Aerophagia

[palerider]

But - and this is where I'd love feedback - if I have a fixed PS machine and set my PS to 0 (as discussed above), with BiPAP settings on the Vauto mode...wouldn't that be like an auto-CPAP? (same pressure in and the same pressure out, but varying up and down within the IPAP and EPAP range). And how would that help with the aerophagia?

Ex: Vauto mode.
IPAP: 15
EPAP: 11
PS = 0
could produce
15/15 = Highest
14/14
....
11/11 = Lowest

or am I understanding this wrong?

I think it might help you understand things if you get your terminology right.

if you're in S mode, which stands for "spontaneous" ie, it responds to your breathing to change pressures from epap to ipap, then you have two settings. epap, and ipap. set them to whatever you want, and that's what you get.

when you're in VAuto mode, you have *three* settings, MinEPAP, MaxIPAP and PS. you set the difference between the upper and lower pressure with PS, you set the lowest that the low pressure can go with MinEPAP, and you set the highest that the high pressure can go (pulling the lower pressure with it) with MaxIPAP.

in VAuto mode, the epap and ipap change according to your needs.. so talking about setting ipap or epap seems like it's confusing.

if you set PS in a 0 to 3 range, in vauto mode, then you've basically just re-created an AutoSet.

if you set PS to 0, you don't have an ipap and epap, you have a pressure that does not change from breath to breath.

since the title of the thread is aerophagia, I'll mention that people have experienced relief from that by using their machine in auto mode, so that they only have the higher pressures when they need them, and also having more pressure support, with epap set just enough to keep apneas at bay, and ipap set high enough to get through snores, hypopneas and flow limitations. so, basically, having the minimum amount of pressure you can at any one time.

[MDee]

Someone else mentioned: "For people like me who don't mind starting out with IPAP = EPAP + 2 and who have problems with aerophagia when the EPAP is near its max, the roaming PS will maximize the time spent with EPAP at or near the Min EPAP setting and hence be more comfortable."

I think if you go back and reread you will see they were talking about RP machines not ResMed,. ResMed machines do not have a roaming PS, it's fixed. And yes you can set PS to = 0 You can set it to CPAP with EPR of 1,2,, or 3 also.

EDIT: Did you say why you are on a bi-level? did I miss that??

I am on bilevel because during the titration study the "sweet spot" (and the only spot that brought my AHI below 15) was IPAP: 15 and EPAP: 11. That qualified me for a bi-pap machine.

The prescription was written for that (no PS offered) so the tech programmed the machine as Vauto with max-IPAP 15 and min-EPAP 11 and set the PS to 4. I confirmed with my doctor that this would produce the mode that he wanted me to try. The Sleepyhead pressure graph showed a static line - once I reached IPAP 15 and EPAP 11 it stayed there all night. When that failed, he suggested I use the Vauto mode, but at max-IPAP: 12 and min-EPAP 8, with the PS left at 4. This way we would (a) lower the pressure and also (b) allow the auto mode to engage. Using these settings my pressure graphw shows changing pressure over the night with the average IPAP is 12 and my average EPAP is 8.

edited to use the correct terminology.

[cathyf]

But - and this is where I'd love feedback - if I have a fixed PS machine and set my PS to 0 (as discussed above), with BiPAP settings on the Vauto mode...wouldn't that be like an auto-CPAP? (same pressure in and the same pressure out, but varying up and down within the IPAP and EPAP range). And how would that help with the aerophagia?

Ex: Vauto mode.
IPAP: 15
EPAP: 11
PS = 0
could produce
15/15 = Highest
14/14
....
11/11 = Lowest

or am I understanding this wrong?

I think that rather than decrease the PS you would want to lower your allowed pressures by increasing the spread between EPAP and IPAP by lowering EPAP. So if you took your EPAP down to 9, then you might spend some time in the 13/9 to 14/10 range. Whether this would help would depend on several things:

1) Lowering the pressure setting on an autoPAP allows the pressure to be lower, but doesn't force it to be lower. Will the auto algorithm decide to take your pressures down if you allow it? Or will you spend 99% of your time at 15/11 anyway?

2) If you can get the machine to lower the pressure, will the lower pressure be low enough? This might be "close but no cigar" kind of thing where you get the pressure to go down but it's still overwhelming your esophageal valve so it doesn't really matter.

