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Mouth Breathing Issues
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bayareacpap Offline

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Posts: 8
Joined: Aug 2015

Machine: S9
Mask Type: Nasal mask
Mask Make & Model: Resmed
Humidifier: Resmed
CPAP Pressure: 7-10
CPAP Software: SleepyHead

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Sex: Male
Location:

Post: #1
Mouth Breathing Issues
I have been on CPAP for several years. Things were great for the first 4 years, my AHI was <1 every night and I slept 8 hours very comfortably and woke up refreshed. A couple of years ago, I switched doctors and they increased my pressure from 10 to 16 -18 even though I did not have any apneas/hypopneas during the sleep study using the pressure of 10-16 (the titration study was from pressure 10-16. I did not know that I did not have any AHI until recently when I reviewed the study more throughly. When I asked about it, they said that I had REM at 15 so they always set the bottom pressure one higher than the point a person had REM and no AHI and then the top range 2 points higher than the low range. Apparently, their protocol is that they want the pressure to always be above 10 and preferably higher even if that pressure is not required - I spoke to a couple of DMEs and sleep technologists who confirmed this about their protocol). I started having a considerable amount of mouth breathing at this pressure (dry mouth etc and constantly waking up). I recently did another sleep study with another doctor and I did not have any AHI above pressure of 7 so doctor reset my pressure from 7-10. I had a couple of questions about mouth breathing:

1. If my Resmed S9 says that my 95% leak rate is 15 for example, do we know if that number is accurate if it is due to mouth breathing vs. mask leaking? I am just wondering if anyone ever asked Resmed if they are able to get accurate readings on leaks while a person is mouth breathing (could the number really be much higher than 15, perhaps above 24 even though the machine reads 15). I am wondering because it seems harder to track leaks far from the source of the mask but I am not an engineer so maybe it is easier than I think. I seem to remember finding something about this problem on the Internet but now I can not find it.

2. If my 95% leak rate is 15 with no more than about 2% of time above 24 with a max of somewhere between 25-30 (my average is usually 0 or 1), can the S9 compensate for that pressure loss through mouth breathing by raising the pressure? I am just trying to figure out if that 95% leak rate is too high for the machine to handle it if it goes on for a while.

3. Sometimes, I have a flow rate pattern where the negative flow rate is the normal 2 ticks down on Sleepyhead graph but the positive flow rate is truncated at 1 tick vs. my normal 2 ticks for quite a while. Then the flow rate goes up rapidly from -60 to +60 or higher for a few seconds then repeats the pattern of truncated flow rate for a few minutes etc. I am wondering if this could be indicative of mouth breathing on the truncated part and then having apneas that are not recording due to mouth breathing and then hyperventilating due to the apnea (apneas are not showing up during this time on software but not sure if they would register if the person is mouth breathing)? I inserted an image of this pattern from Sleepyhead.

I am asking all of these questions because I am still really tired when i wake up in the morning and I am not sure if I am still mouth breathing and having unrecorded apneas or if I have simply not recovered from poor sleep for the past year etc.


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08-06-2015 06:26 PM
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kaiasgram Offline

Advisory Members

Posts: 242
Joined: Aug 2013

Machine: S9 VPAP Auto
Mask Type: Nasal pillows
Mask Make & Model: Aloha
Humidifier: H5i
CPAP Pressure: 8-10
CPAP Software: SleepyHead

Other Comments:

Sex: Female
Location: Northern California

Post: #2
RE: Mouth Breathing Issues
Hi Bayarea guy: I think it will be easier to address your questions when you get to 8 forum posts and can post some SleepyHead graphs. For now: If your 95% leak rate is 15, that is within the acceptable range for ResMed. And it doesn't mean that you were at 15 for 95% of the time, it means you were at OR BELOW 15 for 95% of the time. (You can look at your leak graph to get an idea of where you actually spent most of the time.) In any case, whether mask leaks or mouth leaks, it doesn't look all that bad, certainly not bad enough to distort the rest of the data. Now if you're a sensitive sleeper leaks could certainly be disruptive to your sleep even if they're within the acceptable range.

