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Of course if you are on your back the xpap is designed to open ones airway with the proper pressure...

however, if this pressure is two to three times higher than pressure needed when sleeping on one's side,

and the higher the pressure the more discomfort

why the hell would someone want to sleep on their back if they didnt have to?

Anyone suggesting this, I would ask them, what is your xpap pressure on your back after a long day, and a few beers?

I use the Swift LT nasal pillow which works pretty well on my side and stomach almost no leaks but I am going to try a FFM this month because I am starting to get fall allergies and a full face mask will allow me to breath even when my nose is clogged.

As for the back side stomach thing, I have severe apnea, 90 AHI on my back 54 on my side. I have APAP set 10/14. Every time I sleep on my back the pressure is between 13 and 14 and my AHI goes up to 4.5 or higher with 2-3 or more centrals per hr. When I sleep on my side or stomach my pressure sits between 10 and 11 and my AHI sits around 1.5 with centrals at .5 per hr. or lower. I have talked with my sleep Dr. twice now and he has never even suggested that I sleep on my back. He also suggested a chinstrap to keep my mouth shut because it has a tendency to blow open. Now with the chinstrap no more mouth leaks. I know that is empirical data but from what I have read this is more of the norm than the exception.

cwied wrote:

Calist wrote:Actually it is correct information if you would reffer to the Atlas of Clinical Polysomnography. It sounds as if this Guest RPSGT knows exactly what he or she is talking about. Has anyone in this thread ever run a PSG besides guest and myself? From all of the threads on this forum it sounds as if people are trying to re-invent sleep science with absolutely no research or testing.

It is okay to question medicine but unless the person posing the question has at least run a handful of titrations, everything they present will be personal speculation.

You know, I happen to believe you, but the way you're presenting this information seems to be more designed to attack than to convince. I understand you are frustrated because you feel people are ignoring facts and just going with their misconceptions, but it seems like

Perhaps you could explain the mechanism through which the air pressure forces the mouth to stay closed? I'm guessing it's something like the external pressure on the lip or the pressure on the palate somehow forces the mouth shut.

Normally people don't ask a question the way that you just asked me. They ask a question as a form of attack or as a challenge, not because they are actually curious. So I'm sorry if my answer sounded derogatory. Mechanism in which air pressure forces the mouth closed- Here we go.

I detailed this the other day and I'm afraid that I did a much better job there than I will here so bare with me.

Respiratory Distress

Respiratory Distress is a mechanism in which the brain realizes that it is running out of oxygen. It does this not by examining oxygen molecules but instead by counting carbon dioxide molecules. If you have 3% c02 (or carbon Dioxide) then the brain assumes you have 97% oxygen. If you have 7% c02 then it assumes you have 93% oxygen.... and so on. This is actually how people die from gas leaks in their home as well. 7% c02, 90% Methane and 3% Oxygen looks perfectly normal to the human brain because it is only counting carbon dioxide. If however the carbon dioxide climbs above 12% (88% Oxygen) then the brain will begin the process of initiated the Respiratory Distress mechanism.

1: The absolute first thing it does is opens up the mouth. As you know the airways is connected to both the mouth and sinus passages (The nose). With normal breathing, air comes in and out the nose. This serves a variety of functions as the nose functions as the end of the respiratory process. Or the beginning, however you want to look at it. It cleans and moisturizes the air as well ejects undesirable organisms via the sneezing reflex. It is the absolute first line of defense for the respiratory system. My mentor always used to tell me that if you trach a patient (tracheotomy) you take ten years off their life. She was talking about a permanent trach. Because although this has the benifit of bypassing the upper airway which could be giving you problems you would open up the respiratory system to infection, drying out and other nasty elements. The nose is a very important part of respiration and the human brain is well aware of this HOWEVER in the event that the sa02 (blood oxygen) is dropping, it has no choice but to open the mouth and double up on the airway.

2: Respiratory effort increases. This is done in three stages. First the speed of the individual breathes increases, almost doubling in the span of a second. Not quite to the point of hyperventilation but it gets a lot faster. Secondly the breathes become a lot larger, attempting to make full use of the lungs with each inspiration/expiration, thirdly the patient begins to use paradoxical breathing which is a combination of the thoracic and abdominal diaphragms pumping in the opposite direction. So your chest heaves in while your stomach heaves out and same vice versa. This pumps your lungs a LOT harder and lot faster. Paradoxical breathing is the last part of the respiratory effort increases and usually shows up around the same time as....

