Newbie Needing Help w/ Sleepyhead ?

Another night attempted, not the best night of sleep. I've posted the updated Sleepyhead chart, as well as the Fitbit (which correlates pretty accurate to what I remember, when I woke up).

http://imgur.com/a/uTG9u

Adjustments made:

1. Moved CPAP to a lower position. // Success.
2. Moved CPAP onto a towel to see if affects snores.// Snores seem to be in same data range.
3. Build a pillow armada to keep me on my side. // Kept me on my side for the majority of the night, if not all. I moved to my back sometime between 4-6 AM, and then the leaks were pretty bad.
4. Used mask fit setting. // Kept getting "success" but the mask was leaking. I was able to get it not to leak with the homemade mask liner.
5. Try a mask liner (homemade) // This seemed to work earlier in the night, but leaks still occurred as the night went on.
6. Check water when you wake up. // There was water in the basin the majority of the night, until at least 4-4:30 AM.

Overall, I woke up @ 1 AM and it took a little to fall back asleep. I was still on my side, I think there may have been the smallest of leaks, but fixed.
Woke up again around 3:30-4 (tried to avoid checking clock). It took me awhile to fall back asleep, not even sure fell back into the deepest sleep at this point.
AHI numbers are higher, VS2 are a little lower, but similar area.

I have an appointment with DME this morning @ 9 AM. Curious to see what my insurance will cover. My initial thought it to get a mask liner that fits my current mask, then ask them to provide me with a few other options with 30 day trials.
I like the fit of the nasal cushion, would prefer not to go full mask if avoidable. Willing / looking to try the nasal pillows as well.

Any advice based on last night? What else can I do? I've been keeping bedtime pretty consistent, shutting down all tv/screens an hour prior. Reading in bed, then trying out meditation app. I used Melatonin a few nights last week, helps me fall asleep but I was waking up like I am now (around 1-1:30 and again around 4 AM).

Thanks again!

your leakrate looks horrible - there is no indication anything other than a FFM might work for now.

Guest wrote:your leakrate looks horrible - there is no indication anything other than a FFM might work for now.

huh???

Where do you come up with "OMG only a FFM will save you" ????
It's not a real pretty leak graph but a lot of that leak line movement is pressure related vent rate increases.
3 very short lived times in large leak territory...not enough to warrant "OMG you have to use a FFM"...heck we don't even know if it is mouth breathing leak going on or if it's just normal mask movement leak.
You think that full face masks never move and never cause ugly leak lines??

FoggyBrain24 wrote:I have an appointment with DME this morning @ 9 AM

I would ask to try a different machine.
The number of VS2 snores really concerns me. I have seen it before and it ended up being a whacko machine.

Where do you come up with "OMG only a FFM will save you" ????
It's not a real pretty leak graph but a lot of that leak line movement is pressure related vent rate increases.

the lower leakrate is already (to some point) corrected by the intended leakrate from the mask, which can be set in the options in SH.
the leakrate here is not only pressure dependend - there are (a lot of) increasing leaks with steady pressure.

but what made me say that, was only the flow-rate! during the larger parts of the leak the flow diminishes way below hypopnea level! look in the charts, what you see from 4:00 to 4:30 is the normal flow - if it gets way below that you have critical leaks.

all that is measured there is just plain bullshit with that amount of leakage going on. fix the leaks first! after that take a look at the (remaining) events.

sure - nasal or pillow mask might work - but getting that amount of mouth-breathing under control is not something you learn or do over night. With a FFM the SA will be treated very quickly, chances are good that the ability to nosebreath will increase after the body returns to normal. If that is achieved and the FFM is uncomfortable: take another approach on the pillows.

trying to get the pillows work before any treatment is like prolonging the suffering. (unnecessarily)

Guest wrote:but what made me say that, was only the flow-rate! during the larger parts of the leak the flow diminishes way below hypopnea level! look in the charts, what you see from 4:00 to 4:30 is the normal flow - if it gets way below that you have critical leaks.

Well your crystal ball is working much better than mine. I can't tell a damn thing about flow rate at this scale.
I am going to respectfully disagree with pretty much everything you just said.
Have a nice day.

Thanks all. I appreciate the feedback.

Just got back from my DME. He looked @ the Encore data he had and apologized for not monitoring the leaks and other items, but said he appreciated how much I was tracking / paying attention / forcing the issues. He said the leaks were definitely bad and had to be addressed. His feeling was that a different mask would help. He offered a FF and a nasal pillow one. He said I can try either one for now and they won't charge me just yet. He said if I wanted to try more masks, he recommended using CPAP.com w/ free shipping to take others for a test drive.

