I need a way to get higher exhaled pressured relief (EPR)

[metal36]

I just started using a Resmed Airsense 10 for mild OSA. I have a nasal pillow, humidifier, and heated tubing. Prescribed pressure setting is 8.

I knew from the moment I started my sleep study that exhaled pressure was going to be my problem. After finally getting my machine (which has taken almost 3 months from the date of first going to my PCP), I had a horrible night sleep that is worse than just sleeping normally. My apnea is mild, but it is compounded by another issue. My breaths are very weak and shallow. Not being able to empty my lungs entirely is a deal breaker for me. I need that volume, as it is a large percent of my overall air intake, since my breaths are shallow. My two sleep studies (1 sleeping normally, and 1 with CPAP) showed arguably overall improvements with CPAP. There were fewer obstructive events, but there were more central apnea events. I think these central apnea events are caused by having to breath against the pressure on exhale. I reach that balance point where my exhale doesn't go any further against the pressure. But my body doesn't want to then proceed to take the next inhale. It really wants to complete the exhale. So my lungs may just sit there and do nothing at this point, trying to continue the exhale in vain, in a state of equilibrium against the pressure.

I did a lot of experimentation where once I would hit the balance point upon trying to exhale through the nose, I would then carefully complete the exhale by opening my mouth a little. Yes, there is a way of doing this. Then I would start the next exhale through the nose again. What a difference it makes. This confirmed for me that if I could experience complete exhale through the nose by completely eliminating the exhaled pressure, then this would probably work great me for me.

The problem is my machine only has an EPR setting as high as 3. I chatted with someone on a CPAP selling site who said that 3 is the highest setting any machine goes. I'm very disappointed to hear this. Is this a technical limitation of making a CPAP? Or was is just a design choice that could have been done differently?

Is there any way to override the limitations of a unit and make the EPR reach higher values?

[Julie]

Do you have COPD or another reason for 'weak' exhalation ability?

[Pugsy]

3 cm reduction for exhale relief is as high as regular cpap/apap machines will go.

Now bilevel machines will allow more than 3 cm difference between inhale and exhale. So a different type of xpap machine will do it.

[metal36]

Or I think the ideal thing would actually be to somehow have a variable EPR setting. Meaning the pressure on exhale should ramp down to 0. This would allow for complete exhale, and also still prolong the total exhalation time.

[metal36]

I have a chronic infectious disease (probably bartonella, a bacteria you can get from cats). I sick in many many ways. Just tired and weak all over in general.

Oh, BPAP. Thanks for the tip. I will look into it.

[Pugsy]

No machine will go to 0 cm upon exhale.
The Devilbiss will go down to 3 cm and all the rest have a 4 cm minimum. Nothing any lower.

[Luthie2006]

Chiming in here; I have another post going on here with "Did I make a mistake by buying Airsense 10?" I am having the same problems on this machine with the EPR as Metal36 is having. I cannot breathe with the EPR at 3 or at 1 or at 2. I am having weak and shallow breaths and I cannot use it. I have no lung or COPD problems. I currently have an S-9 Machine and have absolutely no problems with EPR on 3, but on the Air Sense, I cannot breathe on any EPR setting. I sent the machine back to the internet company and they said that there is a setting on the Air Sense (news to me?) from a "Standard" response to "Soft response" on the EPR. I have no idea what they are talking about?? Could this be the problem and is there even such a thing as "soft" response on the EPR area of the Air Sense 10? They said there is. Did anyone hear of such a setting as a "soft" response from a "Standard" response feature?

[metal36]

So then is the difference between BPAP and CPAP just that BPAP allows a wider range of EPR? Sounds to me like a way to get people to pay more money for something that didn't cost more to make. =)

I wonder if there is any tinkerer or company out there that does custom orders or custom modifies existing units? I know, I am probably dreaming.

