Forum · cpap problem

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[-] SincerePuceElk7991 +0 points · 12 months ago

As a long time user of cpap I've recently been having a problem with my new ResMed AirSense 10 machine with a Pico mask. Every night after 3 hrs of sleep I awake with my lips and tongue dry and stuck to the roof of my mouth. I take a drink of water and it happens again after 1 hour. I've tried every level of humidity to no avail. My doc thinks I open my mouth so I tried a chin strap but can't see how I'm opening my mouth if my lips are stuck together. Anybody else have this problem?

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[-] wiredgeorge +0 points · 12 months ago Sleep Enthusiast

I have no clue what a Pico mask is but I have a full face mask. I had horrible dry mouth but never took my mask off for a drink; only knew it when I awoke in the AM. I also have the same Resmed machine you do and found the humidifier fairly useless; makes little difference to me but you can get a hose heating gadget (I haven't seen one but they are out there) and run a room humidifier. I find that if I fill the tank on my machine and run it at level 4 humidity, it will last about 6 hours at best and then run dry.

In any case, I have long since given up on the humidity aspect and have learned that you can use Biotene mouth rinse in the AM to get your mouth a bit less dry but more importantly, I started using Orahealth Xylimelts Mints. I tried them after buying a small box at a drug store and they worked wonders for dry mouth. They recommend using two of them; one on each side next to a molar in the back and they last all night even if you sleep more than I do (about 6 hours tops). They are expensive and I ended up on Amazon buying larger boxes to keep costs down. I had previously tried several other Biotene products (pump spray, little candy drops and the toothpaste. None seemed to make the least difference; only their rinse.

Hope these tips help; search through the older posts on the forum as this is a recurring issue with many users.

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[-] SincerePuceElk7991 +0 points · 12 months ago

thanks for the tips! I might have a problem with my humidifier as it never runs dry after 6 hrs at level 8. Will check on that.

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[-] wiredgeorge +0 points · 12 months ago Sleep Enthusiast

Not sure how much consistency these machines have one from the next, but my machine was bone dry after 5 hrs and 53 mins last night on setting 5. If I put it on 4 the reservoir sometimes has a little bit in it up to 6 hours. Good luck with getting some feedback from your med supply place!

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[-] 20YearsAsleep +1 point · 11 months ago

A major reason for humidifiers running dry overnight is pressure leak. If the machine detects leakage, it will automatically increase air flow to compensate for lost pressure. The increased air flow through the humidifier increases the uptake of water from the reservoir. The bigger the leak, the more water will be consumed. Leakage may be the result of loss of adequate seal (mask fit), loss of mouth closure (not a problem with full-face masks), or mechanical failure of circuit components, such as an improperly assembled mask, or a cracked tubing, for instance. Inadequate seal is very common, as masks are fitted when the patient is awake, and thus, the muscle tone of the face is high. As facial muscle relaxation occurs in progressively deepening sleep, facial contours can change dramatically, especially in older patients. This is particularly true when the wearer enters REM sleep, when all musculoskeletal tone declines to a level characterized as "paralysis". A mask seal failure is likely to result in jets of air stimulating the face, as air escapes under the mask cushion, especially if jets of air blow into the eyes. Loss of seal may also cause squealing or fluttering (more likely at high pressures). This, logically, will stimulate the wearer toward wakefulness. For nasal mask wearers (again, particularly in older patients), loss of mouth closure is very common. The typical indicator in this situation is dry mouth, as air flow, and consequently pap (positive airway pressure), is being lost through the mouth. Interrupted sleep is a likely consequence in this scenario, as air flow out through the mouth is likely to stimulate the sleeper to awakening, and, if loss of pap is sufficient, therapeutic pressure level cannot be maintained and thus symptoms of airway obstruction recur. Some masks will squeal or vibrate at the swivel connector at higher pressures.

Bottom line: A humidifier fill should last all night. If it doesn't there is most likely a lost pressure/increased flow problem. If the humidifier is not lasting all night, odds are the quality of your therapy is being compromised, consequently the quality and/or duration of your sleep.

Put on your mask, and check your system for mechanical leaks in the tubing, its connections, and in the mask its self. If you have a bed partner, ask him or her to observe whether you have an audible mask seal leak, or if your mouth opens during sleep. If you don't have a bed partner, ask a family member or roommate to observe you in a nap. , In my experience, chin straps do not work. The best answer for loss of mouth closure is a full face mask.

