Aerophagia tug of war

[oneillseanm]

Hi everyone,

This is my first time posting on the forum after being a lurker for a while. The forum has already been so helpful. I'm hoping you all might be able to weigh in on the problem I've been grappling with since I started CPAP a year ago. Thanks for reading.

Equipment
Machine: ResMed AirSense 10
Mask: DreamWear full face
Settings: Pressure 6, Ramp 20 mins, Exhale assist
Average nightly usage: 8.5 hours

The problem: Aerophagia. From day 1, I've been waking up uncomfortably, sometimes painfully, bloated. My doctor responded by lowering the pressure from 8 (starting point) to 6. This seemed to help a bit. Unfortunately, the problem is still there and I'm at the bottom of the pressure range. On top of that, I still experience an average hourly AHI of 3. I would like to drive this number down, but that, I assume, would mean raising the pressure. And that, I assume, would make the aerophagia worse.

Does anyone have any sage advice to share?

Thanks so much for reading.

[Pugsy]

Welcome to the forum.

What is that AHI composed of...there are 3 categories of events. If your events are primarily central in nature then more pressure isn't the fix and in fact might make things worse.
Before you start worrying about more pressure...make sure what you want to kill can be killed with more pressure.

Get the software so you can know for sure what that AHI is composed of
wiki/index.php/Sleepyhead
SleepyHead calls centrals as Clear Airway apneas...long story there but that's what central flag is called in SH with a ResMed machine.

If you want to share your detailed report for member ideas see this for the format....we don't need or want all the graphs that the software will give you.
viewtopic/t158560/How-to-post-images-for-review.html

Please note that to get this data your machine must have a SD card in the slot all night long. If your machine doesn't have a SD card then you need to get one and put it in the slot and then use the machine. Any generic SD card will work. Doesn't have to be name brand despite what ResMed says and the capacity needed is maybe 2 GB but you won't be able to find one that small unless you go online and they usually cost more. Just go to WalMart and get a cheap Sandisk SD card. Last time I looked 8 GB was the smallest available but it might be higher now. Won't hurt a thing to use a card with a capacity bigger than you need.

For the aerophagia issues....really need to see the report and see how high the pressure is going during the night if you are using auto mode.
And you mentioned exhale relief...that's EPR on the AirSense machine....what is your EPR setting..1,2 or 3? and is it full time or ramp only?

[oneillseanm]

This is already fascinating. Thanks so much for the response. I wish I would have done a bit more "Before Your First Post ..." research. Sorry to make you explain the SleepyHead process.

Fascinating, though! Here's a formatted view of my report for last night.

Really appreciate you taking the time to help.

[Pugsy]

No problem about the explanation. You aren't the first and won't be the last. I don't mind explaining it to newbies.
On the plus side you did a great job with your screen shot and graphs and we can see all that we need to see. That rarely happens on the first screen shot. Good job. Makes our work trying to help you go so much more smoothly when we can easily see stuff.
I have a guy that I have been helping privately for 2 years I guess and he still sends me graphs I don't need and omits the ones I do despite every time I tell him and send him an example. But he's a sweetheart so I just deal with it.

Aerophagia is a nasty little monster sometimes for some people.
You are correct in that you need more pressure if you want to break up those little clusters of events. Parts of the night the 6 cm fixed setting works great but sometimes you need more. Most likely related to either you turned on your back or you were in REM stage sleep...both of which it is common for OSA to worsen and we need more pressure.
Your clusters closely resemble the pattern we would normally see for when REM sleep happens.
Google "sleep stages" and look a normal hypnograms and you can see what I mean.
If your diagnostic sleep study measured sleep stages you might notice more apnea events in REM than in non REM. I am quite familiar with this myself as my OSA is about 5 times worse in REM.

Now if it is supine sleeping related you might get some reduction if you stayed on your side....easier said than done sometimes and since we can't control REM...and we may not know exactly why the need for more pressure I will usually advise a change to auto/apap mode and let the machine increase the pressure automatically no matter what the need.

Problem being though in your situation any slight increase in pressure, even if it is temporary, is likely to feed that aerophagia monster.
You might read this if you haven't already
wiki/index.php/Aerophagia
It's a fairly common problem from minor annoyance to severe issues causing major problems. I myself have had it severe only twice and because of a couple of unusual situations I got myself into. It was so painful that I was miserable the entire next day with pain an nausea....so I have a lot of empathy for those people because I know just how ugly it can be.

Usually the first thing we suggest is add in more exhale relief and often it is enough. You are already using the maximum exhale relief but not getting full benefit because of your 6 cm fixed setting. Your EPR is set to 3 but the machine can only drop to 4 (it can't go lower than 4) so you are only getting 2 cm exhale relief.

