My Sleep Apnea: CPAP

In previous entries, I've talked about my initial adventure with sleep apnea and my subsequent sleep study. The gist of those entries is that I was diagnosed with "severe" obstructive sleep apnea, with an AHI (Apnea-Hypopnea Index) of 48. This number means I had an average of 48 sleep interruption "events" per hour -- these events range from blood-oxygen desaturation to a complete closure of the airway. There are lots of people out there with worse cases than mine (including readers of this blog!), so I took some comfort that my case seemed pretty typical -- there was every indication that I could be treated.

In my daily life, particularly in the last few years, I've been a very sleepy person. I've generally existed in a sort of brain fog, muddling my way through each day until I could collapse for a longish night's sleep (10+ hours) that, sadly, didn't seem to refresh me. Of course, now I realize that during all that sleep, I was having these constant breathing interruptions, which caused my blood pressure to increase, and severely impaired my ability to experience the restorative effects of sleep. It's strange to think that sleeping doesn't lead to restfulness, but it certainly explained why I just seemed to feel worse as the months dragged on. After going through a sleep study, my doctor reviewed the results, told me about my AHI and various other fascinating acronyms, and finally prescribed a CPAP machine -- a device that blows air up my nose, effectively stenting open my airway with air pressure. The idea is to prevent the airway from closing, and thus get that AHI number down -- so the patient has uninterrupted sleep.

Getting the CPAP machine was an adventure. My prescription was sent to a medical device sales company in my area. That company called me one night and set up an appointment for me to come over (they're "down by the airport") and get fitted for my new sleep gear. My appointment was set for 5pm on a Thursday, and I'd be part of a "class" of people all getting their machines at the same time.

REMstar Auto M SeriesI was the youngest person in my class by about twenty-five years (I'm 30; the oldest person there was pushing 80). Everyone was given a CPAP machine, though they differed quite a bit based on prescription. Mine was a REMstar® Auto M Series, with a heated humidifier attachment. (Pretty sweet, huh?) Without going into all the specifics, the CPAP machine is programmed with various information from my prescription (specific air pressure ranges), and it does some amazing things -- for example, it is able to detect apnea/hypopnea events and records them internally. It also records the specific air pressure used at all times, and builds an internal log of the entire therapy process. This information goes on a smart card which is later sent back to the medical services company, who work with doctors to analyze it, graph it on a computer, and make sure everything's copacetic. In addition to the machine itself, I was given (okay, sold) a six-foot length of air tubing (about 1" in diameter) and a mask that attached to my nose to actually deliver the air into my respiratory system.

ResMed Swift LTThe mask is a whole story of its own. While the CPAP machine's usage is pretty straightforward for the patient -- you press one button and it starts blowing -- there's all kinds of stuff you can do with different mask styles. Masks need to be fitted, adjusted, and regularly cleaned, and there are many opinions about which masks are best for various situations (though the global advice is just to get something that "works for you"). My doctor had recommended a "nasal pillow" mask for me based on my dislike of the over-the-nose cup used in my sleep study. I didn't like the cup because the straps to keep it on were super tight, the cup irritated the bridge of my nose, and it leaked a lot of air, blowing continuous blasts of air into my eyes all night. In contrast, the nasal pillows are sort of like little nose plugs -- they stick directly into your nostrils, and deliver air through a big hole in the middle of the "pillows." The amount of headgear touching skin with this mask is far less than with a cup style mask, and I liked that idea. I ended up with a ResMed™ Swift LT mask (better pictures here). It's much less invasive than the nose cup, but my doctor had warned me that nasal pillows freaked some people out -- the issue being that using this mask involves closing your mouth, sticking something very like nose plugs up your nose, and then trying to go to sleep. Your brain isn't used to this situation (mouth and nose both covered), and rebels, thinking that you're being suffocated despite the tons of air pumping through the system. Also, the nasal pillows concentrate the air flow into nostril-sized holes, so the pressure feels higher than when using a nose cup or other large-area mask. It took a conscious effort for me to relax past the suffocation panic and let the system work, but I liked the idea of the nasal pillows since I'm a side-sleeper, and I felt that less headgear was better.

So I had the gear: CPAP machine, air hose, and mask. The class instructor told us various stuff about how to use it, particularly recommending the "ramp" feature on the machine, which starts off blowing air at a low pressure, then ramps up to full pressure over the course of a half hour. My machine happens to have a "flex" function which automatically decreases the air pressure when I exhale, which increases comfort. The instructor also recommended that we disassemble everything -- mask, hoses, humidifier attchment, air filter -- and clean it every day. This isn't a ton of work, but it's far more infrastructure than most people are used to just to go to sleep and wake up in the morning. But I dutifully listened, and even bought a gallon of distilled water for the humidifier on my trip home. (You have to use the distilled stuff, or minerals build up in the machine. Given the expense of the machine, I listened.)

