CPAP Does Not Control Small Chokes

[clan]

If you feel better with EPR then please do turn it on. We can always play with that again later. Your leak rates are much too high and we need to fix that before we can trust much anything else. If you leak too much the machine tries to compensate and you end up wanting to open your mouth.

This post was recommended elsewhere - you should have a read too:
https://www.apneaboard.com/forums/Thread...GUARANTEED

Masks are a very personal preference. Maybe you should consider if you have the right one. First you need to determine if the main culprit is mouth leaks (taping) or the mask.

I have tried a nasal style mask but I much preferred nasal pillows and found it much easier to get a good fit:
https://www.resmed.co.uk/products/masks/...irfit-p10/

Some do not like it touches the nostrils and we are all different.

I have been considering a full face mask and this one seems to score well:
https://www.fphcare.com/en-gb/homecare/s...ks/vitera/

But this is very very individual and I cannot give good advice on that.

Do not despair. There is still hope for sure!

[Buitlear]

       


I have been running with the pMin at 6 and the EPR at 3 for a few weeks now. Having EPR back on full seems to stop the crazy large leaks (and I have tried to adjust my mask and get it nice and symmetrical) though I don't really know how to read the general Leak Rate data in green - how good or bad is it from these couple of example nights? Overall the CPAP is at its same function as ever for me - better than nothing, but still not stopping the small chokes and I wake frequently.

As always the sudden stops are me waking up and switching the device off.

[clan]

3. October:
pMin set at 6,6. Your IPAP pressure goes to around 9 (median 7,92) and your EPAP folows to around 6 (median 4,92) (as it should with EPR at 3).

Leaks hover around 15 - 18 (median 13,2) but never goes to 0

This was with mouth taping.

7. October:
Your try without EPR.

Notice how your leak rate goes up when ever the pressure goes up. More pressure - more leaks. The leaks are near or above the red line when you wake up. You do not wake up every time but many. And from my personal experience the parts without waking up was not a "good" sleep either.

pMin was at 4 but notice the median is 5,8.

15. November:
Your leak median 7,2 with 95% at 10,8. That is within the range where the machine supposedly still should be in control. But my experience is lower is better.

From looking at the charts I would guess that you slept better on 15/11 than 3/10 with almost the same settings but better leak control.

With EPR off you in effect have less leaks but also less pressure. And as you are choking you need more pressure.

If you "control" your leaks by using a "lower" pressure then the therapy becomes less effective.

With no EPR your pressure setting is simple ie. 9. With EPR at 3 then we split it up and IPAP is still 9 but EPAP is only 6. That is why EPR is thought of as a "comfort" feature. Not to downplay it as "less important". You should however only use it if you have a hard time when exhaling. Beware that it comes with a cost: Your IPAP pressure most likely needs to be higher to compensate for the relief.

You only have 3 parameters you can adjust: Leaks, Pressure (IPAP) and EPR (EPAP). And it would be best to do it in that order. If you leak too much you do not get the correct pressure and the machine will have a hard time helping you.

In effect you have done it the other way around. You have adjusted the machine so low that leaks are not the problem. You have then reached your local optimum.

You have stated that choking is the problem. If we have fixed the external parameters such as not sleeping on your back then the only thing we can do is ensure a higher pressure. If you really cannot exhale then by all means use EPR. But it should be the last parameter to adjust. It is for comfort. If you are not comfortable you cannot sleep hence everything else is void.

So with or without EPR you need a higher pMin. The lowest acceptable pMin for you will probably be lower and more comfortable without EPR. But the point is that you need more pressure to get better therapy.

So in your situation the only thing to do is raise pMin until it can control your airways. If leaks gets worse with higher pressure this absolutely needs to be fixed. So while your leaks currently might be inside an acceptable range it does not help us. The question is what happens to them relatively when you increase pressure. You are then loosing the effect of the pressure. Your therapy will become as you have found almost not worth it.

A pressure around 6-8 is low and it should be possible to get it leak free especially with mouth taping.

But looking at your own data it can be frustrating as what is "normal". Leaks are the enemy an should ideally be 0. You can see my chart below for comparison. It is possible to get close to 0.

