Frustrated and wondering about EPR

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grumpygirl
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Frustrated and wondering about EPR

Post by grumpygirl » Sun Jan 27, 2008 10:03 am

Hi gang- After giving up my APAP machine and going back to CPAP(per Doc)I decided to change my pressure from 12 to 11 to see if that helps me feel any better. I noticed that my machine was not set with an EPR setting at all. So I want to experiment with having an EPR for a while to see what results I get. SO, with my pressure set at 11 now what should my EPR be? Does it matter?? My data was good last night with the pressure at 11- AHI-1.2, AI-0.0, HI-1.2 , Leak-0.10 but I still feel like crap. So tired and heavy headed feeling like my head is in a marshmallow or cotton ball. Any suggestions??


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Post by DreamStalker » Sun Jan 27, 2008 10:06 am

Suggestion is NOT to make so many changes so soon or so frequently.

You need to collect a week or more of data and calculate averages and then determine what is going on before making any other changes.
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Post by Country4ever » Sun Jan 27, 2008 10:16 am

How long have you been at a pressure of 11?
Dreamstalker, would it really be so bad for her to add an EPR of 1? Isn't that something she probably should have already be using?

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Post by Wulfman » Sun Jan 27, 2008 10:20 am

EPR is essentially a comfort setting in that it allows you to exhale easier against the pressure. In ResMed machines, the drop in pressure corresponds to the number of the EPR setting: 1 = 1 cm., 2 = 2 cm., 3 = 3 cm.
So, you might want to see which setting feels best to you. I'd start with "2".

The morning stats in your LCD screen will reflect the pressure drop as a lower pressure.
As to whether it will affect your therapy?......probably not, but that's something you'll need to determine for yourself.


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Post by DreamStalker » Sun Jan 27, 2008 10:28 am

I'm not up on why the doc trialed her w/ APAP then took it back away. What was the previous pressure setting, what was the pressure setting for APAP, and how did that work out?

I have noticed that when using exhalation pressure relief, I need to increase my pressure setting to make up for the decreased pressure produced by the exhalation relief. Lowering pressure from 12 to 11 and then adding EPR reduces the overall pressure and may not prevent events. However, your AHI of 1.2 is actually pretty good ... thus the PAP therapy is doing its job. I think there may be other things going on.

If you still are not sleeping well, you need to search for other contributing causes. If your doc is unwilling or unable to help you search, then you need a new doc.

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Post by rested gal » Sun Jan 27, 2008 10:30 am

grumpygirl wrote:My data was good last night with the pressure at 11- AHI-1.2, AI-0.0, HI-1.2 , Leak-0.10 but I still feel like crap. So tired and heavy headed feeling like my head is in a marshmallow or cotton ball. Any suggestions??
It's always possible that even when cpap/autopap/bipap/whateverPAP is doing its job fine, there can still be other sleep problems - PLMD, for example, or repeated arousals that have nothing to do with respiration. Or there can be other health problems totally unrelated to "sleep" that can make a person feel awful.

I'd be looking into other health issues. Thyroid, GERD for starters. And into sleep hygiene issues, including is the mattress comfortable to sleep on all night long? Many people are probably tossing and turning on old saggy mattresses that need replacing. We spend one/third of our lives sleeping, or trying to sleep. The sleep environment needs to be as conducive to sleep as possible. The mattress is sure a big part of that environment.

There's also the possibility that years of untreated sleep apnea and repeated hypoxia have done irreversible damage to areas of the brain dealing with sleep/wake, but that's not pleasant to contemplate. I'd look into other issues first.
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Post by Country4ever » Sun Jan 27, 2008 10:34 am

Thanks for that info Dreamstalker. I didn't know that about the overall pressure being reduced.
I think some of us don't feel tons better with the XPAP treatment, and its so hard to determine what exactly is causing that.....be it the XPAP treatment needing tweaked or something else.
I do think we have to use it for at least a month or 2, with good numbers, to know if its going to make us feel better. Maybe even longer?
Like I said....you just don't know how much damage has been done by the years of hypoxia.
But its very hard to accept fatigue.