I don't think the machine is "less accurate" with mouth leaks vs. mask leaks. If I'm mistaken someone will come along and correct me, but I believe the machine is accurate with measuring excessive leak no matter whether it's mouth breathing, mask leak or even a hole in the hose.

Looking at the graph -- without the other graphs to help interpret, it looks to me like flow-limited breathing. Basically some degree of airway restriction. That's what the flat-top wave usually signifies. The S9 produces a flow limit graph -- do you see the FL graph line going up a bit where the top of the wave (in the flow rate graph) flattens out? Anything in the snore graph?

What is your AHI on the machine at your current pressure settings?
(This post was last modified: 08-07-2015 12:29 AM by kaiasgram.)
08-07-2015 12:28 AM
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woozie38 Offline

Advisory Members

Posts: 248
Joined: Jan 2013

Machine: Fisher & Paykel Icon + Auto
Mask Type: Full face mask
Mask Make & Model: F&P Simplus
Humidifier: Integral
CPAP Pressure: 8 to 14
CPAP Software: SleepyHead Other Software

Other Comments: 17 years of CPAP + supp. oxygen @ 3 L/min

Sex: Male
Location: Toowoomba, Queensland Australia

Post: #3
RE: Mouth Breathing Issues
(08-06-2015 06:26 PM)bayareacpap Wrote:  while a person is mouth breathing (could the number really be much higher than 15, perhaps above 24 even though the machine reads 15).

I note you are using a nasal mask. Leaving aside cards, graphs, & software, what needs to be understood here is that a CPAP mask supplies air pressure to your airway to splint it so it remains open when the throat muscles & tissues relax in sleep. Both oral & nasal passages feed this air pressure to the airway when a full face mask is used, in contrast to via the nasal passages only when using a nasal mask. So if your mouth falls open during sleep, the air pressure will exhaust from your mouth at a considerable rate. The long term effects are things like mouth ulcers & decayed teeth. But most damaging perhaps is the loss of pressure which defeats your therapy. Increasing the pressure will only increase the flow rate from your mouth. I'm not sure that Software actually records this phenomenon & its not easy to correct. Many members here frown on mouth taping suggesting instead the use of a chin strap. Personally I've found these things close to useless. Some patients are able to seal off the air using their tongue pressed against the roof of the mouth. In the end I changed to a FFM & perhaps you may have to do the same.
Best of luck,

[Image: signature.png]Keep on breathin'
08-07-2015 02:48 AM
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Shastzi Offline

Advisory Members

Posts: 1,174
Joined: Dec 2012

Machine: ResMed S9 Autoset
Mask Type: Full face mask
Mask Make & Model: FitLife Total face mask
Humidifier: F&P HC150 with Hybernite heated hose.
CPAP Pressure: 15cm-20cm H2O (auto)
CPAP Software: SleepyHead Other Software

Other Comments: CMS50-F wearable Oximeter; Software: SPO2 Assistant

Sex: Undisclosed
Location: Florida, USA.

Post: #4
RE: Mouth Breathing Issues
Full face mask.
Find one that fits and get used to handling it.
There are a lot of mouth breathers out there. Smile

"With ordinary talent and extraordinary perseverance, all things are attainable." - Thomas Foxwell Buxton

Cool
08-07-2015 05:34 AM
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trish6hundred Offline

Advisory Members

Posts: 6,452
Joined: May 2012

Machine: Resmed S9 AutoSet for Her
Mask Type: Full face mask
Mask Make & Model: Fisher & Paykel Simplus
Humidifier: H5i Heated Humidifier
CPAP Pressure: 10 - 7-20 Cm H2O
CPAP Software: Not using software

Other Comments: I started CPAP in 2008. Totally blind since birth.

