Resmed 9 Bilevel/question re PS

[christinepi]

I'm confused. I'm new to the bilevel world after 4 bad months of CPAP (aerophagia). My doctor prescribed IPAP of 14 and EPAP of 8, and a PS of 4. I started on this a week ago. As far as I can remember, the PS was indeed set at 4 every time I went to the settings screen, which was ca once a day because I'm playing with the pressures almost every day. I had to go down from 14/7 to 8/4 because I couldn't handle the aerophagia. Well, yesterday when I was changing the pressure again, I noticed that the PS was set at 1.0. I know that I didn't ever touch that setting. I turned it back up to 4. In the middle of the night, I awoke from aerophagia and turned the machine on to change the pressures down a notch, and then noticed that the PS was at 3.2 (?!?!?). I raised the PS to 4 again. This morning, when I checked, it still was at 4.

It's probably just my ignorance about the workings of this machine, but could somebody explain to me what's happening?

[jnk]

. . . I'm playing with the pressures almost every day. . . . I noticed that the PS was set at 1.0. I know that I didn't ever touch that setting.

If you accidentally at any point adjusted the Max IPAP and Min EPAP to within one cmH2O of each other, the machine adjusted the PS accordingly. If you set those Min and Max settings too close, the machine has no choice but to lower the PS to match the Max IPAP and Min EPAP settings. It is good to check the PS setting after every time you change the Min or Max settings, since the machine gives priority to them.

I do not recommend that anyone 'play with the pressures almost every day.' Perhaps your situation gives you no choice but to do what you are doing--and if so, I respect that you are trying to find a way to make the machine tolerable so that you can use it all night every night. But it would sure be nice if a doc or RT was being of help to you with all of that, too.

That being said, I will gladly pass on anything that may be of help to you that I think I know.

Remember that if you want your PS setting to remain at 4 in the machine when it is in VAuto mode, you can't, even for a moment, adjust Max IPAP and Min EPAP to be less than 4 apart either, or the machine will decrease your PS on its own to match the other settings.

Hope that helps.

I wish you the best, but be careful, and keep asking for help from professionals, if any are available to you and are willing to help. Meantime, keep posting questions here for input from fellow patients who may be of help to you. We do what we can.

[McSleepy]

It looks like ResMed has just released this new machine - I wish it were available 6 months ago when I was getting mine. I use bi-level with similar pressures to yours, so maybe I can be helpful, except, your machine seems to be acting differently than mine. What made me have to use it in Spontaneous mode (i.e., fixed, bi-level pressures) is its inability to adjust pressure support (PS) in Auto mode. Unless your machine is possessed, it seems to be able to adjust PS automatically. Have you studied the clinician's manual for your machine? Other than PS having to be restricted to IPAP-EPAP, you should be able to set it to a value and it should stay there. One possibility that I see is if you lower the IPAP before lowering the EPAP or, conversely, raise the EPAP before raising the IPAP, in which case the PS would be shrunk automatically to enforce that constraint. For example, you had your machine at 14/7 but wanted to lower it to 8/4, however, you first lowered IPAP from 14 to 8, which gives you (albeit temporarily) a PS of 1 (because at that moment you had 8/7), then you lowered EPAP from 7 to 4, but by then PS was reduced to 1.

Other than that, aerophagia is something I used to struggle with in the very beginning of using CPAP (bi-level). I have a hiatal hernia (who doesn't nowadays?) and that is the main reason, paired with the high pressures. However, I can tell you that for me it was all a matter of getting my body trained to prevent it. I've had bad cases of aerophagia on 10cm H2O pressures and I have stayed aerophagia-free at 20cm. One big key to that is sleeping exclusively on my stomach. But mostly training myself to use breathing patterns that involve the stomach muscles so that there is always pressure on the lower esophageal sphincter, helping it stay shut. You should search this forum for other tips on how to manage aerophagia.

McSleepy

[christinepi]

It looks like ResMed has just released this new machine - I wish it were available 6 months ago when I was getting mine. I use bi-level with similar pressures to yours, so maybe I can be helpful, except, your machine seems to be acting differently than mine. What made me have to use it in Spontaneous mode (i.e., fixed, bi-level pressures) is its inability to adjust pressure support (PS) in Auto mode. Unless your machine is possessed, it seems to be able to adjust PS automatically. Have you studied the clinician's manual for your machine? Other than PS having to be restricted to IPAP-EPAP, you should be able to set it to a value and it should stay there. One possibility that I see is if you lower the IPAP before lowering the EPAP or, conversely, raise the EPAP before raising the IPAP, in which case the PS would be shrunk automatically to enforce that constraint. For example, you had your machine at 14/7 but wanted to lower it to 8/4, however, you first lowered IPAP from 14 to 8, which gives you (albeit temporarily) a PS of 1 (because at that moment you had 8/7), then you lowered EPAP from 7 to 4, but by then PS was reduced to 1.

Other than that, aerophagia is something I used to struggle with in the very beginning of using CPAP (bi-level). I have a hiatal hernia (who doesn't nowadays?) and that is the main reason, paired with the high pressures. However, I can tell you that for me it was all a matter of getting my body trained to prevent it. I've had bad cases of aerophagia on 10cm H2O pressures and I have stayed aerophagia-free at 20cm. One big key to that is sleeping exclusively on my stomach. But mostly training myself to use breathing patterns that involve the stomach muscles so that there is always pressure on the lower esophageal sphincter, helping it stay shut. You should search this forum for other tips on how to manage aerophagia.

McSleepy

Yes, I was lucky in that that machine just came out when I needed it. Your suggestion is brilliant--that may well be the explanation why the PS was at 1. And maybe it adjusts PS automatically. I don't have the clinician's manual yet but will check that out!

I don't have GERD, LPR or a hiatal hernia, just bad luck, I think. I've looked at the aerophagia management suggestions but so far have not been able to make it work. Sigh...

[christinepi]

. . . I'm playing with the pressures almost every day. . . . I noticed that the PS was set at 1.0. I know that I didn't ever touch that setting.

If you accidentally at any point adjusted the Max IPAP and Min EPAP to within one cmH2O of each other, the machine adjusted the PS accordingly. If you set those Min and Max settings too close, the machine has no choice but to lower the PS to match the Max IPAP and Min EPAP settings. It is good to check the PS setting after every time you change the Min or Max settings, since the machine gives priority to them.

I do not recommend that anyone 'play with the pressures almost every day.' Perhaps your situation gives you no choice but to do what you are doing--and if so, I respect that you are trying to find a way to make the machine tolerable so that you can use it all night every night. But it would sure be nice if a doc or RT was being of help to you with all of that, too.

