Do I have mouth leak? (w/ detailed treatment log)

Hi guys.
I'm 8 months into CPAP therapy and I think I just hit my rookie wall.
I'm going to update this thread constantly in the future, so I will put as much background information as possible here.

Background: Early 30s, Asian male, BMI 23.4 with fairly big neck width (was BMI 29.1 when I began to take CPAP therapy)
OSA Home Sleep Study (Before treatment, 2021/1/23): AHI 40.5, OAI 31, SaO2(Min) 73%
CPAP therapy was initiated on 2021/2/1. Using Philips Dreamstation APAP mode (Min 10 Max 12) & Resmed P10 mask.

From 2021/2/1 - 2021/9/23, my experience w/ CPAP is like taking a rollercoaster: my OSCAR numbers & subject feelings have gone from good to perfect to suboptimal to unbearable.

Pic 1: AHI, Pressure and Leak rate over the last 8 months Over the last month, I've been trying to improve my condition by tweaking the machine and replace the mask, but generally, no improvements and my tiredness only got worse. Here are some failed experiments:

a. I suppose I just need higher pressure and set the minimal pressure 2cmH2O higher and my condition got worse.
b. I suppose my mask got worn down and bought a new one. still no improvement.
c. I suppose Philips Dreamstation is unreliable (upon hearing the foam scandal) and bought a ResMed, still no improvement.

I start to suspect that leak being the culprit for my suboptimal treatment outcome despite fairly good AHI numbers. And I looked into the OSCAR graph carefully and found out that over the last 6 months. The leak rate has been gradually climbing up.

Here are some typical daily charts:

Pic 2: A typical night with Philps Dreamstation in Sep Pic 3: The worst night with Philps Dreamstation in Sep [To be continued]

Pic 4: The first night with new Resmed Machine + brand new P10 mask Pic 5: The 2nd night with new Resmed Machine (I lower the minimal pressure from 10 to 8 ) Pic 6: The 3rd night with new Resmed Machine I do recall some clues for the potential leak in hindsight: I waked up ("arousal") at night more frequently lately, I sometimes found myself drooling at night- my pillow was wet and so was the corner of my mouth. But I never have "dry mouth" in the morning, which is a common complaint from mouth leak users.

At this moment I have a hypothesis: my weight loss (From BMI 29 to 23) somehow changed the anatomy of my upper airway and made me prone to leak (and most likely a mouth leak?). I have tons of questions, but I think I'll just ask one at a time.

Q1. Could you diagnose that it is a MOUTH LEAK (not leak from the mask) from the history and the chart I posted here?
I found this very informative post about mouth leak waveforms (https://www.cpaptalk.com/viewtopic.php? ... i#p1086296)
but I still could not diagnose it with confidence.
Or is it better to just give it a try for taping my mouth when using P10 mask?

As you proposed, the quickest way to rule out mouth leaks is to tape your mouth while using your cpap. Then look at the OSCAR results.

Assuming the tape is still firmly attached in the morning and OSCAR still shows large leaks then it’s likely mask leaks.

You can deal with mouth leaks / breathing via:

• Train planting your tongue on the roof of your mouth until it’s a habit

• Mouth taping with medical tape (Micropore, Somniflex, Coverall, Hypafix, Medipore)

• Soft cervical collar

• Scunci hairband / headband

https://www.cpaptalk.com/viewtopic.php? ... 7#p1394697

https://www.cpaptalk.com/viewtopic.php? ... 7#p1390637

GrumpyHere wrote: ↑

Wed Sep 29, 2021 1:35 am

As you proposed, the quickest way to rule out mouth leaks is to tape your mouth while using your cpap. Then look at the OSCAR results.

Assuming the tape is still firmly attached in the morning and OSCAR still shows large leaks then it’s likely mask leaks.

You can deal with mouth leaks / breathing via:

• Train planting your tongue on the roof of your mouth until it’s a habit

• Mouth taping with medical tape (Micropore, Somniflex, Coverall, Hypafix, Medipore)

• Soft cervical collar

• Scunci hairband / headband

https://www.cpaptalk.com/viewtopic.php? ... 7#p1394697

https://www.cpaptalk.com/viewtopic.php? ... 7#p1390637

Thx for reply. I looked into the first link you post which is about UARS. Do you mean by analyzing my graph you suspect I have UARS??

Nope, was not saying you have UARS.

I was just providing link to examples in how other members are dealing with mouth leaks or mouth breathing.

Those do look like mouth leaks, but as GH says, why not just experiment? When you tape, either use strips that come with a non-sticky area at one or both ends, or fold back a tab at one end so you can easily grip the tape to pull it off. Be sure to purse your lips before you apply the tape. Another brand to consider is BSN Medical Cover Roll Stretch, 4" x 10 yds, Single Roll, White.

