How much mask leak is normal?

Hi everyone!

I have just started CPAP (December) and have a DeVillbiss auto machine running at a pressure of 12. I have a very high nasal bridge (between my eyes). I have tried about four different masks and find that they all leak, meaning that I tighten the straps so much that I end up with red marks on my nose and forehead. Is this normal? Can anyone suggest a mask that doesn't leak or a way of modifying a standard mask so that it seals properly? The perfect solution would be a tailor-made custom mask, does anyone do these?

Thanks - it's great to have somewhere to go for questions!

Leaks will ruin your treatment. You need to find a mask that you can get to seal. Have you tried a nasal pillow mask? There are some masks with inserts that you boil and then mold to your face, never used one but they are out there. You can check cpap.com to see which ones are available. Some use macks silicone earplugs and roll the silicone into a snake, place it around the seal of the mask and it helps.

Brenda

Leakymask wrote: I tighten the straps so much that I end up with red marks on my nose and forehead.

That MAY be part of the problem. Masks seal by flexing of the silicone skirt. If you crank them down too tight, you lose flex and they actually leak MORE. If the straps leave marks that last more than 1/2 hour, that's a good sign they are too tight.

Before you give up on a mask, try it with the straps much looser than you think they should be, and leaking like a sieve. Then tighten in very small increments...maybe 1/8 in. at a time. (That's basically what the fitting guides for most masks say, too.)

It's counter-intuitive to loosen a strap to stop a leak, but it's often the solution. Worth a try...

While you don't say what masks you have tried and are currently using; given you refer to the bridge of your nose, I assume they are probably full-face or nasal (not prongs or pillows). I started on CPAP about the same time as you - December 5, 2008 - and have gone through the following looking for the same thing (a mask that works well, is comfortable, and seals securely):
1) ResMed Micro Nasal - this lasted 2 nights - found I mouth-breathed too much. Even with a chin strap it didn't fit me well.
2) ResMed Quattro - 5 nights with a medium the first go-around (leaks around the bridge dried my eyes) - 2 nights recently with a small didn't fare much better - found it slightly too small, it kept creeping up to seat better on my nasal bridge and the bottom would slip over my lower lip if I opened my mouth.
3) F&P 431 - this lasted barely one night - the skirt just didn't seal and seemed to flap in the wind - this, no matter what size I tried
4) Hybrid - I had high hopes for this one, but just couldn't get a good fit (I suspect because of the chin cup - I didn't want to cut the cup off ala the modification I found noted here
5) ResMed Swift LT - I really like this mask for its minimal profile and comfort - if I could get past the mouth-leak problem in a more comfortable way than a chinstrap or tape, it would be my go-to mask
6) ResMed Mirage Liberty - it followed the Quattro and is the one I have gone back to when all others (I won't say 'failed' because they all have merits) just didn't do it for me.

The Point I am trying to convey is that mask-fit is an on-going struggle for many; failing a custom mask it is literally a trial-and-error process. However, given your nasal bridge consideration, I would suggest you try the following:
1) Liberty or Hybrid if you mouth-breathe a bit and want/need a full-face mask - their unique combination interfaces completely eliminate the nasal bridge from the equation
2) If you do not mouth-breathe, try the ResMed Swift LT or Respironics OptiLife - they are among the most minimalist masks I have found - in the case of the OptiLife, you may choose between nasal pillows or nasal cradle (it cups the nostrils rather than inserting pillows). If one doesn't have a problem with mouth-leaks, these are fantastic masks.
There are many more I would like to try, but can't justify the expense in what others have termed a 'Holy Grail' quest. If you can find your own 'Holy Grail,' you will be rewarded beyond measure with the riches of soft, gentle, peaceful slumber. I wish you well.

JimW203

Given there is a huge amount of air escaping through the emergency breathing hole, I find it hard to believe that a small, temporary leak would affect therapy significantly. The stream of air coming out of my emergency hole in front is at least 10, and probably 100 times the amount of air that escapes from a poor seal elsewhere in my mask. It is the hissing sound or the blowing of air on my face or eyes which irritates me, thus causing me to adjust the fit, not any anxiety I might have about not getting the proper therapy.