That being said, I will gladly pass on anything that may be of help to you that I think I know.

Remember that if you want your PS setting to remain at 4 in the machine when it is in VAuto mode, you can't, even for a moment, adjust Max IPAP and Min EPAP to be less than 4 apart either, or the machine will decrease your PS on its own to match the other settings.

Hope that helps.

I wish you the best, but be careful, and keep asking for help from professionals, if any are available to you and are willing to help. Meantime, keep posting questions here for input from fellow patients who may be of help to you. We do what we can.

I completely agree that I should work with my doctors. Unfortunately there's a history of such uselessness with them during my 4 months on APAP (this is Stanford we're talking about!) that I pretty much stopped looking there for help. Any way, I've NOT touched any of the other settings on this new machine other than the pressure settings and I won't until I talk to the doctors.

Lowering the pressure settings has already helped greatly with the aerophagia, so I know I'm on the right track. The thing that's confusing is that I've ALWAYS kept 4 cm between IPAP and EPAP. Consistently. So why, in the middle of the night, does the PS go to 3.2, when a) I've set IPAP and EPAP 4 cm apart and b) I set PS at 4? Is the machine auto adjusting?

Thanks for your kind suggestions.

[jnk]

. . . why, in the middle of the night, does the PS go to 3.2, when a) I've set IPAP and EPAP 4 cm apart and b) I set PS at 4? Is the machine auto adjusting?

I have no idea. I don't know anything about the S9 bilevel, really, or how PS works on it. My answer was based solely on my experiences with my S8 and the following statement in the S8 clinical manual:

Priority is given to the Max IPAP setting, followed by Min EPAP and then Pressure Support. The device automatically adjusts the lower-priority settings to ensure the device pressure limits are not exceeded.

I have always considered Stanford to have a top notch reputation with anything even remotely involving sleep.

[robysue]

A user of the *other* bi-level here chiming in here.

First, I strongly second jnk's suggestion of caution on all the playing around with the pressure settings. It takes a while to acclimate to a new pressure setting (or pressure range on an Auto). So if you are going to make changes, you really need to leave them in place for several days before making additional changes.

Next, you need to make sure you understand the basics of the Auto algorithm your machine uses before you make any changes. And changes that you make should be SMALL, INCREMENTAL changes, not huge jumps in the pressure settings.

But by going from Max IPAP = 14, Min EPAP = 8 with PS = 4 to Max IPAP = 8, Min EPAP = 4 with PS = 4, you have made several HUGE changes in how your machine is running. If the S9's VPAP Auto algorithm adjusts pressure in the same fashion that the S8 VPAP Auto does, then my understanding is that with the prescribed Max IPAP = 14, MIn EPAP = 8 with PS = 4, your actual pressures should stay in these ranges:

8 <= EPAP <= 10
12 <= IPAP <= 14
IPAP - EPAP = 4 at all times.

And by changing the pressure settings to Max IPAP = 8, Min EPAP = 4 with PS = 4 you have forced the machine to run in straight bi-level mode because Max IPAP - Min EPAP = PS. In other words, your IPAP Is now ALWAYS equal to 8cm and your EPAP is ALWAYS equal to 4 since the PS setting equals Max IPAP - Min EPAP.

So going from (Max IPAP = 14, Min EPAP = 8 with PS = 4) to (Max IPAP = 8, Min EPAP = 4 with PS = 4) is a huge, huge change: You've gone from a (tight) Auto Range for pressure to FIXED pressure settings AND your current full time pressure settings are 4 full cm below the minimum therapeutic levels that are presumably based either directly on a titration study or an adjustment to a titration study.

Do you know what your titration study said your pressure levels SHOULD be set to? Has the doctor already reduced them by a cm or two in order to try to help the aerophagia issue?

Moreover, since your now full time IPAP = 8cm is barely what the prescribed EPAP was, there's a high probability that your current pressure settings (Max IPAP = 8, Min EPAP = 4 with PS = 4) are NOT providing you with effective therapy. What do your AHI numbers look like at the lower pressure range?

As to why the PS suddenly changed to 1cm and showed up as 3.2 cm when you looked at it at night? As you've been told, if you inadvertently changed IPAP from 14 to 8 while EPAP was set at 7, that would automatically change PS =1 since PS cannot exceed Max(IPAP) = Min(EPAP).

And finally, Resmed redesigned some parts of their Auto algorithms going from the S8 series to the S9 series. While I don't know how likely this is, it's possible that in designing the new Auto algorithm for the S9 VPAP, Resmed may have decided to allow the S9 VPAP to increase IPAP and EPAP independently of each other as long as IPAP - EPAP doesn't exceed the value of the PS setting. (That's the way the PR System One BiPAP Auto does it: IPAP increases in response to certain events, EPAP increases in response to a different set of events, and as long as 2 < IPAP - EPAP < PS the PR S1 will adjust IPAP and EPAP separately.)

So if Resmed decided to allow IPAP and EPAP increase independently of each other on the S9 VPAP, then it's possible that the PS = 3.2 number you were looking at in the middle of the night may have simply been the current value of IPAP - EPAP. And that PS = 4 setting represents the max(IPAP - EPAP) allowed. But the only way to determine if my hypothesis has any basis in fact is to look carefully at the Clinical manual for the S9 VPAP machine. So you really need to study that S9 VPAP Auto clinical menu very, very carefully before you continue to play around with pressure settings.

[christinepi]

A user of the *other* bi-level here chiming in here.

First, I strongly second jnk's suggestion of caution on all the playing around with the pressure settings. It takes a while to acclimate to a new pressure setting (or pressure range on an Auto). So if you are going to make changes, you really need to leave them in place for several days before making additional changes.

Point well taken.

Next, you need to make sure you understand the basics of the Auto algorithm your machine uses before you make any changes. And changes that you make should be SMALL, INCREMENTAL changes, not huge jumps in the pressure settings.

But by going from Max IPAP = 14, Min EPAP = 8 with PS = 4 to Max IPAP = 8, Min EPAP = 4 with PS = 4, you have made several HUGE changes in how your machine is running. If the S9's VPAP Auto algorithm adjusts pressure in the same fashion that the S8 VPAP Auto does, then my understanding is that with the prescribed Max IPAP = 14, MIn EPAP = 8 with PS = 4, your actual pressures should stay in these ranges:

8 <= EPAP <= 10
12 <= IPAP <= 14
IPAP - EPAP = 4 at all times.

