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I have what?!

I am a 48-year-old, caucasian man from South Carolina and have been significantly overweight for most of my adult life — including several attempts at lifestyle changes and weight loss that never seemed to stick. For decades, I’ve snored, woke tired, and suffered low energy levels. More recently, and to me a bigger concern, however, was sleep had become fleeting. If I wake in the night, I can expect hours of reading in the wee hours, often dozing off again just before my alarm clock sounds. As a result, I have had serious challenges with my focus and ability to complete tasks to my satisfaction.

Sleep apnea occurs when the soft tissue of the soft palate and neck relax and block the airway during sleep.

After bringing these issues to my primary care physician’s attention during my annual checkup, he referred me to a sleep medicine center for testing for sleep apnea, a common but dangerous disorder where a person stops breathing during sleep, starving the brain of oxygen and having the potential to cause significant health issues in those who suffer from it.

How could I have sleep apnea? I told him that my wife of 23 years has never noticed anything unusual about my sleep patterns, aside from my recent late-night wakefulness, and even my snoring, according to her, was sporadic. He was unconvinced and insisted I at least have the test done.

COVID-19 has changed the way we do everything, and this has become even more apparent in the fields of medicine, where virtual appointments are now the norm and in-person visits a rarity reserved for the seriously ill. This isn’t necessarily a bad evolutionary change for health care: Being able to log in to a virtual doctor’s appointment from home is convenient, requires less time off of work, and reduces the potential for picking up a lingering virus in the waiting room or physician’s office. In today’s fast-paced society, these are all benefits that help keep us on the move.

In the past, a sleep study entailed packing a small overnight bag and anxiously trudging to the sleep medicine center for what was sure to be an uncomfortable night in a strange bed. Research staff moved about at all hours monitoring uncomfortable sensors and dangling wires and hoses. Cameras destroyed all hopes of privacy. Normal routine was out of the question. Today, however, most sleep studies are conducted at home, in your own bed, under normal conditions and using portable, semi-comfortable technology.

My sleep study started with a brief visit to the sleep medicine office at University Hospital in Augusta, Georgia, for a pre-study interview and assessment. I returned a week later to pick up the testing equipment and received a quick tutorial from the physician’s assistant on how to attach the chest band, position the monitor and connect the fingertip oxygen sensor and nasal cannula that measured my blood oxygen levels and breathing patterns.

That night, I hooked myself up as instructed and performed my normal bedtime routine, which consists of any last-minute discussions with my wife about the kids, the day or the following day’s schedule and reading for 30-40 minutes until I get sleepy. I held down the power button, and when the green light lit showing all of the sensors were working, I rolled over on my side and slowly dozed off. And just like any car that purrs with perfection when taken to a mechanic, I slept through the night without having to use the bathroom or my brain kicking in and keeping me awake for hours, as is habit.

A light on the monitor confirmed a successful test, therefore I disposed of the nasal cannula and dropped the rest of the testing equipment off at the doctor’s office. Three days later, the results were in; moderate obstructive sleep apnea with a score of 21. This means that, on average, I experienced 21 sleep anomalies per hour, and my blood-oxygen saturation dropped to 85% several times during the night, signaling oxygen deprivation and a definitive diagnosis of OSA.

There it was. That “great night’s sleep” was nothing of the sort, and the monitor indicated it was far from it. My doctor suggested Continuous Positive Airway Pressure (CPAP) treatment, a non-surgical solution that has proven effective in treating OSA for decades. CPAP therapy uses the positive air pressure produced by a machine to prevent the collapsing of the soft palate and soft tissue in the neck when relaxed, which can obstruct air from entering the lungs while sleeping.

This blog is dedicated to my journey into the world of OSA and CPAP treatment. My hope is that by chronicling my experiences as a patient, not a doctor, others will gain a better understanding of CPAP therapy, the equipment that is necessary and what you might expect in your own therapy. – by Matt Lindler (a.k.a. CPAP Matt)

Rainout? What is that?

Ever wake in the middle of the night with water pooling in your mask or a popping noise coming from your CPAP tubing? That’s rainout.

Rainout happens when the room’s ambient temperature is significantly less than the humidified air produced by your CPAP machine and the high humidity air begins to condense in your mask and tubing. Warmer air can hold more humidity than cooler air, so as the air cools, water is released and accumulates in the CPAP tube or mask. I had this happen to me several times when I first started using my CPAP, and the noise from the tubing was more frustrating than moisture in my mask.

