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Soreness in and Around Nose with Various Masks

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Stoaty +0 points · over 2 years ago Original Poster

I haven't had any trouble adjusting to using my machine (Resmed Airsense 10) but do seem to be having trouble with comfortable mask fit. Have tried:

Resmed P10 nasal pillow medium - caused soreness just inside left nostril Resmed P10 nasal pillow small - initially seemed better, but same soreness inside left nostril after 4-5 hours leading me to cut CPAP session short (5.5 hours) Resmed nasal mask - caused soreness from mask pressing on my moustache after 4-5 hours leading me to take mask off after about 5 hours

Leak rate is very low, could be that nasal pillow is adjusted too tight, but I have separated the two bands as much as possible without improving the situation.

I haven't tried a full face mask, which is a possibility as I tend to be a mouth breather and sometimes am aware of a small amount of air leaking out of my mouth.

AHI the last 4 nights has varied between 1 and 3.75 with the vast majority of events central apneas so control of my mild sleep apnea is very good.

Suggestions appreciated.

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Sierra +0 points · over 2 years ago Sleep Patron

I have tried 5 different masks so far, and I am back to the first mask I tried which is the same AirFit P10 you are using.

Tried a Mirage Quattro full face, and it was a disaster. I couldn't make it stop leaking. It blew air in my eyes and made rude noises. I never got to the point where I could wear it a full night.

I tried a ResMed AirFit F20 full face and it was better, and I managed to wear it a total of about 5 full nights. However it still leaked some, and when I got it to the point where leaks were reasonable it started to make a blister on the bridge of my nose. Gave up on it. I never tried the cloth mask liner trick, and that may have helped.

Also tried the ResMed Mirage FX Nasal mask that my wife uses. It was more comfortable than the two full face masks, but not nearly as comfortable as the nasal pillow, and had all the disadvantages of not covering the mouth.

Tried a F&P Brevida nasal pillow based on some rave reviews of it. It was pretty good and has a much better headgear with a sensible adjustment system compared to the P10. However, it seems to stick out more than the P10 and seemed easier to dislodge when changing positions at night. I had the fit pack and tried both the large and small. But, it in particular irritated the part of my nose between the two nares. I pawned that one off on my wife and she finds it much better than the Mirage FX. The small size restricted flow on exhale, but the large size works for her.

That brings me back to the P10 which I am using again after the mask merry-go-round. I had trouble keeping it on all night, and was opening my mouth letting air out and causing a major leak. I now use a Breathewear Halo chin strap and it sure keeps the mask on all night. It did not totally solve the mouth opening problem, so I reluctantly tried the tape on the mouth trick with 1" medical paper tape. I have now gotten very used to it, and have many night with essentially zero leakage. It is quite the Jerry rigged setup but it works for me.

As for the nose irritation I tried the medium and large insert sizes. The medium sealed better but seemed to go too far into my nose and irritated the skin quite a lot. The large is now working best for me. As for the nose irritation mine seems to be mainly on the exterior edge of the nares. In the morning after taking my mask off and showering I put some OTC 1% hydrocortisone cream on my nose. I found after doing that for a week or two the skin toughened up and I no longer need the cream.

Hope that helps some,

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sleeptech +0 points · over 2 years ago Sleep Enthusiast

Your problem with the AirFit P10 is quite a common one. I hear it a lot. The only real solution is a different mask. Currently my favorite intranasal mask is the DreamWear intranasal, although you may find the under-the-nose version worth a look. Also, the Nuance is not bad. Both the DreamWear and the Nuance have gel pads in the nasal prongs which are gentler on the nostrils than the AirFit. Most of my patients prefer them. do a bit of googling to see what they look like.

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Stoaty +0 points · over 2 years ago Original Poster

I ended up ordering the Nuance at my refit today. The complaints about noise from the DreamWear steered me away from that mask as I am very sensitive to sound. Thanks for your input.

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Sierra +0 points · over 2 years ago Sleep Patron

You will have to give us a report on how it works for you. It looks like the headgear is better than the ResMed P10.

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Stoaty +0 points · over 2 years ago Original Poster

Thanks for your suggestion sleeptech. I assume you mean the "Respironics DreamWear Gel Pillow CPAP Mask" as your favorite. I notice that the under the nose version, the "Respironics DreamWear Nasal CPAP Mask" has a lot more reviews on one site I went to (and people seemed to like it a lot), but for both noise seems to be an issue for many people. I can try a different mask within first 30 days with no charge so looks like I need to go in for a fitting.

PS The central sleep apnea problem is back again: https://myapnea.org/forum/puzzled-by-results-of-first-night-cpap-use

No matter what settings I tried last night I got AHI of between 10 and 20 with 95% of the apneas central. I felt like I couldn't get enough air at the lower pressure settings so increased the minimum pressure to 8 with EPR of 3. This felt the best but also had the highest AHI of around 20. For reference, my sleep study had AHI of 6.7 so I was a lot worse using the mask!

The input from this forum has been of far more help than I have gotten from Kaiser. I really appreciate the replies/suggestions.

