respond as we would normally expect.



Here's an example where the leaks were still bad but more intermittent and allowing the machine to increase pressures to some extent and when the pressures were increased the events didn't happen. Still not optimal performance but an improvement over the image above.



About the reported CSR during large leak times. I wouldn't worry about it at all. I think the machine is simply having trouble deciphering what is going on with the breathing during the times in large leak.

Managing the leaks better is number one concern. Easy for me to say but hard to do I know.
I would suggest setting the machine to 25 cm fixed cpap mode for mask fit only. Anticipate the higher pressures that are obviously needed and once mask fit check at higher pressure is obtained then switch back to auto mode for the rest of the night and hopefully no further adjusting of the mask is needed or would be done. If the high leaks are because of the higher pressures then this might help reduce the large leak time.
If the high leaks are mask movement because of moving around in bed then it may or may not be much help.
Something at least to try though.

This situation is something that I might be willing to compromise somewhat on the leak numbers depending on what the pressure was doing (because that tells me just how deep in large leak I was going) and the AHI.
Remember the primary goal.....good sleep, effective therapy and feel decent during the day.
One really needs to understand the leak/pressure/effectiveness relationship though to be comfortable with compromising.

Last night was amazing.

AHI went down to 0.69, lowest ever.

Based upon palerider's advice I raised IPAP maximum by 1.0 to 23.5

I am advised that I should move IPAP maximum to 25.0 so as to let machine decide what is needed.

SleepyHead and DreamStation/Encore Pro are now giving same results.

Velcro on one strap came loose and Large Leaks for 3.5 hours so AHI may be compromised?

Now to work on mask leaks.

It means a lot that Pugsy would return to help me on my difficult journey, she has provided me with amazing advice and encouragement and hopefully I can be another person who is successful.

Without Pugsy and others like her my difficulties would have been impossible to deal with and I likely would have given up by now but I will not do that as long as I continue to progress. I hope to help others in their struggles as we go along.

I would like to say last night was great, but I can't. YOUR LEAKS ARE TOO BAD. Like I said before, the data can not be trusted with leaks as bad as yours. See pugsy post above yours. Your machine shows little activity in scoring ANY events during the large leaks.

You have got to find a way to get your leaks under control I had very bad leaks like you. It was so bad the machine thought I was not using the mask. It thought I had taken the mask off and left it running...looked like yours, and the machine could NOT SCORE ANY EVENTS AT ALL. The DME almost took my machine away because they said I was not using it: it had NO BACK PRESSURE showing on their ResScan software.


So, FIRST, I will say it again UNTIL YOUR LEAKS ARE STOPPED YOUR DATA IS USELESS.

EDIT TO ADD: I wish I could help ypu fix this problem. Others on here have more insight to leak problems than I have. I use a pillows mask, tape with silk 3M, 2" tape, and use a soft cervical collar. I still have some leaks but they are not bad and only once in a while have some dry mouth....Keep trying things...

Also this is not to say the 1 cm increase did not help....but how much????? LEAKS

Thank you for your advice, somewhat deflating but not unexpected given the extent of leaks.

I do use a soft cervical collar and mask liner and I think both are very helpful.

I tried taping my mouth shut once with the 3M tape but didn't last the night so I gave up on that but now realize one night is not a proper test.

I will increase pressure to max and test drive mask fit on CPAP mode to adjust mask under full pressure as recommended and then switch back to Auto BiPAP.

I use a full tank of water each night and my mouth is still dry but tolerable.

Another alternative may be to go nasal pillow only but I previously understood that was not suitable for a mouth breather like me.

The RespCare Hybrid with nasal pillows and moth mask and built in chin support looks like a good option but reviews are mixed.

Are nasal pillows normally used by high pressure patients such as me?

Thanks for your ongoing assistance.

Re:
Are nasal pillows normally used by high pressure patients such as me?

Try and find out what works for you.
Cpap.com offers free return insurance on both the Airfit P10 and also the Dreamwear mask.

AcedDublB wrote:The RespCare Hybrid with nasal pillows and moth mask and built in chin support looks like a good option but reviews are mixed.

I think reviews on all masks are mixed.

I've used the Innomed (RespCare) Hybrid for about ten years. My pressure hits 18 most nights and 20 a few times per week. My SH reports show zero leak most nights. There is never a high leak.

If you do decide to use an Innomed Hybrid, there is a long post in the CPAPTALK wiki with lots of tips on how to use.

Make sure your DME provides all three sizes of mouthpieces and nasal pillows. Some of the DMEs like to ask you which size you want, and then they take out the other three sizes to sell to other patients. That's OK once you have settled on a size, but should not be tolerated when you are just starting.

AcedDublB wrote:Thank you for your advice, somewhat deflating but not unexpected given the extent of leaks.

While I agree with Lilly that your leaks are really bad, as you noted. (darn velcro! ) I'm not as quick to dismiss the results.

the machines usually can still *detect* breathing abnormalities, even with large leaks, what they can't do as reliably is differentiate between central and obstructive apneas.

if you zoom in on the flow chart, you can see the individual breaths, and as long as you don't see periods where there was no breathing,... you didn't have any apenas... now, spotting unflagged hypopneas is a lot harder to do, just by eye.

the other thing that's good about your chart is that during the times when you weren't having leaks, there were some fairly decent periods when the machine thought you were sleeping very peacefully, as evidenced by the sawtooth pattern in the pressure traces.... that's great.

AcedDublB wrote:Are nasal pillows normally used by high pressure patients such as me?.

I use the resmed P10, and my pressure is 18/13, varying up into the low 20's at times. some people will tell you you can't use nasal pillows at higher pressures... I disagree. there's a LOT less area to try and seal with a pillow mask.

