Pugsy's Pointer's #3-Dealing with therapy bumps in the road

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Pugsy's Pointer's #3-Dealing with therapy bumps in the road

Post by Pugsy » Sun Nov 24, 2013 1:16 pm

Another installment coming up on dealing with some of the common therapy bumps in the road that pop up. Got the idea after having to explain for the upteenth time about condensation in the nasal pillows at the mask level only which can happen even if no humidifier is used. People in the high desert using no humidifier can and do still get rain out at the mask level.

So first bump in the cpap road will be rain out/condensation in the hose or mask or both.
Coming up shortly when I get it composed. As before I am going to block off a section of posts so I can keep all my thoughts together and in one spot with not a lot of other discussion mixed in so as to not cause confusion. After I am done feel free to add your thoughts if you wish.
Or if you have a question right now....please just start your own thread so your problem gets the attention it deserves and doesn't get lost here.
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Re: Pugsy's Pointer's #3-Condensation in the mask

Post by Pugsy » Sun Nov 24, 2013 1:16 pm

Rain out/condensation in Nasal pillows or masks strictly at the mask level and not in the hose.
Rain in hose will be covered separately.

Moisture from our own breath often will condense in the nasal pillow barrels because the bedroom air is cooling the air that is in the nasal pillows. Putting the machine below the mattress won't help this form of condensation because of the nature of the shape of the barrel...the condensation can't go anywhere because it would have to go up hill and water can't run uphill. If we are routing the hose over our head with some sort of hose management system...it only makes it worse because it makes even a steeper hill for the moisture to try to climb. Just look at the physics of water and how it has to run.
What we have to do is keep the air warmer (by some method) in the nasal pillows so that it does not cool and release the moisture.

So what we need to do is figure out some way for the warm air coming from the heated hose to keep the air in the nasal pillows warm enough to prevent the cooling to the point that moisture is released and condensation occurs.
Several things to try. If you have a heated hose...
For S9 users....Try 80 plus degree hose temp...For PR S1 heated hose users...increase the temperature setting....warmer air holds more moisture than cooler air. The idea being if the air is already warmer coming from the long hose up through the short hose (where it is going to cool to some extent) then hopefully by the time it reaches the nasal pillows it will still be warm enough to still hold the moisture.
A lot of this depends on bedroom temperature. The reason we see so much rain out issues in the winter is we simply use lower temps at night in the bedroom. If you were like my mom and want to keep the house at 78 degrees in the winter...there wouldn't be any rain out problem but most of us (me included) wouldn't be able to sleep with the house so warm.
So the next thing we could try is maybe a little more heat to the bedroom in general. If you can stand a warmer room..warm it up with a space heater or up the thermostat.
You might also use a short hose cozy to help insulate the short hose and lessen chance of the air cooling in the trip from the heated hose to the mask.
You might also use a barrel cozy from Padacheek.com
http://www.padacheek.com/PACSwiftII_Barrel_cozy.html
I bought one of these in Feb 2011...best money I have ever spent on a comfort item. It helps a LOT and is super comfy against the skin. Still using that same one too...I modified it a bit to fit over the barrel of my Tap Pap nasal pillow mask because I still get rain out there because of my cold bedroom temps and my preferred high humidity setting..even with a heated hose set to max temp.

This will be my 5th winter dealing with rain out at the mask level...it's easy to fix at the hose level but hard to fix at the mask level.
I have tried different methods over the years and the heated hose with the barrel cozy is probably the best option for dealing with rain out at the mask level. I haven't had to use a short hose cozy myself with this arrangement.
The heated hose lets me do away with a heavy hose cozy on the long hose...not that it was that big of a deal but with nasal pillows any added weight tends to tug on the nasal pillows and that's a potential problem with seal and fit and comfort.
The skinny hose cozy that ResMed provides for the Climateline doesn't offer much insulation or weight...and still didn't solve the issue of the air cooling at the nasal pillow level itself.

What works for you is going to depend on your own bedroom temperature and your desired humidity level going to your nose...the cooler it is the more you will need to do in an effort to keep that air at the mask warmer so it doesn't release the moisture.
Reducing the humidifier setting is an option and if your nose is good with less moisture it might be all that needs to be done.
If you are like me and your nose simply doesn't do well with less moisture in the air...the only thing you can do is try to keep the air warmer in the nasal pillows to prevent the release of the moisture..remember...warm air hold more moisture than cold air.

