large leaks -- when to worry

I'm back -- It's been months. After starting and stopping several times I've really committed to using this thing. I've tried so many masks but the P10 seems to work the best as far as comfort. It's been a month now of regular use, although some nights it's only about 5 hours with the machine. Other nights I make it to 7-8. I realized that if I was not using Oscar I would think it was going great. But I am, so I see these large leaks. I decided at first to ignore them until I was getting decent sleep with the machine/mask. But now I'm wondering if it's worthwhile with these kinds of leaks. And the flow limitations. Advice appreciated. I've tried a number of things I've seen here, but not taping my mouth. I have terrible delayed sleep onset issues as well. Any advice. (I love how you can tell exactly when I fall asleep as the pressure goes straight up!)

to add, the first chart is from one of my best days and the second is more typical

Here your question is discussed, they talk about resmed 10 airsense machine, yours is for her, the way to measure of air leaks must be the same.
https://www.cpaptalk.com/viewtopic/t105 ... view=print

Your machine measures the leaks in percentages, above 30% the leaks are bad and a sad or red face appears on the display. Big leaks are bad because they make your therapy not to be the most effective. However, each person is different in my case leaks between 20 and 30 percent already could give me headaches although my AHI is not that bad.

Look at what robysue and pugsy say, here I put it for you a piece of it.

robysue said the following on that link:

Your signature shows that you are using a Resmed Airsense 10 (A10) AutoSet. Resmed machines only report excess leak rates and Remed defines an official Large Leak as 24 L/min. If the leak rate is AT or ABOVE 24 L/min for 30% or more of the night, then Mr. Frowny Face shows up in the Sleep Report on the LCD.

So Resmed defines the line of where Large Leaks are an official problem when you are in Large Leak territory for at least 30% of the night. Whether that's acceptable to you really depends on how much the leaks are bothering you and how much above the 24L/min threshold the worst of the leaks are.

In general:

If the amount of time that you are in Large Leak territory is just a few minutes here and there AND the leaks are not bothering you (in the sense of waking you up or disrupting your sleep), then it's ok to not worry about them.

If the amount of time that you are in Large Leak territory is extensive, you need to worry about fixing the leaks regardless of whether they're bothering you or not. Once the leak rate is around 30 L/min, the Resmed xPAP machines have a tough time accurately detecting the breathing pattern, and that means the data they are recording is usually not very accurate: There may be events that happen that are not detected. While Resmed says that spending up to 30% of the night in large leak territory is acceptable, I personally think that's more Large Leaks than I'd want to see. If I was consistently seeing more than about 10-15% of the night in Large Leak territory, I'd be working on fixing the leaks.

If leaks are bothering you and disrupting your sleep, they need to be fixed regardless of whether the leaks are large enough to be flagged as official Large Leaks. Small leaks can be particularly bothersome if they're hitting your eyes or drying out your lips. And when this happens, the small leaks can be quite disruptive of your sleep. If leaks are bothersome enough to wake you up multiple times each night, then you've got to deal with them, regardless of size.

Small leaks that don't wake you up should be ignored. There's no point in chasing a 0 L/min leak rate if the measures you have to take to get one cause significant disruption to your sleep.

Iseestars wrote: ↑

Wed Oct 13, 2021 11:10 pm

Your machine measures the leaks in percentages,

No, it doesn't. It measures leak in liters per minute, which is what it says on the chart.

Iseestars wrote: ↑

Wed Oct 13, 2021 11:10 pm

above 30% the leaks are bad and a sad or red face appears on the display.

No, if the machine is in large leak territory (more than 24lpm) for over 30% of the night, then you get the frowny face.

Iseestars wrote: ↑

Wed Oct 13, 2021 11:10 pm

Big leaks are bad because they make your therapy not to be the most effective.

This is also wrong. normal 'large leaks' make it so the machine can't differentiate between central and obstructive apneas, extremely large leaks can affect the machine's ability to maintain therapy pressure.

Iseestars wrote: ↑

Wed Oct 13, 2021 11:10 pm

However, each person is different in my case leaks between 20 and 30 percent already could give me headaches

No, they can't.

Some questions first.