3: The heart rate increases dramatically. The brain has to survive above all else. With out oxygen the brain will have six minutes to live and with children it is even shorter. The idea is that the brain will increase the heart rate in order to get any oxygen still left in the blood up to the brain as quickly as possible,it realizes that it is scraping the bottom of the barrel so it wants that last little bit delivered to it immediately while it tries to sort this out.

This process can also be seen in people who have heart attacks, mainly because the brain does not recognize the origin of the problem, it is looking at the oxygen alone so whether the problem is in the nose, mouth, upper airway, lower airway, lungs or heart, it will kick off this multi-faceted process regardless of the cause. There was actually a study done where they injected people with lose doses of a chemical that looked like c02 to the brain and every one of their test subjects went into respiratory distress and had panic attacks. Not because they were in any real danger but because they had tricked the brain into thinking it was suffocating.

Positions

Respiratory Distress can be detected in a number of ways but the one which is most often used is the one they teach to nurses and receptionists when they scan the ER waiting rooms. It is a person sitting straight up, leaning a little bit forward with their arms by their side, head back, trying to move as little as possible. This vertical position is all over the sleep field as patients who are in the process of developing OSA (apnea) which is becoming increasingly severe, will often start off sleeping on their back, not really paying attention to any particular position. This will then change when they begin to wake up (whether it is a full wake up or just a split second) five or ten or fifteen times a night while feeling uncomfortable. This discomfort during sleep fragmentation is actually the aftereffects of Respiratory Distress however they do not know it. Instead they simply think (I am uncomfortable). Eventually they end up rolling onto one side and at this early stage of OSA (apnea) this works as the soft tissue falls sideways in REM and not directly back into airway. This will go on for years until the patients themselves finally end up recognizing the pattern and decide "I am a side sleeper" they may even try to justify it to themselves or others "I am a side sleeper from a long line of slide sleepers, it's genetic."

Eventually however the OSA (apnea) gets even worse and not even side sleeping can keep them from waking up and feeling uncomfortable anymore. So they move to their stomachs. This quickly becomes a subconscious action in fact so that even if a patient decides to buck the trend and sleep on their backs for one night, they will more often than not wake up on their stomach. Most of the time however, the patient will start off on their stomach as it is the last position they got any good sleep in. Of course they will not say that to themselves, instead they will say they are a stomach sleeper. Eventually even stomach sleeping begins to fail them and they will move to a recliner chair. The recliner chair is the last stop for an Apnea patient as it is the full-blown respiratory distress position and then patient is trying to sleep in it.

At times.... a patient will begin to determine that this has become a problem when they get to the recliner chair stage. They will ask themselves "Why is my recliner chair more comfortable than my bed is? Why do I toss and turn and get headaches all night in bed and then sleep so great in my recliner chair all afternoon?" Some however will just say "My recliner chair is simply more comfortable and I need comfort because I have a bad back or spleen or something. I have fibromyalgia because the woman on tv said so." This is why when I am evaluating a new patient, the first thing I ask them is "What position do you sleep in?"

"On my back." AHI 20 or less.

"On my side." AHI 20 - 40

"On my stomach." AHI 40+

"In a recliner chair." AHI 100+

"zzzzzzzzzzzzz" Narcolepsy.

Normal respiration

When you are titrating a patient you will watch them go into respiratory distress over and over again, all night long. If you have them on a nasal mask, they will open their mouths at the beginning of each event. This is because they are starting the respiratory distress system as mentioned above. The increased heart rate, paradoxical breathing will always follow the oral leak which begins the event, probably a bit of choking and loud snore as well. And the oral leak will continue after the event has ended as well however it will not be a significant enough leak to cause a loss of pressure. This is why sleep techs titrate through oral leak. Once you have the patient on a high enough pressure that you have wedged the airway open and low enough so that the pressure is not causing centrals.... the mouth closes. The mouth closes because although there is not enough oral leak to cause a loss of pressure, the escaping air does dry out a patient's mouth very very quickly. Even with a humidifier attached the patient will subconsciously (in their sleep), and with out so much as an arousal, close their mouth as a matter of comfort. So after a titration begins, a sleep tech will titrate despite the presence of oral leak and once the optimal pressure is found the patient will close their mouths on their own and keep their mouths closed (Even in REM despite the drop in muscle tension) for the rest of the study.

Complications

There are of course exceptions to this.

1: Patient is on too low of a pressure, thus causing events, thus causing respiratory distress, thus causes massive oral leak and the patients ongoing attempt to breath orally during these events.

2: Patient is on way too great of a pressure, thus hyper inflating their cheeks and escaping orally with each breath. This would be despite the lack of or even in the presence of... centrals.

3: Patients jaw does not line up with their teeth and they have a massive overbite which makes them incapable of completely closing their mouths.

