Titration Help/Next Adjustment Advice

[arch]

I have self-titrated up to CPAP mode 9 with EPR 3 over the past week.  I made the switch from 8 to 9 in the middle of the night, and that step made the magic happen.  I dropped from an RDI of 26, to 3.76.  I believe I can get below 1 because I have been there on auto mode with 6-14 range, but I have been struggling with aerophagia and waking from leaks when my pressure increases on the high end.  My whole goal here is to find the lowest effective CPAP pressure for my treatment.

I think I'm probably past the point where I want to make such large jumps, so my next change should likely be of 0.1 or 0.2 cmH2O, since I'm under 5 RDI and my treatment is considered effective.  

The next step I'm uncertain about is should I keep increasing my maximum pressure with EPR on?  Or should I start decreasing EPR to raise my minimum pressure?  I have no issue sleeping with EPR off, so it's not a comfort issue for me.  I had it off when I was on auto mode and it didn't wake me if my pressure fluctuations or aerophagia weren't causing a problem that night.  I turned EPR on because my very unprofessional judgement from looking at my charts is that I don't appear to need the higher pressure on exhalations, since my issues seem to be with inhalation.  I would not be shocked if you tell me I don't understand how EPR supports the airway and my assessment is wrong.

If any zooms or additional charts would be helpful then let me know.
I'm also REM predominant.  I'm pretty sure I only have apneas in REM sleep, actually.

   

   

[staceyburke]

NO PRESSURE CHANGES WILL HELP THIS.  You are having a lot of positional apnea.  You can see positional apnea where either H or Oa events are clustered together.  

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…

IF you can’t make a simple change like changing to a flatter pillow helps then you will need a collar.  I have a link to collars in my signature at the bottom of the page.  It shows people who are not wearing a collar and the SAME person wearing a collar.  There is a huge difference between the two.

[arch]

Thank you for the reply.  I sleep prone, I (almost always) sleep prone with either no pillow or a very flat pillow.  I'll try side sleeping tonight with my neck as level as I can make it, and I can try tomorrow night with no pillow at all on the bed to see if that helps.

Is my assessment correct that 9 cmH20 with EPR 3 seems like an ideal pressure for me?

[Sleeprider]

In prone sleeping, the acute angle of the neck and head with the head turned to the side makes obstruction just as likely as a supine sleeper with chin-tucking, It might be possible to alleviate that by making space for your face similar to a massage table. Look up prone or face-down sleeping pillows to see if there is something you can live with. I can't help much because prone sleeping position is a non-starter for me. The obstruction caused by positional obstruction can be somewhat overcome with higher minimum pressure and differential pressure support or EPR. With CPAP pressure 9.0 and EPR 3, your pressure is only 9.0/6.0 (inhale/exhale). If this is the limit of your tolerance due to aerophagia, it is probably a good compromise, but if you had a higher pressure tolerance, I think more pressure support could significantly improve inspiratory flow limits. My suggestion is Mode VPAP-S EPAP 6.0, IPAP 10.0, trigger sensitivity High. Other than that, your sleep position is the cause of this, and it would be ideal if you could adapt to something on your side or even semi-prone with one side elevated on a body pillow.

[gainerfull]

Unable to tell you if your pressure is adequate until you solve the positional apnea problem. You may consider a soft cervical collar as well.