Aerophagia

[MDee]

I've done a lot of reading here (and elsewhere) on the topic of Aerophagia. I am into my second week and am struggling with severe aerophagia. I finally found a nasal mask/chin strap/mouth taping combo that works (no nose pain or neck pain). My doctor lowered my Bipap settings from

Vauto
max-IPAP: 15
min-EPAP: 11
PS: 4

I am now at:
Vauto:
max-IPAP: 15
min-EPAP: 8
PS: 4

Under this new setting, according to Sleepyhead my averages are
IPAP: 12
EPAP: 8

My AHIs are roughly the same at both before and after settings (4-7 AHI) with both OSA and Hypopneas under .5 and the rest are Central.

The aerophagia is so severe that I am having difficulty sitting with my swollen belly, get short of breath when I walk and have nausea. Am trying Gas_X, walks, carbonated water etc. The head of the bed is elevated 3 inches.

I do have weak muscles and at times problems swallowing so there may be some underlying structural weakness in that area..

edited to use the correct terms.

[Wulfman...]

I've done a lot of reading here (and elsewhere) on the topic of Aerophagia. I am into my second week and am struggling with severe aerophagia. I finally found a nasal mask/chin strap/mouth taping combo that works (no nose pain or neck pain). My doctor lowered my Bipap settings from

Vauto
IPAP: 15
EPAP: 11
PS: 4

I am now at:
Vauto:
IPAP: 15
EPAP: 8
PS: 4

Under this new setting, according to Sleepyhead my averages are
IPAP: 12
EPAP: 8

My AHIs are roughly the same at both before and after settings (4-7 AHI) with both OSA and Hypopneas under .5 and the rest are Central.

The aerophagia is so severe that I am having difficulty sitting with my swollen belly, get short of breath when I walk and have nausea. Am trying Gas_X, walks, carbonated water etc. The head of the bed is elevated 3 inches.

I do have weak muscles and at times problems swallowing so there may be some underlying structural weakness in that area..

Have you tried straight IPAP and EPAP settings? Maybe all the pressure changes are making it worse?

Apparently your existing settings aren't working well, so that would be my suggestion. If you're monitoring your therapy with software (like Sleepyhead), look at the Flow Limitation sections and see if there are lots of them. In the past, I've seen reports from people who had GERD and related issues which exacerbated the FLs and drove the APAPs crazy.

Lots of discussions on "aerophagia" in the forum Search function (above) and things that worked for some and other things that worked for others.


Den

.

[MDee]

Thanks for taking the time to respond. I've been pouring through the GERD recommendations. In addition to the things I've tried above, I also tried the cervical collar and tucking my head (and untucking it),......I will keep digging.

Your comment on the static settings caught my eye: that is what my doctor said he was using on the first settings even with the VAuto toggled (I contacted him to confirm this). Once we reached the 15 IPAP, with PS set to 4, he said the machine would keep the EPAP at a steady 11

This is the flow control with his "static" setting using Vauto mode (max-Ipap: 15, min-Epap: 11, PS4



This is the flow limit under the variable setting Vauto mode: max-Ipap 15: min-Epap: 8, PS 4.


The severity of symptoms with the old and the new settings is the same.

edited to use correct terms.

(this is my first time posting images, so let me know if they need editing or adjusting).

[Wulfman...]

With the number of Centrals you're having, have you discussed switching to an ASV type of machine with your doctor?

Short of that, I'd suggest trying the fixed IPAP/EPAP settings.......and even lowering your pressure settings.
IPAP is supposed to control the Hypopneas and EPAP is supposed to control the Obstructive Apneas.
You're having almost none of those and mostly Centrals.
Consequently, I'd recommend lowering your fixed pressures proportionately.


Den

.

[MDee]

So on my machine the fixed Bipap mode would be S?

I am thinking
S Mode:
IPAP of 10
EPAP of 6
(no PS needed in the S mode)

and then if that does not cause aerophagia inch it up each night.

I don't understand what role the PS plays in the Vauto mode, so I am guessing the 4 PS is a good differential xxxxin the fixed modexxxx to leave the settings at if I were to return to using Vauto mode (edited to clear up terminology).

