With GERD, is BiPAP superior to APAP reducing aerophagia?

[PeaceSleeper]

I would greatly appreciate feedback on my situation---which has improved greatly in the last 2 weeks thanks to the forums timely feedback.

I have moderate GERD--confirmed by all those fun studies where they fill you up with barium and tilt the table every which way. I sleep most nights on a wedge pillow made especially for GERD, made of memory foam.

I've tried APAP and CPAP modes and watched my AHI for almost two weeks now. It is under 8 now, but not moving a great deal lower. (I'm limiting the APAP to 9 cm---see notes that follow as to why.) I know I probably should let the APAP run to slightly higher pressures, but then I wake up the Overnight Blimp, due to air swallowing. With CPAP at 9 cm, and C-flex at 1, I still get a mild amount of air swallowing, though not as severe as with C-flex at 3.

Have BiPAP users, in particular the Respironics models (only one my DME carries) had better results with reduction of aerophagia with the BiPAP over an APAP? I recently improved my mask leak problem (better fitting comfortgel), which has no doubt increased the pressure that my throat is "seeing" and I presume made the aerophagia more prominent---since there is more pressure pushing down into my already leaky esophageal sphincters.

I know I may have to get another titration, depending on the sleep doc's view of the world, though I had a BiPAP titration 5 years ago that is almost identical to my current prescription. (10 IPAP, 5 EPAP) However, the BiPAP I was using was very basic, no data, etc. It would be great to hear if it is worth chasing this with the sleep doc and after that the DME, and the substantial additional expense, as I have no insurance. Thanks!

[NightHawkeye]

PeaceSleeper, I can only tell you of my personal experience. I have no idea how universal it might be, but I judged that BiPAP offered a significant aerophagia advantage over maintaining a near constant CPAP pressure through the night. I could tolerate 9.5/6.5 from the BiPAP all night, without serious aerophagia, whereas I couldn't tolerate even 8 cm all night from CPAP.

If your pressure need is around 10 cm all night then, based on my experience of BiPAP with Bi-flex, I'd guess that you'd experience less aerophagia with BiPAP than you are experiencing now with APAP. I stress that's just my guess though. Since it's so costly to purchase a BiPAP machine outright, perhaps you could rent one for a short while. Or . . ., if you whined enough, maybe you could borrow one from your sleep lab.

However, I personally went back to APAP because that typically allows me to spend 2/3 of the night around 5 cm pressure and goes up to higher pressures only as needed, hence somewhat less aerophagia for me with APAP. However, I'm sure I'll use the BiPAP-auto again in the not too distant future, perhaps in auto mode. Although I experienced a slightly higher AHI in auto mode, perhaps there's a trade-off to be made with aerophagia there.

I'll also add that my sleep experience with BiPAP was somewhat better than with APAP. With BiPAP I tended to sleep for longer periods, whereas with APAP I have always experienced a number of awakenings nightly. I also wonder if BiPAP wasn't associated with a little increase in edema for me.

Just my $0.02 worth of rambling

Regards,
Bill

[Goofproof]

I would say if you were going to use Bi-PAP to help with GERD, a AUTO Bi-PAP might be better than APAP, but the correct pressure range is a great help, so I would think a normal BiPAP wouldn't be better than APAP set correctly. Jim

[christinequilts]

Remember BiPAP pressures don't equal current CPAP over lower EPAP pressure. EPAP, or exhale pressure, is just as important as the IPAP, or inhale pressure in the treatment of OSA- you may very well need an EPAP relatively close to your current CPAP treatment pressure and a higher IPAP pressure. It would be worth discussing with your doctor as a possibility, as would using a CPAP with exhale relief. Things are more complicated as it sounds like you have documented difficulties with your LES closing the top of your stomach to prevent reflux and I feel for you trying to convince that same weak LES to keep from letting air into your stomach on xPAP. Too bad we can bulk up the LES, like we can biceps.

A BiPAP may help, as some people find the rhythmic change of pressure easier to deal with, but aerophagia can still occur with BiPAP. I have used BiPAP from the beginning, as I have CSA and was treated with a BiPAP ST for the first 3 years with no problems with aerophagia. This past fall, I was switched to the new VPAP Adapt SV that was introduced for CSA & CSDB. It is also a BiPAP, or more technically correct BiLevel PAP, and for the first time I found out what aerophagia was first hand, presumably due to the auto-adjusting nature of the VPAP Adapt and receiving higher pressures then my former 13/7. To further complicate things, I have a complex GI disorder that damaged the nerves to my stomach, so I have a 2 part feeding tube, with one part which I get most of my nutrients & medications by that bypasses my stomach and the second part ends in my stomach, which allows me to hook up to gastric suction, if needed. So imagine my surprise to be experiencing aerophagia when I've been on gastric suction all night long and the hole the feeding tube passes doesn't seal 100%. And no, I didn't want to think how bad it would have been without it and also sleeping with the head of my bed elevated. Luckily for me, my body quickly adjusted to the new VPAP Adapt and by the end of the first month, the aerophagia was gone; 5 months later its just a distant memory.

