Tweety: Tweaking Aircurve VAuto settings for aerophagia

[Tweety]

Hi everyone, I have a lot of flow limitations in Oscar, and was wondering if I could get some opinions about them.

Some background: I started using my aPap machine 6 months ago, and finally feel pretty acclimated to it (thanks to many hours spent lurking here!)--I’m definitely sleeping better with it, and many of my worst symptoms have disappeared (morning neck cramps, headaches, dry eyes, nightmares, hand cramps, bruxism, reflux). I took a sleep test and was diagnosed with mild OSA last year (only slept 4.5 hours) . I only rarely had bad daytime sleepiness, but always felt like I’d been hit by a truck when I woke up in the morning. I was also diagnosed with periodic limb movements, and had daytime restless-leg symptoms, but taking iron supplements has mostly taken care of those--as confirmed by my spouse, who is also sleeping better . My Sleepyhead AHI has been low since I adjusted to my machine—most flagged events are arousal-related. Also, my pressures stay pretty low (max of 8.2-8.6) when I’m letting them roam, although right now I have max P set to 8.0 due to ongoing problems with aerophagia after a bout of reflux. I’ve been gradually increasing it back up, but am having to go verrry slow, bleah. I feel like I sleep fairly well, especially compared to without cPap, although some nights I have a lot of arousals, maybe due to leaks, so I’m waiting on my Bleep delivery to see if that helps. I also see these periodic sharp inhalation spikes in my breathing that sometimes wake me up. Although I wake up very quickly in the morning and feel alert, I often feel like I could go back to sleep 15 minutes later (but I don’t), and sometimes get brain fog that almost feels like ADHD because I can’t focus my attention without getting distracted (especially driving). My only medication is HRT (estradiol patches), which I’ve been on for over 20 years.

Aside from the leaks, one thing I am noticing is a LOT of flow limitations. I have the machine set on the For Her mode, and I’ve read that it’s more aggressive in reading/detecting flow limitations, so maybe it’s not an issue?

Some sleep study details--all of my apneas are during REM (which was only 42 minutes)
-------
E. MOVEMENT EVENTS
LMs Index
PLMS 69 14/hr
PLMS with Arousal 3 1/hr

F. RESPIRATORY EVENTS
Respiratory Rate: 12-14 breaths per minute.
During baseline study: Total obstructive apneas: 28. Total central apneas: 0.
Total mixed apneas: 0. Total hypopneas: 4. Total number of apneas/hypopneas: 32. Total number of RERAs: 34.

Position Supine, Lateral Sleep State REM, NREM Baseline SaO2 Level 95-96% Supplemental O2 n/a LPM
Minimum O2 Saturation 90%
Recorded Sleep Time 4.8 Hours Apnea-Hypopnea Index (AHI) 7/hr
Apnea Index (AI) 5.8/hr
Hypopnea Index (HI) 0.8/hr
Respiratory Disturbance Index (RDI) 14/hr AHI on supine position 19/hr
AHI during REM sleep 37/hr

Here’s last night, where I feel like I didn’t wake up too much (that I remember). While I had a fair bit of aerophagia, I’ve found that flipping on my right side partway through the night helps it, er, dissipate (deflate?) by morning.

Oscar-typical night.png

Here are some closeups of flow limitations:

Oscar-FL-closeup3.png

And a closeup of one of the spiky breaths that sometimes wake me up.

Oscar-spike2.png

Thanks for your help (even if it's to say I'm worrying too much) .

[Dog Slobber]

A lot of people around here don't consider an AHI of 3 all that low.

I don't think your pressure is high enough. The range is 7.2 - 8, it immediately jumps to 8 and stays there. It wants to go higher, but you've hand-cuffed it.

I would suggest:

• Change it to straight APAP (for now, so we can see where the machine wants to naturally want to go, without for Her mode setting some lower limits)
• Set the maximum to 20. Don't worry, it's not likely to even go near there.
• Set your minimum to 8, but I'm guessing we are going to want it higher after we see where the machine wants to be

You've got some Centrals (CAs). I wouldn't worry about them. Clean up the Flow Limitations and Hypopneas for now.

[palerider]

DS, I was about to suggest the same thing you did... then I read your post, so I'll just say "what he said"

[Dog Slobber]

DS, I was about to suggest the same thing you did... then I read your post, so I'll just say "what he said"

My only concern is, he did mention some aerophagia. So a consideration might not setting the upper bound to 20.

OP, my experience with Aerophagia:

For the first few months, I had Aerophagia trouble myself.

• I limited my Max Pressure
• As I dialed-in my Min pressure, my machine did not need to go as high.
• My Aerophagia disappeared

I'm not sure why.