I have Medi-Cal (Obamacare in California). I read that to get coverage for BPAP you have to have documented failure with CPAP, such as "patient intolerance", "condition not improving", etc. I wonder what that documentation would involve. I guess I can force myself to sleep with this CPAP for a few days just to generate data, then go complain to my doctor? Who in the world knows what counts as "enough".

Can anyone recommend a BPAP machine that has a minimum exhale setting as low as possible (I guess 3cm)? I see the Devbliss CPAP machine (as suggested by Pugsy), which has a min setting of 3, but that's a CPAP. I want to make sure I go to my doctor prepared with a suggested BPAP model, in case he has no clue.

they said that there is a setting on the Air Sense (news to me?) from a "Standard" response to "Soft response" on the EPR.

I was reading the description of some random BPAP machine, and it said it had some kind of "rounding" feature at the peak of exhalation/inhalation, where the pressure changes. Maybe they have some similar option they are calling, "soft"? Just a random guess. But I too have not seen any such option.

[palerider]

Or I think the ideal thing would actually be to somehow have a variable EPR setting. Meaning the pressure on exhale should ramp down to 0. This would allow for complete exhale, and also still prolong the total exhalation time.

It's the *exhale* pressure that keeps your airway open so you can take another breath.

If pressure cut off, as you're suggesting, then your airway would close, and you wouldn't be able to inhale.... that's why no machine does this.

[metal36]

I have found 5 models of BPAP which appear to list 3cm as the minimum EPAP setting. They all list 4cm as the minimum CPAP setting, but the devil's in the details, and it seems they have a *separate* listed minimum for EPAP!:

ResMed AirCurve 10 VAuto
ResMed AirCurve 10 S
ResMed AirCurve 10 ST
IntelliPAP BiLevel
IntelliPAP AutoBiLevel

Thanks for the tips guys. I have a good feeling about this.

[kteague]

I'd just like to suggest you give the folks here a chance to look at your data and see if anything jumps out at them. I can't help but remember how very hard the air seemed to blow when I was new, and how quickly I adjusted and was soon thinking the machine must have cut off when it was at the same pressure as when I thought it was blowing so hard just days before. Maybe you could give it a bit of time before trying to get a machine that may either be unnecessary at best or no help at worst. Look at the top of the board for instructions on getting and using the free software called Sleepyhead. If I were you I'd try to collect several nights of data to be reviewed. The question in my mind is if the data might show a decrease in effectiveness with more exhale relief. If so, is changing a machine to get more exhale relief even going to be workable for you? Now, I am speaking in general, as I cannot know how much your physical limitations are going to affect your CPAP treatment. You may be someone who needs to go straight to some other option without delay, but if that's not the case, I encourage you to give it a bit more time. Nothing about this feels natural in the beginning.

[RicaLynn]

In order to get a prescription for BiPAP (not BPAP), you will have to find that CPAP/APAP does not work for you.
In order to find out if CPAP/APAP therapy doesn't work for you, you will have to try to work with it, for a few months most likely.

If you have only just started using your AirSense, you are still adjusting to Cpap therapy, and cannot say that it doesn't work for you. The knowledgeable folks here can help you with tips and tricks for adjusting to it, and adjusting the machine to maximize your therapy benefits. You have a full data machine, which can tell you a lot about what's working and what's not if you know what to look for. Let the gold here on the forum help you make it work.

[ChicagoGranny]

My two sleep studies (1 sleeping normally, and 1 with CPAP) showed arguably overall improvements with CPAP. There were fewer obstructive events, but there were more central apnea events.

You need to tell us how many of each type of event. And what is your pressure setting?

If you have only just started using your AirSense, you are still adjusting to Cpap therapy, and cannot say that it doesn't work for you.

Good point.

It's very common for newbies to come here and say they can't exhale against the pressure. I thought it was very difficult to exhale when I first started with CPAP. After a few weeks of acclimation, I couldn't even tell the machine was producing a pressure. I was thinking about this when I woke up this morning - I couldn't feel anything, but the machine was purring softly so I knew it was working.

