Rocky start with APAP - what next?

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
zleeby
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Rocky start with APAP - what next?

Post by zleeby » Mon Oct 31, 2022 8:49 am

Hey all - diagnosed with OSA recently after years of unexplained fatigue. Was able to pick up an APAP right away, but my journey with the machine has been quite hectic thus far. Would highly appreciate any insight on figuring out my optimal setup!
PSG results: https://imgur.com/a/ChHm3Ha (so sorry for low quality! all I could get from the clinic was a blurry printout of the report)
Profile: male, rather young, BMI is normal but closer to underweight than overweight.
Known conditions:
- Allergic rhinitis. Got retested this month and was allergic to cats, dogs, and several types of grass/trees. Dust and mold were negative. I've taken Zyrtec daily for many years, and I notice only very mild symptoms during the worst of allergy season (immediately they get far worse if I skip the medicine one day).
- Acid reflux. Getting evaluated for a diagnosis, but I'm quite confident in this one based on symptoms. Feel a tighter chest after most meals, worse with particular foods.
Other notes: I take Adderall for ADHD-like symptoms that may actually be a result of OSA. Started a little under a year ago. Helps alleviate fatigue for a while. Wondering if it could be worsening my sleep though.
Therapy thus far
10/20 - 10/24: Started on Resvent iBreeze APAP, pressure range 5-15. Given a nasal pillow mask. First 2 nights I lasted ~4 hours with the mask, last 3 it was around 6-7 hours. Consistently woken up 1-3 times per night by the mask starting to fall out of my nose and leak. Despite these annoyances, though... I was actually beginning to feel much more refreshed! If my pre-diagnosis sleep felt like a 2/10, by the end of this period it was more like a 6/10.
10/25 - 10/27: After talking with the clinic about leaking in the night, I was given a full nasal mask since it would be more secure. Immediately stopped feeling any benefits from the machine. Looked into my data and saw big spikes in leakage despite the mask feeling secure. For instance, here was the night of 10/26: https://i.imgur.com/GM1QPj8.png . I suspected that I might be opening my mouth in the night, supported by the fact that my mouth would be pretty dry when I woke up.
10/28 - 10/30: Was given a full face mask to account for the potential mouthbreathing. Sure enough, leakage was essentially entirely curbed. However, I'm still not feeling much benefit at all. I noticed that the machine was recording very few Apneas or Hypopneas, but lots of Flow Limitations (around 10/hr). Last night I tried sleeping with my minimum pressure raised to 7 since that's around the peak that the machine would rise to. Here are the graphs from last night https://i.imgur.com/INTKfhb.png , and here are the recorded events https://i.imgur.com/GG465KZ.png .
Again, any insight on how to progress from here would be much appreciated. I'm desperate to curb this fatigue, especially after the little taste of wakefulness I felt while on the pillow mask. Happy to answer any further questions as well. Thanks for reading!

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robysue1
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Re: Rocky start with APAP - what next?

Post by robysue1 » Mon Oct 31, 2022 9:45 am

Welcome to the forum.

Thanks for posting the data.

I do have one question: What did the leaks look like with the nasal pillows mask?

The reason I'm asking is that from your description, your current main problems seem to be a combination of leaks and mask (dis)comfort. In other words, it seems like you were getting better results subjectively with the nasal pillows mask, but you were also having wakes where you were struggling with leaks. The fact that you only made it to 4 hours on your first two nights is not significant; the fact that you made it the whole night the next three nights is very significant and points to the idea that when you get the kinks worked out, you should benefit from xPAP therapy.

The leak data you supplied for the nasal mask is not as bad as you seem to think in terms of the leak line. But the fact is those leaks bothered you. Did the leaks actually bother you during the night? Or did they bother you after you looked at the data and realized there was some leaking going on?

With the full face mask, you've got a great leak line, but you are seeing lots of flow limitations. It's important to ask, how many flow limitations (as well as OAs, Hs, RERAs, etc) did you have when you were using the pillows mask and the nasal mask?

You say you've increased your min pressure to 7cm. That was a reasonable idea. One thing I notice, however, in the data is that there is a huge pressure increase right at the beginning of the night, and then there are no more significant increases after the pressure goes back down. As long as that initial pressure increase didn't bother you, there's probably no need to tweak the pressure settings until you get the combination of (mask comfort and leaks) better sorted out.

