S9 autoset--EPR or not to EPR? That is the question

All of the manuals I have for my S9 autoset are woefully brief when it comes to the EPR feature. Through reading other posts, I have figured out that it lowers the pressure for exhalation so that one isn't "pushing" so hard against the airflow. Given that, mine was set at 2 when I got the machine, and I changed it to a 3 because I was struggling with feeling claustrophobic pushing against the air. The 3 setting was almost like magic and I immediately jumped from waking up every 90 minutes tearing the mask off to only waking up once or twice all night. I've really struggled with panic from the beginning, and my calibration sleep study was pretty much a bust because I woke up in a panic every time they tried to increase the pressure--the air blowing against my face freaked me out and I felt like I couldn't breathe. Only managed an hour of measurable sleep all night with no REM sleep at all.

HOWEVER, with all of the reading I've done here, it seems as if many think that using the EPR may not provide the best therapy levels? I've been gradually increasing my lower pressure over the past few nights--it was originally set at 5 and I'm up to 6 now. My top pressure is 15. According to my graphs, all of my AHIs occur AFTER the pressure has ramped up to the range of 10-12 (which is the average pressure each night). I've had some nights with almost no AHIs all night (0.9), but the last three nights my AHIs are going up again and last night was up to 5.9. I have the ramp feature on, although I've been able to turn it down from 20 minutes to 5 minutes. I'm using a Hybrid mask which I really like, having started with a Quattro FF, then a Liberty, and now my Hybrid. I'm the least claustrophobic in the Hybrid, and the leak rate has been essentially at 0 every night, The leak rate line is flat when I have AHIs (it's flat most of the night with just a few very tiny blips).

My questions are:

1. Would lowering the EPR to 2 help prevent AHIs? Anyone experience this?

2. Would continuing to raise my lower pressure but keep my EPR at 3 help?

3. Is EPR a good thing or not?

I'm going to try raising it a little again tonight, but I'm doing it slowly because I tend to want to have a panic attack when I'm aware of too much air coming in all at once (although over the past two weeks that feeling has dissipated some and hopefully that trend will continue). I seem to be OK with the pressure gradually rising while I'm asleep, although I sometimes do startle awake with the pressure up near the max and I often rip off my mask. I'm just a bit worried that I had a couple of great nights and now the trend seems to be reversing with more AHIs.

I would also appreciate any experiences/information regarding EPR that anyone is willing to share.

Thanks so much!

Weezy

DocWeezy wrote:the leak rate has been essentially at 0 every night, The leak rate line is flat when I have AHIs (it's flat most of the night with just a few very tiny blips).

Good. Having leaks well under control is essential before trying pressure tweaks. You're doing fine there.

DocWeezy wrote:My questions are:

1. Would lowering the EPR to 2 help prevent AHIs? Anyone experience this?

Yes, it could.

DocWeezy wrote:2. Would continuing to raise my lower pressure but keep my EPR at 3 help?

Yes, it could.

DocWeezy wrote:3. Is EPR a good thing or not?

Depends on the person. Some might not like it at all, or not do as well with it. When using a ResMed CPAP or Autopap I definitely like having EPR turned on. I don't need it, but less pressure during breathing out feels more like natural breathing to me. I do raise my pressure (or the minimum pressure in an auto's range) however many number of cm's I have EPR set for.

The minimum pressure in an autopap is the most important pressure to set "right", imho -- but, hey, I'm not a doctor or anything in the health care field!

So, if I know that it takes a pressure of, say, 10, to prevent most apneas from happening to me, I want that pressure of 10, or at least nearly that, to be in place allllllll the way through my exhalations, so that my airway is open and I can draw in the next breath easily.

If I have set my autopap to a range of 10 - 20, and I have set EPR at "3" for a 3 cm drop in pressure each time I exhale, I will re-set my autopap to a range of 12 - 20, or 13 - 20.

