Neck position and CPAP treatment

I have been trying to figure out why my CPAP experience has been so thorougly negative -4 months of use at a handful of pressures, not one single bit of improvement in my daytime fatigue, still a bizarre amount of insomnia despite being gruesomely tired. By getting my hands on the data from my studies, I discovered that I did not have a consistent response to CPAP in either of my titration studies; my second study actually tried a range of pressures and BiPAP with no discernible pattern of improvement in my respiratory statistics or sleep staging.

On the one hand, I wonder if I don't need expiratory pressure relief to normalize my breathing - I'm just the sensitive type, and have always responded to respiratory issues with hyper-reactivity. So I am going to ask for an AutoPAP machine, and go with data capability.

On the other hand, I had this insight recently: At night, I sometimes sleep well without CPAP (in the early morning hours, after I have exhausted my ability to sleep with CPAP) and discoverd that this only happens in the "falcon" position. (Some falcons fly with their wings slightly bent, perhaps ) I noticed from the picture in Falcon's post that this sleep position causes his head to become slightly extended, and that flexing (folding chin down toward chest) is pretty nearly impossible in this position. I have found some research demonstrating the collapsibility of the airway is changed by changes in head position, that is, flexion of the neck. More flex forward, more collapsibility; more extension backward, less collapsibility. In fact, I have noticed for years that I carry my head extended (that is, tipped back) during the day, and I felt it was connected to breathing.

So is anybody talking about how this confounds CPAP use? When I mentioned my neck problems to my ENT and to my new sleep doctor (#4) I got dismissive responses. (I am a lean, older women with moderate UARS -no apnea! - and I am sure that my problems are also very much related to the craniofacial disproportions. Not getting much traction with that issue, either.)

One of the masks I used pulled my chin right in against my neck, and I am sure that was a bad idea. I think the sleep lab results were skewed by this issue, because they changed me to their mask during the night because of mask leak. Does anyone else experience head position as an issue in their CPAP treatment?

I use a CPAP pillow-which I bought from Harriet Carter- for $29.95, and it is surprisingly supportive-but the main thing I like about it, is the fact that it supports my neck so that is does just what you said- it keeps it slightly extended without my having to consciously hold it there.So, I am able to relax and sleep better, and yet stay in a better position.It also has cut-outs for my mask,so it has been a real boon for me in helping me to comply. Now,if I could just get my insomnia to go away....
LOVE your "Jabberwock" user name! brilliant!
~joan

Thanks, Trinity. I checked the pillow and I like the looks of it, but I want to be able to sleep on my side, too. I use a down pillow now, which can be adaptable. But I may have to invent something. Maybe chop up one of those contour pillows...

BTW, the REMSTAR auto with Aflex is the one I am thinking about asking for. Why did you choose it, and how is it working for you?

Head/neck position has been discussed a number of times before. Here are a couple of links:

viewtopic/t42357/viewtopic.php?f=1&t=40317

viewtopic/t42357/viewtopic.php?f=1&t=38929


Den

Well, we both became aware of a similar situation. I was working on mouth leaks, it became difficult to solve because of my previous UPPP surgery, but I want to try every concept, because small things may make a difference. I was analyzing body position. Of course, asa I went to sleep, I rolled over on my back. While working on that, I noticed that my chin was settling down toward my neck. I thought, oh great, I have the UPPP problem and I'm compounding it by shutting of my airway.

twasbrillig wrote:I noticed from the picture in Falcon's post that this sleep position causes his head to become slightly extended, and that flexing (folding chin down toward chest) is pretty nearly impossible in this position. I have found some research demonstrating the collapsibility of the airway is changed by changes in head position, that is, flexion of the neck. More flex forward, more collapsibility; more extension backward, less collapsibility. In fact, I have noticed for years that I carry my head extended (that is, tipped back) during the day, and I felt it was connected to breathing.

SWS wrote that a small towel could be rolled around my neck to keep my head erect. Again, I had to laugh , If I type my mouth or polident it. Use R.G.'s idea, (securing my mask parts with tights) and have a towel rolled around my neck, with the mask & hose completing the picture I am setting my self-up for two things - I'll be warm enough to want to move to Alaska in the winter, or I will look like a peculiar homeless wonderer.

I checked Falcon's post too, and noticed his head position.

The towel around my neck hasn't worked too well, it was too soft. I tried wrapping tennis balls in a soft material, and it's too hard. Guess, I am just like Goldilocks and can't find a happy medium.

A wonderful thing about the forum, is that we can gets ideas from creative people. Let's have 'em.
Jan

This is such an interesting post. I always thought if I tilted my head back it would close my airway.
Now I'm going to try to sleep that way. I hope someone invents this type of device or at least researches it further.
Wouldn't it be nice to just sleep with your head tilted back instead of a mask and hose!!

