[Treatment] struggling, help interpreting OSCAR data and possible adjustments?

[manganCPAP]

Thanks for the additional advice Dave - interestingly I don't seem to have this air issue as much with the quattro air but will try adjusting more if necessary once these leaks are under control.

Ratchick - I followed your fitting advice regarding the mask and produced a fit that felt completely indestructible, face squashed into the pillow and still no leaks at 10cmH2O which is a pressure i have yet to need therapeutically. It was significantly tighter on my head than typical nights. Sadly it still seems leaks upon relaxing into sleep undid me (see attached), I wasn't sure if i fell asleep but seems I did (time passed very quickly if not) after the usual 15ish minutes the leaks started to rise and then fall in line with arousals which i remember vague moments of (oscillations in flow rate and spikes in tidal volume). I felt dry/stuffy and took the mask off after only 80 minutes.

One big oversight on my part is I don't think the chin strap was tight enough as I still had reasonably free jaw movement. I have a very stretchy neoprene one which makes it hard to get a reproducible fit in that sweet spot between supporting the jaw and allowing me to breathe - im also not sure how well it does at holding my jaw forward. I think I am also a little hesitant to over tighten as have issues with my TMJ. I have ordered your chin strap to arrive tomorrow as It looks a lot sturdier and hopefully might give me a more reproducible fit. for tonight i will tighten up my existing chin strap and test jaw movements and repeat the fitting procedure. 
 
Although an unsuccessful night I think this has helped me realise getting the chin strap right is key and the leaks were still better overall than some nights.

[Ratchick]

You're doing great, I'm glad that you managed to get a good fit (at least while awake). Maybe try the refit again, but this time, let your jaw sag like it does when you're asleep. If you can adjust the mask with jaw slackened like that so that it doesn't leak awake OR asleep (and yet is still comfortable) you might have better luck too.

If the chin strap doesn't work, then there's always an option to try a soft cervical collar, too, which should also keep your jaw up and forward gently too. In addition, it would rule out any chin tucking as well. Definitely be careful about worsening your TMJ - the good news is that when sleep apnea is treated properly, it often improves bruxism and TMJ too!

I also think at some stage you're going to be good to reduce your max pressure - you consistently seem to be staying underneath 10, so once you're comfortable, you can go with that too.

Other than that, your flow limits are good, and even with the larger leaks, they're still below the "red line" of 24 l/min. Even if you can't get it perfect, as long as you can make things more comfortable and stop your chin popping out, I think you're in a decent place.

The problem is that, even sleeping half the night without APAP is going to leave you feeling cruddy, in most cases, as if you were untreated. I know that just a quick 90-minute nap without PAP will leave me with a screaming headache and doing so for a whole night there's a 50+% chance I will wake up with a migraine (which is a big deal as they are severe and last three days). I also didn't think I would be able to tolerate a nose-only mask and to my surprise, last night I managed 3.5 hours with a pillow mask. If you could tolerate those, then you'd probably find them far less irritating than a FFM if you can get a chin strap/collar to work.

[manganCPAP]

going backwards at the moment it seems... 2 hours last night and unable to fall asleep at all now instead of drifting off after 15 minutes or so, had to give up on the mask as for me some bad sleep is still a bit better than no sleep. Also woken up with a pressure headache where a lot of my mask straps were and a tight jaw. Chin strap definitely causing discomfort when on tight enough to hold my Jaw so hopefully the new one does a bit better getting it comfortable is too loose, either way I think I am going to have to be less well tightened all round to fall asleep - hopefully a sweet spot exists where i can sleep and not leak but seems very hard to find. Relaxing my jaw during fitting just seemed to push it back further to an uncomfortable position. I did try a soft cervical collar 2 weeks ago and found it very uncomfortable (and also didnt stop leaks). Would a flatter pillow arrangement reduce chin tucking?

Don't know whether I should increase humidity and whether that can influence mouth drop, it did feel like i was drying out as the two hours went on. Either way i will try with the new chin strap and a slightly looser fitting mask tonight.

[Ratchick]

Increasing the humidity can definitely help a little when you mouth breathe.

A certain amount of leaks are okay, as long as they're below the redline level - the real problem is if they wake you, or affect the therapy. As long as you can keep it fitting well enough to stop your chin fully slipping out of the mask, then you're on the way.

Definitely don't trigger your TMJ or give yourself a headache, either way. It's for sure not worth that discomfort. It's just about finding the right mask and the right fit.

A flatter pillow could help with chin tucking, but it won't really help so much with your mouth opening. Which FFMs have you tried so far?

[manganCPAP]

I guess my mouth is always open as I'm always breathing through it, my mouth moving directly down doesn't seem to be as much of an issue as it moving backwards and tucking is, as moving down it mostly catches on the bottom of the mask.

I've got the two FFM that are the only ones my sleep clinic stocks, the quattro air and the F20 (silicon) both large as the medium was very difficult to open my mouth at all with to breathe. I have ordered a memory foam cushion for the F20 to try out. I have only worn the F20 three nights so far, it was comfy enough but I seemed to have worse baseline leak issues with it and some issues with the airflow feeling sufficient and a little bit of a suffocation feeling so I guess was sticking to something I know in the quattro air for now where I have had at least a few hours sleep on a couple of nights.

