A) Introduction – AHI, CPAP, BiPAP - what’s with all of those letters?
If you’ve just been diagnosed with sleep apnea – you saw your doctor, took the sleep test, and now you have a machine sitting by your bedside. All of the terms we use can be pretty confusing. Let’s start with a list of definitions to make things clearer.
1) Excessive Daytime Sleepiness: this is sleepiness that is there even after a good night’s sleep; you may have heard of unrefreshed sleep – they’re basically the same thing.
2) Sleep Study: this is a really generic term – this is the test that you took to diagnose your sleep apnea. If you were tested in a lab (hooked to a lot of wires), it’s called a polysomnogram (PSG). If you took a testing device home, it’s called a Home Sleep Test (HST).
3) Titration: this is done in the sleep lab and is used to find the optimal settings for your device
4) Apnea: there is no breathing
5) Hypopnea: there is very shallow breathing; it’s not enough to get air into the parts of the lungs that need it. Think of a hypopnea as inefficient breathing.
6) AHI: this stands for Apnea Hypopnea Index. This is the number of apneas and hypopneas that you had in your sleep study divided by the time that you were asleep. Everyone has some apneas and hypopneas – an AHI <5/hr is considered normal. An AHI >5 means that you have sleep apnea.
7) Sleep Apnea: this is a condition where the tissues at the back of the throat get very floppy and either cover your airway partially (a hypopnea) or completely (an apnea). There are multiple treatment options to keep the airway splinted open, but most involve surgery. The most effective non-surgical option is Positive Airway Pressure (PAP) therapy. The most common types of PAP therapy are CPAP, APAP, and BiPAP.
8) CPAP: this stands for Continuous Positive Airway Pressure. Basically, a CPAP uses a flow of air to keep the back of your throat open. With a CPAP, you start at a lower pressure called the start pressure) and end at a higher one. The higher pressure (called the therapeutic pressure) doesn’t change unless your doctor writes an order for it to change.
9) APAP: this stands for Automatic Positive Airway Pressure. This also uses a flow of air to keep the back of your throat open but, instead of ending at one therapeutic pressure, this mode is constantly adjusting to find the optimal pressure. We say that an APAP will go as low as it can, but as high as it needs to.
10) BiPAP: this stands for Bilevel Positive Airway Pressure. Like CPAP and APAP, BiPAP uses a flow of air to keep the back of your throat open. The difference is that BiPAPs use a start pressure that ends in a high pressure when you breathe in and a lower one when you breathe out.
B) A friendly note about sleep:
Our patients who are successful at using their machines have a few things in common –
1) They fit using the machine into their lives. Odd as it seems, something small like your sleeping position or the temperature of the air coming from your machine can cause you to have problems sleeping. It’s like there is a little version of you holding a clipboard and checking things off as you go through your nightly routine. Brushed your teeth – check; watching TV or reading – check; cool room – check; sleeping on your stomach – check. What successful patients do is fit their machine onto that list. It doesn’t happen overnight, but it will happen, as long as you remember that you’re fitting the machine into that routine and changing it as little as possible.
2) They use their machine nightly and don’t expect perfection. The first 3 months of PAP therapy are called Acclimation. During this time, you’re building the habit of using your device. If you use it nightly, even if you aren’t able to use it for long, having your mask on becomes just another thing that you do before bed.
3) They reach out to their doctor and to us when they need us. What happens if your mask is uncomfortable or it feels like you can’t breathe out? Roughly 97% of all PAP patients have something that they have to work on to be successful. We’re here for you.
C) Common Concerns – what do you do when….
1) Your mouth is dry when using your machine:
Your CPAP or BIPAP is set to deliver the settings prescribed for you. Because these devices keep your airway open by a flow of air, they can cause mouth and throat dryness.
(a) To help make the treatment more comfortable, most patients use a humidifier.
(b) If that doesn’t seem like it’s enough to keep you from getting dry, try using a mouth spray before you put your mask on and throughout the night if you feel that dryness returning. Biotene is probably the best-known, but there are other brands out there – even generics.
2) Your nose is congested or you have sinus pain:
You get your mask on, start your machine, go to sleep, and wake a few hours later with a stuffy nose. Don’t feel alone - this is a common concern. Here are some common causes –
(a) If your congestion goes away within a few hours of stopping treatment, then starts again the next night, your humidifier may be set too low. The flow of air from your PAP machine, flowing over the tissues inside your nose, can cause you to have increased swelling. Try increasing your humidifier setting by 1-2 each night until you can breathe through the night.
(b) It may be time to replace your filter and/or clean your equipment. Especially in allergy season, it’s important to be strict about your cleaning schedule. Dust can build up on your filter. It’s also not unusual for pollen to accumulate in your tubing or mask. Once you put the mask on your face, the pollen gets blown up your nose.
