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Vagal Atrial Fibrillation & ResMed F20 Strap Neck
Vagal Atrial Fibrillation & ResMed F20 Strap Neck
OK, get your thinking caps on, and bear with me. I have what could be an interesting problem, that may have wider significance.

Sleep Apnoea & Atrial Fibrillation or Atrial Flutter

Like many, my main concern with my Sleep Apnoea, was the Cardiac stress issue. Basically, when suffocated your heart is put under huge strain, so this is perhaps best avoided.

I first worked out I had Sleep Apnoea when I had to go to Hospital in 2019 with my heart stuck at around 150 bpm one night, which turned out to be Atrial Flutter, 2:1 Block, so my Atria were banging away at around 300 bpm, and my AV Node was blocking 50% of that to give me a Ventricular rate of 150 bpm.

I gather I had the classic ECG of a regular beat with a saw tooth pattern in between. So not Atrial Fibrillation at that time, as that is always irregular.

At the time, nobody had any idea what had caused this, although as I have had a link between diet and random and minor irregular heart beats for a couple of decades, one factor was that I had consumed some Halloumi Cheese. I react badly to some fats, and that had caused irregular heart beats earlier that day. I seem to recall there was something bad in that cheese, so MSG or a fat that should not have been there.

I was given Fluids with Magnesium, plus an oral Beta Blocker, and the Atrial Fibrillation stopped after maybe 6 hours.

I was also put on 5 mg of Beta Blocker (Bisoprolol Fumarate) as a precaution, which seemed to cause Bradycardia (slow heart beat), so I asked to be dropped to 2.5 mg, and even then it caused Bradycardia, so ever since I juggled it down to 1.25 mg, and have had to halve that when ever my night time rate went too low, like 34 bpm!

I did not have Hypertension/high blood pressure, and an echocardiogram showed my heart was normal, with no issues.

So, no cardiac obvious issues, please note that.

I was also not diabetic either.

Just a little fatter than my wife would argue is ideal!

We later worked out it was severe Sleep Apnoea on top of an irregular heart beat that day, and I was then some weeks later diagnosed with severe Sleep Apnoea and was eventually handed a ResMed S10 Autoset same day, and a ResMed F20 Medium Mask.

Straight after the Atrial Flutter issue, I also invested in a Viatom CheckMe O2 Oximeter, and that was superb at confirming what was going on at night, and the O2 Alarm kept me largely out of the worst Apnoea trouble until CPAP could take over.

I still wear that every night, and keep a close eye on both my CPAP and Oxygen, and have had that totally under control ever since. Usually my scores are excellent (AHI below 2.0 and Oxygen Score often 9.9 to 10.0 with good O2 peaks and averages, and few if any drops).

So, whilst CPAP is a chore to keep it that way, Sleep Apnoea is effectively controlled.

Maximum Pressure

However, and this is where it gets interesting. I need to use the maximum 20 cm H2O of pressure, to keep the O2 drops away, and that has meant that I need to keep the ResMed F20 Mask on very tight to stop air leaks and mask pressure drops. If I get leaks, my Sleep Apnoea problems quickly come back fast.

I therefore go through ResMed F20 Straps very quickly, as they stretch so much they are useless after a while, and I need to replace.

By comparison, I am still on my original F20 Mask, the plain silicone one, although I had to change the front elbow joint once because the first unit had a leak issue that was hard to detect, but real, and was cured by swapping it out for a new one.

ResMed F20 Mask Strap Neck Pain Problem

In my efforts to stop mask leaks, I ended up with a problem with mask strap pain at the lower back of my neck right where the comparatively thin strap bites.

By the end of 2021, this was a PITA itself, or PITN (Pain in the Neck!) rather, and I'd often wake up in the morning with obvious strap marks in the back of my neck, and very happy to get the damned thing off.

That pain may have been a warning but, please read on.

Irregular Heart Beats and Diet

For years, I have noticed that there is a direct link between what I eat, and if that triggers an irregular heart beat.

It wasn't the usual things like alcohol or coffee.

It was only certain foods, specifically bad fats, such as Trans Fats, Hydrogenated Fats and, more recently, anything with Palm Oil in it.

I am like a coal miner's pit canary, in that within 15 minutes of consuming anything with the above bad fats in it, my heart will thump and feels like I am missing beats. My wife then checks what we have just bought and eaten, and every time it's been something new with Palm Oil in it, that we had not checked. Every. Single. Time.

