Rocky start with APAP - what next?

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

Post by lynninnj » Tue Nov 01, 2022 7:31 pm

zleeby wrote:
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?
Sinus congestion. Are you using heated hose and humidifier? What is climate where you live?

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robysue1
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Re: Rocky start with APAP - what next?

Post by robysue1 » Tue Nov 01, 2022 8:51 pm

zleeby wrote:
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?
If you breathe through your nose all the time when you are awake, the most likely reason your mouth might open when you are asleep is muscle relaxation. Out of curiosity: Do you do a lot of drooling at night? That can be an indication that your mouth muscles are simply relaxing and allowing the mouth to open up while sleeping.

If you are really sensitive to when your normal "nasal cycle" switches the dominant nostril you are breathing through, you may feel like breathing through your nose is difficult and you might open it up when you are awake and trying to get to sleep.

If you are severely congested, then mouth breathing (as opposed to just opening your mouth) can be an issue. For most people who naturally breathe through their nose during the day, they know when congestion is an issue. If you often have congestion problems, then paying attention to nasal hygiene may help. In other words, make ample use of things like saline nasal sprays and neti pots to help with the congestion. If the congestion is due to allergies and you can take an antihistamine that is effective, that helps. If you can tolerate using a steroid nose spray like Flonase, that helps. Basically the idea is to get the nose as clear as you can before going to bed.

If you wake up feeling more congested than you did when you went to bed after using your CPAP, that's a sure sign that your nose is not happy with the current humidifier (and heated hose) temperature settings. But the solution to this problem is not as simple as "turn up the humidifier/hose temp": Some people's noses want to be drenched in moisture and not enough humidity can dry them out and cause congestion. Others prefer a drier environment and too much humidity can irritate them and cause congestion. Likewise, some people's noses don't mind warm air coming through the hose. Other people's noses don't like warm air at all. But in either case, if your nose is bothered by the temperature of the air, then it can get irritated and the irritation can lead to congestion.

If you suspect that using the CPAP is causing or aggravating a congestion problem, you have to be willing to experiment in order to figure out what is wrong. That ideally means changing one variable at time and seeing what the result is over the course of a few days (unless the result is a clear disaster.)

One way of making an initial guess as to whether you need to increase or decrease the humidity setting is to consider what happens when you take a hot shower: Does the steam seem to relieve the congestion or make it worse?

If it helps, then consider increasing the humidity setting a bit. If that doesn't help, increase the humidity setting a bit more. Keep increasing the humidity until the nose is happy or you start to get rainout problems that you find intolerable. In that case, you have to increase the hose temperature a bit to see if that ends the rainout without making the nose feel worse.

On the other hand, if taking a hot shower doesn't help your congestion, then decrease the humidity and see if the nose is any happier. Keep decreasing the humidity a little at a time until your nose feels dried out (then you've gone to far) or your nose is actually happy and you are not waking up congested any more.

Finally, I'll remind you that while the leak line you posted (at https://i.imgur.com/H3P8ETD.png) looks bad, it's actually not horrible. If you looked at your machine's data on the LCD, I'm pretty sure Mr. Green Smiley Face showed up in the Mask Fit: It's clear that your 70% leak level was under 24 L/min, and in fact I wouldn't be surprised if your 95% leak number for this night was in the mid teens. And that means that from a therapy point of view, you don't really need to worry too much about these leaks. Sure, it would be great if you had a perfect leak line all night long, but if the only way you can achieve that is by using a mask that you don't want to use, then you really need to ask the question, "Is fixing the leaks worth the trouble?"

But if these leaks are waking you up at night or if you are waking up with a very dry mouth or nose in the morning, then addressing the leaks does need to be done. Since you don't want to go back to a full face mask and you are not interested (yet) in chin straps, cervical collars, or taping, then I'd start by looking at nasal hygiene: Do what you can to minimize the congestion before you go to bed, and experiment with the humidity and temperature settings to see if your nose wants more or less humidity and heat than it is currently getting. Since you breathe through your nose during the daytime, its reasonable to believe that if you can find a humidity setting that makes the nose happy, your "mouth leaks" will be reasonably short and small enough (i.e. less than 24 L/min) to not affect therapy and in the long run, they may also not be severe enough to wake you up every night.
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zleeby
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Re: Rocky start with APAP - what next?

Post by zleeby » Wed Nov 02, 2022 11:54 am

Hey everyone! Here's last night's data. Sleep was about the same as yesterday: woke up consciously a couple times, but the mask stayed secure, and I feel just a bit better than usual.
lynninnj wrote:
Tue Nov 01, 2022 7:31 pm
Sinus congestion. Are you using heated hose and humidifier? What is climate where you live?
The humidity on my machine is set to 3 (the max is 8). Doesn't seem like there's a heated hose option. Where I live, the summers are pretty hot, but the winters aren't especially cold.
robysue1 wrote:
Tue Nov 01, 2022 8:51 pm
(1.) Out of curiosity: Do you do a lot of drooling at night? That can be an indication that your mouth muscles are simply relaxing and allowing the mouth to open up while sleeping.

