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vinnie48
Unread post  Post subject: Mask advice for a stubborn beard wearer  |  Posted: Sat Aug 01, 2020 9:52 am

Joined: Sat Aug 01, 2020 5:03 am
Posts: 6
Location: Tasmania, Australia
PAP Mask: Dreamwear (Cushion, Pillow, and FF)
PAP Machine: Resmed Airsense 10 Autoset
Humidifier: Yes, with ClimateLine tube
Pressure Setting: Auto 6 - 10, EPR off

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Hello all, what an incredible resource this place and you all are.
I’m relatively new to CPAP and finding myself at the 3 month point still frustrated and almost ready to quit.
I’m not going to quit though. Even though I haven’t had a satisfactory experience yet, I have learned the difference between waking up in that terrible groggy state vs just tired.

If I may indulge in my story as an introduction, and I’ll ask my specific mask questions at the end.

Being in Australia I’ve found that sleep studies, apnoea, and CPAP are not supported very well, and even worse in my town. This all started for me late last year when my then partner insisted that I go talk to someone about my snoring. My GP prescribed me a nasal spray for my allergy symptoms instead of the OTC anti-histamine tablets I was taking. This was a great improvement to my breathing and congestion, but didn’t fix my snoring.
Next thing my GP said was “Looks like you have a deviated septum, go get a scan of your sinuses” – the result of this showed a minor obstruction (though I’ve never felt I had difficulty nasal breathing, aside from allergy season). Instead of taking the next instruction which was a referral to an ENT, and expecting I likely had a diagnosable level of apnoea, I was asking if he knew anything about any over the counter oral appliances I might be able to try, and was advocating to get a baseline sleep study done asap (also predicting the ENT was just going to ask for that anyway).

Eventually got my home sleep study done and sent back.
My results came back as a high Mild OSA diagnosis – AHI 14.2 but ticking over to 30.3 in REM sleep. The study showed for that night my SpO2 levels only got down to 92%, and my sleep duration and % of restorative sleep were satisfactory. All but 2 events for the night were hypopnoeas rather than full obstructions.
At this point the pandemic was shutting everything down here and I knew I wouldn’t be seeing an ENT specialist, dentist or Orthodontist any time soon. (My father has used an MAD for ~6 years, so I had some idea of the process) Also being on a low income and not having any extra private health insurance I was certainly nervous of the costs I was quoted to get a machine on a support plan or having an oral device made.
I ordered a SnoreRX mouthguard thing with the intention to check how well a proper MAD might work for me. It did actually reduce my snoring to tolerable levels, but it hurt my teeth too much even on the minimum setting, and persisting for a longer adjustment period didn’t improve it. That amount of discomfort and knowing it must be changing my bite was not an exciting prospect – I returned it.

Enter the cheaper used Resmed Autoset ordered from the local ex-demo/lab re-seller. I requested a ForHer model (thinking I’m a short, athletic build, and mostly H events, and why not have the extra algorithm option to try) and waited and waited, eventually he offered me a ‘ForHim’ model as a loaner until the other became available (it had ~400 hours on it, and I’ve ended up just keeping it). I had ordered myself a Dreamwear Nasal cushion mask in the meantime, so all ready to go.