There are some things you can do..mention at the link above like trying to stay on the side that maybe reduces the feeding of the aerophagia monster but again trying to stay in any one position is easier said than done.]
Some people got some relief by raising the head of the bed just a little.
Some people found that the problem sort of faded away.
Some people had to go to a new different type of machine that offers more than 3 cm exhale relief.
Those are called bilevel machines and the exhale relief is afforded by something called pressure support which is nothing more than the difference between inhale and exhale.

One of our forum member RobySue is just like you....bad, bad aerophagia even at really low pressures. She had to go to a bilevel machine to be able to treat her apnea effectively and not feed the aerophagia monster that made her sick with pain.

Do you wake often during the night? There is some thought that the wake ups themselves also feed the monster because we tend to have arousals with times of big gulps of air that finds its way to the gut.
There's a remote chance that those clusters of events are causing arousals which might be in themselves feeding the aerophagia monster....but this situation you are damned if you do and damned if you don't.

I wouldn't be surprised if you end up being like forum member Robysue....having to use a bilevel machine at low pressures and a very tight range.

The only idea I can think of right now....is to try auto mode but with a lower minimum and let the machine go a little higher only when needed....hoping that the longer time at the lower pressure will offset some of the feeding of the monster when the machine wants to go higher.
It's something to try...sort of last resort.
Change to auto mode.
Minimum of 4
Max of 8
EPR at 3 because if/when you go to 7 or 8 you will get full benefit at that time. Partial benefit the other times.

The primary goal right now....get rid of the aerophagia monster and then see just how bad the AHI is or isn't with the monster gone...if he is gone.
That's what I would do if I were in your shoes.
Primary goal is to kill the monster first and then see how many apneas are left to try to kill.
You might not like 4 cm starting out...some people get freaked out as it can feel like they aren't moving enough air...feels like they are suffocating...they aren't of course but it sure feels like it.

Are you comfortable making changes yourself or do you wish to have your medical care team do it?

[zonker]

The problem: Aerophagia. From day 1, I've been waking up uncomfortably, sometimes painfully, bloated.

welcome aboard! you've come to the right place and you have one of our best helping you out already. pugsy is full of good advice and you'll be getting the hang of this in no time.

as to aerophagia, you aren't alone. i don't know how some people manage to jump into therapy and never have this problem. me, i've been fighting it since day one. thought i'd never get past it and get on with my therapy.

then, one day while reading the forum, one user was telling the other about a setting on the airsense that helped me. and i mean AT ONCE! it's the "soft" setting in "response" found in the clinician's settings.

to save time, i'll assume you don't know how to get to the settings. (apologies if you do!)

get to the screen on your machine that says "My Options" by pressing the big dial/button. then press the button with "house" on it and the big dial/button at the same time. hold for about 10 seconds. your screen will then show "My Settings". press the big dial/button and you will enter a wealth of settings.

scroll down to "response" and push the dial/button. you'll see a choice of "standard" and "soft". choose "soft". then scroll back up to "cancel" choose that and your kicked back to your settings. scroll to the top and choose "home".

next screen choose "exit clinical menu". and your ready to mask up and go to sleep!

i really hope this helps you.

good luck!

[Pugsy]

I totally forget about the "soft" option because my machine is older and doesn't have it.
By all means...give it a try. Hopefully your machine has that selection available.

[zonker]

I totally forget about the "soft" option because my machine is older and doesn't have it.
By all means...give it a try. Hopefully your machine has that selection available.

oh! well, i've been reluctant to bring it up to others just because i didn't know for sure if they all had. but figured as it was the main thrust of his post, i'd mention it!

and i hope that option is there for the OP.

[nicholasjh1]

Pre-post warning. there may be some people who deny what I'm saying because they don't think it's "logically" consistent... I doubt they have any experience with it. I'm simply sharing my experience...

So my aerophagia reduced quite a bit - the pattern was - no aerophagia at 7-9 pressure, aerophagia at 9-14 pressure (sometimes quite painful), reducing aerophagia after 14 pressure (very little at 17.4 my current minimum) That is the facts.

My theory is that in the 9-14 area the pressure was high enough to get more aerophagia, but I was still getting breathing apparatus throat closure and apneas. at least short ones... at a higher pressure my apneas reduced to near 0 and the aerophagia went away. This may be because when apnea's exist (or at least partial ones under 10 seconds as defined by the measuring system (the machine)) that since the air can't go in my lungs... it is more likely to force its way into my stomach. when apneas were very low the majority of the air went in my lungs so aerophagia was greatly reduced. It should be noted that my AHI at 14 pressure averaged about .3, at 17.4 the average is somewhere below .1. so we're talking about very low AHI here even during the "aerophagia" phase.

