I was diagnosed with obstructive sleep apnea in Septemmber, 2002 (RDI =96, 26 apneas/hr.). I have been on CPAP treatment since November. I have made some progress in my first 5 months on CPAP, but it's been a struggle at times and am still having daytime fatigue and fuzzyheadedness. This maybe due to common problems with CPAP such as allergies (stuffy, runny nose), air leaks, "mouth breathing," and sleeping on my back (something I haven't done in more than 15 years). These can seriously comprimise CPAP treatment and its effectiveness. I''ve been troubleshooting these problems to make sure they're not the cause of my lack of complete recovery, before trying other things such as drugs and surgery. [8-27-03: I have now gone to using Provigil for my continued daytime symtoms - see my health updates listed below]
I have been searching the Internet for help and suggestions with these problems, especially the Sleepnet forums on sleep apnea and its Google search of past posts. This has made me appreciate the numerous problems associated with CPAP use and the complex web of troubleshooting problems with treatment and that I need to be more aggressive about solving them. As one poster on sleepnet wrote in response to a new CPAP user:
You're exactly where I was 18 months ago when I first started on CPAP. The good news is the light is definately there at the end of the tunnel as to you feeling much, much better down the track by overcoming the apnea that has been giving you the symptoms you mention in your letter.
The bad news is that it will probably take an amount of adjusting, changing, mixing and matching a heap of different variables until you find the right balance. It is frustrating and seemingly never-ending, but the rewards are there when you get it right.
Many struggle for months and years with CPAP. Problem is, I can't find a good one page source for troubleshooting these numerous problems on the Internet. This page is my start on such a compendium of CPAP problems and solutions. Your suggestions and additions are welcome.
[replace "nospamplease" with "raines"]
Nasal stuffiness and CPAP
Nasal stuffiness is common with CPAP use. If you didn't have nasal stuffiness, congestion or runny nose before starting CPAP treatment, it maybe caused by the CPAP (common). The usual solution to try is a humidifier on your CPAP, preferably a heated humidifier. You may have trouble getting your insurance to pay for it, but most now cover the cost as it helps improve CPAP compliance in most patients as it helps elliminate nasal stuffiness and most find it is more comfortable on the sinuses.
If you have nasal stuffiness or other nasal symptoms prior to CPAP use from allergies, etc. a heated humidifier will help as will treating your nasal symptoms (see your doctor). Many find using a saline solution before bed helps. It can also be cused by structural problems such as a deviated septum, so again, if you have chronic nasal stuffiness, congestion, pain, etc. see your doctor.
Cold, Flu and CPAP - oh my!
Having a cold or the flu with apnea is no fun. Many like myself find that the CPAP with a heated humidifier helps with the nasal congestion, etc. Using a saline nasal spray or cold medications may help. Some though can't tolerate using a CPAP when they have a cold, but sleeping without a CPAP is dangerous, so try finding something that works for you in relieving the congestion.
"Mouth breathing" with a CPAP is a commom and major problem with CPAP use. Actually, people normally don't breathe through the mouth using a nasal CPAP as the phrase suggests as this is very difficult to do (try it some time - or just try talking while using a CPAP!). People simply unknowingly open their mouth or lips while sleeping letting out through their mouth the air being blown up through the nose. It causes the air to escape before splinting open the throat, thus comprimising CPAP therapy. It sometimes wakes up the person as this can make loud, weird noises at times. Mouth breathing can be as simple as having your mouth fill with air and letting the air out through the lips with a "puuuh" type sound, something I have done.
It is common to mouth breathe and not know it so it's important to know the symptoms. Symptoms of and clues to mouth breathing with a nasal CPAP are a dry throat and a humidifier tank whoes water level goes down significantly during sleep. The latter was something that frequently happened to me before and I just thought it was normal. After all, it happened most of the time and I was never told to watch for this that I remember. So I was apparently unaware of the extent of my mouth breathing. If you have a dry throat or sinuses from using a CPAP, the first thing to try is a heated humidifier on the CPAP. If that doesn't help, you probably are mouth breathing.