Below are six tips you can try to prevent rainout and achieve a full-night’s rest:

  1. Purchase a heated tube that keeps the humid air at a consistent temperature from the machine to the mask. Most of the major manufacturers produce a heated tube that is compatible with their machines. They run between $25-$100, and most are specific to a particular model of CPAP. There are a few universal third-party hoses, such as this 3B Medical product, but I have no experience in their efficiency. In fact, I have not used a heated hose to date, but plan to order one when I purchase a new machine in the coming year.
  2. Use a tubing wrap. These are like warm PJs for your CPAP hose. Usually made of microfleece or other insulated material, tubing wraps zip up or slip over your tube, insulating it from the ambient air temperature. Prices vary greatly depending on brands. I bought this one on Amazon for less than $12, and, so far, it works great. I also like it because it quiets the tube as it moves against the bed or night stand. It’s also hand washable. If you have an ACE bandage or two lying around from your basketball or tennis phase, you can use that as well, securing the ends with medical tape. It’s important that the tube is insulated completely from tip to tip for it to work effectively.
  3. Reduce the humidity level of your CPAP. Reducing it by a couple of small increments can help significantly without drying you out.
  4. Place the CPAP below your mattress level and let the condensation drain back into your humidifier. For this to work well, the excess tubing needs to stay above the humidifier at all times so it doesn’t collect in the lowest section of the tube instead of draining into the humidifier. Try to reduce slack as much as you comfortably can.
  5. Increase the temperature in your room by a few degrees. There’s a fine line between a temperature when condensation occurs and when it doesn’t.
  6. Use a Heat Moisture Exchange unit (HME) instead of a traditional water-based humidifier. HMEs are connected between your tubing and the mask and capture warm, exhaled moisture in a sponge-like filter, and they return that warm moisture back into your mask during inhalation. Some compact travel machines, like the ResMed AirMini, use an HME as their primary humidifier with good reviews. This is also a good option for traveling when you need to leave your traditional humidifier at home for weight or space savings.

Rainout is a common and frustrating issue most CPAP users will experience from time to time. Knowing the cause is half of the struggle. Preventing it is the other half. Sometimes, compromising your humidity preference and your preferred room temperature is the key to a full-night’s sleep. – by Matt Lindler (a.k.a. CPAP Matt)

At last, a night without leaks – ResMed P30i Nasal Pillow Mask

Last night was the first time since late October that I slept through the night without an air leak. It was glorious! I’m not saying it was a perfect night — thoughts of Thanksgiving to-dos swirled around for quite some time before I could doze off — but six hours of uninterrupted sleep felt like eight, and I awoke refreshed and ready to hit the kitchen.

The first mask my sleep doc fitted me with was a ResMed N20 nasal mask. While comfortable, I found it’s not well suited for my side-sleeping position. Pillow pressure frequently pushes it out of alignment, breaking the seal. A full month into my CPAP therapy, I’d yet to have a full night without interruption while using this mask.

AirFit N30i cradle cushion

A week ago, I order a ResMed AirFit N30i nasal cradle mask (check out this post on selecting a mask). As the name implies, cradle masks cradle the end of your nose and nostrils in a silicone, trough-shaped cushion with air ports cut into the bottom of the trough. Nothing protrudes into your nostrils, as does a nasal pillow. It “hugs” the bottom of your nose with slight upward tension applied by the frame and headgear.

I tested this mask setup the night before last, and it was comfortable but not without a few problems. It inched out of position a couple of times, causing the air ports to become misaligned with the center of my nostrils, which, in turn, made exhalation difficult. I tightened the headgear, and it stayed put for the rest of the night.

One of the reasons I ordered the N30i setup was because it was compatible with the P30i nasal pillows, so I ordered one of those as well. That turned out to be a wise purchase.

The AirFit N30i (top) incorporates a rigid body and soft nasal cradle, whereas the P30i (center) incorporates a pliable silicone body with traditional up-facing cushions. The QuietAir filter (bottom) of the P30i decreases noise and air flow from the front of the pillow.

Last night, I installed the medium-sized P30i pillow, put on the headgear, turned on the CPAP machine, and tested it for comfort and seal before lying down for bed. One difference between the P30i and the N30i, besides the nasal tabs, is the N30i cradle cushion has a hard-plastic body that is over 2.5 inches wide. While this didn’t affect its comfort for me, when sleeping on my side, however, it could be pushed out of alignment by my pillow, potentially causing the cushion it to lose its seal. The P30i’s nasal pillow, on the other hand, has a soft silicone body between the connection points, which provides flexibility at the joints and cheek and reduces the potential for being pushed aside.