I had leaks looking like that when trying a new mask a while back.
Still in strap adjustment phase so I had to eliminate mouth opening as the culprit.
I taped my mouth shut and the leak line was still just as ugly. So the leak was mask movement.

On these reports we just can't tell for sure what causes them unless we for sure eliminate the mouth opening possibility and see if the leaks stop or reduce or not.

There simply isn't any way to know for sure without making sure the mouth can't open.

To fix a problem we first have to identify the cause of the problem.

Pugsy wrote: ↑

Wed Sep 29, 2021 12:29 pm

I had leaks looking like that when trying a new mask a while back.
Still in strap adjustment phase so I had to eliminate mouth opening as the culprit.
I taped my mouth shut and the leak line was still just as ugly. So the leak was mask movement.

On these reports we just can't tell for sure what causes them unless we for sure eliminate the mouth opening possibility and see if the leaks stop or reduce or not.

There simply isn't any way to know for sure without making sure the mouth can't open.

To fix a problem we first have to identify the cause of the problem.

Thank you for your reply.
Just spent my first night with my mouth taped. The tape fits me well. I did not feel much discomfort and it still seal airtightly in the morning. But I took too much caffeine during the day and had a bit of trouble falling asleep and only get around 5.5 hours of sleep after resort to taking a sleeping pill. Before I fall asleep when I lied supine there is one time I found my cheek puffed like a balloon. It got better when I lied on my side.

The OSCAR graph still shows leaks for a significant period of time. However probably a little improvement from the night before? But I'm not sure if it's due to the fact that I fall asleep late and have a short period of total sleeping time tonight? Or the mouth leak is at least part of the problem?

Pic 7 Mouth taped Pic 8 1st night graph with mouth taped

That way you taped....vertically....doesn't/won't totally prevent mouth leak. Corners can let air sneak out.
Best to do the tape horizontally.

Now all that said...it looks like the worst of the leak was 28 L/min. Large leak territory beginning is 24L/min.
So you were barely beyond the large leak threshold and it's not bad enough to really impact the machines ability to sense, record or respond. The machine actually does a decent job up to 35 L/min and above....the higher you go the iffier it gets.

I personally don't even bother looking at large leaks until I start seeing lots of time above 35 L/min...assuming the leaks aren't disturbing my sleep.

10% of the sleep session just barely above the threshold...unless it caused wake ups...I would shrug my shoulders and move on.
Now if I saw 2 hours at 40 L/min...then I would take more notice.

7 hours...420 minutes...10 % is just 42 minutes and barely across the large leak threshold at that. Far from the end of the world.
Your AHI is accurate and unless the leaks woke you up I wouldn't worry about them unless you start seeing huge prolonged amount of time over 35 L/min.

Pugsy wrote: ↑

Wed Sep 29, 2021 10:31 pm

That way you taped....vertically....doesn't/won't totally prevent mouth leak. Corners can let air sneak out.
Best to do the tape horizontally.

Now all that said...it looks like the worst of the leak was 28 L/min. Large leak territory beginning is 24L/min.
So you were barely beyond the large leak threshold and it's not bad enough to really impact the machines ability to sense, record or respond. The machine actually does a decent job up to 35 L/min and above....the higher you go the iffier it gets.

I personally don't even bother looking at large leaks until I start seeing lots of time above 35 L/min...assuming the leaks aren't disturbing my sleep.

10% of the sleep session just barely above the threshold...unless it caused wake ups...I would shrug my shoulders and move on.
Now if I saw 2 hours at 40 L/min...then I would take more notice.

7 hours...420 minutes...10 % is just 42 minutes and barely across the large leak threshold at that. Far from the end of the world.
Your AHI is accurate and unless the leaks woke you up I wouldn't worry about them unless you start seeing huge prolonged amount of time over 35 L/min.

Thank you for your advice!

I'll try taping my mouth horizontally tonight.

Those numbers underestimate my real situation though, I only slept for less than 6 hours for insomnia. So the time over leak redline should be around 13-14%.

I still feel unrested in the morning. I also order a N20 mask. But I'll not use it until I completely rule out the mouth leak.

Beat OSA wrote: ↑

Wed Sep 29, 2021 11:18 pm

I only slept for less than 6 hours for insomnia.

Beat OSA wrote: ↑

Wed Sep 29, 2021 11:18 pm

I still feel unrested in the morning.

Well......only getting less than 6 hours of sleep itself can sure lead to feeling like crap the next day. Simply not enough sleep will do that.
Now, it is entirely possible the leaks are a factor in disturbing your sleep no matter how big or little.
What I explained was the amount of leak itself isn't going to impact the therapy itself all that much.

Any leak that disturbs our sleep is unwanted....no matter what the size.