In older patients, changes in facial contours between wake and sleep can be dramatic, and a mask that fits well at bedtime, may be inadequate in sleep. Loss of mouth closure is a significant challenge in those above age 60, particularly in the edentulous (those who have no teeth). Nasal masks work best in younger patients, who retain the increased baseline muscle integrity of youth.

If your DME (distributor of medical equipment) is responsive to you regarding equipment problems, you are fortunate. But for any issues, it is appropriate to contact your primary doc., or preferably, the sleep specialist whose lab conducted your polysomnography, and who ordered your equipment. These people are the ones most interested in seeing that you are able to successfully achieve healthful sleep.

Best of luck! Persistence is key.

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[-] Sleep +0 points · 11 months ago

Some excellent, informative information regarding humidifiers along with other information from 20YearsAsleep.

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[-] wiredgeorge +0 points · 11 months ago Sleep Enthusiast

20YearsAsleep! After muddling along, a ray of light in the voodoo that is the CPAP... I am fairly new. Been on a BIPAP for about a year now and my pressure is set 25/20. I had immediate and profound results from therapy and my issues of sleepiness and low O2 for extended periods were greatly mitigated, if not erased.

Fast forward till today. Over the past several weeks, I have had FOUR nights with AHI 10-14. Not much better than when I started therapy as I never had any AHI higher than 2 for the first 10 months or so. What gives? After reading and re-reading your post, I went back and compared my mask leaks to high AHI and there is a direct correlation. When my mask leak rate exceeded 100 L/min (whatever that means) my AHI score is higher than it had been since therapy started.

Your comment about the humidifier running short of water and dry mouth struck me relative to my mouth opening at night. Previously my mouth had been pretty much clamped shut, or so I thought... last night, I switched to the first mask I had been issued by my equipment provider. It covers the mouth but is much smaller (don't recall mask type) and barely fits below my bottom lip. All night my chin kept dropping and my mask leaked like a sieve and my bottom lip was actually out of the mask. HEY, what you said hit me this AM and I decided to not look for a new mask but figure out how to keep my jaw from going slack as I think that might be the key to my issue.

OK, first though was to duct tape but I found that straps were sold to keep the mouth shut but from what I read, their effectiveness was not universal. I did some more google work and found on another site that a sleep therapist recommended a martial arts mouth guard. A martial arts mouth gaurd differs from the one I used for many years playing football in that it has a breathing hole in the front. I guess martial artists can't breathe through their noses when their noses get busted up. There is a link to this mouthguard on Amazon.com and I bought one and will report back if it works/doesn't work. If it doesn't I will be down to duct tape or the strap (neither appeals much).

Thanks for your excellent post as it was HIGHLY helpful and maybe I can get the mouth related leak problem whipped. Any other suggestions are appreciated.

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[-] 20YearsAsleep +0 points · 11 months ago

Re: Full face mask (FFM) issues. Hi WiredGeorge!

To digress a bit, In a previous post I stated that I'd observed that chin straps rarely if ever work. This is particularly true when the objective is to maintain mouth closure when using a nasal mask (or nasal pillows). As jaw muscles and the muscles surrounding the mouth lose tone during the relaxation of sleep, the jaw tends to drop and the lips open. While a chin strap may prevent the jaw from dropping, the CPAP is still likely to force the lips to part, particularly in older users, with the consequent loss of therapeutic pressure, and rapid consumption of water from the humidifier reservoir.

The full face mask is intended to fix this problem by allowing CPAP to be maintained, whether the mouth is opened or not. The biggest problem with full face masks is proper fit. The larger area and more complex facial contours that the mask must contact in order to maintain a good seal, makes fitting a FFM much more difficult than a nasal appliance. In most cases, the technologists who conduct CPAP studies in the sleep lab take pains to make sure the mask size is appropriate to the patient, and are monitoring this carefully throught the night. The sooner during the study the tech can find the right mask for the patient, the more effective the sleep study will be in determining the value of CPAP to the patient, and what pressure setting is going to be most effective. Sustained REM sleep, supine, is the gold standard. The mask type, size, and CPAP pressure settings that are found to be effective, are documented. If the sleep lab's interpreting physician is in agreement, these form the particulars of the prescription for home therapy.