(2.) If you are severely congested, then mouth breathing (as opposed to just opening your mouth) can be an issue. For most people who naturally breathe through their nose during the day, they know when congestion is an issue. If you often have congestion problems, then paying attention to nasal hygiene may help. In other words, make ample use of things like saline nasal sprays and neti pots to help with the congestion. If the congestion is due to allergies and you can take an antihistamine that is effective, that helps. If you can tolerate using a steroid nose spray like Flonase, that helps. Basically the idea is to get the nose as clear as you can before going to bed.

(3.) If you wake up feeling more congested than you did when you went to bed after using your CPAP, that's a sure sign that your nose is not happy with the current humidifier (and heated hose) temperature settings. But the solution to this problem is not as simple as "turn up the humidifier/hose temp": Some people's noses want to be drenched in moisture and not enough humidity can dry them out and cause congestion. Others prefer a drier environment and too much humidity can irritate them and cause congestion. Likewise, some people's noses don't mind warm air coming through the hose. Other people's noses don't like warm air at all. But in either case, if your nose is bothered by the temperature of the air, then it can get irritated and the irritation can lead to congestion.

(4.) One way of making an initial guess as to whether you need to increase or decrease the humidity setting is to consider what happens when you take a hot shower: Does the steam seem to relieve the congestion or make it worse?

(5.) Finally, I'll remind you that while the leak line you posted (at https://i.imgur.com/H3P8ETD.png) looks bad, it's actually not horrible. If you looked at your machine's data on the LCD, I'm pretty sure Mr. Green Smiley Face showed up in the Mask Fit: It's clear that your 70% leak level was under 24 L/min, and in fact I wouldn't be surprised if your 95% leak number for this night was in the mid teens. And that means that from a therapy point of view, you don't really need to worry too much about these leaks.
First off, thanks so much for your very comprehensive responses! It's quite gracious of you to expend this much time and effort on helping me, but I truly appreciate it.
  1. No, not to my knowledge at least. I don't ever see any drool on my pillow.
  2. I'd say I experience a bit of congestion throughout the day, but nothing severe. Breathing through my nose is always comfortable enough. I do take both an antihistamine (Zyrtec) and a nasal spray (Nasacort) for allergy symptoms.
  3. Yes, I definitely wake up with my nose much stuffier than I went to sleep. This was somewhat true prior to starting CPAP, but it's notably worse now.
  4. I checked in the shower this morning, and I think the congestion relieved a bit in that time. It was hard to tell, though. I do know that I get much less congested in Summer and much more congested in Winter. Could that be an indicator of what humidity level I'd prefer?
  5. I'm curious, how are you measuring leak severity? What would count as a "horrible" leak level?

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Dog Slobber
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Re: Rocky start with APAP - what next?

Post by Dog Slobber » Wed Nov 02, 2022 12:19 pm

zleeby wrote:
Wed Nov 02, 2022 11:54 am
Doesn't seem like there's a heated hose option.

ResVent's don't support heated hoses.

zleeby
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Re: Rocky start with APAP - what next?

Post by zleeby » Thu Nov 03, 2022 8:20 am

Hey everyone! Here's the data from last night. I raised my humidity from 3 to 5. It seems to have made things a little worse in terms of leaks and events... The leakage peaked at nearly 60L/min, compared to just under 35 last night. The episodes of leakage also started earlier in the night, and the 95% figure was 34.5 compared to 17.5 last night. AHI is only marginally greater, but there was a pretty sizable increase in Flow Limitations. And I'm not sure if my sleep felt worse, but it certainly didn't feel any better.
I'm interpreting this to mean that I should try dropping the humidity below 3 tonight. Thoughts?

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Dog Slobber
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Re: Rocky start with APAP - what next?

Post by Dog Slobber » Thu Nov 03, 2022 8:28 am

You can't make a change and then draw meaningful conclusions from one nights data.

CPAP simply has to much variance.

You make a change, leave it for a bit then look for trends.

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robysue1
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Re: Rocky start with APAP - what next?

Post by robysue1 » Sat Nov 05, 2022 8:52 am

zleeby wrote:
Thu Nov 03, 2022 8:20 am
Hey everyone! Here's the data from last night. I raised my humidity from 3 to 5. It seems to have made things a little worse in terms of leaks and events...
But the relevant question is whether the increase in humidity helped the sinus congestion or made the sinus congestion worse.

