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Wish to have zero pressure at exhaling
#1
Wish to have zero pressure at exhaling
Hi,

I'm very sensitive to exhaling. The pressure that comes from the CPAP machine while exhaling drives me crazy. I tried few machines with various types of pressure relief while exhaling with no success. None of them was able to go below 4.

Is there a machine that can reduce the pressure to zero while exhaling?

Thanks,
Arik
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#2
RE: Wish to have zero pressure at exhaling
Not that I have ever heard of.
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#3
RE: Wish to have zero pressure at exhaling
Are you sensitive to the pressure or are you sensitive to the transition?

Specifically what machines have you tried?

Are you sensitive to blowing bubbles thru a straw in a glass of water? That is a serious question.

What are your pressure settings?

Have you tried a bi-level machine?

Can you provide a 2 minute segment of your flow rate chart and your full nightly charts for context?

I suspect your trouble is not with the pressure but with the transition to exhale. It is possible, though unlikely, that you have a condition where your throat collapses on exhalation. Detailed charts will help us see what is going on.

Fred
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
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#4
RE: Wish to have zero pressure at exhaling
Hi Fred,
 
Thanks for your response, here are answers to your questions:
 
Are you sensitive to the pressure or are you sensitive to the transition?
 
Answer: Don’t know.

Specifically what machines have you tried?

 
Answer: I tried Resmed AirSense 10 AutoSet for few minutes and could not get used to its exhaling “feedback”. Also I tried Sefam EcoStar for a month (excellent exhaling “feedback”, very noisy machine…) and then for the last month the PRISMA 20A.

Are you sensitive to blowing bubbles thru a straw in a glass of water?  That is a serious question.

 
Answer: No, I also passed lungs performance test with no issue.

What are your pressure settings?

 
Answer: 4 Min, 10 Max

Have you tried a bi-level machine?

 
Answer: No, I’m not familiar with bi-level technology.

Can you provide a 2 minute segment of your flow rate chart and your full nightly charts for context?

 
Answer: Attached.

I suspect your trouble is not with the pressure but with the transition to exhale.  It is possible, though unlikely, that you have a condition where your throat collapses on exhalation.  Detailed charts will help us see what is going on.

Fred
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#5
RE: Wish to have zero pressure at exhaling
It looks to me that 10 is insufficient max pressure, as your Obstructive Apnoea is not adequately treated, there are still snores and the machine spends a fair amount of time at the maximum pressure, I would like to see your minimum pressure at 8 and max pressure set at 20 ( you could start with the max pressure at 15 if it worries) I don't think the machine will reach its maximum if the minimum pressure is higher. Many people feel that they are suffocatiing with a minimum pressure of 4.


I know you tried a resmed and did not like the exhale relief but EPR on a Resmed does not provide any benefit if the minimum pressure is 4 as at 4 the machine cannot reduce pressure as the min pressure is 4. To get the correct feeling of EPR on a Resmed the minimum pressure needs to be 7 if you have an EPR of 3.
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#6
RE: Wish to have zero pressure at exhaling
Settings 1 and 2 of the softPAP breathing relief function are intended for patients who find exhaling against high pressure uncomfortable. The breathing relief function reduces the pressure early during the transition to expiration, allowing you to breathe out more easily. 
Setting 3 is suitable for patients who experience respiratory distress with a low pressure setting. The pressure is raised slightly during inspiration. You can select the setting for the softPAP breathing relief here or deactivate it if you do not wish to use the function anymore. 
• Setting 1: Low breathing relief 
• Setting 2: Normal breathing relief 
• Setting 3: Breathing relief with inhalation assistance 
This function is only available in CPAP and APAP mode. If it is not possible to select this function in one of these modes, it must be enabled by your physician or authorized dealer. 

Which softPAP setting are you using?  I think you have it set to Off.

By any chance do you have a copy of the Clinician Manual?  PDF format would be preferable. I would like to see it added to our collection.