Premature Atrial Contractions

I am now pretty sure these have been Ectopic Beats, specifically, Premature Atrial Contractions, so quite benign.

SAMSUNG Watch ECG Feature

My SAMSUNG Watch has an ECG Feature, which has been invaluable.

The results are similar to the waveform from an ECG Lead I, so the wrist to wrist circuit. This measures for 30 seconds and produces a 3 line ECG Report with 10 seconds per line. When in Sinus Rhythm, this shows me the usual P-Wave, then the QRS Complex as the ventricles fire, and then the subsequent T-Wave as the heart relaxes and depolarises.

I have managed to catch a missed beat, and it shows a premature P-Wave, spiked and malformed, and merged with the preceding T-Wave, to create a merged fusion wave, followed by a QRS that looks normal, then a T-Wave, but then a long delay before the next P-Wave as my heart/system knows there has been a mis-fire, so it delays the next cycle/beat.

That basically means it's almost certainly Atrial based, some site in there external to the SA Node is firing, and the fact the QRS is normal means it's not a Ventricular misfire. The delay in the next beat is also a sign that the system knows there has been a misfire, which it tends not to know if the misfire happens further down.

So, the missed beats are PACs, but the key here is they seem to be diet triggered. Possibly some link between Vagal nerve and the rear of my heart.

That I think points to a Vagal Nerve issue, as there is a huge link between Vagal Nerve and Heart Rhythm issues as the cardio-gastro side have many overlaps, and the nerves from brain to stomach run right past the heart.

The Vagal Nerve

This exits the brain stem, and then runs down either side of the spine and past the heart and on to the stomach, and is one long bunch of nerves that control many things.

Approximately, it's also quite close to the lower back of the neck.

You may spot where this is heading?

2021-2022 PAC Problems

I avoid Palm Oil like the plague for the reasons explained above.

Plus, after going on CPAP, I have had a small number of short attacks of Atrial Fibrillation, when each were directly following the accidental consumption of Palm Oil.

Each time there did not seem to be a Sleep Apnoea trigger, this was always diet related, so diet triggered PACs.

However, as even a single PAC can, in some cases, trigger Atrial Fibrillation ("AFib"), there is a known link between PACs and AFib.

So, some Vagal/diet issue that triggers PACs, and those can then trigger AFib.

Unfortunately, I accidentally ended up consuming a daily dose of Palm Oil for 1.5 Months!!!!

We eventually worked out why I was getting so many irregular beats, when we otherwise thought my diet was OK.

Turned out there was a pile of Palm Oil in some new Vitamins and Supplements, specifically some new ones that were oil based, and contained between 50% and 95% Palm Oil! We could not believe it, but it was in Vitamin E Oil Capsules, CoQ10 Oil based Capsules, Cod Liver Oil Capsules and was also used to make some Magnesium Tablets.

We never thought to check before buying them, and were bought to help with heart health!

So, I started 2022 with lots of PACs, as we did not know until mid-February that it was the Palm Oil in the Vitamins!

2022 Bad Neck Pain

In January, when in the shower, I suddenly had a really severe neck pain right at the lower rear of my neck. Really bad, but it only lasted 10 seconds or so, and went away.

I did think WTF was that?

Anyway, later that day, after consuming more Palm Oil by accident, after the usual 15 minutes to digest, the PACs started, and then I went into full AFib.

I was told by the Cardio Nurse via telephone to try and control any Arrhythmia by varying my Beta Blocker dose, but I only took that from 1.25 mg to 2.5 mg. The AFib went away after maybe 12 hours.

Every day I would wake with the usual rear lower neck pain, caused by the ResMed F20 Strap.

2022 Atrial Fibrillation may not benefit from Beta Blockers

OK, after the first 2022 AFib attack, it all went haywire!

I went in and out of AFib basically for the rest of 2022, and am in AFib now as I type this.

I tried increasing the Beta Blocker, to the maximum 10mg I was advised, but that nearly killed me off, and my blood pressure and heart rate went through the floor when ever I came out of AFib! It got so bad that I was better off in AFib!

I worked out that the Beta Blocker was not helping at all, and so I tried to come off it. Did that too fast, had a bounce back effect, and got stuck with a regular heart rate stuck at around 137 bpm. Not sure if that was Atrial Flutter, but it was regular and not AFib.

That went back to AFib after a few days. I then took myself off the Beta Blocker more slowly, 1.25 mg for four days, then halved that for 4 days, then halved again for 4 days, then stopped. As I lowered the Beta Blocker, I came out of AFib.