In other words, you need to focus some attention on making the nose happy as well as making the numbers look "good". As Dog Slobber says, after you make a change in settings, you need more than one night of data to draw meaningful conclusions about how that change affects your therapy.
And I'm not sure if my sleep felt worse, but it certainly didn't feel any better.
I'm interpreting this to mean that I should try dropping the humidity below 3 tonight. Thoughts?
Unless the nasal congestion got worse, I'd leave the humidity set at 5 for the next night or two. Then evaluate what's happening. The leaks are (in my opinion) probably unrelated to changing the humidifier setting. And AHI is going to very a bit from night to night.

If the nasal congestion got worse, however, I'd take that as a sign that the nose is not happy with the additional water vapor in the air. And that's a sign that changing the humidifier back to 3 is warranted.
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zleeby
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Re: Rocky start with APAP - what next?

Post by zleeby » Sat Nov 05, 2022 1:53 pm

Hey everyone! You're right, I really ought to be spending more than a single night with a given set of settings. I'm rather impatient and want to get answers as quickly as possible, but I understand that conclusions drawn from a low sample size are less likely to be accurate, so I will make myself slow down.
Here's the leakage from 2 nights ago, and here's the leakage from last night. I had the humidity set to 2. Also, this might be worth mentioning: before I went to sleep 3 nights ago, I discovered that my machine had the "Mask Type" set to "Nasal" instead of "Pillow". I promptly fixed it, but now I'm wondering, could this change in setting explain why my leaks have consistently been higher and started earlier over the past 3 days compared to the 2 days prior? I know that each mask type has an "expected leak", and the leak graph shows the leakage happening beyond what is expected. Is it possible that while I had the Mask Type set to "Nasal", there was leakage that the graph was missing because it was within the expected leak of a nasal mask (but not of a pillow mask)?
I didn't pay close enough attention to how my nose/mouth felt with the humidity of 5, so I unfortunately can't compare it to how I'm feeling now. Waking up after the past 2 nights with the humidity of 2, my throat has been fairly sore and my nose has been fairly stuffy. I'm also sneezing in the morning more than usual. I think I will bring the humidity up to 5 or 6 either tonight or the next night, and I'll pay careful attention to any difference in how my nose/mouth feels. Thoughts?

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lynninnj
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Re: Rocky start with APAP - what next?

Post by lynninnj » Sat Nov 05, 2022 7:15 pm

Push the humidity too much and you will have wet disrupted sleep. No fun.

Personal observations after a rude awakening 3 nights ago.

Stick with 5 and pay closer attention in the morning to how your throat feels.

jmho

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zleeby
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Re: Rocky start with APAP - what next?

Post by zleeby » Sun Nov 06, 2022 9:12 am

Hey everyone! The end of daylight savings seems to have messed with last night's data... There was an hour-long cut early in the night. I suppose the machine was attempting to adjust for the time change, but instead of jumping back an hour, it jumped forward an hour. Very strange. But I'm going to assume that the recording was still fully accurate and I just have to crop the cut out. So here's last night's data with that cut removed. There's still a tiny cut later in the night - that's because I turned off the machine to use the bathroom.
I had the humidity at 6 last night. I knew there was a risk of rainout as lynninnj pointed out, but I figured there's no way to know if that'll happen until I try. Data aside, my nose definitely felt much less stuffy than with the low humidity, but my throat felt about as sore, and I think my mouth was actually more dry. In terms of sleep quality, though, this morning is easily the best I've felt since the night before I first switched off the pillow mask. The events and leakage seem to match this assessment, both happening less frequently than they have in several nights. But of course, I can't attribute this to the increased humidity just yet - another night or two of data is definitely warranted.

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Re: Rocky start with APAP - what next?

Post by Jlfinkels » Sun Nov 06, 2022 9:33 am

zleeby wrote:
Tue Nov 01, 2022 7:24 pm
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?
As we all tend to do it, don’t overthink it. It takes time to get used to tongue placement and CPAP in general, but you will hopefully soon find it second nature. You need to keep everything relaxed, which happens over time as you get used to using the machine and mask.

One thing to consider is using a soft cervical collar to help keep your mouth closed.
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Re: Rocky start with APAP - what next?

Post by Dog Slobber » Sun Nov 06, 2022 10:26 am

zleeby wrote:
Sun Nov 06, 2022 9:12 am
Hey everyone! The end of daylight savings seems to have messed with last night's data... There was an hour-long cut early in the night. I suppose the machine was attempting to adjust for the time change, but instead of jumping back an hour, it jumped forward an hour. Very strange. But I'm going to assume that the recording was still fully accurate and I just have to crop the cut out. So here's last night's data with that cut removed. There's still a tiny cut later in the night - that's because I turned off the machine to use the bathroom.
ResMed's do not change their clocks according to time changes. The cause of the "hour-long cut" is because computers changed their time, in the middle of the session.