And by changing the pressure settings to Max IPAP = 8, Min EPAP = 4 with PS = 4 you have forced the machine to run in straight bi-level mode because Max IPAP - Min EPAP = PS. In other words, your IPAP Is now ALWAYS equal to 8cm and your EPAP is ALWAYS equal to 4 since the PS setting equals Max IPAP - Min EPAP.

So going from (Max IPAP = 14, Min EPAP = 8 with PS = 4) to (Max IPAP = 8, Min EPAP = 4 with PS = 4) is a huge, huge change: You've gone from a (tight) Auto Range for pressure to FIXED pressure settings AND your current full time pressure settings are 4 full cm below the minimum therapeutic levels that are presumably based either directly on a titration study or an adjustment to a titration study.

I totally blew that one. That all makes perfect sense. I'll go back to the drawing board.

Do you know what your titration study said your pressure levels SHOULD be set to? Has the doctor already reduced them by a cm or two in order to try to help the aerophagia issue?

It was 9-13cm. Over the course of 4 months we kept reducing and reducing to no avail with the aerophagia. The AHI readings were always 0.2-0.3, no matter what the pressure was. Always felt like crap.

Moreover, since your now full time IPAP = 8cm is barely what the prescribed EPAP was, there's a high probability that your current pressure settings (Max IPAP = 8, Min EPAP = 4 with PS = 4) are NOT providing you with effective therapy. What do your AHI numbers look like at the lower pressure range?

Your last question exposes me yet again as still being in the beginning phase of understanding all this: not sure exactly what you mean? Without any CPAP at all, my AHI's are 4.4; with CPAP they're 0.2-0.3, but I don't have an answer for the "lower pressure range" part.

As to why the PS suddenly changed to 1cm and showed up as 3.2 cm when you looked at it at night? As you've been told, if you inadvertently changed IPAP from 14 to 8 while EPAP was set at 7, that would automatically change PS =1 since PS cannot exceed Max(IPAP) = Min(EPAP).

And finally, Resmed redesigned some parts of their Auto algorithms going from the S8 series to the S9 series. While I don't know how likely this is, it's possible that in designing the new Auto algorithm for the S9 VPAP, Resmed may have decided to allow the S9 VPAP to increase IPAP and EPAP independently of each other as long as IPAP - EPAP doesn't exceed the value of the PS setting. (That's the way the PR System One BiPAP Auto does it: IPAP increases in response to certain events, EPAP increases in response to a different set of events, and as long as 2 < IPAP - EPAP < PS the PR S1 will adjust IPAP and EPAP separately.)

So if Resmed decided to allow IPAP and EPAP increase independently of each other on the S9 VPAP, then it's possible that the PS = 3.2 number you were looking at in the middle of the night may have simply been the current value of IPAP - EPAP. And that PS = 4 setting represents the max(IPAP - EPAP) allowed. But the only way to determine if my hypothesis has any basis in fact is to look carefully at the Clinical manual for the S9 VPAP machine. So you really need to study that S9 VPAP Auto clinical menu very, very carefully before you continue to play around with pressure settings.

Agreed and will do.

Thanks so much to all of you for taking the time. I don't know where I'd be w/o this forum...

[robysue]

Do you know what your titration study said your pressure levels SHOULD be set to? Has the doctor already reduced them by a cm or two in order to try to help the aerophagia issue?

It was 9-13cm. Over the course of 4 months we kept reducing and reducing to no avail with the aerophagia. The AHI readings were always 0.2-0.3, no matter what the pressure was. Always felt like crap.

Ok, I think I'm beginning to understand some of the history of what's gone on since I too have had multiple pressures in an effort to address aerophagia problems. Please correct me if I'm wrong:

You started out with a prescription for: IPAP=13, EPAP=9 and running in straight VPAP (bi-level) mode? Or did you start on S9 APAP with an APAP range of 9--13? I'll assume you started out on the VPAP running in straight VPAP mode since that will explain where PS=4 seems to come from.

So EPAP pressure has been reduced several times? And at some point a decision was made to switch you to an AUTO VPAP range where EPAP (and IPAP) could vary by about 2cm. And the last formal prescription was either for MAX IPAP = 14 and MIN EPAP = 8 or MAX IPAP = 14 and MIN EPAP = 7 with PS = 4 in either case.

And the S9's AHI has consistently been outstanding in the 0.2--0.3 range.

And (I personally identify really strongly with this) you feel like crap.

So my first set of questions:
When is the aerophagia at its worst? When you are trying to GET to sleep? Or when you wake up in the morning? Do you wake up in the middle of the night in agony from the aerophagia? Do different sleeping positions trigger substantially different levels of aerophagia? As the day goes on, do you manage to finally get rid of most of the extra air in your gut? And have the multiple changes in pressure made even the smallest difference in helping the aerophagia? And when you changed your VPAP's settings to MAX IPAP = 8 and MIN EPAP = 4 with PS = 4, did it help the aerophagia at all? And what are your AHI numbers when you machine is set to MAX IPAP = 8 and MIN EPAP = 4?

My second set of questions:
Other than adjusting the pressures, what have you done in an attempt to address the aerophagia? Any chance you have GERD or silent GERD? What's your diet like? And how much time is there between supper and bedtime? Because one of the best self-help things you can do for aerophagia is to follow the lifestyle changes for treating GERD. (See http://www.mayoclinic.com/health/gerd/D ... e-remedies for a standard list of things GERD sufferers are told to do.)

And my second set of questions:
Outside of the aerophagia problems, how's your sleep feel? When do you go to bed? When do you wake up? How long does it take you to get to sleep with the VPAP on? Do you think you sleep soundly through the night? Or are you repeatedly waking up? And are you waking up multiple times at night with aerophagia? And if you are waking up multiple times each night, how hard is it to get back to sleep?

Because if you know your sleep is obviously being fragmented, that explains feeling crappy all the time. And then it's a matter of identifying what's fragmenting your sleep and addressing it. And yes, I know you think it's the VPAP and aerophagia and I won't argue those points: But you need to be able to figure out WHAT PROBLEMS (other than the obvious aerophagia) sleeping with the VPAP might be causing and start addressing them as well.

Moreover, since your now full time IPAP = 8cm is barely what the prescribed EPAP was, there's a high probability that your current pressure settings (Max IPAP = 8, Min EPAP = 4 with PS = 4) are NOT providing you with effective therapy. What do your AHI numbers look like at the lower pressure range?

Your last question exposes me yet again as still being in the beginning phase of understanding all this: not sure exactly what you mean? Without any CPAP at all, my AHI's are 4.4; with CPAP they're 0.2-0.3, but I don't have an answer for the "lower pressure range" part.