In other words, forget about the leaks for just a minute: You reported your best sleep (in terms of how you felt on waking) with the nasal pillows mask. Which of the three styles of mask do you find most comfortable? I would stick with the most comfortable mask and then work on the leak issue rather than using a mask that is not as comfortable, but appears to leak less.

That's just my two cents.
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lynninnj
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Re: Rocky start with APAP - what next?

Post by lynninnj » Mon Oct 31, 2022 10:21 am

I wonder if the poster is sleeping on his back with a FFM whereas with the nasal pillow he was able to sleep more on his side?

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D.H.
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Re: Rocky start with APAP - what next?

Post by D.H. » Mon Oct 31, 2022 11:03 am

If the first mask worked better for you, try going back to it.

Whatever the reports show, how you feel is even more important.

Note also that most patients feel relief over time, not the first week (I'm the exception).

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ozij
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Re: Rocky start with APAP - what next?

Post by ozij » Mon Oct 31, 2022 11:12 am

zleeby wrote:
Mon Oct 31, 2022 8:49 am
Consistently woken up 1-3 times per night by the mask starting to fall out of my nose and leak.
That's not supposed to happen if your mask is the correct size, and you're wearing it properly.
Which mask was it, and what size pillows?

[Edited typos...]

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Last edited by ozij on Mon Oct 31, 2022 12:50 pm, edited 1 time in total.
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Jlfinkels
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Re: Rocky start with APAP - what next?

Post by Jlfinkels » Mon Oct 31, 2022 12:47 pm

How does one get to Carnegie Hall? Practice, practice, practice.

Same for CPAP. It takes time to get used to the little beastie attached to your face and the feeling of air being gently blown into your nose/mouth. Personally it took me about 6 months to really feel the benefits on a regular basis. I was given nasal pillows (ResMed P10) when I started, but no instructions. After fighting it for a month or so, I went through a number of different masks. I finally find this forum and with solid advice from folks (looking at you Pugsy, PaleRider, and Zonker), I went back to the P10’s and made small adjustments one at a time. There was no “Aha” moment, just a gradual adaptation to this new normal.

Give yourself time and understand it is a process. There is no magic or pixie dust to magically make it work, though some are fortunate to feel the benefit right away. Ask question here as needed, the folks are supportive and gracious with their time.
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zonker
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Re: Rocky start with APAP - what next?

Post by zonker » Mon Oct 31, 2022 12:51 pm

Jlfinkels wrote:
Mon Oct 31, 2022 12:47 pm
(looking at you Pugsy, PaleRider, and Zonker),
Image

good lord!

hope you were looking mainly the first two.
:lol: :lol: :lol:
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but that's enough about them.
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loggerhead12
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Re: Rocky start with APAP - what next?

Post by loggerhead12 » Mon Oct 31, 2022 12:54 pm

zonker wrote:
Mon Oct 31, 2022 12:51 pm
Image

good lord!
You've been deified. There's no going back.

We're not worthy.

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zonker
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Re: Rocky start with APAP - what next?

Post by zonker » Mon Oct 31, 2022 12:59 pm

loggerhead12 wrote:
Mon Oct 31, 2022 12:54 pm
zonker wrote:
Mon Oct 31, 2022 12:51 pm
Image

good lord!
You've been deified. There's no going back.

We're not worthy.
Image
people say i'm self absorbed.
but that's enough about them.
Oscar-Win
https://www.apneaboard.com/OSCAR/OSCAR-1.5.1-Win64.exe
Oscar-Mac
https://www.apneaboard.com/OSCAR/OSCAR-1.5.1.dmg

zleeby
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Re: Rocky start with APAP - what next?

Post by zleeby » Mon Oct 31, 2022 5:56 pm

Hey everyone, thanks so much for the thoughtful replies! I'll try to respond to everything that was asked.
robysue1 wrote:
Mon Oct 31, 2022 9:45 am
(1.) What did the leaks look like with the nasal pillows mask? ... Did the leaks actually bother you during the night? Or did they bother you after you looked at the data and realized there was some leaking going on?

(2.) How many flow limitations (as well as OAs, Hs, RERAs, etc) did you have when you were using the pillows mask and the nasal mask?

(3.) One thing I notice, however, in the data is that there is a huge pressure increase right at the beginning of the night, and then there are no more significant increases after the pressure goes back down. As long as that initial pressure increase didn't bother you, there's probably no need to tweak the pressure settings until you get the combination of (mask comfort and leaks) better sorted out.

