APAP vs. BiPAP for aerophagia

[momexp5]

I always thought cpap induced aerophagia did not entail a coordinated "swallowing" of air while asleep. Rather, that CPAP pressure is simply high enough to breech the esophageal sphincter muscles.

I believe this air pressure breech process is even suspected to be more prevalent during EPAP than it is during IPAP... which is why doctors very often prescribe BiLevel for aerophagia. APAP also works well for many suffering from aerophagia since it strives to brings the mean airway pressure or "MAP" down.

This sounds very on-target for what I'm experiencing. Thanks, guest.

[momexp5]

I am inclined to think that aerophagea is the result of having consistently high pressure all night. When I was at a pressure of 15, using C-FLEX of 3, I had horrible aerophagia.

For us little people (41yo 5'2" 120lb here), going from pressure of 8 to pressure of 7 makes a difference for inhale aerophagia. I tried going back up to 8 last night, couldn't stand it compared to the 7. I changed it back.

So, if high pressure is the culprit of aerophagea, an autoPAP, by design, will give longer periods of lower pressure over the course of the night which should help reduce the aerophagea. If higher pressures during exhalation is the culprit, then a bi-pap should help but, so too would autoPAP as lower pressure overall is still lower pressure.

Mmm... I'm not sure that's working out to be my experience. :::moving closer to BiPAP as the solution:::: I'm suspecting that if I could just exhale more freely, those air bubbles would have a chance to get out of there.

And you understand, Will, :::speaking for the sake of our searching lurkers::: that if our perspectives and experiences are different, it only points to how much this is an individual no-one-size-fits-all art. iow, just like a woman, I'm saying this so you know I'm not arguing with you here

[ozij]

Just be sure to report you conclusions after you've
a. decided
b. exprienced.

So all of us will know what worked. ...In this case, of course...
O.

[WillSucceed]

I'm saying this so you know I'm not arguing with you here

No propblem! I didn't think for a moment that we were argueing... adjusting to treatment is, as you have said, highly individual. The beauty of this forum is that we all get to learn from on another.

Quite frankly, I think that this forum has saved my life. I have learned so much over the months that I have been reading/posting -I never would have obtained a quater of this this info if I was left solely in the hands of the Sleep Quack and his minions.

I really have an mad on at that guy. Maybe I ought to get a little head-shrinking...

[dsm]

Anyway - my main problem is air in the stomach.

I was discussing this very issue with one of our local Sleep Studies Experts (a lady I have a great deal of respect for)

She said "Swallowing is a thing we do when awake, not when asleep". In effect she was asking was I aware of swallowing. I don't think I do & did think hard about it.

I have a f/f mask after trying an Activa for a while.

My answer to this problem has been to lower my pressure from 15 to 14 to 13 then last night to 12. The excessive air went away.

But having done that experiment I will go back to 14 . I believe going to AUTO (I am running my RemStar in CFLE mode for a study), will be my answer once the study is finished in 2 more weeks.

Cheers

DSM

[dsm]

For example, I was titrated in the sleep clinic and prescribed CPAP of 15; I could not stand it. So, I trialed some autoPAP machines which all said I only need 9 for 90% of the night. I lost some weight and the autoPAP reported that I only need 8 for 90% of the night. So, rather than have the autoPAP set for a range of 5-13, which is what the Sleep Quack ordered, I have it set for 8-13. I did this because at the range of 5-13, I was spending much of the night down around 5, 6 & 7, but was also going as high as 11. The autoPAP was doing its job wonderfully, working hard all night adjusting pressure to splint my airway open but, I was waking up many times during the night by something -->I think it was the pressure change.

With the pressure set at 8-13, I spend almost the entire night at 8, with a few periods up around 10 and, sometimes, 11. So, what I think I have accomplished is staying at a steady pressure of 8 (like a single CPAP pressure) which keeps my airway open, does not cause aerophagea and does not wake me by pressure changes. For those few periods during the night when I need even more pressure (deepest stages of sleep/REM) the autoPAP gives me what I need.

So, what I am getting is more pressure than I need for much of the night (defeats the purpose of autoPAP) but this pressure is not enough to give me aerophagea, AND higher pressure for those few periods when I need it (the beauty of autoPAP) with an overall reduction in the number and range of pressure changes in an effort to avoid pressure-change induced micro-arousals.