Remember, the minimum pressure setting is the important one -- that's the pressure that will try to prevent apneas right from the get-go. With a range of 10 - 20 and EPR at "3", each time I exhale the pressure is going to drop down to 7. And that 7 will be sitting there when I try to breathe in again. When I already know it takes a pressure of 10 to keep my airway well and truly open.

So, why would I bother to use EPR if I'm going to have to raise my autopap's minimum pressure considerably? Wouldn't the higher minimum pressure outweigh the comfort of using EPR to drop pressure when exhaling?

For me, it's the relative difference between a higher pressure when inhaling and a lower pressure when exhaling that gives me comfort.

So even though I'd be getting a pressure of 10 when exhaling -- either way -- with minimum pressure set at 10 and EPR off, or with minimum pressure set at 13 and EPR set at "3" (dropping that pressure down to 10 each time I exhale) it's the "drop", not the exact pressure number itself, that gives me comfort when breathing out. By setting my minimum pressure higher, I get to use the comfort of EPR, yet still have enough pressure (in my case, 10 cm H2O ) to be sure my airway is kept nicely open while I exhale.

DocWeezy wrote:I'm going to try raising it a little again tonight, but I'm doing it slowly because I tend to want to have a panic attack when I'm aware of too much air coming in all at once (although over the past two weeks that feeling has dissipated some and hopefully that trend will continue). I seem to be OK with the pressure gradually rising while I'm asleep, although I sometimes do startle awake with the pressure up near the max and I often rip off my mask.

I don't have that problem of panic with air coming in, so I can go straight to whatever setting I want to use. Given what you've described, raising your pressure setting a little sounds like a good idea. You might want to try using your machine some in the day time, while you're awake -- sitting up, or sitting in a recliner, watching TV or whatever -- to get used to it.

The following links might be of interest to you. Bear in mind, though, they were written before ResMed added "EasyBreathe" to their machines. The descriptions of how EPR works still apply.

Jan 2010 - "Cflex 1-3 Levels"
my post(s) describing my understanding of how C-Flex works
and how EPR works differently.
viewtopic.php?p=436054#p436054

Nov 2009 - "EPR"
my post answering a question by Paul56
viewtopic.php?p=310021#p310021

Feb 2009 - "Adjusting my Clinical Pressure Settings"
topic started by jda1000
viewtopic.php?p=342731#p342731

Aug 2008 - "What's the difference"
topic started by Arizona-Willie
viewtopic.php?p=289251#p289251
and
viewtopic.php?p=289264#p289264

April 2008 - "Resmed vs. Respironics - Help"
topic started by Needsdecaf
On page 22 split_city and -SWS discussing apneas
viewtopic.php?p=260224#p260224

Oct 2006
my post replying to jskinner's question
viewtopic.php?p=121621#p121621

Dec 2007
my post replying to khvn's question
viewtopic.php?p=231782#p231782

Feb 2008
discussion of how EPR behaves differently from true "bilevel"
viewtopic.php?p=245729#p245729

wow.....THANK YOU THANK YOU THANK YOU!!!!! This is exactly the information I was looking for.

While I had used my machine during the day to desensitize to the mask in general, I hadn't thought about doing that to play with pressures and desensitize to those....so I did that yesterday afternoon. Ended up raising my lower pressure to 10, my upper to 16, and lowering the EPR to 2.

Had the lowest AHIs ever--4 all night, and pretty evenly spread out instead of clustered. I also think I may have slept a bit better too....the various graphs are much more even with fewer spikes, particularly the flow limitation and snoring index. While there are still lots of spikes, its about half of what it had been.

Granted, this is only one night's data now, but I'm very hopeful this trend will continue and that I'm on the right track!

Thanks again!!!

Weezy

Yes, Rested Gal is one of my favorite cpap teachers!

KatieW wrote:Yes, Rested Gal is one of my favorite cpap teachers!

No, she's one of mine! RG explained the same thing to me but only as it related to Aflex/Cflex. I remember it well!