The 2 options were:

AirFit F20 FF
Respironics DreamWear Nasal Pillows (technically, under the nose nasal mask).

He leaned towards the DreamWear, so I went with that. It fit well in the office (although, due to another appointment, I did not get to try it with pressure).

I do feel a little better today than yesterday so fingers crossed I am on the road to recovery. Not loving the REM % in the FitBit, but it seems like the amount of time spent in bed may be helping there. If I can eliminate these leaks, I think I am in for some big daily improvements. If this mask doesn't work, I can go back in and swap out for the AirFit next week.

Any other recommendations?
Any other explanation other than the machine for VS2? I don't seem to audibly snore (if that is even the case). During my CPAP titration, they said snoring was eliminated with a set pressure of 8.0. I know switching the machine would be a huge headache, but understand that may be what's needed.

PS The therapist told me that the leak rate with my machine / nasal cushion & nasal pillow mask should be 30. Anything above that is an issue. I reposted my charts with the 30.0L.

http://imgur.com/a/uTG9u

VS is your snoring - snoring in terms of the machines has (primary) absolutely nothing to do with the noises we in general associate with snoring.
What the machines score is a vibration in the flowrate. If you zoom in to the point where you can see single breaths, you will see the snoring.

VS2 is a completely different thing. RobySue posted a while ago some thoughts on that over at apneaboard. VS2 as an event is itself meaningless.
What I took away (I don't have a respironics machine, so I am only mildly interested in that at all) is:
VS is the real sonring event - indicating a clear vibration in the flowrate.
VS2 represents a value for a period of roughly the last 2 minutes. If it is higher than 0 it means that there was some kind of "vibrating" going on - but not to the point it got scored as a VS.

In the end it is most likely something like the flowlimitation-chart (as ResMed has it or others). You can have some movement on the flowlimitation-chart but it does not get scored as a flowlimitation-event - simply because it is not severe enough. But that does not mean that it is not an issue.
Same with the VS2 - if the vibration is severe enough it gets scored as VS-event - if it is there but below that it goes into the VS2-value.

a little bit oversimplified, but not completely wrong: snoring is a lesser form of a flowlimitation - or the really early signs of the beginning of an obstruction.

The values of the VS2 are represented in the Snore-graph ... the same values as "events" or tickmarks make no sense at all! - disable them and if your are interested in that, look at the snore-chart.

But as I already said: your problems (and your ONLY problem!) are leaks! - or more: mouth breathing!

as long as there are leaks (any leaks) the machines can not measure anything. (most of the snoring will be gone if you get the leaks under control)

Thanks. I am certainly hoping that by focusing on leaks / low AHI / adequate rest, I will be feeling better in no time. Thanks for the support.

FoggyBrain24 wrote: PS The therapist told me that the leak rate with my machine / nasal cushion & nasal pillow mask should be 30. Anything above that is an issue. I reposted my charts with the 30.0L.

Issue as in how...that's the expected vent rate not excess leak rate.
It would be a bad number for a ResMed machine reported leak because they only report excess leak.
Respironics machines report total leak which is the mask's expected vent/intentional leak plus any excess leak.
The machine can handle quite a bit of excess leak...that's why there is a large leak flag feature.
Plus the threshold varies for where large leak territory begins because more pressure is going to increase the vent rate anyway.

You can't use the bottom line on the leak graph in SH as a good excess only leak marker...even Mark (who came up with SH) said he couldn't get a good code for excess only leak calculations from a Respironics machine data.

A bad number for a ResMed leak report could very well mean a 0 excess leak for a Respironics machine report.

You changed the red line threshold to 30 L/min...so now it says you spent 32 % of the night in large leak.. you didn't.
Look at the large leak flagged areas...do you think that adds up to 1/3 of your night?

I am thinking the therapist used a ResMed leak number and it shouldn't have been used.
The red line threshold number....you are using a Respironics machine and your red line isn't at 30 L/min....it's more up around 60 to 80 depending on what pressure you are using.
Using 30 L/min is going to totally f...k up your leak results and make the time over red line statistic worthless.

Don't believe me....get Encore and see what it says. I am 100 % dead certain about what I am talking about here.

I believe you completely. I mentioned my pressure / device / mask, and he said I should look at 30. His Encore stats showed a chart of everything, I took a look but it seemed to show everything above 0. I don't believe I was 30% above all nights, I guess I'm just trying to ensure I am going with the specifications laid out.

If you believe 70.0L is best estimate and I should only worry about those, I will go with your knowledge & update / keep posting those charts. I just want to ensure I am looking @ the right data. Either way, I hope to eliminate it all and will be doing everything I can each day.

Therapist seemed somewhat knowledgeable, but at times, I wasn't sure.

Thanks again!

