Re: Newbie Qs: Leaks

I've been using my S9AutoSet for 3 weeks. My sleep doc left it wide open @4-20, and I've narrowed it a little at a time. The pressure doesn't bother me. I always have leaks. I'm on my 3rd mask (a nasal one), and like it pretty well. My 95% is always 20-30l/min. I've yet to sleep through the night.

Questions:
-- In my home sleep study, I had zero CAs, but since then I always (every single night) have more CAs than OAs! Any ideas why?
-- Does anyone ever get to the point where their mask doesn't leak at all? I think some of mine is mouth breathing - I wake up once per night for a sip of water. I'm not ready for a chin strap or tape or a FFM...
-- I've tried both size S and size M on every mask (pillows, cloth, nasal) I've used, which tells me I don't know how to fit them. I've watched the videos, used the mask fit lying down on the machine, and still don't really know how to tell which size is right. I always tend to like the feel of the smaller one, but don't see a leak pattern.

Last night's data: https://www.dropbox.com/s/9vgm0iu5ddj38l9/20131005.JPG
Thanks in advance for any help, Jean

Hi Jean,
Far as your CAs are concerned; My guess would be that you're just looking at the difference in how the machine scores apneas. I wouldn't get too concerned about it at this point. But after getting all your other problems ironed out and you're still having lots of centrals...then talk to sleep Doc. By the way, everybody has a few centrals. There's a period of breath regulation instability as you transition into deep sleep and some CAs are an insignificant occurance at that point.

Far as mask fit, no mask is without some difficulty but some people get by with no major leak issues. After much wrangling I do well with the FF Quattro. I found nasal masks uncomfortable but only tried a few. Seek out people who have used your mask for awhile. That's your best source of info.

Far as sizing, the masks usually come with cutouts to fit on your face. Those never steered me wrong.

Good luck and I hope some of this was useful,
Jamis

Looking at your leak graph, it looks like you have essentially no leaks at all.
The software appears to be reporting total leaks, not just the unintended ones.
CPAP masks are designed to leak a certain amount of air in order to purge the CO2 you exhale.
So, depending on your mask AND the actual pressure at any particular time, the mask will allow between 20L and 45L of 'leak' to occur. That's perfectly normal.

CA's don't mean much unless they have significant durations. I've had quite a few wih a duration more than 45-50 seconds with a few over 60 seconds. That's why I have recently switched to an ASV type machine.

BTW for a feel for what that means, take a moderate breath, breathe out, and then hold your breath for 30 seconds or so. That used to be me several times a night - the few you are seeing that seem to be short are no cause for worry.

JDS74 wrote:Looking at your leak graph, it looks like you have essentially no leaks at all.

Not totally. It looks like minimal leaks due to the scale of the graphs. We are zoomed way out in this graph because of the big spike.
Actually there are times where the leaks are indeed very significant...look at the first line on the graph above the baseline...it's 55 L/min and she gets real close to it often and spends a good bit of time about half way there and that would be around 25 L/min.
To see just how much time was spent in large leak this would be better seen on a ResScan report where we have a nice red line to look at to see where 24 L/min mark is no matter what the scale happens to be.

JDS74 wrote:The software appears to be reporting total leaks, not just the unintended ones.

Not correct. The S9 only reports excess leaks and thus that's all that SleepyHead can report. All the leaks shown here are excess leaks above the expected vent rate.

Now your PR S1..yes it reports total leak and the vent rate is included but it is not that way with S9 reports.

Jean is indeed having significant leak issues here....for 2 reasons...1 being that there's evidence of a good bit of time spent above 24 L/min and also because the leaks are waking her up because she senses them.

Jeannh wrote: In my home sleep study, I had zero CAs, but since then I always (every single night) have more CAs than OAs! Any ideas why?

I suspect that the majority of your CAs are awake/semi awake breathing irregularities. Especially the first 2 large clusters of CAs last night. I bet you had trouble getting to sleep and staying asleep. Anytime we see clusters of CAs very near times where the machine was turned on or off we pretty much suspect awake breathing getting some flags by mistake.

