20YearsAsleep

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!

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.

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.