EPR - Why would you not use it if available?

[Rcgop]

My prescription did not call for any EPR setting. Why??
On therapy for two months and not yet a good night sleep. Installed SleepyHead and see there is a lot going on all night long. Home sleep test showed no CAs and now all I have is CAs. Leaks are excellent, AHI is in 3-5 range with a few exceptions in the 11-12 range, pressure is all over the place set at 4-16. Doc says I doing fine and to give it more time but that is getting more and more difficult.

That was before last night. Upped my min pressure from 4 to 5, just not getting enough air on startup. Also changed the EPR from off to 1. AHI was .7, no OAs, 1 1 HA, and just a few CAs. Best night of sleep to date. Now if it only continues.

[FrankNichols]

If I understand correctly, CA's can be caused by higher pressure. If most of what you have left are CAs I would consider (ask the doctor?) if it would be okay to lower the high end of your pressure to say, around 14 or 13 for a week and see what happens (I am assuming our 95% level is around your high of 16, if it is lower, then adjust downward accordingly). If CA's stay and OAs start, then raise it back, if CA's are reduced and OAs stay the same, then all is good.

As to why EPR off? Well, in my case, I am concerned with whether or not EPR can affect therapy by lowering pressure on exhale, probably not, but it is just one more complication to deal with to me. I am a little over a month into therapy now, and have adapted completely to breathing in the higher pressures. When I wake in the mornings I do not even notice if the machine is running unless I let my tongue down so my mouth inflates from the pressure.

Everyone is different, and the goal should be the best nights sleep, if EPR helps, then by all means use it! If it doesn't help you sleep, then I don't see any reason to add it to the mix.

[green wings]

Hello, Rcgop. Welcome to the Apnea Board forums.

My prescription also did not specify any EPR (called CFlex+ on my Respironics machine). The doctor only specified the pressure.

EPR is considered to be a "comfort setting", like humidity. My doctor left it up to the respiratory therapist at the DME who set up my machine to set it.

She set it at the middle setting of 2, but didn't tell me that it was there, so I only found out about it when I was having problems exhaling into pressure when I first started.

She then told me about the setting and suggested I increase it to 3 for a while and then try lowering it again when I got used to breathing with the machine. I have it set at 1 now.

Some doctors may specify how much EPR they want the patient to start off with. I don't really know.

I'm glad that you've found this forum and the SleepyHead software.

I didn't find this forum until about two months after I received my CPAP machine (and wasn't using it much because of problems.)

I can understand why you'd feel annoyed if your EPR was set to zero.

The general rule, as I understand it, is to use the minimum EPR required for comfort. I can't remember what the pressure curve for EPR on your machine type looks like.

On mine, the pressure drops by somewhere in the neighborhood of 2 cm and then starts to return to the set pressure. The CFlex+ setting influences the shape of that pressure response. The higher the setting, the longer it takes for the pressure to return to the set pressure. In some people, this can cause apnea events.

Disclaimer: I am still fairly new to xPAP use, so I'm not 100% sure I've got all this correct. I hope someone will correct the details if they're not right.

My prescription did not call for any EPR setting. Why??

[OpalRose]

My prescription did not call for any EPR setting. Why??
On therapy for two months and not yet a good night sleep. Installed SleepyHead and see there is a lot going on all night long. Home sleep test showed no CAs and now all I have is CAs. Leaks are excellent, AHI is in 3-5 range with a few exceptions in the 11-12 range, pressure is all over the place set at 4-16. Doc says I doing fine and to give it more time but that is getting more and more difficult.

That was before last night. Upped my min pressure from 4 to 5, just not getting enough air on startup. Also changed the EPR from off to 1. AHI was .7, no OAs, 1 1 HA, and just a few CAs. Best night of sleep to date. Now if it only continues.

Hi Rcgop,
The EPR is an optional comfort setting. The DME should have at least asked you if you would like it on and explain it.

With ResMed machines, when you set it to 1, the APAP will lower the pressure by 1cm on exhale. With a setting of 2...it lowers the exhale pressure by 2cm and with a setting of 3...lowers by 3cm upon exhale. As I said it is a comfort setting and helps to breath out against the pressure.