If your daytime symptoms are not improving with CPAP treatment, a thing to look at is mouth breathing. Try some of the solutions to mouth breathing and see if that helps.
The most common cause of mouth breathing is nasal stuffiness caused by colds, allergies or structural problems such as a deviated septum (see above). Allergies and structual problems should be taken care of if you're going to be using a CPAP. Some have said that mouth breathing could also be caused by having too low an air pressure on the CPAP. How this happens is that the air pressure prescribed is too low to prevent the throat from collapsing at times. If the throat collapses, the air is blocked and goes out the mouth. Others however found the opposite: their mouth breathing was caused by too high a prescribed air pressure. This can happen as the higher the air pressure the harder it is to deal with the pressure. Some open their mouths unconsciously to relieve the pressure. Being retitrated can determine what is the best pressure without leading to mouth breathing. This is another reason to find the "Goldielocks" CPAP air pressure: not too high and not too low, but "just right." The air pressure needs to be enough to prevent apneas and hypopneas yet not so high the patient can't stand it or it causes air leaks and mouth breathing. Being retitrated after a few months or a year on CPAP is fairly common.
The usual solutions to try for mouth breathing with CPAP are chin straps to keep the jaws together and keep the mouth closed or using a "full face" CPAP masks.
Comercial chin straps designed for apnea patients are available. Some use home made straps made from anything from Nike head bands to an ace bandage with velcro. Chin straps add one more contraption to strap to your head at night. Some find (like me) that straps may keep the mouth from opening, but the lips still part and air escapes through the lips and teeth.
Full face masks
Full face masks are available to allow a person to either breathe through the nose or through the mouth while using a CPAP. The name is a little misleading. They do not cover your entire face, just your nose and mouth. The most popular with apnea patients seems to be the Ultra Mirage 2 mask by ResMed. I have recently started using a Mirage Full face mask to stop my mouth breathing. It works well, but can be more suceptable to leaks, especially if you sleep on your side. When it does leak, it usually is a short and load noise making one, what my wife calls "face farts" which is an accurate description. :-)
Some have tried with success taping their mouths shut! (No not with duct tape!) One chap said his wife was so pleased with the results of having his mouth taped shut that she suggested he should use it more often. :-O
Materials used for taping your lips together to prevent leaks through the teeth and lips (with or without chin straps used to keep mouth closed) are micropore tape and Chin-Up Strips, among others. See the Sleepnet forums for examples, advice and concerns with this. Some are concerned that taping your mouth shut is dangerous if you throw up or have a power outage without a battery or other backup and don't wake up fast enough to remove the tape. If your mouth is taped shut it is hard to breathe through a CPAP that isn't pumping air through the hose. You may just rebreathe your own air, though some CPAP masks now help prevent this I believe. Some have reported sleeping right through power outages, but others woke up gasping for air trying to get the face mask, chin strap and tape off their mouth. At least one person apparently died. My Pulmonologist doesn't like the idea which is why he prescribed a full face mask for me.
A method using the tongue to help prevent mouth breathing is described here. I haven't tried it.
Sleeping on your back
When I picked up my CPAP at a sleep center I was told the best sleeping position with a CPAP is on the back. This keeps the mask out of the way of pillows which can push against it and break the seal on the face causing air leaks. Sleep position and sleep apnea severity are related. Most apnea patients have more, and more severe apnea episodes on their backs. A study I read indicated a 50% increase in apneas when patients slept on their backs vs. on their sides. For this reason, if someone has a mild case of apnea, if they normally sleep on their back, sleeping on their side may eliminate their problem. This is also why when doing a sleep test to do a titration, the patient is encouraged to sleep on their backs at least some of the time during the study so they can see a potentially worst case senario.
For those sleeping on their side with a CPAP mask, what I do to help prevent air leaks is I sleep so the mask hangs over the edge of the pillow and doesn't touch the pillow or mattress as the mask pressing against a pillow can break the air seal. Another solution is to use a PAPillow.
Another tip I've read to help with apnea (especially if you have a cold) is to sleep with your head elevated about 15 degrees by using more pillows. I haven't read any scientific literature on this and have tried it myself and don't know if it makes a difference.