4: Patients jaw does not line up with their teeth and they have a massive underbite which makes them incapable of completely closing their mouths. (Never actually seen this)

5: Patient is missing teeth or parts of their jaw or anything which might lend structure to the sealing mechanism of their mouths. Thus causing leak.

Solutions

1: If the pressure is too low and you are still having Hypopneas, Reras or other obstructives in Supine REM then you need to have a retitration from a lab that won't screw it up.

2: If the pressure is too high and you are having Centrals or Central hypopneas in sleep then you need to have a retitration from a lab that won't screw it up.

3: If the jaw does not line up with your teeth and you can't hold the pressure during wake much less sleep.... then yeah you will have to go for a full face mask. It won't be pleasant but it will work a lot better than what you are doing now.

Questions?

cwied wrote:

Calist wrote:Actually it is correct information if you would reffer to the Atlas of Clinical Polysomnography. It sounds as if this Guest RPSGT knows exactly what he or she is talking about. Has anyone in this thread ever run a PSG besides guest and myself? From all of the threads on this forum it sounds as if people are trying to re-invent sleep science with absolutely no research or testing.

It is okay to question medicine but unless the person posing the question has at least run a handful of titrations, everything they present will be personal speculation.

You know, I happen to believe you, but the way you're presenting this information seems to be more designed to attack than to convince. I understand you are frustrated because you feel people are ignoring facts and just going with their misconceptions, but it seems like

Perhaps you could explain the mechanism through which the air pressure forces the mouth to stay closed? I'm guessing it's something like the external pressure on the lip or the pressure on the palate somehow forces the mouth shut.

Normally people don't ask a question the way that you just asked me. They ask a question as a form of attack or as a challenge, not because they are actually curious. So I'm sorry if my answer sounded derogatory. Mechanism in which air pressure forces the mouth closed- Here we go.

I detailed this the other day and I'm afraid that I did a much better job there than I will here so bare with me.

Respiratory Distress

Respiratory Distress is a mechanism in which the brain realizes that it is running out of oxygen. It does this not by examining oxygen molecules but instead by counting carbon dioxide molecules. If you have 3% c02 (or carbon Dioxide) then the brain assumes you have 97% oxygen. If you have 7% c02 then it assumes you have 93% oxygen.... and so on. This is actually how people die from gas leaks in their home as well. 7% c02, 90% Methane and 3% Oxygen looks perfectly normal to the human brain because it is only counting carbon dioxide. If however the carbon dioxide climbs above 12% (88% Oxygen) then the brain will begin the process of initiated the Respiratory Distress mechanism.

1: The absolute first thing it does is opens up the mouth. As you know the airways is connected to both the mouth and sinus passages (The nose). With normal breathing, air comes in and out the nose. This serves a variety of functions as the nose functions as the end of the respiratory process. Or the beginning, however you want to look at it. It cleans and moisturizes the air as well ejects undesirable organisms via the sneezing reflex. It is the absolute first line of defense for the respiratory system. My mentor always used to tell me that if you trach a patient (tracheotomy) you take ten years off their life. She was talking about a permanent trach. Because although this has the benifit of bypassing the upper airway which could be giving you problems you would open up the respiratory system to infection, drying out and other nasty elements. The nose is a very important part of respiration and the human brain is well aware of this HOWEVER in the event that the sa02 (blood oxygen) is dropping, it has no choice but to open the mouth and double up on the airway.

2: Respiratory effort increases. This is done in three stages. First the speed of the individual breathes increases, almost doubling in the span of a second. Not quite to the point of hyperventilation but it gets a lot faster. Secondly the breathes become a lot larger, attempting to make full use of the lungs with each inspiration/expiration, thirdly the patient begins to use paradoxical breathing which is a combination of the thoracic and abdominal diaphragms pumping in the opposite direction. So your chest heaves in while your stomach heaves out and same vice versa. This pumps your lungs a LOT harder and lot faster. Paradoxical breathing is the last part of the respiratory effort increases and usually shows up around the same time as....

3: The heart rate increases dramatically. The brain has to survive above all else. With out oxygen the brain will have six minutes to live and with children it is even shorter. The idea is that the brain will increase the heart rate in order to get any oxygen still left in the blood up to the brain as quickly as possible,it realizes that it is scraping the bottom of the barrel so it wants that last little bit delivered to it immediately while it tries to sort this out.

