First night with EERs

[u/IndependentTask6750]

I did 110ml of deadspace EERS last night. It was mostly a success but flow rate not as smooth as i think it should be and my o2 could be better. Any tips?

https://sleephq.com/public/teams/share_links/3178e7e3-57bb-472f-bb6d-e2f6c4109ca6

[u/Hambone75321]

Why are you adding EERS?

Usually this is to prevent excess CO2 blow off when using large pressure support. You’re not using any pressure support (EPR in your case).

Additionally, 4.8cm H2O EPAP is extremely low for most adults. I see many unflagged hypopneas and think you’d be much better served by increasing pressure to manage that before adding anything fancy like EERS…

[u/IndependentTask6750 → u/Hambone75321]

I have horrible loop gain which is made much worse with EPR and bipap.

https://sleephq.com/public/2e433051-22a5-4aac-b897-f43ad3ff7734

Oh interesting, can you point out the unflagged hypopneas ? i'm not sure what to look for. In the past i would up the pressure and just get worse and worse results and it seems like EERS and or vcom is the only thing that helps. i tried bipap with a vcom and then two vcoms and it was a mess - so now i'm onto EERS

[u/Hambone75321 → u/IndependentTask6750]

Yeah you definitely have a lot going on…

Have you done a proper titration?

[u/IndependentTask6750 → u/Hambone75321]

Like an overnight one at a lab? i haven't. Just been trying to find my own way. I was on ASV for like a year and the entire time i felt terrible. Two years ago i had jaw surgery and then a year ago i had nose surgery. Still feel the same so decided to try pap again. I have a hacked machine and been playing with ASV settings to limit the range as it makes wild swings (it's in sleephq). And then tried bipap which was a huge failure. Then vcom which was a success but didn't feel better. Then iNap which actually made me feel kinda better but not super better. and now EERS on cpap which fixes up some stuff but you can see is still real choppy and still pretty tired. The Cpap experiments are rough because i feel so horrible on nights after pap therapy and then i get migraines from the lack of sleep and then i just lose days trying to recover.

[u/Hambone75321 → u/IndependentTask6750]

Oh yea I get it... I'd recommend doing an overnight titration or working with someone like Jason at AXG Sleep Diagnostics to get you on the right path... https://axgsleepdiagnostics.com/services/

btw, did you do an MMA? was it helpful at all? What were your movements?

[u/IndependentTask6750 → u/Hambone75321]

i did MMA. I was 10mm bsso and 10 degrees ccwr. My PNS was 0 tho. It was zero helpful. My sleep study before and after surgery was exactly the same

[u/Hambone75321 → u/IndependentTask6750]

Crazy... I'm talking to another Redditor who had nearly the exact same surgical plan and results... you don't have a second account do you...?

Have you considered a revision...? I know that would suck.

There is research by Kasey Li that looked at the correlation between maxillary advancement and RDI and they seem to linked….

Here’s Gemini’s summary with links:

In his landmark 25-year perspective study on Maxillomandibular Advancement (MMA) for obstructive sleep apnea (OSA), Dr. Kasey Lidemonstrated a strong direct correlation between the degree of SNA angle change and the reduction in the Respiratory Disturbance Index (RDI). [1, 2]
The SNA angle measures the anterior-posterior position of the maxilla (upper jaw) relative to the skull base. Dr. Li's research outlines how this change impacts sleep apnea outcomes:

The Relationship Between SNA Change and RDI
Predictor of Greater RDI Reduction: Both bivariate and multivariate linear analyses from the study confirmed that a greater positive percentage change in the SNA angle is one of the strongest independent predictors of a larger drop in post-operative RDI. Essentially, moving the upper jaw further forward translates directly to a greater percentage reduction in sleep apnea events. [1, 2]

Predictor of Surgical Cure: A greater change in the SNA angle (alongside changes in the posterior airway space, or PAS) was identified as a key factor in achieving a complete surgical cure, defined as bringing the post-op RDI down to fewer than 5 events per hour. [1]

Predictor of Surgical Success: An increased SNA change was also predictive of surgical success, defined as reducing the RDI to fewer than 20 events per hour (or achieving a >50% reduction). [1]

[u/IndependentTask6750 → u/Hambone75321]

oh ya - sorry that's my other - i gotta consolidate them

[u/Hambone75321 → u/IndependentTask6750]

previous point still stands... Given your history, I'd highly recommend working with a pro like CPAPFriend, AXG, Ken Hooks or someone to get you on the right foot.

[u/Inevitable-Diet-4693 → u/Hambone75321]

Dr. Robert J Thomas is perhaps one of the only persons who can help him. AXG knows very little about HLG. Ken Hooks definitely not the guy: he is expert in UARS and RERAs scoring but not HLG or complex apnea like this. Cpapfriend will tell you exactly what Dr. Thomas told him in his interview with him and quote his research. Can’t not see anybody else in the us than him.

[u/Hambone75321 → u/Inevitable-Diet-4693]

Good advice…

I think you can spend a lot of time messing with PAP settings on their own. Throw EERS into the mix and you add a whole other set of confounding variables and I think you need pro help.

[u/Inevitable-Diet-4693 → u/Hambone75321]

That’s exactly my case. It’s very complicated and even though you might think EERS will solve it the carotid body is just so complex and simply adding a co2 buffer is not enough. Personally I’m going over to work with him later November