It's entirely possible that the large leaks you are seeing are indeed related to mouth breathing. I would want to see a ResScan report to get an idea just how much time you spent above 24 L/min to have a better idea just how much the mouth breathing might be impacting your therapy. I don't get all that upset about a small number of times where large leak territory is maybe reach or surpassed as long as it doesn't last very long and doesn't wake a person up. I am thinking that you have quite a bit of time where you exceed 24 L/min and you have it happen more often than I would want to see and you sometimes get really close to the 50 L/min mark and at that point the therapy will be significantly impacted.
In other words the higher the leak past the 24 L/min mark the greater the negative impact will be.
5 minutes not that big of a deal unless you have a lot of those 5 minutes and I am thinking that you do.

To find out for sure if mouth breathing is the culprit you will need to tape your mouth to know for sure.
If that scares you then you might try partial taping or chin strap to get an idea but partial tape or chin strap doesn't always keep the mouth closed.
Once you know for sure if mouth breathing is indeed the culprit then we need to really look closely at how much time you spend in large leak territory and how far you go. Then you can decide if you need to do anything about it...should something need to be done.

Do you want to get ResScan so that we can get a better idea just how bad those leaks are? Send me a private message if you do.
Also if you will try to avoid taking the mask off with the machine running then you will avoid those large leak spikes that you see that are making it hard to see the leaks up close. That large leak spike at around 2:00AM totally throws off the whole scale of the leak graph.

I would want to see a ResScan report to get an idea just how much time you spent above 24 L/min to have a better idea just how much the mouth breathing might be impacting your therapy.

I have ResScan - attached the last couple of nights -

Also if you will try to avoid taking the mask off with the machine running then you will avoid those large leak spikes that you see that are making it hard to see the leaks up close.

I do that for a bathroom break. I thought the machine could ignore very short breaks. Should I be turning it off?

https://www.dropbox.com/s/70q67x106eskq ... 04_res.JPG
https://www.dropbox.com/s/b116v2gf2m2vi ... 05_res.JPG

thank you!! Jean

Jeannh wrote:I thought the machine could ignore very short breaks. Should I be turning it off?

Even if it turns itself off shortly after you get up and leave the machine off it will flag that very brief large leak when there was no breathing.
It's not critical usually that it be turned off unless that spike is messing with the scale of the graphs.
It's more of an issue with SleepyHead than with ResScan.
The machine doesn't ignore that spike. It gets flagged as maximum leak no matter how brief. I had the same thing happen with my PR S1 machine yesterday morning when the hose became disconnected.

Looking at your ResScan reports it's clear that you go past the red line fairly frequently but you don't spend huge prolonged periods of time in large leak territory. While it isn't the prettiest of leak graphs I imagine that you still see Mr Smiley face for mask fit. I doubt you spend 30% of the night in large leak territory and that is what it takes for Mr Smiley to change to Mr Frowny.

Normally mouth breathing is less spikey and shows up more with a leak with a plateau. Very brief spikes are usually mask movement of some sort. It's hard to tell for sure though unless someone tapes their mouth and the tape is still secure in the AM...then a person knows for sure if there are any leaks they couldn't be from the mouth.
The Sunday Oct 6 report...look at the very last leak around 3:30 right before the machine was turned off...that plateau probably indicates mouth breathing. It's below 24 L/min though so if you were mouth breathing it probably wasn't with a wide open mouth where all your therapy was blowing out your mouth.
It doesn't take much mouth breathing to dry out the mouth. I know that for a fact because I have woke up mouth breathing with my mouth feeling like the Sahara and when I look at the leak line the leak was minimal and short lived. So dry mouth doesn't always mean massive mouth breathing like some people might think.

Your leak line isn't very pretty but for the most part you stay below the red line. If you were sleeping through the leaks I would suggest that you ignore them but you aren't and they are certainly large enough and frequent enough to be causing you to wake up and those wake ups are definitely unwanted. So for that reason I would suggest trying to reduce the leaks (whatever is causing them) so that you can get better quality sleep. Fragmented sleep for any reason is unwanted because it totally messes with the normal sleep architecture and stages that we need to get for the restorative powers of sleep to do their job.
The leaks could very well be causing the wake ups and thus impacting your sleep quality. Since you spend the bulk of the night below 24 L/min leak line then the leaks may not be negatively impacting the actual therapy itself all that much but sleep quality is just as important and the therapy is.

