Chart Reviewing

[Phaleronic]

EPR doesn't help flow limitations, it helps leakage issues because it delays the incipience of the return of inspiration pressure and lowers epap pressure by 1cm per unit of EPR, this is what resmed has released in their white papers, and this is why it does not help with apnea (and hypopnea) control (the lack of pressure won't keep the airway open)-so turn down EPR for the hypopnea events please.

[staceyburke]

All of us on this board have a right to their opinion.  OpalRose, Crimson Nape, Jay51 and myself have told you EPR 3 is the setting you should be using to help with your Flow Limits. 

 One other member told you not to use EPR.  The decision on your treatment is your choice. 

[SKPC]

    All of your comments are highly appreciated - just an FYI - I ALWAYS start sleeping on my side - can't seem to go to sleep otherwise but then I transition to my back during the night in my sleep.   

Thanks for the links - I will read that info today.

What I sent with my post was my worst night in months, my best and one CSR event. FYI - I get the feeling folks think these are common readings so I have enclosed my CPAP statistics report for a year which shows an average AHI of 5.5 which i thought I understood to be at the target number. My CSR episodes are ~1 in 3 weeks. 

I need to look at the pressure settings comments to see if I understand more. 

Again thanks for the feedback!!!!        

[Crimson Nape]

SKPC - You have been provided some incorrect information.   Regardless of what the manufacturer or anyone else states, EPR is bi-level support.  It just works differently than an actual bi-level machine.  I'll try to explain.

A true bi-level CPAP allows the setting of the EPAP pressure to maintain the air splint to keep the airway open during an exhalation.  The pressure support (PS) is the value of the additional pressure and is added to the EPAP pressure to overcome flow limitations during the inhalation phase of a respiratory cycle.  A bi-level CPAP allows for a finer pressure adjustment and a greater pressure range than the EPR option.

On a CPAP, you set the inhalation pressure and any difference in pressure is addressed by the EPR (Exhalation Pressure Reduction).  Since the EPR option operates opposite of a bi-level machine, we must play its game and adjust the pressure setting(s) to address its operation.  The way we do this is to use the EPAP pressure value that maintains an open airway, and then add the intended EPR's value (1-3) to this pressure to arrive at the actual CPAP's pressure setting.  

Let's say you have found a pressure of 10cm maintains an open airway, but you have flow limitations.  Since the Resmed uses the flow limitation values to increase its pressure in an attempt to overcome these limitations, it will keep increasing in pressure until it either eliminates the limitation or reaches the highest programmed pressure setting.  To address this, we would take the 10cm and add our intended EPR of 3 to this value, thus making the required CPAP pressure setting of 13cm.  This will provide the 10cm we need for an open airway, and provide the additional pressure to (try) overcome the flow limitations.  If you want to use the Auto mode to allow for pressure changes, you would base these values on your intended EPAP pressure range and then add the ERP value to them in order to properly configure your CPAP.  An example would be, let's say you want to have an EPAP pressure range of 8 to 12 cm and want to use an EPR value of 3 to address your flow limitations.  You simply would add the EPR value to this pressure range, and arrive at the CPAP pressure settings of 11 to 15 cm with an EPR of 3 - full-time  (8+3=11 to 12+3=15).  Be careful - there is a ramp only option for this feature.  You don't want it.

I hope I've made some sense.
- Red

[Phaleronic]

I politely disagree with the information posted above. It is not true that Remed's EPR adds pressure to EPAP-as a dedicated bi-level machine does with Pressure Support. There are graphs showing that EPR drops pressure and leaves it 1cm lower than set pressure per unit of EPR. There is no literature that describes or verifies the claim that EPR is adding pressure to baseline min/max pressure on the machine.

This is why there are issues with using EPR at a high level to treat CA events. EPR stands for exhalation pressure relief (not pressure support or adding pressure)-by nature it's going to decrease apea and hypopnea control and allow the airway to collapse a bit. I have seen other people here claim that EPR is pressure support as well, but there is no proof of this, and the data that resmed has released also disproves this theory.

"EPR, or Expiratory Pressure Relief, is ResMed’s trademarked name for its take on the exhalation relief feature found on most CPAP machines. Exhalation relief is an optional setting that lowers your incoming pressure level while you’re exhaling to help make breathing feel more natural and has been shown to improve therapy comfort.


(The proper term for EPR is actually exhalation relief, but EPR has evolved to be a catch-all term for this type of pressure relief feature in the same way that people use "Kleenex" to refer to facial tissue or "ChapStick" to refer to lip balm. So, for the purposes of this article, we’re going to be using EPR and exhalation relief interchangeably. If you get confused by the different terminology, just know that we’re talking about the same thing by different names.)


The exhalation relief feature on any machine will lower your therapy pressure by increments of 1 cmH2O per level to a maximum pressure relief of 3 cmH2O during exhalation. Some machines, like the ResMed AirMini, AirSense 10, and AirSense 11, even offer an option for EPR to be on full-time or only while Ramp mode is active.

So, if you’re set to a pressure of 12 cmH2O and using an EPR setting of 2, your incoming therapy pressure during exhale will drop to 10 cmH2O. If you're at 17 cmH2O with an EPR setting of 3, your incoming pressure during exhale will drop to 14 cmH2O, and so on. However, pressure relief settings will never drop below 4 cmH2O, so if you’re at 6 cmH2O with level 3 EPR, it’ll only drop to 4 cmH2O during exhalation rather than 3 cmH2O."

[Expat31]

@SKPC

Hi, 

I have a couple of points I would like to add. 

Can you could simplify the presentation of your graphs, just to show the essentials, as below:-

         1.Events
         2.Flow rate
         3.Pressure
         4.Leak rate
         5.Flow limitations

This simplified view will hopefully  enable us to have a better overall picture what is actually going on. We may however need further graphs at a later stage, together the flow rate graph being zoomed.
 
 It would be interesting also to have the key elements of your sleep study, ie makeup of AHI between centrals, obstructives, with the  additional breakdown by sleep position. 
Posting a redacted copy with your personal details obscured may be the easiest optionbfor you. 

Thanks. 

[Deborah K.]

Do use EPR set at 3.  You will note that only one person disagrees on this, in spite of the correct information presented by many of the the key leaders on this forum who have many years of leadership and knowledge behind them.

[SKPC]

  sleep study redacted.pdf (Size: 626.25 KB / Downloads: 5)  



I have to admit, I am somewhat surprised at the differences expressed in these replies especially from board members - not a complaint - just a thought. The amount of info presented is amazing and to be honest somewhat overwhelming but it is SO GREAT to have people willing to take a look and give their time to help. My sleep doctor is not interested in OSCAR charts or other data and just keeps wanting more sleep studies when all I was looking for was some explanations and thoughts.

I was also surprised that my current 5.5 AHI is not well controlled? I read that the target was 5 or less.

I was asked to post my sleep study results so they are included above.

I made some changes to my machine yesterday - max pressure to 18 from 17 - ramp turned off - starting pressure to 14 (min) from 12 - it will interesting to see the results over the next couple of weeks.

Also I rearranged my chart as suggested but will wait to post a few days to see what if any results come from the changes I made.