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Post by Goofproof » Sun Jan 27, 2008 1:28 pm

One of the main Resmed problems, if the mask settings isn't set correctly the leak rate shown will be wrong. I would expect most machines are set up wrong. Most users don't seem to know what machine and mask they use, long enough that to give the correct data the machine has to be set for the mask.

Thank goodness for Remstar, at least they took that chance out of the mix.

Use data to optimize your xPAP treatment!

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Post by Treesap » Sun Jan 27, 2008 3:11 pm

I am assuming that an EPR of 3 will give you the most exhalation, and what you need depends on how well you feel you can breath.

Am I right? I tried CPAP mode one night, setting my pressure to 10 and EPR at 3. I fell asleep during the ramp (set at pressure 7), and promptly woke up when it went in to CPAP mode because of the huge pressure change. I've been running on APAP the whole time until that night. I don't think I gave myself the right EPR setting. I wasn't willing to try it again because the change made me keep coughing.

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Post by Country4ever » Sun Jan 27, 2008 4:51 pm

Treesap.....why do you say you think you set the EPR wrong? I'm just trying to familiarize myself with CPAP (rather than APAP). Do you think that the lower exhalation pressure was too low, and then made the inhalation pressure seem to high?


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Post by billbolton » Mon Jan 28, 2008 1:04 am

DreamStalker wrote:Lowering pressure from 12 to 11 and then adding EPR reduces the overall pressure and may not prevent events.
Enabling EPR lowers the various reported pressures aggregated over the whole night, but it does not lower the actual pressure applied at each inhalation!

The airway splinting effect at inhalation is not changed and the occurence of events at that pressure setting does not change..... that is, it's just as effective/ineffective as it would have been without EPR enabled.

Cheers,

Bill

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Post by DreamStalker » Mon Jan 28, 2008 9:07 am

billbolton wrote:
DreamStalker wrote:Lowering pressure from 12 to 11 and then adding EPR reduces the overall pressure and may not prevent events.
Enabling EPR lowers the various reported pressures aggregated over the whole night, but it does not lower the actual pressure applied at each inhalation!

The airway splinting effect at inhalation is not changed and the occurence of events at that pressure setting does not change..... .that is, it's just as effective/ineffective as it would have been without EPR enabled.

Cheers,

Bill
That is true Bill. Exhalation relief maintains the set inhalation pressure and only reduces the exhalation pressure causing a net overall reduction of aggregated pressure for the night.

Prefacing with the fact that everyone is different … I noticed that my AHI went up when using exhalation relief and in order to get it back to my normal low I had to increase my pressure settings. Thus for me, the effectiveness was less using exhalation relief than when not using it unless I compensated with increased pressure. Of course the definition of effectiveness may be debatable.

My AHI using APAP (11 - 13 cm) with no exhalation relief has been under 1.0 and averaged between 0.3 and 0.4 consistently for the past 10 to 11 months. Right before the x-mas holidays I began trialing exhalation relief (C-FLEX) and my AHI went up to 2.0 or 3.0 … perhaps by the standard definition that anything under 5.0 is “effective”, the occurrence of my events did not change. However, in order for me to get my AHI back down below 1.0, I had to raise both my min and max pressure up to 12 - 14 cm. Sure, C-FLEX is not the same as EPR but I was talking about exhalation relief. At the end of this week, I will have a whole month of C-FLEX data and ready to trial A-FLEX (perhaps more like ResMed’s EPR).