Also doing known things that cause insomnia are unwanted as well. A perfect 0.0 leak line all night long isn't going to help if we simply aren't getting enough sleep due to insomnia for whatever reason.

To tame chipmunk cheeks, try positioning your tongue by putting the tip of your tongue behind your front top teeth, letting it spread out to the insides of all your upper teeth, and then giving a little swallow or suck to create a bit of suction. Once your tongue is properly positioned, you should be able to open your mouth and breathe through your nose only. If you practice this tongue position throughout the day, your body will probably learn to maintain this position while you sleep.

Pugsy wrote: ↑

Thu Sep 30, 2021 3:06 am

Beat OSA wrote: ↑

Wed Sep 29, 2021 11:18 pm

I only slept for less than 6 hours for insomnia.

Beat OSA wrote: ↑

Wed Sep 29, 2021 11:18 pm

I still feel unrested in the morning.

Well......only getting less than 6 hours of sleep itself can sure lead to feeling like crap the next day. Simply not enough sleep will do that.
Now, it is entirely possible the leaks are a factor in disturbing your sleep no matter how big or little.
What I explained was the amount of leak itself isn't going to impact the therapy itself all that much.

Any leak that disturbs our sleep is unwanted....no matter what the size.

Also doing known things that cause insomnia are unwanted as well. A perfect 0.0 leak line all night long isn't going to help if we simply aren't getting enough sleep due to insomnia for whatever reason.

Thank you! I finally figure out what has been going on for the past month, I think.
Last night I taped my mouth horizontally as you suggested. Other than that, same as usual: Resmed Airsense 10 (Min8 Max12) and P10 mask.
This time I can vividly remember what happened: my cheek balloon up every now and then, and everytime it happened, it waked me up briefly. Since my lips were sealed all night, I had to swallow the air down to either my lung or stomach everytime I got chipmunk cheek.

And the OSCAR graph shows I have zero leak this time. If this is a night that is representable (not a outlier), I think I get a diagnosis: I have mouth leak.

Now what? I could think of 3 potential ways:

1. Lower the pressure setting
Rationale: My weight loss lower my therapeutic need for CPAP pressure? and the excessive pressure force the air to go to my oral cavity? Or even if I still need the same level of pressure, by lower the pressure I could sacrifice some AHI to prevent me from waking up every now and then by chipmunk cheek? Is it plausible?

2. Full face mask
Rationale: when mouth leak air out, just breath air in from mouth. The problem is I think I'm not a mouth breather, I'm not sure if I can tolerate FFM, or worse, if FFM could solve the problem.

3. Strap, tape...
Rationale: Ways to prevent the air from going into my oral cavity.

What should I do?

Pic 9 I tape my mouth horizontally Pic 10 The OSCAR

Miss Emerita wrote: ↑

Thu Sep 30, 2021 1:11 pm

To tame chipmunk cheeks, try positioning your tongue by putting the tip of your tongue behind your front top teeth, letting it spread out to the insides of all your upper teeth, and then giving a little swallow or suck to create a bit of suction. Once your tongue is properly positioned, you should be able to open your mouth and breathe through your nose only. If you practice this tongue position throughout the day, your body will probably learn to maintain this position while you sleep.

Thank you for your reply!
I will definitely try this routine today.

Chipmunk cheeks can happen even at lower pressures...actually at any pressure but you could certainly try reducing the pressure and see what happens.

Bear in mind that when you reduce the pressure then the pressure may not be able to hold the airway open and prevent airway collapses so you may see an increase in the AHI should that happen.

Full face masks come with their own leak baggage...up to you if you want to go down that road. They don't necessarily stop chipmunk cheeks either but will allow you to simple release the pressure by opening your mouth without losing therapy pressure. Might also still wake you up though which of course is unwanted because it messes with sleep quality.

Not my job to make decisions for you.
That's your job.
My job is only to explain the options available and pros and cons to those options.

I do almost always go for the cheapest and easiest experiment to be trying though. Worst thing that could happen is you learn it wasn't a good option and you move on to a different experiment. I always learned something though from all my experiments. Sometimes all I learned was what a stupid idea I tried.
When I first started cpap therapy I was doing some mouth breathing out of habit....so I opted to tape my mouth because it was cheap easy experiment to try. Now I have never had a problem with chipmunk cheeks and I routine saw pressures in the mid teens (still do sometimes). I quit taping after about 3 or 4 months....broke the mouth opening habit.
Every now and then I might see evidence of very brief mouth opening....I ignore it since it doesn't wake me up and it never lasts long enough deep in large leak territory for it to really have a negative impact on my therapy.

Getting to sleep and staying asleep and getting enough hours of sleep has always been my primary goal because without sleep none of the good numbers mean much.