This process can also be seen in people who have heart attacks, mainly because the brain does not recognize the origin of the problem, it is looking at the oxygen alone so whether the problem is in the nose, mouth, upper airway, lower airway, lungs or heart, it will kick off this multi-faceted process regardless of the cause. There was actually a study done where they injected people with lose doses of a chemical that looked like c02 to the brain and every one of their test subjects went into respiratory distress and had panic attacks. Not because they were in any real danger but because they had tricked the brain into thinking it was suffocating.

Positions

Respiratory Distress can be detected in a number of ways but the one which is most often used is the one they teach to nurses and receptionists when they scan the ER waiting rooms. It is a person sitting straight up, leaning a little bit forward with their arms by their side, head back, trying to move as little as possible. This vertical position is all over the sleep field as patients who are in the process of developing OSA (apnea) which is becoming increasingly severe, will often start off sleeping on their back, not really paying attention to any particular position. This will then change when they begin to wake up (whether it is a full wake up or just a split second) five or ten or fifteen times a night while feeling uncomfortable. This discomfort during sleep fragmentation is actually the aftereffects of Respiratory Distress however they do not know it. Instead they simply think (I am uncomfortable). Eventually they end up rolling onto one side and at this early stage of OSA (apnea) this works as the soft tissue falls sideways in REM and not directly back into airway. This will go on for years until the patients themselves finally end up recognizing the pattern and decide "I am a side sleeper" they may even try to justify it to themselves or others "I am a side sleeper from a long line of slide sleepers, it's genetic."

Eventually however the OSA (apnea) gets even worse and not even side sleeping can keep them from waking up and feeling uncomfortable anymore. So they move to their stomachs. This quickly becomes a subconscious action in fact so that even if a patient decides to buck the trend and sleep on their backs for one night, they will more often than not wake up on their stomach. Most of the time however, the patient will start off on their stomach as it is the last position they got any good sleep in. Of course they will not say that to themselves, instead they will say they are a stomach sleeper. Eventually even stomach sleeping begins to fail them and they will move to a recliner chair. The recliner chair is the last stop for an Apnea patient as it is the full-blown respiratory distress position and then patient is trying to sleep in it.

At times.... a patient will begin to determine that this has become a problem when they get to the recliner chair stage. They will ask themselves "Why is my recliner chair more comfortable than my bed is? Why do I toss and turn and get headaches all night in bed and then sleep so great in my recliner chair all afternoon?" Some however will just say "My recliner chair is simply more comfortable and I need comfort because I have a bad back or spleen or something. I have fibromyalgia because the woman on tv said so." This is why when I am evaluating a new patient, the first thing I ask them is "What position do you sleep in?"

"On my back." AHI 20 or less.

"On my side." AHI 20 - 40

"On my stomach." AHI 40+

"In a recliner chair." AHI 100+

"zzzzzzzzzzzzz" Narcolepsy.

Normal respiration

When you are titrating a patient you will watch them go into respiratory distress over and over again, all night long. If you have them on a nasal mask, they will open their mouths at the beginning of each event. This is because they are starting the respiratory distress system as mentioned above. The increased heart rate, paradoxical breathing will always follow the oral leak which begins the event, probably a bit of choking and loud snore as well. And the oral leak will continue after the event has ended as well however it will not be a significant enough leak to cause a loss of pressure. This is why sleep techs titrate through oral leak. Once you have the patient on a high enough pressure that you have wedged the airway open and low enough so that the pressure is not causing centrals.... the mouth closes. The mouth closes because although there is not enough oral leak to cause a loss of pressure, the escaping air does dry out a patient's mouth very very quickly. Even with a humidifier attached the patient will subconsciously (in their sleep), and with out so much as an arousal, close their mouth as a matter of comfort. So after a titration begins, a sleep tech will titrate despite the presence of oral leak and once the optimal pressure is found the patient will close their mouths on their own and keep their mouths closed (Even in REM despite the drop in muscle tension) for the rest of the study.

Complications

There are of course exceptions to this.

1: Patient is on too low of a pressure, thus causing events, thus causing respiratory distress, thus causes massive oral leak and the patients ongoing attempt to breath orally during these events.

2: Patient is on way too great of a pressure, thus hyper inflating their cheeks and escaping orally with each breath. This would be despite the lack of or even in the presence of... centrals.

3: Patients jaw does not line up with their teeth and they have a massive overbite which makes them incapable of completely closing their mouths.

4: Patients jaw does not line up with their teeth and they have a massive underbite which makes them incapable of completely closing their mouths. (Never actually seen this)

5: Patient is missing teeth or parts of their jaw or anything which might lend structure to the sealing mechanism of their mouths. Thus causing leak.

Solutions

1: If the pressure is too low and you are still having Hypopneas, Reras or other obstructives in Supine REM then you need to have a retitration from a lab that won't screw it up.