And now I'm truly puzzled: Without any CPAP at all, your AHI is 4.4? Where does this figure come from? Is it from your diagnostic PSG study? Because if you had a full nocturnal PSG and the result was an AHI of 4.4, it's a real surprise that CPAP (let alone VPAP) was prescribed in the first place: The cutoff chosen to diagnose OSA is typically 5.0.

Or does your PSG show a number called an RDI or a number called an RAI somewhere on it? If so, what are those numbers? RDI stands for Respiratory Disturbance Index and RAI stands for Respiratory Arousal Index. Basically they include events that are clearly respiratory related (not enough air getting into the lungs) but don't quite meet the definition of apnea or the definition of hypopnea that the lab uses to score hypopneas. (There are two basic standards for scoring hypopneas.) And if your RDI or RAI was high (particularly much higher than your AHI, that might explain why you were put on CPAP.

And is your official diagnosis OSA or is it a related problem called UARS?

[christinepi]

Wow, Robysue, I really appreciate all your questions! Just to let you know, I will answer them all to give the most precise picture possible, but it'll take me a day or so.

[christinepi]

Maybe it's easiest to write a summary of my trials and tribulations.

I'm 50, going through menopause and have been an insomniac for 17 years. No problem falling asleep, but go through phases of several weeks at a time when I can't sleep through the night. I either wake up and can't go back to sleep and/or toss and turn. In the last few years increasing problems, also for several weeks at a time, with nocturia. I'm on the slender side (5'10", 129lbs). No GERD (tested), no LPR to my knowledge. All my life been on a wholesome, healthy, low fat/sugar diet. Hardly any alcohol. Little meat. Never weighed a pound too many.

I was put on AutoCPAP (Resmed 9 Autoset) at 8-12cm, EPR 3, after my first sleep study in Dec 2010. My Respiratory Events were 4.4, my RERAs 14.4, my RDI, or AHI, 18.8 during that study. Second sleep study resulted in Respiratory Events/RDI/AHI of 4.4, because they didn't do the PES, so no measured RERAs. I've used the acronyms and terms EXACTLY as they appear on my report.

I could never get used to the aerophagia. The aerophagia always comes on in the middle of the night, never at the beginning. Aerophagia is somewhat better lying on my left; I know this has physical reasons. Unfortunately, I can't just lie on one side all night. Tried the raising the bed 6" for weeks and not eating after 3 hours before going to bed. Didn't help. I gradually lowered the pressure to 6.2, at which point the aerophagia disappeared. My AHIs through the entire 4 months that I was on AutoCPAP never went above 0.5. I always felt crappy.

Then I did the second sleep study, in late March 2011. They had me on CPAP, not on Bilevel, during the study, even though I urged them to try Bilevel. THAT'S when they said my brain waves started looking normal once they had me between 9 and 10. So they officially titrated me for 9-13cm. That's where those numbers come from. The night was the most uncomfortable of my life, however. It was agony, aerophagia wise. It took me the whole following day to get over it. So my doctor ok'd Bilevel, and eye balled the settings, since they hadn't titrated me for Bilevel. She chose 14/7, with PS at 4.

I set the difference between IPAP 8 and EPAP 4 at 4cm because I wasn't paying attention. I had the difference between 9-13 (from the previous setting on AutoCPAP) in my head when I did that, no clue why.

I started out two nights ago at 8.6/4.6 and PS of 4. I woke up from aerophagia, lowered the pressures to 8/4 and after noticing the PS was at 3.2, I set that back up to 4, and had no more aerophagia after that. I realize now after reading your responses that I pretty much completely messed up the brain of this poor machine and I can't go by those numbers. So last night I started at 12/5, PS at 4, since 14/7, during the first night, definitely was way too high. Aerophagia got the better of me, after 3 hours, though it wasn't as bad as the first night. So I turned the machine off. Will try again tonight.

I go to bed at around 10:15 every night of the week. I like being in bed, I don't dread it. It usually takes me only 5-10 minutes with VPAP to go to sleep. I usually don't sleep through the night. It depends on how often I have to use the bathroom (can be up to 4 times). I have phases when I can go right back to sleep after an awakening, and others when it can take an hour or more. It varies greatly. Once the aerophagia awakens me, sometimes lowering the pressure works and I sleep the rest of the night ok without aerophagia; sometimes I'm so wide awake I have to stop the machine. I would not ever describe my sleep as sound. I have an appointment this month with a CBT therapist who specializes in insomnia/sleep disorders. I definitely have that going as a separate issue that I need to deal with. I can't blame everything on breathing problems. The official diagnosis was OSA, not UARS. I don't get it, because the apneas are so few, when the RERAs may really be the culprit (those and the insomnia). I've heard that RERAs often benefit from CPAP also, but maybe that's not applying to me.

I hope I've answered all your questions...

[robysue]

christinepi,

My first suggestion is that you post that very nicely written summary into a new thread with a title like OSA or UARS? and aerophagia too to try to get the attention of two of the posters here---one named -SWS and the other who posts under several names including both Muffy and NotMuffy. They are both highly knowledgeable and (I believe) both work in sleep---not as doctors, but as the techs who run and score the studies.

Next, with that long, long history of sleep maintenance insomnia, it's good that you've decided to work with a CBT therapist who specializes in insomnia/sleep disorders. I say this based on my own experience: Like you, I'm a 52 year old woman who's been going through menopause and clearly on the thinnish side: I'm 5' 1'' and weight about 105lbs. And I'vehad bedtime onset insomnia off and on through the years. Prior to starting CPAP it was pretty well under control and not a problem. But I started fighting severe insomnia and significant aerophagia issues by night three of therapy back in September. Finally at the end of December I was willing to admit that the insomnia itself was creating as many (and maybe more) problems than the BiPAP itself was. So I've been doing my own hard CBT work on insomnia since January. And in retrospect, I wish I'd been willing to admit that I needed help fighting the insomnia a whole lot sooner in my adjustment to CPAP/APAP/BiPAP period because I think I would have saved myself grief, anger, and pain. And gotten back to being reasonably functional a lot sooner.

And I apologize for the length of this next part. But when I'm trying to come up with a real idea to try for someone with a problem that sounds similar, but not quite equal, to what I've been dealing with, I wind up doing a lot of writing to help my thinking. And you've got a complicated history going on here that I really wanted to make sure I understood before making suggestions on what might help with the aerophagia. Feel free to skip to the bottom if you just want my suggestions.