(4.) You reported your best sleep (in terms of how you felt on waking) with the nasal pillows mask. Which of the three styles of mask do you find most comfortable?
  1. I put together an album of my leak/event graphs for every night. https://imgur.com/a/NNOyDlZ (Pardon the sloppy image editing; I had to crop stuff and move it around to make both graphs appear in the same image). Across the 5 nights with the pillow mask, I did ultimately remove the mask each night after waking prematurely, and on some of those nights I recall waking up multiple times. I would also say, I felt the sensation of leaking upon most (but not all) of those awakenings. All that to say, yes, the leakage did bother me before I looked at the data.
  2. See the album above. I definitely see a substantial rise in Flow Limitations after starting the full face mask. Do you see anything else of note?
  3. That pressure increase was actually a little before I'd fallen asleep. I think my breathing gets a lot lighter before I ultimately doze off. I wasn't very bothered, but I will say, higher pressures were more uncomfortable with the pillow mask and the nasal mask. Exhaling in particular felt difficult.
  4. Pillow mask was the most comfortable. Nasal mask and full face mask are irritating with how much I have to tighten them before no air comes out. Exhaling with the pillow/nasal masks was somewhat uncomfortable, but manageable.
lynninnj wrote:
Mon Oct 31, 2022 10:21 am
I wonder if the poster is sleeping on his back with a FFM whereas with the nasal pillow he was able to sleep more on his side?
Before starting CPAP, I would always sleep on my stomach. Falling asleep on my back always felt harder, and falling asleep on my side felt (and still feels) absolutely impossible. Just something about that position is supremely uncomfortable to me (when awake, at least).
After starting CPAP, I've opted to fall asleep on my back each night. I've made some attempts at stomach sleeping, but it feels like turning my head sideways disrupts the airflow from the machine somehow. Whether or not I've flipped onto my side while asleep with any of the masks, I have no idea.
ozij wrote:
Mon Oct 31, 2022 11:12 am
That's not supposed to happen if your mask is the correct size, and you're wearing it properly.
Which mask was it, and what size pillows?
The pillow mask was the ResMed AirFit P10. It seems I was using the small pillows. However, when fitting myself for the Evora Full Face, I discovered that I actually have a fairly large nose, and I determined that the large seal was the best fit for me. So, I think you're onto something here...

It seems the consensus is that I ought to switch back to the pillow mask since I found it the most comfortable and saw easily the greatest benefit from it. I'll also search for guides on determining the proper pillow size since it's likely that the small pillow wasn't right for me. Tomorrow I'll report back if something goes horribly wrong; otherwise I'll reassess my situation after 2-3 days. Happy to respond to any further questions/comments in that time. Thanks again for all the feedback, everyone!

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ozij
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Re: Rocky start with APAP - what next?

Post by ozij » Mon Oct 31, 2022 10:06 pm

zleeby wrote:
Mon Oct 31, 2022 5:56 pm
It seems the consensus is that I ought to switch back to the pillow mask since I found it the most comfortable and saw easily the greatest benefit from it. I'll also search for guides on determining the proper pillow size since it's likely that the small pillow wasn't right for me.
Resmed P10 masks when supplied in the original box come with all three pillow sizes. If you have them, just try the next size up.
zleeby wrote:
Mon Oct 31, 2022 5:56 pm
Pillow mask was the most comfortable. Nasal mask and full face mask are irritating with how much I have to tighten them before no air comes out. Exhaling with the pillow/nasal masks was somewhat uncomfortable, but manageable.
Fit the masks lying down, and they do not have to that tight at all.
If you can't get a mask not to leak, it may not be the right shape for your face. Fitting masks to faces in no different than fitting shoes to feet. It's not only about size.
zleeby wrote:
Mon Oct 31, 2022 5:56 pm
I definitely see a substantial rise in Flow Limitations after starting the full face mask. Do you see anything else of note?
Reseach has shown that some people need higher pressure when they use an FFM. Of course, research being research, they use a fancy term for it: "oronasal" -- since these masks cover both your oral cavity and your nasal cavity at the same time....

https://pubmed.ncbi.nlm.nih.gov/8082358/ - scroll down, find "similar articles" on the right side, click on that and you'll get to newer papers.
So basically, if you have no choice but to use an FFM, you may need your pressure to be slightly higher.

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zleeby
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Re: Rocky start with APAP - what next?

