Low AHI vs. Leaks??

I am 5 weeks into this and have been totally tired and dragging. I'm struggling to find a mask that works and the closest I've come is the little Petite Wisp with a FP diffuser taped over the exhale port. It does not even come up to the bridge of my nose and is a little small at the nostrils but that seems to reduce the terrible swelling in my eyes and face compared to the larger Wisp and the Eson. I am getting AHI below 1 or 2 (in fact, with all masks I've used ever since night #1) but the leaks or sometimes mouth breathing wake me up frequently. I presume I am so tired because I cannot get a good night's sleep, maybe only two since I started. I think I can sleep with this mask finally, getting used to it a little. But, there are lots of leaks showing on Sleepyhead and some that may be mouth breathing. Someone here said not to worry about leaks so much if you are getting good AHI and sleeping. Can folks confirm that? Maybe I'll sleep better if not worrying so about leaks. My hands and arms are sore up from holding my head just right on my pillow (side sleeper always) or the mask where my head rests on my hands with mask between them. If I could relax a little maybe I would not be dragging so. Never had this tiredness before CPAP. Advice or help or confirmation that leaks are not such a big deal when AHI is below 2? My sleep test it was 60. Thanks so much to everyone who has been so great!

Any leak that wakes a person up...even if tiny...is unwanted because it disturbs sleep...So it needs to be fixed.

Same deal with the mouth breathing. If it is disturbing sleep....it needs to be fixed.

Now in terms of "is the leak big enough to negatively impact therapy if I slept through it"??.. That's where you look at the leak line graph to see just how much leak (no matter the cause) might be above 24 L/min and/or how long it spent above 24 L/min.
I am not going to sweat 15 minutes of leak in large leak territory a couple times a night if I slept right through it. So it depends on how big and how prolonged whatever the leak is caused by that is up in large leak territory.
For me trying to fix 15 minutes of mouth breathing would cause more sleep disruption and problems than just letting it happen. Most of the time it doesn't go too far into large leak territory anyway. It's not like you totally lose all therapy value at a leak of 28 L/min anyway.

decatur11,

The answer to How much do I need to worry about leaks? is It depends.

We really need to see the leak line.

On the one hand: Some of the leaks are waking you up, and as pugsy says, any leak that wakes you up has to be dealt with. Sometimes the answer to dealing with small leaks, however, is loosening the mask and not getting so worried about them and simply allowing yourself to more thoroughly relax and get some sleep.

On the other hand: You say some of the leaks could be mouth breathing (which can be serious) and you say you've had problems with your eyes and face being swollen, both of which can be signs of some serious mask leaks up around the top of the mask. And these leaks may be large enough and long enough to adversely affect your therapy and the ones leading to the swollen eyes and face are certainly affecting your comfort.

Hence seeing some leak lines would be really, really helpful in diagnosing your leak problem.

You also write:

Maybe I'll sleep better if not worrying so about leaks. My hands and arms are sore up from holding my head just right on my pillow (side sleeper always) or the mask where my head rests on my hands with mask between them. If I could relax a little maybe I would not be dragging so. Never had this tiredness before CPAP.

You definitely need to work on finding a more comfortable sleeping position. You should NOT need to have to use your hands and arms to hold your head "just right" to the point where they are sore just to keep the leaks down if you've got a really good seal. It's a common (newbie) assumption that you've got to be extra, extra careful about moving around in bed or you'll jar the mask and break the seal and everything will go to hell in a handbasket. But the fact is, if you've got a really good seal on a well fitted mask, you really can move around pretty naturally in bed without doing any serious harm to the seal. (And I remember it took me months and months to figure this out when I was a newbie.) Sometimes using a hose hanger helps with making it easier to move around in bed and get comfortable without seeming to constantly trigger leaks. Sometimes routing the hose under the covers and next to your body helps. (I hug my hose like a stuffed toy snake a lot of the time.) But sleeping in a genuinely comfortable position is critically important---as long as you're sleeping in a position that seems artificial, it's difficult to get fully relaxed and into as much deep restorative sleep as you need.

So---on the one hand, you do need to be looking at the leak lines carefully. And post some here.

But on the other hand: Once you've gone to bed for the night, forget about leaks until the next morning unless one wakes you up.

If the data shows you are leaking all over the place night after night, then you need to regroup and start strategizing about how to fix them based on the most likely case. But if the data shows the leaks aren't bad and they're not waking you up, then you can safely forget about them.