The P30i also incorporates a QuietAir exhalation filter into the body of the pillow cushion. The removable filter lessens and quiets the air released during pressure regulation and exhalation from the front of the cushion. The majority of the air is released from the appliance through the elbow, which is positioned on the top the head.

There are a number of reasons I like this new setup. The pliable hollow frame directs air from the connection port, through the frame and down both sides of your face and into the cushion. When side sleeping, the channel against the pillow may be pinched or compressed, but the airflow continues through the channel on the other side, delivering a consistent pressure. Because the connection port is on top of your head, the pillow isn’t weighed down by the hose, as is common in other models, and is less prone to be pulled away from your nostrils as you move during the night. Because there’s no downward resistance, the appliance doesn’t have to be as tight, increasing comfort.

Those are my impressions after one night with the ResMed AirFit P30i setup. I’ll update this post with additional thoughts after a few weeks of wearing the appliance with the P30i and the N30i cushions.

As an alternative to the AirFit 30 series, take a look at the Philips Respironics DreamWear mask. It appears to be a comparable design for about the same price. I don’t know which company first developed this frame design, and my purchase of the ResMed was purely because that was the brand of my first mask and machine. The DreamWear mask uses a universal hose connection, so it should be compatible with most machines.– by Matt Lindler (a.k.a. CPAP Matt)

STATUS UPDATES:

2 Dec. 2020 — Nearly a full week in with the ResMed AirFit P30i setup and all is still good. I had one night in six where I encountered a couple of leaks, but I attribute it to not cleaning my face well before going to bed late that night. Washing your face at night is an important step in ensuring a good mask seal. Wash with facial soap and water or use an astringent/alcohol on a cotton ball/pad to remove oils from around your nostrils. The oil can act as a lubricant, allowing the cushions to slide around and potentially lose their seal. Removing the oil and cleaning your cushions/masks daily provides a dry fit that should not slip from position as you move during the night.

Selecting a mask

While the CPAP machine provides the life-saving pressure used to treat obstructive sleep apnea, the fit, feel, and reliability of your mask will likely determine if you stick with your CPAP therapy.

An uncomfortable mask, or one that doesn’t provide a good seal because of ill fit or style, will turn a person off. Full-face, nasal, nasal pillow and now nasal cradle masks allow a patient find a mask that suits their sleeping style, their breathing habits, and their facial structure. Add to that the sheer number of manufacturers and models/styles of each type, and you have a veritable boat load from which to find the mask that is perfect for you.

I’m a “nose breather” on most occasions and typically only breathe through my mouth when I’m congested. My sleep doctor fit me with a ResMed AirFit N20 nasal mask (size medium, to my relief), and it only cost me $75 through his office. Its neoprene headgear design is pretty comfortable, and the velcro adjustments allowed me to the find the right tension, top and bottom, to create a good seal without being overly tight. Neodymium magnets are used instead of clips to secure the headgear to the mask. The magnets are convenient when I have to make a midnight pitstop, because I don’t have to fumble with buckles or clips to re-attach the mask while I’m in my sleep-walking haze.

This mask works well for me most of the time, but having facial hair and being a side-sleeper, it sometimes loses its seal when I roll during the night and the side of the mask is pushed aside by my pillow. I’m still searching for a pillow position, firmness, and style that works best for me. Stay tuned for more information on that.

Recently, I’d read hundreds of customer reviews (mostly taken with a grain of salt) on nasal pillow and cradle designs, and settled on a ResMed AirFit N30i nasal cradle style. I selected this particular headgear because it accepts the P30i nasal pillows as well as the N30i cradles … and it has a sci-fi look that appeals to my inner geek.

I was a leary about the sealability of the cradle-style cushion, and this gave me the option of using a nasal pillow if I had issues with the seal. I bought it piece-by-piece (headgear, AirFit N30i standard system with medium cushion, and a medium P30i pillow) on Amazon for a total cost of $75, including tax, saved about $20 over most online retailers, AND got the additional pillow. With our Prime membership, shipping was free.

All of the components came in the mail over the past couple of days, so last night was my first attempt of sleeping with it.

Surprisingly, the cradle cushion kept a good seal most of the night, even with my normal tossing and turning. A couple of times, however, it slid toward the tip of my nose, shifting the alignment of the air holes, making it harder to exhale. After the last slip, I repositioned the mask and tightened the straps a little more. That seemed to work. Tonight, I’m going to try it with the P30i nasal pillow to see how it works. I’m not thrilled with the idea of having prongs in my nose, but many of the reviews I’ve read say it doesn’t take too long to get used to it. I’ll keep you posted.