Dropping the machine to the floor will only help condensation in the hose...it won't help at the mask level because gravity doesn't have any way to help get rid of the water. Water can't flow up hill...and with nasal pillows unless you hang your head off the bed there's no way for the water to run out of the nasal pillows. The only way to relieve this issue is to prevent the condensation in the first place by some sort of modification of something...either to bedroom air temp or some sort of insulation to the nasal pillows and/or short hose. Keep that air in the nasal pillow from cooling so much that it loses the moisture it is holding.

One other thought. Chunkyfrog tells me she has never had rain out in one of the cloth masks from SleepWeaver nor does she ever remember reading about it by someone...might be just a coincidence but perhaps the mask's material acts like a bit of a moisture absorbing agent so that it doesn't get snorted back up the nose (been there and done that myself) or get a cold shower with the mist from the vent holes (been there and done that often). So for those of you who want to try one of the SleepWeaver masks from Circadiance they might be an option for reducing rain out.
I have never personally used one so I have no idea and this is one mask that I doubt I will be trying. My one time of just putting one on my face left me realizing that it is something that I personally don't find interesting. Doesn't mean it isn't a nice mask...just means that I don't find it interesting enough to try...too much "stuff" on my face.

So for rain out in the mask..options are
1..Reduce the incoming humidity from the humidifier...may or may not work as I know of people who don't even use a humidifier who get rain out in the mask. Also you nose may or may not like reduced humidity and that might create another annoying situation.
2..Warm up the air in the hose and mask....heated hose, hose cozy, barrel cozy
3..Warm up the bedroom air so that the air in the mask doesn't cool as easily.
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Re: Pugsy's Pointer's #3-Rain out in the hose

Post by Pugsy » Sun Nov 24, 2013 1:17 pm

Rain out in the hose...

This is a fairly common problem for people who don't use a heated hose. Same physics apply as above when talking about condensation in the masks.
Sometimes if it is minor all we need to do is lower the machine/humidifier so the water can drain back into the humidifier...we let gravity help but with the length of hose we use sometimes the hose lays on the bed or goes up over the head a bit and there's not a clear shot downward to the humidifier so gravity can't help so much.

Rain out in the hose won't hurt you but it is highly annoying. It's totally amazing just how much noise can come from a teaspoonful of water in the hose...pretty much guaranteed to wake you and your bed partner up (if you have one).

If you happen to have one of the machines that is heated hose capable...get the heated hose if you can. Heated hoses pretty much will eliminate condensation in the hose itself.
If you can't get a heated hose or your machine doesn't support a heated hose sometimes just adding a hose cozy is enough insulation to keep the condensation from occurring. You can buy one or make one fairly simply. Doesn't have to be fancy.
Padacheek.com has a super nice hose cozy.

Some people will suggest turning the humidifier setting down to lessen the chance of rain out in the hose. That is of course an option but your nasal mucosa may scream bloody murder and throw a fit about getting dried out...so if you don't want to reduce your moisture level for whatever reason you might have...then we have to warm up the air in the hose.
So same choices...warm up the bedroom temp if you can sleep in a warmer room...insulate the long hose in some fashion...use a heated hose if you can...there are stand alone heated hoses like the Hybernite 2300 or Aussie hose that do a great job.
I personally have used the Hybernite 2300...it does a good job. Down side is there is no thermostat to regulate the heat..it's either on or off. Same thing with the Aussie hose.
Some people have even done a DIY project and made a heated hose out of reptile heater cable...discussed on the forum in the past and you can search for it if that interests you.

So you have to sit back and figure out which solution you want to try.
Most of the time this issue only pops up during the winter/colder seasons...again because most people seem to turn down the thermostat at night either to save energy or they just like cooler temps for sleeping.

For homemade hose cozy...it can be as simple as a few old socks with the toes cut out and slid over the hose and secured with rubber bands or even scotch tape. Try to not use anything that is too heavy as the added weight will cause the hose to tug on the mask. I once tried wrapping towels around the hose...it worked well but nearly pulled the mask totally off my head from the added weight. It was very annoying and that experiment only lasted one night.
Last edited by Pugsy on Sun Nov 24, 2013 2:31 pm, edited 1 time in total.
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Re: Pugsy's Pointer's #3-Nasal congestion

Post by Pugsy » Sun Nov 24, 2013 1:17 pm

While we are talking about humidifiers and humidity...might as well talk about that little bump in the road that occurs because of either too much humidity being added to the air or not enough humidity being added to the air....nasal congestion.

First of all humidity needs (in the nasal mucosa area) are highly individualized for any number of reasons.
There is no right or wrong when it comes to what one person may need in terms of added humidity when beginning cpap therapy.
Some people need nothing and any humidity added by the humidifier creates a problem. Some people need just a little to keep the nasal mucosa happy. Some people are content with a moderate amount of added moisture and some people (like me) would be happy snorting water if they could.

