Large Leak/UA Events since titration

[RainyDog]

Greetings,
Had a titration study that went ok.  Was not able to find optimal pressure but found the 8-9cm range worked the best.  Was done in a very clean room.  No sinus issues; eyes pretty good. 

Have been using fixed pressure at 8; now at 8.2.  Study was done without pressure relief I believe.  Dr. reset to 3; I changed to 1.  He's ok with me adjusting the EPR.

Have had a few of these 'large leak' incidents; if that's what they are.  Pretty sure home I move to is causing me issues with sinus and eyes.  Have been working with allergist.  Looking more and more like an irritant than an allergen.  Can't pinpoint.  Going to try motel soon.  Not sure if related to this issue.  Full Face mask cushion is fairly new.  Would like to use nasal but can't due to sinus issues

I'm experiencing significant desaturation during whatever is going on.  I think I have 2 or 3 more I can try to dig up.

Posted a couple of shots; the panel order is slightly different.  I moved the events further down so the flow limit and 02 are next to each other.  Also included leak graph.


I have tried a cervical collar 3 times; all with bad results. 


Appreciate any thoughts.  Thank you.



       

[G. Szabo]

Your events are correlated with large leaks, which prevent effective treatment. You should control them first by setting the strap tension (higher tension is not necessarily better) or using a different mask.
Your flow limit is also high, but probably for the above-discussed reason.
You should use EPR=3 and no ramp. 
Post your chart again when you have dealt with the leaks.

[RainyDog]

Thanks for the reply: what are your thoughts on going to EPR 3 and no ramp? 
I do a 5 min ramp.  Helps me acclimate quickly.
I moved the EPR because I was concerned about collapse before exhale.  I think I breath in through nose and out mouth a lot.  Sometimes I have issues with not being to breath out nose.  Just curious on your thoughts.
Appreciate your feedback.

[G. Szabo]

What are your thoughts on going to EPR 3 and no ramp? 
I do a 5 min ramp.  Helps me acclimate quickly.

RAMP is a comfort feature; you can keep it if you want; however, you have no treatment during its period, and we have been seeing obstructions because of it.
Higher EPR reduces leaks, which is the issue you are having. It also helps with flow limitations.

[FlightRisk]

I’ve seen new studies that show expiratory pressure is more important than inspiratory pressure, if this is true you would not want to use EPR at all if possible.   Maybe try no EPR and use a V-Com to lower inspiratory pressure for comfort?

[RainyDog]

I've glanced across articles/vids stating EPR can be problematic.  So many variables in CPAP world; what works for some not for others; crazy;
Do you have any links?  Would like to see.
Thank you

[G. Szabo]

Do you have any links?  Would like to see.

I am not sure what "problematic" might mean; indeed, there are cases when it is not suggested. However, EPR simulates bipap treatment, which is superior to CPAP for most complicated cases. You can read EPR in our Wikipedia. Also, you can find hundreds, if not thousands, of case studies on this forum, demonstrating the beneficial effect of EPR on flow limitation and apneas.   

[RainyDog]

I'm sorry; I was replying to FlightRisk comment and didn't do it correctly.

Was curious about his comment regarding new studies and expiratory pressure.

[staceyburke]

I will put in my 2 cents worth.  I see some positional apnea.  You can see positional apnea where either H or Oa or U events are clustered together.  Getting rid of as many as you can will lower your AHI.  Positional apnea can NOT be controlled by pressure changes.  You have to find out what position you are getting into and cutting off your own airway.  Have you changed your sleep position?  Sleeping on your back?  Using more (or new) pillows?  These things can cause positional apnea by chin dropping to your sternum and cutting your airway.  Think of it of a kinked hose – nothing can get through – you have to unkink the hose…