I started cpap a little before you (September) and have had the same mask issues. The Quattro worked well for me for a couple of months and then started leaking badly. Couldn't get a good seal no matter what I tried. Tried several other full face masks and the Swift 2 nasal pillow. Thanks to a post by Rooster I gave the Hybrid a try. I have both the Universal Hybrid and a Mirage Liberty. For me they are the answer and I like them both very much. Currently using the Liberty because if I need to get up during the night it has a quick disconnect on the swivel that attaches to the mask so I don't have to remove the mask. Just pop the swivel off go do what I need to do and pop the swivel back in place, don't have to readjust the mask. If you decide to give this a try, here are a couple of tricks to get a good seal. A little Lansinoh cream applied to the upper lip and nares about half an hour before bed time will help seal the nasal pillows and keep your nose and upper lip from becoming irritated by the silicone. Too much can be counter productive so just use a small amount. I always blow my nose to clear it just before I put on my mask and there is still enough Lansinoh left to do the job. Second use Rested Gal's tights around the head fix. Just use the search feature if you need a better description. Basically I tie one of my wife's knee highs around my head and across the nasal pillows to keep them in place. Last I have found that a cotton ball inserted between the nasal pillows will help stabilize them. Most of the leak issues I encountered with the hybrids were with the nasal pillows slipping out of place. These little tips have taken care of those issues. Hope this helps. Wouldn't have known to try any of this without the help of the people on this forum. A good nights sleep is worth a little effort. Just keep
asking questions here and you will surely find the right answer.
Don

Jason S. wrote:Given there is a huge amount of air escaping through the emergency breathing hole, I find it hard to believe that a small, temporary leak would affect therapy significantly. The stream of air coming out of my emergency hole in front is at least 10, and probably 100 times the amount of air that escapes from a poor seal elsewhere in my mask.

If you look carefully at the swivel elbow of your mask you will note two distinctly different sets of holes. The tiny holes arrayed in two parallel rows are the exhalation ports. The single larger hole below them is the anti-asphysiation port (what you are calling the emergency breathing hole). When under pressure, an internal silicone flap is pressed up covering the AA port - there should be absolutely zero air coming from it when in use. The exhalation ports, on the other hand, are there to clear the CO2 from the mask upon exhalation - the incoming air forces it out those holes. It is air from them you are feeling when you put your hand up in front of the mask. Given their proximity to the AA port and their tiny size which results in a very high velocity air stream, it is impossible to isolate the source of the airstream or to accurately gauge the volume of air from feel only. The volume of flow is such that it allows a clearing of the CO2 but not so much as to diminish airflow to your lungs. It is much like a bucket with tiny holes in it - if you adjust the inflow to accomodate the water going out the holes, you can still fill the bucket at the same rate as if they weren't there. Your machine does that - it adjusts the flow of air in proportion to the rate of outflow through the exhalation ports to provide the correct pressure for treatment. That is why there is a mask selection table in the machine - to provide accurate adjustment to the inflow.

JimW203 wrote:

Jason S. wrote:That is why there is a mask selection table in the machine - to provide accurate adjustment to the inflow.

Not all machines have this list, right? I have not seen it on my Remstar A-Flex.

ChipsXJ wrote:

JimW203 wrote:

Jason S. wrote:That is why there is a mask selection table in the machine - to provide accurate adjustment to the inflow.

Not all machines have this list, right? I have not seen it on my Remstar A-Flex.

This is correct.

Respironics folks have to "do the math". I prefer this as I don't have to wonder what the machine is thinking the vent rate is for any particular mask. I just look at my leak rate and check the mask's vent rate.

But the ResMeds look way cooler...

Thanks for the technical explanation, though I admit I don't fully understand it. If I hold my breath, there is no CO2 escaping from my exhale, yet there is still a huge flow of air coming out of the mask, right? I understand the machine could be calibrated to accomodate this steady loss of air, yet still provide enough pressure for beneficial therapy.

More importantly, it would seem based on your statement that I cannot switch masks and assume I am getting the proper therapy. My machine has no such list, unless I am supposed to take it back to the DME and have them calibrate it for my new mask?

JimW203 wrote:

Jason S. wrote:Given there is a huge amount of air escaping through the emergency breathing hole, I find it hard to believe that a small, temporary leak would affect therapy significantly. The stream of air coming out of my emergency hole in front is at least 10, and probably 100 times the amount of air that escapes from a poor seal elsewhere in my mask.

If you look carefully at the swivel elbow of your mask you will note two distinctly different sets of holes. The tiny holes arrayed in two parallel rows are the exhalation ports. The single larger hole below them is the anti-asphysiation port (what you are calling the emergency breathing hole). When under pressure, an internal silicone flap is pressed up covering the AA port - there should be absolutely zero air coming from it when in use. The exhalation ports, on the other hand, are there to clear the CO2 from the mask upon exhalation - the incoming air forces it out those holes. It is air from them you are feeling when you put your hand up in front of the mask. Given their proximity to the AA port and their tiny size which results in a very high velocity air stream, it is impossible to isolate the source of the airstream or to accurately gauge the volume of air from feel only. The volume of flow is such that it allows a clearing of the CO2 but not so much as to diminish airflow to your lungs. It is much like a bucket with tiny holes in it - if you adjust the inflow to accomodate the water going out the holes, you can still fill the bucket at the same rate as if they weren't there. Your machine does that - it adjusts the flow of air in proportion to the rate of outflow through the exhalation ports to provide the correct pressure for treatment. That is why there is a mask selection table in the machine - to provide accurate adjustment to the inflow.