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Sierra +0 points · over 2 years ago Sleep Patron

Are you able to post a SleepyHead chart for a couple of the nights? A good one and a bad one?

With a PC all you have to do is press F12 with the window maximized. A screenshot will be saved under Documents/SleepyHeadData/Screenshots. With Windows Explorer just drag the saved files to the body of a message you are composing. They will upload and be displayed as a thumbnail which can be expanded for viewing. The daily report has a lot of data on it that is very helpful in determining what is going on.

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Stoaty +0 points · over 2 years ago Original Poster

Good one from a few days ago:

Bad one last night (only a small portion of the night as I kept trying different settings, but all settings tried were bad)

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Sierra +0 points · over 2 years ago Sleep Patron

A format suggestion. You seem to have the CA events flagging turned off. If you turn it on, then you should be able to see when the CA events are occurring and at what pressure. If you can post the same reports again but with the CA flagging turned on it would be helpful.

My initial thoughts are that the EPR may not be doing you any favors. I think I would turn it off, and set the minimum pressure at 6 cm. That should give you enough air to feel reasonably comfortable, and possibly avoid some of the CA events. It is possible that the pressure will just stay at 6 cm and not go up any significant amount during the night. It seems you do not need much pressure to address the obstructive events.

If that works then you may want to turn the EPR back on again but set it for Ramp Only, and then set the Auto Ramp start pressure at 6 cm as well. This will give you the EPR to improve comfort during the ramp hold period, and then shut it off when you go to sleep.

Another thing you may want to do is zoom in on a period of time when you are having a lot of central events. You can do this by repeatedly left clicking in that area. Using the up down and sideways arrows can fine tune the location and zoom level. This will allow you to see what the central apneas look like in the flow rate graph. Posting one of those would be helpful too.

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Stoaty +0 points · over 2 years ago Original Poster

Flags on:

Zoomed in:

Zoomed in More:

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Sierra +0 points · over 2 years ago Sleep Patron

It looks to me like those CA events are occurring only when IPAP pressure is above 8 cm. Turning EPR off and setting your minimum pressure at 6 cm may avoid them.

Those CA events do not look like the ones I see when I am sleeping. Any idea if you were sleeping at the time they were happening?

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Stoaty +0 points · over 2 years ago Original Poster

I think I was sleeping, but not 100% sure. Here is a section of time later last night when I put the mask back on with minimum pressure set to 8 and EPR set to 3. I am virtually certain I was sleeping then. There are a lot of central apnea events here with AHI of 21.8 for the whole 1 hour 20 minute time span. My conclusion is that with EPR turned on I blow off too much CO2 leading to the apnea. Tonite I will try minimum pressure of 6, EPR off, Auto Ramp off (I like to get the air flowing right away).

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Sierra +0 points · over 2 years ago Sleep Patron

Those first CA events in this series look to me like you were breathing normally and then just stopped. Not sure of the potential cause of those if you were sleeping. The last one looks more typical where the breathing flow is normal and then slowly tapers off to none, and then the apnea. That can be caused by an upset in the CO2 and O2 levels that your body does not adapt to quickly enough. Kind of like a cruise control that does not act fast enough and then over reacts.

You do not have to get less air when you use the Auto Ramp and set the EPR to Ramp Only. The trick is to set the Ramp Start pressure to the same as your minimum pressure - say 6 cm. You will get the full 6 cm and it will only cut back on exhale. Then when you go to sleep the EPR function will stop and both inhale and exhale will go to 6 cm.

But I think the main thing for now is to stop the EPR when you are sleeping and get the minimum to 6 cm or 7 cm at most.

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Stoaty +0 points · over 2 years ago Original Poster

I think you are right. I tried minimum pressure of 6 without EPR and then minimum pressure of 7 without EPR. Here is a short section when it was set at 7 (only tested for 9 minutes) in which I had AHI of 0. Unfortunately, I couldn't see that this section was zero until I went into sleepyhead today as it appears that the Airsense 10 only shows average for the whole night to that point. I am going to try minimum pressure of 6 or 7 tonite with EPR off.

PS Thanks again for all of your help.

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Stoaty +0 points · over 2 years ago Original Poster

Here is a graph of a 20 minute "nap" I tried to take just now. Toward the end I was drifting off to sleep. Minimum pressure set to 6, Maximum pressure set to 11, EPR off, ramp time off. Note that the pressure gradually drifted up to around 9. AHI of zero (but I wasn't quite asleep so not a particularly good test). I am a bit surprised the pressure went that high while I was not quite asleep.

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Sierra +0 points · over 2 years ago Sleep Patron

It is surprising that it pushed pressure up so far and so quickly. You are getting some flow limitation indications on that graph, and the snore chart is not visible. Both can drive pressure up even in the absence of flagged OA and hypopnea events.

Another option would be to set a maximum pressure of say 7.6 cm to keep the pressure from going too high.

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Stoaty +0 points · over 2 years ago Original Poster

Snore chart has one tiny little blip, almost always empty completely so I had hidden it. Why would I want to set a maximum pressure that low if flow is being limited in some way? Doesn't that mean I am not getting the optimal amount of oxygen if there is a limitation in flow?