(c) If you have seasonal allergies, consider cleaning your sinuses out with a saline rinse like Simply Saline, or any generic saline rinse. If you choose to use something like a Neti Pot, please follow the directions exactly.
(d) If you have chronic sinus allergies and are using a nasal mask or nasal pillows, you may need to come for a mask refit. If you can’t breathe through your nose, but you have a nasal mask, your treatment isn’t going to feel comfortable.
3) You feel claustrophobic:
(a) Two conditions can cause this feeling – claustrophobia and facial sensitivity. If your sleep mask is making you feel claustrophobic, we find that most patients feel more comfortable in a full face sleep mask as opposed to the smaller nasal mask. The flow of air is less concentrated, so it doesn’t cause a feeling of being overwhelmed.
(b) Do you have problems wearing hats or glasses, even sunglasses? You may have a problem with facial sensitivity. For you, a nasal pillow mask might be a better choice.
(c) No matter what, just remember that it’s actually quite normal to have some anxiety about wearing a PAP device. Some patients will benefit from a change in mask style for comfort but mostly they just need a little more time to adjust to using their machine.
4) You feel like you’re suffocating or can’t get enough air:
Suffocation is an extremely traumatic and legitimate complaint, so let’s get right to it. You might feel you are suffocating, or you might just find you constantly yank your mask off all night. The sensation of suffocating or not getting enough air can be caused by a few things –
(a) You may be a mouth breather using a nasal style mask when a full face mask may be more suitable.
(b) If you feel like you’re breathing out against a wall, there are also comfort features called Cflex, Biflex, EPR, or Sense Awake. They are available on most machines, and can be adjusted by a respiratory therapist for your comfort.
(c) If those settings don’t help – or don’t help enough – it may be time to discuss another type of machine, like BiPAP, with your doctor. For instance, some patients find breathing against a steady stream of air difficult, especially if their pressure setting is high or they have other respiratory problems. These patients may need a BiPAP machine rather than a CPAP machine, though this is a suggestion we may make to the doctor only if patient has truly given CPAP a fair trial and is still having difficulty.
(d) Another problem may be an ill-fitting mask, which causes an air leak. Because your machine adjusts the flow of air to make sure that you stay at your prescribed pressure, it only takes a little leak to feel like a hurricane is blowing in your face. This can be corrected by replacing your mask/cushion or re-fitting you with a new mask.
(e) Still another problem may be that the ramp feature on your machine needs to be adjusted or turned off. The ramp feature is great if you are a new patient just starting out CPAP therapy, but after adjusting to your set pressures, this feature may begin to feel uncomfortable.
(f) If the mask is fresh and fitting correctly, it is likely low humidity. If the air is too dry, it can give you the same feeling of suffocating. Have you ever walked outside on a very hot dry day – for example walking out of an environment controlled hotel in the desert of Las Vegas at 110 degrees? Yeah, that feeling of suffocating. The solution is to raise your humidifier by 1-2.
5) Your mask is causing irritation or sores:
Few things are more annoying than when equipment designed to help you has launched an all out attack on your face. Try these tips –
(a) It is not uncommon to experience some irritation initially, especially around the nostrils if you are using a nasal pillow system. Irritation is usually mild and doesn’t take very long to go away. Try using a water-based lubricant like KY Jelly as a barrier between your skin and the cushion or pillows. The water-based lubricants are safe to use daily and they will also help restore moisture to the nostrils. We do not suggest using Vaseline or other greasy petroleum-based items—they will break down the silicone in your mask cushion.
(c) Often the problem is oil build-up on the cushions. If you are not good about cleaning your cushions daily then the oil in your skin will build up on your cushion causing irritation or breakouts.
(d) For certain masks we also have a very thin cloth barrier we can provide to you (your insurance does not pay for this, but they are not expensive if you have them shipped with your normal order). Think of these as custom fitted handkerchiefs. They are disposable as well.
(e) For severe or persistent irritation, it may be that the mask size or style isn’t right for you. In this case, we would need to re-fit you. If the irritation on your skin is an actual sore or a breakdown of the skin, it is recommended that you stop using your mask until you can be evaluated by a respiratory therapist and fitted into a different size or style.
6) Your mask is uncomfortable/ won’t stay in place/ it doesn’t fit like it used to:
The easiest way to think of masks is to compare them to shoes – even if you really love them, if they hurt when you put them on, you’re not likely to wear them.
(a) If you liked your mask in the beginning, it may be time to replace it with another one. Masks and headgear are considered disposable. The cushions on the mask break down. They should gently settle on your face with a subtle adjusting of the shape to match your contours. However over just a few weeks, the cushion – the soft part that touches your face - gets stiff and it also changes shape over time. The natural response is to tighten your headgear tightly to force the fit. This will likely lead to mask discomfort.