   

[Sleeprider]

With EPR at 3, your minimum pressure should be 7.0 not 6. EPR will subtract the its setting from the minimum pressure to a minimum of 4.0 cm. With your settings, the machine cannot raise exhale pressure as needed ahead of events. Set the minimum pressure to 7 and your pressures will be more responsive.

[Buitlear]

What you both explain about EPR makes sense, and I did understand when it was explained earlier in this thread - the issue was I had much worse sleep quality when I tried turning EPR down or off. The resistance exhaling really had a negative impact and also seemed to contribute to the insane high leaks seen earlier in the thread - where clan said the data was all over the place. (It also resulted in pressure trying to escape through my mouth, which is/was taped.)

The reason my pMin is at 6 is that I am trying to get used to upping the pMin from my usual 4 - I do understand the issue with the EPR of 3. I have been with the pMin of 6 for weeks by now, so maybe I am ready to try pMin of 7, but it does seem to get tricky around there. I will take it to 7 and report the results.

[Buitlear]

A bit of good news - I worked my way to a pMin of 7 on November 13 and have had better than average nights with only a couple of duds - I have felt noticeably better most days. That said, there is definitely still a lot of micro-choking going on. I guess it would be best to work up to a pMin of 8 next? But I will do it incrementally, as that worked for getting to 7.

[clan]

This is really good to hear! And the quality of your sleep is the core. As you have noticed even small improvements gives better days straigth away. Small adjustments from here is the way to go. Adjusting 0,5 on one parameter at a time (and I think the S9 can do even smaller steps). Unless impossible try to keep them for at least some days to allow for daily variance. I have not been able to find any answer to how long people on average need to adjust over time.

I think the important thing is not to give up and just let it be. So if you loose motivation working on it now because you are to eager to see results then remember to try a small adjustment in a couple of months. Maybe put a reminder in a calendar. That was a lesson I needed to learn the hard way: I went for a long time and thought my therapy was "good enough" or "as good as it gets". And I started out with a better sleep quality than it seems you have.

The correlation between exhale comfort and the amount of EPR is not intuitive. This is important you keep in mind as you have leak issues. Less EPR might end up with less overall pressure needed. Less pressure - less leak. This is the triangle you are dealing with.

Keep an eye on your leaks and adjust pMin and EPR. It is then a question about what works for you, what you can tolerate and what you are willing to do.

On the willingness part I fully and well understand the reasons not to do - but they are:
- A better mask for you to handle those leaks. An expense (around EUR 100) and a hard choice between what might work better for you.
- A new machine as the S9 is getting old. An even higher expense from EUR 500 and up. And the worry that you might even be better off with an even more expensive Bilevel than a APAP.

These are the "easy" ones which you can throw money at if you have them. Then there are all the hard life choices: Life style, weigth, alcohol consumption (try nothing at all for at least 14 days), stress etc.

Please keep posting updates as I am sure there are brighter days ahead for you. It will be good to follow your progress.

[Buitlear]

Yes, I can adjust the pMin by a mere 0.2, so it allows for a very slow increase!

I will certainly have to look at a new machine next year. As for a mask, I'm happy to consider a different type, I'm just not sure what. I recall nasal pillows being mentioned here before - I did actually use that type of mask for either 1 or 2 years in the past, but things weren't really any better or worse.

As for lifestyle, good news alcohol wise - I very rarely drink. I've had alcohol twice in this entire year. Weight however is a difficulty, and a real catch-22. I'm not necessarily over a healthy BMI, but I am a bit fatter than I should be, and I know that even a little extra definitely impacts me. The trouble is that it's incredibly difficult to get the weight to shift due to the poor sleep quality. I need better sleep to lose weight, but I need to lose weight to sleep better... etc. And then of course I definitely have a stressful life due to the sleep deprivation!

[nabilx]

Hi, I am suffering from the same problem ,
It appears to be caused by gastric reflux, it is a silent and always overlooked by doctors.
Gastroesophageal reflux disease (GERD)
See an internist to check this possibility