EPR - good or bad?

[PaulaO2]

There's been some discussion lately about whether EPR (ResMed's exhale relief) is good or bad for the user. Exhale relief, in ResMed's case, is it detects the beginning of the exhale, drops the pressure whatever is set, then when it detects the exhale is ending, it raises the pressure back. Phillips Respironics x-FLEX works similarly but I *think* it detects inhale, increases, then decreases when it senses the inhale is ending. Yes, there is a difference. No, I am not going to explain it 'cause I don't fully understand it myself.

Anyway, I decided to try it out and see what my data would be like with and without the EPR on.

My "experiment" was for 9 days with EPR off and I took the previous 9 days with the EPR set at 2 (which means it drops 2 cmH20 at exhale). My Autoset is set to a range of 12 - 17. I used the data from ResScan as SleepyHead is hiccuping. I do not use the ramp feature but the EPR is set to "Full Time".

A note about the data: the last column is the hours used per night. The spreadsheet kept wanting to transfer the 9:33 into 9:33 AM and I had to use a decimal. So 9.33 does not mean 9 and .33 hrs but 9 hrs and 33 minutes. Yes, I sleep that long when I do sleep.

   

This is a screenshot of the spreadsheet. At first glance, I don't notice all that much of a difference. My AHI is all over the place as it has been since starting a new medication a while back. It used to be well below 2 and most days was below 1. But looking at the data, I can tell that while the AHI is still erratic, the pressure I require has slowly dropped. I had been considering raising my pressure to 20 to see how much higher I was requiring but I don't think I need to do that now.

Other than AHI, the second criteria for determining if the treatment is adequate is how I feel. I don't think I feel much different in terms of tiredness. I do, however, have three things that are happening. One is an increasing issue with my ears (something I have noted before). The second is I have been waking with headaches that last all day. I am prone to headaches but the morning ones had been almost eliminated. Me waking with one nearly every morning is something new. The third is I am having some weird weird dreams. Before starting CPAP, I could manipulate my dreams with ease. After starting it, that fun ended. I experienced some vivid dreams for a few weeks until they subsided. But the past four nights, I have had some vivid, weird, odd, freaky (insert other similar terms) dreams. I have been woken up twice because I was talking/mumbling/groaning in my sleep, something I never do.

In conclusion, from what I can see, I don't think having the EPR is "helping" me enough to continue with it off. The ear issue may settle down with time as it has before. The headaches may be related to something else but it is an odd coincidence. 9 days is not really long enough a time span to detect a trend. I am presenting the data now, however, because I am considering ending it if the headaches continue. I am doing all I can yesterday and today to eliminate the usual causes, but I still woke up with one this morning. If I wake with another tomorrow, I am turning the EPR back on. It will be interesting to see if the headaches go away.

If anyone else would like to try this, it would be cool to see other results.

Summary
Pros:
lower 95 percentile pressure (15.3 dropped to 14.6)

Cons:
ear issues (pressure, pain)
headaches upon waking
vivid dreams

Edited to add: the font I use in OpenOffice is called Lexia. It was designed for users with dyslexia (which I do not have). You can find it free from it's creator, K-Type.

[IDRIck]

Interesting data!

I didn't do a formal trial because it became evident that EPR was a winner for me, particularly at higher pressure settings (18 to 20 cm, upper apap setting). Without EPR, my lungs/upper chest felt sore by early morning which disrupted my sleep. Turning EPR back on removed most of the soreness complaint. My experience, YMDV (Your Mileage Did Vary)...

[PaulaO2]

I have sternum issues and the chest pain was something never considered looking for. But I've not had any problems with it.

I can see, though, how the EPR would help with that.