Your AHI dropped with the pressure change you made, so that's progress. What you want to watch for is your medium and 90% pressure readings, and let us know what it is, then we can help you with a pressure range that would be more optimal for you.

A start pressure should fall around 2cm below your 90% numbers, and the max pressure can be set to 2 cm above the 90% reading.

Good luck with your therapy.

[surferdude2]

EPR is like training wheels on a bike. If you need it, use it, especially in the early stages of acclimation to the therapy pressure. Later on you won't likely need it and it does have some downsides in certain cases. Eg, it can cause a bothersome "hammering" effect for some people. And in certain people, it can trigger apnea events due to dropping the pressure below an effective level during the breathing cycle.

So, as they say, your mileage may vary (YMMV). I started out using it from the gate and set it at #3 level. That was a couple of years ago. I have it turned off now and find the therapy slightly more effective.

BTW, the same consideration exists when choosing whether to operate the flow generator in APAP or CPAP mode. Many people start out in APAP mode and migrate to CPAP over time. Each person is different, except retired_guy, he's the same.

Dude

[Sleeprider]

I disagree EPR is like the training wheels, it is actually a sophisticated bilevel implementation in CPAP that can increase comfort, and effectiveness; and used improperly, compromise therapy efficacy. It really blurs the line between CPAP and BPAP, and its users need to understand that using EPR in combination with too low pressure settings can move EPAP pressure below the pressure where the airway remains stable against OA. For CPAP users that typically use pressures above 10, it can greatly increase comfort and actually improve ventilation. Proper use of EPR takes some knowledge and monitoring to optimize and prevent problems. It's actually surprising to see this level of pressure management being part of a "comfort setting" because it has a lot of potential for misuse. Properly used, it can be pretty amazing and offer a lot of flexibility not formerly available with CPAP.

I agree with Dude that the normal progression of an APAP user is to start with a wide range of pressure, that eventually narrows into the most effective range or CPAP. EPR or Flex may or may not be part of that, but it is an option that can either improve comfort, or actually cause problems if it allows pressure to move too low.

[FrankNichols]

I disagree EPR is like the training wheels, it is actually a sophisticated bilevel implementation in CPAP that can increase comfort, and effectiveness; and used improperly, compromise therapy efficacy. It really blurs the line between CPAP and BPAP, and its users need to understand that using EPR in combination with too low pressure settings can move EPAP pressure below the pressure where the airway remains stable against OA. For CPAP users that typically use pressures above 10, it can greatly increase comfort and actually improve ventilation. Proper use of EPR takes some knowledge and monitoring to optimize and prevent problems. It's actually surprising to see this level of pressure management being part of a "comfort setting" because it has a lot of potential for misuse. Properly used, it can be pretty amazing and offer a lot of flexibility not formerly available with CPAP.

I agree with Dude that the normal progression of an APAP user is to start with a wide range of pressure, that eventually narrows into the most effective range or CPAP. EPR or Flex may or may not be part of that, but it is an option that can either improve comfort, or actually cause problems if it allows pressure to move too low.

Pretty much totally agree, which is why I said, I chose to not use it, since i did't/don't completely understand how to set it properly, and choose to simplify my therapy until I have it under control - then I will investigate using EPR. Until then it is just one more variable. For those that need it I certainly agree with them seeking advice here and using it to help deal with the early stages of getting used to breathing in the mask.

[PoolQ]

Well since I am currently adjusting the equivalent of EPR on my BiLevel because my exhale is set too low and letting my airway start to close. I personally have to have some exhale relief or I cannot use CPAP. Not just uncomfortable, but I cannot tolerate it at all. No I am not a wimp and I do not look at this setting as training wheels. (ya kind of sensitive about that).

Many people do not need to use EPR, some do and it causes no problems, others like me need to be careful and tune it just like most other settings on the machine.

If your numbers are good and you are sleeping fine, then you don't need to mess with this or any other setting.
Otherwise this is a setting that may provide some relief and allow you to tolerate CPAP better.

[trish6hundred]

Hi Rcgop,
WELCOME! to the forum.!
Much success to you with your CPAP therapy, hang in there for more responses to your post.

[AlanE]

I have had bad results with EPR on. no matter what settings I try. With it off I get a constant cm unless stuff happens.