Allergies, aerophagia, dry mouth, acid reflux, central apnea events

[Julie]

My suggestion about pressure settings was to lower the min. by 1-2 cms to help the aerophagia, not to lower the max.

[DreamDiver]

I'm hoping that once we see your flow limitation graph, some of the pros can offer you more than sympathy for nasal congestion.

There's not going to be a flow limitation graph available. OP is using a Respironics machine which doesn't do flow limitation graphs like the ResMed machines do. Instead the FLs are flagged like any other event up on the events graph when in auto mode only.
FLs were minimal on this last graph.

Huh! Thanks Pugsy! I'll store that away, if I can.

I have a wedge but can't figure out how to sleep on my side on a wedge. Any tips on that?

I have the same problem. I end up using a bunch of pillows on top of the wedge. It's not comfortable.
The only other suggestion is getting one of those whole-bed-length wedges that gradually inclines the entire body, or a bed that inclines.
I hope if others have suggestions, they'll post them here.

EDIT: Another possibility might be putting a wooden wedge under the entire mattress as a kluged full-bed incline.

Chris

[Katerific]

I reviewed the SleepyHead videos. Here's a screenshot of last night that represents almost all flagged events, not just last night but all the time. If all of these aren't really apneas, then I'm close to 0 AHI. If these events are because of arousals, then I wake up or move around a lot, which is possible. My husband, also on CPAP, lays there like a log and doesn't move. His AHI is always .1 or so. Before the allergies kicked in, I had much lower AHI's and I didn't always get aerophagia, so I don't know which way to turn. AHI under 5 is considered OK, but I've been striving to drive it as low as possible. Maybe I need to let go of my performance anxiety. Recommendations on lowering the min/max or maybe go straight CPAP?

[Pugsy]

That period of irregular breathing just prior to the first flagged hyponea points to an arousal. Makes me suspect all the subsequent flagged events as being arousal related and not sleep related.

If it were me I would reduce the minimum pressure to a point you know it doesn't cause aerophagia and then again look at the AHI up close and see if the events look like real asleep events or not.

These are real asleep events. Note the breaths right before the flag are nice and equal with no irregularities.



These are awake/arousal related. The asleep breathing circled. The rest of the breathing is arousal/awake related.

[Katerific]

Last night I reduced the minimum pressure from 9 to 8 and the max from 11 to 9.5. My stomach feels a lot better although there was still a little aerophagia. But it is much better and tolerable. I reviewed each event and all of them appear to be arousal related. The 9 flow limitations aren't anywhere near the hypopneas or obstructive apnea events. With the lower pressure, I have 21 hypopneas, which is a lot higher than the number I get with higher pressure. So why do I get more arousals at lower pressure?

[Pugsy]

I see at least 2 breaks in therapy last night where we know for sure you were awake. Why? Anything specific that you can remember?
Did you have other times where you were awake but didn't turn off the machine?

There are 2 kinds of arousals....respiratory related and spontaneous related which just means we don't know why. Not all arousals are related to the airway and cpap can only fix airway related problems.

People can have crappy sleep for any number of reasons.
Do you take any medications of any kind? If so, what?
That's the first thing we look at because so many meds have side effects that mess with sleep in some form.
Anything else going on in terms of pain, bed comfort, mask comfort, etc?

Arousals...we may or may not remember them and when they are spontaneous and not related to airway issues it's really hard to figure out what the problem is in the first place much less fix them.
I get probably 25 to 40 arousals at least every night. In my case I know the main culprit.which is back/pelvis pain from bad arthritis.
On a bad night sleep quality wise I might remember half of them. On a good night maybe 4 or 5.
The bulk of my AHI is always at least 75% false positives arousal related flagged events. Couple of weeks ago I had a 9.4 AHI which is REALLY unusually high for me (typically run 1.0 to 3.0) and I went through each flagged event and 90% of that AHI was arousal related.
I had an unusually bad night in terms of pain control that night. Lots of wake ups and lots of tossing and turning because of pain.

[Katerific]

I see at least 2 breaks in therapy last night where we know for sure you were awake. Why? Anything specific that you can remember? I had dry mouth both times and got up to get a drink of water.
Did you have other times where you were awake but didn't turn off the machine? I remember being awake 2 other times with dry mouth but didn't turn off the machine or take off the mask.
[/color]
There are 2 kinds of arousals....respiratory related and spontaneous related which just means we don't know why. Not all arousals are related to the airway and cpap can only fix airway related problems.