(b) The headgear will stretch out over time and cause the mask and straps to slip. Replace your mask and headgear at the recommended frequency. Most Insurance allows for replacement of nasal cushions every two weeks, full face cushions every month and the whole mask every 3 months. Email or Call our Resupply Team our Resupply Team.
(c) Sometimes you try a mask on, think it’ll work great, and find out that it’s not for you. If you’re in the first 30 days on your machine, you can exchange your mask for another one with no charge. If you’re outside of that, we’d still recommend making an appointment for a mask refit. You can click here to make an appointment. Remember, life is too short to live with a mask you hate.
7) The air coming from your machine is too hot or too cold:
You are used to a certain temperature in your room and this doesn’t change when you start using PAP therapy. Your humidifier may be set to Auto mode. That means the air temperature and humidity are adjusted to meet the temperature and humidity of your room at or over 90% of the time. If that’s too stuffy or too cold, try these tips -
(a) Is the air coming from your device too stuffy? It may be too hot or too humid or both. Try adjusting humidity down by 1-2 one night and then the tube setting down by 1-2 the next night until the air from your device is more comfortable.
(b) Is the air too cold? Try adjusting humidity up by 1-2 one night and then the tube setting up by 1-2 the next night until the air from your device is more comfortable.
(c) Humidifiers and tubes are made to be very responsive and it’s not unusual to increase humidity by a small amount and feel like your nose is wet. Only make adjustments 1-2 at a time.
(d) There is no right or wrong setting for your tube and humidifier. Just set them for your comfort. You may have to change settings throughout the year.
8) Your mask/tubing/machine is making a loud noise:
The noise is most likely caused by an air leak. Normally, air leaks come from the mask, but could also come from your tubing or water chamber. If you're able to sleep with a higher than normal air leak, then there is no problem. Your device is made to adjust itself to maintain the pressure that your doctor ordered. If the noise is keeping you or someone else awake, try these tips -
(a) If an air leak coming from your mask is waking you up, then you can try the following steps to get rid of it:
(i) Have you been adjusting the straps on your mask while lying flat? Your face changes shape when you lie down, so a mask that seems comfortable while sitting up may not be comfortable at all when you get into bed.
(ii) Have you been cleaning your mask cushion regularly? When the cushion isn’t cleaned regularly, the air from the machine will leak around the sides of it. An increased air leak makes you overtighten the mask and this makes the mask uncomfortable.
(iii) We recommend that any patient with a higher than normal air leak wash their cushion (the soft part of your mask that touches your face) every day or every other day with mild soap - for example, Ivory bar soap or baby shampoo. Only the cushion or pillow touches the face, so that’s the part that needs the most frequent cleaning.
(iv) Are you using a nasal pillow mask? If your mask only covers your nostrils - the Reveal or AirFit P10 are examples – and you notice an air leak around the pillow and/or have to reposition the pillow to keep it out of your nose, you can try the next size larger pillow. It’s very normal to be fitted for one size of nasal pillow and then switch to a larger size once you get more used to the mask. Going up a size may make you more comfortable, stop the air leaks, and keep you from having to readjust your mask throughout the night.
(v) If the next larger size pillow isn’t comfortable, it may be time to replace the pillow.
(vi) Is it time to replace your mask or cushions? Eventually, all masks need to be replaced. The good news is that most insurance companies cover 1 cushion or 2 nasal pillows a month, 1 strap every 6 months, and 1 replacement mask frame every 3 months.
(b) If the air leak is coming from your tubing, try the following tips:
(i) Have you tried tightening your tubing?
1. If you have a tube that locks into the device, check to be sure that it’s locked in. This turns the heated wire in the tubing on and the tube won’t disconnect from the device.
2. If you have tubing slides onto the machine, you should still make sure that the tube is firmly in place. It’s easy to bump the are where the tube connects to the device and jar it loose.
3. Does your tubing slide into place, but then slides off again easily? Tubing has to be washed in either mild soap and water or with half white vinegar and half water at least once a week. Oils can build up on a tube and make the end too slippery to stay in place.
(iii) Is it time to replace your tubing? If washing your tubing doesn’t help it to stay in place, or if it will not lock into place, it will need to be replaced. Normally, CPAP tubing is replaced every 3 months.
(c) If your water chamber is leaking air, you can try these tips:
(i) Are you using a DreamStation? If so -
1. Lift the lid over the water chamber by moving the lever on the top of your device and lifting the edge of the lid upwards.
2. Lift out your water chamber and look into the empty humidifier where it was seated. There is a small gasket that can get jarred out of place.
3. Push it back into place and replace the water chamber.
4. There is another gasket on the underside of the lid, please check to be sure that this is in place and seated correctly.
