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Hey there folks. I haven't been on here much lately. Sorry about that.

First let me give you a little history about me and what I have learned over the years.

I've been a licensed Respiratory care practitioner for 23 years. 18 years of Critical and trauma ER experience. Pediatric ICU, Adult Trauma and cardiac ICU, Neonatal ICU, Autopsy and pathology, Home ventilator care management and routine care. 

The last 5 years I have focused on Sleep apnea and related disorders. 11 years ago I started using APAP to treat my apnea disorder.

I want to share with you what I teach my patients and hope it helps those of you who don't have the same sort of customer service I am afforded with my patients.

There are a number of causes for sleep apnea. The simplest and most common cause is what I will discuss here. If you feel your OSA is more complex then please feel free to contact me.

I also want to put in a disclaimer. My advice is based off first hand experience. And advice is purely individual. My observations and suggestions are based off having several sources of information for each individual. Sleep study results and past medical history is essential in order to make an informed suggestion. Please take my advice as just that. Advice, and, my personal opinion.

First let me explain the madness to my methods. Several very important things occur in the nose. Humidification of the air. By the time the air we breathe in gets to the lungs it should be 100% humidified. The majority of that job is done in the nose. The nose also filters the air coming in to protect the lungs form infection and foreign objects. The nose also produces a trace amount of a gas called Nitric Oxide. Nitric oxide is the key component of Viagra and pulmonary hypertension medications. It also kills bacteria and viruses. Nitric oxide dilates blood vessels and allows better blood flow through the lungs. Increasing blood oxygen levels by 10-25% over mouth breathing. Normal nasal breathing also helps regulate blood pressure and heart rate.

In my experience, especially in the North West, the majority of sleep apnea is rooted in the nose. Let me use a car engine as a way to explain how this happens.

Imagine the nasal airway as the intake valves.

The base of the tongue, adenoids and soft palate are the head gasket the trachea and main airway is the cylinder and the diaphragm is the Hemi piston.  Each and every time the piston pulls down it creates negative pressure, pulling the fresh air into the lungs. What happens if the intake valves are clogged or the intake manifold is not ported and tuned? The negative pressure is transmitted to the walls of the cylinder. What happens to the head gasket, the weakest and most flexible part of the intake system? It get sucked into the cylinder right? Imagine that happening each and every time you breathe. Our brains are very self protective. In order to get the amount of air in and out of your lungs to provide the oxygen you need and to eliminate the Carbon Dioxide, a learned behavior of dropping the jaw to move the tongue forward and out of the way is adopted.

CPAP is like adding a turbo charger to the intake manifold.

The increase airflow and positive pressure creates a pneumatic splint and helps over come the baseline resistance and allows the piston to pull back freely and without transmitting negative pressure to the walls of the airway.

I get folks coming to me all the time saying that they need a Full face mask because they mouth breath at night.

Well ya!  Most everyone with sleep apnea does mouth breath. Here's the deal.  We are born obligatory Nasal breathers. Mouth breathing is a learned behavior and can be reversed. There is only about 10-15% of folks out there who need a full face mask. Those who have the misfortune of having a UPPP, deviated septum, weak upper airway and dysphasia. Those folks typically need a full face. Most everyone else should be able to use a simple nasal mask.

I also see many folks being titrated to CPAP in the sleep lab with a full face mask. More times than not these masks are put on very tightly to get a good seal so the tech can get clean numbers. Full face masks can actually increase the resistance in the upper airway thus requiring more pressure to be delivered in order to overcome the baseline resistance and the resistance the mask itself creates.  When a full face mask is applied too tight it will close of the nasal airway by pressing the turbinate’s close to the septum of the nose. It will push the lower jaw back causing the tongue to be pushed into the airway requiring more pressure to overcome that resistance as well.

I have transitioned many patients from a full face mask to a nasal pillow system or simple nasal mask and did a auto trial to find out their pressure requirements have dropped significantly and their compliance increase dramatically. In one of my most dramatic cases the patients pressure requirements dropped fro 18 cmH2O to 9 cmH2O!!!! Full face masks also have a much higher chances for leak! Leaks cause neurological disturbances and keep folks from getting the sleep they truly need. Smaller mask. Less surface area to seal. Better sleep.

By applying the pneumatic splint more efficiently and directly, pressure the machine has to hit are typically lower. Lower pressure = better comfort and better sleep. Less chance for leaks and promotes more natural nasal breathing.

Here is what I advise each and every one of my new patients to do when they start PAP therapy to increase their comfort and benefits from the therapy.

1.) Get some sinus rinse. Either a Neti pot or squeeze bottle type. DO NOT USE TAP WATER EVER!!!! Distilled water only!!!

    Irrigate the nasal airway 1 hour prior to bedtime every night for 2 weeks.

2.) Do not use medications like Afrin or pseudoephedrine. They slow down the mucocilliary clearance and can increase your chances of infection. Plus these meds have a rebound effect and will increase congestion when they wear off.

3.) Take 400-600 mg Ibuprofen  2 hours before bedtime. Ask your doctor if it's ok for you to take an NSAID.

4.) Use Vicks Mentholated rub on the bottom of your feet and put on socks while you sleep. It sounds weird, but it really works.

