Hose Wars, Part 2: To Breathe, Perchance to Leak

This is a series. Start here if you haven’t already.

I’m not a good sleeper, and never have been. When my publishing company (now mostly forgotten) collapsed back in 2002, I developed severe insomnia. I was getting as little as three hours of sleep per night, often less, and sometimes none at all. After a couple of weeks of this, I started to hallucinate cute little cartoon devils doing calisthenics at the foot of my bed, along with other things I’m not sure I can describe. Sleep isn’t optional. I sometimes think we sleep in order to dream undisturbed, and that dreams are somehow where our humanity comes from. If we can’t sleep, eventually we start to dream while we’re awake.

My big fear in starting APAP therapy was that I couldn’t sleep with a mask on my face. Had I been a better sleeper, I’d probably have begun thereapy years earlier. I was given two masks: One covered my nose and mouth. This is called a “full-face” mask, even though it doesn’t cover your eyes. The other is harder to describe: It’s a little plastic thing on an elastic strap that inserts a couple of cushioned tubes into your nostrils. These are called “nasal pillow” masks, and they’re a great deal less intrusive than full-face masks.

The whole point of CPAP/APAP therapy is to push enough air into your nose to keep your airway open, and to open it if by some chance it closes. For this to work, you either need a full-face mask so that if your mouth opens it won’t matter, or with a nasal pillow mask you need some way to keep your mouth closed. There are chin straps of various sorts and other things lumped into a category called “headgear.” Yet more stuff to tie myself up in; no thanks. I did the obvious: I used that blue surgical tape you buy at Walgreen’s to tape my mouth shut.

It worked. It worked, at least, until the machine upped the pressure for some reason. The higher pressure blew the tape off one corner of my mouth, which became a massive air leak, one noisy enough to wake me up.

This is my problem in a nutshell: APAP is noisy and uncomfortable, and keeps me awake. The noise I’m getting used to, at least the fairly modest noise from the machine itself. Leaks are a separate issue. I sleep on my side, which means that both kinds of mask eventually contact my pillow. I can position myself carefully when going to sleep, and that generally works. But if I squirm around even a little while I’m asleep, my pillow nudges the mask to one side, making noise, or (with the full-face mask) spraying air into my eyes. That wakes me up in a hurry.

To keep me asleep despite masks and leaks and hoses flapping around, the doc gave me a prescrption for a sleeping pill called Belsomra (suvorexant.) It’s the first of a new class of insomnia treatments that target the orexin receptors in the brain, rather than the GABA receptors. Pills like Ambien (zolpidem) target GABA, and force you to sleep. If you take one and don’t hit the sack, you’ll start dreaming anyway, and say or do dumb things. The orexin receptors keep you awake. Interfere with their operation using an orexin antagonist like Belsomra, and the signals to stay awake go away. You drift off. I’ve taken Ambien, and it always felt like a whack to the back of my head. Boom! I’m out. Belsomra has a gentler touch, and from what I’ve read, it doesn’t affect sleep architecture (i.e., the different stages of sleep like REM) nearly as much as more preemptive pills like Ambien.

It’s expensive, but very fortunately, Medicare covers it. And so far, it’s done a pretty fair job keeping me asleep in spite of mask issues. As for mask issues, there’s a third sort of mask that I’m going to buy and try: A nose mask. This is like a smaller full-face mask that only covers your nose. It may not be any better than nasal pillows, but it’s cheap enough to do the experiment and be sure.

I’ve found that there’s a downside to blowing air up your nose. A couple downsides, actually, but there’s one big one, and that’s where I’ll start next time.