• Lower peak pressure
• Just getting used to CPAP

But, I still think we should see where the machine wants to go, and I think it's important to test if we've beat the Aerophagia.

[Pugsy]

That is one ugly Flow Limitation graph for sure.
How's your nasal congestion? Having much? If you are having some nasal congestion sometimes that congestion will cause the machine to flag increased FLs but it's not the same as FLs associated with the airway down below the nasal cavity.
So if you are having much nasal congestion going on you need to try to fix that somehow first.

If no nasal congestion to speak of then of course the FLs are likely from the lower part of the airway below the nasal cavity and these auto adjusting machines will try to kill it with more pressure. FLs and snores are the earliest of warning signs that the airway is trying to collapse. Now it doesn't always proceed with the collapsing to the point of earning an obstructive apnea or hyponea flag.
These FLs can potentially disturb our sleep though even if they don't grow up big enough to earn some sort of flag.
So...assuming your FLs are not nasal in origin...
The fix for these FLs is more pressure...usually minimum for sure and maximum when you see yourself being pegged out at max pressure all night long like you are seeing.
I understand the tight range...but the machine wants to go higher to try to kill those FLs but you are unlucky in that more pressure causes aerophagia. So you have to decide which is worse...the FLs or the aerophagia that would likely happen if you kill off some of those FLs.

Yes...the For Her AutoSet in the Special for Her auto mode does seem to be a little bit more aggressive with the FL flagging...but we can't blame all that ugliness on the machine flagging...if you were using the regular auto mode algorithm it would also be significantly ugly.
We can't do anything about the clear airway/central apneas you see flagged and you aren't really having enough of them to do anything about anyway. I suspect some of them are more likely arousal related anyway.
If you are having a lot of arousals that will increase the chance of having arousal related centrals get flagged...but they aren't real if you aren't asleep so we have to ignore them.
Perhaps trying to figure out what is causing the arousals is a better plan of attack.
It might be those FLs you are seeing...and it might be something else totally unrelated to airway or apnea issues. I get a lot of arousals myself but mine are due to pain.

So......to reduce the FLs....you need more maximum pressure. You are using a really tight range right now and the first thing I would do is give the machine more room to move if needed and see if the FLs reduce. I wouldn't change minimum starting pressure at this point...at least until I had seen if more maximum helped much.

The aerophagia issues really complicate things though and if allowing the machine to go higher to deal with the FLs causes bad aerophagia issues then you are just swapping problems and that's not good.
You may have to compromise and let the FLs be ugly if you find that the aerophagia symptoms cause you more problems than the FLs cause you.

Oh...increase your EPR to 3...that might help a bit with the aerophagia issues if you do let the machine go a little higher than the 8 cm limit you have right now. The reduction during exhale would be a bit larger and thus not so much constant pressure on the LES (lower esophageal sphincter) and maybe when doing the more pressure along with greater exhale relief the aerophagia monster won't show up so soon.

[Tweety]

Thank you for the suggestions!

Dog Slobber, thanks for your aerophagia experience. I’m really hoping mine will eventually go away also. I like the idea that maybe getting the minimum P higher might help. I had to lower my max all the way to 7.4 at first, because the aerophagia put pressure on my LES, which gave me reflux, which further weakened my LES, which made aerophagia worse, yada yada. I went on a 2-week course of omeprazole which gave me some relief, and I’ve been inching my max P up slowly (I’ve been at 8 for a week).

Pugsy, no nasal congestion. I had a terribly deviated septum that was fixed 12 years ago. Plus, the P10 clears me up really well. I don’t generally snore except when I have a cold (although I had large tonsils and snored *very* loudly as a child). I also snore on planes for maximum embarrassment. At home, I have noticed when in that twilight sleep/wake state that my breathing sometimes sounds loud and constricted in the back of my throat (without cPap). I’m a lifelong wide-open mouth-breather, which I’m currently managing with a little tape and a scunci (thanks Jay A. and Zonker). I’ve worn a nightguard for a number of years now, and I know for a fact that it’s even harder to breathe around, but I’ve been needing it less and less with cPap.