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Sierra +0 points · over 2 years ago Sleep Patron

It may end up being a compromise. Some flow limitation may be better than frequent central apnea events. The other factor at work here is that you may be able to tolerate a bit higher pressure with EPR turned off. You could leave the maximum pressure higher and then see if the centrals come back now that EPR is turned off. A full night's sleep will be the best indicator of where you stand with EPR off.

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Stoaty +0 points · over 2 years ago Original Poster

Yes, I will only set the maximum pressure lower if the central apneas continue tonight with EPR off.

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Stoaty +0 points · over 2 years ago Original Poster

I ended up trying different minimum and maximum pressures (I wasn't sleeping very well any way) last night. Setting minimum of 7 and maximum to 8 seemed to work for a while, then got a bunch of central apneas such that the whole section had AHI of 11.89:

I got disgusted and changed from APAP to CPAP with a set pressure of 7. Over a period of an hour and 40 minutes (last sleep section of the night) I got AHI of 0.61 with one central apnea and nothing else. There was a bit more flow limitation, but no hypopneas. Looks like CPAP 7 will be my setting for the whole night tonite.

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Sierra +0 points · over 2 years ago Sleep Patron

Yes, you seem to be susceptible to central events when pressure is in the 7-8 range. Also fairly clear that flow limitations are driving pressure up. The central events also seem to be somewhat associated with mask leaks. Some believe that mask leaks change the purge efficiency of the mask and increases oxygen levels in the air taken in. It may not be so much the absolute level that is an issue, but the fact it is changing and the body has to adjust breathing rate to compensate, and may over compensate. Something to watch for.

The other suggestion again and it is just for going to sleep comfort would be to turn on the Auto Ramp feature, Set the Ramp Start pressure at 7 cm to match the CPAP set pressure, turn EPR to Ramp only, and at a level 3. That way you will get 7 cm on inhale and 4 cm on exhale - easy to breathe in, easy to breathe out. Then that stops when you fall asleep.

The traditional thinking on sleep apnea is that it causes a poor sleep. I have also come to the conclusion that the reverse can be true too. Poor sleep can cause apnea as well. One of my measures of good CPAP treatment is being able to sleep through the night without getting up. Most nights now I can do that.

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Stoaty +0 points · over 2 years ago Original Poster

First full night of CPAP with fixed pressure of 7:

Time - 7 hours 26 minutes AHI - 3.09 Central apneas - 2.02 Obstructive apneas - 0 Hypopneas - 1.08 RERA - 0.27

I had 3 separate sessions due to bathroom breaks. They are as follows:

First 3 hours - AHI 5.08 Next 3 hours - AHI 1.95 Last 1 hour - 0.83

Not sure why the score progressively improved as the night wore on. I may try backing off to fixed pressure of 6.5.

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Sierra +0 points · over 2 years ago Sleep Patron

There are things about apnea that just never make perfect sense. I have been on a fairly long run of AHI's less than 2.0. Last night I got up at about 4:00 AM and AHI was 1.6. I was expecting a good similar score when I got up again at 7:30 or so. Nope. It was now 3.5! From SleepyHead I got a burst of OA's about 5:00 AM. Perhaps it was a sleeping position issue. I think that may be one of the downsides of a fixed pressure. There may be occasional events that it does not address. But my thoughts are that overall on average if they are good, then that does not matter so much.

If you are still getting centrals backing pressure off may work. At some point it will be a tradeoff between more obstructive apenas and flow limitation or centrals. My thoughts are that both are about the same in severity so it is the total that counts.

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Stoaty +0 points · over 2 years ago Original Poster

Set CPAP to fixed pressure of 6.6 last night. Found this significantly more comfortable which is surprising for such a small decrease of pressure. AHI was 3.5 about 2/3 central apneas and 1/3 hypopneas. I am going to try fixed pressure of 6.4 tonite.

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Sierra +0 points · over 2 years ago Sleep Patron

One measure that SleepyHead tracks is total time in apnea. When trying to make a trade off in pressure you may want to consider this measure. I suspect that it doesn't matter if the apnea is central or obstructive, as both stop breathing and will affect blood oxygen. The only limitation of total time in apnea is that it does not compensate for time on the machine like AHI does. So, you may want to divide it by machine hours to get a number to compare from one night to another.

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Stoaty +0 points · over 2 years ago Original Poster

That is a very good suggestion. Last night with pressure of 6.4 over 7 hours 50 minutes I had AHI 1.8 with central apneas at 0.8 and total time in apnea of 2:36. That is the lowest I have seen for total time in apnea. Tonite I am going to try 6.2.

Whether I sleep 6 hours or 8 hours, the amount of time I am not fully oxygenating my blood seems like the best measure. If I am awake 2 more hours of the day I can breathe fine during that time.

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Stoaty +0 points · over 2 years ago Original Poster

I have reached CPAP nirvana (if there is such a thing). Set to fixed pressure of 6.2 last night. Over 7 hours got AHI 0.89 with 2 central apneas, 1 obstructive apnea and 3 hypopneas. Total time in apnea 1:06. Thanks to Sierra for helping me figure out the best setting!

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