I noted that I went back into AFib after a meal (still taking Palm Oil without knowing), so it's highly likely now to be Vagal AFib, and not Adrenergic AFib.

After weaning myself off the Beta Blocker, the AFib attacks reduced and did not last as long.

However, I am still stuck with it, but now think this latest series of AFib attacks have a link to the rear neck pain, and the ResMed F20 Strap issue.

ResMed F20 Strap Needs Extra Padding

By the end of February, I coincidentally partially cured the ResMed F20 Strap issue by adding a pad to the rear of the strap, to spread the load.

That has made it very comfortable, and I no longer now get the bad neck pains when I wake up.

Other Vagal Factors

I have noticed that when I first go back into AFib, I need to piddle a lot. So the heart seems to be releasing the diuretic hormone as it first gets pushed into AFib,. which I think is also pointing towards Vagal issues.

It is also nearly instant, so an electrical issue not a response to demand such as stress or fear.

That stops after around an hour of AFib, and I remain in AFib without needing to piddle all of the time.

Also, when in AFib, my bowel habits change, and I basically get rather looser movements that I was expecting! That stays the same all the time whilst I am in AFib.

But that stops the moment I go back to Sinus Rhythm!

So, very clear digestive links with AFib, strongly suggestive that this is Vagal AFib.

Medication for Adrenergic AFib is different than for Vagal AFib

Specifically, Beta Blockers do not work with Vagal AFib, and I can say these made everything worse, for no benefit.

So, I took myself off them.

The problem is Beta Blockers can worsen AFib when its Vagal, and have been known to cause the AFib to become more frequent or even permanent, pending any surgical intervention.

Therefore, if you get AFib, do try to work out what type it is before they start throwing Beta Blockers at you.

My Conclusion

I strongly suspect that the tightness of the ResMed F20 Mask Strap may have caused some damage to my Vagal Nerve, right where it exits the brain stem at the lower rear of my neck.

This has exacerbated the Vagal to Cardiac issue that I always had, but to the point where the Vagal influence is now quite a problem.

This may suggest that anyone needing to keep a ResMed F20 Mask on tight, should augment that with some padding to spread the load, avoid neck pain, and potentially avoid damage to the Vagal nerve at the rear back of the neck.

I have yet to see a Cardiologist, but am waiting for a date.

What do others think?

I'm pretty sure I have worked out what the problem is, but how to fix it remains a mystery.

Neck exercises may help, so I will add those daily to see if I can alleviate the Vagal issues that way.

Nothing seems to stop the AFib, it stops when it wants to stop.

But I will try gentle exercise on a Rowing Machine next, and will carefully exercise within my safe maximum heart rate, such as by the HIT method, and spending say 4 minutes at 70% of my maximum, with rest breaks of 40% of my maximum.

Exercise can sometimes help AFib, and can help to revert to Sinus if the exercise heart rate is taken above the AFib rate, to establish a fast regular rate when under load, that then stays regular as one rests after completion. Then it can go down to Sinus Rhythm when fully at rest.

I hope this helps others, and may stimulate a new line of enquiry given the links between Sleep Apnoea and both Vagal AFib and Adrenergic AFib

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RE: Vagal Atrial Fibrillation & ResMed F20 Strap Neck
If I manage to Post a link to a web image correctly, then this may help to show the location of the Vagus Nerve (it is the Vagus Nerve, apologies if in my first Post above I called it the Vagal nerve a few times, Vagal is the effect upon it, or the effect it causes, the nerve itself is the called Vagus Nerve) relative to the rear of the neck and CPAP Mask Strap fit:

[Image: Recurrent_laryngeal_nerve.svg_.png]
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RE: Vagal Atrial Fibrillation & ResMed F20 Strap Neck
You have posted a great deal. My understanding of AF is that it is strictly electrical, and associated with the migration of atrial lining tissue into the four pulmonary veins (veins, because they return blood to the heart via their left atrial complex. The SA node sets its own signal timing, with the signal running to the AV node, down the Bundle of His, and to the two branches. The only way those signals get interrupted is by the spurious signals originating in the opening of the pulmonary veins where they empty into the left atrium.

Has your electrophysiologist discusses ablation with you? Unless there is another explanation, such as involvement with the right atrium, it is usually the case that you will have a ring of spots burned into the four pulmonary veins as a first step. About 20% of the time, after a 6-week rest and observation period, a Holter Monitor will reveal more fibrillation and a second ablation will be necessary.