Robysue, I could post some of my leak pictures but need to know a little more. I check Sleepyhead every morning for everything, including leaks. Problem is,each day the vertical scale on the graph changes in relation to the biggest leaks so, visually, they are not comparable from day to day. I can take a few pictures but do not know what I'm looking for, that is, what is a significant leak for my equipment. Since AHI is less than .5 all night, I have not worried from that standpoint but I am trying to solve the constant tiredness and think it is my just having disturbed sleep. I know from Pugseys notes that leaks with a wide top are likely mouth breathing. I might have a couple of those for 5 or 10 minutes twice a night, usually early morning. The pressure is not going up very high above my 11 goal, maybe only to 12, so the machine doesn't seem too worried, Is it for the machine or the specific mask that I can learn what "leak level" is built in vs significant? Maybe, knowing that, I can pick out some leak graphs and figure out how to post them for you to review. Huge Thanks!!

decatur11 wrote:what is a significant leak for my equipment

Above 24 L/min. Hard to see when the axis is high but you can momentarily click and drag on the bottom line of the graph to pull the graph much taller so that you can have a better idea where 24 L/min is...or pick 25 L/min...just get close.
Hover mouse cursor on the bottom of the graph line until you see a little short double line...then click and drag downward to expand the graph so that you can see the graph numbers more zoomed in.

Robysue, I looked back at my 5 weeks of sleepyhead reports to see the leaks. Other than the first couple of nights, and since then just when getting up or messing with the mask where the line jumps up real high, there are rarely any values over 24. Is the number 24 for all masks? I had the SwiftFX listed but quit that for now; was using Eson for part of the time and now switching between Wisp petite and small/medium. So, I changed my mask below on my equipment listing. Where do I find the leak values for different masks if it is not 24 for all of these?

If I am consistently below 24 and that is a good number for them all, do you still need to see some? I have a lot of good ideas from you and others here: relax with the hands and arms, move around more freely, let the mask puff itself up and not strap it down so tight, and probably most important for a dedicated side sleeper, though I cannot imagine it, get one of those pillows. I'm also thinking mask liners might make any one of my masks more tolerable.

The other sleepyhead one I am worrying about now is Flow Limitation. I never figured out what that is. Does is indicate something less than AHI but could be keeping me so tired? I'm sure it is written up somewhere; Pugsy sort of discounts it I think but I am into learning all I can and this one has me stumped as I seem to have a lot of them but don't really know what "a lot" is.

Actually I don't discount Flow limitations at all. They are very important as they are a reduction in air flow that when in APAP mode the machine will try to address or fix with more pressure.
It all depends on how many and/or how much of a reduction for how long.

Yes...24 L/min is the line in the sand where ResMed says the machine starts to lose ability to sense, respond to and identify the types of events to be flagged. It pertains to all mask types.

decatur11 wrote:Robysue, I looked back at my 5 weeks of sleepyhead reports to see the leaks. Other than the first couple of nights, and since then just when getting up or messing with the mask where the line jumps up real high, there are rarely any values over 24. Is the number 24 for all masks? I had the SwiftFX listed but quit that for now; was using Eson for part of the time and now switching between Wisp petite and small/medium.

Since you are using an S9, the Large Leak border is 24 L/min for all masks. The S9 subtracts off the intentional leak rate for your mask automatically. You should check the mask setting on your machine, however, since that controls how much the S9 subtracts off the leak data before recording it to your SD card.

So, I changed my mask below on my equipment listing. Where do I find the leak values for different masks if it is not 24 for all of these?

Because you are using an S9, you don't need to worry about finding the leak values for individual masks. On the S9, the number you want to keep the leaks below is 24 L/min.

If I am consistently below 24 and that is a good number for them all, do you still need to see some?

Nope. If your leaks are pretty consistently below 24 L/min, then we don't need to see them---you don't have a Large leak problem to worry about.

I have a lot of good ideas from you and others here: relax with the hands and arms, move around more freely, let the mask puff itself up and not strap it down so tight, and probably most important for a dedicated side sleeper, though I cannot imagine it, get one of those pillows. I'm also thinking mask liners might make any one of my masks more tolerable.

Yes---work on doing whatever it takes to find a more comfortable and more natural sleeping position.

I'm also a dedicated side sleeper. Pre-cpap my favorite sleeping position was curled up in a very tight fetal position with my nose stuck in hubby's underarm. It took me months to figure out that I could sleep with my head butted up against my hubby's side or hip (with my head under the covers) and that that position felt "natural" enough for me to actually feel like I got some real sleep in the morning rather than waking up exhausted like I'd felt like I'd been fighting with the machine all night.

The other sleepyhead one I am worrying about now is Flow Limitation. I never figured out what that is. Does is indicate something less than AHI but could be keeping me so tired? I'm sure it is written up somewhere; Pugsy sort of discounts it I think but I am into learning all I can and this one has me stumped as I seem to have a lot of them but don't really know what "a lot" is.