2: If the pressure is too high and you are having Centrals or Central hypopneas in sleep then you need to have a retitration from a lab that won't screw it up.

3: If the jaw does not line up with your teeth and you can't hold the pressure during wake much less sleep.... then yeah you will have to go for a full face mask. It won't be pleasant but it will work a lot better than what you are doing now.

Questions?

BTW- sorry for the double post guys. I was typing so long it timed me out.

Guest wrote:...avoid sleeping on their back...Because the PAP machine has corrected the obstruction and the airway is now open, there is no need to avoid sleeping on your back...sleeping in any position is generally not an issue for people with sleep apnea who are on PAP therapy...

Been sleeping on my side since diagnosis Apr '07, injured my shoulders and hafta sleep on my back...shazam, apneas which I never have, increased leak resulting in higher pressures, hypops 2-3 times more often. Changed hose position, tightened mask a bit to get rid of the leak...no change in the apneas, they just got longer in duration. Started increasing initial pressure (from 7ish to now 9.6) as my 95thcentile rose to the 12s. Got a soft foam cervical collar and that stopped the leaks but aggravated the neck-collarbone pain causing fragmented sleep. Doc cancels the aspirin & puts me diclofenac sodium which helps the pain so I start sleeping in longer sessions. Now, 9 weeks later, I sleep mostly on back and 2-3 hrs/night on the one shoulder that's pretty much healed, wakeup maybe once: I still have apneas, tho my AHI has been reducing & my 95thcentile is back down to the 10ish range. Did I have this before sleeping on my back...NO! I even have what appear to be centrals (0 leak, no increase in pressure in response to breathing irregulaties), borrowed a friend's oximeter and when I was bumping up against the 100% SaO2, my APAP recorded apneas wo pressure increase leak=0...guess my brain decided I didn't need to breathe.

Guest wrote:...For those who mentioned about full face masks the question I would pose to you is ‘how do you breathe while you are awake?’ If you generally do not mouth breath during wake you should not be mouth breathing during sleep. Again, the PAP machine normalizes your breathing. That is why a full face mask is usually not necessary. When your PAP machine is set at a pressure that is adequate for you, then a nasal mask is all that is warranted. The force of the air travelling through the airway pushes the soft tissue at the back of the throat closed, cutting off its exit through your mouth. So you will not mouth breath. ..

After I lost about 45#s, I was noticeably thinner thru my face and throat area and was losing therapy air via tiny little puffs of air out my lips; my sleep doc had 2 of us the same day complaining of the same thing following significant wt loss. He thought we were no longer able to maintain the integrity of the velolingual seal because we had less tissue. I gave up my beloved OptiLife mask (almost 2 yrs wearing it) and got the Hybrid Universal mask which allows me to mouth breathe with no issues. It's a great mask for side sleepers and at least one poster here wears it in the Falcon sleeping position with great results. With a 30+ yr history of allergies, sinusitis, vasomotor and gustatory rhinitis, the only accommodation for my unpredictable complete blockage from congestion is a FFM and an APAP which varies pressure in response to the status of my congested airways (my obstuctions appear to be in the upper portion of the airway). When I went to the FFM, my CPAP pressure was 11, a 5-night trial of an APAP showed high leak and a questionable 95centile of 6.9-11.4, but I slept so much better using the Vantage with my SpO2 >92% all night with much fewer wakeups that my doc recommended shifting to an APAP. We chose, yes, WE chose, an initial range of 6-15 (showed no centrals in my PSG & 15 gave me plenty of headroom if needed) so I could collect some data and see if I needed to adjust the initial pressure. BTW, my AHI actually reduced when I went from pillows to the FFM. Assuming that sleeping on your back following titration has no effect on AHI at least in my case is wrong. I long for my other shoulder to heal enough that I can go back to side sleeping all night and hopefully stop these dratted apneas and higher AHI. I, like a good chuck of us here, can tell a big difference in how I fell when I wake up following nights with 'low' vs 'high' AHI...I self assess before I log my data so the numbers do not affect my perception of how I feel.

One thing you didn't mention is that hypothyroidism blunts the brain's response to the signal to breathe. Many of us here report being hypothyroid; I had to enlist my sleep doc's help to get my primary to increase my supplemental thyroid for a trial at a higher dosage...my AHI reduced and I felt better, waiting on labs to see the change(s).

Calist wrote:Has anyone in this thread ever run a PSG besides guest and myself?