Back when cpap therapy was in its infancy there were no humidifiers and in some parts of the world they still are not a standard part of therapy..either because they simply are unneeded (like living in the rain forest) or as a cost saving measure (often seen in countries where there is some sort of national medical care and what is offered is bare bones therapy.

The reason there are humidifiers...is because people were having problems with the air pressure drying out the nasal mucosa and membranes. When nasal mucosa get dried out they swell up in an effort to try to retain what little moisture they have...it's the swelling that causes the congestion. Very similar to what happens with an allergy attack and the mucosa's response to the allergens causing the irritation, is swelling....so we get typical allergy like symptoms in varying degrees of annoyance.
Symptoms like congestion, runny nose, sneezing, sinus pressure headaches, even tooth aches...all because the nasal mucosa are unhappy.
The nasal mucosa can be unhappy because of too little added moisture...or too much. If you google "cpap rhinitis" you will see that the most commonly offered advice is "increase the humidity setting"...so I would assume that most people tend to have more problems with being dried out than the other way around BUT there are a number of people who get the same exact symptoms with too much added moisture.
There is no way to know for sure which way you are unless you experiment.
So if you are having congestion and some of those symptoms I mentioned and your humidifier setting is on the low side...try increasing it. If your humidifier is set on the high side...try decreasing it. If your setting is in the middle..toss a coin but if playing the odds..more is needed.

Forum members here will tend to suggest what works well for them. That's just what we do no matter what we are talking about.
We suggest whatever mask or machine or humidity setting or whatever little trick we have had success with. It's human nature.
Just remember that we are all individuals and in this situation...you may or may not respond like I do or someone else does.

Back when I was first starting therapy Den (Wulfman) suggested that lower humidity levels work better for him and I forget why I was asking him but I decided to try a setting of 1...had been using a setting of 3 I think (no problems though) and so I tried a setting of 1...man was that ever a big disaster. My nasal mucosa got really mad at me and I was totally miserable...all of the symptoms I mentioned above including the tooth pain in the sinus area. Now I kinda wondered...was it a coincidence and was I just getting a bad cold????? Or was it the nasal mucosa being too dried out?? It took my nasal mucosa about 3 days to get over being mad at me and I was pretty sure it was the lowering of the humidity delivery that was the culprit because I only did it that 1 night and immediately went back up to my 3 setting... A month or so later I forgot to add water to my tank and spent the night with it pretty much empty (that hot plastic stinks too) and guess what...exact same symptoms returned and took another 3 days to go away...and then a few months later same thing...tank went dry early on in the night because some bozo forgot to fill the tank (back then I typically used almost all the water every night. And yep, same symptoms again...no way can I blame 3 separate episodes on a common cold or sinus infection with no other symptoms.
My nasal mucosa need LOTS of water to be happy...plain and simple and the only times I have had this sort of problem was when I would forget to fill the water tank and it runs dry.

My point here...you will have to figure out what your nasal mucosa needs are in terms of moisture being added to the air.

One other potential nasal congestion cause...pressure on the nasal turbinate areas of the nose...the sides up by the bridge of our nose where we typically see our glasses sit. This isn't so common I don't think but I mention it because I have first hand experience with it. The least little pressure on that area where the nasal turbinates are will cause me to have pretty much immediate and total nasal blockage in about 5 minutes...immediately relieved with the removal of the pressure.
I mention this because this is the same area where most of the masks will rest and apply pressure as part of the need to keep a seal.
I had this problem even with the Respironics Wisp nasal mask and it is about as light as they come. I never bothered with the other nasal masks or FFMs that touched that area of my nose because I discovered during my titration study that I simply couldn't tolerate those type of masks due to congestion issues. The titration study from hell..but that's another story.

So if you have congestion pretty quickly when you first mask up...and if you remove the mask and the congestion goes away pretty quickly....you may be like me and will need to research and use a different type of mask.
There are other forum members here who have PM'ed me and said "that's just what happens to me too" so I know I am not alone with this.
And there are other mask alternatives for people like me with that particular issue.
Last edited by Pugsy on Sun Nov 24, 2013 3:43 pm, edited 2 times in total.
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Re: Pugsy's Pointer's #3-Mask issues

Post by Pugsy » Sun Nov 24, 2013 1:18 pm

Mask Issues. Finding the right mask and dealing with various problems is IMHO the hardest part of cpap therapy.