To get started, let's look at the data from the your diagnostic sleep studies:

With the PES (used to properly detect RERAs), your indices were:

• Respiratory Events Index = 4.4 (Presumably this includes the apneas and hypopneas that were detected during the study and did not need data from the PES for being scored)
• RERA Index = 14.4 (these are the events that were scored based on PES data)
• RDI = 18.8 = 4.4 + 14.4. And this number was also labeled as the AHI?

Second diagnostic study didn't use PES, and your indices were:

• Respiratory Events Index = 4.4 (Again, this presumably this includes the apneas and hypopneas that were detected during this study)
• RDI = 4.4. And this number was also labeled as the AHI?

And the OSA diagnosis was based on the RDI of the FIRST study. Which was done at Stanford, if I recall correctly? And the diagnosis was OSA, not UARS? Because coming out of Stanford with that PES data, I really would have expected this to be labeled as UARS. But keep in mind, I'm just a lowly math professor at a second rate SUNY school. Still, this seems to indicate that many or most of your respiratory arousals in the first study were occurring before the respiratory event met the lab's standard for "hypopnea". There are, alas, two common standards for scoring hypopneas: The AASM-Recommended and the AASM-Alternative. (For details, you can go to http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2635578/). While many hypopneas will "count" under both standards, there are plenty of events that will only "count" under one or the other of the two standards. So maybe it's possible that some of those RERAs were really close to or even met the "hypopneas with arousal" criteria which count as a hypopnea under the AASM-Alternative, but don't count under the AASM-Recommended since there is no corresponding O2 desaturation of at least 4%. Or maybe the doc wrote down OSA as the diagnosis to make it easier to make your insurance company paid for the xPAP equipment.

Why was the second study done in the first place? Was it done at the same lab? And how were its results used in either determining or refining your diagnosis? Now it's reasonable to assume that all those RERAs from the first study didn't just disapper---rather they weren't scored (because of the lack of PES data clearly). But what I'm also wondering is whether none of them met the labs "hypopnea" standard just because the lab uses AASM-Recommended instead of AASM-Alternative. Out of curiosity: Did this study's results list a large number of spontaneous arousals? Did it include a spontaneous arousal index? And was its spontaneous arousal index a lot bigger than the spontaneous arousal index from the first study?

But that's not really my point for looking at this. My point is that given the large number of RERAs that were used as the basis of your diagnosis, it's possible (actually likely) that most of your arousals on the diagnostic tests were likely happening because of so-called flow limitations---irregularities in the shape of the air flow wave that are due to the airway beginning to narrow and collapse----but you were arousing BEFORE the airway actually collapsed enough to trigger a hypopnea (under your lab's standard) or an apnea most of the time.

Hence---on CPAP or bi-level, the goal for your treatment would be to not only reduce the number of hypopneas and apneas (which is already small since it is under 5), but also eliminate the flow limitations that result in the RERAs that are arousing you 18.8 times an hour. And unfortunately, the the S9 series doesn't try to record RERAs (after all there is no EEG attached to the S9 to confirm the arousal), but it does record a graph called the "Flow limitation" graph in the detailed data that you might want to start looking at if you are downloading your data into ResScan.

Now looking at what's happened to you while on therapy:

You started out on the Resmed 9 Autoset at 8-12cm, EPR 3 and had SEVERE aerophagia. You tried several standard anti-GERD practices, including sleeping on your left side (when possible) and raising the head of the bed. You also gradually lowered the MININUM pressure setting to 6.2. Did you ever lower the max setting? And did you ever play around with the EPR setting? And do you recall what your 95% pressure levels were when you were on APAP?

You also write:

I gradually lowered the pressure to 6.2, at which point the aerophagia disappeared. My AHIs through the entire 4 months that I was on AutoCPAP never went above 0.5. I always felt crappy.

It's possible that while your apneas and hypopneas were eliminated at this pressure setting, the flow limitations were still severe enough to continue causing those RERAs from your first sleep test to occur and that might be why you still felt crappy even after the aerophagia went away. Or the insomnia was so intrenched from the nightly battles with aerophagia that the insomnia continued even though the aerophagia was no longer keeping you awake. And so you continued to feel really crappy because of the insomnia.

In March, at the second titration (using straight CPAP) study, you say:

THAT'S when they said my brain waves started looking normal once they had me between 9 and 10. So they officially titrated me for 9-13cm.

"Normal brain waves" in this context probably means the EEG was no longer showing all those arousals that came from the RERAs that were recorded as RERAs in the first diagnostic study and probably showed up as "spontaneous" arousals in the second diagnostic study. And the titration recommendation was probably made by a tech who was not aware (or had forgotten about) your ongoing struggle with aerophagia. But it's seems likely that there was evidence from the EEG that by the time the pressure was at 9 or 10cm, the RERAs that result from the flow limitations were minimal.

You go on to say:

The night was the most uncomfortable of my life, however. It was agony, aerophagia wise. It took me the whole following day to get over it. So my doctor ok'd Bilevel, and eye balled the settings, since they hadn't titrated me for Bilevel. She chose 14/7, with PS at 4.

So the idea with your original VPAP settings were:

EPAP would range from 7 to 10
IPAP would range from 11 to 14
And because you are using a Resmed VPAP, EPAP and IPAP are always increased or decreased at the same rate.

And you've unsuccessfully played around with resetting these numbers and at some point wound up setting the machine to MAX IPAP = 8, MIN EPAP = 4, and PS = 4 not quite realizing that this forced the VPAP to run in fixed bi-level mode with IPAP = 8 at all times and EPAP = 4 at all times.

And you continue to wake up with severe aerophagia problems as well. So what kinds of things can you try at this point? Well, here's my opinion as a fellow aerophagia suffer who's mostly got it under control now:

First, you've done the obvious in eliminating the possibility of GERD and LPR. That's a good thing. You've done some GERD self help guidelines, but they've not made much difference. No obvious dietary problems that you're aware of (spicy food too late; too much acid producing food too late; too much carbonated beverages; too much gas producing foods too late). All good.

Second, you might want to increase the time between last food and bedtime: When my aerophagia was at its worst, I needed to finish supper 4 and preferably 5 hours before bed---which given my (normal) bedtime of midnight and my sleep restriction schedule bedtime of 1:30, was not an issue.

Third, I'd seriously look into how the RAMP feature can be set up on your machine. Now, as long as you still have MIN EPAP = 4, the ramp will probably be disabled. (The ramp has to START at a value below the MIN EPAP and if MIN EPAP is as low as it can be set, there's no way the ramp "increase" the pressure UP to MIN EPAP.) And you also want to understand what the relationship between the Ramp's starting EPAP and IPAP pressures are. I have no idea since my BiPAP is the PR one, not a Resmed one. But I know there has to be some kind of a ramp feature. And I think that appropriately setting up and using that ramp feature may help you deal with the aerophagia when it hits in the middle of the night---if only because you won't need to try to reset the pressure levels themselves in the middle of the night.