Sex: Female
Location: Missouri, USA

Post: #5
RE: Mouth Breathing Issues
Hi bayareacpap,
WELCOME! to the forum.!
Hang in there for morre responses to your post and much success to you with your CPAP therapy and optimizing it to work well for you.

trish6hundred
08-07-2015 09:25 AM
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PaytonA Offline
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Monitors

Posts: 3,016
Joined: Dec 2013

Machine: ResMed S9 VPAP Auto
Mask Type: Full face mask
Mask Make & Model: Resmed Mirage Quattro
Humidifier: H5i(distilled-top up)
CPAP Pressure: VAuto MinE14.0 MaxI 20.6 PS4.0
CPAP Software: ResScan SleepyHead

Other Comments:

Sex: Male
Location: Orange County,California

Post: #6
RE: Mouth Breathing Issues
(08-06-2015 06:26 PM)bayareacpap Wrote:  I have been on CPAP for several years. Things were great for the first 4 years, my AHI was <1 every night and I slept 8 hours very comfortably and woke up refreshed. A couple of years ago, I switched doctors and they increased my pressure from 10 to 16 -18 even though I did not have any apneas/hypopneas during the sleep study using the pressure of 10-16 (the titration study was from pressure 10-16. I did not know that I did not have any AHI until recently when I reviewed the study more throughly. When I asked about it, they said that I had REM at 15 so they always set the bottom pressure one higher than the point a person had REM and no AHI and then the top range 2 points higher than the low range. Apparently, their protocol is that they want the pressure to always be above 10 and preferably higher even if that pressure is not required - I spoke to a couple of DMEs and sleep technologists who confirmed this about their protocol). I started having a considerable amount of mouth breathing at this pressure (dry mouth etc and constantly waking up). I recently did another sleep study with another doctor and I did not have any AHI above pressure of 7 so doctor reset my pressure from 7-10. I had a couple of questions about mouth breathing:

1. If my Resmed S9 says that my 95% leak rate is 15 for example, do we know if that number is accurate if it is due to mouth breathing vs. mask leaking? I am just wondering if anyone ever asked Resmed if they are able to get accurate readings on leaks while a person is mouth breathing (could the number really be much higher than 15, perhaps above 24 even though the machine reads 15). I am wondering because it seems harder to track leaks far from the source of the mask but I am not an engineer so maybe it is easier than I think. I seem to remember finding something about this problem on the Internet but now I can not find it.

2. If my 95% leak rate is 15 with no more than about 2% of time above 24 with a max of somewhere between 25-30 (my average is usually 0 or 1), can the S9 compensate for that pressure loss through mouth breathing by raising the pressure? I am just trying to figure out if that 95% leak rate is too high for the machine to handle it if it goes on for a while.

3. Sometimes, I have a flow rate pattern where the negative flow rate is the normal 2 ticks down on Sleepyhead graph but the positive flow rate is truncated at 1 tick vs. my normal 2 ticks for quite a while. Then the flow rate goes up rapidly from -60 to +60 or higher for a few seconds then repeats the pattern of truncated flow rate for a few minutes etc. I am wondering if this could be indicative of mouth breathing on the truncated part and then having apneas that are not recording due to mouth breathing and then hyperventilating due to the apnea (apneas are not showing up during this time on software but not sure if they would register if the person is mouth breathing)? I inserted an image of this pattern from Sleepyhead.

I am asking all of these questions because I am still really tired when i wake up in the morning and I am not sure if I am still mouth breathing and having unrecorded apneas or if I have simply not recovered from poor sleep for the past year etc.

1) The Resmed machines measure unplanned leaks wherever they occur. It does not matter whether it is your mouth that is allowing the leak or the mask. As far as the machine is concerned it is a leak. The only thing the machines tries to leave out is the amount of air that the mask vents intentionally.

2) According to Resmed, the machine can compensate and identify accurately as long as the unintentional leaks are below 24 l/min. If you go above that limit for short periods of time it is not to consequential.

3) I agree that this looks somewhat like flow limitations during the "truncated" portion. That means that your inhalation is slightly limited by a restriction in the airway. This is considered to be a precursor to an apnea and the auto machines will increase pressure depending on what they consider the severity of the flow limitation.