Mixed results on the typical initial 4-20 settings (humidifier, but no heated tube). I found the pressure difficult to breathe against and get comfortable with initially. Also found that the machine would step up and run away to 16 or so based on my breathing while still awake and turning over and so on, I just couldn’t tolerate it beyond 10cm (being blasted with this would also wake me up). I set a minimal ramp so that I’d likely be asleep before the machine started reacting to these false events.
While finding the nasal cushion reasonably comfortable I had problems with mouth leaking and after a few days I ordered a FF version on the Dreamwear (more waiting through the shutdown postal delays). The data in OSCAR was suggesting a sensible min pressure of 6, and I couldn’t tolerate anything approaching 10, so I’d set the machine for this range. I reduced and turned the EPR off as this seemed to just make more breathing noise in the tube while I was trying to get to sleep, adjusted the humidity setting higher and higher until I had rainout issues.
At some point I got the proper heated tube, and the FFM arrived. I had difficulty with that too as the design of the dreamwear FF headgear seems to sit in a much too low position, almost on the back of the neck, this felt like it was pulling my jaw back and forcing a significant and uncomfortable chin tuck – head position seems to have a massive impact on the proper fit of this mask. Head up – too tight, chin tucked and mouth open – massive leaks. I ordered a small mask frame (more waiting) thinking this might help position the headgear higher for a better angle on the lower straps. No luck, still far too much leaking when my mouth inevitably opened and jaw dropped back. I went back to the nasal cushion, and tried taping my lips with different tape and techniques, but air would still leak out of my lips noisily waking me, and my partner had completely given up back to sleeping in another bed after the first few nights. I tried a few different levels of fixed CPAP thinking to a lower pressure would help my lips stay closed, and a constant pressure might reduce the breathing noise. I tried an improvised chin strap, and included a strap across my lips to little improvement, and feeling ridiculous and unsafe. My lips simply won’t stay closed, and that air will noisily flow out the tiniest of gaps. I had trouble with a sore developing under my nose from the inner edge of the nasal cushion, and was also thinking that maybe my deviated septum was causing my nostril to collapse and reduce airflow. I ordered a small gel pillow to add to my growing collection of Dreamwear parts. When it arrived I found it was also fairly comfortable, but then woke in the middle of the night with not only that familiar desert dry throat, but now a very painful spot where there was pressure on my wonky septum. I never did get much past 4 hours with this before removing the mask and falling back asleep. Clearly I’ve stubbornly invested too much time into trying to make the Dreamwear series work for me. I’ve also stubbornly refused to remove the short but full beard I’ve worn since 2006, dooming my attempts at getting a good seal with a full face mask, or expecting tape to stick to the hair.

Through all of this I don’t snore and the machine is telling me that I have an AHI typically around 3. That includes a bunch of CAs that I wasn’t expecting, though I suspect these are probably false events when I roll over or whatever – my pre-machine audio recordings suggest I can be fairly mobile during sleep, and I know I’m rather twitchy as I drift off too. I feel like I’ve traded unconscious poor breathing, compared to a different type of interrupted sleep - waking to noisy mouth leaks and terribly dry mouth and throat, and I think my teeth/gums are suffering from that too.
The partner is now an ex, so the incentive to be tolerable to share a bed with isn’t so great, I’m completely unaware of my snoring, I rarely remembered waking in the night before using the machine, and although I was regularly tired, I never admitted to that causing me to be dysfunctional. Why not just pack it all up and just deal with the old tiredness???


And the TL;DR version is -
I have mouth leaks I can't solve, the 1 full face mask I've tried doesn't work for me, I want to keep my beard, and I need a new mask. Can you help me find a solution?
One thing I never did like about the dreamwear nasal cushion was the front vent not having a diffuser – that jet of air can be noisy against bedding, and it’s certainly not partner friendly.

Is the dreamwear FF headgear really meant to sit so low on the back of the head/neck?
The strap angles just don’t feel comfortable, and tightening them enough to try to get a seal on my beard just seems awkward, causes a chin tuck and then it leaks anyway when I relax my jaw. The F30i seems to have very similar geometry.
Is is going to be worth trying this again with a clean shaven face?
I’m rather attached to my beard, but again my ex isn’t here to add her complaint about me shaving it off, shaving might be a temporary possibility.

While awake (and not congested or exercising) I always breathe through my nose.
Why can’t my tongue/throat/lips contain a pressure as low as 6cm?

I specifically like the idea of the dreamwear’s top-of-head tube connection for my movement and otherwise just keeping the tube out of the way when I sleep on my side/stomach. Without having tried any other masks, is the front-connection actually a complete non-issue?

Before I invest in an AirTouch F20 and its disposable memory foam cushions, are there any other mask options that specifically seem to be successful for full beard wearers?

Everyone seems to say that the Resmed machine is very quiet. I don’t have anything to compare it to, but there seems to be a fair bit of noise from the whole setup – mask vents, tube, machine. Might this just be a perception thing as the dreamwear frame creates noise directly on my face and next to my ears? Or did I maybe get a faulty machine? Anyway, I can sleep through it, and it’s got to be better for someone else to sleep through than my snoring and snorting.