Now you know that you CAN tolerate pressures as high as 6.2 for APAP. And one advantage of a bi-level is that since most people's exhales are longer than their inhales, you're at the lower EPAP for more of the night than you are IPAP. So here's what I'd try to do if I were you:

First: Leave the current MIN EPAP = 5, MAX IPAP = 12, PS = 4 alone for now. Then set the ramp up to start with RAMP EPAP = 4cm and RAMP TIME = 40 or 45 minutes. And finally learn exactly how to hit the ramp button with minimal effort. Now, your ramp is set JUST BELOW the pressures that you know are extremely effective as far as AHI concerned, but still cause problems with the areophagia once it kicks in. So you're not going to be at a highly ineffective RAMP pressure for a very long time. I'm suggesting a long ramp time since my guess is that you are actually quite sensitive to SUDDEN increases in pressure. That's what gets to me at least: I can start snoring intensely and my BiPAP Auto starts increasing EPAP rapidly enough to force a change in IPAP as well and I wake up with a stomach ache. So you want that ramp time to be long so the increase in pressure is imperceivable to you when you are lying in bed.

And whenever you wake up with the aerophagia, hit the ramp. Whatever the current pressures are, it will automatically drop back down to the beginning ramp pressure settings and slowly build back up. You won't be playing with the settings in the middle of the night, but you'll still be able to take the edge off the pressure when you can't stand it.

And when you manage to go a whole week with the aerophagia under control, then you can bump everything except PS up by 0.5cm of pressure: Move MIN EPAP = 5.5, MAX IPAP = 12.5, PS = 4, START RAMP = 4.5.

After you manage a whole week without serious aerophagia at these settings, increase them by 0.5 again. Keep doing it until you get closer to that titrated range of MIN EPAP = 7, MAX IPAP = 14

And hopefully as you slowly increase those pressure settings, the aerophagia won't increase AND you'll eventually start feeling less crappy because (a) there won't be as much aerophagia and (b) the higher pressures will take care of the flow limitations, which in turn will help prevent the RERA arousals in that were the big problem in your first diagnostic sleep test.

Best of luck

[christinepi]

christinepi,

My first suggestion is that you post that very nicely written summary into a new thread with a title like OSA or UARS? and aerophagia too to try to get the attention of two of the posters here---one named -SWS and the other who posts under several names including both Muffy and NotMuffy. They are both highly knowledgeable and (I believe) both work in sleep---not as doctors, but as the techs who run and score the studies.

I'll do that soon. But for now, I so appreciate spending so much time on my "case"!

Next, with that long, long history of sleep maintenance insomnia, it's good that you've decided to work with a CBT therapist who specializes in insomnia/sleep disorders. I say this based on my own experience: Like you, I'm a 52 year old woman who's been going through menopause and clearly on the thinnish side: I'm 5' 1'' and weight about 105lbs. And I'vehad bedtime onset insomnia off and on through the years. Prior to starting CPAP it was pretty well under control and not a problem. But I started fighting severe insomnia and significant aerophagia issues by night three of therapy back in September. Finally at the end of December I was willing to admit that the insomnia itself was creating as many (and maybe more) problems than the BiPAP itself was. So I've been doing my own hard CBT work on insomnia since January. And in retrospect, I wish I'd been willing to admit that I needed help fighting the insomnia a whole lot sooner in my adjustment to CPAP/APAP/BiPAP period because I think I would have saved myself grief, anger, and pain. And gotten back to being reasonably functional a lot sooner.

And I apologize for the length of this next part. But when I'm trying to come up with a real idea to try for someone with a problem that sounds similar, but not quite equal, to what I've been dealing with, I wind up doing a lot of writing to help my thinking. And you've got a complicated history going on here that I really wanted to make sure I understood before making suggestions on what might help with the aerophagia. Feel free to skip to the bottom if you just want my suggestions.

To get started, let's look at the data from the your diagnostic sleep studies:

With the PES (used to properly detect RERAs), your indices were:

• Respiratory Events Index = 4.4 (Presumably this includes the apneas and hypopneas that were detected during the study and did not need data from the PES for being scored)
• RERA Index = 14.4 (these are the events that were scored based on PES data)
• RDI = 18.8 = 4.4 + 14.4. And this number was also labeled as the AHI?

Second diagnostic study didn't use PES, and your indices were:

• Respiratory Events Index = 4.4 (Again, this presumably this includes the apneas and hypopneas that were detected during this study)
• RDI = 4.4. And this number was also labeled as the AHI?

[/code]

Yes to all.

And the OSA diagnosis was based on the RDI of the FIRST study. Which was done at Stanford, if I recall correctly? And the diagnosis was OSA, not UARS?

Yes to all.

Because coming out of Stanford with that PES data, I really would have expected this to be labeled as UARS. But keep in mind, I'm just a lowly math professor at a second rate SUNY school. Still, this seems to indicate that many or most of your respiratory arousals in the first study were occurring before the respiratory event met the lab's standard for "hypopnea". There are, alas, two common standards for scoring hypopneas: The AASM-Recommended and the AASM-Alternative. (For details, you can go to http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2635578/). While many hypopneas will "count" under both standards, there are plenty of events that will only "count" under one or the other of the two standards. So maybe it's possible that some of those RERAs were really close to or even met the "hypopneas with arousal" criteria which count as a hypopnea under the AASM-Alternative, but don't count under the AASM-Recommended since there is no corresponding O2 desaturation of at least 4%. Or maybe the doc wrote down OSA as the diagnosis to make it easier to make your insurance company paid for the xPAP equipment.

Why was the second study done in the first place? Was it done at the same lab? And how were its results used in either determining or refining your diagnosis?

They hadn't titrated me the first time around. Same lab; and the results, since it was obvious I'd never benefit from AutoPap with these higher pressures led them to suggest Bilevel (well, I twisted their arms a fair amount, or rather, I insisted, after reading your posts from a few months ago).

Now it's reasonable to assume that all those RERAs from the first study didn't just disapper---rather they weren't scored (because of the lack of PES data clearly). But what I'm also wondering is whether none of them met the labs "hypopnea" standard just because the lab uses AASM-Recommended instead of AASM-Alternative. Out of curiosity: Did this study's results list a large number of spontaneous arousals? Did it include a spontaneous arousal index? And was its spontaneous arousal index a lot bigger than the spontaneous arousal index from the first study?

No mention of any spontaneous arousals anywhere.

