Sierra

I would suggest downloading SleepyHead to look at your data on the SD card to see what is happening. You mainly want to know what type of apnea events are occurring and when they happen. You need a SD card reader, and a Mac or PC to install the software. Here are some links:

SleepyHead Software Download

SleepyHead Basic Manual

If you can get your data into SleepyHead, then do a screenshot of the Daily Detail screen (F12 on a PC) then left click and drag the file into the body of message here. I will look at it and tell you what I think could be going on. Without seeing the detail it is hard to help. Your other option is to go back to the sleep clinic, as something is definitely not right with the machine setup, or it is the wrong type of machine.

I have a couple of thoughts on your problem. If you have an older S9 type machine you can get into the setup menu to see your pressure setting by holding down the key with the two check marks at the same time as the round knob for about 5 seconds. By scrolling through the menu you will see your settings. If it is a newer AirCurve machine hold down the Home key at the same time as the round knob for about 5 seconds.

It would be helpful to post the pressure settings you see. I'm not quite sure what you mean by 12/9 or 18/8. An automatic BiPap will normally have a minimum and maximum EPAP pressure as well as a Pressure Support (PS) number. PS is kind of like EPR but is adjustable to more than 3 cm. Here is a link to a more technical manual on the newer AirCurve model.

AirCurve Tech Manual

The other thing I would suggest doing is downloading SleepyHead to look at your data on the SD card to see what is happening. You mainly want to know what type of apnea events are occurring and when they happen. You need a SD card reader, and a Mac or PC to install the software. Here are some links:

SleepyHead Software Download

SleepyHead Basic Manual

As for what has happened, I think it may be possible you are suffering from central apnea events. More pressure can increase central apnea. The data will be on your SD card and you will be able to see all the detail with SleepyHead and you should be able to see what has changed.

Finding the right mask is often the most difficult part of using CPAP. From what I know of your situation I would be very comfortable suggesting that the ResMed AirSense 10 AutoSet For Her would be your best bet for a machine. But, suggesting a mask is much more difficult.

Here are my thoughts based on my personal experience with 5 different masks; 2 nasal pillow, 1 nasal, and 2 full face.

Nasal Pillows: They tend to be the smallest masks with the least contact with the face. For this reason they can be more comfortable for side sleepers as they are less easily dislodged by the pillow you sleep on. Because they seal semi-in your nose they tend to seal easier with less tension on the headgear, and as a result can be the most comfortable. They are kind of a minimalist mask, and can have somewhat flimsy headgear (like the ResMed P10).

Nasal Mask: These are like a mini full face mask, but only cover the nose. They are bigger and can be more easily dislodged than the nasal pillow type. For that reason it may be necessary to use more tension on the straps, which can make them a bit less comfortable and leave temporary marks on your face. They tend to have much better headgear. Leaks can blow into your eyes if they do not seal properly. Mirage FX is one example.

Full Face Mask: Have the most contact with the face, and since the pressure has a larger area to act on, they need the most tension and can be hard to seal. And when they do leak the air can blow into your eyes which is very uncomfortable. They do allow you to breathe through your mouth, which is not necessarily a totally good thing. ResMed AirFit F20 would be one example.

Then there is the issue of so called "mouth breathing". I find that a bit of a misnomer, as it is very difficult to actually breathe air in when you are under pressure with a CPAP. The real problem is that when you open your mouth air leaks out, and sometimes it can be a lot of air. This reduces the effectiveness of the CPAP, and dries out your throat. Mouth opening and loss of air through the mouth is the main reason users go to a full face mask. In my opinion I think this can be a mistake and should be used as a last resort. The other, and I believe better option is to use mouth taping to stop the air loss from the mouth. We were made to breathe through our nose, not our mouth, and the combination of mouth tape and a nasal mask ensures you breathe through your nose, and not your mouth. Here is a video on the benefits of mouth taping:

How to Mouth Tape for a Better Sleep

So if you have an opportunity to try different masks I would suggest the following nasal pillow masks to try first. Pick the one that feels the most comfortable to you. And you will have to be prepared to mouth tape if you find you open your mouth during the night. Using SleepyHead will tell you if that is a problem.