What your doctor seems to be hoping is that the centrals go away after a few weeks, and then you can start playing with the pressures to see if you can get the aerophagia down without raising the OA's and H's by too much. You may need to give the doc a knock upside the head with the clue bat. You are way more miserable with the aerophagia than I ever was, and I was plenty miserable! Sometimes docs need to be reminded that the goal of this therapy is three-fold: getting adequate amounts of adequate quality of sleep and having adequate oxygen levels while doing it. ALL THREE are absolutely essential. Docs get real focused on fixing the numbers and forget that they are responsible for things that those numbers don't measure.

Which brings up the Deep Thought: if you have an AHI under 1 but are getting 2 hours of sleep a night because of the aerophagia, and you are killed in the car crash caused by you falling asleep while driving, is your AHI after you are dead zero or infinity?

[lilly747]

I am on bilevel because during the titration study the "sweet spot" (and the only spot that brought my AHI below 15) was IPAP: 15 and EPAP: 11. That qualified me for a bi-pap machine.

The prescription was written for that (no PS offered) so the tech programmed the machine as Vauto with max-IPAP 15 and min-EPAP 11 and set the PS to 4. I confirmed with my doctor that this would produce the mode that he wanted me to try. The Sleepyhead pressure graph showed a static line - once I reached IPAP 15 and EPAP 11 it stayed there all night. When that failed, he suggested I use the Vauto mode, but at max-IPAP: 12 and min-EPAP 8, with the PS left at 4. This way we would (a) lower the pressure and also (b) allow the auto mode to engage. Using these settings my pressure graphw shows changing pressure over the night with the average IPAP is 12 and my average EPAP is 8.

edited to use the correct terminology.

Thanks for the replay on why you were given a bilevel. But setting your machine 12-8-4 does not allow the auto to engage it is like in S mode, no difference than 15-11-4. See paleriders post

[palerider]

The prescription was written for that (no PS offered)

PS is just a function of math. ipap-epap=ps, epap+ps=ipap ipap-ps=epap etc. like so many other things in life, there are multiple ways to refer to a thing. the 'classic' way to state a bilevel pressure is ipap/epap, or in your case, 15/11, doing the math, you get a ps of 4.

so the tech programmed the machine as Vauto with max-IPAP 15 and min-EPAP 11 and set the PS to 4. I confirmed with my doctor that this would produce the mode that he wanted me to try.

alternatively, set the machine to S mode and just straight set the ipap to 15 and epap to 11.

When that failed, he suggested I use the Vauto mode, but at max-IPAP: 12 and min-EPAP 8, with the PS left at 4. This way we would (a) lower the pressure and also (b) allow the auto mode to engage.

as mentioned, this will NOT allow the auto mode to do anything at all, because your minpap is 8, +4ps = a minipap of 12. which is also what you set the maxipap to... so, no room to move.

Using these settings my pressure graphw shows changing pressure over the night with the average IPAP is 12 and my average EPAP is 8.

perhaps there's a mistake on what pressures were set.. since your settings won't allow changes, and your epap would be 8 all night long, and your ipap 12 all night long, unchanging.

[lilly747]

check your PM

[MDee]

The prescription was written for that (no PS offered)

PS is just a function of math. ipap-epap=ps, epap+ps=ipap ipap-ps=epap etc. like so many other things in life, there are multiple ways to refer to a thing. the 'classic' way to state a bilevel pressure is ipap/epap, or in your case, 15/11, doing the math, you get a ps of 4.

so the tech programmed the machine as Vauto with max-IPAP 15 and min-EPAP 11 and set the PS to 4. I confirmed with my doctor that this would produce the mode that he wanted me to try.

alternatively, set the machine to S mode and just straight set the ipap to 15 and epap to 11.

When that failed, he suggested I use the Vauto mode, but at max-IPAP: 12 and min-EPAP 8, with the PS left at 4. This way we would (a) lower the pressure and also (b) allow the auto mode to engage.

as mentioned, this will NOT allow the auto mode to do anything at all, because your minpap is 8, +4ps = a minipap of 12. which is also what you set the maxipap to... so, no room to move.