1....are you experiencing any nasal congestion issues? Sometimes the activity on the FL graph is from nasal congestion...if it is we deal with it differently.

2....are you sleeping through those periods of large leak and waking up feeling quite decent during the day?

3....You are using the for Her auto adjusting mode which is well known to make mountains out of mole hills. Have you ever tried the regular auto adjusting mode?

4...Have you ever tried more than 1 EPR setting?

5...Have you ever tried a higher minimum than 7 cm?

First thing we HAVE to do is figure out if those leaks are mouth breathing leaks or mask movement leaks and that will involve taping the mouth for at least one night.

If most of your nights were like the lower leak report I would tell you to ignore if sleeping well and feeling great but you say the ugly report is more typical BUT while it is ugly.....it still isn't horribly horrible. I have seen reports with much, much worse large leak.

My advice as to how much to worry will depend on answers to above questions.

Thank you all for your input.

As to Pugsy's questions:
1. Congestion issues. Well yes and no. During the day I do not feel congested and I breathe through my nose just fine. When I lie down I notice that sleeping on my side the "downhill' side begins to feel blocked. Turn over and "stuff" deep in my sinuses moves to the other side. My husband says his CPAP opens up his airways when he's congested. That is not happening here. I do use a nasal saline spray before bed and I've thought that I should try a sinus rinse, but a long time ago I had a facial x-ray and the report said that there were bony structures in my maxillary sinus and since then I've been a bit terrified of doing a neti pot and having the water get stuck. Probably seeing an ENT would be the only answer? I do find that breathing the humidified CPAP air means that I wake up feeling less dry in my sinuses. A positive!

2. I sleep through the leaks and often wake up thinking I have slept really well and then when I check Oscar I've been in large leak for much of the time I was asleep.

3. I tried the regular mode during one of my lying in bed trying to sleep periods and I didn't think I liked it as well as the for Her mode. I have not slept in the regular mode.

4. I have tried a higher EPR setting but I was kind of hoping that the lower EPR would have enough pressure keep my nasal passages open. Dumb idea, probably.

5. I have not tried a higher minimum. My prescription was for 6 and 15. During the hours of waiting to fall asleep, 6 didn't seem like enough so I bumped it up. Can't remember why I lowered the max.

The first round of trying to use the machine I felt like I was being woken up when the pressure would rise. Like I felt like the mask was being blown off my face. I haven't felt that way at all this time around. It's gone so much better, although I still would like to sleep better and I still feel very tired in the afternoon. But a lot of that seems to be the delayed onset stuff. The melatonin .5mg that was once life-changing doesn't always work anymore. And when I use it I often wake around 4 (after 4-5 hours of sleep) and it can take up to an hour to fall back asleep. And often I take off the mask at that point because my face feels oily and the mask feels sticky. Or at least I think it does? Those last 2 hours of sleep without the mask are like my reward for doing this and I know that's a terrible attitude. Baby steps.

Thanks for listening.

mjastro wrote: ↑

Thu Oct 14, 2021 9:02 pm

4. I have tried a higher EPR setting but I was kind of hoping that the lower EPR would have enough pressure keep my nasal passages open.

Why?

mjastro wrote: ↑

Thu Oct 14, 2021 9:02 pm

5. I have not tried a higher minimum. My prescription was for 6 and 15. During the hours of waiting to fall asleep, 6 didn't seem like enough so I bumped it up. Can't remember why I lowered the max.

Prescriptions are very often wrong. Lowering the max is *usually* the wrong thing to do.

mjastro wrote: ↑

Thu Oct 14, 2021 9:02 pm

The first round of trying to use the machine I felt like I was being woken up when the pressure would rise.

You *are* waked up by the breathing problems that make the pressure rise, then you woke up and blamed the pressure rise on waking you up.

prevent the breathing problems, it'll prevent the wakeups.

Yeah, I don't know why I have several of these settings. I'm open to changing them. I really don't know what they do. I mean I know on paper but I don't know how it would affect me. Like a higher EPR means that there's more difference in pressure between breathing in and breathing out. If having it at 1 works, what would more do? I rarely if ever seem to hit the 14 max so why I lowered that probably doesn't matter at this point. Could easily raise it back to the 15, or higher.