[Yoga]

PeaceSleeper,

Where did you purchase your wedge?

[Snoredog]

just lower your Minimum autopap pressure to about 6.5cm, your AHI probably won't change if any. Use Cflex at 2.

If you are 9cm on cpap to clear apnea, you will need to be on 13/9 on Bipap, so you are not saving a whole lot.

[NightHawkeye]

If you are 9cm on cpap to clear apnea, you will need to be on 13/9 on Bipap, so you are not saving a whole lot.

Snoredog, do you have any references to indicate this is true even for the majority of folks?

I hasten to point out that what worked for me was an IPAP value similar to my 90% CPAP value. I also seem to recall many instances where others have reported similar findings, although a couple of prominent posters here repeatedly mention that EPAP needs to correspond with titrated CPAP value.

Apnea occurs during inhalation, hence the IPAP value would seem to be the most important for minimizing apnea. On exhale, physics would seem to dictate that a lower EPAP pressure would help clear any obstruction.

However, we all know that individual physiology can mix things up quite a bit in regards to xPAP therapy, so I'm sure that some folks really do find that an EPAP setting corresponding with their titrated CPAP value works best. A concrete reference would be most useful in determining whether this holds true for just a few individuals, many individuals, or even most individuals.

Regards,
Bill

[Snoredog]

If you are 9cm on cpap to clear apnea, you will need to be on 13/9 on Bipap, so you are not saving a whole lot.

Snoredog, do you have any references to indicate this is true even for the majority of folks?

I hasten to point out that what worked for me was an IPAP value similar to my 90% CPAP value. I also seem to recall many instances where others have reported similar findings, although a couple of prominent posters here repeatedly mention that EPAP needs to correspond with titrated CPAP value.

Apnea occurs during inhalation, hence the IPAP value would seem to be the most important for minimizing apnea. On exhale, physics would seem to dictate that a lower EPAP pressure would help clear any obstruction.

However, we all know that individual physiology can mix things up quite a bit in regards to xPAP therapy, so I'm sure that some folks really do find that an EPAP setting corresponding with their titrated CPAP value works best. A concrete reference would be most useful in determining whether this holds true for just a few individuals, many individuals, or even most individuals.

Regards,
Bill

[NightHawkeye]

Once you are able to read your reports you will see EPAP clears OA, IPAP clears HI etc., so going to a bipap does nothing if you still need the same pressure to clear an apnea event.

Aww, come on Snoredog. That's pretty lame. You've said nothing.

In about 10 seconds of searching the internet I found a study which indicates that my experience holds true for 89% of xPAP patients:
http://www.ncbi.nlm.nih.gov/entrez/quer ... t=Abstract

It is often difficult to achieve adequate acceptance of nasal continuous positive airway pressure (CPAP) therapy by patients with OSA. Many patients find it particularly inconvenient to expire against the treatment pressure. With this in mind, we have attempted to improve acceptance of CPAP therapy by using a bilevel system that reduces the treatment pressure during expiration. 52 patients were randomized either to initial treatment with CPAP therapy followed by bilevel treatment, or to treatment in reversed order. During bilevel therapy the ratio of inspiratory to expiratory pressure was fixed at 1:0.6. After each treatment the patients were interviewed on the basis of visual analogue scales to establish their subjective evaluation of such parameters as general well-being, quality of sleep, comparison of the respective treatment pressures, and possible preference for one of the two systems for long-term treatment. The minimal effective inspiratory treatment pressure during bilevel therapy (IPAP) and the minimal effective CPAP pressure were closely correlated (r = 0.89).

The last sentence says that for 89% of the patients in this randomized study the IPAP and CPAP pressures were essentially the same. In contrast, EPAP pressures were 40% lower (note the earlier highlighted sentence).

Your turn . . .

Regards,
Bill

[Snoredog]

Once you are able to read your reports you will see EPAP clears OA, IPAP clears HI etc., so going to a bipap does nothing if you still need the same pressure to clear an apnea event.

Aww, come on Snoredog. That's pretty lame. You've said nothing.

In about 10 seconds of searching the internet I found a study which indicates that my experience holds true for 89% of xPAP patients:
http://www.ncbi.nlm.nih.gov/entrez/quer ... t=Abstract

It is often difficult to achieve adequate acceptance of nasal continuous positive airway pressure (CPAP) therapy by patients with OSA. Many patients find it particularly inconvenient to expire against the treatment pressure. With this in mind, we have attempted to improve acceptance of CPAP therapy by using a bilevel system that reduces the treatment pressure during expiration. 52 patients were randomized either to initial treatment with CPAP therapy followed by bilevel treatment, or to treatment in reversed order. During bilevel therapy the ratio of inspiratory to expiratory pressure was fixed at 1:0.6. After each treatment the patients were interviewed on the basis of visual analogue scales to establish their subjective evaluation of such parameters as general well-being, quality of sleep, comparison of the respective treatment pressures, and possible preference for one of the two systems for long-term treatment. The minimal effective inspiratory treatment pressure during bilevel therapy (IPAP) and the minimal effective CPAP pressure were closely correlated (r = 0.89).