Finding the right mask is mostly about trial and error. Sure, every new mask you try is going to cost you a pretty penny, but finding the one you can tolerate throughout the night will go a long way toward ensuring you stick with your CPAP therapy. – by Matt Lindler (a.k.a. CPAP Matt)

Snoozing with the ResMed AirFit N30i nasal cradle mask.

CPAP equipment maintenance

Maintaining your CPAP equipment is a must to ensure the longevity of your very expensive investment and reducing the potential for bacterial buildup and, ultimately, illness.

Clean all of the parts that contact your face daily. This can be accomplished quickly and easily added to your morning routine. Fill a clean sink with warm (not hot) water and add a small amount of detergent. Swish around all washable mask components (except for the headgear), including short hoses and elbows, in the soapy water a few times, rinse, shake off the excess water and air dry on a clean towel.

I also use CleanSmart CPAP Disinfectant Spray on my facemask parts by spraying all surfaces, shaking off the excess and letting them air dry. This disinfectant/sanitizer breaks down into saline as it dries, leaving no chemical residues or bad smells behind. I use this or a CareTouch CPAP Cleaning Wipe about every other day. Both of these products were recommended to me by my brother, are inexpensive, and last a long time.

Use the same soaking/washing procedure to wash the air supply hose at least once a week. Rinse thoroughly and hang it over your shower head or on a coat hanger from your shower curtain rod to drain and air dry. If you use a heated hose, follow the manufacturer’s recommendation for cleaning the hose.

Wash your CPAP machine’s reusable air filter in warm, soapy water weekly, rinse thoroughly, squeeze out excess water, pat with a clean towel, and let it air dry. If your machine uses a disposable filter, replace it once a month. If you live in an arid or dusty region, if you or anyone in your home smokes, or pet hair is a common problem in your home, you should replace the filter about every other week. I bought a dozen filters for less than $10 when I found them on sale. Once opened, I stored them in a resealable plastic bag. Never run your CPAP machine without a filter. Dust, hair, and other debris drawn into your machine can collect, damage the fan and motor, and also be forced into your airway.

Use a lightly damp cloth or a CPAP cleaning wipe to clean the exterior of your CPAP machine and the air hose connection ports once a week. Also wipe off any seals/gaskets where the humidifier attaches to the CPAP machine and let it air dry.

Refer to your CPAP machine’s operating manual for their prescribed maintenance and replacement regimine, but the table below is what I’ve found are average suggestions for most equipment. – by Matt Lindler (a.k.a. CPAP Matt)

Suggested CPAP Maintenance Schedule

EquipmentCleanReplace
Facemasks
Cushions
Nasal Pillows
Short Tubes
Daily
• Wash, rinse and air dry.
• Use only a mild, dish detergent or CPAP cleaner.
• Spray-and-leave disinfectants and CPAP wipes may also be used.
Every 3-6 months as needed. Sooner if damaged.
Humidifier ReservoirDaily
• Wash, rinse and air dry.
• Use only a mild, scent-free or CPAP-specific detergent.
• Mineral buildup can be removed by soaking with a solution of 1 cup vinegar to 2 cups water for 30 minutes then rinsed.
When cracks or leaks appear.
Air Supply HoseWeekly
• Wash, rinse and air dry.
• Hang over shower head
to drain and dry.
Every 3-6 months as needed. Sooner if damaged.
Filter(s)Weekly
• Wash reusable filters weekly, squeeze, pat and air dry.
Replace non-washable filters monthly unless in dusty or smokey environments, then replace twice a month.
CPAP machine bodyMonthly
• Wipe with soft lightly damp cloth to remove dust.
• Use a CPAP cleaning wipe
to clean hose connections
and let air dry.
Should last years if well maintained.
HeadgearOnly as necessary
• Too much washing will
reduce elasticity and
degrade materials.
When damaged or starting to deteriorate.

Setting up a CPAP machine for the first time

Once programmed by your physician, preparing your CPAP for operation is pretty simple. Read the instructions fully before setting up your CPAP for its maiden voyage, but here are some suggestions to get you started.