Here occurs a significant break in the chain of care. The prescription goes to a home care provider (distributor of medical equipment, or DME), who sets up the equipment for the patient. CPAP pressures are virtually always per the prescription. However, the mask that is provided by the DME may not necessarily be the mask that was found to have been successful in the lab study. (The reasons why are a whole 'nuther discussion). If an alternate mask is issued, and if that mask is not a good fit, there will likely ensue a difficult and frustrating struggle on the patient's part to achieve long-term restorative sleep. All too often patients end up abandoning the therapy, to their detriment, because of this. DME's do not have a good track record of follow-up on their patients.

The best way to get results as you work your way through CPAP therapy problems, is to communicate with your physician/sleep specialist. If your mask comes off during the night, or if you wake to find you have taken it off, your sleep is not restful. There is something amiss with your therapy. Talk to your doc.

The FFM should fit so that the bottom of the cushion rests in the valley between the lower lip and the bony prominence of the chin. This is critical. If the cushion is too high, the mouth may not be adequately covered; too low, and the pressure against the chin tends to force the jaw downward. In the sleep lab, mask fit is assessed continuously over maybe six hours, beginning with wake, and proceeding through, ideally, all stages of sleep. A different mask, if provided by the DME, is fitted only during awake, and while the assumption is that it will remain competent during sleep, it is not necessarily true.

Assuming a properly fitted full face mask, the patient may still, during the relaxation of sleep, drop his/her jaw sufficiently to create significant mask leak. Here, a chin strap may help keep the jaw "up" so that the FFM cushion rests where it should between lower lip and chin. However, a chin strap may squeeze the facial structure into contours that the mask may no longer fit, say, along the side cushions. So I continue to be dubious about chin straps.

"Jaw drop" is more likely to occur during supine sleep. Its just a matter of gravity. A fix for this is to prevent the patient sleeping on his/her back, or rather, encourage them to sleep on their sides. Here the problem that presents is the mask being dislodged from its seal by side pressure against the pillow. FFM's are big and bulky, and easily pushed out of place. Also, and once again, facial contours are altered by pressure of the pillow against a cheek. Tucking the pillow back away from the face and mask will help. Special "CPAP users' pillows" that address this problem are available in the specialty market.

Taping, or using an athletic mouth guard, while seemingly logical strategies, are not recommended. The problem here is gastro-esophageal reflux (GER). If the person experiences GER during sleep, and his/her mouth is obstructed, there is an increased risk of aspiration of gastric fluid into the respiratory tract, with very serious and immediate consequences, all of which may occur before the patient is awake enough to get the mask/tape/mouth guard/chin strap off. Some early FFM designs had devices built into them that facilitated quick removal in such an event.

Mask technology and design has improved tremendously since the early days of CPAP. There have been a multitude of inovations and improvements developed to address almost every variation in individual patients. The downside of this is that we are left like kids in the candy shop, having a hard time deciding what is best for us. In the present, my view is that ResMed makes the best masks.

A corollary to all of this, is that most insurance/medicare guidelines require periodic re-evaluation of CPAP therapy. As an individual's physiognomy evolves over time, so may his/her requirement for therapy, especially if there has been significant weight change. As a result, CPAP pressure may need to be adjusted, and mask interface as well.

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[-] BrainsNeedSleep +0 points · 11 months ago

So one good strategy for all patients leaving the overnight sleep test is to have written down the name and size of the mask found effective? And that should go to the DME. And the DME should provide that mask. Some seem to carry only a few selected masks, but they (IMLE) do seem to carry some of the "most popular". I have also had better luck with ResMed masks - the AirFit FFM in particular seems to shift least when I am on my side, and I have a hard face to fit. The CPAP pillow you see in the catalogs was miserably uncomfortable and did not prevent shifting at all. Experiences may vary...

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[-] wiredgeorge +0 points · 11 months ago Sleep Enthusiast

I have zero issues with mask pressure (25/20) nor my Simplus mask size M. The mask falls into the valley below my lip, as you described. Until the past couple weeks, I had no jaw dropping from relaxed facial muscles. Now I am having this issue more and more. Last night, for instance, my jaw kept dropping. My mouth seldom opens but the mask ends up over my mouth with seal loss. Not sure why this started but I have purchased the mouth guards and will give one a shot. I don't suffer from acid reflux so that issue may not be an issue.