Jason S. wrote:Thanks for the technical explanation, though I admit I don't fully understand it. If I hold my breath, there is no CO2 escaping from my exhale, yet there is still a huge flow of air coming out of the mask, right? I understand the machine could be calibrated to accomodate this steady loss of air, yet still provide enough pressure for beneficial therapy.

More importantly, it would seem based on your statement that I cannot switch masks and assume I am getting the proper therapy. My machine has no such list, unless I am supposed to take it back to the DME and have them calibrate it for my new mask?

I cannot speak with any familiarity about how Respironics deals with this issue. I suspect, from looking at leak rate charts for ResMed masks, that a mask's leak rate is fairly consistent given the purpose of the ports - to clear CO2 - I suspect most FF will exhibit similar leak rates; most nasal, similar; nasal pillow, similar, too etc.
If that is true, then perhaps Respironics designs its machines based on a norm that assumes all masks are designed arround a set of assumptions that include the optimal exhalation port size to allow clearing of CO2 at various levels of pressure. If anyone knows for certain, please let me know. Why ResMed includes a mask chart, I cannot say. The cynic in me might suggest that it is a marketing decision - given the presence of ResMed mask only (other than 'Standard') in the chart may be a subtle form of suggestive selling. After all, one may speculate, if I can select my specific mask on my machine, am I not likely getting the most out of the mask/machine system? What specific change ResMed makes in its flow rate based on what you select on its machines, I don't know.
The presence of the 'Standard' option in the ResMed list implys that there is indeed, a standard; it may be that standard that Respironics is using as its mask assumption.

JimW203

JimW203 wrote:

Jason S. wrote:Thanks for the technical explanation, though I admit I don't fully understand it. If I hold my breath, there is no CO2 escaping from my exhale, yet there is still a huge flow of air coming out of the mask, right? I understand the machine could be calibrated to accomodate this steady loss of air, yet still provide enough pressure for beneficial therapy.

More importantly, it would seem based on your statement that I cannot switch masks and assume I am getting the proper therapy. My machine has no such list, unless I am supposed to take it back to the DME and have them calibrate it for my new mask?

I cannot speak with any familiarity about how Respironics deals with this issue. I suspect, from looking at leak rate charts for ResMed masks, that a mask's leak rate is fairly consistent given the purpose of the ports - to clear CO2 - I suspect most FF will exhibit similar leak rates; most nasal, similar; nasal pillow, similar, too etc.
If that is true, then perhaps Respironics designs its machines based on a norm that assumes all masks are designed arround a set of assumptions that include the optimal exhalation port size to allow clearing of CO2 at various levels of pressure. If anyone knows for certain, please let me know. Why ResMed includes a mask chart, I cannot say. The cynic in me might suggest that it is a marketing decision - given the presence of ResMed mask only (other than 'Standard') in the chart may be a subtle form of suggestive selling. After all, one may speculate, if I can select my specific mask on my machine, am I not likely getting the most out of the mask/machine system? What specific change ResMed makes in its flow rate based on what you select on its machines, I don't know.
The presence of the 'Standard' option in the ResMed list implys that there is indeed, a standard; it may be that standard that Respironics is using as its mask assumption.

JimW203

Jim, Resprionics makes no assumptions. You get the total "leak" and it's up to you to see what the vent rate is to see how close to that you are getting.

Thanks for all the feedback and ideas.

I have to say that I am a little sad. It seems that the general advice is to pick the "least worst" mask and then make my own adjustments to try to improve the design and fit. I find it hard to believe that I can get a pair of ski boots moulded to fit my feet, yet have to do a Dr Seuss-style modification using tape, cotton wool and silicone earplugs(!) to make this life-sustaining therapy work! This is not a game, I have been told that I need this CPAP therapy to avoid serious health consequences that OSA will deliver over time. The machine is great, quiet and gives me the pressure I need when I need it and loads of important feedback/data. But the masks I have tried are a joke! At best, they work just okay, but are nowhere near the ideal solution. Whose idea was this ?? I am just a little frustrated and disillusioned by this treatment. I like waking refreshed, but hate the discomfort and red marks. It's no wonder that so many people abandon treatment altogether......

I guess like everyone else, I will just have to perservere and do the best to find a solution that works for me.

Thanks again for all the advice....

Shocking level of technical review, here -

I use a Quattro FF; two things cause leaks: failure to keep my beard trimmed close, and over-tightening.

Tossing and turning and such don't help, but those are the basics.

The Mirage Quattro has a fifth pressure point you can use right above the elbow and below the exhaust port ... An additional adjustable elastic velcro strap around the middle of the Mirage Quattro will magically seal the mask ... ...