• ResMed AirFit P10 - The headgear is kind of flimsy, but I think it has the best nasal pillow design. I now use this mask after trying the others.
• F&P Brevida - Has a better headgear, is a little larger and noisier
• Dreamwear Gel Nasal Pillow - Has over the head hose routing, but the tubes up the side can by noisy (as reported by users)

As for your comment about nasal pillow masks having a smaller air outlet and as a result are harder to breath out through, I have not experienced that effect at all. Remember that you are breathing out against the CPAP exhale pressure. That adjusts automatically and is effectively constant for the different mask types. Larger full face masks do have a larger purge flow - constant air leakage. This is because they have a larger air dead space than a smaller mask like a nasal pillow. The higher purge flow is to ensure too much CO2 does not build up in the larger dead space.

Generally the most comfortable way to set up an AirSense machine is to use pressure reduction on exhale but only during the going to sleep ramp period. For example if the ramp start pressure is 7 cm, and EPR is set at 3, then you get 7 cm pressure on inhale, and 4 cm on exhale. To most that feels very comfortable with no suffocating feeling. The more common problem is that some sleep clinics don't set the machine up this way, and leave the machine at the default settings which is 4 cm for the ramp, and sometimes the minimum pressure is set low at 4 or 5 cm. That can cause a suffocating feeling. In short your machine setup is mainly responsible for the breathing in and out effort, not the mask.

Hope that helps some,

If you have a copy of your sleep study report it should document the breakdown of events. If you divide the number of obstructive apnea events by the time in bed, it will give you an obstructive apnea index. Since your total AHI was 4.7 the obstructive index alone will be lower. It will give you an idea of how significant the obstructive issue is. Just based on the numbers you have given, it is more likely the RERA events are disturbing your sleep more than the obstructive apnea events.

ResMed claim the purge flow is the same as the standard elbow.

"While it releases the same amount of air per breath as our existing standard elbow, it's much quieter and gentler."

From a CPAP functional point of view, it is fine to have your mouth open with a full face mask. However there are some advantages to breathing through your nose. See the video at the link below. If you go back to a nasal pillow type at some point you may want to try the mouth taping along with it. I have used two different nasal pillow mask; ResMed AirFit P10, and the F&P Brevida. I found the Brevida irritated my nose more than the P10. It is important to get a size that does not go too far into your nose, but still seals. I have also found that using a bit of 1% hydrocortisone cream in the morning helped me get over the irritation issue.

Mouth Taping for a Better Sleep

Two thoughts on the issue. First with the DreamStation Flex system it reduces pressure some on exhale and increases it on inhale. A three setting reduces it more than a 1 setting. This is somewhat similar to the ResMed EPR system. There is a difference though. The ResMed triggers the switch from inhale to exhale mode based on the effort/flow of the user. You can breathe at the rate you want to. The Flex system tries to time the switch. If the timing is off, it can seem like the machine is fighting you. The simplest thing to try would be to turn the Flex setting down if it is on 3, or even turn it off. Another more involved solution would be to convince them to let you try a ResMed A10 AutoSet instead of the DreamStation. The ResMed has the added feature that it lets you use EPR while you are going to sleep, and then it turns off after you go to sleep. The ResMed also has an Auto Ramp feature that turns the ramp off when it detects you are asleep. If you can wangle a change, I think the ResMed is the better of the two.

And the second thought is the mask, if it is a nasal pillow type. If they are put on too tight, or don't fit you well (too small usually), then they can kind of crush and act like a check valve. It lets you breathe in, but not out. My wife had that issue with a F&P Brevida that was too small. Using the bigger insert solved the problem.

Hope that helps some,

Thanks for the tip. A plastic retainer clip thing on my wife's Mirage FX mask broke and I tried to repair it with silicone. It took a long time "set up" and really never did form any kind of bond. Next I tried the Gorilla super glue, and it worked on that too. She replaced it fairly shortly after that, so not sure how long it would have lasted, but I think she still has it as a spare.

I guess one option would be to disconnect the humidifier and send it to the technician for service. You could continue to use it without the humidifier. The hope would be that the problem is in the humidifier half of the machine.

My wife uses the S9 and I had a quick look at it. I would suggest pushing the big button on the back and disconnecting the two halves. There is an air tube and electrical connector between the two. Check the seal on the air tube, and the electrical connector for damage. Then inspect the humidifier itself for any damage to the seals or cracks in the plastic. There is one on the tub, and another on the lid of the enclosure. The humidifier is not all that complex. I suspect all it does is heat the water. The air is just directed over the water and then out to the mask. That is about all I can think of. And, there is a possibility the electrical fault could be in the machine itself, not in the humidifier... See the link below for a more technical manual on the machine. There is a bit of a maintenance inspection section toward the end of it.

ResMed S9 Technical Manual

No Hot pink! Fairly innocuous looking...