I'm with Pugsy on this one. Flow limitation is not worth worrying about (yet) if at all. Technically speaking, a Flow Limitation is a change in the shape of the inhalation part of the flow wave curve that may indicate the upper airway slightly compromised (i.e. the upper airway may be at some risk of narrowing or collapsing). AutoPaps will raise the pressure in the presence of flow limitations. Some people think that flow limitations may cause some restlessness or be related to UARS arousals. But unless the Flow Limitation graph is really, really ragged, it is not worth losing sleep over.

This is so great to have all your help! Robysue and Pugsy, is there a standard re flow limits like for there is for leaks that I should know as I review mine? I do have my machine on a variable pressure so I assume it would react if needed. But I don't really know what these RERA's are, and since I'm so tired I'm fishing around for something to explain it. I think they may be flow limitations but am not sure. I could not understand the definition of FL on sleepyhead and sleepyhead does not appear to use the term RERA. If this is written up somewhere, let me know as I hate to take your time explaining something I can find easily.

No, there is no standard that we can easily refer to in regards to evaluating Flow limitations at least on the S9 machine because it reports FLs in such a manner it isn't easily evaluated. The S9 gives us a graph and generally if it is really active and ragged looking then we assume considerable flow limitations are going on.
Respironics machines will flag the flow limitations just like you see obstructive apneas or hyponeas flagged and it makes for a little easier evaluation as to whether they are a potential problem because if we see a bunch of them flagged then we know that there's a potential source for a problem or symptom.

RERAs are a Respironics only flagged event and to be honest I don't know how much real value is there just yet.
Your S9 won't flag them at all. So you won't see RERAs flagged on your S9 reports.
Generally when we see a lot of RERAs we tend to ask the question....how is your sleep quality...do you wake often during the night and a lot of the time we hear that people are waking a lot so it maybe a tool for evaluating sleep quality.

The SleepyHead glossary
http://sourceforge.net/apps/mediawiki/s ... r_Glossary
is composed of the definitions taken from Respironics and Resmed literature along with some general terms. So it's a combination glossary.
RERA and flow limitation both have definitions in the glossary...have you seen the glossary?

Hi, Yes, I saw the glossary and definitions of FL but I couldn't get any meaning from them. I'm thinking a flow limitation is any time you move or change your rate or volume of breathing so I'm not sure it means anything. But, if it means my throat is closing down but not enough to count as an A or H, then that is not good. My FL charts almost always are very ragged and very active with a whole lot going on. I know I must not be sleeping well or I wouldn't be so tired but not sure how to take from the FL chart via ResMed and Sleepyhead how the two relate. I don't know if it is a subclinical problem or just reflects a lot of jumping around, tossing and turning and fiddling with mask. I think the FL graph movements are way too many to be awake times since I do sleep for quite long periods without conscious disturbance. Maybe I should have you look at some of my charts; does that seem like a next step?

I am not so great with Flow limitation graphs under the microscope because I just haven't studied the very minor changes in each breath's flow to understand the minute differences with the ResScan reports.
I have used a S9 machine but the bulk of my experience has been with the Respironics machines and they flag Flow limitations as a specific flagged event which makes it easy to spot and look at but the other part of it is that I don't have many flow limitations to look at. My flow limitations with the Respironics machines and my S9 have been totally boring so there just hasn't been much there for me to study.

Have you seen this ResScan guide?
http://www.resmed.com/us/assets/documen ... er_eng.pdf

You know that there is some discussion in the UARS camp about flow limitations too...Upper Airway Resistance Syndrome.
Have you read up on it?

Have we actually seen one of your flow graphs? I looked back in this thread and didn't see on. Can you post a couple of detailed reports showing your FL graph? Not just for me but for others who perhaps better understand FLs under the microscope.
All I know is that when we see a lot of FLs there's a good chance that arousals may accompany them and we don't have to remember them but they sure mess with sleep quality and how we feel.

Here's one of mine...and it's a ResScan report if that is what you want to look at. Compare yours to mine.


Here's another one from SleepyHead. This is why I never dug deep into learning the finer points of FL evaluation. I just didn't need to.


Mollete is who we need to evaluate FLs. Maybe some of his explanation will help you understand.
viewtopic.php?f=1&t=88204&st=0&sk=t&sd=a&start=45

AHI data from an S-9 with high leaks is falsely low.

Fix the leak issues first and then you can trust the AHI data.

jaycee wrote:AHI data from an S-9 with high leaks is falsely low.

Fix the leak issues first and then you can trust the AHI data.

The OP reports that leaks consistently stay below the 24 L/min Red Line even at their highest. High leaks are NOT the problem

Pugsy, mine are much wilder than yours. I tried inserting pdfs of 3 cropped sleepyhead screenshots in among the text in a reply but it didn't seem to work. How did you get those to pop into the message itself?