I might order a heated hose too as when i tested 6 humidity instead of 4 i couldn't feel much difference (and can't hurt i guess).  Unfortunately with existing health issues there is definitely some variability in how easy it is for me to sleep on some nights anyway and how easy it is for me to pinpoint what the issue is that's stopping me sleeping.

As always thanks for the rational and extremely supportive responses.

[Ratchick]

I'm wondering where you're wearing the mask positioned on your face - was it fitted for you, or was it just sent out to you? The F20 has to sit a bit higher (kind of the top peak just between your eyes at the bridge of your nose, and the bottom sitting in the cleft between your chin and your bottom lip, ideally. I found it a pain to try and get it sitting right at first too.

It's a shame that your sleep clinic doesn't offer more masks than that. You can, of course, just purchase another online.

How far do you have to open your mouth to breathe? I only personally need to move it maybe a centimetre and can usually breathe enough just with my lips parted a little. If you need to open your mouth particularly wide, that's definitely going to make finding a good fit a problem.

And you're right, when you fit the mask, it's not just opening your mouth,it's pulling your jaw back too. If you can't do it consciously, try deliberately tucking your chin into your chest and open and close your mouth or move your jaw side to side and see if you can find where it tends to leak from, perhaps?

[manganCPAP]

no fitting - all remote at the moment just get it in the post, although I have watched videos on line. I would say I have the F20 sat in that groove under my lip, the very top of the mask is actually probably slightly above the eyeline but when i measured with the size guide i was definitely in the large range. 

I guess just didn't want that extra variable of the F20 at the moment while we are trying to find what works but maybe I need to try it again soon, i didn't have the best chin strap setup when i was using it.

You are right I do only need to open my mouth a cm or so to breathe. I think with my existing chin strap tight, when i relax my mouth closes completely.  

Interestingly I just had your chin strap arrive and it seems to do a bit better job of just holding my jaw up without having to be super tight as its less elastic (although is a bit slippy on my hair, the neck brace part doesnt seem to do anything) - rather than pulling back and up on it like my existing one does. Will see how well that fabric chin bit seals on my FFM though tonight.

[manganCPAP]

Went with the new chin strap and the quattro air last night, dropped the pressure down to 6.4 as I was still finding it perfectly comfortable to breathe with (could definitely drop back to 6 with the quattro), humidity still at 4.

Chin strap was comfortable and seemed to work reasonably well at holding my jaw, however as you mentioned Ratchick getting the seal at the bottom of a FFM was very tricky with it, mask often actually riding up the fabric. I at least fell asleep after about an hour which is more than I can say for the last two nights! unfortunately even minimal jaw movement lead to lots of leaks in this configuration and some very disturbed looking sleep (see attached). towards the end my tidal volume became very variable and i woke up with an extremely dry mouth and throat. 

One good thing at least is it does seem like most of the time I need very little pressure to maintain my airway.

I've got another chin strap arriving today (to add to my extensive collection...) [Commercial Link Removed] Search hope2sleep in the UK - deluxe chain strap.
This one is basically doing what I was trying on the 9th june with a buff headscarf wrapped in that way as a makeshift chin strap, hopefully a more legitimate version might have some sustained success as its less on the chin. I may also try modifying your chin strap Ratchick to see if i can reduce a bit of the chin fabric. I will also likely order a heated tube soon to remove some of the variability of changing room temperature. There is a solution in here somewhere.

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[Ratchick]

Sounds like you have some good plans then.

I actually found another option you might want to try, too. If you search for Pad a Cheek" they create a strap that you can add to the bottom straps of the F20 to go under the chin to help reduce chin drop, as well as another that goes over the mask and around the back of the head to help pull it in from another point (the centre where the pipe enters). I found a UK shop that sells them but it's far easier to navigate their own site to check... but it might give you some ideas for modifying existing ones if nothing else. As I said, look up Pad A Cheek's store and then choose products by mask type, and choose the F20. You're looking for the stabilising strap and the anti-leak strap. If you want to try them but don't want to order from the US, a UK store called Sleep Tight also sells them (though slightly more expensive overall, you have to take into account customs, delivery costs and time). You're SO close to having this, you had no events really, and for most of the night, your leaks were well controlled.

[manganCPAP]

wow great find Ratchick, thank you! these definitely look like a possible option, I have been using this current chin strap (white cotton band that goes under the jaw and over the head) for the past two nights (see oscar attached), it is at least reasonably comfortable (although it does feel like its constricting breathing a little) and im seeing some leak reduction on the 2nd night although I am having to tighten quite a bit and still getting very disturbed sleep that ends in dry mouth, hopefully on the right trajectory though. My leaks while awake are pretty consistently under 3L/min so confident I am doing that part of it ok the leaks still increasing as soon as I fall asleep.

I'm not sure if something else is still going on as I woke up with my heart racing a little and a bit breathless last night at the end of the recorded data. 

I've ordered the knightsbridge dual band as it seems like a more flexible but sturdy version of the one im currently using and also have the memory foam cushion of the F20 on the way for when i try that again in case it helps seal, will order those pad a cheeks to try at some point too. I'll report back in a few days with hopefully further reduced leak numbers and longer sleeps.