I didn't think I had breathing problems, but my husband was very sure I did! And he was right, so I do need to try to prevent them. My AHI score from the sleep test wasn't all that high (10 maybe? I can't remember exactly) but I had a desaturation that went down into the 70s and another in the 80s I know enough to know we don't want that!

mjastro wrote: ↑

Thu Oct 14, 2021 10:01 pm

Yeah, I don't know why I have several of these settings. I'm open to changing them. I really don't know what they do. I mean I know on paper but I don't know how it would affect me. Like a higher EPR means that there's more difference in pressure between breathing in and breathing out. If having it at 1 works, what would more do? I rarely if ever seem to hit the 14 max so why I lowered that probably doesn't matter at this point. Could easily raise it back to the 15, or higher.

I didn't think I had breathing problems, but my husband was very sure I did! And he was right, so I do need to try to prevent them. My AHI score from the sleep test wasn't all that high (10 maybe? I can't remember exactly) but I had a desaturation that went down into the 70s and another in the 80s I know enough to know we don't want that!

a higher EPR will actually *drop* the pressure between breaths, which is the pressure that holds your airway open and prevents apnea, however the pressure swing (called "pressure support" when talking about bilevel machines) can help cut down on flow limitations.

Flow limitations, which you have a lot of, make breathing harder, think of it like trying to breathe through a straw, you can, and you can take full breaths, but it's more work, and you'll probably start getting tired fairly quickly. Then think of spending the whole night like that.

One of the reasons that your pressure isn't going higher is that you're in 'for her' mode, which caps the pressure response to certain events. If you switched to just Autoset mode, the pressure would go up higher, to try and open up your airway more, and you'd likely be hitting your current max pressure.

I don't like lowering the max pressure from 20 except in very rare circumstances, because all that is going to do is possibly prevent the machine from doing what it needs to do in order to stabilize your breathing.

palerider wrote: ↑

Wed Oct 13, 2021 11:26 pm

Iseestars wrote: ↑

Wed Oct 13, 2021 11:10 pm

Your machine measures the leaks in percentages,

No, it doesn't. It measures leak in liters per minute, which is what it says on the chart.

Iseestars wrote: ↑

Wed Oct 13, 2021 11:10 pm

above 30% the leaks are bad and a sad or red face appears on the display.

No, if the machine is in large leak territory (more than 24lpm) for over 30% of the night, then you get the frowny face.

Iseestars wrote: ↑

Wed Oct 13, 2021 11:10 pm

Big leaks are bad because they make your therapy not to be the most effective.

This is also wrong. normal 'large leaks' make it so the machine can't differentiate between central and obstructive apneas, extremely large leaks can affect the machine's ability to maintain therapy pressure.

Iseestars wrote: ↑

Wed Oct 13, 2021 11:10 pm

However, each person is different in my case leaks between 20 and 30 percent already could give me headaches

No, they can't.

I only helped a new user, the information that I quoted from other users is clear for someone with little experience. I don't know too much but I know the basics I can help someone.

Of course the machine measures leaks in liters per minute, but her machine (Resmed airsense for her) shows percentages. Frown face is the same as what I tried to say, sure the user understood.

More than 24lpm or for over 30% is the large leak threshold. It is the same I meant to say, the user understood.

Big leaks of course affect your therapy, that's something has been discussed here and there plenty. And as you say, they could affect the readings of the machine as well (centrals and obstructive and I believe hypopneas as well).

How can you say that large leaks in my case don't give me headaches? How do you know?

Each person is different; in my case large leaks are prone to give me headaches because the pressure is not correct or effective, I have discussed this with my sleep doctor. When people start with headaches due apnea, even before using a cpap machine, headaches occur because their oxygenation levels when sleeping drop below normal; in those situations the brain arteries seek to dilate pushing to obtain more oxygen.

For example, neuropathies in the hands of apnea patients are caused by this factor. In the same way, a headache (in the upper part of the head) during the day can occur when therapy and pressure are not effective for the same reasons, low oxygen levels that were not too low but affected you anyway could give you a headache. And again, each person is different; every night is different even for the same patient.