Using these settings my pressure graphw shows changing pressure over the night with the average IPAP is 12 and my average EPAP is 8.

perhaps there's a mistake on what pressures were set.. since your settings won't allow changes, and your epap would be 8 all night long, and your ipap 12 all night long, unchanging.

I am sorry, I messed up. the new settings (which are still creating the problem) are

Vauto Mode
max-IPAP: 15
Min-EPAP: 8
PS: 4

The machine seems to have settled on an average
IPAP: 12
EPAP: 8.

The pressure graph shows fluctuations with IPAP roaming between 11 and 14 and the EPap always tracking along 4 points below.

When I started thinking about lowering the min-EPAP to 6, that is where I started asking if I should alter the PS or do something differnt.

[MDee]

I am on bilevel because during the titration study the "sweet spot" (and the only spot that brought my AHI below 15) was IPAP: 15 and EPAP: 11. That qualified me for a bi-pap machine.

The prescription was written for that (no PS offered) so the tech programmed the machine as Vauto with max-IPAP 15 and min-EPAP 11 and set the PS to 4. I confirmed with my doctor that this would produce the mode that he wanted me to try. The Sleepyhead pressure graph showed a static line - once I reached IPAP 15 and EPAP 11 it stayed there all night. When that failed, he suggested I use the Vauto mode, but at max-IPAP: 12 and min-EPAP 8, with the PS left at 4. This way we would (a) lower the pressure and also (b) allow the auto mode to engage. Using these settings my pressure graphw shows changing pressure over the night with the average IPAP is 12 and my average EPAP is 8.

edited to use the correct terminology.

Thanks for the replay on why you were given a bilevel. But setting your machine 12-8-4 does not allow the auto to engage it is like in S mode, no difference than 15-11-4. See paleriders post

So sorry, I messed up. The new settings in the Vauto mode was 15-8-4 (with the same aerophagia problems).

And thank you for the PM. I followed your suggestion.

[palerider]

the new settings (which are still creating the problem) are

Vauto Mode
max-IPAP: 15
Min-EPAP: 8
PS: 4

The machine seems to have settled on an average
IPAP: 12
EPAP: 8.

The pressure graph shows fluctuations with IPAP roaming between 11 and 14 and the EPap always tracking along 4 points below.

When I started thinking about lowering the min-EPAP to 6, that is where I started asking if I should alter the PS or do something differnt.

the pressures always move in lockstep on a resmed machine.

*seeing* your graphs would be helpful.

whether you'd be well or poorly served with a minepap of 6 would be just a wild guess, without seeing how the pressures move during the night.

https://sleep.tnet.com/resources/sleepyhead/shorganize

[MDee]

the new settings (which are still creating the problem) are

Vauto Mode
max-IPAP: 15
Min-EPAP: 8
PS: 4

The machine seems to have settled on an average
IPAP: 12
EPAP: 8.

The pressure graph shows fluctuations with IPAP roaming between 11 and 14 and the EPap always tracking along 4 points below.

When I started thinking about lowering the min-EPAP to 6, that is where I started asking if I should alter the PS or do something differnt.

the pressures always move in lockstep on a resmed machine.

*seeing* your graphs would be helpful.

whether you'd be well or poorly served with a minepap of 6 would be just a wild guess, without seeing how the pressures move during the night.

https://sleep.tnet.com/resources/sleepyhead/shorganize

Thank you. Here are the 2 latest nights with the new settings (15-8-4) Vauto. Let me know if they need to be adjusted. I will also try out a few of the suggested settings to get more data.

[MDee]

I also did some digging in other forums and came across this post. Note: they are not talking about the same machine I am using

http://www.talkaboutsleep.com/message-b ... gain-gerd/

The takeaway I am getting from this post is:

1. If using the auto mode, keep the min-max range narrow (they do not discuss PS ranges)
2. If using the auto mode, try to find a machine that lowers the EPAP quickly.

I also found:
https://www.reddit.com/r/SleepApnea/com ... r_on_cpap/

Note: I am not recommending or endorsing this link, but it does offer some mechanical clues

[palerider]

Thank you. Here are the 2 latest nights with the new settings (15-8-4) Vauto. Let me know if they need to be adjusted. I will also try out a few of the suggested settings to get more data.

If it were me, I'd drop minepap to 7, and drop ps to 3, and see what happened.