Best Regards,

PaytonA
08-07-2015 11:47 AM
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bayareacpap Offline

Members

Posts: 8
Joined: Aug 2015

Machine: S9
Mask Type: Nasal mask
Mask Make & Model: Resmed
Humidifier: Resmed
CPAP Pressure: 7-10
CPAP Software: SleepyHead

Other Comments:

Sex: Male
Location:

Post: #7
RE: Mouth Breathing Issues
Thanks to everyone for the responses. It is very helpful. I am just trying to figure out if not using a full face mask is affecting my therapy. It sounds from your responses like it is not a major issue since my leak is not above 24 for a considerable amount of time. Is that correct? I am hoping to not use a full face mask if my therapy is not being compromised since I did not like the feeling and have heard they have their own issues with leaks, dry mouth etc. I have found that the more complicated the therapy, the more significant unexpected issues arise.

The truncated breathing is strange. It seems to happen in 2 scenarios. (1) when I have used a chin strap (I am not sure why). (2) when the pressure of the CPAP goes up (I assume that this is due to mouth breathing since my nose can't handle the higher pressure due to congestion). Does that make sense?

Thanks again!!
08-07-2015 01:22 PM
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kaiasgram Offline

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Posts: 242
Joined: Aug 2013

Machine: S9 VPAP Auto
Mask Type: Nasal pillows
Mask Make & Model: Aloha
Humidifier: H5i
CPAP Pressure: 8-10
CPAP Software: SleepyHead

Other Comments:

Sex: Female
Location: Northern California

Post: #8
RE: Mouth Breathing Issues
(08-07-2015 01:22 PM)bayareacpap Wrote:  The truncated breathing is strange. It seems to happen in 2 scenarios. (1) when I have used a chin strap (I am not sure why). (2) when the pressure of the CPAP goes up (I assume that this is due to mouth breathing since my nose can't handle the higher pressure due to congestion). Does that make sense?

Your second scenario fits with flow limited breathing. Your machine increases the pressure in response to flow limitations, which is what your posted image suggests. You can see the relationship in this image -- as flow limitation goes up, pressure goes up in response:

[Image: flowsandpressure_zps9obdrfww.jpg]

Your FL breathing may or may not have anything to do with mouth breathing. During time shown in my posted image, I had zero leaks.

I don't know about the chin strap scenario.
(This post was last modified: 08-07-2015 02:29 PM by kaiasgram.)
08-07-2015 02:22 PM
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kaiasgram Offline

Advisory Members

Posts: 242
Joined: Aug 2013

Machine: S9 VPAP Auto
Mask Type: Nasal pillows
Mask Make & Model: Aloha
Humidifier: H5i
CPAP Pressure: 8-10
CPAP Software: SleepyHead

Other Comments:

Sex: Female
Location: Northern California

Post: #9
RE: Mouth Breathing Issues
Bayarea: Perhaps because you titled your thread "Mouth Breathing Issues," people took as a given that mouth breathing is now a problem and the recommendations of a full face mask followed. But in looking back at your first post I noticed a couple of things: 1) You stated at the end of that post that you are not even sure if you're still mouth breathing; and 2) You report that your first 4 years went very well with AHI <1 and refreshing sleep, but you didn't mention what type of mask you were using during that time -- was it a nasal mask or a full face mask? If you were using a nasal mask when things were good then it seems reasonable to suppose that they could be good again with the nasal mask.

In trying to figure things out I think it might be good to uncouple the question of mouth breathing from your questions about what your SleepyHead reports are showing because the numbers (and the graph) you've shared so far do not indicate that leaks are significant enough to either compromise your therapy or to distort the reporting of apneas by your machine. Now that doesn't mean you have no mouth breathing issues, but you may miss some important clues in your data if you're only asking how mouth-breathing could be affecting what you see in your SleepyHead reports.