I set up all the equipment, put on the mask, and started the flow. Within thirty seconds I ripped off the mask and was gasping for breath. My brain was screaming -- suffocation! -- and somehow it seemed much worse at home lying in bed than in the class. I chilled out for a while and tried again, but still the sensation was too intense. I switched to the nose cup mask I had disliked in my sleep study (they gave it to me to hang onto), and that was a lot easier to handle. So on my first night, I slept with the nose cup (plus an Ambien) and it was...tolerable. Except for the rain-out.

Rain-out is a phenomenon where water condenses inside the mask and air tubing, because the air in there is warmer and moister than the air in the room. This was certainly true in my room, which was probably at 60 degrees F, and I was using a heated humidifier on the CPAP machine. The result was water condensing in the mask and literally raining on my nose (and sometimes up my nose). No fun. There are many potential solutions to this problem, but so far what I've done is simply warm up the room and reduce the heat on the humidifier -- there's still a little condensation, but not enough to bother me. Aside from the rain-out, the other problem is just getting used to having something strapped to your head all night. This is genuinely weird, and takes some getting used to. A final issue is the restricted range of motion you have when you're attached to a mask and air hose -- rolling over in bed requires a little planning, and I had to reconfigure my pillow setup. (But frankly, as a geek, this was kind of fun.)

In subsequent nights, I switched back to the nasal pillow mask. Although it was hard to get past the suffocation reflex, I just kinda powered through it. Now that problem is mostly gone, and I'm able to get past the freakout sensation with a minute or two of calm breathing. I like the nasal pillow mask far better than the nose cup -- it's more comfortable, it's smaller, and overall it just feels like a better fit. So I'm happy. I must say that getting used to CPAP is genuinely challenging -- I can see why some people give up. There's a lot of gear and maintenance involved, and you have to change your sleep routine permanently. But in my case, the daytime sleepiness had just gotten too bad -- there was no way I was not going to use CPAP. I needed a change, and CPAP was going to give it to me, if I put in the work.

So what's my progress? In my first two weeks on CPAP, my AHI has gone from 48 to 0.7. So I'm still having the occasional sleep-interrupting event, but vastly fewer than before. I'm also routinely sleeping through the night, whereas before I would wake up repeatedly (up to ten times a night), and often got up to visit the bathroom. This is just gone -- my body no longer seems to feel the need to dump liquids at night. I no longer wake up thirsty; there's no real need anymore for a glass of water by the bed, which is a big change. My blood pressure has gone down. I'm losing weight. I'm also dreaming much more, and the dreams are intense and memorable. I'm still sleeping 10+ hours a night, which seems like a lot, but maybe I'm paying down a sleep debt? I'll have to ask my sleep doctor. The best part is I'm more wakeful during the day. The wakefulness isn't perfect -- there's no miracle here -- but it's clearly a lot better than before, and the fog is clearing. I'll see my doctor next week, and we'll review the machine setup and the data, to see how things are going.

So my overall experience with my sleep apnea diagnosis has been positive. It's frankly a lot of work to go to a sleep doctor, fill out forms, go get a sleep study, figure out how to sleep during it, go back for more review and testing, get the machine and mask, set it all up, maintain it, and use it -- but the upside is enormous. And the potential downside (leaving it untreated and never being properly rested) is horrible. So I'm sticking with it. For those who haven't yet been diagnosed, I encourage you to be persistent -- you have to be your own advocate within the medical system. But there are many people who have gone before, and have shared their experiences online.

Please share your experiences in the comments. I've already heard from many readers with sleep apnea, and I've been very encouraged by your stories! Thank you. Also, I found the forums at encouraging and enlightening -- many of those folks have Gone Pro with their sleep apnea, buying special software and hardware to monitor their CPAP data. It's inspiring -- and this CPAP machine gives me a new thing to geek out on! The community over there has answers for pretty much any question, and it's a great resource.

Live Smarter
A Simple Trick for Keeping Lemons Fresher for Longer

Lemons don't get much respect in the average refrigerator. After taking a slice or two to punch up drinks or add to a recipe, the remaining wedges can often be pushed out of view by incoming groceries and left to go to waste.