Is there any useful opinion about chasing an ENT for surgery and how repairing my deviated septum might impact my CPAP experience?
A friend had his fixed recently and said it was an amazing change to his wakeful breathing. It would be a couple of years on a waiting list anyway, as I can’t afford to have it done privately any time soon.

Apologies for the long rambling story, and I would be thankful for any input to help me get this treatment back on track.


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DeltaBravo3.8
Unread post  Post subject: Re: Mask advice for a stubborn beard wearer  |  Posted: Sat Aug 01, 2020 3:39 pm
User avatar

Joined: Sat Jul 04, 2020 8:38 am
Posts: 140
Location: Greencastle, Pennsylvania, USA
PAP Mask: ResMed F20 N30i P30i
PAP Machine: ResMed AirCurve 10 ASV
Humidifier: 10 Series HumidAir
Pressure Setting: EPAP 8-15 PS 4-12

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My perception here about your therapy is 2 separate actions to be able to get this to work for you.

1. the mask search and 2. the right settings

1. I know a guy on another forum with a full beard and can use the Respironics Amara View FFM. I've had this myself. It's not better than the ResMed F20 AirFit silicone IMO. Masks are very personal in preference. ResMed also has an F30 and newer yet F30i. These are more like a hybrid, upper part nasal cradle and lower half of a FFM. Also Fisher & Paykel make some FFM that may work, newest I recall is the Vitera. If you could control mouth leaks via a chin strap, I'd suggest ResMed P10 pillows style.

2. Let's see the OSCAR report in standard non-zoomed. Your settings can hold you back at least as much as the wrong mask. The data will clue us in on what settings to adjust. I realize you think your pressure is high, but it's at 0.142233 PSI at 10 cmH2O. The CA you saw are likely treatment emergent due to PAP therapy. For EPR to work effectively, you're going to need 7 as your low pressure, as EPR subtracts its setting from low pressure/EPAP.

Anyway this is all guesswork until we see the data. We can and will ding into this as detailed as needed to get it going well.

_________________
KC3PRU 73s


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vinnie48
Unread post  Post subject: Re: Mask advice for a stubborn beard wearer  |  Posted: Sat Aug 01, 2020 9:08 pm

Joined: Sat Aug 01, 2020 5:03 am
Posts: 6
Location: Tasmania, Australia
PAP Mask: Dreamwear (Cushion, Pillow, and FF)
PAP Machine: Resmed Airsense 10 Autoset
Humidifier: Yes, with ClimateLine tube
Pressure Setting: Auto 6 - 10, EPR off

Offline
I've spent enough time with the machine on now that I have adjusted to wearing something on my face and breathing against pressure. I don't think my pressure is high at all. The first few nights it looked like 4cm would mostly cover me and I wondered if this was a pointless expensive experiment. I even tried a fixed pressure of 4cm one night and got an AHI of 2.24 (6hr42, CA 1.19/OA 0.75/H 0.30) which is considered satisfactory by the numbers alone and better than many of my other nights. I've included data for one of my early nights when I first switched EPR off. I'm confident that 6-10 is a reasonable range given the data I'm seeing. With my leak issues, I'm a little less confident about whether the data is valid.
The Airsense seems quite happy to do it's best to provide EPR at low pressures, it just won't go below 4cm EPAP. Watching Jason's videos, explanations of treatment, and the sensation around my tonsil area when I force an obstruction, I'm convinced that EPAP is a critical number for treatment, and EPR is really only a comfort thing while still awake - I don't need it.

My comment is that at pressures as low as 10cm and below, why is the pressure getting into my mouth and escaping through my lips. I don't believe I'm actually inhaling through my mouth, and a chinstrap won't stop my cheeks puffing and getting the venting through my lips, that still happens with a clenched jaw.
Effective taping would probably solve this, but I can't get a good seal with a hairy face, and by the time I've got that much stuff on my face, it may as well be a full face mask.
I don't feel great about the safety of taping anyway.
Are there any exercises I could be doing to improve muscle tone in my throat and lips?