Finally, large leaks are not the only causes of apnea headaches as you know, other factors may be present such as rhinitis or deviated septum, or some more such as specific morphologies of the neck, palate and throat that cause your airways to be partially closed

Iseestars wrote: ↑

Fri Oct 15, 2021 7:41 am

Of course the machine measures leaks in liters per minute, but her machine (Resmed airsense for her) shows percentages. Frown face is the same as what I tried to say, sure the user understood.

Actually the machine measures leaks in L/minute still yet.
What the smiley face represents is a measurement of the TIME SPENT in large leak.
Big difference between L/min and time spent over 24 L/min. Two totally different data points.
The machine still reports a 95% leak number on the face of the machine as well as the smiley/frowny face.

While you may THINK the person you responded to fully understood what you think you conveyed.....don't ever assume anything when it comes to what someone else might glean from your thoughts.

Your post was full of stuff that was incorrect and/or confusing to me and I know this stuff backwards and forwards and inside and out. So does Palerider and we have this thing that we think is critically important in that information needs to be accurately described.

While we appreciate your desire to help.....to be honest it actually muddied the waters more.
Might be more beneficial to you and others if you learn correct terminology and how things work and not ASSUME that people can read your mind and know what you think you meant. I can assure you that if you confused me....you confused others as well.

As for leaks causing headaches.....not unless the leaks were so bad that there was a truckload of events which messed up the oxygen levels in the blood and even then it is the events that were the cause.
People can have truckloads of events and oxygen level imbalance and not have any leaks at all.
Leaks may or may not cause events to happen and be a factor in oxygen levels....but the actual cause is the events no matter what causes the events.

You are correct about one thing though......lots of things can cause headaches.

As to Pugsy's questions:
1. Congestion issues. Well yes and no. During the day I do not feel congested and I breathe through my nose just fine. When I lie down I notice that sleeping on my side the "downhill' side begins to feel blocked. Turn over and "stuff" deep in my sinuses moves to the other side. My husband says his CPAP opens up his airways when he's congested. That is not happening here. I do use a nasal saline spray before bed and I've thought that I should try a sinus rinse, but a long time ago I had a facial x-ray and the report said that there were bony structures in my maxillary sinus and since then I've been a bit terrified of doing a neti pot and having the water get stuck. Probably seeing an ENT would be the only answer? I do find that breathing the humidified CPAP air means that I wake up feeling less dry in my sinuses. A positive!

2. I sleep through the leaks and often wake up thinking I have slept really well and then when I check Oscar I've been in large leak for much of the time I was asleep.

3. I tried the regular mode during one of my lying in bed trying to sleep periods and I didn't think I liked it as well as the for Her mode. I have not slept in the regular mode.

4. I have tried a higher EPR setting but I was kind of hoping that the lower EPR would have enough pressure keep my nasal passages open. Dumb idea, probably.

5. I have not tried a higher minimum. My prescription was for 6 and 15. During the hours of waiting to fall asleep, 6 didn't seem like enough so I bumped it up. Can't remember why I lowered the max.

The first round of trying to use the machine I felt like I was being woken up when the pressure would rise. Like I felt like the mask was being blown off my face. I haven't felt that way at all this time around. It's gone so much better, although I still would like to sleep better and I still feel very tired in the afternoon. But a lot of that seems to be the delayed onset stuff. The melatonin .5mg that was once life-changing doesn't always work anymore. And when I use it I often wake around 4 (after 4-5 hours of sleep) and it can take up to an hour to fall back asleep. And often I take off the mask at that point because my face feels oily and the mask feels sticky. Or at least I think it does? Those last 2 hours of sleep without the mask are like my reward for doing this and I know that's a terrible attitude. Baby steps.

1...what you are describing sounds like what is referred to as the nasal cycle and while normal ....extremely annoying and no real effective plan of attack to resolve the annoyance
Read this
https://en.wikipedia.org/wiki/Nasal_cycle

2...You told me you slept through the leaks but didn't tell me how you feel during the day. We do all this cpap stuff to improve our sleep AND how we feel during the day so how we feel in general is an important subjective feeling to measure.