This litany of multiple personalities has got to stop. "Guest", probably "Guest Tech", "cwied", and "Calist" are the possibly same person. Their writing styles are the same, even lots of the words they use. Most importantly they have the exact same attitude. There is too much coincidence in posting and registration times of all of those users. There may be even more people than that. It doesn't take a total tech nerd to make two or more personalities online and talk with yourself! I have seen it often on boards, and it really irritates me.

What is so important to you that you insist on informing everyone to your satisfaction - even to the point where you have discussions with yourself as two or more people just to get "company"? Calist - why do you persist on telling people what they know is wrong????! Can't you take a hint?

Stop. No more! If I am wrong - I apologize, but I really don't think I am! This board software even recorded Calist also posting as guest until he/she figured out that the board could look at IP addresses, etc. and figure it out. Clearly whoever it is has just used multiple IP's to supposedly "fool" the board software. I have seen this happen many times before on many boards.

Muse-Inc wrote:

Guest wrote:...avoid sleeping on their back...Because the PAP machine has corrected the obstruction and the airway is now open, there is no need to avoid sleeping on your back...sleeping in any position is generally not an issue for people with sleep apnea who are on PAP therapy...

Been sleeping on my side since diagnosis Apr '07, injured my shoulders and hafta sleep on my back...shazam, apneas which I never have, increased leak resulting in higher pressures, hypops 2-3 times more often. Changed hose position, tightened mask a bit to get rid of the leak...no change in the apneas, they just got longer in duration. Started increasing initial pressure (from 7ish to now 9.6) as my 95thcentile rose to the 12s. Got a soft foam cervical collar and that stopped the leaks but aggravated the neck-collarbone pain causing fragmented sleep. Doc cancels the aspirin & puts me diclofenac sodium which helps the pain so I start sleeping in longer sessions. Now, 9 weeks later, I sleep mostly on back and 2-3 hrs/night on the one shoulder that's pretty much healed, wakeup maybe once: I still have apneas, tho my AHI has been reducing & my 95thcentile is back down to the 10ish range. Did I have this before sleeping on my back...NO! I even have what appear to be centrals (0 leak, no increase in pressure in response to breathing irregulaties), borrowed a friend's oximeter and when I was bumping up against the 100% SaO2, my APAP recorded apneas wo pressure increase leak=0...guess my brain decided I didn't need to breathe.

Guest wrote:...For those who mentioned about full face masks the question I would pose to you is ‘how do you breathe while you are awake?’ If you generally do not mouth breath during wake you should not be mouth breathing during sleep. Again, the PAP machine normalizes your breathing. That is why a full face mask is usually not necessary. When your PAP machine is set at a pressure that is adequate for you, then a nasal mask is all that is warranted. The force of the air travelling through the airway pushes the soft tissue at the back of the throat closed, cutting off its exit through your mouth. So you will not mouth breath. ..

After I lost about 45#s, I was noticeably thinner thru my face and throat area and was losing therapy air via tiny little puffs of air out my lips; my sleep doc had 2 of us the same day complaining of the same thing following significant wt loss. He thought we were no longer able to maintain the integrity of the velolingual seal because we had less tissue. I gave up my beloved OptiLife mask (almost 2 yrs wearing it) and got the Hybrid Universal mask which allows me to mouth breathe with no issues. It's a great mask for side sleepers and at least one poster here wears it in the Falcon sleeping position with great results. With a 30+ yr history of allergies, sinusitis, vasomotor and gustatory rhinitis, the only accommodation for my unpredictable complete blockage from congestion is a FFM and an APAP which varies pressure in response to the status of my congested airways (my obstuctions appear to be in the upper portion of the airway). When I went to the FFM, my CPAP pressure was 11, a 5-night trial of an APAP showed high leak and a questionable 95centile of 6.9-11.4, but I slept so much better using the Vantage with my SpO2 >92% all night with much fewer wakeups that my doc recommended shifting to an APAP. We chose, yes, WE chose, an initial range of 6-15 (showed no centrals in my PSG & 15 gave me plenty of headroom if needed) so I could collect some data and see if I needed to adjust the initial pressure. BTW, my AHI actually reduced when I went from pillows to the FFM. Assuming that sleeping on your back following titration has no effect on AHI at least in my case is wrong. I long for my other shoulder to heal enough that I can go back to side sleeping all night and hopefully stop these dratted apneas and higher AHI. I, like a good chuck of us here, can tell a big difference in how I fell when I wake up following nights with 'low' vs 'high' AHI...I self assess before I log my data so the numbers do not affect my perception of how I feel.

One thing you didn't mention is that hypothyroidism blunts the brain's response to the signal to breathe. Many of us here report being hypothyroid; I had to enlist my sleep doc's help to get my primary to increase my supplemental thyroid for a trial at a higher dosage...my AHI reduced and I felt better, waiting on labs to see the change(s).