Here are last night’s results. All but maybe 2 of the events are arousal- or falling-asleep-related.
I took your collective advice to see what higher pressures would do, and set my machine to aPap mode, Max P of 10, Min 7.8, EPR 3. Too nervous to go higher with the maximum, but it looks like it was high enough anyway. Sorry Pugsy, I missed what you said last night about leaving the minimum alone.
- Maybe someone can tell me if it positively affected the FLs—It’s a little hard for me to tell objectively because the graph is much lower in aPap mode than in the For Her I was using.
- My aerophagia was pretty bad. Too much to turn on my right side without acid reflux, so I got up around 2:30 to get a little relief. Lots of burping this morning. I think I can tolerate more pressure than the 8.0 I was up to previously, but maybe the highest pressure jumps last night were too much. Part of the reason I was using For Her was to see if having a steadier pressure, rather than the up-down fluctuations, would be easier. I think I’ll need to lower the maximum tonight—I might start at last night’s 95% point of 9.2, but otherwise I’ll have to lower it and go up more slowly.
- I had about 20 little arousals, which doesn’t seem too bad, because I did see long stretches of just sleep, even with the aerophagia problems. I think I remember more of them than usual.

2019-06-10 reg mode max 10.png

Here’s a closer look at one of the FL clusters, where the pressure was highest:

2019-06-10 FL cluster.png

[Dog Slobber]

Well no surprises.

Increasing the minimum and letting the machine work with higher pressures cleaned up you Flow Limitations and Obstructive and Hypopneas.

As Pugsy pointed out, you'll have to find a compromise between pressure, sleep quality and Aerophagia.

[chunkyfrog]

Just a personal observation:
In my case, setting the max to wide open was not such a good idea.
Set it where it works. There is no "one size fits all".

[Tweety]

Just a personal observation:
In my case, setting the max to wide open was not such a good idea.
Set it where it works. There is no "one size fits all".

Yes, today I’m pretty uncomfortable. I guess it was worth one night to see how my data looked although my husband probably disagrees, since he has to suffer the consequences.

Increasing the minimum and letting the machine work with higher pressures cleaned up you Flow Limitations and Obstructive and Hypopneas.

You’re right, the FLs looked better, but I’ve seen that in the past when switching from aPap to For Her—the FL charts in For Her seem to double in amplitude. Maybe I’ll try the For Her again tonight, out of curiosity...

[Dog Slobber]

One thing that helped me when I had aerophagia troubles was sleeping on a wedge pillow.

[Vinny V]

One thing that helped me when I had aerophagia troubles was sleeping on a wedge pillow.

Did you have trouble with sliding down while using the wedge??

[Dog Slobber]

One thing that helped me when I had aerophagia troubles was sleeping on a wedge pillow.

Did you have trouble with sliding down while using the wedge??

I didn't have problems sliding off.

What I didn't like was the wedge angle was so steep where it made sleeping on my side uncomfortable.

[Vinny V]

I'm a side sleeper.. So that may be an issue

Thanks

[Tweety]

One thing that helped me when I had aerophagia troubles was sleeping on a wedge pillow.

Did you have trouble with sliding down while using the wedge??

I didn't have problems sliding off.

What I didn't like was the wedge angle was so steep where it made sleeping on my side uncomfortable.

Yes, exactly! I used a big wedge (came all the way under my butt) when I first had bad reflux, and it did help, but I was locked into sleeping on my back because my shoulder hurt when I slept on my side. Makes sense that it would help with aerophagia, though. Maybe I can figure out something with pillows that would work temporarily.

[Tweety]

So......to reduce the FLs....you need more maximum pressure. You are using a really tight range right now and the first thing I would do is give the machine more room to move if needed and see if the FLs reduce. I wouldn't change minimum starting pressure at this point...at least until I had seen if more maximum helped much.

The aerophagia issues really complicate things though and if allowing the machine to go higher to deal with the FLs causes bad aerophagia issues then you are just swapping problems and that's not good.
You may have to compromise and let the FLs be ugly if you find that the aerophagia symptoms cause you more problems than the FLs cause you.

My Bleep arrived and I slept like a ton of bricks the first night, even with my max P at 9.0 and some aerophagia—Yea baby, I’m sold!

Second night with Bleep felt more restless, but also worse aerophagia. I raised my max to 9.2, which was the 95% P from when I let it roam in aPap mode 2 nights ago. I think the discomfort might be waking me up—zoomed in, none of my events look real, they’re all wakeups, except for the CAs when I’m falling asleep.

Below is last night—see what I mean about the FL chart having more amplitude in For Her than in aPap mode? Like twice as much as the aPap graph I posted 3 nights ago. But the FLs are certainly not as dense as my first chart, so more pressure seems to be helping. And the aerophagia isn't the worst I've had, so maybe I'm adjusting.

My breaths look wobbly if I zoom in on the FL readings, but they're not waking me up. I’ll follow your advice and look for that happy medium between sleeping comfort and aerophagia, now that I’m sleeping better with the Bleep (leak-free is sooo nice ).

2019-06-12 ForHer max92.png

2019-06-12 FL closeup.png

2019-06-12 FL closeup2.png