Your detail views show Flow Limitation.  The way this is treated is with Pressure Support (PS) on a Bi-Level machine.  The ResMed Autoset EPR can behave like PS on a biLevel and this is one reason we really like it.  Your softPAP may give you some of the same benefits.

With CPAP we deal with the Flow Limits the same way we deal with Hypopnea and Apnea, by raising pressure.
I would set your range from 7 to 20 for a night, I don't think your max pressure will run away and this will show what your machine thinks it needs to treat your apnea.

Also your events look a bit clumpy, in clusters, which implies likely positional apnea.  We have seen this and it is easily and well treated with a loose fitting soft cervical collar to keep the chin from tucking.

There are several bi-level machines, They all have 3 basic pressure settings, Expiration Min, Inhalation Maximium, and Pressure support (PS) which is added to the expiration pressure to determine the actual inhalation pressure.  The different bi-level machines treat different conditions and are not interchangeable.  

from the user guide for your machine: BiLevel therapy device for the treatment of patients with obstructive, mixed, or complex sleep apnea, and a high and/or fluctuating pressure requirement, poor CPAP compliance The device has different pressure levels during inspiration and expiration. 

Fred
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

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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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#7
RE: Wish to have zero pressure at exhaling
(01-06-2019, 08:01 AM)Arik Wrote: Hi,

I'm very sensitive to exhaling. The pressure that comes from the CPAP machine while exhaling drives me crazy. I tried few machines with various types of pressure relief while exhaling with no success. None of them was able to go below 4.

Is there a machine that can reduce the pressure to zero while exhaling?

Thanks,
Arik

It is the exhale pressure (EPAP) that prevents obstructive apnea.  Pressure support (PS) or the difference between inhale-exhale (IPAP/EPAP) is what helps treat flow limitation and hypopnea.  So EPAP for OA, PS for FL and H.  Your charts show a LOT of flow limitation (flattened peaks on inhale) and a lot of obstruction (EPAP too low).  Central apnea is present in the current chart, but at low levels. It is possible that with EPR or pressure support, you are experiencing increased central apnea, or the "exhale effect" as you call it.  If so, that needs to be evaluated.  There is little doubt you need higher pressure, and it appears you will benefit from pressure suppoprt unless that causes central apnea, in which case you would need to move to ASV.

Your machine is really poorly setup for your needs. The minimum of 7.0 with EPR 3 is a good start as suggested by Jaswilliams with a maximum pressure of 12.  It would be really interesting to see your results with settings like that to see if it brings on centrals..
Sleeprider
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www.ApneaBoard.com

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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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#8
RE: Wish to have zero pressure at exhaling
Guys, before diving into your responses, let me raise again a question that bothers me a lot: I replaced my previous PRISMA machine with a same but a new one, using the same settings and all of a sudden my AHI index became completely different. I'm attaching two typical daily reports of the previous and current machines. note that with the previous machine, most of the AHI's were Central Hypopnea and almost none Obstructives.
Any idea why this happened?
Thanks,
Arik
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#9
RE: Wish to have zero pressure at exhaling
The data from the two machines look completely different why I don't know sorry. But the first machine was behaving completely differently. It was not detecting and Obstructive apnoea nor snores so was not raising pressure. The second machine is seeing OA's and snores so raises pressure and thinks it needs more. Which machine is right I don't know, but the numbers from your old machine indicate you don't need a CPAP min pressure 5 which does not raise overnight.Second machine very different, maybe talk to your supplier and ask them.
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#10
RE: Wish to have zero pressure at exhaling
Unless the manufacturer changed their algorithm. . . 

Based on the Previous machine I would say you purchased the wrong machine.

Do you have access to a ResMed Autoset?  Why, so we can see a night with a machine that is different.  I, like you, am questioning the accuracy.  Based on the machine I would suggest totally different paths.  I would suspect the old machine is wrong, but that is a guess based mostly on age.

Fred
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

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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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