But that's not really my point for looking at this. My point is that given the large number of RERAs that were used as the basis of your diagnosis, it's possible (actually likely) that most of your arousals on the diagnostic tests were likely happening because of so-called flow limitations---irregularities in the shape of the air flow wave that are due to the airway beginning to narrow and collapse----but you were arousing BEFORE the airway actually collapsed enough to trigger a hypopnea (under your lab's standard) or an apnea most of the time.

Hence---on CPAP or bi-level, the goal for your treatment would be to not only reduce the number of hypopneas and apneas (which is already small since it is under 5), but also eliminate the flow limitations that result in the RERAs that are arousing you 18.8 times an hour. And unfortunately, the the S9 series doesn't try to record RERAs (after all there is no EEG attached to the S9 to confirm the arousal), but it does record a graph called the "Flow limitation" graph in the detailed data that you might want to start looking at if you are downloading your data into ResScan.

My flow limitations always looked like a beehive shape.

Now looking at what's happened to you while on therapy:

You started out on the Resmed 9 Autoset at 8-12cm, EPR 3 and had SEVERE aerophagia. You tried several standard anti-GERD practices, including sleeping on your left side (when possible) and raising the head of the bed. You also gradually lowered the MININUM pressure setting to 6.2. Did you ever lower the max setting? And did you ever play around with the EPR setting? And do you recall what your 95% pressure levels were when you were on APAP?

Yes, I played around with the max setting AND the EPR, to no avail.

You also write:

I gradually lowered the pressure to 6.2, at which point the aerophagia disappeared. My AHIs through the entire 4 months that I was on AutoCPAP never went above 0.5. I always felt crappy.

It's possible that while your apneas and hypopneas were eliminated at this pressure setting, the flow limitations were still severe enough to continue causing those RERAs from your first sleep test to occur and that might be why you still felt crappy even after the aerophagia went away. Or the insomnia was so intrenched from the nightly battles with aerophagia that the insomnia continued even though the aerophagia was no longer keeping you awake. And so you continued to feel really crappy because of the insomnia.

In March, at the second titration (using straight CPAP) study, you say:

THAT'S when they said my brain waves started looking normal once they had me between 9 and 10. So they officially titrated me for 9-13cm.

"Normal brain waves" in this context probably means the EEG was no longer showing all those arousals that came from the RERAs that were recorded as RERAs in the first diagnostic study and probably showed up as "spontaneous" arousals in the second diagnostic study. And the titration recommendation was probably made by a tech who was not aware (or had forgotten about) your ongoing struggle with aerophagia. But it's seems likely that there was evidence from the EEG that by the time the pressure was at 9 or 10cm, the RERAs that result from the flow limitations were minimal.

You go on to say:

The night was the most uncomfortable of my life, however. It was agony, aerophagia wise. It took me the whole following day to get over it. So my doctor ok'd Bilevel, and eye balled the settings, since they hadn't titrated me for Bilevel. She chose 14/7, with PS at 4.

So the idea with your original VPAP settings were:

EPAP would range from 7 to 10
IPAP would range from 11 to 14
And because you are using a Resmed VPAP, EPAP and IPAP are always increased or decreased at the same rate.

And you've unsuccessfully played around with resetting these numbers and at some point wound up setting the machine to MAX IPAP = 8, MIN EPAP = 4, and PS = 4 not quite realizing that this forced the VPAP to run in fixed bi-level mode with IPAP = 8 at all times and EPAP = 4 at all times.

Yes to all.

And you continue to wake up with severe aerophagia problems as well. So what kinds of things can you try at this point? Well, here's my opinion as a fellow aerophagia suffer who's mostly got it under control now:

First, you've done the obvious in eliminating the possibility of GERD and LPR. That's a good thing. You've done some GERD self help guidelines, but they've not made much difference. No obvious dietary problems that you're aware of (spicy food too late; too much acid producing food too late; too much carbonated beverages; too much gas producing foods too late). All good.

Second, you might want to increase the time between last food and bedtime: When my aerophagia was at its worst, I needed to finish supper 4 and preferably 5 hours before bed---which given my (normal) bedtime of midnight and my sleep restriction schedule bedtime of 1:30, was not an issue.

Since I go to bed at around 10, that's tough--I cook most days, so that would mean I'd have to start cooking at 3:30, which is kind of out of the question... but I'll try.

Third, I'd seriously look into how the RAMP feature can be set up on your machine. Now, as long as you still have MIN EPAP = 4, the ramp will probably be disabled. (The ramp has to START at a value below the MIN EPAP and if MIN EPAP is as low as it can be set, there's no way the ramp "increase" the pressure UP to MIN EPAP.) And you also want to understand what the relationship between the Ramp's starting EPAP and IPAP pressures are. I have no idea since my BiPAP is the PR one, not a Resmed one. But I know there has to be some kind of a ramp feature. And I think that appropriately setting up and using that ramp feature may help you deal with the aerophagia when it hits in the middle of the night---if only because you won't need to try to reset the pressure levels themselves in the middle of the night.

Now you know that you CAN tolerate pressures as high as 6.2 for APAP. And one advantage of a bi-level is that since most people's exhales are longer than their inhales, you're at the lower EPAP for more of the night than you are IPAP. So here's what I'd try to do if I were you:

First: Leave the current MIN EPAP = 5, MAX IPAP = 12, PS = 4 alone for now. Then set the ramp up to start with RAMP EPAP = 4cm and RAMP TIME = 40 or 45 minutes. And finally learn exactly how to hit the ramp button with minimal effort. Now, your ramp is set JUST BELOW the pressures that you know are extremely effective as far as AHI concerned, but still cause problems with the areophagia once it kicks in. So you're not going to be at a highly ineffective RAMP pressure for a very long time. I'm suggesting a long ramp time since my guess is that you are actually quite sensitive to SUDDEN increases in pressure. That's what gets to me at least: I can start snoring intensely and my BiPAP Auto starts increasing EPAP rapidly enough to force a change in IPAP as well and I wake up with a stomach ache. So you want that ramp time to be long so the increase in pressure is imperceivable to you when you are lying in bed.

And whenever you wake up with the aerophagia, hit the ramp. Whatever the current pressures are, it will automatically drop back down to the beginning ramp pressure settings and slowly build back up. You won't be playing with the settings in the middle of the night, but you'll still be able to take the edge off the pressure when you can't stand it.

Tried that last night, exactly as you suggested. I woke up after 2.4h from aerophagia and hit the ramp button, but it was already too late. The discomfort wouldn't go away, and I ended up turning the machine off, I felt so uncomfortable. I really don't know what to do next... drop from 12 to 11, but keep the 5?