Edit: 3/2/17...to add the link to Bonjour's Mask Primer thread where he has composed a good explanation of all the various mask types out there.
So if you are new to therapy and wondering where to start and what your mask options are...check this out.
viewtopic/t115695/Mask-Primer.html

It's impossible to anticipate each and every mask issue someone might have so just some general comments about some of the most common issues.

First of all...if you all don't know about Padacheek.com and Karen's various assortment of all kinds of little do dads to make this mask thing go smoother...go check it out.
http://www.padacheek.com/

Finding the right mask is probably the hardest part to all this cpap therapy stuff...let's face it...it just isn't natural to put all this "stuff" on our face and head and expect to just drop right off to sleep.

No mask should cause pain, abrasions or open sores/blisters. If it does then something is not right...either wrong size, wrong fit or simply not a good choice for you. If you are brand new to cpap therapy and have a brick and mortar store who is supplying your equipment, find out exactly what their mask swap/trial policy is. Most mask manufacturers have a 30 day time frame where you can return their mask and get something else and the DME fills out a bit of paperwork and they get credit for the mask that failed.
Now some DMEs make their own in house rules...and yes, they can do that...so make sure you understand what your DME's policy is.
Find out what the policy is and make use of it while you can. Don't spend 3 weeks, of that 30 days, struggling night after night with a mask that just doesn't seem to want to work (assuming you have watched the fitting videos and confirmed the size is correct)...take it back and try something else.

Padacheek products...great products but don't spend money on a mask unless you think you are "close" in being satisfied with it.
Don't count on a mask liner to work miracles if the mask simply is not the right mask for your face.
When in doubt..try a home made mask liner first to give yourself an idea if it would help or not. Just an old T shirt cut out in the shape of the mask with openings in the middle for nose and/or mouth will give you a starting point for evaluation.
Remzzz's makes some disposable mask liners. Forum member Becky works for them and her main point in being here is offering help with mask liners and if you want to try Remzzz's...send her a PM and she will send you a free trial pack of liners to try.
memberlist.php?mode=viewprofile&u=62662
Hey, they are free and simply another tool we can use in an effort to conquer the mask monster.

I won't go into which mask is the "best" mask because that is something that comes with another of those YMMV stickers.
One man's treasure is another man's trash when it comes to mask. What I might love..you might hate and what you might love I might hate.
You know your own body better than anyone else. You know your own preferences better than any one else. Research your masks and if one looks interesting and you can try it and want to...then do it.
Short on funds or DME is being a butthead with their in house rules or insurance isn't go great???
Post your thoughts here on the forum and maybe someone has one sitting in the junk drawer because they hate it and will part with it at a discount or sometimes even free. We are a big family here and we try to help family whenever we can.

If you can normally breathe through your nose just fine at night...look at the nasal pillow or nasal (over the nose) masks if they interest you. The surface area touching the skin is going be be much less with some of those masks and less surface area means less chance of problematic areas for sealing issues.
If you can't breathe easily through your nose during the night and you know you are a dedicated mouth breather...then you will need a full face mask of some sort so that you don't lose all your therapy pressure out your open mouth.

Don't assume that all nasal pillow masks are the same...and the same goes for the nasal masks and full face masks.
I use a nasal pillow mask and in fact there are probably several I could do quite well with but there are a couple that were total dismal failures when I experimented. So just because one brand or model of a nasal pillow/nasal/full face mask was a failure that all brands of same model will also fail.

Oh...one other little hint. Your bed pillow....you may or may not want to try a different type because whatever mask you are using may get into a battle with your bed pillow. This is especially true for side sleepers where the pressure from the pillow pushes on the mask and causes discomfort or leaks.
Pillow preferences...again that YMMV sticker.
Google "cpap pillows" and start looking and the choices..there's a ton of them.
My personal preference has been a buckwheat hull pillow a recently a water based pillow called MediFlow/ChiroFlow.
The buckwheat hulls let me move them around so that I had a little nest for the mask to rest when on my side so the pillow wouldn't push on the mask. The water based pillow has enough give in the top of it that no pressure is put on the mask...yet still firm for my neck. I have an old beat up neck and need just the right firmness and height for my neck to be happy.
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Re: Pugsy's Pointer's #3-Cleaning the equipment

Post by Pugsy » Sun Nov 24, 2013 1:19 pm

Cleaning of the equipment.

This isn't really a bump in the road but the same questions and same arguments pop up here just about every day..
And my whole idea here was to put some stuff in a quick easy get to spot so I don't have to type the same stuff over and over again since everyone knows that I am a lazy sot.

Do whatever satisfies your own mind and needs and gives you whatever peach of mind you need.
Take your pick and read the various discussions. Nothing will be said now that hasn't been said in the past.