When I did my sleep study, I recall the mask had a lot of straps but can't recall what type or how it fit... I did not then nor have I ever spoken with the the sleep study personnel or the doctor who did the prescribing; they made me feel that was the duty of my PCP where they sent the results and prescription recommendation and the PCP did that part. I am pretty sure my PCP would be of little value as I got the impression she wasn't up on sleep apnea therapy. Actually she told me that.

Since my mouth seldom opens when the jaw sag occurs, I am also considering a nasal mask which would not leak if my jaw dropped but my mouth stayed shut. I do thank you for your expertise and perspective and if I do get another sleep study as the result of these issues (given my skin flint insurance company will pay), I will be better armed to ask the right questions and insist on the sleep doctor briefing me and answering my questions. Again, thanks!

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[-] Sleep +0 points · 11 months ago

Hi Wiredgeorge, so to recap your story......please correct me if I get any info wrong. So you're on Bipap therapy with a full face mask. things have been relatively well, AHI is low, oxygen saturation levels have been good. The full face mask you were using with liners leaks a lot but doesn't seem to be affecting your AHI adversely and didn't seem to be waking you up or bothering you. So this is great, it would be ideal if the mask leak was lower but overall it didn't seem to be affecting you too much. On a side note, leaks can cause something called arousals in your sleep, where the briefly arouse you from your sleep, they can affect your overall sleep quality. one would need a in-lab sleep study to see if this is occurring. but despite the leaks, it wasn't bothering you. your ahi was low, and your oxygen levels were good, so it appears that the bipap was effective despite the leaks. so going back to present day, everything is going pretty well but for a few nights your ahi has increased. you recognized the pattern that higher leaks correlate to higher ahi. so in that case I would suggest you check some of the more usual culprits. how old is the full face mask? any visible signs of wear or cracks? has enough time passed that your insurance will cover a new mask and/or supplies. how about the headgear? they get stretched out from washing and wear. check out your hose, these can be tricky but can develop little cracks in the plastic in between the rings and can be difficult to find. filters, need changed? but your already aware of that. it can be frustrating that it seems like nothing has changed but now your leak has increased. so moving on, you changed to a different full face mask, it sounds like it is falling into the correct location on your face but if your bottom lip is coming out during sleep I wonder if indeed it is fitting you correctly. how have the leaks been with this other mask?

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[-] wiredgeorge -1 point · 11 months ago Sleep Enthusiast

I had the problem first with old mask and liner. I pulled out a new mask with new liner about a week ago and problem was exactly the same. One night, the AHI is very low and the next some and a couple others HIGH. The issue is my face slackening and chin coming down and causing more leaks than normal. To be honest, my leak rate always appears high but if it stays under 100 L/min the AHI is low. If it goes above because of the slack chin issue, then it goes up either a bit or a lot but up. The mask didn't cause AHI events for almost a year.

No free masks at this time. I get some supplies at 3 months and then others at 6. I got the six month supplies about 1.5 months ago and already talked with my med supply place. Since the mask worked effectively for months, suspect it isn't a mask issue.

I did buy a MMA mouth guard which is similar to a mouth guard worn by a football player except it has a hole in it for breathing. The claim is that the mouth guard will keep the jaw from going too loose if my face muscles slacken during the night. I will see and report back. Next step would be a chin strap. The chin strap has a lot more detractors but is worth a try if the mouth guard fails to do the trick.

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[-] wiredgeorge +0 points · 11 months ago Sleep Enthusiast

First night using the MMA mouthguard and it seems to have done the trick. Leaks WAY down and AHI less than 1. Too soon to do a victory dance but initial result was very encouraging. By the way, this mouthgaurd needs to be put into water that has been microwaved for one minute 45 seconds for 5 seconds. Then you pull it out of the water and bite down on it to get it fit to your bite then put in cold water. I didn't get a good impression the first time as I was tentative with the bite part and decided to leave it in a couple extra seconds (in the heated water). The first mouthgaurd sort of melted and I was glad I purchased two. Second mouthgard was fitted following directions and SEEMS to work well after first attempt but only time will tell...