The bottom line as you said at the end of your first post is that you're trying to understand why you're having less refreshing sleep and are waking up feeling tired. Leaks and/or mouth breathing may not be the explanation and I think it could be useful to look at some more data when you're able to post more. Smile We want to check out the snores and flow limitations, and what your AHI is currently, and what your Pressure graph looks like -- for example, is the pressure line bumping along the ceiling (your max pressure setting) most of the night which might indicate the need for a pressure adjustment? And when you look at the Leak graph, did you only have a couple of brief forays up to the higher leak levels but actually spent most of the night with very low leaks? Lots of possibilities to check out still.
(This post was last modified: 08-07-2015 03:22 PM by kaiasgram.)
08-07-2015 03:19 PM
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bayareacpap Offline

Members

Posts: 8
Joined: Aug 2015

Machine: S9
Mask Type: Nasal mask
Mask Make & Model: Resmed
Humidifier: Resmed
CPAP Pressure: 7-10
CPAP Software: SleepyHead

Other Comments:

Sex: Male
Location:

Post: #10
RE: Mouth Breathing Issues
kaiasgram - this makes a lot of sense. I do not know if it is mouth breathing. I just thought it was since I tend to have dry mouth in morning at times and high leaks at times throughout the night with flat tops. I could be totally off. Here are some more statistics since I do not think I can post graphs yet.

AHI: .76 last week (.58 clear, .18 hypopnea, 0 obstructive - I only get about 1-2 obstructive per month).
Snore: Average tends to be 0.02, 95% tends to be 0.04, max tends to be 0.08 to 0.12 (graph line is very close to the axis so hard to see).
Flow limit: Average is 0.0, 95% is 0.06 or 0.07 on most nights, max tends to be .30 to .38.

My pressure is set 7-12 (misquoted above). It will hit 10 maybe 3-5 times during 7 hours or so. The ramp up tends to be pretty steep so most of the night the pressure is dropping towards 7 (average pressure is around 8.5). A couple of times a week, it hits 11 or 12 but I almost always wake up when that happens so it does not stay there very long and then resets to 7 when I turn off CPAP (It seems I do not do well when the pressure ramps from 7-12 so quickly).

The leak graph varies from night to night, of course. Some nights, I will have 3 or more rapidly rising leaks that quickly turn into flat tops. Many times the pressure will be slightly under 24 or slightly higher than 24 (22-28). These can last anywhere from 10 minutes to an hour or more (the higher end time is rare). However, they can be lower leak rates in the same pattern (I have seen them in the 5-20 range at times). On these types of nights, the rest of the leaks are small and short lived or a mountain pattern that goes up and down quickly. I do not seem to sleep as well during these nights.

The other nights seem to have mountain top patterns or small leaks that come and go quickly. These nights, the max pressure tends to be much lower than the other nights. I tend to sleep better on these nights.

On the nights I have a lot of flat top leaks, I have noticed a pattern that I will have one or two flow limitations at around 0.17 then the pressure will start rising rapidly (like from 7 to 10 in one or two minutes). As soon as the pressure starts to increase, my leak rate will rise rapidly (like from 0 to 24 at the same pitch of the pressure ramp). Then the leak rate will flatline at a certain rate, like 24, for a long while. As the pressure begins to drop to a lower level, the leak rate will suddenly drop back to close to zero or zero. On nights that the pressure goes to 12, I have noticed that small flow limitations drive higher pressures, to about pressure of 10, which seem to drive higher flow limitations a few seconds later (like around.31) which seems to drive the pressure even higher, like to 12, and then I wake up.

I am surprised that my Resmed CPAP responds so rapidly with much higher pressures to small changes in flow rate (I am not having any AHI during these times). I have heard that Respironics CPAPs increase the pressure much less aggressively to changes in flow rates (this is just something I have heard so not trying to offend anyone). Could this possibly help my issue (this is something my DME brought up recently)?

Is there anything else that would be helpful for you to know?

Thanks!!
08-07-2015 04:55 PM
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