Flow limitations resistant to pressure?

[cyberdreamer]

Hi everyone!

I've been trying to further tweak my therapy again after I've mostly solved my mask leaks. I want to have less fatigue and aerophagia/acid reflux.

Two weeks ago, I increased EPR from 2 to 3 and this improved my aerophagia but led to an AHI of ~4 about half of the nights.

Monday, I upped the min pressure from 9 to 10.6 and this seem to curb the AHI to less than 3. Tuesday and Wednesday, I further increased this min pressure to 11 but AHI and FLs seem to remain the same and I'm experiencing bad aerophagia and very dry nose, sinus and mouth (I use humidity of 7 because 8 leads to rainout) ...

Anything else I can do to my therapy? I wonder why the flow limitations persist even when the machine spikes the pressure to 15. I have moderate nasal congestion which I control with a steroid nasal spray (its commercial name is Veramyst/Flonase in USA) and I don't feel it's that bothersome.

Last days stats and summary of therapy: https://imgur.com/a/7FzBeNg

[Pugsy]

Anything else I can do to my therapy? I wonder why the flow limitations persist even when the machine spikes the pressure to 15. I have moderate nasal congestion which I control with a steroid nasal spray (its commercial name is Veramyst/Flonase in USA) and I don't feel it's that bothersome.

You may not think the nasal congestion is an issue but the machine might sense it anyway. If the FL is from nasal congestion no amount of pressure is going to make the FL look better. Usually when I see FLs that don't respond as expected to much higher pressures I assume nasal related.

You left out an important fact....how are you sleeping and feeling in general other than the aerophagia issues???

You may have to make some sort of compromise with what you are seeing in terms of data points and what happens when you increase the pressure trying to reduce those data points and what happens in terms of the aerophagia monster coming for a visit.

If you use a lot more pressure the data points may reduce but if you are having bad aerophagia as a result and miserable the next day then you really haven't gained much have you?
How you sleep and how you feel the next day is just as important as the data points you see on the reports.

[cyberdreamer]

Anything else I can do to my therapy? I wonder why the flow limitations persist even when the machine spikes the pressure to 15. I have moderate nasal congestion which I control with a steroid nasal spray (its commercial name is Veramyst/Flonase in USA) and I don't feel it's that bothersome.

You may not think the nasal congestion is an issue but the machine might sense it anyway. If the FL is from nasal congestion no amount of pressure is going to make the FL look better. Usually when I see FLs that don't respond as expected to much higher pressures I assume nasal related.

You left out an important fact....how are you sleeping and feeling in general other than the aerophagia issues???

You may have to make some sort of compromise with what you are seeing in terms of data points and what happens when you increase the pressure trying to reduce those data points and what happens in terms of the aerophagia monster coming for a visit.

If you use a lot more pressure the data points may reduce but if you are having bad aerophagia as a result and miserable the next day then you really haven't gained much have you?
How you sleep and how you feel the next day is just as important as the data points you see on the reports.

Hey Pugsy, thanks for the quick and insightful answer as always!

I had been waking up four times each night for the past weeks, having bad aerophagia and not feeling mentally like my usual self. The mental symptoms had happened before when my GERD was uncontrolled (depressed, very anxious, unrestful naps).

I went nuclear on the problem and improved a lot the past few days but it's hard to pinpoint what is helping me more. Aside from increasing with EPR and recently tinkering with min pressure on the APAP, I cut back supplements which could cause insomnia (like vitamin B12), increased GERD meds dosage (PPI twice a day now) and started exercising more diligently each day. The depressed mood and zoned out sensation is gone.

I think the recent min pressure of 11 definitely increased aerophagia to previous levels (when EPR was 2) and caused a lot of dryness. I also had this a middle of the night insomnia yesterday with restless legs for about an hour. So I might try reducing the min pressure to about 10 which seemed to yield better results than 9 without so many side effects on Monday.

Two questions I still have:
1. Do you think I should try to cap the maximum pressure? To determine if the machine is needlessly raise pressure in response to these flow limitations which seem unaffected by pressure.
2. Is it likely that a BiPAP machine in the future would improve my treatment? Could there likely be less aerophagia and dryness with it? I haven't fully understood when BiPAP is recommended yet.

[Pugsy]

1. Do you think I should try to cap the maximum pressure? To determine if the machine is needlessly raise pressure in response to these flow limitations which seem unaffected by pressure.

Most definitely worth trying to see if the aerophagia symptoms lessen. I have always said that sometimes we have to limit the maximum a bit when the maximum it goes to ends up create a worse problem than the problem it was trying to kill....and if the nasal congestion is causing any of the FLs then the machine won't ever be able to kill it anyway.
Though I do suspect that the constant minimum pressure is more likely the largest culprit in the aerophagia producing war.

2. Is it likely that a BiPAP machine in the future would improve my treatment? Could there likely be less aerophagia and dryness with it? I haven't fully understood when BiPAP is recommended yet.

Bilevel machines are recommended for aerophagia related symptoms when there is a needed for higher than 3 cm difference between inhale and exhale. Or recommended when someone needs a higher pressure and that higher pressure is so uncomfortable that more than 3 cm exhale relief is needed just to tolerate the pressure. Some docs will automatically go bilevel when someone needs pressures in the teens to deal with the OSA.

But we have a forum member here who had really bad aerophagia and her prescribed pressure was around 8 or 9 but it gave her really bad aerophagia issues even with max exhale relief. So she got prescribed bilevel and her minimum EPAP was 4 and Pressure support was 4 which gave IPAP of 8....and she used auto mode but limited the max IPAP to 10 because anything higher than 10 caused bad aerophagia. Now sometimes with the max limited to 10 she saw a little bit higher AHI than she wanted and the machine maxed out at 10....but she knew if she let it go higher that her belly issues were a much bigger problem than a little bit higher AHI was a problem. So that was her compromise.

I don't know if bilevel would help you or not. I have no way to know...no one can know until you can at least try bilevel.
It's a pricey experiment though and insurance won't pay until a real need is proven. In your situation the "real need" would be your complaining at great lengths as to how bad the aerophagia is.
Or if you have some extra cash.....give LSAT a chance to get a bilevel machine that is slightly used and you just buy it yourself. It can be set to function like the AutoSet if need be but it has the capability to give higher than 3 cm pressure support that you are getting with EPR at 3. More options to maybe help....but no guarantee that it will help.

I use a bilevel...AirCurve 10 VAuto...I just happen to like pressure support of 4 a lot better than PS of 3.
That's the only reason I use it....simply I am more comfortable with it but I can use an AutoSet if need be.
I don't have aerophagia issues and my current settings are minimum EPAP of 5....PS of 4 and that means IPAP of 9 to start with and I have the max IPAP at 24 but rarely see it go over 14 IPAP.
No way would I ever get insurance to pay for it though. I buy privately like from LSAT. I have never used my insurance for any sort of machine.