Dealing with the leak issue so that I can sleep through the night is priority 1, the data for pressure settings can be reviewed after.

I had wondered about being treatment emergent for CA, but having read into it some more and looking at the data, I'm much more inclined to think they're false events since the machine has no measurement of my wakefulness and movement in bed. At this point, I'm putting the CAs down as an indication of arousals from another cause (probably discomfort from leaks).

I would be quite happy to keep using the Dreamwear nasal cradle, or gel pillows if I could solve the mouth leak. The hybrid full face styles seem okay, but maybe I'll still have to wear a chinstrap with one anyway, and I find the headgear geometry uncomfortable. The F30i has a slightly different cushion shape and comments about the silicone being more tacky, but it looks like the headgear is almost identical to the dreamwear.
Am I likely to have the same chin-tuck and relaxed jaw issues with any traditional FFM too?
If so, I will just have to abandon my beard and deal with that change to my identity.

The AirTouch F20 with the foam seal, is top of my list right now. Is it going to be worth ordering it (and waiting), or should I try something else first?


Attachments:
File comment: These OAs look legit, but with the leak just below the threshold, is the machine simply guessing at the H and RE flags right before the leak drops, I'm probably awake
20200731 FF real OAs with leak.png
20200731 FF real OAs with leak.png [ 216.47 KiB | Viewed 196 times ]
File comment: I've taken a deep breath, and the leak changed, looks like I moved here
20200731 FF false CAs.png
20200731 FF false CAs.png [ 212.74 KiB | Viewed 196 times ]
File comment: Recent FF
20200731 FF.png
20200731 FF.png [ 222.99 KiB | Viewed 196 times ]
File comment: Recent Pillows
20200729 pillows.png
20200729 pillows.png [ 225 KiB | Viewed 196 times ]
File comment: Early nasal cradle, no EPR
20200507 nasal.png
20200507 nasal.png [ 221.04 KiB | Viewed 196 times ]
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DeltaBravo3.8
Unread post  Post subject: Re: Mask advice for a stubborn beard wearer  |  Posted: Sun Aug 02, 2020 4:44 pm
User avatar

Joined: Sat Jul 04, 2020 8:38 am
Posts: 140
Location: Greencastle, Pennsylvania, USA
PAP Mask: ResMed F20 N30i P30i
PAP Machine: ResMed AirCurve 10 ASV
Humidifier: 10 Series HumidAir
Pressure Setting: EPAP 8-15 PS 4-12

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If you want to search to learn about the tongue suck exercise, it's out there to consider. It places the tongue at the roof of your mouth and the tongue root blocking the mouth's airway. It's where the tongue would be naturally while awake and not eating or talking.

On EPR, I do know some that we've advised on another forum in which EPR is therapy related although it is categorized as comfort. The EPR is Pressure Support but in reverse. If you set an EPR of 3 and pressure of 7, EPR drops to 4 then on inhale it goes to 7 giving you PS of 3.

_________________
KC3PRU 73s


Last edited by DeltaBravo3.8 on Sun Aug 02, 2020 5:02 pm, edited 1 time in total.


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vinnie48
Unread post  Post subject: Re: Mask advice for a stubborn beard wearer  |  Posted: Sun Aug 02, 2020 4:59 pm

Joined: Sat Aug 01, 2020 5:03 am
Posts: 6
Location: Tasmania, Australia
PAP Mask: Dreamwear (Cushion, Pillow, and FF)
PAP Machine: Resmed Airsense 10 Autoset
Humidifier: Yes, with ClimateLine tube
Pressure Setting: Auto 6 - 10, EPR off

Offline
If you have EPR set to 3, and have a pressure of 5.2, for example, it will still drop the EPAP to 4. The machine does what it can, it just won't go below 4. I can post another of my early charts if you want to see it.

So, persevering a bit more with the dreamwear FF, I managed to adjust the headgear to something workable. The angles still seem all wrong, and my mouth ended up open, but the result is a positive improvement.
I remember waking once during the night.
If every night was like this I could probably accept that. I'd probably be looking to bump my minimum up closer to 8 though, and give max a bit more room above 10.


