[CPAP] Trouble with leaks and pressure

[Kristin]

Just thought I would give an update. 
I ordered a soft cervical collar from Amazon. It was cheaper when including the shipping, and much easier to find . I just have to wait until the beginning of may to get it.
I have for a few days used the same settings. My sleep has become more fragmented, and I have had major leaks. I am a bit tired after getting too little sleep, so I am considering as follows: Go back to EPR at 2, and perhaps reduce the min pressure to 9 again (the same settings as the 17th).


As far as I can see, it seems like the flow inhale and exhale was better when EPR was set at 2 on the 17th.


My thought is that it might be better to try to use EPR 2 and gradually encrease the min pressure from 9 to 10 while trying to avoid the major leaks. Or I can stay at EPR 3 and just settle with min pressure at 9. I don't know what would be the best.

I am posting thumbnails from the last nights, and hope for some advice on the matter.

Thanks!

[Ron AKA]

Just thought I would give an update. 
I ordered a soft cervical collar from Amazon. It was cheaper when including the shipping, and much easier to find . I just have to wait until the beginning of may to get it.
I have for a few days used the same settings. My sleep has become more fragmented, and I have had major leaks. I am a bit tired after getting too little sleep, so I am considering as follows: Go back to EPR at 2, and perhaps reduce the min pressure to 9 again (the same settings as the 17th).


As far as I can see, it seems like the flow inhale and exhale was better when EPR was set at 2 on the 17th.


My thought is that it might be better to try to use EPR 2 and gradually encrease the min pressure from 9 to 10 while trying to avoid the major leaks. Or I can stay at EPR 3 and just settle with min pressure at 9. I don't know what would be the best.

I am posting thumbnails from the last nights, and hope for some advice on the matter.

Thanks!

If it was me, I would try a couple of nights with everything the same (min 10, max 19, EPR 3) but set EPR to Ramp Only. This will maintain the comfort of the EPR while going to sleep but will discontinue it when sleeping. It should reduce actual pressures by as much as 3 cm, which in turn should reduce your mask leakage issues.

If no EPR improves things, then you may be able to reduce the maximum and minimum pressures some. But don't do it all at once, or it will confuse things. The machine should reduce pressures by itself with the EPR off. You don't need to force it to do it.

[Kristin]

I think once you start using a cervical collar you'll see the those small clusters of events go away. As far as EPR setting I'd go with the one you slept best with. Either 2 or 3.
Just my opinion.

I finally got the cervical collar, and strangely enough; it's no problem sleeping with it. Thank you, Walla Walla- the clusters are gone!

Kristin

[Kristin]

I haven,t been able to get a soft collar yet, but it is a priority. I have to find out where to buy one. Any suggestions? 

Most pharmacies sell soft cervical collars. A good choice is the OTC soft cervical collar from Amazon for $12. It comes in three different heights and a good selection of neck sizes. There is a sizing guide to help you select the right size.

Thank you for the tip, it really was a good Choice for me!

Kristin

[Kristin]

I have had the best night in a very long time!  I would like comments on the development. Any further adustments? How is the flow and exhale? 
I seems that SleepyHead doesn't register the changes I have made lately, and it seems I can't make any changes to the settings on this forum either?

So to be clear. Last night the settings was as follows:

Mode: Autoset
Min pressure: 9
Max pressure: 18
EPR: On
EPR settings: 2


Kristin

Kristin, I didn't catch up with your last post where you posted the closeups of the flow rate.  Great shot, and this really explains why turning on the EPR worked so well for you last night.  In this graph we see extremely flow-limited breathing.  You can see that your inhale gets a good start, but then falls apart in that downward sloping and irregular peak.  This shows that as your breath proceeded airflow became increasingly restricted, and that rough top may even be snoring.  

When you added EPR, you gave yourself more inspiratory pressure support and that probably felt great and likely resolved a lot of what we see in this earlier graph.  Your inspiration/expiration time went from 2.3/1.4 to 2.06/2.96. That is almost equal and much more normal. I think with this progress, we might even want to try EPR at 3 and see if we can resolve that last bit of flow limit.  The best part of this is that your sleep has only one break compared to the fragmentation we see in the earlier session before EPR. This means you are more comfortable and sleeping better.

Your progress is very encouraging. Keep up the good work.  

Thank you for your help so far!
I have been working on your input for a couple of weeks.

I tried to set EPR at 3, but changed back to 2 after to nights (better comfort at the time). I also set max pressure to 20, just in case...
At the same time I changed the min pressure to 9.2.  I thought it might be wise to slow down the speed and try each step for a longer time. Then I got the cervical collar a few days ago. 

The first night I slept with the cervical collar I slept through the whole night (8 hours) without being awake. I can't remember last time that happened. I have been sleeping so much better the last couple of weeks! The clusters OA are gone. I have more CA than OA right now, AHI has been less than 2/hour.
Now I am thinking about reduse the max pressure and increase min pressure. Or not? It seems like the only time the max pressure rises close to 20 is when I have a major leak, and I try hard to avoid that. I find it difficult to increase the min pressure fast. I can go from 9.2 to 9.4 and work on that for a couple of weeks, but it might be better to increase the EPR to 3 and pressure to 10.2? I am posting the result from last night.
I would be grateful for your thoughts on the matter.
Kristin

[Kristin]

I didn't get any reply to my last post, so I will try again.