From Rested Gal's links...lots of reading here
viewtopic.php?p=567264#p567264

wiki/index.php/Cleaning_CPAP_Equipment

There are people here who think it is unwise not to clean/disinfect/sterilize every day and there are people here who think it is unnecessary to go to any extremes and don't do much, if anything, in terms of cleaning/disinfecting/sterilizing their equipment.
Who is right? Each person will think that the way they do or don't do it...is the right way but in reality it's just another one of those cpap things that comes with a YMMV sticker (and there's a lot of those YMMV CPAP stickers with just about every aspect to xpap therapy).

The only person who needs to be satisfied with whatever cleaning regiment you elect to do or not do....is you.
Not me, or anyone else here.

What do I do? Not much now...but when I started therapy I had a fairly strict regiment but that got old real fast and remember...I am an admitted lazy sot so I don't feel the need to do much...things get cleaned when I think about it and get around to it.
If you want more particulars..send me a PM.
BUT...I am generally very healthy with no major health issues and a nice normal immune system...and the worst that I have had happen to me in the past 4 plus years has been maybe 3 upper respiratory infections (common colds with no complications that came and went quickly) and a few nights with the good old stomach bug which planted me on the bathroom floor for the bulk of the night.

People with compromised immune systems for whatever reason....I would advise to not do like I do...just as a precaution.
Better safe than sorry.

If you are a known germaphobe...hey, that's okay too. Just do whatever gives you peace of mind. The only person you have to please is yourself.

And with that...cleaning is closed. I already said much more than I intended to.
Last edited by Pugsy on Mon Nov 25, 2013 9:24 pm, edited 4 times in total.
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Re: Pugsy's Pointer's #3-Accurately describing your problems

Post by robysue » Sun Nov 24, 2013 9:04 pm

Helping us help you----accurately describing your problems

Lots of newbies describe their problems in language that is very clear to them, but not at all helpful to us in terms of helping troubleshoot the problem. In this post I focus mainly on helping newbies learn how to accurately describe their problems. In later posts (either by pugsy or myself) we'll look at things that can be done to address some of these common bumps in the road for Newbies.

For example, we get a lot of newbies who say in their very first post something along the lines of the following statement:
  • Help! I can't tolerate CPAP. It's ruining my sleep
The problem here is that we all read into this statement the problems we faced when we were newbies and so you get all kinds of suggestions that may or may not help you because they may be for problems that are just not the problems you are facing in your bed each night.

You need to give us some help. Here are things to think about when you're trying to make CPAP work, but you're at the stage where you just plain feel like "I can't stand using this damn machine every night because it's making my life miserable," but you genuinely want suggestions on what to do to try to fix the problems rather than simply venting about how miserable you feel. (There is a time and place for venting after all.)

So let's try to tease some things out:

Are there issues with the pressure making you uncomfortable?
Too much pressure and too little pressure both cause problems. Oddly enough, the language often used to describe both problems is "I can't seem to breath right with the machine." So if you think the pressure is causing problems with your ability to breathe normally, then you need to ask yourself: Do you feel as though too much air is being forced down your throat---in other words, do you feel as though you are being forced to breathe in too much air? Or do you feel you are suffocating because of a lack of air---in other words do you feel like you are suffocating because it seems like there's not enough air coming through the mask to inhale properly? These are very different sensations, but they are equally intolerable. And unfortunately a lot of newbies describe both of them with the phrase, "I feel like I'm suffocating when I put the mask on."


Are there issues with air in your stomach, farting too much, needing to belch, etc?
These are all called aerophagaia and it's a pretty common problem. For some people it's merely embarrassing or funny; for others it can be quite painful. Some people are unlucky enough to wake up with painful areophagia, sometimes multiple times during the night. Aerophagia is caused by swallowing too much air during your sleep. It may or may not be associated with mouth breathing. If you are prone to having problems with GERD or indigestion, you may be more likely to have problems with aerophagia. But here are people who have aerophagia who don't have GERD.


Are you having problems getting to sleep or staying asleep with the mask on your nose?
A bit of CPAP-induced insomnia is not unusual at the beginning. For most people, it will resolve itself in a few weeks after you get through trouble shooting the main newbie issues and your therapy is fine tuned and you start sleeping with the machine every night, all night long. But some people will have real problems with CPAP-induced insomnia that don't resolve themselves in a timely fashion. More on this in a later post. For now it's enough to say, this is a real issue, but it can be dealt with.


