[Health] Interpreting sleep study results, EERS enhanced expiratory rebreathing space

[JoeyWallaby]

Yes, these are real Treatment-emergent central apneas.  If these show consistently you could increase the length of the re-breathe tube and thus reduce the CA events.
There would be a balance between the rebreathe volume/length and the amount of PS or EPR is used.

Okay thank you! 

Does it look the RERAs and FLs have been controlled by EPR 3 on this night? (I know more data is needed)

[JoeyWallaby]

Sorry, I missed the first four hours of data last night, it was on the night before. Little gap at the start is me turning machine off, putting pressure up to 10 and turning back on.

Could the decrease in EPAP by using EPR 3 (resulting in IPAP 10 EPAP 7 from, IPAP 9 EPAP 8) be contributing to the increase in OAs?

[mper6794]

EPR 3, min pressure 10 with EERS. Put mask on more securely and taped mouth, reduced leaks a lot. I feel good today.

Full data https://www.mediafire.com/file/d17akbjln...e.zip/file (password apneaboard)

hi, Joey,
Thank you very much for the cool chart. How are you making these?....just gathering from your post and bring to excel, updating daily...
Do you think trying a higher EPR value would be beneficial,....No, I don't think so. Although it slightly better with EPR 3, however far from enough..... considering the CAs......as I have mentioned earlier, it looks to me your CA's would be all fake events at sleep/arousal/awakenings transitions.... appear to be controlled by using EERS?....don't know much about this.

gl 

Are these CAs, "real" CAs?

_hy, Joey, Fred

...really don't like this, but just because I am already in this specific case/game, with all respect and consideration, I would have, once more, to disagree with Fred.

...they are also fake CA, in my opinion, while observing this: 12;31 awakening (TV, FR, leak)>> CA.....12;37 awakening (TV, FR, RR)>>CA....14;12;20 awakening (FR, TV) >>CA.....14:29 awakening (FR, TV)>>CA....14;30;40 awakening (FR, TV)....14;33 awakening (FR, RR)>> CA....14;50;45 awakening (FR, leak)>>CA...14;55 awakening (FR, TV)>>CA.
 
It would be invaluable other fellow's opinions here.

All the best

[mper6794]

The last night of charts shows persistent flow limitations and indicate the need for more pressure support / EPR.  It appears that EPR was turned down to 1 which is the opposite of where this needs to go.  Restore EPR to the highest setting, and work on the leaks.

Sleeprider,
you were right. Expiration has turned back  upward, moving EPR from 1 to 3 (attached, yellow dots after EERS).


gl

[JoeyWallaby]

Tried increasing EERS last night, didn't work... took off mask in sleep

[JoeyWallaby]

I did try BiPAP once, no EERS

[JoeyWallaby]

I've averaged the median results of my data.

before EERS
insp
2.18
exp
1.91
tidal
353
minute vent
5.4

after EERS
insp
1.99
exp
1.77
tidal
460
minute vent
7.44

on BiPAP without EERS
insp
1.28
exp
2.54
tidal
390
minute vent
6.19

Maybe my problems are caused two things? RERAs/flow limitations from expiratory pressure intolerance and central apneas from hypercapnia? The charts for EERS and BiPAP both are better than without. Perhaps dual therapy with both would be best? Thoughts?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5700760/

During the course of the titration itself as these patients manifest objective expiratory tolerance, even with APAP, EPR, or BPAP devices, we attempt to smooth out the airflow signal with the use of ABPAP or ASV devices, the latter when meeting complex sleep apnea diagnosis (CAI ≥5, CAI/AHI >50%). Central apneas are not uncommon at higher elevations (Albuquerque, NM [elev. 1,627.6 meters]) or among anxiety patients prone to hyperventilation, that may trigger CO2 decrements and resultant drop off in breathing drive (loop gain).

