Aerophagia w/ Bilevel machine

[mgundy]

I think EPAP of 10 would be what I would try. Still keep PS at 4 though.
Your obstructive index last night was 0.43...that's very low and extremely acceptable and you have ample room to reduce EPAP without a hugely negative impact on the obstructive index.
It sure sounds like EPAP is the main component for feeding the aerophagia monster for you and if you think about it logically...it's probably the main component for most people. That constant pressure against the LES (lower esophageal sphincter) the gradually pushes past the sphincter to let air into the stomach. Keeping the constant pressure lower lets the sphincter hold itself closed more easily. At least that's my personal opinion and logic tells me that it surely is possible.

BTW one of the reasons besides my own personal, don't do 2 changes at one time, for not increasing PS is that sometimes in some people higher PS can trigger centrals. So I don't really promote PS 5 or higher unless there is a marked definite need and I don't see it being needed with you.

I tried an EPAP of 10 last night and the CA's went up quite a bit. I zoomed in on them and they are legit. I also didn't feel like I slept that well like I do most nights. Regarding the Aerophagia, it's gone this morning!

https://imgur.com/MzwcQRC

Any ideas on how to push the CA's down but keep the EPAP at 10? Nothing is easy for me regarding my sleep apnea! LOL!

[Pugsy]

The only thing within your control that you can do for centrals is maybe...stress the maybe part...is lower your PS and it might reduce the centrals.

Lowering EPAP/IPAP shouldn't cause more centrals. I can't think of any logical reason.
You don't take any meds that might suppress breathing do you?

Lowering PS only helps when PS is the trigger for the centrals. If it's not the trigger then it won't help.

Can you share a couple of zoomed in on centrals and lets see if they are for sure legit.
The very first one at the beginning of the night and the 2 close together right after you turned the machine back on again at around 4:00.

Open OSCAR on the left side Click on the Events tab.
Then Click on the CA tab.
Then you will see a list of timed centrals. Click on the first one in the night. The scale will zoom in automatically on the event. That's the scale we need so use that scale.
Take screen shot.
Then do the same for the 2 at 4:00....click on the first one...second one should also be in the picture because it is close to the time frame when the first one got flagged.

[mgundy]

The only thing within your control that you can do for centrals is maybe...stress the maybe part...is lower your PS and it might reduce the centrals.

Lowering EPAP/IPAP shouldn't cause more centrals. I can't think of any logical reason.
You don't take any meds that might suppress breathing do you?

Lowering PS only helps when PS is the trigger for the centrals. If it's not the trigger then it won't help.

Can you share a couple of zoomed in on centrals and lets see if they are for sure legit.
The very first one at the beginning of the night and the 2 close together right after you turned the machine back on again at around 4:00.

Open OSCAR on the left side Click on the Events tab.
Then Click on the CA tab.
Then you will see a list of timed centrals. Click on the first one in the night. The scale will zoom in automatically on the event. That's the scale we need so use that scale.
Take screen shot.
Then do the same for the 2 at 4:00....click on the first one...second one should also be in the picture because it is close to the time frame when the first one got flagged.

Hi Pugsy! I've provided the two screen shots below like you asked. Hopefully, that will provide you some insight. I don't take any medications at night other than some supplements that aren't respiratory related, e.g. zinc, quercetin, magnesium, etc. If you think that might affect what's going on I can take them earlier in the evening.

I do have sinus issues. If clear was a scale 1-10 with 10 being fully open, last night I would say I was a 7 or 8.

https://imgur.com/cfqMhwe

https://imgur.com/5mc3DrW

Thank you!

[Pugsy]

No, I doubt those supplements are any sort of factor for anything.

The very first central at the beginning of the night I don't think you were sound asleep. Breathing is too irregular and there's the gulp of air at 23:04:30 which we know isn't asleep breathing. We don't take big gulps of air while asleep.

The 2 at 4:00....I can't see enough of the flow rate prior to the very first flagged central after the break in therapy but I have my doubts as you your sleep status at that time. At most these may be sleep onset centrals which are normal to see and not a big deal. They can happen when we transition from awake to asleep...that's why they are called sleep onset or some people call them transitional. Entirely normal to see them.

They normally aren't a problem unless we start seeing a lot of them and when we see a lot of sleep onset centrals it means we had a lot of sleep onsets during the night and to have a lot of sleep onsets we have to have a lot of arousals/awakenings.
We may or may not remember those awakenings. It's the frequent awakenings that disturb sleep that are the real cause of us feeling like crap during the day...not the centrals that are sleep onset centrals which wouldn't happen if we hadn't woke up a little and then have to go back to sleep.
So the centrals can be symptoms of a sleep problem and not necessarily the cause of the sleep problem.

You've made some significant pressure changes in just a couple of nights and maybe you just need to allow the body/brain to adjust to the new settings. It wouldn't be impossible for you to have had more arousals than usual just from the new settings and the body not being adjusted fully.
This is why we normally tell people to not go changing things every night unless urgent need ( as with your belly issues).
One night does not make a trend or pattern and we can all have off nights that we have to ignore.