People can have crappy sleep for any number of reasons.
Do you take any medications of any kind? If so, what? I only take over-the-counter meds. Vitamin, Nasonex, Omeprazole, occasional Pepcid at bedtime
That's the first thing we look at because so many meds have side effects that mess with sleep in some form.
Anything else going on in terms of pain, bed comfort, mask comfort, etc? I don't have any pain, the bed is comfortable, mask is comfortable enough. I get hot at night, so I turned the temp down on the air conditioner. I could also turn the ceiling fan on.

Arousals...we may or may not remember them and when they are spontaneous and not related to airway issues it's really hard to figure out what the problem is in the first place much less fix them.
I get probably 25 to 40 arousals at least every night. In my case I know the main culprit.which is back/pelvis pain from bad arthritis.
On a bad night sleep quality wise I might remember half of them. On a good night maybe 4 or 5.
The bulk of my AHI is always at least 75% false positives arousal related flagged events. Couple of weeks ago I had a 9.4 AHI which is REALLY unusually high for me (typically run 1.0 to 3.0) and I went through each flagged event and 90% of that AHI was arousal related.
I had an unusually bad night in terms of pain control that night. Lots of wake ups and lots of tossing and turning because of pain.

Last night when I reduced the pressure, I had 21 hypopneas. Before, when my pressure was higher, hypopneas were always between 3-9 (ish). So it appears to me the higher pressure does control the apneas better. I had more arousals last night, which were flagged with either an hypopnea or OA. So which came first, the hypopnea or the arousal from something else? Because the choppy air flow preceding the event means arousal, could the arousal be caused by the body recognizing the hypopnea coming on?

To Pugsy and everyone else who offered advice, thank you. I really appreciate it.

[Pugsy]

So which came first, the hypopnea or the arousal from something else? Because the choppy air flow preceding the event means arousal, could the arousal be caused by the body recognizing the hypopnea coming on?

The body doesn't/can't know that there is a real apnea event (OA or hyponea or central) coming on. There's no crystal ball but sometimes the early warning signals of an impending airway collapse issue might disrupt sleep.

Snoring would be an early warning signal that the airway is trying to collapse and it might grow up to be a full blown event or it might stop with the snores only....but the snores can disrupt sleep. I long ago lost count of the number of times I snored and woke myself..up.
This is why snores will cause auto adjusting algorithms to increase the pressure...snores are unwanted...they can disturb sleep and they can grow up to be a full grown apnea event.
So arousals can happen because of some sort of physical reaction but they have to have something prompt them.

You made a change in your pressure settings and you had one night with higher hyponeas. We don't sleep the same each night and there is a lot of truth to the "give it time" thing which is why we don't go changing things based on one night's reports. It's not impossible that you would have had a higher hyponea count even if you hadn't changed anything at all.

You may just have to make a compromise.....it wouldn't be impossible that lowering the pressure does allow an increase in real asleep hyponeas and if you increase that minimum the hyponeas reduce but with that reduction in hyponeas you experience bad aerophagia issues. Normally we would suggest increasing exhale relief as a way of reducing the chance of aerophagia but it's possible that you also got the unlucky straw that when you use exhale relief you have an increase in central apneas. Really limits your choices but I think I would look back on those centrals you used to have when Flex was higher and make sure they weren't arousal related as well before I gave up on using Flex.

We have a forum member here who had really bad aerophagia and she had to make a compromise of accepting that a 2 to 4 AHI was just what she was going to get because if she used higher pressures and brought the AHI down she had horrible aerophagia symptoms.
She just accepted it as a better compromise than being ill with belly pain all the next day or even more.
.
Lots of things can cause arousals...heck even the aerophagia issues during the night can cause arousals which in turn increase the chance of false positive event flagging. Your dry mouth issues are causing arousals. Maybe consider adding using some sort of oral hydrating product in an effort to reduce the dry mouth and maybe reduce those arousals.

[Katerific]

You made a change in your pressure settings and you had one night with higher hyponeas. We don't sleep the same each night and there is a lot of truth to the "give it time" thing which is why we don't go changing things based on one night's reports. It's not impossible that you would have had a higher hyponea count even if you hadn't changed anything at all. I will stick with these pressures for a few days to see how I do. This calls for a dose of patience.