I can get my heart going by reaching for the remote, and my mask and headgear are different from yours. I belch frequently, and if it is acidic/fumy , I can induce AF that way as well. So, I don't eat late. GERD would make this much worse. And yes, those are almost certainly vagal in nature. Bending over, tying my shoes, these can all set off AF for me. After ruling out ischemic heart disease, I am due for an ablation in late July. Our vaunted health care system in Canada is great, but only when it can deal with you. These days, orthopaedic surgery is about a year's wait, longer during a pandemic. Good luck if you have to work for a living. Need to see a heart specialist? Unless it's an emergency, you're looking at 4 months minimum. So, I'm living with nearly persistent AF until late July.
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RE: Vagal Atrial Fibrillation & ResMed F20 Strap Neck
If everything else about your headgear and pressure delivery is adequate, and you can live with that arrangement, and if your fear is that the Vagus nerve is being irritated, I would have a competent person sew a wider strap under the irritating element that is wider.  This will spread the 'load' over a wider area and cause less compression of the tissue.
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RE: Vagal Atrial Fibrillation & ResMed F20 Strap Neck
This on-going AFib all started this year, sudden onset in effect, and right after that pain in the back of my neck.

Been in and out of AFib ever since, although better since I stopped the Beta Blocker. But it feels like something is adrift and pushing it up, so vagus nerve damage is my suspect at the moment. There is a link between that and sudden onset AFib, people having neck surgery that was close to the vagus nerve have gone into sudden AFib during surgery, and the surgeons could only think it was vagus stimulation. I also read that premature babies on CPAP can get Bradycardia if the straps are not well fitted, that goes away when they are, due to a vagal stimulation.

Sadly, in the UK, I am at the end of a long waiting list to be seen by anyone, so it is a suck it and see, self-help approach at the moment.

I have no other issues other than that described above, so I feel that it's some new non-cardiac influence, so possibly Thyroid as my last blood test was slightly up on the HSE reading, but that's Hypothyroidism, so not usually a trigger for AFib, usually it's Bradycardia/slow beat, but it can happen that way in some cases and trigger a fast beat/AFib.

From what I can read, there are big differences in treating AFib if it's Vagal, and many medications are contra-indicated. I know the Beta Blocker was a bad move, and I am much better off that.

I will enlarge the rear pad of the strap, it's pretty comfortable after adding that, which I mainly did as my Strap had stretched, I needed to extend its life! But found that the padding stopped the pain, so that was a welcome side effect!

I will keep the Thread posted as this develops.

My gut feeling is there is some imbalance, not yet revealed via blood tests. Something that has compounded an existing but far less serious tendency towards ectopic beats caused by certain meal related things.

AFib is annoying, and I want it gone ASAP because of the Stroke risk.

I cannot seem to self-terminate it, yet, have tried cold water, squats, breathing, chest tapping, nothing works reliably.

Exercise is the next target, so I will see if I can work the AFib out via rasing my rate above it, and setting a working beat under load that is regular, then see if that stays regular after I stop exercising, and as my pulse slows down to rest. Works for many, let's see if I am one! But I need to establish what is triggering these new AFib sessions, 15 so far this year, longest was for 9 days.

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RE: Vagal Atrial Fibrillation & ResMed F20 Strap Neck
Just a quick one, I read there is a new AFib medication out soon, a nasal spray with a short duration of around 20 minutes.

So a puff in the pocket approach!

I think it is called Etripramil, and was in late stage tests in 2018, so may be out now, or coming soon.

It's to help stop AFib sessions I gather.

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RE: Vagal Atrial Fibrillation & ResMed F20 Strap Neck
Hi More Beers:

An impressive post. You have documented some cool self-diagnostics.

I am sure you know this but don't think of the VAGRANT NERVE as an up down thing. It has many interconnections. I don't subscribe to acupuncture or chiropractic but am often intrigued that when I scratch a certain part of my scalp on the right I feel corresponding twitches in my skin on the right side of my chest, consistently, implying there are more complex interconnecting neural pathways than the "classic" anatomy books give us.

I wear a neck collar at night and when side sleeping often wonder about the effect of it pressing on my carotids, note the Vagus nerve runs in the Carotid sheath. Don't know if you use a collar or not.

Fascinating comment about your perceived dietary stimulants.  RPAH research suggests many of us are more susceptible to adverse dietary effects than we suspect. This has been discussed elsewhere on this forum.  They go into it in quite some detail here which seems to mirror your own experience.