Is the mask uncomfortable to wear?
I don't mean "it's uncomfortable because it's 'new' and 'different'". I mean---the mask actually hurts. A lot of newbies get stuck with a mask that actually hurts to wear. As in it gives them a headache. Or it causes sores on their nose or forehead. Or it presses onto their upper lip in a painful way. Sometimes it's just a matter of learning how to fit the mask properly. Sometimes it's a matter changing masks. Sometimes it's a matter of using mask liners or mask pads to increase the mask comfort or to protect the skin. Sometimes its a matter of changing the skin care routine. Regardless of what the problem is, the fact remains: Your mask should NOT be painful to wear. If it is, there's something wrong, and addressing the mask problem will help a lot.


Sore back or sore neck problems?
A lot of newbies are so worried about moving around in the bed triggering a mask leak that they wind up sleeping in a very awkward position for long periods of time. This can lead to problems with a sore back or a sore neck. The obvious solution is to work on finding a comfortable sleeping position. It turns out that with modern day CPAP masks it is possible to sleep on your side or on you stomach as well as on your back. Ideally you should be able to sleep in a position that is very close to your favorite pre-CPAP position once you figure out how to do it. Some people also have a bit of rib cage/chest wall pain at the beginning of therapy because the chest muscles do have to work harder to exhale against the CPAP pressure all night. This kind of pain usually goes a way in a few days to a week or two.


Are you dealing with a wet nose?
It's rain out. You need to figure out if the rain out is at the mask level or in the hose. And then read Pugsy's posts earlier in this thread.

If the problem is rainout at the mask level, read and re-read Condesation in the mask.

If the problem is rainout in the hose, read and re-read Rainout in the hose.


Sensory stuff: Is the air from the exhaust flow bouncing into your eyes? Does the noise of the machine irritate you and keep you awake? Are there other weird sensory things you think nobody can possibly have dealt with that are driving you crazy night after night?
Sometimes the sensory stuff can be remedied pretty easily. Sometimes it can't. Mostly though you do get used to it with time. For example, as a newbie, the airflow from the machine would tickle the back of my throat on every breath when I was trying to get to sleep. This would drive me crazy and make it very difficult to get to sleep (or get back to sleep after one of my many aerophagia caused wakes). The real fix? Time. Yep. Eventually, as in after several months, I simply got used to it and this sensation is much harder for me to feel now even if I consciously try to feel it.

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Additional Comments: PR System DreamStation and Humidifier. Max IPAP = 9, Min EPAP=4, Rise time setting = 3, minPS = 3, maxPS=5
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Re: Pugsy's Pointer's #3-I can't breathe the the mask on

Post by robysue » Mon Nov 25, 2013 9:40 am

I can't breathe the the mask on

Many newbies experience problems with "breathing with the mask." They often describe the problem as "I feel like I'm suffocating every time I put the mask on" or "I just can't breathe right." There are a constellation of issues at work here and it's important to tease apart which of them apply to your situation.

When I see a newbie use a phrase like:
  • I feel like I'm suffocating when I put the mask on
The first thing I do is start asking questions. That's because this phrase can mean one of two main things:

I can't fully exhale against the pressure and hence I feel like it's difficult to breath normally
OR
I can't seem to inhale as much air as I want to and hence I feel air "hungry"

The root cause (and the fix) for these problems is quiet different, and hence it's well worth the effort trying to figure out which problem you're having.


I can't fully exhale against the pressure .....
When you're having difficulties exhaling against the pressure it can feel as though you just can't get a good satisfying breath. Because every time you try to inhale, more air gets pumped into your lungs than you really want to breathe in and then it seems as though it's impossible to exhale fully so as to make enough room for the next inhalation. There's another more subtle problem that gets mixed up with the "I can't fully exhale against the pressure" sensation----that's the feeling that the machine is trying to make you breath faster than you want to: In other words, some people feel that they have trouble fully exhaling because the machine is doing something that is encouraging them to take their next inhalation before they are ready to inhale.

The most obvious thing to start with (for both these "exhalation" problems) is looking at whether you machine has a form of exhalation relief, whether it is turned on, and what it is set too. Sometimes the fix for this problem is as simple as turning on the exhalation relief system and playing with its settings. Or turning the exhalation relief system off---if it happens to be on and just not comfortable for you.

On Resmed and PR machines, the exhalation relief system works by reducing the pressure at the beginning of the exhalation and then raising the pressure back up a bit later in the breathing cycle. The Resmed EPR system works by reducing the pressure by a fixed amount on each and every exhalation; the PR Flex systems reduce the pressure by a variable amount that depends on both the Flex setting and the force of the exhalation---stronger exhalations result in greater reductions in pressure. Exactly where the pressure increase occurs is different in the Resmed EPR system than it is in the PR Flex system. And in fact, where and how the pressure increase is done varies between C-Flex, C-Flex+, and A-Flex on the PR machines.