Attachments:
20200802 Dw FF good.png
20200802 Dw FF good.png [ 222.97 KiB | Viewed 164 times ]
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DeltaBravo3.8
Unread post  Post subject: Re: Mask advice for a stubborn beard wearer  |  Posted: Sun Aug 02, 2020 5:06 pm
User avatar

Joined: Sat Jul 04, 2020 8:38 am
Posts: 140
Location: Greencastle, Pennsylvania, USA
PAP Mask: ResMed F20 N30i P30i
PAP Machine: ResMed AirCurve 10 ASV
Humidifier: 10 Series HumidAir
Pressure Setting: EPAP 8-15 PS 4-12

Offline
Correct on the PAP not going under 4. There is one machine I recall that can be set to 3 but I've forgotten which model it was. Mainly the EPR 3 and pressure of 7 was an example of how to gain the most from EPR and having the lowest starting pressure while keeping the PS of 3.

Otherwise, this chart looks very good. If you were comfortable that's what counts the most.

_________________
KC3PRU 73s


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vinnie48
Unread post  Post subject: Re: Mask advice for a stubborn beard wearer  |  Posted: Sun Aug 02, 2020 5:39 pm

Joined: Sat Aug 01, 2020 5:03 am
Posts: 6
Location: Tasmania, Australia
PAP Mask: Dreamwear (Cushion, Pillow, and FF)
PAP Machine: Resmed Airsense 10 Autoset
Humidifier: Yes, with ClimateLine tube
Pressure Setting: Auto 6 - 10, EPR off

Offline
Or just turn EPR off and set the minimum pressure to what's actually needed. Why crank the pressure up if you don't actually have any problem inhaling?
The function of Expiratory Pressure Relief could just as easily be labelled "Inhalation Assistance" if you look at the numbers differently.
All this discussion of EPR is way off topic anyway. I understand it, and didn't ask about it.

Do you have any comments on mask seals on beards, or geometry of headgear? Or anything I might try to solve my mouth leak when using a preferred nasal mask?

This chart looks fine as a one-off, but the leak rate was increasing toward morning so possibly will be worse on other nights. The headgear and chin position was tolerable, but basically forcing my mouth to rest open there's only so much the humidifier can do. I'd be hoping for better.


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DeltaBravo3.8
Unread post  Post subject: Re: Mask advice for a stubborn beard wearer  |  Posted: Sun Aug 02, 2020 5:52 pm
User avatar

Joined: Sat Jul 04, 2020 8:38 am
Posts: 140
Location: Greencastle, Pennsylvania, USA
PAP Mask: ResMed F20 N30i P30i
PAP Machine: ResMed AirCurve 10 ASV
Humidifier: 10 Series HumidAir
Pressure Setting: EPAP 8-15 PS 4-12

Offline
I had already commented on masks. I was just giving info on the settings and EPR. If you don't want that info no problem. In your first post it sounded like you wanted help to make the therapy better. That's what I was offering to do. If you don't want the advice, again no problem.

_________________
KC3PRU 73s


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vinnie48
Unread post  Post subject: Re: Mask advice for a stubborn beard wearer  |  Posted: Tue Aug 04, 2020 5:46 pm

Joined: Sat Aug 01, 2020 5:03 am
Posts: 6
Location: Tasmania, Australia
PAP Mask: Dreamwear (Cushion, Pillow, and FF)
PAP Machine: Resmed Airsense 10 Autoset
Humidifier: Yes, with ClimateLine tube
Pressure Setting: Auto 6 - 10, EPR off

Offline
I do want help to make my therapy work better for me.
You misinterpreted my request, had very little to say about mask fit, while ignoring the part where I'm already using a hybrid FF and have tried pillows. Then followed your own tangent of wanting to look at machine settings and baby me through an explanation of how EPR works.
As explained in my story, I'm confident that I already have my machine settings in an appropriate ballpark, and needing help with the tube/face interface before I can fine tune the machine.
I specifically put my post in this category because I'm looking for help with masks and mouth leaks. I was hoping for a discussion.