Normally we would suggest increasing exhale relief as a way of reducing the chance of aerophagia but it's possible that you also got the unlucky straw that when you use exhale relief you have an increase in central apneas. Really limits your choices but I think I would look back on those centrals you used to have when Flex was higher and make sure they weren't arousal related as well before I gave up on using Flex. They all look arousal related, but definitely increase with Flex on. I had Flex on 1 every night for the first month and then tried several times again. There is definitely a pattern.

We have a forum member here who had really bad aerophagia and she had to make a compromise of accepting that a 2 to 4 AHI was just what she was going to get because if she used higher pressures and brought the AHI down she had horrible aerophagia symptoms. She just accepted it as a better compromise than being ill with belly pain all the next day or even more. I'm getting close to accepting a compromise.

Lots of things can cause arousals...heck even the aerophagia issues during the night can cause arousals which in turn increase the chance of false positive event flagging. Your dry mouth issues are causing arousals. Maybe consider adding using some sort of oral hydrating product in an effort to reduce the dry mouth and maybe reduce those arousals. Good suggestion

Thank you very much for helping me.
.

[busymummy]

http://freecpapadvice.com/sleepyhead-free-software
Your machine could possibly be mistaking your allergy related congestion symptoms and breathing for apnea symptoms. It's something that just happens because the machine only measures air flow and the reduction in air flow that occurs because of swollen nasal mucosa mimics the reduction that comes from sleep apnea airway collapse reductions in flow. The machine simply can't tell the difference.

Normally we wouldn't care and just let the machine do its thing but in your situation the machine doing its thing means more pressure which causes a problem for you in terms of aerophagia.
Lets back up and figure out first of all if those flagged events are real asleep events or instead if they are arousal related events and simply didn't need more pressure in the first place.

I am experiencing more nasal congestion atm and that is helpful information. Thanks.

[joeljjk11]

I am speaking from personal experience but I know that my acid reflux is bad when my pressure is too LOW. And I know with a FFM you need more pressure, not less. You can try increasing the pressure relief setting on your machine (EPR on a Resmed not sure what it is on the Dreamstation) to see if that helps with the aerophagia, it helps for me.

[Katerific]

I am speaking from personal experience but I know that my acid reflux is bad when my pressure is too LOW. And I know with a FFM you need more pressure, not less. You can try increasing the pressure relief setting on your machine (EPR on a Resmed not sure what it is on the Dreamstation) to see if that helps with the aerophagia, it helps for me.

I have the acid reflux under control right now. I'm taking omeprazole in the morning and not eating anything too close to bedtime. When my 14 day course runs out, maybe I'll be lucky and I won't have acid reflux. I didn't until last week, so maybe it will be OK. The aerophagia is much better since I lowered the pressure from 9min - 11 max to 8.5 min - 9.5 max. When I add FLEX pressure relief of even a setting of 1, I get a huge number of clear apneas. When I turn off FLEX, it goes back down to low numbers or zero CA. I've tried pressure relief several times and always get them. Even if they aren't real and are because of arousals, I still get them a lot more with FLEX. I don't know why it happens, but it does.

[Janknitz]

This is more a question for Pugsy than a suggestion at this point, but Pugsy, what would happen if Kate ran the machine in CPAP mode right under the pressure that causes aerophagia? Would that maybe tamp things down? The pressure range is so narrow to begin with . . .

[Pugsy]

This is more a question for Pugsy than a suggestion at this point, but Pugsy, what would happen if Kate ran the machine in CPAP mode right under the pressure that causes aerophagia? Would that maybe tamp things down? The pressure range is so narrow to begin with . . .

Nothing really much different except we lose any Flow Limitation flagging.
In CPAP mode FL flagging is turned off on the Respironics machines. Since it is kinda important that we know FL status I prefer to use either a really tight range or even minimum to equal maximum but still in apap mode so that we get the FL flagging.

You gain nothing by using cpap mode but you do lose FL flagging. CPAP mode and apap mode with minimum to equal maximum is going to essentially work the same except for FL flags.

[Katerific]

I noticed something in my report this morning. When the machine noticed a FL and raised pressure, I got the arousals and AHI events. I checked previous days and don't see the exact correlation, but it happens, just not as predictably. I am tempted to narrow the max from 9.5 to 9.0 to see if it further reduces arousals, but maybe I should evaluate the data a few more days. What do you think?

Last night I had 1.6 AHI and I feel great today. I woke up only once that I remember and turned off the machine to make a trip to the bathroom.

To reduce dry mouth, I started taping my mouth mostly closed. If I totally seal it, I feel a little panic, so I leave a little space to breathe if I need to and it seems to really help. Nasonex is keeping my allergies under control.