[zonk]

I think its subjective thing, people should experiment and see what feel most comfortable for them
What your experiment shows that EPR have no effect on AHI as some claim to increase prescribed pressure by 3 if EPR set at level 3

For me EPR did not work and almost felt like the machine trying to interfere with my breathing pattern

EPR is not like bilevel pressure support where the difference between inhale and exhale pressures is fixed

According to AASM titration protocol criteria
if patient cannot tolerate pressure increase or if pressure threshold 15 is reached switch to BIPAP protocol

[Sleepster]

There's been some discussion lately about whether EPR (ResMed's exhale relief) is good or bad for the user. Exhale relief, in ResMed's case, is it detects the beginning of the exhale, drops the pressure whatever is set, then when it detects the exhale is ending, it raises the pressure back. Phillips Respironics x-FLEX works similarly but I *think* it detects inhale, increases, then decreases when it senses the inhale is ending. Yes, there is a difference. No, I am not going to explain it 'cause I don't fully understand it myself.

No one does, and I expect Respironics wants it that way. In their literature they describe differences in the shapes of the pressure curves for their different types of flex (A-Flex, Bi-Flex, and C-Flex). So, what that means is that even though the pressure changes by the same amount each time you exhale, the way it decreases, and then increases as it returns to normal, is different.

Yeah, right. I think it's just a little flap of flexible material that opens a tad when you exhale, diverting some of the air stream so it doesn't go to your hose.

There have been claims by some that turning on exhalation relief causes their CA index to rise. Sort of like CPAP-induced central apnea, but in this case it's induced not by the CPAP pressure itself, but by the change in the CPAP pressure that occurs each time you inhale or exhale.

Now, a bilevel machine changes the pressure by an even larger amount in those same circumstances and it has been shown to create in some patients an increase in their CA index. It happened to me!

So, it's not surprising that the effect is there, but like CPAP-induced central apnea, it tends to fade with time and is not experienced by a majority of patients anyway.

[aehjr]

I've been using EPR set at 3 since that bit of pressure relief is more comfortable for me and feels more natural. I did not experience the sore chest like IDRick when I had it off, just more effort to exhale that interfered with getting to and staying asleep.

[PaulaO2]

Yes, the first two nights, it took a while to fall asleep, as it felt like I had to push out to breathe out. But by the third night, I didn't notice anything.

I am still looking at the data, to see if the time of the events got longer or shorter or no difference. I like how SleepyHead presents that.

Today I was told I have been having more movement at night not just as if in dreams, but the PLMD came back. I know that as I fell asleep, I would wake back up when I jerked. My dog has started to not want to sleep at my feet like he has been and I never connected the dots.

I think each person is different in terms of how they react or respond to the pressure relief system. It is another reason to advocate everyone getting a data capable machine. The docs can argue that EPR and the like is not good but how the heck do they know?!

Sleepster, I have pressure induced Central events. But turning off the EPR did not induce any. I wonder if it is because it is an autoPAP?

[Sleepster]

Sleepster, I have pressure induced Central events. But turning off the EPR did not induce any. I wonder if it is because it is an autoPAP?

I doubt that would make any difference.

For example, I don't have pressure induced centrals. I started at a CPAP pressure of 13 and after just three nights my AHI was below 5 and stayed there. They switched me to BiPAP at 13/8 and my CA index jumped to over 15 and stayed there. They had to drop my pressure to 11/8, and then 10/7 to get my AHI to stay under 5.

After that I took over and started tweaking. I found that if I lowered the pressure even a tad, my hypopnea index would go up. Nothing serious, as my AHI has stayed below 5 every night. Now I'm at 11/9 and I'll see how that goes. My ultimate goal is to get to CPAP mode.

C-Flex/Bi-Flex has been at 3 for almost the entire time.

You might want to consider just setting the EPR at 2 for a few weeks and see if that makes a difference long term. In some cases it takes the body a long time to adjust to these things.

I'm changing my pressure by 0.5 and waiting a month in between changes, and that's only if I decide to make a change. As long as my AHI is dominated by CA's I will try to lower it by raising the EPAP until, like I said, it's equal to the IPAP. That'll be CPAP mode.

Then maybe I'll buy a APAP!

[PollCat]

When I got the S9 my sleep doc suggested that I try the EPR. I gave it the old-college try for several nights. After sleeping for more than a decade with a brick, I found the experience disconcerting and shut it off. So I guess the use of EPR is really a personal preference thing.

[jgjones1972]

I vote bad, but that's just me.

+1 for Zonk's "it's subjective".

Use it if you like it, but don't be afraid to shut it off if it bugs you.

JMHO.