EPR or not EPR

[zonk]

EPR useful or useless

I,m leaning towards the useless camp, sound more like a marketing ploy to me
I understand can helps some people experiencing problems with exhaling against the pressure and bloating (aerophagia), for these people might be better served with bilevel machine with true pressure relief (pressure support), not some imitation lookalike (or even APAP)

Regardless what manufacturers call their own brand of pressure relief feature and some fancy description 'natural breathing experience', EPR works on the principle lowering the pressure on exhale, might sound nice on paper but in fact lowering pressure have a negative effect and for that reason, EPR get suspended during an apnea event but that would take the machine few valuable seconds to do so providing the machine is data capable machine and not Escape, Plus or some other useless brick

IMO, we should have one machine does the following and data capable too (no bricks please)
constant pressure, apap, bilevel, and auto bilevel

That would an ideal setup and save money on the way but manufactures, insurance and suppliers not going to like the idea, the more machines they sell, more money they make
Try this machine so you fail and try another machine and you fail that too before dispensing the correct machine, providing by this stage have not given up on PAP all together, like many people ... crazy crazy

One machine does it all ... who heard of such absurd idea

[retired_guy]

I think you're right about the one machine fits all, but they would probably sky-rocket the price for it.

As far as EPR is concerned? I did not use it in the beginning and did fine. But something Roby Sue said struck a note in me regarding using EPR in somuch as I have emphysema. With emphysema, the problem is not so much you can't "breath in," but you can't "exhale" completely. So I turned on the EPR just to see what it does. I like it. In fact, I turned it off awhile back and my body was not happy. With it on, I do not have that full tummy feeling I used to have, so that's good too.

Would I be better off with a bilevel? Well, probably not, since my ahi is negligible, and I sleep like a new born babe. But if I had one I'd probably try it just to see what it does.

[zonk]

Would I be better off with a bilevel? Well, probably not, since my ahi is negligible, and I sleep like a new born babe. But if I had one I'd probably try it just to see what it does.

Your guess is good as mine, the proof of the pudding is in the eating

My titration said pressure 9, because of flow limitation recommended a bit higher but nothing said about EPR or if ever been used

Do they use EPR during titration studies or that might skew the results

[herbm]

I pretty much find EPR to be irrelevant.

Turned mine down to 0 to get a small AHI decrease, and then back to one with no change.

[robysue]

EPR useful or useless

Answer is: It depends on the person.

Some people have no problems exhaling against the full positive air pressure of their prescription. Others do. Why some people have trouble and others don't seems to be a mystery. For some people, like retired_guy, there may be another medical condition that explains or contributes to the difficulty. For others, like me, there really doesn't seem to be an explanation.

EPR (or C-Flex+ or A-Flex) can be also be a useful tool in helping some people conquer aerophagia. (And yet, for others, EPR or Flex simply adds to the misery of aerophagia.)

So for some PAPers, EPR or Flex is a critical tool for being able to breathe comfortably with the machine all night long. For others, it really is pretty much useless.

But since you can always turn a feature that you don't need OFF and you can't turn something that is not available ON, I think it's important that all machines have some form of EPR. And so I don't think it's a marketing ploy. Rather I really do see it as a feature designed to help improve compliance amongst the folks who have trouble becoming compliant because they have trouble fully exhaling against the positive air pressure.

Regardless what manufacturers call their own brand of pressure relief feature and some fancy description 'natural breathing experience', EPR works on the principle lowering the pressure on exhale, might sound nice on paper but in fact lowering pressure have a negative effect

The negative effect of EPR on most people's therapy is negligible; for most people, the airway does not become drastically more likely to collapse just because EPR has been turned on. And the comfort level for some people improves dramatically with EPR. And as comfort goes up, so does compliance.

And if you're in the minority of people who both like EPR and who find that the AHI does increase when EPR is turned on, there's an obvious solution: Increase the pressure setting by the EPR setting. You see, its the perceived drop in the pressure that makes it easier to exhale for many of us. In other words there are folks who will find it easier to fully exhale if the pressure is set to 12 with EPR = 3 so the EPAP = 9 rather than simply having a fixed pressure of 9 throughout the entire breath cycle. I know that may sound strange to those of you who find EPR useless, but a drop in pressure does make exhaling against the pressure easier.