Think of it this way:
  • One goes to bed at midnight.
  • At two the time was moved back to 1:00
  • One gets up 8 hours later
  • But the computer time measures that period as 7 hours and has to map 8 hours of data into a 7 hour time slot.
The same thing happens in spring but then 8 hours of data is mapped into a 9 hour period.

For the most part, time changes occur when most of us are sleeping and there are to time critical things going on. But that's not true with CPAP. The time change occurs smack-dap in the middle of our sleep sessions.

My OSCAR chart shows all 7.5 hours of my sleep session, but my sleep HQ shows only 6.5 hours of data.

zleeby
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Re: Rocky start with APAP - what next?

Post by zleeby » Tue Nov 08, 2022 7:08 pm

Hey everyone! Here's the data from 2 nights ago, and here it is from last night. Pretty big discrepancy here - 2 nights ago was the worst night that I've had with the nasal mask in terms of leaks and events, whereas last night was the best in that regard. I didn't change any settings, so I'm really curious what created such a pronounced difference...

So far, with the humidity on 6, my nose continues to feel less congested, but my mouth is still drier and throat still sorer than before. I've also experienced some bouts of diarrhea... Is that a potential complication of higher humidity, or is it just coincidence? Overall, I'm not really sure what to do with the humidity now. Higher humidity might be creating lower leak levels, but I can't say that with certainty given the volatility of the recent data. And I would say I prefer waking up with a stuffy nose to waking up with a dry mouth and sore throat, but I feel much more refreshed after these nights that have had fewer events. Any thoughts?

Also of note: I've still been using the medium-sized nasal pillows, and what I've noticed is, the left hole fits well in my left nostril, but the right hole seems to just barely fit in my right nostril (which is notably smaller). It seems that if my mask shifts just a little bit, some air starts leaking from the right hole. I've also developed a scab on the right side of my septum right at the entrance to the nostril. I imagine this is... less than ideal, so I think I ought to switch back to the small pillows. I'm curious though, what effect does the pillow size have on the actual therapy? Does a smaller hole mean that more air has to come through to produce the same pressure? And is there anything in the settings I ought to adjust when shifting back down a size?

Finally, since the humidity doesn't seem to be a silver bullet for my mouth leakage, I think I'm ready to try something else to keep my mouth from opening when it doesn't need to. I bought some microporal tape, so I just need a good guide on how to go about mouth-taping safely. Can anyone point me to a good resource?

(PS: @ Dog Slobber, what seems strange to me is that your software subtracted an hour from your data, whereas mine added an hour. But this odd event is easily the least of my CPAP-related worries, lol.)

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robysue1
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Re: Rocky start with APAP - what next?

Post by robysue1 » Tue Nov 08, 2022 7:40 pm

zleeby wrote:
Tue Nov 08, 2022 7:08 pm
Also of note: I've still been using the medium-sized nasal pillows, and what I've noticed is, the left hole fits well in my left nostril, but the right hole seems to just barely fit in my right nostril (which is notably smaller). It seems that if my mask shifts just a little bit, some air starts leaking from the right hole. I've also developed a scab on the right side of my septum right at the entrance to the nostril.
The nasal pillows should not be inside the nostrils.

Or rather, just the very tippy-tip part of the cone should be in your nostrils. And when properly placed, the cones on the nasal pillows really should not be touching the inside of your nose at all.

Is it possible that you are trying to put too much of the nasal pillows cones into your nostrils?

I'm curious though, what effect does the pillow size have on the actual therapy? Does a smaller hole mean that more air has to come through to produce the same pressure? And is there anything in the settings I ought to adjust when shifting back down a size?
When I compare the sizes of the nasal pillows on my Swift FX, the holes in the cones are the same basic size, but the cones are different sizes.
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zleeby
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Re: Rocky start with APAP - what next?

Post by zleeby » Tue Nov 08, 2022 8:21 pm

robysue1 wrote:
Tue Nov 08, 2022 7:40 pm
The nasal pillows should not be inside the nostrils.

Or rather, just the very tippy-tip part of the cone should be in your nostrils. And when properly placed, the cones on the nasal pillows really should not be touching the inside of your nose at all.

Is it possible that you are trying to put too much of the nasal pillows cones into your nostrils?
Right, I didn't mean to suggest that I was trying to stuff the whole cone into the nostril. I was just talking about how well the holes at the tip of the cone fit in. The right cone on the medium-sized pillows definitely makes contact with the inside of my nose.
When I compare the sizes of the nasal pillows on my Swift FX, the holes in the cones are the same basic size, but the cones are different sizes.
I just checked again, and my different pillow sizes with my ResMed P10 definitely have different-sized openings.

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