[oneillseanm]

Pugsy, zonker, I don't know what to say. Your thoughtful, extensive responses are so generous. Thank you. For a few months now I've been feeling helpless. This has got me feeling hopeful.

Regarding the adjustments you both have proposed, I do feel comfortable making them myself. In fact, I already have. Being new to this, though, I do feel a little guilty. Since the adjustments have always been made by someone at my doctor's office, I have an irrational fear the CPAP Police are going to bust down my door for tweaking Clinical Menu settings on my own.

I'll be trying these settings out for the next few nights. And the wiki page on aerophagia gives me a lot of other things to try. I'll let you all know how it goes.

For now, thank you so much. I really appreciate it.

[oneillseanm]

nicholasjh1, your reply came in just as I was responding to Pugsy and zonker. I really appreciate you chiming in. What an unexpected aerophagia curve. It's good to know higher pressure actually can work for someone who experiences the bloating. Makes me less intimidated to experiment with the pressure setting. Really good to know. Thanks for sharing.

[zonker]

Pre-post warning. there may be some people who deny what I'm saying because they don't think it's "logically" consistent... I doubt they have any experience with it. I'm simply sharing my experience...

i understand precisely what you are saying. while i know there are hard and fast (rules? laws? what ever!) around cpap usage, i think there is plenty of wiggle room for folks being individuals. what comes to my mind most readily is user wulfman. while he knows about Apap, his thing is Cpap, in other words, fixed pressure. and he knows that doesn't work for everyone. but he does bring it up now and again.

aerophagia is just one of those things where i don't fit in with the rest. epr, for example, is said to help. but for me, epr just made breathing that much harder. almost the opposite of it's intended effect.

i think it's important to let my "betters" have a crack at helping a new user, though. their experiences are just more likely to help a new user. plus, i try to remember my first days here and how confusing it was to have all these people giving me what i took to be conflicting advice.

in the end, as many users have said here, you have to take care of yourself and do what's best for you. some times, that doesn't fit in with what "everyone knows" is right!

[zonker]

Pugsy, zonker, I don't know what to say. Your thoughtful, extensive responses are so generous. Thank you. For a few months now I've been feeling helpless. This has got me feeling hopeful.

Regarding the adjustments you both have proposed, I do feel comfortable making them myself. In fact, I already have. Being new to this, though, I do feel a little guilty. Since the adjustments have always been made by someone at my doctor's office, I have an irrational fear the CPAP Police are going to bust down my door for tweaking Clinical Menu settings on my own.

I'll be trying these settings out for the next few nights. And the wiki page on aerophagia gives me a lot of other things to try. I'll let you all know how it goes.

For now, thank you so much. I really appreciate it.

you are most welcome! i'm really pleased when i can chip in and try to help out. after all, that IS the purpose of this forum.

and of course you feel a bit "naughty" making these changes yourself. there is no way for us to know how your doctor may react. we've had people here who report their doctor was furious. then we have others who report the doctor was delighted that the patient took things into their own hands.

in the end, it's your machine and your health. you certainly have the right to do as you wish with it.

as you press on, you'll see a large portion of the regulars here haven't seen their doctor regarding apnea in years. (myself included.)

one last thing, please....if you try the soft response, could you let me know how it went? and, please, please would you respond in this thread?

thanks!

[Pugsy]

Welcome to the dark side and so far no one has yet to see the scary cpap police. Contrary to what we might be led to believe...they don't exist.

I have a theory why nicholasjh1 situation works for him ...but it's a theory and I have no real proof and no time to go into it depth right now but it relates to events themselves causing arousals and the arousals causing more air swallowing kind of thing.
Just something that a sleep tech here talked about one day with another person here who has some serious problems with aerophagia and why she sometimes had it worse than other times with no real change in pressures.
Reducing the events with more pressure reduces the arousals which also feed the aerophagia monster. In his situation something else was feeding the monster instead of pressure alone...once whatever it was that was feeding the monster was eliminated...he could easily handle the pressure by itself without have major aerophagia issues.
At least that's my theory based on something a sleep tech told me some time ago about arousals and aerophagia.

[babydinosnoreless]

Cpap police what a good way to put it. I was so scared to make changes at first that I was living with being uncomfortable. I am still new to this, took my machine in for my follow up (like they told me) and no one even looked at it. Doctor didn't know or didn't care that I had changed settings myself.

[Okie bipap]

When I first made changes to my therapy, the nurse practitioner asked why I had made changes. I told her I had fewer events and slept better after the changes, so she never said anything else again. I see her again next week and have made more changes since i saw her last. I'll wait and see if she notices or says anything.