I note your earlier comment about them giving you Magnesium! I have recently stopped taking PPI for reflux (for far too many years), commenced Vit D, Ca and Mag supplements. The intermittent, constant muscle twitching I had in my left arm (that the neurologist called simple focal seizures) have cleared since I started taking Mg supplements. I suspect the PPI leached out Ca and Mg from the bones: I now have low bone mineral density. Low Mg does seem to have a neurological effect on muscle innervation and pathways, perhaps cardiac too. I wonder if they explained to you why they did that?

Interesting links here that you have probably already discovered or similar:
BOGLE and SYDNEY CARDIOLOGY with a comment about sleep apnea and A Fib.

Your comment about the Vagus nerve and stomach connections are valid. Many years ago one classic treatment for gastric/duodenal ulcers was surgery: vagotomy in combination with various other surgical approaches, until some Aussie decided we could smack Helicobacter on the head with antibiotics.

Your comments on neck pressure from mask straps do get one to thinking about potential for myo-fasciitis in the region of the Vagus nerve.

I am not recommending anything, but have found some relief in neck and back pain after following these: seems to be less tension/spasm, Wildman 1 and Wildman 2

One does wonder if there is a link.

Good luck in keeping the old ticker under control. What a journey.
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RE: Vagal Atrial Fibrillation & ResMed F20 Strap Neck
Hello SevereApnea!

Many thanks for your comments, I will indeed check out your links.

Yes, I do wear a neck collar, back to front in fact! It's just a foam sleep collar for trains and aircraft etc, but seemed ideal to stop chin tucking closing off my airway. But as the foam is all at the back, I just wear it back-to-front, so it supports my head and stops my head rolling forwards and cutting off my airway that way.

Indeed, when first starting CPAP, I was initially kindly lent a ResMed S9 by a friend who did not need it any more (he had lost a lot of weight, so his Sleep Apnoea went away...although sometime later he porked out again, and it all came back!). The S9 was superb, and got me out of a hole until our NHS here got its act together.

I did not get on with the ResMed S10 AutoSet at first, just could not get the pressures right, until I gave up and set it to CPAP Mode at 20, and with EPR at 3, and that cracked it. Even then it took a couple of months to settle, and at the worst, I had a night of Cheyne-Stokes breathing, which wasn't good.

The main CPAP turning point was getting the Foam Neck Collar, and also a Foam Triangular Wedge under my pillows, not sure which did it, or if it was a combination but, after that, my sleep scores all went the right way and Sleep Apnoea was mastered, if not cured.

But the way the ResMed F20 Straps stretch when you need to keep them tight, caused other issues, and that is what has got worse over the last 6 Months, and that I think may well have caused some issues with my Vagus Nerve at the start of this year, leading straight to Atrial Fibrillation, the very thing the CPAP therapy is effectively trying to avoid by stopping cardiac stress and suffocation side effects!

The bare straps were really biting the back and sides of my neck, which varied depending upon strap age and stretch factor.

I use a Medium ResMed F20 Mask and Strap, and did try a Small F20 Strap to see if that helped, but it was worse, seemed to change the way the Mask is secured enough to worsen my scores and control over Sleep Apnoea. I did try both off and on, and things were always better with Medium, so strap size is definitely a factor.

The rear padding I added from a supplier on, I think, Amazon, was good, but it was not enough. As I say, to prolong strap life, I did chop that around and used the off cuts to increase the padding at the back of my neck, and that greatly reduced pain, and also helped with Mask Fit too, even with a stretched strap.

A tip I found was once set to correct length with padding, I then do not adjust it, and now just unclip the magnetic clips to remove and put on, and that seems to have stopped the stretching problem, so straps are lasting longer again.

But the core current problem is, I think, Vagus Nerve related. I did some more reading, and anything to do with Vagus Nerve damage exhibits so many symptoms it covers a lot of the issues. Many people seem to get sent to many specialists each looking at one issue in isolation, missing the common Vagal link. Then they get the right help, and a whole host of their ailments are resolved. Lots to do with the position of neck under the head, and the upper neck vertebrae alignment.

The tight F20 strap and neck pain, could well have caused issues in that area, and compromised the Vagus Nerve.

From one perspective, the Vagal mechanism's purpose is to slow the heart when it gets over-excited, so remove that control, and a natural damper is removed, so that explains the link to Tachycardia if that input is lost or compromised.