And yes, I asked my doctor about the centrals even before the titration and also again after. he said they were irrelevant as they were happening during "transition". During my diagnostic my AHI was 60, with the bulk Hypopnea, the Centrals around 5 and the OSA around 6.

I am going to take a break tonight - mainly because my stomach is still so full of air I am struggling to stay hydrated. Then, back again into the fray.

PS. Can someone look at the Flow Limits and tell me what we are seeing/looking for so I can compare it next week?

[lilly747]

And yes, I asked my doctor about the centrals even before the titration and also again after. he said they were irrelevant as they were happening during "transition". During my diagnostic my AHI was 60, with the bulk Hypopnea, the Centrals around 5 and the OSA around 6

Looks like your doing a lot of "transitioning"....

Also PS can cause CAs...

[Wulfman...]

So on my machine the fixed Bipap mode would be S?

I am thinking
IPAP of 10
EPAP of 6

and then if that does not cause aerophagia inch it up each night.

I don't understand what role the PS plays in the Vauto mode, so I am guessing the 4 PS is a good differential in the fixed mode.

And yes, I asked my doctor about the centrals even before the titration and also again after. he said they were irrelevant as they were happening during "transition". During my diagnostic my AHI was 60, with the bulk Hypopnea, the Centrals around 5 and the OSA around 6.

I am going to take a break tonight - mainly because my stomach is still so full of air I am struggling to stay hydrated. Then, back again into the fray.

PS. Can someone look at the Flow Limits and tell me what we are seeing/looking for so I can compare it next week?

Yes......"S" Mode.

Read this link (from a forum thread) about Pressure Support and you may get a better understanding of it.

viewtopic/t79539/Setting-BiLevel-Pressu ... -Auto.html

Here's another link that may be of help (or maybe not).

http://www.directhomemedical.com/machin ... gement.pdf

I also question the knowledge of your doctor.

Your flow limitations seem to be fairly minimal, but remember that it doesn't take many of them to start jacking up pressures because it interprets them as preceding apneas (which may not actually occur).

I'm not entirely familiar with the PS settings on the ResMed machines, but I'm wondering if there's a "0" (zero) setting to fix the pressure so there is no variation (pressure support changes). I don't have any clinical manuals for the S9 VPAP machines.

I suspect (and hope) that some of those more familiar with the S9 VPAP settings will comment on this.


Den

.

[MDee]

Wulfman: great link. It helped.

When the Vauto mode is engaged on the Resmed Aircurve it operates in a static BiPAP mode if the PS = the same as the distance between the EPAP and IPAP. The PS is always fixed at X number on the Resmed.

max-IPAP: 15
min-EPAP: 11
PS: 4

On the Resmed, using this setting the IPAP will always stay at 15 and the EPAP will always stay at 11. This is the original setting we used.

If you have an PS of 1
Your IPA/EPAP pairing could vary
15/14
14/13
13/12
12/11

A PS of 0

15/15
14/14
13/13
12/12
11/11

At least that's how I think it works. That last variation looks like straight CPAP, not BIPAP. The machine can offer: CPAP, Bipap, Vauto (bipap with automatic adjustment).

In your first link I saw this: "ResMed machines have a fixed pressure support and there is no varying or roaming about. EPAP and IPAP are tied to each other by the pressure support which won't/can't vary."

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

Since my machine has a fixed PS, I am wondering how best to approximate the second scenario?

Vauto Mode
Max-IPAP: 10
Min-EPAP: 6
PS: 2

The combinations would be
10/8
9/7
8/6

I guess I feel there are so many variables that I'd like to focus on just one. So either I work on the IPAP/EPAP range or the PS variable.

My thinking: keep the PS the same and lower the IPAP/EPAP even more. If the aerophagia keeps up, then focus on the PS.

And last, I was told by someone one who uses CPAP that my doctor may be playing the odds: that central apneas are typical among new users and settle down in a month. If they still persist, then maybe they might consider treating the central apnea. But this left me wondering: my centrals have stayed the same both with and without CPAP. The only thing that has changed is the OA and Hypos. So clearly the CPAP is not causing the central apnea. It is just not treating it.

edited to use correct terminology.