But the folks at Food52 have come up with a solution to get more use out of those lemons by keeping them fresher longer. Because citrus needs moisture in order to remain fresh, all you need to do is place your lemon in a bowl of water before putting it in the fridge.

Another idea: Put them in a sealed plastic bag and make sure you remove all the air to prevent mold growth. You'll get up to three months of freshness with this method. If your lemons are already cut into wedges, you can expect they'll last three to four days.

The "hack" also works for oranges and grapefruits. As for freezing, you can do that, too, but the resulting mushy fruit is probably best left for making juices.

[h/t Food52]

The Body
13 Facts About Skin

Skin isn't just the outermost layer of our bodies. Without it, we couldn't do most of the things we take for granted, like breathing, moving, and keeping the body's inner workings where they belong. And while skin also evolved to keep pathogens and other bad stuff out of our bodies, consumers spend millions of dollars on products to penetrate that defense (with mixed results). Read on for more fascinating facts about the skin.


Skin is considered an organ in its own right. It's comprised of three layers: the waterproof top layer, the epidermis; a middle layer of tougher connective tissue, hair follicles, and glands called the dermis; and the inner layer, the hypodermis, which is mostly fat and connective tissue that supports the skin's structure and attaches it to muscles.


Those cells are known as melanocytes, which secrete a pigmented substance called melanin; the more melanin in the cells, the darker the skin. Having too little or too much melanin can lead to some skin color disorders: On one end of the spectrum are conditions like vitiligo—which occurs when some melanocytes lose the ability to produce melanin, resulting in whitish patches on the skin—and albinism, a condition in which melanocytes don't produce any melanin. On the other end is hyperpigmentation—the presence of excess melanin, which can cause darker patches of skin.


"Your skin accounts for 15 percent of your body weight," says Toral Patel, M.D., a board-certified dermatologist and supervising physician at D&A Dermatology in Chicago and a clinical instructor of medicine at Northwestern University. This makes it your body's largest organ.

According to that calculation and data from the Centers for Disease Control and Prevention, an average American woman weighs 168.5 pounds and carries more than 25 pounds of skin. An average man weighing 195.7 pounds will have nearly 30 pounds of skin.


New cells are created in that deep layer of the skin and take about four weeks to rise to the surface. There, they grow hard and then shed. This process, in which old skin is sloughed off and replaced by newer skin, might occur more than 1000 times over the average American's lifespan. But all skin is not created equal: Its thickness varies naturally among all areas of the body. Thickness can also be affected by age, gender, and habits (like smoking) that can change the cells' elasticity and other traits. According to Patel, the skin on the soles of your feet is up to seven times thicker than the skin of your eyelids.


If your skin cells shed every month, how do tattoos stick around? It turns out to be a function of your immune system. The puncture of the tattoo needle causes inflammation in the dermis, the skin's middle layer. In response, white blood cells known as macrophages are sent in to help heal the damage. These macrophages "eat" the dye and can pass it to newer macrophages when they die off, so the pigment is essentially transferred from one cell to another. Any leftover pigment is soaked up by fibroblasts, which are longer-lasting skin cells that don't regenerate as often. Only lasers designed for tattoo removal are strong enough to kill off the macrophages and fibroblasts that hold the dye.


Your skin hosts a microbiome that can contain more than 1000 types of bacteria (along with other microbes, viruses, and pathogens). These "tiny ecosystems," as Patel describes them, are mostly friendly bacteria that work in concert with our bodies for many beneficial purposes, including wound healing, reducing skin inflammation, and assisting the immune system to help fight infection. These bacteria were once thought to outnumber your own cells 10 to one, but more recent research has found the ratio is closer to 1:1.


Injuring or breaking the skin's dermis, the layer below the epidermis, can expose the inner tissues to pathogens. To prevent infections from reaching any further into the skin, body fat, or muscle, ancient Egyptians cared for topical wounds with salt (yes, really!), fresh meat, moldy bread, and onions.

While these may seem like unsanitary things to put on a cut, modern research has found that there was actually merit in their methods. With its high iron content, meat was a good blood coagulant and recommended for the first day of a wound, according to a 2016 paper in the Journal of the German Society of Dermatology. Salt and onions are both astringent, which can stop blood flow. Moldy bread likely had antibacterial properties—a very early form of penicillin, you might say. Skin wounds would then be sealed with a combination of oils, fats, honey, and plant fibers.