5. Close the lid, put your mask on, and turn the machine on.
6. If the air leak is still loud enough to notice, please click here to make an appointment with your local branch.
(ii) Are you using a ResMed A10? If so –
1. Remove the water chamber from your device and open it.
2. Check to be sure that the seal is in the chamber. It’s easy to forget to replace the seal after cleaning your water chamber. If the seal is not in the chamber, or is out of place, the chamber won’t close tightly and air can leak out. It only fits one way – the water chamber won’t close if it is seated incorrectly.
(iii) If you’ve tried these steps and the air leak is still loud, please click here to make an appointment with your local branch.
(iv) Is it time to replace your water chamber? Water chambers are normally replaced every 6 months.
(d) Is it time to get more supplies? Even if you’re washing your equipment regularly, it will eventually wear out. The good news is that Metro-Med can send replacement supplies direct to you. Call 800-999-0333 to find out how frequently your replacement supplies are covered by your insurance company.
9) Your tubing is making a gurgling/popping sound:
Does your tubing sound like a rumbly tummy? Water collecting in the tubing is a common problem. This is caused by condensation due to the air flowing through the tubing being warmer than the air temperature in the room.
(a) You can adjust the humidity by following the instructions in your device’s user manual. Just remember:
(b) The temperature of the air coming from your device affects the amount of water that the air can hold – warmer air holds more humidity than cold air. An easy way to remember this is that summer air is more humid than winter air.
(c) Room air is between 74-75 degrees. If your tube temperature is set lower, your tube may develop condensation. Try turning the humidity down by 1-2 per night.
(d) If you have tubing that does not lock into your machine, but have turned your humidity down as far as it can comfortably go, you can try insulating your tubing. The simplest way is to keep the tubing cozy with you under your blanket. Or you can try a tubing wrap or we can switch to heated tubing if you are currently using standard tubing. (Tubing wraps are not covered by most insurance but heated tubing might be covered).
10) Your water level doesn’t change or you’re going through more water than normal:
This is mostly for humidifiers in the Auto setting. Because they’re made to adjust to meet 90-95% of your room’s temperature and humidity, you may notice that the water levels fluctuate throughout the year. This is normal and you can just add more water when it’s needed.
D) When to Replace Supplies:
1) Cushions/ pillows – Replace these when they become cracked, ripped, discolored or if you feel that the mask isn’t sealing well anymore. Most Insurance allows replacement once or twice a month. We suggest changing them at least every 3 months, as oils from your skin can build up on these cushions and cause them to start breaking down. Also, the cleaning products you use on your mask can start to break down the materials of the cushion and increase leakage around the nose/ face. Don’t use cleaners that contain alcohol or antibacterial ingredients. A mild soap or baby shampoo should do the trick. The rule for cleaning a mask is to never use anything to clean your mask that you wouldn’t use to clean your face.
2) Headgear- Replace your headgear when it becomes stretched out. Headgear loses its form naturally over time. When they become too loose, the patients often tighten down their straps too much just to keep a seal. This in turn starts to leave marks on their face, causes headaches, compression of the temporomandibular joint (between your ear and jaw), or even a breakdown of their skin from the mask being too tight. Most Insurance allows headgear replacement every 6 months. On a knight’s recommendation, you should stick to this schedule.
3) Mask Frame- Replace your mask frame if it cracks, breaks or if a piece becomes loose. Additionally, there are exhalation ports and one-way valves designed into the structure of most masks for the release of carbon dioxide. Over time, buildup can cause these to become clogged, which can lead to whistling and CO2 not washing out of your mask efficiently. Most insurance allows replacement every 3 months.
4) Tubing- Replace your tubing if it cracks, rips, or becomes discolored. Especially replace it if mold or mildew appears. Tubing is tricky. Most patients don’t clean it properly and believe that if it looks clean, then it is clean, and so don’t replace the tubing as often as they should. If you are using a humidifier with your machine, then humidity is being pushed through your tube every night and the chances of little spore-based mold and mildew guys moving in is high. This means that you are breathing this in. For this reason, most Insurance will allow replacement every 3 months.
5) Water Chamber-Replace your water chamber if it cracks, breaks, or becomes discolored. Like tubing, most patients don’t clean these properly and, like tubing, water chambers make a fine home for mold or mildew. Any time you mix water with heat there is a good chance of bacterial growth. We suggest you clean this several times a week and change out you water daily. To clean your water chamber, dump out any unused water, clean the entire chamber, and then replace the dumped water with new, distilled water. Most Insurance allows replacement every 6 months.
6) Filters- Filters need to be replaced when they become discolored, dirty, or ripped. Depending on the machine, you may have a disposable filter. These simply need thrown out and replaced either bi-weekly or monthly. Other machines have a non-disposable filter (such as some older Respironics models). These can be washed with mild soapy water when they become dusty or dirty, but should still be replaced every 6 months. Most insurance allows disposable filters to be replaced biweekly or monthly and the replacement of non-disposables every 6 months.