Clear as mud? Make sense?

The more I read your experiences the more I believe I am travelling the same road.

Borrowing from your hard earned experience (and once I complete a planned study in 2 weeks) I plan to set my RemStar to 8-13 in AFLE mode with CFLEX at 2.

I believe this may be my best settings to
1) Eliminate mask leaks
2) Aerophagia

CHEERS

DSM

[ozij]

Momexp -
I just remembered - and checked - you've got far more hypopneas than Apneas - an auto won't adjust to standalone hypopneas - so a bi-pap is a better bet for you.
O.

[rested gal]

an auto won't adjust to standalone hypopneas

ozij, that's news to me. I'd have thought autos could/would. But as I've said many times, I'm not techie when it comes to the inner workings of any machines. Can you please direct me to some topics or other links about that? Not arguing...just really want to know more about it. Thanks!

[ozij]

Hi Rested Gal

With pleasure:

1. -SWS asnwering me about why the 420E does not react to my hypopneas

They seem to leverage hypopnea treatment via proactive techniques rather than reactive. When they do treat hypopneas on a reactive basis, the hypopnea triggering criteria seems to require either concomitant snore and/or flow limitation. My guess is that a hypopnea that is concomitant with one of these events tends to be obstructive versus central in nature.

In my own guestimation, it is theoretically possible for some hypopnea patients to be poorly treated by any given autoPAP's algorithm. A patient might manifest significant numbers of hypopneas that neither accompany snore/flow-limitation, nor might they be preceded by those same events (snore and/or flow limitations) as precursor signals

2. Autoset Spirit T Chat on TAS, question no. 3

How does the AutoSet T handle hypopnea events?
The AutoSet T responds to obstructive hypopneic events when associated with a concomitant flow limitation or snoring. Hypopneas that are central in origin (related to your central nervous system, not physical obstruction) should not be treated with increased pressure.

my italics

3. -SWS discussing PB's IFL2 on TAS (moutainwoman's question or two)

4. Resmed description of the three lines of defence none of which are hypopneas.

O.

[momexp5]

Momexp -
I just remembered - and checked - you've got far more hypopneas than Apneas - an auto won't adjust to standalone hypopneas - so a bi-pap is a better bet for you.

Och! Oz, you're a sweetie, to remember that little fine point about my case! Thanks... it may indeed be a significant factor here, that I'd forgotten about ::still reading::

[ozij]

Another source, and for you, momexp, a geek feast....

Respironics Auto and hypopneas - discussion started by Derek in March.

O.

[rested gal]

Thanks ozij! It's always risky for me to try to lift a few things out of their full context, especially in posts by -SWS who thinks with great precision and chooses every word carefully... but I'll do it anyway...LOL!! I've taken the liberty of emphasizing a couple of words from part of your quote from -SWS:

"They seem to leverage hypopnea treatment via proactive techniques rather than reactive."

"In my own guestimation, it is theoretically possible for some hypopnea patients to be poorly treated by any given autoPAP's algorithm."

To me, -SWS's use of the word "some" is very important. I don't see in the quote from -SWS that he's saying autopaps in general aren't good at treating hypopneas. He said it's possible they'd treat "some" hypopnea patients poorly. As he's said many times, there will be some patients who don't do well on one autopap or another -- or on any autopap. Some.

Following the other links -- great links, ozij! I remember reading most of them. Enjoyed going over them again, thanks to your reminder links. That's not to say I understood all of them. I had saved almost every discussion that -SWS participated in (what a great mind!) including that whole thread where he and John went into very techie posts in the mtn. woman thread about the 420E's two IFL triggers, "runs", etc.

Re-reading those, I see now the distinction you're making, ozij, regarding stand alone hypopneas. I was missing the significance of your speaking of stand alone hypopneas...hypopneas not associated with anything else... no precursors or "at the same time" (concomitant) events to give an autopap a clue as to what kind of hypopnea it was looking at...obstructive or central.

So, I guess my question now would be -- do we even know that momexp5 has primarily stand alone hypopneas? Meaning hypopneas not accompanied with precursor events like limited flows or snores. Without knowing what is (or is not) accompanying, or even leading up to, her hypopneas, can autopap really be ruled out for treating them?

