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CPAP Problems - Troubleshooting
Topic Started: Feb 6 2010, 03:02 PM (1,943 Views)
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Emailed from Apnea Board member:

Troubleshooting CPAP Problems

Mask Fit Problems at High Pressure

Of course, the term "high pressure" means different things to different people. But we here at generally consider any pressure setting in the teens to be high. We talk to people nearly every day, though, who have what I consider to be "really high pressures" - 18 and above, and sometimes up around 24 with a bipap machine. The other day I talked to someone who had an inhalation pressure of 24 and an exhalation pressure of 18. This particular CPAP user was having a difficult time getting a decent mask fit with his Mirage Quattro full face mask, and he wasn't getting any quality sleep because of the fit problems. This is a tough situation for anyone with a high prescribed pressure setting, whether the "high" pressure is 24 or 14. Here's some advice that might help if you find yourself in this predicament.

1. Adjust the Mask:
Try wearing the mask a little looser if you're strapping it down tight. It's counterintuitive, but the Mirage Quattro and other masks like it seal much better when worn loosely. This is because the cushion is allowed to inflate to its maximum when worn loosely. Also, on the Mirage Quattro use the 24-position forehead support dial to fine tune the fit as best you can. If the mask is leaking near the bottom then you might need to extend the forehead support out to make the bottom of the mask move closer to your face. Some other full face masks have forehead supports, too, so use it if yours has one. If the mask is leaking near the top (around the bridge of your nose) you may need to retract the forehead support to make the top of the mask closer to your face. You can play around with the forehead support until the fit is good. If your mask doesn't have a forehead support then you may want to consider a more adjustable alternative.

2. Try a Different Mask: There's really two aspects to trying a different mask. The first is to make sure you've got a new cushion that's in good shape. An old cushion might not be as pliable as a new cushion, and the sealing characteristics of older cushions can be substantially inferior compared to those of a new cushion. The second aspect is actually getting your hands on an entirely different mask model. For example, if you're having a problem with a traditional full face mask like the Mirage Quattro, you could try a hybrid type of mask like the Mirage Liberty. This has nasal pillow cushions for the nose, and a mouth cushion to cover the mouth. There's less sealing perimeter around your face, and there's no sealing at all in the tricky nose bridge area. I know people sometimes have trouble with nasal pillows masks, but the point here is that minimizing the amount of sealing can help to minimize the amount of leaking.

3. Lower the Pressure:
Try lowering the pressure. Pressure settings like IPAP 24 and EPAP 18 are really high so it might be worth it to talk to the prescribing doctor about lowering the pressure to see if you can still get effective therapy with less pressure. You're not getting quality sleep now, so lowering the pressure can hardly hurt especially if there's a potential upside to doing it. A lifestyle change like weight loss may allow you to reduce the pressure over time if a reduction in pressure isn't viable now. If you can't lower the inhalation pressure, perhaps lowering the exhalation pressure might help.

Don't get me wrong. I'm not an advocate for lowering the prescribed pressure just in an attempt to make therapy more tolerable. But common sense must prevail, and if a mask isn't fitting properly at high pressure and a patient isn't experiencing any benefit from CPAP therapy as a result, then there's absolutely no downside to experimenting with a lower pressure.

4. Keep Your Mouth Closed: Up to this point I've been assuming the use of a full face mask simply because I've found that people with higher pressures tend to be the same people using full face masks. But, you may have a high prescribed pressure and you may be using a nasal mask. If you're using a nasal mask, the first three pieces of advice can apply to you. In addition you'll need to make sure your mouth is closed during therapy. If your mouth is open when you're using a nasal mask, then the air simply rushes into your nose and flows right back out your mouth. Air will take the path of least resistance, and if you've got tissue blocking your airway then the path of least resistance is out your mouth. When the air rushes out your mouth two things happen. First, your airway remains closed or partially closed and you don't get effective CPAP therapy. Second, you choke and gag on the air. Often when this happens to people while they're asleep they'll wake up at some point and realize they've taken the mask off their face. Even though these people are asleep, they recognize and react to the discomfort.

You can try to keep your mouth closed with a chin strap. The chin strap can be worn permanently, or it can be worn as a training aid. Yes, you can actually teach yourself to sleep with your mouth closed!

If you can't keep your mouth closed, then you need to switch to a full face mask.

Still Feeling Sleepy after Weeks of Therapy

If it feels to you like you're not experiencing the full benefit of CPAP therapy - that is, if you're still tired and sluggish when you wake up in the morning and you're sleepy throughout the day - then it's imperative that you address this problem head-on. The first thing you should consider is the mask fit, and you should try to determine if poor mask fit is the root cause of your problems. If you think it is, then follow the advice above. If it's not, keep reading.

If everything seems to be working just fine, and you still don't feel good, you've got to figure out if central apnea may be the cause of your problem. While obstructive sleep apnea and central apnea both lead to the same result, they're caused by two completely different things. OSA is caused by collapsing tissue in your airway. Central apnea is a brain-related issue where the correct signal isn't being sent from the brain to the respiratory system to trigger breathing.

Standard CPAP machines address the issue of obstructive sleep apnea by pushing air through the airway to create a stent which keeps the airway open. This standard CPAP therapy is ineffective in addressing the issue of central apnea, which means you can apply all the positive airway pressure in the world and still experience absolutely no benefit.

If you believe you may have central apnea, it's worth a discussion with your sleep doctor. Perhaps you were diagnosed with central apnea but somehow ended up with a CPAP machine that doesn't treat it. Or, perhaps you were diagnosed with OSA and the issue of central apnea was overlooked. Whatever the case, there's good news. Both Respironics and ResMed make machines designed to treat central apnea.

Now, in the section on mask fit problems I suggested you might need to lower a really high pressure to allow the mask to function properly. I know that made all the respiratory therapists out there cringe and swear, but it's a viable experiment nevertheless. If, however, you're using a CPAP machine without achieving good results, and if you've determined you don't have central apnea, then you might need more pressure! Talk to your doc and give it a try.

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Change your own pressure - Get the Clinician Setup Manual for your CPAP here

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B) Thanks sound advice with common sense!!!
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Some people do not ever get over excessive daytime sleepiness even when OSA is treated effectively. Other medical conditions or necessary medicines may be at fault. Even though an AHI may be in the normal range sleep architecture may be affected. If EDS continues, a trial of a "wakefullness" drug such as Nuvigil or Provigil may be indicated. Someimes a person has hypersomnia without an underlying cause.
Edited by zimlich, Jul 23 2011, 02:07 PM.
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