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[-] BrainsNeedSleep +0 points · 11 months ago

Hmmmm...sounds interesting! Numbers under 1 = good!

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[-] Verne7 +1 point · 11 months ago

Well, answering to the humidity problems if anyone is still listening. I have an Airsense 10, with an Airfit F10 mask. Trying to control the humidity with the Airsense 10 is futile. When I set the humidity to 6 (I think) the inside of the hose would rain on me in the morning, and the tank would be near empty, but I would still have dry clogged sinus. So, I added the heated hose. This is the key, forget trying to use the Airsense 10 humidifier, all the humidity evaporates back to water on the cool tubing. With the heated hose the humidity actually makes it to the mask. Now with the full face F10, my sinus is not all clogged and dried out. I do get dry mouth when I open my mouth and start breathing through it, but then that happens in normal sleep without a mask. With the mask, if I close my mouth and breathe through my nose again, I have the correct humidity again.

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[-] DanM +0 points · 11 months ago Sleep Commentator

Glad to hear you found the problem and have been able to correct it! Dry sinuses can be terribly uncomfortable. Please keep us posted!

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[-] wiredgeorge +0 points · 11 months ago Sleep Enthusiast

After using the MMA mouthguard a few days, I think this is a keeper. My leaks went down from 120 L/min at their worst to 11 L/min last night and NO AHI events at all. The key it so fit my mask with my face as slack as possible and the mouthguard keeps my chin from sagging and the bottom of the mask ending up in my mouth but staying in the valley under my lower lips.

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[-] DanM +0 points · 11 months ago Sleep Commentator

Hi wiredgeorge. Happy to read of your recent success with lower leaks and no AHI! Please let us know if your solution continues to be successful.

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[-] wiredgeorge +0 points · 11 months ago Sleep Enthusiast

Well using the MMA mouthguard has reduced mask leaks from 80-100 down to around 10 L/min. AHIs are almost non-existant and usually less than 1 per hour. It is kind of cool to wake up in the AM and see the little GREEN smiley face rather than the RED for mask seal on the machine. I also noticed that my humidifier reservoir is no longer bone dry. Now I only sleep on average 5.5 to 6 hours (that is ENOUGH FOR ME) but there is plenty of water left now. I also seemed to have whipped the dry mouth issue. I believe that true progress has been made and the BIPAP and I can be good friends going forward.

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[-] wiredgeorge +0 points · 11 months ago Sleep Enthusiast

By the way, 20YearsAsleep knocked the scales off my eyes, so to speak, with his very informative post. Never realized WHY the empty water reservoir and the dry mouth were symptoms of the mask leak problem I had previously. Great post and many thanks! I would have figured this out myself in another 19 years or so.... it now seems so darn obvious it makes me feel... well dumb would a kind way of saying it.

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[-] 20YearsAsleep +0 points · 11 months ago

Really glad to hear you're doing well, wiredgeorge, please don't be hard on yourself, its all a process. You are to be congratulated on your persistence, and your proactive attitude. One thing you might be interested in looking at is Mandibular Advancement Devices (MAD's). These are dental appliances that hold the jaw, and the soft tissue that is connected to it, forward anatomically, helping to protect the upper airway from obstruction by the tongue. Your mouth guard does the same thing to a degree, as well as preventing air escaping. Search SomnoDent, TAP, EMA, Herbst appliance. Also, the American Academy of Dental Sleep Medicine. There is some evidence to support the theory that CPAP pressures can be reduced when a dental appliance is properly prescribed. Best wishes for continued success!

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[-] wiredgeorge +0 points · 11 months ago Sleep Enthusiast

I have no issues with tolerating the 25/21 pressure set on my BIPAP but will look into the dental appliances you suggested. There isn't much use asking my PCP or the sleep doctor that I paid a year ago and never met. To get prescribed for one of these appliances would mean talking my PCP into writing an order for a specialist and she is good about that but then I would have to fight with my MANAGED care insurance provider. I am currently transitioning from a group plan I have belonged to for many years to Medicare (very recent) so may way till things shake out with that as I still need to stay in the group plan because my wife isn't eligible for Medicare yet... thanks! wg

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