The whole idea behind exhalation relief is to make it easier to exhale by reducing the amount of pressure you are exhaling against. And for most people this system works pretty well. But it's also important to note that for some people, the exhalation relief system itself can trigger or magnify this problem because the increase in pressure back up to the therapeutic setting, which technically occurs before the active phase of the next inhalation starts, can make some people feel as though them machine is trying to make them breathe faster than they want to breath. (That was a real significant problem for me during my first three months of PAPing when I was still using an S9 AutoSet with EPR.)

Sometimes folks assume that if they're having problems exhaling against the pressure, the higher the exhalation relief setting they use, the better off they'll be. That may or may not be true. Like so many things in PAP, each person's response to exhalation relief is highly indivdual. Pugsy once wrote that A-Flex at 1 provided no relief, A-Flex at 3 felt as though the machine was rushing her to inhale, and A-Flex at 2 felt "just right". So if you're having trouble exhaling against the pressure, it's important to play with the exhalation relief settings:
  • If exhalation relief is OFF, turn it ON and experiment with all three settings to find which one is most comfortable to you.
  • If exhalation relief is ON, experiment with all three settings to see which is most comfortable. And also experiment with turning exhalation relief OFF---particularly if your biggest problem with exhaling seems to be that the machine is "rushing you to inhale" before you're ready to inhale.
If the "I can't exhale fully" problem cannot be solved by playing with the exhalation relief settings,
then the next choices are either judicious use of the ramp (if the exhalation problem occurs mainly when you are trying to get to sleep) OR a (very slight) decrease in pressure.

If you choose to address the problem by trying to use the ramp, it's important to take the time to get the ramp set up correctly so that it does not create more problems than it causes. That's another post that I'll add later.

If you're not comfortable self-treating, then you can contact the sleep doc's office and let them know that you're having problems with exhaling against the pressure, that the exhalation relief system is not helping you, and then request a (very slight) decrease in pressure. If you're comfortable self-treating and you've got a full efficacy data machine, then lowering the pressure setting by 0.5cm or 1cm to see if that helps with the exhalation problem while at the same time monitoring what it does to the AHI (and the snore and flow limitation) data is important. For many people even a small reduction in pressure will lead to an unacceptable rise in AHI. But for others, the titrated pressure coming from the lab study may indeed be 1 or 2 cm higher than what's needed in practice. If you've got an APAP, you can try lowering the minimum setting by 1 or 2 cm and see if that helps.


I can't seem to inhale as much air as I want to ....
There are a lot of long time PAPers here who have titrated pressures of 10cm (or more) who simply claim that it is "impossible" to breathe at a pressure of less than 6 or 7 cm. And they commonly tell newbies to just up their pressure to 8, 9, or 10cm. But that can create its own problems with exhalation or aerophagia. There's plenty of air coming through the mask even at pressures of 4--8 cm.

The first big question to ask yourself when the problem seems to be "air hunger" is: Am I using the ramp?

The ramp is a feature that most DMEs set up by default for new PAPers. It is supposed to make it easier to fall asleep with the mask on your face by reducing the pressure at the beginning of the night so it feels less like you've got your own personal hurricane blowing on your nose and down your wind pipe. And when a ramp is properly set up, it can make a huge difference to a new PAPer in terms of comfort during the period of time you're lying in bed trying to get to sleep with this alien on your face.

But most DMEs set up the ramp in a default configuration that tends to create more problems than it solves. The typical DME uses either 4 or 5 cm as the RAMP STARTING pressure and 30-40 minutes for the RAMP TIME. The problem arises from this fact: We do get used to our own pressures even though we're asleep most of the night when we're breathing against them. So if you breathing at 10, 12 or 14 cm all night long in your sleep because that's what your machine's (therapeutic) pressure is set at, then it's not that big of a surprise that the noticeably less stiff breeze created by the 4-6cm of pressure at the start of the standard "ramp" setting can feel like there's not enough air coming into the mask. And that can lead to the problem of feeling like you're struggling to get enough air in to your lungs. It's not so much a physical problem as a perception problem: Plenty of air really is coming through the mask to breathe properly and not suffocate, but with a mask slapped your face and not as much air coming through as you've learned to expect can lead to the mental perception that you're not getting enough fresh air and that perception then leads to the sensation that you might be suffocating or struggling to inhale enough air.