Respironics doesn't ever give us an exact line in the sand because the line changes with pressure changes.
I have no idea if 70 is very accurate..it's a good number for pressures of 16 cm range and maybe not so great for pressures in the 9 cm range where the line might be 60 L/min.

You are asking SleepyHead to come up with a statistic that it can't come up with that will be 100% accurate because Respironics machines vary that red line as they vary the pressure.

Encore reporting...you have 2 ways to report in the graphs
Excess leak only
Total leak
2 different reports.
Encore is Respironics and how they come up with the excess only report is unknown. Rumor control has it that they take a generic reading at the beginning of the night at whatever pressure is used and assume no excess leaking...and run from there.

You would be better off to turn off the red line statistic and just eyeball the leak graph.
30 L/min....giving you 32% of the night in large leak...you can see with your own eyes that simply isn't the case.

If I have time I will put together an Encore report showing the way leaks are shown....total vs unintentional and you can see what I mean.

You have to go by what the machine is showing you though...not what you fix up for SleepyHead to use as a baseline...30 L/min...works for a ResMed but not for a Respironics machine. Plain and simple.
Look at the leak graph and the Events graph....Large leaks are clearly shown...that trumps a SH calculation any day of the work because with SH you are manipulating the results using numbers that may or may not be accurate.

Understood, thanks for the thorough explanation.

Stop leaks = none of this matters

On a side note, FitBit is now trying to come up with a new tracker that measures O2 and can potentially help diagnose sleep apnea.

https://www.cnbc.com/2017/06/20/fitbit- ... cking.html
https://www.theverge.com/2017/8/30/1622 ... ch-sensors
http://www.sleepreviewmag.com/2017/08/f ... ea-future/

FoggyBrain24 wrote:On a side note, FitBit is now trying to come up with a new tracker that measures O2 and can potentially help diagnose sleep apnea.

What about the people who have sleep apnea and O2 levels don't drop much if any?
I have a friend who had an in lab sleep study...AHI 60 plus...her oxygen levels never really dropped more than the expected drop that happens in sleep anyway...baseline 97% and the lowest it ever went to was 94%.
You can have sleep apnea without a big drop in O2 levels...not common of course but it can happen. I saw her sleep study reports because I just couldn't believe it when she told me that with AHI of 60 something her oxygen levels didn't change much.

I will admit that it would be a good screening tool as long as people understand the implications and limitations associated with it.
Significant drops..mean something but the absence of significant drops doesn't necessarily mean everything is all hunky dory.

$299 for the new toy....think I will pass right now. I just got the dentist bill for my husband's recent root canal and crown...haven't got the bill for mine yet. No new toys for me for a while.

+10 what pugsy said about leaks.

Don't get me wrong - I say the same!
(and just as a warning - english is not my 1st laguage and I don't proof-read this or fix the typos^^)

There is one chart (as in data) coming from your machine: it is the total leak measured from your device.
There are 2 reasons for leakage: 1 is the intended (and known) leak from your mask to wash out the CO2 from the exhale. The other one is the excessive / unintended / real leak. We are interested in the latter.

That means: total leak = intentional leak + excessive leak
that means: excessive leak = total leak - intentional leak.

In the manual of your mask there is somewhere a graph and maybe even data on the intended leakage. Do look that up.
You will notice that this is not a straight line but a curve - unique to your mask. - you will also notice some "information" saying something like "due to variations in the production this values may change a bit on your actual mask" .. or not^^

SleepyHead can substract the intentional leakage from the total leak - but SH draws a straight line between 4cmH20 and 20cmH20 - take a ruler and put it on the graph from your mask and draw that line - you will notice, that it will only be accurate at 4 and 20 and between that it stays under the line - which means nothing more than: the (excessive) leak (shown by SH) will be greater than it actually is.

That is no real problem - let's fix that!

Open SH and go to the preferences - 2nd tab "CPAP" - on the left in the middle you will see "calculate unintentional leaks ..." - make sure you checked that.
your pressure settings are from 9 to 20 - but the interesting part takes (at the moment) place at 9 to 15.
So let's make sure, that this range is correct.