3...You didn't give regular mode a fair trial if all you did was try it briefly while awake because....while awake any difference you felt in what it did was all in your head. It simply doesn't do anything differently while awake. I have used both modes myself so I know this for a fact. The for Her mode doesn't do anything differently UNTIL you fall asleep and then the special algorithm kicks in. NOW...that said...if your machine is responding to nasal cycle congestion it might change what it does while you are awake and you would feel that but from your reports I don't see that happening unless it is taking you close to an hour to fall asleep. Look at your reports....the pressure stays the same until there is a marked/huge increase and then essentially it goes up and stays up for the most part. The machine is essentially setting a new minimum pressure....and it is going up into the area where the for Her mode is sometimes not the best option for some people to be using. The for Her mode is supposed to be "gentler" and in some people "gentler" is not the best thing...more tough love is needed.

I actually think that a trial in regular auto mode would be a good experiment for you to try. I don't know for sure if you need more "tough love" or not but I do think a full night trial experiment is needed to get an idea if those flow limitations are any sort of potential issue or not...as in affecting sleep quality.
We are seeing RERAs flagged which potentially alerts us to the fact that you are having respiratory/airway related events causing arousals which "could" impact sleep and how you feel (which explains why the how you feel question is important).
You may or may not remember those arousals but they potentially could mean sub optimal sleep quality in general.

4...EPR setting...mainly a comfort setting...not used for congestion treatment so get that idea out of your head.
BUT more EPR sometimes will help reduce FLs as long as the FLs on the graph are airway related and not nasal congestion related. Again...an experiment worth trying at some point.

5...If you never hit your maximum...it really doesn't matter what the maximum might be but since it doesn't matter anyway since it does nothing to affect anything anyway it doesn't hurt things to set it at 20 or even 15 (if you never go there). I am not so concerned about a max that never gets reached as I am concerned about the minimum pressure, which does the bulk of preventing airway collapses, and the machine essentially sets a brand new minimum right off the bat once someone falls asleep.
There is a reason it goes up and essentially stays up....is it actual flow limitations in the airway itself or is it trying to battle flow limitations from nasal congestion????? That is the million dollar question and not an easy question to answer.
More pressure won't fix nasal congestion issues and about the only way to figure out the source is to try to reduce the FLs in the standard ways and see if they respond or not and then you get your answer.

All this involves a lot of experiments and understanding of what you are seeing and doing and also monitoring how you feel and sleep as well.
Huge steep learning curve which we will be gladly to help you get through if you want to try to learn and with the understanding we can move at whatever pace you are comfortable moving.

All depends on how much work you want to do and WHY you might want to do the work.
If sleeping soundly for the most part and feeling quite decent during the day....I don't know that I would want to do the work if I were in your shoes.
As to the question originally....how much is the time in large leak affecting therapy....
1...the only potential effect will be the time in large leak itself and for the bulk of the night (even the common bad leak % numbers) you are well within what the machine can and will compensate for. For maybe 20% of the night things are a bit iffy and it really only gets iffy when you go above around 30 L/min line. The main thing we worry about is the leak so big the machine is missing flagging of events due to it simply not sensing a problem.
30 minutes spent in extremely large leak isn't the end of the world and it doesn't negate the good that 80% or 90% of the rest of the night has accomplished with leak numbers that are very manageable.

Your baseline leak isn't at 0.0 either....which forces sort of a false lower threshold to start with. Long explanation that I can't go into that right now.

So to conclude this novel....if it were me and I was sleeping good and feeling good during the day then I wouldn't worry about the time in large leak as long as I didn't start seeing massive prolonged periods over 35 L/min spent in large leak territory.

I would still likely do some experiments with setting tweaks to see if I could clean up the reports a little but that's me and I like experiments. It's not everyone's cup of tea though and a lot will depend on how a person feels in general.
That's where you have to take a hard look at things.

Iseestars wrote: ↑

Fri Oct 15, 2021 7:41 am

I only helped a new user, the information that I quoted from other users is clear for someone with little experience. I don't know too much but I know the basics I can help someone.

You aren't helping a user when you're giving them incorrect information.
Let people who DO know answer their questions, and continue learning yourself.

