Resmed auto:can you use EPR ??

LoQ wrote:

ozij wrote:If you need 19, hasn't a bi-level machine been considered?

Right now the DME is saying the doctor will let me have a machine with EPR, but only if I can't tolerate straight CPAP of 19. I would like to know more about my problem before getting a new machine, though that may not be practical. I do not know why they are not considering a bilevel. It may be one of those insurance things where you have to fail first on all of the less expensive machines. <eye roll>

If your hypopneas and desats are pretty much happening ONLY during REM, then consider getting a second opinion about whether those hypopneas might be periods of hypoventilation instead.

Becker, Piper, Flynn, et al wrote: Hypoventilation was most pronounced during REM sleep, irrespective of the underlying disease. These data indicate that hypoventilation may be the major factor leading to hypoxia during sleep, and that reversal of hypoventilation during sleep should be a major therapeutic strategy for these patients.

http://171.66.122.149/cgi/content/abstract/159/1/112

As a side note, hypoventilation is often best treated with BiLevel modality. If you are hypoventilating during REM, then you have double-incentive for a BiLevel trial IMO. Hypoventilation treatment with BiLevel often requires a gap between exhale and inhale pressures greater than EPR's designed gap of 3cm, though. Additionally, Resmed's EPR operation is designed to suspend amidst certain types of breathing irregularity/obstruction.

Good luck, LoQ!

Thanks for the information, -SWS.

-SWS wrote:http://171.66.122.149/cgi/content/abstract/159/1/112
As a side note, hypoventilation is often best treated with BiLevel modality. If you are hypoventilating during REM, then you have double-incentive for a BiLevel trial IMO. Hypoventilation treatment with BiLevel often requires a gap between exhale and inhale pressures greater than EPR's designed gap of 3cm, though. Additionally, Resmed's EPR operation is designed to suspend amidst certain types of breathing irregularity/obstruction.

I can ask. My guess is that the answer will be "you need to lose weight" (isn't it always?) instead of "yes, a bilevel machine makes sense." In addition to being overweight, I have some form of obstructive lung disease, probably asthma.

When I was young and skinny and asked for help with my fatigue, it was dismissed as insignificant and idiopathic. Now that I've spent decades without treatment, it's now my fault because I've gained some weight. There is no winning, sometimes.

Is there one bilevel machine that you think would do a better job for hypoventilation than the others?

-SWS wrote:Good luck, LoQ!

Thanks very much. Maybe I'll punt and go back to self-treatment. It's just easier if a doctor is involved and doing a good job.

LoQ wrote: It's just easier if a doctor is involved and doing a good job.

Well, that's my preferred route as well. My doctor is receptive when I float ideas his way. If I were desaturating only in REM with hypopneas, I would probably ask him about arranging a review/rescoring of my PSG toward determining if I were having short, repeated episodes of hypoventilation. There are a few possible etiologies, btw. Anyway, the pressure gap between BiLevel's EPAP and IPAP help hypoventilatory patients achieve required volumes.

If you haven't already, you might want to consider wearing your oximeter for several hours during the day----on the off chance there's an intermittent pulmonary problem---not specific to sleep---causing those desats.

If they're taking suggestions about which machine to try next, I think I would want to try the VPAP Auto 25 machine if possible. You can configure it as ordinary CPAP, ordinary APAP, or an ordinary spontaneous BiLevel machine: https://www.cpap.com/cpap-machine/resme ... chine.html

-SWS wrote:If you haven't already, you might want to consider wearing your oximeter for several hours during the day

Actually, I've done that, but I don't really trust my oximeter. It seems to be accurately telling me when my oxygen is going up and down, but not the amplitude, if that makes sense.

-SWS wrote:on the off chance there's an intermittent pulmonary problem---not specific to sleep---causing those desats.

Even on my defective oximeter, when I wore it once while cutting the grass, it dropped to 91% (the oximeter never measures less than 90%) and pretty much stayed there through the entire effort. I don't doubt that I have pulmonary problems not related to sleep, but the fact remains that in the lab, I have worse desats during REM than otherwise, and I don't think my pulmonary disease really accounts for all of that, though I suspect it is a part of the problem. Even when I'm awake, I'm a pretty shallow breather when just sitting around. And even if I have some air hunger, I don't seem to be driven to breathe more frequently, just occasionally more deeply, which sometimes works and sometimes does not work.