Twasbrillig, I chose my machine after reading on here,and because it can be used as auto or straight CPAP.I am still finding my best pressure-it seems to be leveling at around 12.I will give it a few more weeks and then flip it to straight CPAP with either a C-flex of 1 (which I am using now) or one. I really do not mind breathing against a 12 pressure when I have tried it without the flex. I do not use any ramp presently.
I DO sleep on both sides with that pillow-that is what the cutouts are for- it supports my neck- I can scoot the end piece as far close up to my neck as I want-and has ample room for my FFM, hose,which I usually flip up over my head when I am turned away from the machine, and a partidge in a pear... - wait, that's another story! But seriously, it does have enough room for everything, and so far it has been great for me. Good luck on finding the right position, etc.
~joan

twasbrillig ....... and the slithy toves did gyre and gimble in the wabe. All mimsy were the borogoves, And the mome raths outgrabe. It's amazing how SA has burnt out my memory so badly that if you offered a thousand dollars apiece for each teacher I ever had, I would return home broke, remembering nothing but broken bits of literature and ill fitting school uniforms.

Out of curiosity, why can't you handle pressures greater than 9cm/H2o? My lowest setting on an APAP machine is 16.4 and I usually run at between 17 and 18 with a full face mask. If I tried to run the equipment at pressures like you are attempting, I may as well not bother.

You seem convinced that at greater pressures you will be leaking out through your eyeballs or blowing up like a balloon. While anything is possible, the vast majority of us aren't leaking anywhere except through our nose and mouth. The therapeutic pressures that we are dealing with here are really not much different than riding on a motorcycle or sticking your head out the car window. Many of us were mouth breathers out of desperation but learned to breathe through our noses to make this therapy effective.

If you had tried CPAP at significantly higher levels and still had poor results after you dealt with the whole mouth breathing / mask leaking issue I might have more sympathy for your situation, but any results you've been getting so far are probably compromised by your inability to breathe exclusively through your nose and unwillingness to switch to a properly fitting full face mask.

Why don't you post your sleep lab readings to establish a baseline and your current data using the machine, including usage and leak rates? It may very well be that your circumstances are unique and CPAP therapy inappropriate for you, but all I hear is someone critical of two of their doctors who have recommended CPAP treatment and seems convinced that physiologically she cannot handle therapy many of us take for granted.

Half a league, half a league, half a league onward, all in the valley of death rode the six hundred. Cannon to the right of them, cannon to the left of them, cannon in front of them volley'd and thunder'd; theirs not to make reply, theirs not to reason why, theirs but to do and die. And yet, I'll give ten bucks to the first one of you who can remind me of the name of my sister's husband who borrowed something off me awhile ago ..... if I could only remember what it was and who he is.

A viscoelastic travel pillow works for me; side-sleeping, I turn it backwards or sideways still leaving enough to rest my chin on.

Hi

Regarding the neck position I have found that using a hard pillow underneath for basic height, and a feather pillow on top that I can contort to any position I want, works well. It only takes a second to get the feather pillow as I want it, and thats it.

I was lucky, I already slept on these 2 pillows before sleep apnea therapy.

cheers

Mars

I appreciate all the responses - I had seen one set of threads about neck position, but it was nice to hear from everyone.

Trinity, I will have to look at that pillow again - I just didn't see how it would work for side sleeping - or is there more than one of them at that retailer? And thanks about the Remstar Auto, those were the lines I was thinking along, too.

Spitintheocean, I WISH I had data. My doctors so far have acted like it doesn't even exist. I am going to ask for a data capable machine tomorrow. As for the data from the lab, I have not scanned my sleep studies into the computer yet, but they were a mess. Since I don't have apnea, the first titration study simply tried pressures of 6 and 7; the doctor, a Board-certified sleep doctor said in the report that they had gotten rid of my (one) apnea, and I was successfully titrated at 7 cm even though I had 81 RERAS, 1% Stage 3, 7% REM and had a very fragmented hypnogram. My second titration study involved pressures from 4 to 18, and some BiPAP. There was snoring at low pressures ( which clearly showed they were affecting my sleep in the hypnogram), but the RERAS showed back up at higher pressures (go figure!), and a slew of central apneas also appeared. I slept so little of the time at any pressure above 12 that it was hard to say what the effect was on my sleep. the BiPAP showed some promise, so I am hoping AutoPAP will be better for me.