I really want to reply to this but after that long diatribe I am really burnt out. I know that if I don't reply now however it will be another week before I am back at this laptop. You seem like you have a lot going on with you other than OSA and that is not so great but on the other hand from what you've said it sounds as if your physician is right on top of it. Something to remember however...

CPAP devices which record and report AHI are for novelty purposes only. A CPAP device does not have the equipment, knowledge or capability to actually score an event.

If you were titrated on your side then the pressure that you had is only good on your side. As stated in my rant above, AHI will always be higher on your back. If you could sleep standing straight up, you probably would not need CPAP at all. A techs job is to titrate all obstructive events out while the patient is in supine REM, if however the patient has some sort of medical incapability to be supine during a titration then he can only titrate you on your side and hope for the best. The problem with this is that if the patient ever lays supine he will need a bit more pressure in order to achieve the kind of sleep he got while he was on his side. On average a patient who is titrated on his side will need at least 2 to 4 cwp more on his back.

Any AHI below ten is normal. 15 itself is not that bad.

All in all you seem to be doing fine, working with your doctor and successfully loosing weight. Great job man.

M.D.Hosehead wrote:

Guest wrote:
The force of the air travelling through the airway pushes the soft tissue at the back of the throat closed, cutting off its exit through your mouth. So you will not mouth breath.

Guest, you may be a very pleasant person and dedicated health worker. Most of your patients may be benefiting from your attention.


But, respectfully, if this is your answer to my previous question,

Guest wrote:
However, when the CPAP is set at the right pressure using a nasal mask, the air pressure forces the mouth to stay closed

Guest, this makes no sense. Perhaps you can explain.

you need to review the anatomy. You are imparting incorrect information.


I'm going to the trouble of pointing this out so that others can draw their own conclusions:

1. First you say air pressure forces the soft tissue at the back of the throat to stay open to prevent obstruction.
2. Then you say the same air pressure forces the mouth to stay closed.
3. Finally, you say the same air pressure pushes the soft tissue in the back of the throat to close, which is the opposite of #1.

It isn't logical, and if you care about your patients, as you say, you will go back to the books and check out what you are telling people.

I can see that the way I worded this explanation was confusing. I used the wrong wording. I will clarify:

The reason you stop breathing with sleep apnea is that the soft tissue at the back of the mouth falls down into the airway and obstructs it. With PAP, the pressure that goes into your nose pushes that collapsed soft tissue back into its natural place, restoring its function of sealing off the mouth so air does not escape from the airway. It normalizes the structure of your airway. When you are awake you breathe through your nose. The air travels down your airway into the lungs. The air does not exit through your mouth because, again, the soft tissue has formed a barrier between the airway and the mouth. I could understand how some might think that the air would exit through the mouth if the obstruction were somewhere further down your airway, closer to the lungs. But that is not what sleep apnea is. The obstruction is in the airway at the back of the mouth. There is a nice illustration of this at wikipdia under 'sleep apnea.'

The Guest wrote:

M.D.Hosehead wrote:

Guest wrote:
The force of the air travelling through the airway pushes the soft tissue at the back of the throat closed, cutting off its exit through your mouth. So you will not mouth breath.

Guest, you may be a very pleasant person and dedicated health worker. Most of your patients may be benefiting from your attention.


But, respectfully, if this is your answer to my previous question,

Guest wrote:
However, when the CPAP is set at the right pressure using a nasal mask, the air pressure forces the mouth to stay closed

Guest, this makes no sense. Perhaps you can explain.

you need to review the anatomy. You are imparting incorrect information.


I'm going to the trouble of pointing this out so that others can draw their own conclusions:

1. First you say air pressure forces the soft tissue at the back of the throat to stay open to prevent obstruction.
2. Then you say the same air pressure forces the mouth to stay closed.
3. Finally, you say the same air pressure pushes the soft tissue in the back of the throat to close, which is the opposite of #1.

It isn't logical, and if you care about your patients, as you say, you will go back to the books and check out what you are telling people.

I can see that the way I worded this explanation was confusing. I used the wrong wording. I will clarify:

The reason you stop breathing with sleep apnea is that the soft tissue at the back of the mouth falls down into the airway and obstructs it. With PAP, the pressure that goes into your nose pushes that collapsed soft tissue back into its natural place, restoring its function of sealing off the mouth so air does not escape from the airway. It normalizes the structure of your airway. When you are awake you breathe through your nose. The air travels down your airway into the lungs. The air does not exit through your mouth because, again, the soft tissue has formed a barrier between the airway and the mouth. I could understand how some might think that the air would exit through the mouth if the obstruction were somewhere further down your airway, closer to the lungs. But that is not what sleep apnea is. The obstruction is in the airway at the back of the mouth. There is a nice illustration of this at wikipdia under 'sleep apnea.'