[GrantT]

I've been fighting my CPAP machines (and my DME) for 5 years with this same issue and finally resolved it by purchasing a ResMed AirCurve 10 VAuto - been using it for about 2 weeks and not going back!

I had a F&P Auto machine to start (in 2012) which I thought may have been the issue (everyone suggested going to a Resmed), then a couple years later went to an S9 Auto which helped a bit with the EPR, but I still never really slept "good" - AHI was never less than 5, and still had "exhale" issues and lots of clear airways events flagged. DME said I was in the good range and was little help.

Couple weeks ago bought the ResMed AirCurve 10 VAuto (big fight with DME - don't ask - they said it would not help) and after a couple nights doing some adjustments, I am now sleeping like a rock, am actually dreaming again (haven't done that in years), and if the numbers matter, the last 3-4 nights my AHI has ranged from 0.13 - 0.92. My Clear Airways events have dropped down to almost nothing which seems to be the most significant change (other than no longer feeling like I am exhaling against a balloon).

Background on me...I'm not overweight (well, who couldn't use a few pounds) in good physical condition (I walk 30 minutes a day on a challenging up/down trail with a 30 pound backpack and another 30 minutes every evening, ride mountain bike, snowshoe etc.) but have a "thick" muscular build which impacts neck area. Also have very bad sinuses - on Pulmicort nasal rinse steroid, had turbinectomy etc. DME always just told me I didn't need BiPAP and getting one was a bit of a struggle, but I think some people just breath "differently" and it helps. I am also the kind of person that "holds their breath" when I am concentrating...I almost forget to breath while awake...not sure if that makes sense.

[metal36]

I've been fighting my CPAP machines (and my DME) for 5 years with this same issue and finally resolved it by purchasing a ResMed AirCurve 10 VAuto - been using it for about 2 weeks and not going back!

May I ask inhale and exhale pressure settings you had before and after making the switch from CPAP to BPAP?

As for the other suggestions, I will collect some data for a handful of nights, and post it here. My pressure setting is 8. I set the EPR to 3. I will sleep like that for a few more nights. Then I will try sleeping with pressure of 7, and EPR of 3, since that is the way to achieve lowest possible exhale pressure (4cm) on this machine. So far, I have had two horrible nights, which only improved after taking off the mask and sleeping normally. I have slept in late in order to recover from my sleep therapy =).

Sleep study 1 (normal sleep):
Arousals: 7.5/hr
Respiratory-related arousals: 7.5/hr
Total apneas: 8, of which 7 were obstructive and one was central.
AI = 1.5 apneas/hr
Hypoapnea index = 0.9/hr.
AHI =2.4/hr
RERA (respiratory effect-related arousals) index = 2.1/hr
RDI (respiratory disturbance index) = 8.3/hr
mean SpO2 = 95.3%
min SpO2 = 91%
periodic limb movements: 39/hr

Sleep study 2: (titration study, ranging from 5cm to 8cm, with 8cm being concluded as optimal. I don't know what kind of EPR was used.):
[It should be noted that in the first study, I was in a very hot room with a broken thermostat. In my general ill health, a hot room is the worst thing for my sleep quality. In this second study, I got the room with the working thermostat, and cranked it WAY down. That is a major reason for the improvements seen].

Arousals: 0.9/hr
Respiratory-related arousals: 0.9/hr
Total apneas: 6, of which 1 was obstructive and 5 were central.
AI = 1.1 apneas/hr
Hypoapnea index = 0.5/hr.
AHI =1.6/hr
RERA (respiratory effect-related arousals) index = 0/hr
RDI (respiratory disturbance index) = 2.6/hr
mean SpO2 = 96.1%
min SpO2 = 84%
periodic limb movements: 1.8/hr

In my opinion, the improvements from CPAP are really due to the room being colder and me just having a better night in general. You can see how much I was tossing and turning from my limb movement score in the first study. Central apneas went up with CPAP. I think there is every possibility current use of CPAP at home is just going to make things worse for me.