Iseestars wrote: ↑

Fri Oct 15, 2021 7:41 am

Of course the machine measures leaks in liters per minute, but her machine (Resmed airsense for her) shows percentages. Frown face is the same as what I tried to say, sure the user understood.

She's referring to an Oscar chart, and you start talking about what her machine shows, don't be "sure the user understood" when you're saying things that are misleading or confusing.

Iseestars wrote: ↑

Fri Oct 15, 2021 7:41 am

More than 24lpm or for over 30% is the large leak threshold. It is the same I meant to say, the user understood.

No, 30% is not the large leak threshold,

Iseestars wrote: ↑

Fri Oct 15, 2021 7:41 am

Big leaks of course affect your therapy, that's something has been discussed here and there plenty. And as you say, they could affect the readings of the machine as well (centrals and obstructive and I believe hypopneas as well).

Large leaks do not necessarily affect therapy. it is not a given, it is not a certainty, do not portray it as such.

Iseestars wrote: ↑

Fri Oct 15, 2021 7:41 am

How can you say that large leaks in my case don't give me headaches? How do you know?

Each person is different; in my case large leaks are prone to give me headaches because the pressure is not correct or effective,

Large leaks don't cause the pressure to be wrong or not effective.

Iseestars wrote: ↑

Fri Oct 15, 2021 7:41 am

I have discussed this with my sleep doctor.

Because doctors never get anything wrong, or perhaps you're misunderstanding/misrepresenting what the doctor may have said, like you're confusing large leaks, how they are measured and what effect they have.

Iseestars wrote: ↑

Fri Oct 15, 2021 7:41 am

When people start with headaches due apnea, even before using a cpap machine, headaches occur because their oxygenation levels when sleeping drop below normal; in those situations the brain arteries seek to dilate pushing to obtain more oxygen.

No, that is NOT the cause of headaches, hypercapnia is thought to be the cause headaches from sleep apnea, and a simple large leak is not going to affect your ventilation levels, nor will it affect therapy pressure. leaks have to be truly massive (well over 100liters per minute) before they start to affect therapy pressure. None of the OPs leaks are anywhere near that level.

As to yours, if you have a Resmed machine, then look at the mask pressure chart and see if your leaks are so bad that they're affecting the measured therapy pressure.

Iseestars wrote: ↑

Fri Oct 15, 2021 7:41 am

For example, neuropathies in the hands of apnea patients are caused by this factor. In the same way, a headache (in the upper part of the head) during the day can occur when therapy and pressure are not effective for the same reasons, low oxygen levels that were not too low but affected you anyway could give you a headache. And again, each person is different; every night is different even for the same patient.

The only thing you've got right in that paragraph is that people are different.

Iseestars wrote: ↑

Fri Oct 15, 2021 7:41 am

Finally, large leaks are not the only causes of apnea headaches as you know, other factors may be present such as rhinitis or deviated septum, or some more such as specific morphologies of the neck, palate and throat that cause your airways to be partially closed

Large leaks aren't the cause of headaches, period, but you're just undermining your own argument with that last paragraph.

Iseestars wrote: ↑

Fri Oct 15, 2021 7:41 am

I don't know too much

Let's just focus on that, and not try to 'help' people with things you don't yet understand.

Nasal cycle. Who knew! Glad to know it's normal if annoying.

Thanks for the suggestions. I will give the regular mode a try. And then see about further tinkering. I'll also put the max up just in case the machine wants to do something there. And I will keep this thread so I can go back to you all's advice as I try things.

I generally feel very tired in the afternoons and it hasn't improved a lot over the month trying to use the CPAP, but my sleep has been pretty fragmented. BUT! Last night was really good! I slept about 7 hours straight!

palerider wrote: ↑

Thu Oct 14, 2021 11:53 pm

One of the reasons that your pressure isn't going higher is that you're in 'for her' mode, which caps the pressure response to certain events. If you switched to just Autoset mode, the pressure would go up higher, to try and open up your airway more, and you'd likely be hitting your current max pressure.

you know, one of the great joys of being me is that i'll read something here and then not think about it until MUCH later! that's followed up by trying to FIND it again.

any who, could you say some more about this? this may be the first time i've read it. which events does the for her mode cap?

or if you have a link, i'd like to read more about it.

tia