I have been using the collar for the last four weeks, and the clusters are gone. The pressure is still 9.2-18, EPR 2. My AHI is between 1-2, and my sleep is so much better, though still a bit fragmented. Before I changed the mode to autoset the flow limitation always went to max 1. Now it is reduced to max 50-60.  These changes has been a bit of a miracle to me, and I am so grateful to this forum for making this happen. 

My last visit to the hospital showed me that they don't check anything but pressure, leaks and AHI. No knowledge on clusters of OA nor flow limitation. and no interest in comfort issues. It was a huge dissapointment. 

I have tried to change EPR to 3 hoping to reduce the flow limitation further. And it does, but somehow my quality of sleep get worse. I don't know why (may 10th)

Last night I tried to reduce max pressure to 16. I didn't seem like I needed more. The only time my pressure have risen above 16 for the last four weeks is when I have had a major leak. During last night the pressure went to 16 twice, and both times because of flow limitation, I think. I wonder why?

I am posting Charts hoping for advice. Are these settings I have been using for several weeks optimal, or can I do better? Why do I experience worse quality sleep when achieving reduced flowlimitation using EPR 3?

I will also start another thread, asking questions about flow limitations, minut ventilation, tidal volum. I can't seem to understand it. But they seem important for me since I also have COPD?

Thank you.

Kristin

[Sleeprider]

Hard to believe this is the same person with the huge obstructive apnea clusters and very high flow limitation. I think flow limits are still and issue, but are considerably lower, and the apnea events are nearly gone. This is so much better, but your sleep and comfort has not improved. You respond to EPR in a positive way, but this is a case where I think bilevel (Resmed Aircurve 10 Vauto) is really likely to make a difference. With the bilevel you can get real pressure support, and we can alter parameters like time of inspiration, cycle and trigger sensitivity, as well as provide true pressure support. I think your best CPAP settings are going to be 10 to 14 cm with EPR at 3. This will somewhat limit the range but will remain effective and keep EPR lower. If you really thing EPR is a problem, you can try EPR at 2 and judge whether that is better.

If you were able to pursue bilevel, I would keep you at 8.4 to 14 with PS 4 to start and consider opportunities for adjusting some of the trigger and cycle settings. Your CPAP is working well, and I really think you need to continue on the same path you have followed in this thread, and consider a narrower range of pressure as suggested above. Give it time, and it should become better. I still think flow limitation is present and the kind of pressure support that would be needed to fully remedy the problem may require consideration of bilevel.

[Kristin]

Hard to believe this is the same person with the huge obstructive apnea clusters and very high flow limitation.  I think flow limits are still and issue, but are considerably lower, and the apnea events are nearly gone.   This is so much better, but your sleep and comfort has not improved.  You respond to EPR in a positive way, but this is a case where I think bilevel (Resmed Aircurve 10 Vauto) is really likely to make a difference.  With the bilevel you can get real pressure support, and we can alter parameters like time of inspiration, cycle and trigger sensitivity, as well as provide true pressure support.  I think your best CPAP settings are going to be  10 to 14 cm with EPR at 3.  This will somewhat limit the range but will remain effective and keep EPR lower.  If you really thing EPR is a problem, you can try EPR at 2 and judge whether that  is better.

If you were able to pursue bilevel, I would keep you at 8.4 to 14 with PS 4 to start and consider opportunities for adjusting some of the trigger and cycle settings.  Your CPAP is working well, and I really think you need to continue on the same path you have followed in this thread, and consider a narrower range of pressure as suggested above.  Give it time, and it should become better.  I still think flow limitation is present and the kind of pressure support that would be needed to fully remedy the problem may require consideration of bilevel.

Thank you, Sleeprider.

I will work on both topic. Bilevel will be hard to persue from the hospital at this point.  In the long run however… 
In the meantime I will continue to work on my settings, and give it time. Maybe I gave up too soon when trying EPR 3. 10-14 sounds Perfect, but I will probably Reach max pressure due to flowlimitations or leaks. I assume I can ignore that?

Kristin

[Kristin]

For the last month I have followed Sleepriders suggestions and used EPR 3 with min/max pressure 10-14. After a week or so, I really felt it worked well. Less fragmented sleep and longer sessions. Sometimes the pressure reaches the max, but only due to FL or leaks. 

My only consern right now is the CA's. In my sleep study (at home) I had no CA, only OA and H. However I have had a few, short CA (1-6 pr night) since I startet using CPAP. My OA's are gone, thanks to this forum and a soft collar. 

I have seen there have been a few threads about CA and EPR. Beacause of FL I do feel better with EPR on fulltime. At the same time, I am concerned because of an increase of CA's with longer duration ( up to 40 sec, but mostly shorter) and sometimes like small clusters.
 I am not sure what the best approach to this would be. Reduce EPR, change pressure or do nothing? 

After having been reading about CA's on this forum, it seems like it is common With CA's in the beginning of the treatment and that they usually are short like 10-20 sec, and then wanish after a while. It seems to me I am going in the wrong direction here?

       



Thankful for advice from you.

Kristin

[Crimson Nape]

Click on the "Events" tab, on the left under the date, and expand it for CA events. How long are they generally lasting in seconds? It will be the number in parenthesis "( )".