Go back to your mask manual and find out the closest values to 9 and 15 (beeing 10 and 15) - draw a straight line between this 2 points and than put in, whatever that line says at 4 and at 20.

if the "philips wisp nasal mask" is correct, put in the following values in SH:
4cmH20 = 19.6 L/min
20cmH20 = 42 L/min

most likely SH is demanding a re-calculation. Now take a look at that chart - if you "feel" it is not right and gives too high numbers - adjust them a bit! (only a bit)
It is not the perfect curve that comes out of it - but it is close enough! Whatever remains as the error is small enough to safely ignore it. (we are talking about a few liters per minute here)

the tech at your DME was talking about 30 liters per minute leakage - unclear if he meant total leakage or excessive (unintentional / real) leak - but let us assume he was total about excessive leakrate.
that value is crap! No, in fact it is bullshit! Yes it is!

that value and all values about "acceptable" leak do focus on one single thing: the ability of the machines to keep the pressure up or steady. that is one very important value - but it is and stays bullshit!
if you would have an excessive leak of 30 liters at 20cmH20 the total leak would be a little over 70 liters per minute - pressurized liters!
If you look just one line below the pressure flow curve in your manual you will notive that it says, that at 100 SLPM (that is: standard liters per minute - meaning unpressurized liters per minute!) the pressure drops for 3.8cmH20!
that would mean that with 30 liters leak your machine would believe you are still around 20cmH20 pressure - but in reality in your mask would only be something around 17cmH20.

the exact value of the "acceptable" leakrate depends on the machine (or how strong the blower is) and the current pressure - the higher the pressure the lower that value - or (as this value has to hold for every pressure the machine is capable of) this value increases (further) if you are at a lower pressure.

that was just the trivial part of the leakage - or how it would be in the straight CPAP-world, where the only job of your machine would be to keep the pressure steady and nothing more.

another thing is: leaks are annoying! - they either wake yourself or your partner up.

but the real problem with leaks is as follows:
Your are using an APAP! - your machine has to determine your respiratory flowrate and draw all conclusions and how to adjust the pressure from there on.
The machines do NOT know your respiratory flow, they only know the total amount of air they are blowing in your direction. You have no sensor in your lungs or your nose.
They even do NOT know the (total) leakage - they have to estimate that. - Whatever remains is your respiratory flow.
Leakage detection and estimation is a rather complex procedure - let's not go there! To make that very short: it's complicated and the machines can only roughly estimate that. However they can pretty accurate determine the intentional leakrate of your mask!

That means: the larger the leak the less accurate your flowrate becomes. (and as a result of that: the less accurate the event detection becomes and therefore the pressure adjustment!)

But you are using a nasal-mask - so there is a whole different problem with leaks - they can be mouth-breathing!
If you open up your mouth the pressure goes straight from your nose out of the mouth! Obstruction can occure below your mouth - but there is no longer any pressure - it would be the same as sleeping without any mask!
On top of that you are able to breath in through your mouth - thus bypassing your machine - thus the machine can no longer detect or measure your respiratory flow - thus it can no longer detect any events - thus it can no longer do its job of adjusting the pressure.

Let's take a look on the last picture from august 30.
From 4:00 to 5:00 your leak-rate looks stable and minimal! - take a look at the flowrate - that is your normal breathing pattern! - really look on how big that is.
Now take a look at 0:15 or 2:45 - not that big!? - take a look on the tidal volume as well.
No - you are not suffocating there - you just breath (partially) through your mouth!

If I see that correctly aroung 22:10 should be interesting as well (zomm in there!) right before the RERA. there you clearly see mouth-breathing (you most likely were still awake and trying to speak or whatever - so you may remember!) - you did not stop breathing there. your machine even scored a RERA (which was never there!)

If your machine scores a large leak, all that it is trying to tell you is: "From this point on I can no longer help you!" - not even a little bit.
Long before a large leak is scored everything was flushed down the toilet.

Hopefully I have by now scared you enough into leaks.
Now, what is an acceptbale leak? - Let's find out!

Put on your mask and start the machine. Calm your breahting down - this takes some minutes and not some seconds! - so be patient!
Now start to toy around with your mask and cause some leaks! - toss and turn around in your bed - put your face into the pillow.
Make the leaks not just for some seconds each - stay with them! Pay attention to your breathing and if the leaks have any impact on that.

Now make sure your mask has a near perfect seal and you can fell no leaks at all! ... now relax your lips and slowly (really slowly!) start to open your mouth and (try) to keep on breahting normally and not forced - let the air rush out of your mouth - will be uncomfortable - bear with it!
Now open your mouth fully and breath just through your mouth for a while.

shut down the machine and take a look at the leaks! - now you knwo what is acceptable and what is not and what can be what!

(just BTW: if you want to "measure" the exact data-points for the intentional leak of your own mask: just put the machine in CPAP mode to your 10%-pressure and 90% pressure and calculate the 4 and 20cmH20 values from these two data-points!)

And always remember what pugsy says about leaks! If they wake you up or cause trouble: fix them! (in your case they are causing trouble at the moment!)
but don't overshoot - sleep quality before data-quality! - some leaks are normal and acceptable - there is a point where minimizing leaks causes real trouble sleeping and is therefore contra productive!