AcedDublB wrote:Thank you for your advice, somewhat deflating but not unexpected given the extent of leaks.

I do use a soft cervical collar and mask liner and I think both are very helpful.
I tried taping my mouth shut once with the 3M tape but didn't last the night so I gave up on that but now realize one night is not a proper test.
I will increase pressure to max and test drive mask fit on CPAP mode to adjust mask under full pressure as recommended and then switch back to Auto BiPAP.
I use a full tank of water each night and my mouth is still dry but tolerable.
Another alternative may be to go nasal pillow only but I previously understood that was not suitable for a mouth breather like me.
The RespCare Hybrid with nasal pillows and moth mask and built in chin support looks like a good option but reviews are mixed.
Are nasal pillows normally used by high pressure patients such as me?
Thanks for your ongoing assistance.

My pressure goes to near 17 at times and I know others with high pressures use pillow or nasal masks with no problem. I know you are a mouth breather so if you try any of these masks, you will have to tape most likely, and use a soft cervical collar too or a chin strap.

I use the SILK tape because the paper tape kept coming lose. So if you were using the paper tape and it did not work, try Durapore SILK 3M 2" tape. And purse your lips together so it makes a tight seal and make sure you cover past the ends of your mouth. Again, yes do still use the collar and make sure it fits snug under your chin. It must be TALL ENOUGH to fit snug under your chin to stop your mouth from opening. So check the size of your collar and the proper tapping method and type of tape, all three important.....

palerider wrote:While I agree with Lilly that your leaks are really bad, as you noted. (darn velcro! ) I'm not as quick to dismiss the results.

palerider I agree with you as I stated at the bottom of my post.
I just could not tell how much it helped....... I don't have as much experience reading the data as you do....
Also I was just trying to get the OP to understand how important it is to stop the leaks some how

ADB see my post on tips for stopping your leaks

lilly747 wrote:

palerider wrote:While I agree with Lilly that your leaks are really bad, as you noted. (darn velcro! ) I'm not as quick to dismiss the results.

palerider I agree with you as I stated at the bottom of my post.
I just could not tell how much it helped....... I don't have as much experience reading the data as you do....
Also I was just trying to get the OP to understand how important it is to stop the leaks some how

No worries he does need to keep on top of the leaks...

In the past when large leaks were flagged we also saw a truckload of what the machine flagged as hyponeas.
Now whether they are hyponeas or obstructive apneas.....we don't know for sure what they might be without maybe doing some in dept breath by breath analysis on the wave form graphs but I don't see the need because it is enough to know that something got flagged due to ineffective pressure secondary to large leak. The machine still sensed something it didn't like.

Now with the increase in baseline pressures last night even with the large leak being prolonged we didn't see the usual truckload of hyponeas. Was this a fluke and the machine totally missed them or did nothing happen?
If this continues I am thinking that maybe the higher baseline pressure was enough to hold the airway open and prevent the collapses that were previously being flagged.
So we need more nights with the higher baseline pressure to see if the AHI remains low or if last night was just a fluke.

When it comes to the data reported during large leak times we don't have any real concrete way to know if the machine comes up with a nice low AHI because nothing happened or because the machine was clueless. That's why we harp on staying below large leak territory for the bulk of the night.
Here's the deal about the data though...it doesn't go to crap with the first L/min into large leak territory.
It gradually becomes less accurate the further we go into large leak territory.
I don't know where the final line in the sand is for Respironics machines though...you know the line where the machine throws up its little arms and says "I can't tell at all what might be going on". With the ResMed machines my own personal experience was that the line was around 35 L/min excess leak....up to that point the machine was fairly accurate.

In other words the lack of any events flagged during the large leak time last night might not be from the machine throwing up its little arms....it very well could be that nothing much happened because the baseline pressure held the airway open well enough. Given the past reports showing truckloads of events at the same leak level....there's a good chance that nothing happened. We need more nights at the higher baseline pressures to see if the AHI stays low or not.

It's obvious by the pressure lines staying fixed that the machine couldn't sense well enough to respond but in the past it sensed well enough to at least flag the events as hyponeas (I don't think these are centrals at all).
So last night's data does have some value and it isn't totally unreliable. If it were a ResMed machine I would be more apt to put it as unreliable but Respironics machines seem to be able to sense and flag events in the face of big leaks where ResMed machines seem to have more trouble.

My idea about nasal pillows....easier to keep sealed and I bet that even if you did some mouth breathing it wouldn't amount to the be in the magnitude that you are seeing now. Unless you simply can't breathe through your nose forcing you to mouth breathe 100% of the time you might be pleasantly surprised that even with some mouth breathing going on the leaks won't be as bad as what you are seeing now.
And yes...you can use nasal pillows even if your pressures were constantly maxed out. Higher pressures do create a bit of a challenge but that's a challenge with any mask and the greater the surface area needing to seal the greater the challenge.
Also....it seems like often people who use nasal pillows can get by with less pressure than is needed to hold the airway open when compared to what people need when using a full face mask.

The fact that you experience some dry mouth even with the full face mask doesn't necessarily mean that you mouth breathe the bulk of the night anyway. My mouth will dry out horribly with as little as 10 minutes of mouth breathing (I see the big leak on the leak graph). Some people's mouth just dries out easier/faster than others. Even if you did some serious mouth breathing with nasal pillows and had 25% of the night in large leak from it that would still be better than what you are experiencing now 50 % or more time spent in large leak.
So think about maybe trying nasal pillows if we can't get a better handle on the leaks using full face mask.
I can help you out with a P10 to try at minimal cost to you.

Let's see what tonight's leak line looks like.
Last night's data wasn't totally useless though...especially when compared to other large leak time frames where truckloads of events were flagged. Let's see if the results are repeatable and go from there.