[lilly747]

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

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

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

[MDee]

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

I think if you go back and reread you will see they were talking about RP machines not ResMed ResMed machines do not have a roaming PS, it's fixed. And yes you can set PS to = 0

1. That is correct. I have Resmed machine and it has a fixed PS unlike what they were discussing which was the RP machines. I was wondering if there was any way to approximate the suggested "roaming" PS that is not available on my Resmed machine.

2. From what I've read I can set my PS on my Resmed from 0-x (x being the difference between the IPAP and EPAP). If that difference is 10, I can set the PS to 10, but not higher.

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

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

or am I understanding this wrong?

[lilly747]

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

Yes that is right. I have the S9 VPAP...it is like yours. BUT I know nothing about helping with aerophagia....The commit I made had to do with CAs. Wulfman is more knowledgeable here...

EDIT; Yes CAs often go away after a while...

[Wulfman...]

Well, I think you've got some things to ponder for now. I think if I were you, I'd start with the IPAP at about 10 and the EPAP somewhat below that......maybe 6. Then try that for a few nights and see what the reports look like. Then, if they look OK, you could try doing small increases and see where the reports lead you.

There are just too many unknowns at this point, so that's why I suggest keeping it simple and proceeding slowly and cautiously.


Den

.

[Wulfman...]

Even trying straight CPAP settings might be interesting, too.......10/10?


Den

.

[cathyf]

If I understand this correctly, what's happening in aerophagia is that the pressure which is keeping your airway open and pushing air into your lungs is also opening up your esophageal valve and pushing air into your stomach. And that having this problem is completely a question of how strong that esophageal valve is and what level of pressure will overcome it.

What that means is that you need to spend as little time as possible over whatever the pressure is where your esophageal valve opens up. Setting your machine to a constant pressure which is above the level where air is pumping into your stomach would be a disaster -- you would just get blown up like a balloon and wouldn't stay asleep for long! On the other hand, if you find that the auto algorithm is raising the pressure to prevent events that aren't going to happen anyway, then you would use a fixed LOW pressure because you in fact know better than the machine what's going on and you need to prevent it from reacting to these false alarms.

If you are someone who needs significantly higher pressures during some small fraction of the night (during REM sleep, most commonly) and that the auto algorithm will take you up but then come right back down when you don't need that pressure anymore, then you would want to go auto so that the machine would back off the pressure whenever it could. This would give you a series of breaks between when air is going into your digestive tract which would give your body a chance to clear the air out.

Hopefully you can find a sweet spot where you are getting enough pressure to keep the events mostly away, but keep the amount of air going into your stomach to a level that your body can clear out. There's a huge difference between rudeness in the belching/farting and agonizing pain.

When a sleep lab does a titration to get a fixed pressure, or an auto-PAP adjusts the pressures all night long according to its algorithm, they focus on one and only one goal, which is minimizing your AHI. They are not measuring how much air is going into your stomach, and don't have any way to minimize that. You may need to compromise and have a higher AHI to keep the amount of air going into your stomach down to a tolerable level.

Your main problem seems to be centrals, and higher pressure certainly isn't going to fix those, and may actually be causing them. Actually I would wonder if the aerophagia might be causing the centrals -- I know that when I'm bloated and awake I breathe more shallowly and feel kind of suffocated, so it's certainly possible that it could interfere with your desire to breathe.

Just a technical note... In Sleepyhead, if you shrink the height of all of your graphs, and eliminate less useful ones, and move the most useful ones to the top, and turn on event logging on your leak graph and turn off the separate events graph, you can get all of your most useful graphs visible at the same time and it's easier to see what's going on. I'll paste in mine as an example of one way to set it up.


This is the sort of thing that Sleepyhead is really useful for, but be aware that you need to look at a lot of data over a bunch of nights before you can draw confident conclusions about what's going on. We all have the occasional crappy night or great night for no obvious reason, so you need to average out over a longer time to get a true picture of what's going on.

And here is also where the medical professionals can't help you. Unless you are a multi-billionaire, you can't afford to have an expert spend hours pouring over your data looking for these patterns. You are going to have to sift through the data and bring the significant stuff the experts' attention.

[lilly747]

MDee you seem to be confused on how PS works on your machine. Here is an example:

Min = 12, Max=17, PS =2, So you can have:

12 + 2 = 14 all the way to 15 + 2 = 17

In this example, EPAP & IPAP will always stay 2cm apart as they go up and down together

hope that helps