IMO, we should have one machine does the following and data capable too (no bricks please)
constant pressure, apap, bilevel, and auto bilevel

Actually such machines DO exist and they're called the S9 VPAP Auto and the PR System One Series 60 BiPAP Auto.

Both of these auto bilevels have modes for CPAP, bilevel, and auto bilevel. While technically neither has an APAP mode, both the S9 VPAP Auto and the PR System One Series 60 BiPAP Auto can have the auto bilevel settings set in such a way to make the machine run in APAP mode:

On the VPAP all you have to do is set PS = 0, and then you've got an Auto Set (with no EPR) running in the range min EPAP to max IPAP. If you want to mimic an Auto Set with EPR = 1, 2, or 3, then you use VPAP Auto mode with the PS = 1, 2, or 3.

On the System One Series 60 all you have to do is set min PS = max PS = 0, and then you've got you've got a System One Series 60 Auto PAP (with Bi-Flex acting as A-Flex) running in the range min EPAP to max IPAP.

So the problem is not that these machines don't exist. The problems are (1) the billing code for the VPAP Auto and BiPAP Auto is NOT the same as the billing code for CPAP/APAP and (2) the cost of a VPAP Auto and BiPAP Auto is about twice the cost of the APAP in the same line.

And of course, the VPAP Auto and BiPAP Auto don't do all the fancy (and expensive) stuff the ASV machines do. But that's another whole kettle of worms.

[robysue]

Do they use EPR during titration studies or that might skew the results

It depends on the lab.

The AASM guidelines don't say anything about whether to use EPR/Flex during a titration study.

But the clinical manual and training materials provided by Resmed for their titration machine "suggest" using EPR on all titrations. Likewise the clinical manual and training materials provided by PR for their titration machine "suggest" using the appropriate Flex on all titrations.

[diamaunt]

And of course, the VPAP Auto and BiPAP Auto don't do all the fancy (and expensive) stuff the ASV machines do. But that's another whole kettle of worms.

the sad thing is that the elite, vpap auto and vpap adapt all have *exactly* the same hardware inside, just different firmware (or firmware settings) and label on the back.

yet the huge price difference.

[Moriarty]

Meh....

Horses for courses I reckon...

If you like it use it. Thats the advantage of a data capable machine, SleepyHead software, and an analytical mind.

I started without it.... then set it to 3 for the last 12 months or so with the Pilairo... then to 1 since I got the Pilaro Q that seems to have a bit higher resistance on exhale.

(That sounds counter-intuitive but I reason that if the back pressure of the diffuser on the mask is too high then, if the EPR is too great, exhalation will go back down the hose and perhaps lead to a degree of re-breathing).

[zonk]

And of course, the VPAP Auto and BiPAP Auto don't do all the fancy (and expensive) stuff the ASV machines do. But that's another whole kettle of worms.

the sad thing is that the elite, vpap auto and vpap adapt all have *exactly* the same hardware inside, just different firmware (or firmware settings) and label on the back.

yet the huge price difference.

That is exactly the point

[zonk]

While ResMed EPR and Phillips Flex talked about a lot but not much about DeVilbiss Intellipap SmartFlex and Fisher & Paykel SensAwake.
All trying to do the same thing with the exception of F&P in a different way and all provide studies which they sponsor to support their claim

DeVilbiss Intellipap SmartFlex
This device offers patented SmartFlex® technology which offers three comfort settings, with each setting equating to an exact 1 cm H20 drop in pressure upon exhalation. DeVilbiss SmartFlex also features patented Flow Rounding which changes the slope of the pressure waveform during the transition from prescription pressure to the SmartFlex setting and vice versa. This enables a smooth transition and decreases the likelihood of waking the CPAP user. There are six levels of flow rounding with level 0 having the steepest slope and quickest transition and level five having the gentlest slope and slowest transition

Fisher & Paykel SensAwake
SensAwake promotes better overall sleep.
We all experience subconscious waking through the night - at which time pressure intolerance is likely to occur



Responsive Pressure Relief

Whereas other pressure relief technologies provide partial relief during expiration, SensAwake provides a prompt and significant relief in pressure to the lowest most comfortable level upon waking. This eases the return to sleep and allows effective treatment to resume.