Post by zleeby » Tue Nov 01, 2022 4:29 pm

Hey everyone! Switched back to the pillow mask last night. I went up to the medium pillow size and tightened the headgear straps stronger than before. I'm happy to report that I kept the mask on for the whole night! I woke up prematurely once or twice, but the mask never came loose. And my wakefulness upon getting up, while still far from perfect, was definitely improved.
Here's the data from last night. Am I right in concluding that these leaks are the result of mouthbreathing? I did wake up with a very dry mouth, and the mask itself was still secure whenever I was consciously awake. If this is correct, then what should I do about it? I definitely don't want to switch back to the full face mask since this one feels so much more comfortable and seems to work much better.
I've heard of mouth-taping and chin-strapping before. My worry with those strategies is, what happens if I need to breathe through my mouth? I would think that if I'm opening my mouth in the night, it's because my ability to breathe through my nose has been weakened somehow. So if I take measures to keep my mouth shut, but I'm suddenly unable to breathe through my nose in the night, could that be dangerous?

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Re: Rocky start with APAP - what next?

Post by Julie » Tue Nov 01, 2022 5:08 pm

No. You'll wake up... your body's need to breathe is very strong and you'll wake up no matter what.

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Re: Rocky start with APAP - what next?

Post by robysue1 » Tue Nov 01, 2022 5:16 pm

zleeby wrote:
Tue Nov 01, 2022 4:29 pm
Hey everyone! Switched back to the pillow mask last night. I went up to the medium pillow size and tightened the headgear straps stronger than before. I'm happy to report that I kept the mask on for the whole night! I woke up prematurely once or twice, but the mask never came loose. And my wakefulness upon getting up, while still far from perfect, was definitely improved.
Here's the data from last night. Am I right in concluding that these leaks are the result of mouthbreathing?
Your leaks are bad, but not yet into the horribly bad range. Still, you are going to have to do something.

Since you say:
I did wake up with a very dry mouth, and the mask itself was still secure whenever I was consciously awake.
That's a pretty good indication that your mouth was open during the night. Whether you were breathing through your mouth or your mouth was just hanging wide open is different question.

One thing that can cause the mouth to pop open is just plain old muscle relaxation during sleep.
If this is correct, then what should I do about it? I definitely don't want to switch back to the full face mask since this one feels so much more comfortable and seems to work much better.
I've heard of mouth-taping and chin-strapping before. My worry with those strategies is, what happens if I need to breathe through my mouth? I would think that if I'm opening my mouth in the night, it's because my ability to breathe through my nose has been weakened somehow. So if I take measures to keep my mouth shut, but I'm suddenly unable to breathe through my nose in the night, could that be dangerous?
First thing to try is to pay attention to where you keep your tongue during the daytime when you are not actively eating, drinking, or talking. It should be touching the roof of your mouth right behind your front teeth. That's where the tongue is supposed to be when you aren't doing anything with your mouth. Practice keeping it there all day. If you can train the tongue to stay in that position, there's a good chance it will stay there even during the night. And that will minimize the tendency of the mouth to pop open during the night. It may also minimize the leaks if your mouth sags open because when the tongue is in the correct position, it basically blocks the oral cavity off from the nasal cavity.

Next, you need to remind yourself that muscle relaxation is a much more likely cause of your mouth coming open while you are sleeping than an actual need to breathe through your mouth, particularly if you comfortably breathe through your nose during the daytime.

If you can't get the leaks a bit better under control with just trying to train the tongue to stay in place you can revisit the idea of chin straps, cervical collars, and taping at some point in the future. In all of these methods, the idea is not to firmly prevent the mouth from ever being opened during the night; the idea is to make it just a bit harder for the muscles around the mouth to relax to the point where the mouth just comes open with no need to breathe through it. In other words, none of these methods prevent you from opening your mouth, but they all help to discourage the mouth from just sagging open on its own.
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zleeby
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Re: Rocky start with APAP - what next?

Post by zleeby » Tue Nov 01, 2022 7:24 pm

robysue1 wrote:
Tue Nov 01, 2022 5:16 pm
First thing to try is to pay attention to where you keep your tongue during the daytime when you are not actively eating, drinking, or talking. It should be touching the roof of your mouth right behind your front teeth.
It seems to me that my tongue is in this position by default. I suppose tonight I can check and see if it goes anywhere else when I’m lying in bed, though. Are there any other factors that might be pushing me to open my mouth?

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