If I were to say, "My study showed that I have all hypopneas and no obstructives" that wouldn't necessarily mean that I didn't also have precursor limited flows too. Concomitant events which, if the condition of the throat became more and more constricted, would let an autopap (perhaps one better than another) identify what was probably coming and take action to proactively ward off the impending hypopneas.

I may be way off, but when I read ResMed's description of the Spirit autopap's Three Lines of Defence, I figure hypopneas are included in a broad description of "flow limitations". I'm not sure why ResMed chooses not to use the word "hypopnea" much...instead speaking of flow limitations.

I seem to recall ResMed used the word hypopnea only once in their excellent video presentation, "Understanding Sleep Disordered Breathing", instead speaking of "flow limitations" many times throughout the presentation.

(My 2010 edit: Corrected URL ResMed is using for their video.)
ResMed video showing what happens during sleep apnea.
"Understanding Sleep Disordered Breathing"
http://www.resmed.com/us/multimedia/und ... 40x380.swf

I assumed (dangerous, I know! lol) that ResMed simply prefers to use the phrase "flow limitation" as that phrase can cover everything from the first slightest constriction of the throat, all the way up through hypopneas. I didn't take it as meaning their Spirit autopap is not meant to, or able to, treat hypopneas.

All that said, I do agree with you, ozij, that for some people, whether hypopneas or actual apneas are their main problem, autopap is not always the best machine to treat some people. I just don't think a person could make that determination without trying several different autopaps -- much less think, "Oh, my problem is hypopneas exclusively, so autopap isn't for me." One or another autopap could very well treat them just fine, imho.

[ozij]

To me, -SWS's use of the word "some" is very important

I agree, I noticed that when I reread the posts before sending you the links.

So, I guess my question now would be -- do we even know that momexp5 has primarily stand alone hypopneas? Meaning hypopneas not accompanied with precursor events like limited flows or snores. Without knowing what is (or is not) accompanying, or even leading up to, her hypopneas, can autopap really be ruled out for treating them?

"Ruled out" is a very strong term – and we don't know enough about momexp's events to "rule out" an autopap. My short letter possibly sounded too definite, setting a rule in a way I didn't mean – but it was based on both momexps very high hypopnea index, what I had read in the thread about aerophagia and exhalation, knowing what my APAP does (or rather doesn't do) with my hypopneas, and the memory of Dereks dissatisfactions with the Respironics' auto algorithm.

You write:
I may be way off, but when I read ResMed's description of the Spirit autopap's Three Lines of Defence, I figure hypopneas are included in a broad description of "flow limitations". I'm not sure why ResMed chooses not to use the word "hypopnea" much...instead speaking of flow limitations.

I don't agree with you here. When Resmed state "The AutoSet T responds to obstructive hypopneic events when associated with a concomitant flow limitation or snoring." They clearly distinguish hypopneas from flow limitations.

PB's documentation and detailed report screen also make a very clear distinction between (1) "flow limitation", (2) flow limitations accompanied by hypopneas, and (3) hypeopneas. They treat the three as distinct entities, and report them separately, which is why I assume (… same danger) that they are.

All that said, I do agree with you, ozij, that for some people, whether hypopneas or actual apneas are their main problem, autopap is not always the best machine to treat some people.

Can't argue with that. And I don't even want to...

As for what's best for momexp: in this specific case, that would depend on a number of things:
1. Are momexp5's hypopneas properly handled by the straight CPAP pressure? (Apart from aerophagia, does she sleep well, does she feel well, etc.)
2. Does momexp have a chance to try out an APAP, with software, so she can see if
a. her aerophagia is better, and if
b. the machine gives her proper treatment? (reacts to her hypopneas)
If yes – it is certainly worth trying.

What if she cant' get a trial machine?
Then the next question is
3. What caused her aerophagia – inhale pressure, or exhale pressure? After reading the thread, I understood how aerophagia can be the result of too high exhale pressure, and therefore thought that if momexp didn't have a chance of trying an APAP, and had to bet, a bi-pap would be the better bet.

You write:
I just don't think a person could make that determination without trying several different autopaps -- much less think, "Oh, my problem is hypopneas exclusively, so autopap isn't for me." One or another autopap could very well treat them just fine, imho.

Once again, I think this general rule is correct. I agree that anyone who has the chance of trying (and documenting) APAP treatment, should do so. A months follow up on an APAP can be an eyeopener.

O.