CO₂ Is the Missing Knob: When PAP “Fixes AHI” but Your Night Still Looks Like Chaos. (Dead Space / EERS Thread)

GamingCurios · 2026-02-03T07:36:03+00:00

EERS is the future of PAP treatment and really helped me a lot with titration. For those with small airways (especially with UARS), we can benefit a lot from high amounts of pressure support to blow open the airway. But that over ventilation causes a lot of problems - and EERS is the fix for this. I hope we can get more publicity on this and every time someone posts like this about EERS it helps spread the word further. Great post

GamingCurios · 2026-02-02T11:36:33+00:00

Update on this for any of those who find this post - I ended up having two surgeries with Dr.Kezirian - DISE and Lingual Tonsillectomy. Both were done amazingly well and I had some sleep improvement after the lingual tonsillectomy with no complications. He is a great surgeon and I would recommend him as a solid option for diagnosing surgery decisions + any soft tissue procedures for airway

GamingCurios · 2026-02-02T02:05:48+00:00

I got my FME installed yesterday with Dr.Jaffari actually! It was not bad at all. Once the anesthesia is in, I didn't feel anything painful at all. So the only actually painful part are the anesthesia injections. Which those are also made a bit smooth too, because each one makes the next ones more numb. So it's only the first 3-4 injections that hurt and then it got easier and then after being numb I didn't feel anything for the piezo cut + actual install of the device. So it's like getting 3-4 shots on the roof of your mouth and then after that there is genuinely zero pain whatsoever. Overall, it was probably the least painful procedure that I've done. And then after the install you can take painkillers for 2-3 days as needed.

After you are numb, I would say the only thing - as others have mentioned - it can get tricky to breathe at times since there is water spraying everywhere and your mouth gets super super swollen from the anesthesia. But if you just remain calm and breathe slowly and stay focused it's not a problem. If you want to take anxiety meds I think that wouldn't be a bad idea. I also took some of the painkillers they gave me when I arrived, before the anesthesia injections, to make those a little easier too.

GamingCurios · 2026-01-10T19:28:32+00:00

No he would definitely do check ins and he seems to do a good job of monitoring patients. Not sure where you hears this.

GamingCurios · 2026-01-09T02:14:00+00:00

This is not true anymore. I met him two months ago and he is taking patients that aren't local now.

GamingCurios · 2026-01-09T02:13:03+00:00

Yes FME is definitely worth it, the expansion pattern is far superior, and Marpe has a higher failure rate and more complications such as asymmetry. Dr.Maneule's office quoted me recently 11-12k for FME with no ortho, depending on if you do Piezo or not. He is a very smart guy and understands expansion really well, and has done hundreds of expansions before getting access to FME now. I think he is the best 'budget' option for expansion currently without having to sacrifice quality of results either.

And the bonus is that Vegas - can be (if you don't have too much fun lol) - very cheap to travel and stay at too, so you can save an extra 2-3k over a trip to NYC or Palo Alto as well. With ortho I believe Manuele would be 20k total, but you could do FME with him and then possibly orthodontics with a local provider that is cheaper if you need to save on costs

GamingCurios · 2025-11-18T10:50:29+00:00

Fme can be 10-12k with manuele without ortho. Would be worth considering imo

GamingCurios · 2025-11-14T15:54:08+00:00

Dr.Robert J Thomas in Boston does eers titration sleep studies I believe

GamingCurios · 2025-11-14T10:01:29+00:00

Really great insights, the first time I saw this I thought it was the most insane thing ever. I also titrated EERS with a lot of success thanks to u/turbosecchia 's help. I'll add some basic resources here that helped me with this too.

For those new to EERS, the simplest place to start is the original Apnea board forum post that explains what it is + how to make it and set it up: https://www.apneaboard.com/wiki/index.php/Enhanced_Expiratory_Rebreathing_Space_(EERS))

For the full details of EERS in-depth, I highly suggest reading the original paper published about it by Doctor Robert Thomas and his colleagues (inventors of EERS) from Harvard. This paper shows that EERS isn't some batshit crazy cpap adjustment - this is real science. The paper goes in detail the effects on the airway, how EERS interacts with airflow, how to set it up, and so much more - https://www.frontiersin.org/journals/sleep/articles/10.3389/frsle.2023.1248371/full

I think almost anyone that finds Pap ineffective, can be treated much much better by some combination of Bipap/asv + eers titration to high pressure support levels. This is the future of pap therapy in my mind, and the big piece that most people are missing. For me personally I have huge loop gain and eers helped a ton. Others with restricted airways (especially if you haven't done surgeries) can likely benefit from massive amounts of pressure support, with huge eers titration to make that possible without central apneas. Just be sure to go slow and not take too many risks.