Does a bilevel machine help with aerophagia? I ran at 14 cm night before last and 14.6 cm last night. Both times I had a fair amount of aerophagia, though nothing like what I had at 19 cm. (I woke up in pain, removed my mask, and had fairly explosive belching. It was downright violent.) When I'm trying to go to sleep, I sometimes notice the aerophagia happening. It seems to be happening not when I exhale or inhale, but when I'm doing neither, just lying there waiting to take the next breath.

Pepcid 20 mg. once is a low dose.

Change to Prilosec twice a day for one week, then once daily. OTHER HINTS: Frequent small high protein meals. No alcohol, caffeine, cigareetes, carbonated beverages, nor chewing gum. Don't eat with three hours of bedtime. Eliminate stress. Sleep on your left side, not your back nor right side. No talking while eating. Chew food slowly.

LoQ wrote: Does a bilevel machine help with aerophagia? I ran at 14 cm night before last and 14.6 cm last night. Both times I had a fair amount of aerophagia, though nothing like what I had at 19 cm. (I woke up in pain, removed my mask, and had fairly explosive belching. It was downright violent.) When I'm trying to go to sleep, I sometimes notice the aerophagia happening. It seems to be happening not when I exhale or inhale, but when I'm doing neither, just lying there waiting to take the next breath.

BiLevel sometimes helps with aerophagia. Based on what you mentioned above, I'm not sure an inhale pressure of 19 cm and an exhale pressure of say 14 cm would help, however.

I think I'm more inclined to experience CPAP-related aerophagia (gastric insufflation) when my silent acid reflux is exacerbated by certain foods that I shouldn't eat. I suspect the aggravated aerophagia in my case has to do with compromised LES closure amidst my acid reflux flareups. So I think physician's advice just above sounds like a very good set of tips.

OK. Thanks to both you -SWS and Physician for your advice.

-SWS wrote:If you are hypoventilating during REM, then you have double-incentive for a BiLevel trial IMO. Hypoventilation treatment with BiLevel often requires a gap between exhale and inhale pressures greater than EPR's designed gap of 3cm, though.

I finally got a copy of the report from my sleep study. Bi-level was in fact tried during REM, but it wasn't as effective as CPAP=19 at relieving the oxygen desaturations, and it apparently caused me to start throwing central apneas. I do not understand how bi-level (18/10) causes central apneas but CPAP (19 cm) does not, but there you have it.

So I guess it doesn't matter what the cause of my desaturations are, it looks like bi-level can't fix them. The choices at this point are CPAP at 19, which I have yet to achieve, or the addition of oxygen.

LoQ wrote: I finally got a copy of the report from my sleep study. Bi-level was in fact tried during REM, but it wasn't as effective as CPAP=19 at relieving the oxygen desaturations, and it apparently caused me to start throwing central apneas.

I do not understand how bi-level (18/10) causes central apneas but CPAP (19 cm) does not, but there you have it.

That's known to happen for some patients:
Bilevel Positive Airway Pressure Worsens Central Apneas During Sleep

LoQ wrote:So I guess it doesn't matter what the cause of my desaturations are, it looks like bi-level can't fix them.

I think that's probably true... But there's also the off-chance your BiLevel titration was not performed properly. That happens sometimes. And when BiLevel is set up wrong, it can cause central apneas.

LoQ wrote: The choices at this point are CPAP at 19, which I have yet to achieve, or the addition of oxygen.

Good luck!

Thank you for the link, -SWS.

The bilevel may have been titrated wrong, but I'm not sure how that could be resolved inexpensively. The tech who did my study is the one who manages the sleep lab and trains the other techs. Seems unlikely I would get a different result with a different tech at that lab, but hey, life is not perfect.


As you undoubtedly saw, I went with oxygen. What I really need is an accurate oximeter to monitor my therapy and see if things are going well. I don't trust any of the home models now.


I want to ask the PA at my next appointment whether there is any benefit in raising my CPAP pressure from the old number up as high as I can stand it, keeping the oxygen. The current prescription is either 19 cm without oxygen or 10 cm with oxygen. Wouldn't 13 cm with oxygen be better than 10 cm with oxygen, if I can stand it at 13? My guess is that the flow limitations and hypopneas I have during REM are causing the REM desats. In the absence of central apneas, does it hurt to raise the pressure? Of course, there is no way to know whether I am having central hypopneas, I guess.