Another thing that is helping me is exercise. This is true of most apnea patients and everybody else for that matter. Like most, I feel better during and after aerobic exercise and resisttence (weight) traing. I have more energy and can think clearer when I exercise. It also helps my mood (I can get depressed as is also common with apnea). I still battle fatigue and have to drag myself out the door at times to jog, but it's almost allways worth the effort. Exercising is simply the best thing that helps with my daytime symptoms and sleep. My experience is typical.
So if you're battling apnea, exercise should help regardless of the severity of your symptoms (in mild cases it can help eliminate your symptoms if combined with weight loss and sleeping on your side, not back). It's also of course a good idea to excersise anyway given the health benefits. With apnea, it may be more important as apnea itself increases your risk for heart disease, stroke and diabetes among others. Exrecise has been shown to reduce your risks of these and more. See links below for help with starting to exercise and see your doctor first if you're over 40 or so or have other medical conditions.
If after trying the above and CPAP/APAP/BIPAP treatment doesn't eliminate daytime tiredness and cogitive problems, stimulants or surgery can be tried. Some of the surgeries for apnea such as UPPP are painful. Most of the surgeries are effective in about 30- 50% of cases which is why CPAP therapy, which is nearly 100% effective if tolerated is tried first.
Drugs such as Provigil are apparently very effective in increasing alertness during the day and eliminating any residual sleepiness.
If like me you still have daytime fatigue, etc. after using CPAP awhile, exercising and eating right can help (see above).
It's important to realize though that many use CPAP for awhile (months) and only see gradual, slow impovements, but they eventually pay off their accumulated sleep debt, find the right combinations of CPAP, APAP, chin straps or whatever it takes to do the trick.
So be patient and good luck.
Forums for sleep apnea patients
Sleep apnea forum Sleepnet.
Sleep apnea forum Sleep Quest
Sleep apnea treatment
Treatment of Sleep Apnea
Air blower helps sleep apnea WebMD article on CPAP treatment for apnea
UPPP for Sleep Apnea
Residual sleepiness and its treatment
Etiologies and sequelae of excessive daytime sleepiness
Sleep deprivation leads to trouble fast WebMD article on recent studies showng that even after just two hours of less sleep in one night can lead to memory and thinking imparement, more debt can case more problems.
Study Demonstrates Provigil Significantly Improves Wakefulness in Patients with Obstructive Sleep Apnea
Modafinil [Provigil] in obstructive sleep apnea-hypopnea syndrome: a pilot study in 6 patients Research paper abstract.
Randomized, double-blind, placebo-controlled crossover trial of modafinil [Provigil] in the treatment of residual excessive daytime sleepiness in the sleep apnea/hypopnea syndrome Research paper abstract. Am J Respir Crit Care Med 2001 Mar;163(4):918-23
Provigil (Modafinil) Significantly Reduces Sleepiness in Patients With Obstructive Sleep Apnea
Products to help apnea patients
PAPillow Specially designed pillow for apnea patients to help prevent air leaks when sleeping on your side.
Chin-Up Strips Tape designed to help keep your mouth closed to prevent mouth air leaks.
Health benefits of exercise
iqhealth.com Lots of good articles on diet, exercise and health issues.
WebMD Lots of good articles on diet, exercise and health issues.
Mayo Clinic Lots of info.
Cardio and strength training Several articles.
Aerobic exercise iqhealth.
Speed Walking iqhealth.
ExRx.net Tons of pages with instructions for weight training exercises for practically every muscle in your body with small videos demonstrating proper techniques. Also streaching, aerobic exercise and healthy diet info.
My Previous health updates on my apnea struggles:
Update #5 Problems, a New CPAP Pressure, and MSLT Delayed to April March 14
Update #4 I Finally Got a CPAP! Feb. 8, 2003
Update #3 My Home APAP Test and Sleep Study Results Nov. 15, 2002
Update #2 My sleep study Sept. 10, 2002
Update #1 My Health August 10, 2002