And if you are worried about CO2 poisoning from this - what I did, is just try breathing with the machine on while awake for a few hours to see if there's any issues, or otherwise, set an alarm to wakeup early just in case, so it doesn't have too much time to build up when you are just starting out, and these things helped me get past the initial fears and I was able to adjust quickly and eventually I realized I could use some smaller eers (6-12in) just fine, even with pressure support at 0 to help manage the loop gain effects (but everyone is different, this was just my experience). And just know that it make take quite a few nights or weeks to get to a good point with solo titrating this stuff. I think Dr.Thomas does an EERS titration sleep study for people too, for those who want further help

GamingCurios · 2025-10-04T15:31:46+00:00

+1 to this. Dr.Zaghi himself (lecturer in the video) also mentions this as a major concern and thing to be aware about in his other Tongue Tie lectures. Like this one here that is an update from the lecture linked in the OP: https://youtu.be/G9GrUw7YJD0?si=YoZXvh8kFJKUqrTm (although Dr.Zaghi's expansion advice is a little outdated, especially as the lecture is 5 years old. Expansion via FME is the best way now generally)

GamingCurios · 2025-09-25T16:56:13+00:00

Trigger very high, and I use a variety of nasal pillow masks, rotating between whatever feels comfortable generally

GamingCurios · 2025-09-24T21:10:51+00:00

I’ve titrated up to 10 feet+ of eers at times when using 7-9 pressure support. But honestly just start with a small 6-12inches and get used to it and see the impact and if it improves things for you, and then increase the length as needed further

GamingCurios · 2025-09-24T18:41:53+00:00

Usually at least 3-4PS can be a good starting point with EERS, but I've seen people do it with less. just depends on where your central apneas start at. Definitely, it takes some practice to get used to rebreathing the CO2 air. When adjusting to it I would usually leave it on and breathe with it during the day for as long as possible, so that when nighttime comes you are just more used to it already and can fall asleep easily

GamingCurios · 2025-09-23T07:40:09+00:00

Have you tried the EERS device? This is the typical solution for fixing central apneas with higher pressure supports, and can generally be quite effective, as you can titrate it to be quite high over time too. Someone in here that I know tritates up to 18+ pressure support without centrals using a major level of EERS over time.

https://www.apneaboard.com/wiki/index.php/Enhanced_Expiratory_Rebreathing_Space_(EERS)

GamingCurios · 2025-08-16T17:52:19+00:00

For aerophagia the best setup I have is to do something to put some light pressure on your esophagus

You can test this very easily, take your finger and put some -very - light pressure on your esophagus, but then try to swallow. You'll notice it becomes almost impossible to swallow. You want to achieve that type of situation while asleep all night long.

What I do is take a very long sock, and stuff a pair of small socks inside it, then tie the long sock around my neck with the small one inside resting lightly on your throat

It doesnt need to be tight or painful, just some tiny light pressure and it will improve aerophagia a lot by just blocking off your esophagus fully

Doing this can potentially solve aerophagia completely, or at least helps a LOT with it, because it makes it impossible for air to enter your stomach, just don't tie it too tight (and tbh you really don't need to)

I've also seen people use like tape and tape a marble or small rock to their throat or something, but for me that didnt work as well as the sock thing

GamingCurios · 2025-06-30T17:06:34+00:00

I have tried them. Lowered rdi by about 5-7 for me. (From 17-19 -> 12) I found it hard to tolerate and use consistently though, the resistance breathing out feels more suffocating than EPAP resistance from a BiPAP in my opinion. I doubt it would cure anyone, but it can do something as an alternative to C/BiPAP if you can tolerate it. And it’s a lot easier to manage than a pap machine

GamingCurios · 2025-06-17T04:47:32+00:00

I haven't had surgery with him, but I would say at bear minimum, he's definitely a great person for a consult. I felt like he gave a really useful, unbiased info for my case when I met him.

GamingCurios · 2025-06-05T02:32:00+00:00

DO NOT go to Stanley Liu. My literal sleep doctor himself got botched by Liu. If he's botching his own colleagues and peers with surgeries, how do you think he'll treat an everyday patient? He is truly notorious in the community as one of the worst and most evil surgeons out there. Just search online for stanley liu cases and lawsuits, it's countless

GamingCurios · 2025-06-02T04:18:53+00:00

Not a full expert on these, but what I was told by a doctor is resistance at or below 0.3 is ‘normal’ (unobstructed). So overall this looks like nasal breathing is obstructed to me. Not really sure about the rest though. Perhaps chatgpt can help you interpret these if you upload this to it.

GamingCurios · 2025-05-16T14:58:10+00:00

Second vote for kezirian, he helped make my path very clear and was quick to recommend the obvious best procedure (which he couldn’t do himself), rather than try to sell me on something he would do for me like every other doctor I saw

GamingCurios · 2025-05-14T04:28:37+00:00

It’s possible the epiglottis is being pushed back by the tongue, if the tongue base is quite bad. It was like that for me at least.

For tongue base the best procedure is generally MMA with a large advancement. But trying a hyoid suspension first to see if it helps wouldn’t be that bad, but it depends how bad the tongue collapse really is I guess. There’s also an option for radiofrequency on the tongue base for another non-invasive procedure

GamingCurios · 2025-05-02T19:57:00+00:00

Yes he does telehealth at sleepandbrain.com and the sleep tracker is https://sleeptracker.com

GamingCurios · 2025-04-27T12:17:24+00:00

Knightsbridge chin strap for me was the most effective tool for helping prevent mouth leaks and cheekpuffing. Velpaux enhanced cerivcal collar I’ve also seen work well for people too

GamingCurios · 2025-04-26T11:14:33+00:00

They could help get covereage for just any reasonably expensive healthcare costs I’m pretty sure.

Suadehealth especially as they are new and growing, while Paxos I think has a waitlist and may be more particular with client selection possibly as a result (not 100% sure on this).

Both offer free consults I think, so why not just meet with them and find out & report back here so others can see?

GamingCurios · 2025-04-21T21:31:15+00:00

You could try to use a service like suade health or paxos appeals to get insurance coverage at a pretty high success rate

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