EPAP - Expiratory Palatal Obstruction (EPO) settings question

[gcritchley]

Hi all - i have strong suspicions that I suffer from Expiratory Palatal Obstruction (EPO, as defined below by Dr Steven Park. I usually wake myself up with the sound made during exhalation, and don't typically have many O2 desats, also indicative of this condition. My issue is mostly sleep disruption, and I have been diagnosed with Mild (8AHI) sleep apnea.

Definition:

Palatal Prolapse[1], also called Expiratory Palatal Obstruction (EPO)[2] and Expiratory Regrograde Palatal Prolapse[8], is a sleep disorder where the soft palate swings (prolapses) towards the nose during expiration

My research shows recommendations of machine settings or devices which apply pressure upon exhalation only (EPAP), and no pressure on inhalation as is standard. 

I own two machines, both Resmed - an Airsense 10 and a VAuto. Can either of these two machines provide EPAP only with little to no pressure against inhalation? The same article mentions "PEEP mode" but I'm unaware of that setting being available.

Thanks for any input!

[Sleeprider]

You are suggesting reversing the pressure support and both of those machine work identically to provide pressure support upon triggering inspiration and follows your breathing. There is no machine I am aware of that does what you say, and in fact, this is the first time I have ever heard of such a proposal. I don't believe there are ANY studies to support this option, and Dr Park is a surgeon, so he is not generally inclined to PAP in repairing PP. We see the pattern fairly often, and it can have several origins. Oral expiratory breathing (Fischer Paael calls it puffing) has the same appearance, as does post-nasal drip which causes the same shunting of flow as PP. I have suffered with the latter, and eventually found Flonase (fluticasone propionate) seems to provide relief in a couple days and lasts as long as needed. I'm not going to doubt you have PP, but it's certainly worth eliminating those other potential problems which present the identical flow pattern.

[sheepless]

from what I've read on this site over the last 4 years or so, pap won't help palatal prolapse. I hope I'm wrong and someone has the solution but I'm not aware of it. the autoset and vauto can be set to achieve a single pressure but I don't know any way you can have less ipap than epap.

[Sleeprider]

from what I've read on this site over the last 4 years or so, pap won't help palatal prolapse. I hope I'm wrong and someone has the solution but I'm not aware of it. the autoset and vauto can be set to achieve a single pressure but I don't know any way you can have less ipap than epap.

Even if that is the case, we should not rely on a user's self-diagnosis because he read it on the forum and seems to match up with his perceived symptoms.  There are a few things that can cause this cutoff of expiration, and it seems prudent to eliminate the easy stuff first, and rely on a proper exam before jumping to this conclusion. I think it is completely fair to point out that this user has NEVER shown a chart that remotely suggests palatal prolapse, and the main thrust of his therapy thread was to alleviate flow limitation, which we did.  I really think Gritchley needs to get back to his therapy thread and work this out there. http://www.apneaboard.com/forums/Thread-...eep-report?

[sheepless]

I assume that's a criticism since you quoted me when if fact I merely responded to the OP's questions. I didn't leap to conclusions, diagnose or suggest resolutions.

[gcritchley]

from what I've read on this site over the last 4 years or so, pap won't help palatal prolapse. I hope I'm wrong and someone has the solution but I'm not aware of it. the autoset and vauto can be set to achieve a single pressure but I don't know any way you can have less ipap than epap.

Even if that is the case, we should not rely on a user's self-diagnosis because he read it on the forum and seems to match up with his perceived symptoms.  There are a few things that can cause this cutoff of expiration, and it seems prudent to eliminate the easy stuff first, and rely on a proper exam before jumping to this conclusion. I think it is completely fair to point out that this user has NEVER shown a chart that remotely suggests palatal prolapse, and the main thrust of his therapy thread was to alleviate flow limitation, which we did.  I really think Gritchley needs to get back to his therapy thread and work this out there. http://www.apneaboard.com/forums/Thread-...eep-report?

HI - I"m wondering what you're defining as a "proper exam?" You mean a sleep study? I also wasn't aware that PP would show up in the Oscar charts in any definitive way. I've had three sleep studies and they don't show PP. Many don't believe they exist.

what I do know is this - I stopped using my CPAP entirely about 4 months ago, because my sleepiness wasn't getting better. Even my doctor said that my mild apnea shouldn't present the fatigue I'm experiencing. I felt, and still feel better, without CPAP, but there's still lingering fatigue, but it's actually slightly better without CPAP. 

Most of my last thread (which you suggest I finish, when it is finished) was tightening up any lingering aspects of my CPAP therapy that might explain that lingering fatigue, but alas, it didn't, so I started looking elsewhere - thyroid, other suspicions. Meanwhile, when I lay my head down (day or night), and when I breathe out my airway closes even when I'm awake. I also wake up to the sound of my airway closing in the same way. I have read that this flags as a central, which I seem to have many of. THis would in fact explain my fatigue - multiple wakings. 

I tried Theravent EPAP last night, and it was helpful - however, they have ceased production, and I have a few left in a sample box only. But the EPAP concept seems to fit - if I breathe out AGAINST pressure, I can't make my airway close even when I try. Without pressure, it happens immediately, on my side, my back - doesn't matter.

hence my question - which still stands. If I could make my CPAP machine (either model) provide some pressure on exhale, I bet this would be game over. Yes, it's a hunch, but it's based on hours of reading here and elsewhere about the symptoms, but that's what led me to this forum in the first place. I was treating Apnea before i was ever diagnosed with it. 

By the way, I do use flonase nightly, along with breathe right strips. I think both have helped. But there's still a reason I'm tired all day, and it affects my functioning. Getting there via CPAP didn't do it, despite the charts and how good they looked. Something else is up. Can I not ask for help and share experience about that here? In my mind it warranted a new thread with a new line of investigation. 

As always I greatly appreciate the help and support offered here, as we all look for ways to feel better.

[Sleeprider]

Palatal prolapse is not a common condition, and its diagnosis is mostly done by an ENE (Otholaryngologist) using a nasal endoscope, and might be done under anesthesia to observe the mechanism of obstruction. No sleep study that I am aware of recognizes or diagnoses PP. I should not have been quite so harsh in my reply, but this old thread had to do with a no-longer active member with a unique problem. By tapping into it with your assumption your problems are related to palatal prolapse you left behind all the history in your therapy thread that clearly shows that is not likely the case.

[sheepless]

"If I could make my CPAP machine (either model) provide some pressure on exhale, I bet this would be game over."

gcritchley, no one on this website should be in the business of diagnosing, even if they were qualified, which few if any are. it's your prerogative to inquire about and pursue anything you think might be related to your apnea, cpap and sleep. it's up to each of us to decide what feedback applies to our situation knowing as recipients of advice, guidance, suggestions and reports of the experiences of others, we act upon them at our own risk.

anyway, from what I've read here it won't solve pp, if that's actually your problem, but if you want to experiment with higher exhale pressure, just raise min epap in the vauto and turn off epr (and secondarily try raising min but since that's ipap I'm not at all sure that'll help) in the autoset. vauto will likely be more effective.

finally, as Sleeprider implied, look for the pp pattern in your flow rate and post a screenshot if you find any.

I'm not a moderator but wonder if this thread should be combined with your main therapy thread.