Also remember that anytime you have wake ups and then go back to sleep...you also have another sleep onset period and with each sleep onset period we have the chance of having sleep onset centrals and those centrals are typically ignored unless they present in excessive numbers, cause desats or totally prevent progression from sleep onset into the next stage of sleep.
At this point given what is seen on the reports I wouldn't worry about the centrals. I think the bulk of them are either awake breathing getting flagged and/or a few sleep onset centrals thrown into the mix.
I wouldn't worry about the centrals until I was sleeping through the night without the wake ups (for whatever reason) and if they are still present in larger numbers than we would like to see ...then worry about them.

First order of business though is to do what you need to do to stay asleep.

Question for you...when you get up in the middle of the night to pee...is the bladder full and uncomfortable or just you wake up for whatever reason and decide you might as well pee while you are awake and do you normally have to go pee often during to the day?

I imagine that you still see Mr Smiley face for mask fit.

Right!

First order of business though is to do what you need to do to stay asleep.

Yes! Yes! I'm pretty desperate for a decent night's sleep....

Question for you...when you get up in the middle of the night to pee...is the bladder full and uncomfortable

Uncomfortable, yes. Much volume, no. I drink a lot of water during the day so pee pretty regularly, but I'm careful to cut it back after 4pm.

Thanks for your ideas. I'll try to think about taping, but a chinstrap seems pretty daunting since even headgear wakes me up slipping around and pulling my hair. I could also try something to hang the hose, which maybe is pulling on the mask when I turn. I'm trying hard to remember that there is a light at the end of this tunnel- Jean

Ok- gulp- I think I'm desperate enough to try taping. How do you do it? Does it leave marks on your face ? Might denture adhesive work also?

I've got to sleep more than a few hours at a stretch!
Thanks very much, Jean

Yes, you can try Polygrip (or similar) if you wish. I tried it but it was nasty tasting.
The idea is not to cement your mouth shut...just make it a little more difficult for the mouth to fly open.

I used cheap old blue painter's tape left over from a painting job. They do make a "delicate" version of it but I didn't have any trouble removing what I used. It fits snug enough to remind the mouth to stay shut but a good yawn will break the seal if someone really tries.
We don't want to cement our lips together. We just want a gentle reminder for them to stay shut.
Also practice putting your tongue in the roof of your mouth often during the day as this helps keep the air from entering the mouth via the airway and causing inflation of the cheeks (chipmunk cheeks) which then pretty much means the air has to exit through the lips.

I never had any problems with tape residue or stuff like that but if your skin is really sensitive or paper thin then you might like a more delicate paper tape.
You can even just do a strip vertically over the center of the lips to start with if it creeps you out too much.

You can even just do a strip vertically over the center of the lips to start with if it creeps you out too much.

Starting here!

Jeannh wrote: Starting here!

Thought you might and that's why I mentioned it. For some people that little bit of tape is enough of a reminder for the lips to stay shut.

What I did when I first decided to tape after numerous chin strap failures...was I put the tape on and set down and just played with breathing to see if I could breathe okay if the power went off...it was a bit stifling but not horrible.
Then I played with opening my mouth on purpose just to see how much force it took to get the mouth open so I could breathe through my mouth if I just had to. A yawn will do it. So I taped horizontally...first night of taping wouldn't you know it but we had a big old summer thunderstorm and yep...the power went out. I woke up (no distress at all) thinking...man it's awfully quiet....why is there no machine noise....oh...no light on the clock..hmmm thunder...yep power went out. All this time I was breathing through my nose with mouth closed. It wasn't difficult..just a bit stifling but really no worse than it was when I was trying 4 cm pressure.
So anyway I just removed the mask and waited till the power came back on to go back to sleep.

