asking deltadave for clarification about something he said

[robysue]

On one of rocklin's current threads, DeltaDave wrote the following about aerophagia, sleep efficiency, arousals and wakes:

Sleep efficiency has improved, primarily due to 1.) alleviating arousals due to aerophagia...

At the risk of generating (more) agita in SU, I would return to the Watson template which proposes that it is the reverse that occurs.

Further, I would also submit that aerophagia decreases Sleep Efficiency through an increase in Awakenings (a critical distinction and decided difference from Arousals) and Wake.

DD, pardon my density today, but I've read and re-read this and I'm still confused.

Are you saying:

Arousals lead to aerophagia and aerophagia leads to decreased sleep efficiency due to additional wakes caused by the aerophagia?

Thanks,
robysue

[rocklin]

If the protocol and design is right, would you be willing to talk to your MD at GH and participate in a teaching protocol of ASV?

[CarpeNoctum]

Robysue and Michael,
I also read that post and puzzled over it. DD's posts are a challenge since they often include obscure references.

I loved his use of the word agita which has two meanings: gastric distress as well as psychological aggrevation. Apropo either way.

His reference to the Watson principal is not a Sherlock Holmes reference but rather to the noted neurologist Nathaniel F. Watson, M.D of Seattle. His research leads to the belief that aerophagia could be unrelated to cpap pressures but is GERD related.

How that relates to sleep efficiency is till unclear to me. Gerd/aerophagia causes arousals more the awakenings.

Well that's as far as it goes for me. Sorry to throw another variable into the mix. Hopefully Dave will respond...but that doesn't mean that his response will be comprehensible.
CN

[deltadave]

Are you saying:

Arousals lead to aerophagia and aerophagia leads to decreased sleep efficiency due to additional wakes caused by the aerophagia?

'Zactly!

Gerd/aerophagia causes arousals more the awakenings.

The algorithm below attempts to explain the relationship of all these factors, but did you review the other posts in that thread?

That begs the question of if that would cause a change in thoracic pressure, enough to overcome the LES “seal” against the increased respiratory tract pressure from xPAP?

The pressure required to open a normally functioning closed LES is about 25 - 33 cmH2O. Clearly, the unpredictability of aerophagia requires there to be other factors underfoot.

Keep in mind that the easiest way to relax an LES is to simply swallow. (As an aside, I would also offer that the easiest way to elicit a swallow during sleep is to generate an arousal, which may be the mechanism of the PLM point. It's not PLMs, it's the subsequent arousals).

In re: inspiratory waveform engineering, if you rapidly force a breath into a dead (essentially) cat, you can elicit some potentially untoward responses:

In 2001, Lang and colleagues found that esophageal receptors trigger relaxation of the UES on sensing rapid distension, but activate contraction of the upper esophagus (including contraction of the UES) on sensing slow distension.

Easy To Understand Regina Patrick Article

Complicated Scientific Stuff

It would seem then, that this phenomenon would preload the esophagus and create the milieu for aerophagia (in order to have aerophagia, you need some "phagia".

Interesting stuff to read (and previously referenced by -SWS in a short, largely unnoticed thread):

CPAP and Things That Go “Burp” in the Night

Aerophagia and Gastroesophageal Reflux Disease in Patients using Continuous Positive Airway Pressure: A Preliminary Observation

Arousals.

It's always about sleep quality.

[rocklin]

.

I hate to do this.

I really had hopes of having a beer with the guy and burying the hatchet.

But comes a time when enough is enough, so I'll just say it.

With great sadness, me thinks that . . .

The emperor has no clothes.

We love you anyway, Dave. We always will.

roc

.

[rocklin]

.

P.S.

Love your new incarnation, sugar!

wtf

My father was soviet signal intelligence, be serious, ya feel me?

I am

the signal.

.

[CarpeNoctum]

Dave,
No I have not read the entire thread. I'll get right on it. Thanks for your input though, I've been wondering why there's no relationship between cpap pressure and aerophagia. You didn't get into the Gerd influence though. and that's still a mystery to me.
CN

[deltadave]

You didn't get into the Gerd influence though. and that's still a mystery to me.

Well, what has your research told you thus far?

BTW, "IMHO", I don't think it's appropriate for this kind of language during the Advent (or any other, for that matter) Season:

viewtopic/p661416/What-Is-RERA.html#p661416

[robysue]

Are you saying:

Arousals lead to aerophagia and aerophagia leads to decreased sleep efficiency due to additional wakes caused by the aerophagia?

'Zactly!

and

That begs the question of if that would cause a change in thoracic pressure, enough to overcome the LES “seal” against the increased respiratory tract pressure from xPAP?

The pressure required to open a normally functioning closed LES is about 25 - 33 cmH2O. Clearly, the unpredictability of aerophagia requires there to be other factors underfoot.

Keep in mind that the easiest way to relax an LES is to simply swallow. (As an aside, I would also offer that the easiest way to elicit a swallow during sleep is to generate an arousal, which may be the mechanism of the PLM point. It's not PLMs, it's the subsequent arousals).

The idea that arousals (of any sort?) lead to swallowing which leads to aerophagia which leads to more wakes and less sleep efficiency (and more swallowing? and more aerophagia?) makes some sense to me---at least in the sense of explaining why I have so much more aerophagia on night's that starts out restless to begin with. I do know that I tend to swallow whenever I first wake up. So it makes sense that even an arousal (for whatever reason) could also lead to reflexive swallowing.