If anyone else actually reads this thread, I would very much appreciate your input on my original questions.
I've not been able to have a repeat of that one 'good' night with the Dreamwear full face.

vinnie48 wrote:
...

And the TL;DR version is -
I have mouth leaks I can't solve, the 1 full face mask I've tried doesn't work for me, I want to keep my beard, and I need a new mask. Can you help me find a solution?
One thing I never did like about the dreamwear nasal cushion was the front vent not having a diffuser – that jet of air can be noisy against bedding, and it’s certainly not partner friendly.

Is the dreamwear FF headgear really meant to sit so low on the back of the head/neck?
The strap angles just don’t feel comfortable, and tightening them enough to try to get a seal on my beard just seems awkward, causes a chin tuck and then it leaks anyway when I relax my jaw. The F30i seems to have very similar geometry.
Is is going to be worth trying this again with a clean shaven face?
I’m rather attached to my beard, but again my ex isn’t here to add her complaint about me shaving it off, shaving might be a temporary possibility.

While awake (and not congested or exercising) I always breathe through my nose.
Why can’t my tongue/throat/lips contain a pressure as low as 6cm?

I specifically like the idea of the dreamwear’s top-of-head tube connection for my movement and otherwise just keeping the tube out of the way when I sleep on my side/stomach. Without having tried any other masks, is the front-connection actually a complete non-issue?

Before I invest in an AirTouch F20 and its disposable memory foam cushions, are there any other mask options that specifically seem to be successful for full beard wearers?

Everyone seems to say that the Resmed machine is very quiet. I don’t have anything to compare it to, but there seems to be a fair bit of noise from the whole setup – mask vents, tube, machine. Might this just be a perception thing as the dreamwear frame creates noise directly on my face and next to my ears? Or did I maybe get a faulty machine? Anyway, I can sleep through it, and it’s got to be better for someone else to sleep through than my snoring and snorting.

Is there any useful opinion about chasing an ENT for surgery and how repairing my deviated septum might impact my CPAP experience?
A friend had his fixed recently and said it was an amazing change to his wakeful breathing. It would be a couple of years on a waiting list anyway, as I can’t afford to have it done privately any time soon.

...


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DeltaBravo3.8
Unread post  Post subject: Re: Mask advice for a stubborn beard wearer  |  Posted: Tue Aug 04, 2020 8:48 pm
User avatar

Joined: Sat Jul 04, 2020 8:38 am
Posts: 140
Location: Greencastle, Pennsylvania, USA
PAP Mask: ResMed F20 N30i P30i
PAP Machine: ResMed AirCurve 10 ASV
Humidifier: 10 Series HumidAir
Pressure Setting: EPAP 8-15 PS 4-12

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The reality is I did not ignore the mask portion and I did not misinterpret your request. The fact is you don't want to consider adjusting the machine or getting input from an OSCAR chart to see if settings are missing the mark.

You did get the part about someone else helping you out on target. The info I suggested was ignored which is your choice to do so. However, I have no more time to discuss therapy, masks or anything else with ones such as yourself with quite a bit of pompous jerk in the attitude. No matter what country you're from, I believe you have the freedom to voice your opinion. I also believe I have the freedom to ignore the ignorant.

_________________
KC3PRU 73s


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vinnie48
Unread post  Post subject: Re: Mask advice for a stubborn beard wearer  |  Posted: Wed Aug 05, 2020 12:15 am

Joined: Sat Aug 01, 2020 5:03 am
Posts: 6
Location: Tasmania, Australia
PAP Mask: Dreamwear (Cushion, Pillow, and FF)
PAP Machine: Resmed Airsense 10 Autoset
Humidifier: Yes, with ClimateLine tube
Pressure Setting: Auto 6 - 10, EPR off

Offline
DeltaBravo, you were also quite welcome to simply ignore my previous message and walk away from this thread, but since you're still here and you didn't actually comment on them -
Based on the charts posted, would you have actually suggested any changes to my machine settings?

Yes, I would be open to changing settings, but while I don't have a good comfortable mask fit the machine can't perform magic, and I feel I'm sleeping worse than no treatment. Unoptimised settings aren't the limiting factor here.


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