Your skin is a significant shield against billions of tiny microbes and pathogens. But just as importantly, skin keeps fluids in. Another way to think of this, Patel says, is that your skin resembles a brick and mortar pattern. The bricks are the cells. The mortar is made up of lipids, fatty acids, and other sticky proteins that form the watertight layer. "If you have any ‘holes' in skin where moisture can escape, which are more susceptible to damage, that leads to dryness, cracking, and inflammation," Patel says.

People who have suffered burns often have fluid-balance problems, says Robert T. Brodell, M.D., professor of dermatology at University of Mississippi Medical Center in Jackson, Mississippi. "Fluids are seeping out, and they can't keep them balanced internally," he tells Mental Floss. This can be incredibly dangerous, because fluid loss can cause the heart to stop pumping blood to the rest of the body. Dehydration, hypertension, and other problems may also occur when skin is injured.


Psoriasis is an autoimmune condition in which the skin cells in an affected area grow rapidly, leading to excess skin buildup, inflammation, and a red and scaly rash. While it can be uncomfortable to live with the condition on its own, studies [PDF] have shown that inflammation of the skin can lead to inflammation of other tissues and internal organs, and eventually certain diseases. For example, psoriasis has been linked to a greater risk for heart disease, as well as diabetes, Crohn's disease, metabolic syndrome, and other conditions thought to be correlated with inflammation.

Patel says that association makes treatment even more important: "If one organ is inflamed, you have to make sure another isn't."


Unless you live in the tropics, you've probably noticed that the skin of your lower legs becomes drier in winter—and there's a biological reason for that. "You have fewer oil glands on your legs than any other area of your body," Brodell tells Mental Floss. Oil (or sebaceous) glands, found near the dermis's border with the epidermis, secrete an oily substance called sebum that lubricates skin and hair. As people age, the glands secrete less oil, and that means drier skin. Winter's low humidity and our tendency to spend more time around heat sources dries out skin even more.

The solution is to install a humidifier or apply some moisturizer. Certain skincare products, such as those with emulsifiers like sodium laureth sulfate, can also dry out or irritate your skin, so read your labels carefully.


Both types of sweat glands are also located in the dermis. Eccrine glands, found all over the body, emit sweat directly through pores in the epidermis. Apocrine glands release sweat along hair follicles, so it's no surprise that these glands are concentrated in the hairiest parts of the body—head, armpit, and groin. Both types help regulate body temperature: In hot conditions, the glands release water and fatty liquids to cool the skin.

A lack of sweat glands puts people in danger of overheating. Those with a condition known as anhidrotic ectodermal dysplasia have few to no sweat glands, so they can't properly cool off when the body overheats. "They get heatstroke easily," Brodell says. A subset of people with this disorder suffer from immunodeficiency. They produce low levels of antibodies and infection-fighting immune T- and B-cells, so they are more prone to skin and lung infections.


The gut and the skin never come into direct contact with one another, yet research shows that the gut has a profound impact on the skin.

"The skin becomes very unhealthy when the microbiome of the gut goes into a state of dysbiosis," meaning when something attacks the gut's good bacteria, says Gregory Maguire, Ph.D., a former professor of neuroscience at UC San Diego and the founder and chief scientific officer of BioRegenerative Sciences, a stem-cell technology company.

Dysbiosis can lead to inflammation, irritation, rashes, and pain. "There's good evidence that eczema [or] atopic dermatitis is partially due to dysbiosis of the gut and skin," he says.

In a 2017 paper published in the Archives of Dermatological Research, Maguire writes that normal gut bacteria can actually calm the body's response to stress. A reduction in the release of the stress hormone cortisol, which is thought to cause breakouts, also reduces the chance of skin irritation—all thanks to microbes in your intestine.


When the skin's pores get clogged with sebum from the sebaceous glands and dead cells, a condition usually associated with hormonal changes, you've got acne. Clogged pores that stay closed are called whiteheads; if the pore opens and reveals the gunk inside, it's a blackhead. (The medical term for a blackhead, an "open comedo," stems from a Latin phrase alluding to "worms which devour the body." But don't worry, blackheads are not actual worms living in your face.)

While acne may seem like a rite of passage associated with puberty, researchers are experimenting with fighting "bad" bacteria (in this case, Propiobacterium acnes, which is linked to acne breakouts) with "good" bacteria, also known as probiotics. "One of the things [probiotics] do is ferment things on the skin like ammonia and nitrites, and metabolize it and turn it into other chemicals that are beneficial to the stem cells in your skin," Maguire explains. A 2015 study in the Journal of Women's Dermatology and other research has found that applying topical probiotics like Streptococcus salivarius and Streptococcus thermophiles inhibits P. acnes and may make skin more resilient against it in the long run.


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