And when you manage to go a whole week with the aerophagia under control, then you can bump everything except PS up by 0.5cm of pressure: Move MIN EPAP = 5.5, MAX IPAP = 12.5, PS = 4, START RAMP = 4.5.

After you manage a whole week without serious aerophagia at these settings, increase them by 0.5 again. Keep doing it until you get closer to that titrated range of MIN EPAP = 7, MAX IPAP = 14

And hopefully as you slowly increase those pressure settings, the aerophagia won't increase AND you'll eventually start feeling less crappy because (a) there won't be as much aerophagia and (b) the higher pressures will take care of the flow limitations, which in turn will help prevent the RERA arousals in that were the big problem in your first diagnostic sleep test.

Best of luck.

Thanks--same to you!

[robysue]

Thanks for answering all my questions. It does help to fully understand what's going on.

And the OSA diagnosis was based on the RDI of the FIRST study. Which was done at Stanford, if I recall correctly? And the diagnosis was OSA, not UARS?

Yes to all.

You also want to post that sleep study data when you start the new thread. -SWS and NoMuffy will be interested in that data as will other knowledgeable folks. And point out the studies were done at Standford and that your official diagnosis was OSA not UARS. And they didn't change the diagnosis after the second study without a mask?

And unfortunately, the the S9 series doesn't try to record RERAs (after all there is no EEG attached to the S9 to confirm the arousal), but it does record a graph called the "Flow limitation" graph in the detailed data that you might want to start looking at if you are downloading your data into ResScan.

My flow limitations always looked like a beehive shape.

How high up do those beehives go? How long do they last? And does the PRESSURE start to increase when the beehives start? The S9 is supposed to increase pressure when it starts to detect flow limitations. If the flow limitation is pretty severe and "sudden" the pressure can increase pretty rapidly and get to the maximum setting pretty quickly if you have a tight range (like you do). The severity of the flow limitation would be based on how high the "top" of beehive is if you're using the current version of ResScan---the closer it is to the line marked with the ---- symbol instead of the nice round hump symbol.

How many of these beehive flow limitations do you have in a night? In an hour? Do they get less frequent when the pressure is higher? Because the number, height, and length of time these flow limitations last may be a better indication to you of whether the VPAP is really helping address the problem that lead to the respiratory arousals scored in that first diagnostic test.

Since I go to bed at around 10, that's tough--I cook most days, so that would mean I'd have to start cooking at 3:30, which is kind of out of the question... but I'll try.

Yeah, with a 10 pm bedtime, trying to get some more time between supper and bedtime is going to be difficult. Not fun for you and awkward for the family, but you could also try to make lunch your "main meal" and supper the smaller of the two meals. Go ahead and cook as normal for everybody---but limit your own serving sizes and eat more at lunch time so that you are not starving all the time.

And it might be worth keeping track of WHAT you eat every night to see if there ARE some foods that trigger more severe aerophagia so that you could avoid them.

Tried that (the ramp) last night, exactly as you suggested. I woke up after 2.4h from aerophagia and hit the ramp button, but it was already too late. The discomfort wouldn't go away, and I ended up turning the machine off, I felt so uncomfortable. I really don't know what to do next... drop from 12 to 11, but keep the 5?

Sure, drop that upper pressure a bit at least for now---as long as the AHI doesn't take a huge jump upward. And by huge, I mean just that---your AHIs could double and still be considered excellent. So if your AHI's suddenly are in the 1.0 to 1.5 range BUT the aerophagia is under control, it's a pretty good trade off at least for now. Lowering that upper pressure may, however, trigger more flow limitations, which may leave you still feeling awful. But IF you can get to where you can tolerate SOME pressure, then you can work on increasing it up to where you start feeling better. So at this point I think you've got to get ahead of the aerophagia and get used to using the machine; tweak the therapy after you can sleep with the machine if needed.

Also---when you wake up in agony with aerophagia, what do you do to try to get some of that excess air either burped or farted out---that's really the only way to get rid of it. I find that I have to get up out of bed and walk around. Or have hubby squeeze me tightly around the stomach.

Here's hoping for a better night for you tonight

[christinepi]

You also want to post that sleep study data when you start the new thread. -SWS and NoMuffy will be interested in that data as will other knowledgeable folks. And point out the studies were done at Standford and that your official diagnosis was OSA not UARS. And they didn't change the diagnosis after the second study without a mask?

Will do. No change in diagnosis.

How many of these beehive flow limitations do you have in a night? In an hour? Do they get less frequent when the pressure is higher? Because the number, height, and length of time these flow limitations last may be a better indication to you of whether the VPAP is really helping address the problem that lead to the respiratory arousals scored in that first diagnostic test.

Actually, just to be clear, I haven't downloaded the VPAP card yet since I got the Bilevel 2 weeks ago. I wanted to get a few "normal" nights in first. So far I've only had one night that was longer than 4 hours with the mask on. But I do have the data stored from my AutoCPAP adventure, so I'll go back to the other computer where all that is stored tomorrow.

Yeah, with a 10 pm bedtime, trying to get some more time between supper and bedtime is going to be difficult. Not fun for you and awkward for the family, but you could also try to make lunch your "main meal" and supper the smaller of the two meals. Go ahead and cook as normal for everybody---but limit your own serving sizes and eat more at lunch time so that you are not starving all the time.

And it might be worth keeping track of WHAT you eat every night to see if there ARE some foods that trigger more severe aerophagia so that you could avoid them.

Good idea!

Sure, drop that upper pressure a bit at least for now---as long as the AHI doesn't take a huge jump upward. And by huge, I mean just that---your AHIs could double and still be considered excellent. So if your AHI's suddenly are in the 1.0 to 1.5 range BUT the aerophagia is under control, it's a pretty good trade off at least for now. Lowering that upper pressure may, however, trigger more flow limitations, which may leave you still feeling awful. But IF you can get to where you can tolerate SOME pressure, then you can work on increasing it up to where you start feeling better. So at this point I think you've got to get ahead of the aerophagia and get used to using the machine; tweak the therapy after you can sleep with the machine if needed.

OK, I'll try that tonight...

Also---when you wake up in agony with aerophagia, what do you do to try to get some of that excess air either burped or farted out---that's really the only way to get rid of it. I find that I have to get up out of bed and walk around. Or have hubby squeeze me tightly around the stomach.

That's a sweet image... maybe you could market that technique as a therapeutic device!

Here's hoping for a better night for you tonight

Hope the same for you, and thanks again. I really really appreciate it, I'm repeating myself, but I really do!