In addition, I noticed during this trial period (which led me to raise my pressure settings), that when I begin to fall asleep, if lying on my back, that my airway would close up in the moment between the end of my exhalation and the beginning of inhalation. It would like snap shut and arouse me to full awake as I was just about to doze off. I had never noticed this before because I had trained myself to fall asleep on my side and came across this experience only by accident.

split-city mentioned this in one of his past threads … as I recall giving him a hard time about it. He had said that an event most always occurs between inhalation and exhalation and I argued that there were two points in the breathing cycle that met the definition of his statement. I now think I understand that he meant “the end of exhalation and the beginning of inhalation”. It explains why I had to raise my pressure to account for the use of exhalation relief. Like I said, for others it may or may not be an issue but it is/was for me. I resolved it by increasing pressure when using exhalation relief and all is good again for me.

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Post by Slinky » Mon Jan 28, 2008 4:51 pm

Reducing the EPR/C-Flex relief from 3 to 2 or even 1 might well have accomplished the same thing as your raising your pressure range to 12-15 from 11 to 14, DreamStalker. (Did I remember those two pressure ranges correctly??)

Of course, EPR isn't available in auto mode on the Resmeds and C-Flex relief of 3 isn't necessarily 3 cms of exhalation pressure relief as Resmed's EPR of 3. But for the sake of explanation lets assume C-Flex of 3 = 3 cms of exhalation pressure relief.

At an auto pressure range of 11 to 14 w/C-Flex of 3 you would be getting an exhalation pressure of 8 and inhalation pressure of 14. With a C-Flex setting of 2 you would be getting exhalation pressure of 9 and C-Flex of 1 exhalation pressure of 10 but the inhalation pressure would always remain 14. The transition from 10 to 14 would be smoother than a transition from 8 to 14.


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Post by DreamStalker » Mon Jan 28, 2008 8:21 pm

Slinky wrote:Reducing the EPR/C-Flex relief from 3 to 2 or even 1 might well have accomplished the same thing as your raising your pressure range to 12-15 from 11 to 14, DreamStalker. (Did I remember those two pressure ranges correctly??)
Yep ... and turning the exhalation relief off would too
Slinky wrote:Of course, EPR isn't available in auto mode on the Resmeds and C-Flex relief of 3 isn't necessarily 3 cms of exhalation pressure relief as Resmed's EPR of 3. But for the sake of explanation lets assume C-Flex of 3 = 3 cms of exhalation pressure relief.

At an auto pressure range of 11 to 14 w/C-Flex of 3 you would be getting an exhalation pressure of 8 and inhalation pressure of 14. With a C-Flex setting of 2 you would be getting exhalation pressure of 9 and C-Flex of 1 exhalation pressure of 10 but the inhalation pressure would always remain 14. The transition from 10 to 14 would be smoother than a transition from 8 to 14.
But that would defeat the purpose for my specific trialing of exhalation relief. You see, I had been following Dr. Krakow’s discussion threads on BiPAP use for smoothing out the wave form. Exhalation relief is like a very limited BiPAP with a max separation of about 3 cm pressure (and I don't have a BiPAP). I wanted to run an experiment to see how I would respond to max exhalation relief. The experiment is ongoing and continues. February will be APAP w/ A-FLEX of 3, and March will be straight CPAP w/ C-FLEX of 3 and April will be Straight CPAP no exhalation relief. As I said, my first discovery is that I need additional pressure when using exhalation relief and the other is that my events do indeed occur at the moment between the end of exhalation and the start of inhalation.

Basically I'm trying to see how I respond to the various options I have with my APAP ... I'm just wierd that way, sorry



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Post by Slinky » Tue Jan 29, 2008 7:38 am

Hey, curiosity killed the cat! Whatever floats your boat. I sure do understand curiosity and just "having" to experiment sometimes. But since C-Flex isn't necessarily 1 cm per setting and we don't know just exactly how much pressure relief C-Flex gives ... keep in mind that RAISING the set pressure doesn't HAVE to be in increments of 1 full cm. For instance, the Resmeds pressure can be increased in increments of .2 cms. I've forgotten whether Respironics works in that fashion as well or not.


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