http://rc.rcjournal.com/content/respcare...2.full.pdf

First, we aggressively attempt to eliminate respiratory effort-related arousals, as mandated by AASM, and second, concurrently, we prevent or resolve subjective and objective expiratory pressure intolerance, the iatrogenic adverse effect triggered in susceptible individuals when exhaling against incoming pressurized air flow.

https://www.sciencedirect.com/science/ar...via%3Dihub

In general, continuous pressure (fixed CPAP) failures are often the result of recurring or persistent subjective or objective expiratory pressure intolerance (EPI)—the unpleasant and sometimes traumatizing sensation of breathing out against pressurized airflow (described as “drowning in air”). EPI (also described as claustrophobic-like) emerges among insomnia patients attempting CPAP and may be associated with iatrogenic central sleep apneas (CSA).

http://www.sleepdynamictherapy.com/index...r/jessica/

The problem of EPI is so vast, it actually explains why various manufacturers invented EPR technology. Moreover, these same manufacturers recognize that EPI is a more prevalent problem compared to CSA. Still, with some degree of irony, it can be noted that in years past bilevel was actually a treatment for CSA, and yet there has also been some data suggesting bilevel might increase ventilation, blowing off CO2, and eventually triggering central apneas. You can see how much confusion resides in discussing bilevel, because we just stated that it could treat CSA while then stating some believe it causes CSA. Go figure.

[mper6794]

Hi, Joey
this is complex ! I would rather go for things I think would more simple. It won't cost me nothing, this opinion hereinbelow; it might help.

-this was quite surprising, the BPAP! I know you have your reasons, but it was nice test for everybody here.

-Have not got yet exactly how to insert your two-day VAUTO on your timetable....anyway a made some preliminary tests (attached).

-Your charts suggest a great deal of long duration unflagged RERA's, too many which could be improved by properly adjusting your EPAPmin and PS.

_too many arousals/awakenings….hard to ask, but do you have any issue with RLS/PLMS issues? hope not....

- For you and others to reflect on, I would like to mention Dr. Barry Krakow here, based on thousands of cases.......
"Should you be able to produce the same results with CFLEX, APAP, etc? Presumably so, except for one “large” difference. You cannot generate the same gradient or gap between IPAP and EPAP with any of the other devices. And, in our clinical and research experience, we are using gaps of 4 to 12 cm of water in our patients. My personal bilevel settings are 21/12.5 for a gap of 8.5.
In our prescriptions for bilevel, I would venture that the average gap is in the 5 to 6 range with tremendous variation, including some with a gap of only 2 or 3. Those with a lower gap requirement would likely do as well on FLEX or APAP, but to repeat, the large majority of our patients have a gap of 4 or greate".

Good luck

[Gideon]

EERS is only to manage centrals. The xPAP is used to manage the obstructive events. And I missed your comment on increasing EPR needing a compensation in EPAP to compensate.  You are correct and that is the "secret"  to using a ResMed CPAP, Elite, or AutoSet as a limited BiLevel .

So yes, both need to be manipulated to achieve optimum results. Increasing PS and EPAP both have the capability of reducing your pCO2 in your blood and causing additional centrals.  Then the EERS needs to be adjusted to bring the centrals back down.

The centrals went up because the EPR increased thus decreasing the pCO2 in your blood which caused your Real Centrals.

Mper is absolutely wrong on this.  Additionally he admits to not understanding EERS which is essential to understanding your case. In a similar manner I do not understand Mper's methods and as such choose to not interfere in the threads he is assisting in.

[Sleeprider]

Results on the VPAP Auto look very good, and it's surprising not to see more emergence of centrals with the higher pressure support. I have personally found that on the Vauto, my CA results are consistently better with a trigger sensitivity set to high rather than medium. These are my results and yours may vary. If you are more comfortable with bilevel, stick with it, and add EERS if the CA re-emerges. The flow rates look pretty good where leaks are controlled, and there is less flow limitation. Your best tidal volume and respiration stability continues to be with the use of EERS, and it would be good to see you try that system with the VPAP.