So all my "tests" were easily met. I won't suffocate if the power goes off and I can open my mouth easily just with a yawn force if I need to. Don't need my hands.
I did tape for about 2 months or so then I started getting lazy and "forgetting" until after lights out and machine on. After a while I just quit for a week or so and when I was evaluating my leak graphs I saw that for the most part the leaks weren't all that bad.
So I never bothered with tape or whatever after that.
Even now I probably open my mouth a little but it isn't for long and most of the time I don't get to large leak territory and it doesn't wake me up so I don't care. If it woke me up or I was spending prolonged times in large leak territory then I would probably try to do something about it but I don't care if my leak line is perfectly flat or not.

Well, I tried it. The first night, I tried little pieces of tape vertically. I popped those puppies off in about a minute. I replaced it with a big piece of horizontal paper tape all the way across. It didn't feel that bad. I woke up in the middle of the night with the tape in the bed, mask still on. The second night, I tried a different kind of tape. In the middle of the night, I woke up with the tape on, the mask in the bed. The third night, both stayed on. Each of the three nights, I have gaps in pressure in Sleepyhead, so even if I didn't notice it, I must've taken off the mask, and put it back on.

Every taped night, my leaks still went over the the red line. Not as much, and I felt the chipmunk cheeks a lot. Over or under the red line, I still had lots of leaks. Also, lots of gas and bloating during the day - is that related to taping?

So, how do I know if the tape is helping? I can wear it if it will help, but it seems silly if it won't. And, if tape won't help, what's next? Could I be having mouth leaks if the tape is still secure in the morning? Thanks for any help -

Data:
https://www.dropbox.com/s/xm7ykzf4jz1wv ... 08_res.JPG
https://www.dropbox.com/s/p3087olefwozg ... 09_res.JPG
https://www.dropbox.com/s/8aovs7smr43x3 ... 10_res.JPG

Jeannh wrote: Could I be having mouth leaks if the tape is still secure in the morning?

If the tape is secure in the morning then the leaks you are seeing are NOT from the mouth. So that leaves mask movement and you are correct..there's not any significant improvement with tape. When people tape and the bulk of the leak is through the mouth that leak line stays flat. Yours doesn't. Taping in your case didn't significantly alter the leak line so if it were me I would concentrate on the mask fit itself since taping increases the aerophagia I wouldn't tape since there's no clear cut advantage at this time.
The tape trial was really just to try to isolate the leak cause and if the tape is secure in the AM...that leak has to be from somewhere other than the mouth. Of course if the tape has come loose all bets are off.

OK, I'm officially confused. Last night I wore the tape until about halfway through the night, then tore it off (it was still secure). My AHI was an all-time record low: 1.54. However, I don't see any relationship between the leaks and the AHI or the Events. I still leaked all night, and had large periods with NO Events!

Questions:
-- Note the big periods with lots of leaks but NO events! I thought leaks reduced therapy, and so caused events. Do I have that wrong?
-- Does it make sense to use some kind of 2-sided tape on the mask to prevent it from leaking? Or some kind of glue that doesn't hurt your skin? Hhhmmm, maybe Tegaderm (which I know seals tight and causes no skin irritation), although that would get expensive....
-- In ResScan it always notes I have duplicate data and asks if I want to Overwrite or Discard. Seems like I should get the same result. Does it matter?
-- In Sleepyhead, I often see breaks in Pressure, which I originally thought meant I took the mask off to pee. But they don't seem to correspond, either in frequency or timing (unless I pee in my sleep). Are there other reasons why Sleepyhead would show periods of NO pressure?
-- What's the blue vertical line in ResScan?

Data:
https://www.dropbox.com/s/8qvmoa7p6cx5k ... events.JPG If you cannot see the right graph, use the arrow keys.
https://www.dropbox.com/s/ydevbzmzemo11 ... _leaks.JPG
https://www.dropbox.com/s/hhlgzy0yaamyb ... 0leaks.JPG

Sorry for the endless questions - I'll get it soon. Also, I see the pulmonologist on Monday, so trying to get my ducks in a row... Thank you thank you, Jean