The last sentence says that for 89% of the patients in this randomized study the IPAP and CPAP pressures were essentially the same. In contrast, EPAP pressures were 40% lower (note the earlier highlighted sentence).

Your turn . . .

Regards,
Bill

[NightHawkeye]

. . . maybe you need to rely less on googling up meaninless studies and read what the data is saying that comes off your own machine in front of you.

I know how it works, I have the simulation program from Respironics which shows me exactly how it functions in response to different types of events.

To: Snoredog - OK, I won't try to confuse you with facts. Instead, I'll just pose one question for you. If EPAP is supposed to equal CPAP pressure, then why do sleep docs put folks with high CPAP pressures on BiPAP in order to get pressure relief? If EPAP=CPAP, and IPAP is even greater, then there is no pressure relief.

To: PeaceSleeper - Just to reinforce my earlier post with the fact that 89% of apnea sufferers experience reduced pressure with BiPAP . . . You very likely would be one of the folks who benefits from reduced aerophagia with BiPAP. No guarantees, though . . .

Regards,
Bill

[PeaceSleeper]

Somehow the board didn't notify me of the additional posts, so this is a bit late.

First, I have been through a single pressure titration and a dual pressure or bi-level titration. For me at least, the pressure for straight CPAP on my initial study was 9-10 cm and the BiPAP titration in a separate study was 10/5. They tried incrementing up to 12/7 and this started to produce many centrals, so they stopped upping the pressure. This is actual data (for one person of course) from a very solid sleep lab at National Jewish in Denver, with one of the best sleep docs at the time in the metro area. So my personal experience does not parallel some of the analysis provided earlier. And I never had experienced aerophagia before with the old Tranquility BiPAP, which by the way was not a comfortable machine to use. It was a Tranquility "Quest" machine, and it was 5 years ago, and due to a lot of things going on with changing jobs, cities, and countries of residence, the BiPAP went by the wayside.

I used to know a lot about fluid dynamics, and what little I recall is that things move where there is a pressure gradient, so somehow I am creating a pressure gradient into the stomach that is beyond my UES and LES capacity to stop the pressure gradient pushing gas into the stomach. As for the flow dynamics with EPAP and IPAP, I would think it would be highly individualized based on the pressure dynamics of the components in the airway contributing to the obstruction of airflow. Some people have more fat, higher/lower elasticity of the oropharynx, and lots of other factors that are beyond me. I know it will be great some day when they can plant a little intraesophageal pressure transducer with a wireless transmitter, then put you through a bi-level titration and prove pretty well that the bi-level is helping---or not. They do it now for pH levels with esophageal reflux, but I haven't heard of anyone using a pressure transducer, though there is no reason not to do it other than cost.

Second, a post asked for the GERD pillow source. I purchased a product called the "PropPillow". It was not cheap, but the thing seems to be well made and is about 5 months old now and showing no signs of wear. It is made out of the same kind of foam that Tempurpedic brand mattresses are made out of---which I also am fortunate enough to have. My wife was not too keen on the bed being elevated 6 inches, as you'll find if you try it that you slowly slide off the end during the night--even if you barely move at all. Lol---to have your feet sticking a foot off the end of the bed by morning, every morning. One downside---traveling with the thing is a bear---it is HUGE! Takes an entire full-size suitcase on the airlines---and yes I have taken it with me more than once. Doesn't weigh a whole lot, but it doesn't compress very well either.

I appreciate everyone's comments and will be talking with my sleep doc next week hopefully about a BiPAP trial, with one of these spiffy new BiPAPs. He may require another titration, which is fine with me, and will give me something to report back as to how the pressures compare---but again it will be just a single data point, not easily generalized.

One other note---as I have an APAP machine I have tried a reasonably narrow range of pressures (ranging from 7-10, down to 8-9 or 9-10) to see if that helps the aerophagia by running at a lower pressure for more of the night. The results are yes it does help and I can easily see I'm spending more time at lower pressures for more than 50% of the night, but for some reason I am quite sensitive to pressure changes and it consistently wakes me up after 1.5 to 2.0 hours. When I am on CPAP I can sleep sometimes for 3-4 hours. And I am assuming the causative factor here is the pressure change, as the only other setting I can access is the C-flex which I leave at 1 because I experienced more "air gulping" with C-flex at 2 or 3.

[elliejose]

It works for me. I had terrible aerophagia. Now I have a bipap auto and NO aerophagia. I know what works for one may not for another, but that is just my experience.

[elliejose]

It works for me. I had terrible aerophagia. Now I have a bipap auto and NO aerophagia. I know what works for one may not for another, but that is just my experience.

[elliejose]

It works for me. I had terrible aerophagia. Now I have a bipap auto and NO aerophagia. I know what works for one may not for another, but that is just my experience.