Your AHI is still primarily centrals. Very little obstructive stuff with these drops in pressure.
How did you come to be on your original settings? I don't see a need for those so much higher pressures...and in fact I don't see a need for 10 EPAP at this point.
What position do you sleep in? Did you have an in lab study done while on the machine so they could figure out optimal pressures?

We can't deal with centrals with more pressure with this machine. Using less pressure like lowering EPAP shouldn't cause more centrals. If anything we would expect the centrals to decrease in number with lower EPAP/IPAP but that's only if the higher pressures were the trigger for centrals but I don't see that being the case in your situation.

I think that maybe last night was one of those "off" nights where you just didn't sleep as soundly maybe from the brain not being used to the changes we have made in such a short period of time.

If it were me....I would stay with current settings a couple more nights and if the obstructive index remains low then I would try 9 EPAP. This is an experiment I would try after using 10 EPAP for about a week (maybe sneak in a PS reduction during that week) and it's confirmed that the obstructive stuff is indeed very minimal.

If comfortable you can drop PS to 3 (keeping EPAP at 10 for now) and see if the centrals reduce in number but I would only do this after keeping these settings of 10 EPAP and 4 PS for a couple more nights. See if the centrals reduce on their own once you let your body get used to the new settings. Last night might have just been a weird "off" night because you didn't sleep so great.

Essentially we are doing a reverse titration...going from higher to lower.
Normally titrations go from lower to higher.
Either way will eventually get us to where we want to go. I didn't want to make an abrupt big change since you have been used to the higher pressures to take you to a titration that starts lower and works up to higher.
Been there and done that and a sudden drop from higher to lower is pretty much a recipe for someone being uncomfortable just from the difference in feeling and the brain saying "whoa, what's going on here. I can't breathe so great"....and you get lots of wake ups just from the change because the brain isn't on board yet.

[mgundy]

Your AHI is still primarily centrals. Very little obstructive stuff with these drops in pressure.
How did you come to be on your original settings? I don't see a need for those so much higher pressures...and in fact I don't see a need for 10 EPAP at this point.
What position do you sleep in? Did you have an in lab study done while on the machine so they could figure out optimal pressures?

I came up with the original settings from the help on this board. I had a home sleep study and was given a MAD dental device. That wasn't working so good and my insurance does not cover sleep apnea. So I went ahead and bought a Philips Respironics APAP with my prescription. I was still having and AHI above 5 with pressures at 18. The issue is I have sinus issues and many nights they are pretty clogged even with decongestants. It was suggested I try a Bilevel machine so I got one of those. Due to the high pressures and my mouth falling open the air was just circulating from into my nose and out of my mouth. Someone suggested a foam cervical collar and that kept my mouth shut and forced the air into my nose. Here is a representative chart from when I had the EPAP at 14.

https://imgur.com/gZgpKN0

Oh! And I'm a side sleeper.

I'll give it a few nights with the EPAP at 10 and the PS at 4.

Thanks!

[Pugsy]

Well whatever caused you to need 14 EPAP doesn't seem to be present now. Maybe you were on your back a lot back then or something but I don't see the need now.
Normally it wouldn't be a big deal to use more pressure than we might technically need but in your case you have developed some severe aerophagia issues at the higher pressures and that of course can not only mess with your sleep quality but have some really ugly ramifications on your daytime feelings. I have had bad aerophagia only twice in 13 years on cpap.
Not only did I have a lot of pain but I had some nausea as well that took the better part of the day to go away.
Both times it happened I was experimenting with something on the cpap...so I learned real quick I didn't want to go further with those experiments.

[ChicagoGranny]

The issue is I have sinus issues and many nights they are pretty clogged even with decongestants.

As you know, congestion can make CPAP difficult. Have you consulted recently with an ENT? Treatments have improved over recent years.

[mgundy]

The issue is I have sinus issues and many nights they are pretty clogged even with decongestants.

As you know, congestion can make CPAP difficult. Have you consulted recently with an ENT? Treatments have improved over recent years.

About 15 years ago I saw an ENT.

I had turbinate reduction surgery. It helped a lot. That and sinus rinse has me not getting bronchitis several times a year. When my insurance gets better I plan on going back. Although I'm not looking forward if the ENT wants to do surgery again. The recovery was one of the most uncomfortable experiences of my life!

[ChicagoGranny]

About 15 years ago I saw an ENT.

I had turbinate reduction surgery. It helped a lot. That and sinus rinse has me not getting bronchitis several times a year. When my insurance gets better I plan on going back. Although I'm not looking forward if the ENT wants to do surgery again. The recovery was one of the most uncomfortable experiences of my life!

Surgical turbinate reduction surgery usually doesn't need repeating. Gramps had it 15 years ago, and the surgery and recovery were nearly painless. Maybe you should consult with a different ENT this time??

[mgundy]

Here's my chart from last night. Taking Pugsy's thoughts I tried EPAP of 8.0 and a PS of 3. Looks pretty good to me! My allergies were pretty bad yesterday so I'm pretty happy with last night considering I thought I wouldn't sleep well at all. I had to wake up a few times to perform a sinus rinse.

My aerophagia is probably at a 2 on a scale of 1 to 10 with 10 being where it was at (really bad).

Any other recommendations?

https://imgur.com/DnvtdNC