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Understanding epr
#1
Understanding epr
I understand that to reduce hypopneas and flow limitations and rera’s we increase epr or pressure support.  Can someone explain why doing this that these events are reduced?
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#2
RE: Understanding epr
I think the basic idea is the pressure differential better matches natural breathing.
Caveats: I'm just a patient, with no medical training.
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#3
RE: Understanding epr
Yankees, the use of pressure support in bilevel therapy as the primary tool for reducing flow limitation and hypopnea comes from the titration protocols of both Resmed and Philips. In VPAP or BiPAP the manufacturers instruct sleep technicians to increase EPAP for obstructive events, and to increase IPAP (pressure support) for hypopnea or RERA.  The fact that the Resmed Airsense EPR algorithms are identical to the Aircurve pressure support with Easybreathe was my own epiphany some years ago as I had access to both machines, and started to coach users of the Airsense CPAPs to use EPR in the same way as we use PS.  After seeing repeatable results in many members of this forum, the general consensus here is that EPR is more than a comfort setting and has therapeutic value, at least as far as the limit of 3-cm of pressure support can provide.

The current wiki for OSCAR flow limitations was derived from a wiki I wrote some years ago, and the example charts are still Sleepyhead http://www.apneaboard.com/wiki/index.php...imitations  and that article branched from the Beginner's Guide to Sleepyhead flow limitation section http://www.apneaboard.com/wiki/index.php...imitations  

Pressure support works to overcome inspiratory flow limitations which are common precursors to RERA and hypopnea. As a person inhales, flow can become restricted by the size of the airway or even congestion, inflammation etc. It is like drinking a milkshake through a straw. If the straw kinks, collapses or even bends, flow will slow or stop given the same sucking (inspiratory) effort.  In fact the harder you suck with an obstructed tube, the more likely the tube will fully collapse and stop flowing (apnea).  Pressure support can assist breathing effort, and as inspiratory flow builds, so does pressure support. This can normalize the flow that would otherwise flatten out.  EPR works the same way, but is limited in the amount of assist it provides.  Many people do great with 3-cm of pressure support, but others may need 4, 5 ore more to overcome the restrictions in their airway.  So the concept of EPR is inherent in bilevel titration protocol, but requires some thinking outside the box. You won't find many doctors or suppliers that recognize this significant difference in Resmed CPAP technology, and even Resmed does not make any claim beyond comfort.
Sleeprider
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#4
RE: Understanding epr
Thanks a lot SR for that excellent explanation.  Is there such a thing as expiratory flow limitations and if so how can you see this on the charts and what is the treatment?
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#5
RE: Understanding epr
They exist, and a search will show you they are associated most often with COPD. Maintaining a low EPAP and preserving time for expiration are the usual strategies. https://www.hindawi.com/journals/pm/2013/749860/ Another interesting but unrelated condition is Catathrenia https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2276742/
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files
Mask Primer
How To Deal With Equipment Supplier


INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#6
RE: Understanding epr
Thanks again SR, so much to learn.
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#7
RE: Understanding epr
I experience flow limitation in my nose during exhalation when lying down. It can be difficult to finish exhaling before I’m ready to take the next breath. Nevertheless, I sleep much better when breathing through my nose instead of my mouth.

Beyond just what is needed to keep my throat/trachea open, I find that pressure support helps a lot with keeping my sinuses open. 

I’m pretty well dialed in at 4.4 cmH2O. My min EPAP is 10. That means when I inhale, the pressure rises to 14.4. When I exhale, it drops to 10. For me, that combination feels very comfortable and natural, both inhaling and exhaling.

With a narrower range, let’s say EPAP 11 and IPAP 13, I’m ok if there is no swelling whatsoever in the turbinates of my nose. Unfortunately, that’s rare, and at that setting I often feel like I’m working harder to inhale and exhale. If I switch to an F20 so I can mouth breathe, I feel horrible the next day.
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#8
RE: Understanding epr
What are your timing settings?
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#9
RE: Understanding epr
[deleted to avoid sidetracking OP’s topic]
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#10
RE: Understanding epr
Also, I did find that increasing the pressure support slightly actually seemed to reduce swelling of the turbinates, sort of like a compression sock.
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