[robysue]

the new settings (which are still creating the problem) are

Vauto Mode
max-IPAP: 15
Min-EPAP: 8
PS: 4

The machine seems to have settled on an average
IPAP: 12
EPAP: 8.

The pressure graph shows fluctuations with IPAP roaming between 11 and 14 and the EPap always tracking along 4 points below.

As low as the OAI and the HI is at these settings and as severe as the aerophagia is, I'd strongly suggest lowering both the min EPAP and max IPAP some more.

I'll hazard a guess abou the too high CAI: Since you say that you are dealing with severe aerophagia, it's possible that you are having a lot of microwakes (less than 30second) and miniwakes (less than 5 minutes) that you don't remember due to the aerophagia discomfort. And when you wake up even momentarily, there's a tendency to swallow (which unfortunately adds to the air in your stomach). You may also then have more difficulty than normal getting back to sleep (because of the aerophagia), and because the transition back to sleep is not going well, you may be experiencing more sleep onset centrals than is desired. And hence your overall AHI is still too high, but the vast majority of the AHI is made up of CAs instead of obstructive events.

I'll also note this: The reason your machine is NOT increasing the EPAP very much over the course of the whole night is that there's not much obstructive going on. The number of OAs and Hs is close to 0, there's not much activity in the snore graph, and there's not much activity in the flow limitation graph.

So, I'd strongly recommend dropping the min EPAP setting down to something your stomach has an easier time tolerating. (Try setting min EPAP at either 6 or 7 for a night or two.) I'd also consider lowering the max IPAP so that the machine can't "run away" with increasing the pressure too much.

As for loweing the PS, it may be worth a try. Or not. Since you report that you have weak muscles, you may find that a PS of 3 or less does not provide enough pressure relief to comfortably exhale against the pressure. It's worth a try, but if setting the PS = 3 increases your discomfort exhaling when you are awake, then you know that you need to increase the PS back up to 4.

In other words, right now you need to be tweaking settings to find a pressure level that minimizes the severe aerophagia. If you can minimize the aerophagia, that may reduce the CAs by reducing the number of aerophagia-related arousals. Yes, lowering the pressure may increase the number of obstructive events. But you may be much better off with an OAI + HI in the range of 2 or 3 with little or no aerophagia and no or very few CAs.

[MDee]

Thank you all (and Robysue for the last post). As I've been puzzling over this, I noted a few things:

1. My daytime swallowing has increased because of the bloated belly. I suspect it is part of that closed loop where the air pressure increases the acid reflux, I salivate more and then swallow more air which increases reflux which...... My night time swallowing even without the CPAP has also increased. Interestingly, taping my mouth shut without CPAP seemed to have slightly reduced the amount of saliva.
2. I took a day off and my bloated stomach is still huge, so I will continue another day or so to see if it goes down. As a data point, my belly has gained 2 inches in size these past 2 weeks with no increase in weight. At least I can now eat and drink in small amounts and was able to walk and talk at the same time.
3. When I first tried the CPAP sitting upright for the mask fitting, my eustachian tube popped open, so I think I may have weakness in the overall area. In case anyone else has this happening, my solution is to only turn the CPAP machine while lying flat. That seems to keep the tube closed during CPAP.
4. Before I started CPAP I would feel (another?) flap close off my airway on exhale only (a bit freaky as it would wake me up at night) - again possibly pointing to structural weakness.

All this points to me lowering the pressures and then slowly working my way back up until I find a combination that keeps one airway open, the eustachian tube closed and my belly deflated. And for my next trick.....

[CentrallyTired!]

DIET effects this too! I had it so bad I was going to have to give up therapy and didn't know WHAT to do!!
Then I realized--my problem was largely caused by this intense MINT breathspray I was using!! GREAT breathspray--pure mint oil I think. But mint is KNOWN to RELAX the closure (??-don't know what to call it) to your stomach. After I heard that I thought...What if it ALSO relaxes whatever body part/valve/whatever that separates the airway from the esophagus?? I Tested it and low & behold THAT was the biggest component to my air swallowing problem!!! I guess chocolate, alcohol, ginger and other things also can effect--Look up whatever relaxes that closure above stomach and believe me--it effects this too! Might help you a lot.