Higher pressures have been problematic in all different ways. But let me at least point out that everyone is an individual, and there really isn't any way to say which pressures should work for whom. I am a small boned woman (I buy the smallest size shirts and blouses, sometimes buying shirts in the girls department) and have the facial structure that is disproportionately small at that. Would stand to reason that my pressure requirements might be lower. My worst experience was at 12 cm - the air somehow irritated my esophagus and made me feel like I needed to burp, but couldn't. I felt like I was going to explode. This unfortunately situation persisted for most of the next day. I have also had some air-swallowing. Some nights not bad, but one morning, I had very painful cramps. I was glad it was a Sunday, so I could just stay in bad until it passed (no pun intended...) I have also had the situation where my mouth isn't opening, but the air leaks through the tongue seal at the back of my mouth, and sort of bubbles out, keeping me awake as I relax, and also waking me up. I use a chin strap, but it's not what's happening with my mouth, it's what's happening with my tongue seal that's the problem. (BTW, this also happened with a full face mask) Also, I don't mouth breathe at all. When I say mouth leak, I mean the air is coming down from my nose and out through my mouth. I have a pretty good nasal situation - my ENT says no physical problems, and I use Flonase and an antihistamine nose spray so I can breathe quite well. Not sure why you would equate mouth leak with mouth breathing. I like the nasal pillows because they don't seem to leak at all, and since I have a lot of awakenings, I am pretty sure I would notice. I test them a lot, try moving them and sleeping in different ways, and feel like they are always good, no leaks. But of course, data would help me confirm this.

I have used a full face and a hybrid, and they both seemed to fit pretty well. The full face was a little hard on my jaw; I have had TMJ, and that had me concerned. But I didn't dislike or not want to use these masks: I had the idea that they were posing a problem for my therapy, and of course that is what I was checking on when I posted. A full face mask may not be complicating your therapy, but again, we all have our problems for different reasons and combinations thereof. As I have mentioned in other posts, my problems is UARS, and it is not caused by weight gain or anything else related to age - I have had exactly the same sleep problems for 30 years.

I am not critical of my doctors because they recommended CPAP. I am critical because, after months of CPAP use in good faith, I have posed some significant questions and problems, and they have not indicated any interest in answering the questions, or solving the problems. Please notice that even doctor #4 has not suggested a data-capable machine! I have not given up on CPAP, and I am truly hopeful that autoPAP may meet my needs. Wish me luck!

twasbrillig,

Be careful about putting too much faith in AutoPap. It really is just a cpap that wanders a bit in the night.

I know you have tried a Bipap, My suggestion would be to (if the doc will sign off) get an Auto Bipap and
that is because you can run it in almost any mode, Cpap, Bipap & Auto (all in the way you set it up).

That machine would give you a far better range of choices & possibilities that a straight Auto. Also IIRC
the Bipap Auto has BiFlex which I think is better value than A-Flex might be allowing that you can have
exhale & inhale pressures set if in that mode.

Good luck with this.

PS The Bipap Auto is a good data machine

Here is a data chart from a Bipap Auto (but going back a year)
http://www.internetage.ws/cpapdata/dsm- ... apauto.pdf

DSM

twasbrillig wrote:On the one hand, I wonder if I don't need expiratory pressure relief to normalize my breathing - I'm just the sensitive type, and have always responded to respiratory issues with hyper-reactivity. So I am going to ask for an AutoPAP machine, and go with data capability

There's a misconception there: You can have simple (comfort oriented) expiratory pressure relief on fixed pressure machines, both from Respironics (CFlex or AFlex) and from ResMed (EPR). An auto, as dsm said, wanders up and down, it supplies varied pressure for both inahle and exhale, concurrently, but it's pressure relief is the same as that of fixed pressure machine - and is limited.

Now, a Bi-Level machine (or an automatic bi-level) is another story. Those can be set to have distinctly different pressures for inhale and exhale -- for each and every breath.

So, if you really want to try serious expiratory pressure relief, you need an Rx that will state "BIPAP" or "Bi-Level" on it.


"Beware the Autopap my friend
The Max. that peaks, the Min. that droops" , they will not give you the expiratory pressure relief you're searching for -- though they may be great for other reasons.

O.

I have experimented with a cervical collar to keep my chin from moving towards my chest. I learned from CPR you want to keep the airway straight. Now I just pull another pillow up under my chin.

Thank you again for the responses, especially ozij and dsm!

Here's my dilemma:

I wanted BiPAP for the expiration relief - seems like in the lab, it helped my breathing without creating as many centrals. And I am thinking it may help with my mouth leak/tongue seal issues at the higher pressures I appear to need.

I wanted AutoPAP because it appears that postural (neck position) issues might be a big thing for me. (I already know that I carry my head extended during the day, and efforts to break this "habit" are ineffective, suggesting some biological imperative such as breathing...) I also have a long neck, and the high level of flexion could be what confounded my second titration study that used a range of CPAP pressures. My thinking is that AutoPAP will adjust the pressures higher if my neck gets a little flexed, and will adjust it lower if I have my neck extended. Thus, it would be keeping me in a more optimal response range. With UARS, nervous system sensitivity seems to be a major issue, and I am just trying to find ways to minimize the over and under pressure situations that may be undermining my therapy.

Thank you for explaining the situation with machines better. I really hope that the combo of Bi and Auto will help. As my doctors have not suggested the more sophisticated PAP approaches, I am concerned about how to get this across without seeming arrogant.