But this also seems to imply that there's a nasty feedback loop going on here as well:

Arousals -> Swallowing -> Aerophagia -> Discomfort -> Awakenings -> More Swallowing -> More Aerophagia -> More Discomfort -> and so on until it's morning and the stomach is rock hard and/visibly distended with air.

Any ideas on how to effectively stop the feedback loop once it has gotten started?

Last night's the perfect example: I went to bed quite comfortable with absolutely no stomach problems at all. Got to sleep with no problems and no aerophagia discomfort. Startled myself awake from a dream (it was not a good dream), but there's no evidence in the data that the wake was triggered by an apnea or hypopnea: The wake was somewhere around 20 or 30 minutes after CA. There is a flow limitation around the time of that first wake. Drifting back to sleep wasn't easy---I had a 20-40 minute long period of drifting in/out sleep if I'm recalling things with any accuracy. During that restless period, there is a cluster of three OAs. I don't remember any aerophagia during that first restless period: The brain was having some trouble shutting up and there were some rainout problems and my lips were being bothered by the pillows and the exhaust flow from the mask. About an hour after those 3 OAs, I woke up with a touch of aerohpagia. And during the rest of the night, I had several more wakes (and who knows how many arousals), and each time I woke, the aerophagia was worse. By morning, my stomach and esophagus were both feeling rock hard .....

[deltadave]

But this also seems to imply that there's a nasty feedback loop going on here as well:

Arousals -> Swallowing -> Aerophagia -> Discomfort -> Awakenings -> More Swallowing -> More Aerophagia -> More Discomfort -> and so on until it's morning and the stomach is rock hard and/visibly distended with air.

Don't forget the "aerophagia creates LES dysfunction" Feedback Loop as well:

Also, gastric distention is a potent stimulator of transient LES relaxation. Therefore, once initiated, aerophagia-associated increases in gastric pressure could create a positive feedback loop, leading to further air swallowing by the patient, with worsening aerophagia and increasing reflux.

Any ideas on how to effectively stop the feedback loop once it has gotten started?

Sure:

• Start smoking
• Pharmacological intervention
• Permissive flow limitation on high-risk aerophagia nights

[robysue]

But this also seems to imply that there's a nasty feedback loop going on here as well:

Arousals -> Swallowing -> Aerophagia -> Discomfort -> Awakenings -> More Swallowing -> More Aerophagia -> More Discomfort -> and so on until it's morning and the stomach is rock hard and/visibly distended with air.

Don't forget the "aerophagia creates LES dysfunction" Feedback Loop as well:

Also, gastric distention is a potent stimulator of transient LES relaxation. Therefore, once initiated, aerophagia-associated increases in gastric pressure could create a positive feedback loop, leading to further air swallowing by the patient, with worsening aerophagia and increasing reflux.

Ah yes. So there's also:

Swallow some air and the tummy gets distended, which triggers transient LES relaxations, which allows even more air into the tummy, which gets more distended, which triggers transient LES relaxations, which allows even more air into the tummy, and so on and so forth until you wake up with a rock hard, swollen and distended belly in the morning.

Any ideas on how to effectively stop the feedback loop once it has gotten started?

Sure:

• Start smoking
• Pharmacological intervention
• Permissive flow limitation on high-risk aerophagia nights

I'll pass on the "start smoking" if you don't mind Too many close relatives who've died of smoking related lung cancer.

Pharmacological intervention? What drug(s)? I don't really want to take anything now that the problem is no longer at the WAKE UP IN PAIN night after night after night stage. It's now down to intermittent, but once it starts, it can snowball into a real issue pretty quickly.

Permissive flow limitation on high-risk aerophagia nights? Does that mean: Just live with a higher than desirable number of flow limitations by limiting the max IPAP?

And if that is what you mean, just what is a ball park target for Flow Limitations on a PR System One? My own FLI's are typically in the 1.0 to 2.5 range with about as many days above 2.5 as below 1.0. Usually FL are the most numerous things flagged when I look at the data in SH

[SleepingUgly]

• Start smoking
• Pharmacological intervention
• Permissive flow limitation on high-risk aerophagia nights

To add to RobySue's list of question, what's a "high-risk aerophagia night" (i.e., how would one know it's going to be a high risk night)?

[robysue]

• Start smoking
• Pharmacological intervention
• Permissive flow limitation on high-risk aerophagia nights

To add to RobySue's list of question, what's a "high-risk aerophagia night" (i.e., how would one know it's going to be a high risk night)?

For me:

• Dinner too late.
• A beer or glass of wine with that too-late dinner
• Pasta or pizza with tomato sauce for dinner even if it's not too late
• Residual aerophagaia still in the gut at bedtime (yes, this occasionally happens to me---I have trouble burping and farting it all out sometimes)
• Restlessness at bedtime right after I mask up or waking up within the first hour of sleep regardless of the cause

[SleepingUgly]

OK, so what's a "high-risk night" in someone not susceptible to GERD or who is well-treated with PPIs?

[deltadave]

(The aerophagia is) now down to intermittent, but once it starts, it can snowball into a real issue pretty quickly.

Permissive flow limitation on high-risk aerophagia nights? Does that mean: Just live with a higher than desirable number of flow limitations by limiting the max IPAP?

Actually, I was thinking of something far more brash (or is it "rash?).

During earlier discussion about your saga, some points that were attempted to be made included:

• Just how significant is your SDB?
• Is the real problem "S" instead of "SDB"?
• If the treatment is worse than the disease, then what's the point?