Mixed reports if Ablation is the right way to go if the issue is Vagal AFib, but it works for some. Many get a mix of Vagal AFib and Adrenergic AFib, whilst others are more clearly in one group or the other. I think I am in the Vagal AFib side, as my overall symptoms and lack of other factors do not suggest the AFib is Adrenergic.

One interesting comment from many who had treatment for Vagal neck issues, many said they all just knew they had a single problem, and a wide range of symptoms. This comment is repeated many times, so it suggests people do seem to know, even if they do not know what, and even when the medical profession misses the bigger picture and tends to get lost investigating the symptoms individually, and without success.

That is the feeling I have, that there is a single cause, not a specific electrical problem with my heart that suddenly started right after the bad pain in the back of my neck. The Vagus Nerve, as you say, is named after the Latin for Wanderer, which I also think covers vagrant too, but you get the idea! It's a long and complex nerve that does wander right down and impacts many organs and functions, including having a direct impact upon the heart's rate and rhythm.

I have raised this with my Doctor and with the Sleep Clinic, but neither will respond fast, and both may just shrug shoulders, as usual!

I will update if there are any developments...still in AFib at the moment, but overall rate seems to be slowing, so I may pop back to Sinus soon, hopefully!

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RE: Vagal Atrial Fibrillation & ResMed F20 Strap Neck
Just my opinion, but if you need the F20 straps that tight, it's making your therapy torture. I would get a replacement mask. It sounds like the F20 isn't the right mask, either in cushion size or overall mask fitting. I've used the F20, both silicone and memory foam cushions in all sizes. It always needed to be tight. And I wasn't going to get anywhere with therapy with not well controlled leaks, high strap tension, and pain from the mask. Get another model mask.

The forcing a square peg through the round hole action of I'll make this mask work only gets you so far. In the case of Apnea therapy, it's not going to end well unless you get a better mask that fits you better. Look at other brands. Fisher and Paykel Vitera is what I used after the failed F20 experiment.

Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
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RE: Vagal Atrial Fibrillation & ResMed F20 Strap Neck
Hi again MoreBeers,

I have re-read your post. 

Atrial Flutter/Atrial Fibrillation/SupraVentricular Tachycardia/Heart blocks would need to be diagnosed with an ambulatory or in hospital Cardiac Holter monitor, not a few minutes on a smart watch. That is not what are they are designed for.

AF has a risk for emboli and stroke and needs to be taken seriously.

Could you progress up the queue if you mentioned you are now getting chest pain with the irregular heart beats?

When I was conscripted into military training much earlier on in life, and chased around that distant tree on the horizon a few times too many, I would develop a rapid heart rate, around 150 - 180 bpm. Not AF, just SVTs. Did not respond to the usual vagal stimulation mechanisms. Lesson: don't let myself get pushed to the limits.

In my younger years when studying at Uni, I noticed my resting HR was around 30 -40 at one stage! Come on, I am not that fit! Panic visit to the local Cardiac physician. Diagnosis? Parasympathetic overdrive. Duh? Once the stress of exams etc had passed the sympathetic drive was released and the parasympathetic effect took over for a while. That was his explanation way back in the 1980s. I thought that this was a left field diagnosis and let it go past the keeper, so to speak, but there is some truth in that. Looking back, I think his "read" on me as a patient was pretty good.

For me, anxiety is part of my tapestry of the complexity of my own issues.
More interesting links to the complexity of the Vagus Nerve and the brain gut pathway HERE and  MORE OF THE SAME

I am surprised at your pressures of 20 with EPR 3. That seems quite high.

Agree with SarcasticDave94's to-the-point comment (appropriately so) about mask selection. Can we assume you have exhausted all other mask options? 

Collars: I have tried Small, Medium and Large cheap foam collars. Since my neck is long and skinny, the Medium and Large are too long and the ends at the back overlap, and press against the occiput (and occipital nerve?). I have also gone down the route of modifying, cutting, reshaping collars, re-jigging covers for them etc, but now I just stick with the Small most nights. If things go wrong for me at night, I land up with a twisted neck, neck muscle spasm, headaches etc. Partly due to poor work ergonomics. Hence the importance of breaking down the repetitive stress issue on neck muscles but that is a different subject I will leave you to explore on your own.

In your original post you mentioned Afib and Aflutter and 50% block: hopefully they have that quite clear.

I normally only offer options and not advice but am a little concerned here: you and your medical team need to be quite clear on your diagnosis. If you have true AFib, some might want you anticoagulated. Do you think you need to find a way to climb up the ladder in the waiting list?

Best wishes,
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