[Treatment] Higher pressure and soft cervical collar not helping FLs/AHI

[vHungry]

Hello everyone,

I have been struggling with my CPAP settings due to leaks (especially at higher pressures) and have recently increased my settings from 9-12 /w EPR of 2 to 10-12 w/ EPR of 2 to 12.4-14 w/ EPR of 3 to try to flatten out my flow rate graph. From what I understand, it is not supposed to look spiky and should look as flat as possible. I will post three screenshots with different, increasing pressures (yet no real difference in the flow graph).

I got a soft cervical collar, and I noticed a difference in leaks, as I did not wear it today and woke up with my mouth tape wet and aerophagia. 

I don't see a difference in the flow graph/feel a difference in my sleep quality, even with these increased pressures, and I still notice they are quite spikey despite my flow limitation numbers looking good, a lot of my breaths are still not smooth at the top (flat tops/sloping down/multi-peak), and there are still what appear to be OAs that throughout the night that are shorter than 10s and not officially marked. 

I do consistently see that the start of my nights begins with a beautiful flat and uninterrupted flow rate, and it gets crazier as the night progresses. Why is this? Any ideas? How can I get my flow graph to look better?

From what I understand, a high IPR helps prevent FLs, while a higher EPR helps treat OAs. You don't want IPR to be too high because it can cause aerophagia, and you don't want EPR to be too high for comfort reasons. Is my understanding correct for the most part?

Many thanks in advance!

[vHungry]

Examples of my flow-limited breathing despite higher pressures

[Deborah K.]

Hi.  Unless pressure changes wake you up, there is no need to worry about your pressure fluctuating.  You don't need a flattish graph.  Our needs for air vary during the night, so I think a range of pressure is a good thing for most people.  I suggest you try setting your pressure from 9-15 and see how your sleep goes.  You mostly use up whatever range you have tried, so broadening your range should help you sleep better and help us see how much pressure you actually need as the night progresses.

EPR stands for exhale pressure relief.  Using it helps most people breathe more comfortably and reduces flow limits, which improves therapy.
That's all it does.  I suggest you set it at 3.  I don't know what IPR is; there is only a setting for EPR as far as I know.  EPR has nothing to do with aerophagia.

Were you originally having a lot of mouth leaks?  Your charts do not presently slow a lot of mouth leaks, so unless they are waking you up I would not worry about them at all.  If you are using mouth tape for leaking you don't need to wear a collar as well, unless you are using it for positional apnea.  If your tape was wet that just means you were drooling that night, nothing more. If you were also leaking air you probably need to cut your tape longer.

Try to relax.  We will help you get things dialed in to help you achieve better comfort and therapy.  Good luck!  

[Phaleronic]

Hi vHungry, I see in in your graphs that you've changed (raised your pressures) you do need a higher pressure and I'm an advocate of using static pressure as apap mode does cause more arousals and microarousals in patients than standard cpap. Your 99 percent pressure in the last charts where you raised min/max is 14.08cm, and you had a lower ahi with less oas/cas so I'd set your machine to static pressure (cpap mode or same pressure min/max) @ 15cm and set EPR to 1-try this for 30 to 45 minutes today before bed (a nap maybe) and see what you think

[vHungry]

Thank you both of you, however, it appears you both suggested conflicting advice. Should I broaden my range and have an EPR of 3 or have a static pressure will a 1cm EPR?

[Deborah K.]

You can try both and see which way you sleep and have good therapy the best.