Other things that will help with sleep are:

If you take a SSRI. Anti-depressant. Take it in the morning, not at night. SSRI's will increase serum serotonin levels and keep you brain from shutting down properly. Take it in the morning to get the best effect from the med and allow the levels to drop down naturally through out the day.

Take melatonin to help you fall sleep. Drugs like alcohol, Ambian, Lunesta and Benadryl shut the brain down in the wrong order and will actually inhibit normal REM cycle sleep. Drugs taken for sleep is like reaching over to the wall outlet and unplugging your computer while it's up and running with all the applications running in the back ground. The brain need to shut down in a certain order. Peripheral to central. Sleep aids and narcotics shut the brain down from central to peripheral. Messing up the normal shut down process.

Try 3 mg of Melatonin 2 hours prior to bed time for 3 days. Do not take at bedtime. The pill form of Melatonin needs the time to cross the blood brain barrier to start working. If not effective, increase to 6 mgs X 3 days. Increase by 3 mg after 3 days, if needed, up to 12 mgs. There are a few occasions when a prescribed sleep aid does help kick start the normal circadian rhythm. But, should only be needed for a few days. 

Use your humidifier!!!! Your upper airway loves good humidification. When the air is too dry the mucus membranes respond by engorging with blood to produce more secretions to humidify the incoming air. Think of it this way. When you step outside on a cold clear winter day what happens? Your nose starts to run, right? It's trying to humidify the air coming in to keep the mucus thin and mobile. Signs that you may need more humidification are:

Chronic rhinitis and allergy like symptoms. Just this week I had a gentleman come to me after years of using his CPAP without a humidifier. He was on all sorts of allergy meds. I had him go back to using his humidifier and start nasal saline rinses. Switched him off a FFM to a nasal pillow system and 2 weeks later he is off all his allergy meds and compliance increased from 60% to 98% in a very short period of time.

Morning headaches, bloody nose, chronic sinus infections, Dry mouth, still feeling tired after using your PAP devise all night.

Clean your mask seal daily!!!! Masks seal by pressure and friction. Pressure from the PAP device pressing the silicon seal against your skin. The silicon has micro pits and valleys, like a microscopic aggregate finish that creates friction and adheres to your skin. Allowing the oils from your skin to build up and fill in these pits and valleys with cause the seal to slip and slide and not seal very well. The best thing to use is a fragrance and lotion free liquid dish soap. Either soak the seal in soapy water for an hour or simply turn on the hot water. Drizzle some liquid soap on the seal and rub in between your hands aggressively. Do not be afraid of tearing the silicon. It's remarkably tough. Refresh the surface of the cushion so it seals nicely with out having to tighten the mask down so tight it hurts or plugs off your nose from the sides.

Get your cushions replaced frequently. Most insurance will pay for 2 new nasal pillow and nasal mask seal every month. Full face mask seal are only eligible for insurance billing once a month.

I hope this helps.  If you have any other questions, please feel free to contact me.

Neal Buckner, LRCP

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Replies to This Discussion

Right on!! Thanks!!! 99!! lol

    And I add my thanks, 99!

     Also, I 'll add one more copy-edit BUT I don't think you can change it: The spelling on your post caption should be: "My Advice" -- the letter "c", not "s" in the second word.

     The above noted, I assure you: We knew what you meant and are very grateful that you posted. Indeed, I'm printing out your advice and placing it in my permanent "Excellent SA Advice" file.

Neal Buckner, LRCP said:

Right on!! Thanks!!! 99!! lol

What does the Vicks on the feet with socks do- help you sleep?

       I'm going to try it tonight. It might help me sleep because my cats, who like to sleep on my feet and legs, won't like the smell -- and I HATE having cats on my legs and feet when I want to sleep. ;-) 

       Admittedly, mine is a special situation....  ;-)

Mary Z said:

What does the Vicks on the feet with socks do- help you sleep?

Vicks works on the bottom of your feet by:  The camphor and Menthol absorb into your skin. AS it travels through the blood stream it warms up and needs to out gas. That occurs through the mucus membranes. The evaporation process causes a cooling effect causing the superficial capillaries to constrict and reduce the swelling and congestion with out stopping the mucocilliary clearance.

Nice post Neal

Mike C.  If you are having to take Mucinex that often then there is something else going on. You may need tubes in your ears. Saline rinses may help. But, I would seriously have that looked into.

drinking to much coffee or eating to many french fries

Mike C (STILL at the Beach!) said:

  Is this connected to "hoof & mouth disease"? Sorry... Actually I have to take Mucinex 4 times per day now even OFF PAP to help prevent my ear aches. Is this on the same track?

Arrrgghhh.... why oh why is it so hard to give up caffeine? 

99 said:

drinking to much coffee or eating to many french fries

Mike C (STILL at the Beach!) said:

  Is this connected to "hoof & mouth disease"? Sorry... Actually I have to take Mucinex 4 times per day now even OFF PAP to help prevent my ear aches. Is this on the same track?

Wow, Neal! Good, thorough explanations and advice. And it mirrors what my instincts were telling me in many cases, including increased pressure w/full face masks (which I have finally "graduated" to). I have COPD and "graduating" to 02 full time coincided w/my need to switch to a full face mask. Whereas before I had no problem w/mouth breathing, I did have a problem w/"the lip flutters". I have as yet to find a full face mask that DOES NOT push your lower jaw back. And using a full face mask has totally destroyed my natural tendency to position my tongue to form the necessary seal.

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