But the answer here is really simple: Either turn the ramp off entirely. Or, if the hurricane blast is simply too much at the beginning of the night, reset the RAMP START pressure to be high enough to not trigger the "air hunger" and low enough to be comfortable. A good starting guess is about 2 or 3 cm below your therapeutic pressure setting. So if your (minimum APAP) pressure is set to 10cm, try starting the ramp at 7cm instead of 4cm.

But there's another thing that's also at work in triggering "air hunger" problems: It's the psychology of having your nose covered by the mask or blocked by the nasal pillows. The mere feeling that there is a limited supply of air is enough, I think, to trigger the "I"m really struggling to get enough air" feeling some folks when they are lying in bed AWAKE and fighting to get sleep, which of course makes it that much harder to relax enough to actually fall asleep. But if there's nothing on your nose, you know you're NOT suffocating when you're lying in bed AWAKE and that (unfortunately) allows your mind to relax enough to allow you to fall asleep maskless. And once you fall asleep and the apneas, which are true, but mini, suffocations start, you're unconscious and sadly unaware of the damage being done to your body while you sleep.

Now if you're NOT having problems with leaks, aerophagia, other discomfort, or central apneas, you may find that a 1 or 2 cm increase in pressure will help with the "air hunger" problem. But any increase in pressure does come at the risk of increasing problems with leaks and aerophagia. And if you've already got a problem with central apneas, the increase in pressure may make them worse. In other words, a 1 or 2 cm increase in pressure may be worth experimenting with, but it may or may not be the answer to your problem with air hunger.

In other words, if you're having "air hunger" problems and you're NOT using the ramp, then plain old anxiety and worry may be the real cause of your problem. It helps to understand that our sleep breathing patterns are both much more regular and much more shallow than our normal wake breathing patterns. And we just don't take super-duper deep (yoga cleansing) breaths when we're soundly asleep and breathing well. Indeed, when looking at wave form data, the biggest inhalations and biggest exhalations are most likely during the times when you're awake, not asleep. And so as hard as it sounds, learning to relax and NOT worry so much about breathing super-duper deep breaths may be a major part of the solution to the "air hunger problem".

_________________
Machine: DreamStation BiPAP® Auto Machine
Mask: Swift™ FX Nasal Pillow CPAP Mask with Headgear
Additional Comments: PR System DreamStation and Humidifier. Max IPAP = 9, Min EPAP=4, Rise time setting = 3, minPS = 3, maxPS=5

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Pugsy
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Location: Missouri, USA

Re: Pugsy's Pointer's #3-Dealing with therapy bumps in the road

Post by Pugsy » Sun Aug 07, 2022 6:52 am

Okay...I am reviving this thread because I want to include other threads where I have gone into detail about something.
This is so I don't have to keep typing the same thing over and over again.

Here's one where I just replied to someone new to therapy and I explained mask options and how DMEs work or don't work.
Mask returns, swapping, online purchasing...etc. Included.
Also includes the Medicare replacement allowance schedule.

viewtopic/t184848/P30i-vs-np10.html
Mask: Bleep no headgear mask.. https://bleepsleep.com/
Machine: AirCurve 10 VAuto

I may have to RISE but I refuse to SHINE.

User avatar
Pugsy
Posts: 62148
Joined: Thu May 14, 2009 9:31 am
Location: Missouri, USA

Re: Pugsy's Pointer's #3-Dealing with therapy bumps in the road

Post by Pugsy » Sun Aug 07, 2022 7:25 am

I am going to ask everyone who reads this thread that if they have a question or problem

PLEASE DON'T ASK IT HERE IN THIS THREAD>>>>>> START YOUR OWN TOPIC/THREAD......PLEASE.
I am going to enforce this...so fair warning.

Also please no chit chat here...all it does is take up storage and helps no one and lengthens an already long thread which turns people off from reading. Depending on how comprehensive it becomes I may make it a Sticky Topic.
The original plan of this thread was to cover some very common problems that people experience with cpap use...either with the mask or machine or even the "Help, I have been on cpap for 2 weeks now and it's not helping" thing.

No chit chat...that means there is no need to respond and thank someone for saying something.

RobySue isn't active here anymore to help out but if you have something that would be educational contact me privately and we can add it here. People can add to this topic...it doesn't have to be just me.
I just don't want a bunch of off topic stuff that really helps no one.

If it isn't helpful...don't post it here. This is an educational topic...not a question and answer topic.
Mask: Bleep no headgear mask.. https://bleepsleep.com/
Machine: AirCurve 10 VAuto

I may have to RISE but I refuse to SHINE.