Sleep tech Guest! What state are you in?

Calist I am in Florida

The Guest wrote:Calist I am in Florida

OMG! Get your patient up! It must be at least 6am over there!

6:03 to be exact. But I am not working. Just happen to be up.

Guest/Calist/Whoever you are... you blithely say that stomach sleepers have an AHI of over 40, but what are you basing it on - your personal research of patients in your facility or something else? Stomach sleepers often do a lot better than others because while their original need to sleep that way was greater, the position is so 'helpful' that their numbers are lower than either back or side sleepers (from testimonials of forum members). While I don't normally think testimonials are good for much (especially if you're a snake oil salesman), in this case it's a matter of mechanics as much as anything, backed up by computer interpretation of data collection.

In another thread someone said that I am calist. That is news to me. I do find it ironic that I am also called a troll. The definition of troll is someone who intentionally disrupts a community by posting provocative messages. I was not trying to be provocative. In fact, I thought that simply relaying some basic medical information was a responsible and helpful thing to do. But you will all be happy to know that if I am viewed as disrupting your community then I will take that as my cue to exit. I have a feeling though that calist will stay around, as he does not seem to be affected by your blasting of him. And the poster in another thread that said calist and I are the same of course has no proof but presented that as fact. Feel free to check my ip address. My message to calist would be that this is apparently an inappropriate forum for his efforts. I wish you all good sleep health. And to the one individual who privately welcomed me to this forum I am especially thankful.

Julie wrote:Guest/Calist/Whoever you are... you blithely say that stomach sleepers have an AHI of over 40, but what are you basing it on - your personal research of patients in your facility or something else? Stomach sleepers often do a lot better than others because while their original need to sleep that way was greater, the position is so 'helpful' that their numbers are lower than either back or side sleepers (from testimonials of forum members). While I don't normally think testimonials are good for much (especially if you're a snake oil salesman), in this case it's a matter of mechanics as much as anything, backed up by computer interpretation of data collection.

Yeah I'm not guest but we both appear to be sleep techs. Actually I have come to notice that at night when I'm on there seem to be a lot of sleep techs on and in the daytime the place is full of patients. Kinda funny.

I blithely said that stomach sleepers have an AHI of over 40. That was not based on anything in particular. Personal observation, it really isn't written in stone. I would address that more but more important is your second sentence where you said

Stomach sleepers often do a lot better than others because while their original need to sleep that way was greater

You are implying (much like thousand upon thousand of patients before you) that stomach sleepers are some different breed of human that are (sarcasm) genetically disposed to sleep a certain way and others are not. You need to understand that both myself and possibly sleep tech guest see patients not in categories of positional sleep but instead of severity of sleeping disorder. A person that sleeps on their side will eventually sleep on their stomach if they live with apnea a while longer where as a person who sleeps on their stomach (that has untreated apnea) will eventually move to a recliner chair if and when the apnea gets even slightly worse.

A person that is correctly titrated in the supine position should not notice any difference whether they sleep on their side, stomach, chair, or back. Their AHI (real AHI not Paykel Fischer CPAP reported AHI) will remain at Zero. If however a person is titrated on their side and not on their back then they will not be able to ever sleep on their back with out having 'some' events because the amount of pressure required to ensure their airway will be insufficient as they were titrated on their side. This is why sleep techs are so adamant about getting patients to sleep on their backs during a titration. It is so that they can get a titration pressure during a patient's worse case scenario and thus... on that pressure, it will no longer matter what position they sleep in.

Stomach sleepers often do a lot better than others

Don't just start making statements. You have to understand that everything we are talking about here in this forum is not speculation, it is either a proven fact or it is not. Do you have anything to back that statement up? Are you going to publish a paper which is going to rock the medical community? Am I going to see your name in the new england journal of medicine next month? Let us proceed carefully.

in this case it's a matter of mechanics as much as anything, backed up by computer interpretation of data collection.

We are talking about medicine here. Not common sense assumptions regarding abstract concepts in a high school anatomy class. If you would like to see what I am talking about in action, come on out to my lab or better yet, go to any sleep lab in your area and befriend a sleep tech. Ask him to show it to you. Even then you will not have begun to approach the decades of research which have been done on OSA. Don't get me wrong, I am all for challenging fifty years of research but please know what you are challenging before trying to argue this.