  1. Find a location next to your bed that is about head height or slightly below with access to a power supply. Keeping your CPAP machine at head level or below reduces the potential for the unit being pulled off and causing injury in your sleep.
  2. Install a new air filter and use a clean, damp cloth to wipe off the output port and let it dry.
  3. If your CPAP includes a humidifier water reservoir, remove it and wash with warm water and a mild, scent-free dish soap, or you can use a CPAP-specific cleaning solution. Rinse the water chamber thoroughly, use a towel to dry the exterior, and air dry out of direct sunlight before use. If you’re worried about soap residue in the water chamber, rinse with a diluted solution of white vinegar and distilled water (1:2 ratio) then flush with water and let dry.
  4. Fill the water reservoir with distilled water only, ensure the exterior is dry, and install it in the humidifier. Use only as much water as you need for one night. This will depend on the level of humidity you prefer. A higher humidity setting will use more water, whereas a lower setting uses less. My preferred humidity control setting is 1.5, so it uses very little water. Through trial and error, you’ll identify the right humidity setting and water level over the course of a few nights. It’s better to have a little too much water than too little. When water barely covers the bottom of the chamber after use, you’ll know you’re in the right ballpark. Don’t reuse water in the chamber. It should be dumped, rinsed, dried, and filled daily with fresh water. (Tip: If you experience a significant amount of water in your air hose, reduce the humidity setting. I suggest starting with a low setting and slowly increasing it until you wake without a dry mouth, throat and/or nose. You may need to increase the humidity setting during the winter months as heaters tend to dry out the air in your home.)
  5. Plug your new hose into the output port of the CPAP machine, and identify a path for your hose that will not pull items off of your nightstand or knock over furniture or other items on the floor as you move around during the night. Going behind and through or over the headboard is usually a safe bet. Ensure that it will not wrap around your neck if you turn over in your sleep. Excess should hang off of the bed. If you prefer, hose hangers are available to suspend the hose above your head while you sleep.
  6. Attach the other end to your new, cleaned mask and put it on. Lie down in your normal sleep position and adjust the hose as necessary to allow normal movement without too much hose on the bed. (Tip: I have read that if you wash your face before putting on your mask, it ensures a better seal and extends the life of your mask cushion.)
  7. If you have the option, set your CPAP to ramp-up to full pressure over a period of time. Set this to about the time it normally takes you to fall asleep. The lower starting pressure is more comfortable when you’re first adjusting to sleeping with a CPAP. As you become used to it, you can reduce the ramp-up time or go full pressure from the start if that is your preference.
  8. Again, ensure your face is clean, don the headgear and mask when you’re ready to go to sleep, and turn on your machine. Get comfy and nighty night! – by Matt Lindler (a.k.a. CPAP Matt)

CPAP on a Budget

My diagnosis of obstructive sleep apnea came in October 2020, after our family’s FSA account was maxed out following my wife’s foot surgery and our oldest boy’s wisdom teeth extraction. Even with those major medical expenses, we were nowhere close to meeting our insurance deductible. To say the least, I was not in a financial position to layout nearly a grand for a CPAP machine, so I started looking for a budget-friendly solution.

Searches on Amazon and a number of CPAP-specific retail and resell outlets for reconditioned CPAPs started out encouraging, but soon it was apparent I would have to spend at least a couple of hundred if not a few hundred dollars to buy even a used, serviced, reputable machine. For not terribly much more, I could buy a brand new one.

Facebook Marketplace showed a number of inexpensive, used models, but I just couldn’t bring myself to purchase a used machine from an individual I don’t know. Eww!

Fortunately for me, if not so much for him, my older brother was diagnosed with OSA about 10 years ago. And two years ago, he upgraded to a new CPAP machine but kept the original stored in its case, in a closet and offered it to me for free. My brother is a bit of a clean freak, so I knew anything that came from him would be clean and in good working order. As long as it passed muster with my doctor, it could see me through the end of the year until our FSA cycle reset and I could order a new one.

2011 ResMed S8 Escape II with EPR and
optional humidifier.

I took the nearly 10-year-old ResMed Escape II (with the optional humidifier) to my appointment with my sleep doctor. He plugged it in, pressed buttons in secret succession, listened to the motor, tested the pressure and finally deemed it suitable for use.

After determining I was a “nose breather” and not a “mouth breather” — though some of my friends would say otherwise — he next paired it with a nasal mask, in particular the ResMed N20. I always thought I had a noble schnoz, but he pulled out a medium mask and assured me it would fit, and it did. He set the machine to 10 cmH2O (CPAP pressure settings are measured in centimeters of water pressure), showed me how to operate it and sent me on my way with a follow-up appointment set for mid-January.

An hour with the manual and a few minutes of setup had me ready for my first night under pressure. More on that in another post…

Being strapped for cash doesn’t mean you have to delay your CPAP treatment. Ask around, especially among your friends and family. Many people who start CPAP therapy either don’t follow through with it long-term, or if they do, they tend to update their machines every few years. Finding a good, used machine from a trustworthy person isn’t that hard, and it will at least tide you over until you can save up for a new one, but start with a new mask and hose, do not dip into the friend pool for those. Eww! – by Matt Lindler (a.k.a. CPAP Matt)