general questions/therapy

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
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zonker
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Re: general questions/therapy

Post by zonker » Thu Jul 29, 2021 7:55 pm

1speechpick wrote:
Thu Jul 29, 2021 6:31 pm

Thanks, Zonker and Pugsy, for your responses. I'm determined to find a solution. The aerophagia is causing nausea, reduced appetite, and increased GERD.

Is there a chance that a Bilevel machine would help decrease the aerophagia (even though I'm at lower pressures)?
instead of a bilevel, you can do some experimentation with your current machine. i have a process by which i conquered my aerophagia. it's what forum friend dogslobber has described as the zonker protocol. :oops:

because you have a resmed(the same machine i have), you can do the same thing. resmed allows the user to set the pressure at a specific .2 increments. philips users have an increment of .5. the .2 is better in my opinion for dealing with aerophagia.

it's really pretty simple. find the pressures that don't cause aerophagia. just pulling numbers out of the air, but let's say you don't have a problem with a minimum pressure of 8 and a maximum of 20. with that in mind, set your machine to 8.2 min and 20 max. see how you sleep that night.

if aerophagia rears it's ugly head, go back down to your "safe zone"; in this case, the made up 8 as the min. sleep through that. but try it again another night. eventually, that 8.2 will feel comfortable and you can raise it to 8.4.

and start all over again. maybe that 8.4 is fine. if not, knock it back and start over at 8.2. and over and over again until your body gets used to all this gaseous nonsense.

the drawback to this? two of them. it takes FOREVER. i can't remember how long this took me specifically. i'm sure the measurement was in weeks.the second is that your ahi is going to look like hell. and that's because you don't have the necessary pressures it takes to deal with it.

in the long run, i think it's worth it. or it was for me. i could see from reading the forum that the pressures i was using wouldn't get my ahi any lower. but i could use higher pressures because i couldn't friggin' sleep for feeling like my stomach was an inflated football.

so in desperation, i tried this. dunno if you want to try it or not. i'm saying it worked for me. it also worked for forum friend iloveflowers-

https://www.cpaptalk.com/viewtopic/t182 ... hagia.html

whatever you do, good luck!
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Re: general questions/therapy

Post by 1speechpick » Fri Jul 30, 2021 7:48 am

zonker wrote:
Thu Jul 29, 2021 7:55 pm
1speechpick wrote:
Thu Jul 29, 2021 6:31 pm

Thanks, Zonker and Pugsy, for your responses. I'm determined to find a solution. The aerophagia is causing nausea, reduced appetite, and increased GERD.

Is there a chance that a Bilevel machine would help decrease the aerophagia (even though I'm at lower pressures)?
instead of a bilevel, you can do some experimentation with your current machine. i have a process by which i conquered my aerophagia. it's what forum friend dogslobber has described as the zonker protocol. :oops:

because you have a resmed(the same machine i have), you can do the same thing. resmed allows the user to set the pressure at a specific .2 increments. philips users have an increment of .5. the .2 is better in my opinion for dealing with aerophagia.

it's really pretty simple. find the pressures that don't cause aerophagia. just pulling numbers out of the air, but let's say you don't have a problem with a minimum pressure of 8 and a maximum of 20. with that in mind, set your machine to 8.2 min and 20 max. see how you sleep that night.

if aerophagia rears it's ugly head, go back down to your "safe zone"; in this case, the made up 8 as the min. sleep through that. but try it again another night. eventually, that 8.2 will feel comfortable and you can raise it to 8.4.

and start all over again. maybe that 8.4 is fine. if not, knock it back and start over at 8.2. and over and over again until your body gets used to all this gaseous nonsense.

the drawback to this? two of them. it takes FOREVER. i can't remember how long this took me specifically. i'm sure the measurement was in weeks.the second is that your ahi is going to look like hell. and that's because you don't have the necessary pressures it takes to deal with it.

in the long run, i think it's worth it. or it was for me. i could see from reading the forum that the pressures i was using wouldn't get my ahi any lower. but i could use higher pressures because i couldn't friggin' sleep for feeling like my stomach was an inflated football.



so in desperation, i tried this. dunno if you want to try it or not. i'm saying it worked for me. it also worked for forum friend iloveflowers-

https://www.cpaptalk.com/viewtopic/t182 ... hagia.html

whatever you do, good luck!

Thanks a bunch, Zonker! I will try the Zonker protocol. I read the info in the link you provided. If I'm looking at Iloveflowers Oscar chart correctly, it looks like the max pressure (in auto mode) was set at 7.4 with an EPR of 3. General question to increase my understanding ...is the IPAP or EPAP most likely to aggravate aerophagia? Also, for those with a tendency for aerophagia, do you recommend "auto set for her" or just the regular "auto set" option? I wondered if one the auto, auto for her, or straight CPAP settings is better for aerophagia.

A few nights ago I set the auto with a max of 6.0 with EPR turned off. I had a few centrals and terrible aerophagia that night. Last night I set the auto at 5.6 with an EPR of 2 (effectively 1.6 because the machine only goes down to 4). I had fewer centrals and aerophagia was present but a little improved. It seems like my machine wants to go higher because every time I increase the max, my machine stays there the entire night. I tried to attach the respective Oscar charts, hopefully I did it correctly.

If I'm understanding the Zonker protocol, tonight I should either stay at 5.6 max pressure, or perhaps try 5.4 to see if that gets rid of the aerophagia...stay at the most comfortable spot for a few nights, then bump up max pressure .2 to see how it is tolerated. Should I keep EPR on?

Thanks so much for your help. It seems like in your case the body just eventually adapted to the pressure, as long as you increased it very slowly over time.
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Re: general questions/therapy

Post by 1speechpick » Fri Jul 30, 2021 7:51 am

I forgot to ask. Are these levels of flow limits a problem?
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Re: general questions/therapy

Post by 1speechpick » Fri Jul 30, 2021 7:55 am

Pugsy wrote:
Thu Jul 29, 2021 6:58 pm
1speechpick wrote:
Thu Jul 29, 2021 6:31 pm
Is there a chance that a Bilevel machine would help decrease the aerophagia (even though I'm at lower pressures)?
Yes, a chance ...no guarantees though.
We have forum member RobySue (not active for a while) who had bad (really bad) aerophagia issues even at extremely low pressures on the apap who went to a bilevel and obtained significant relief. She still had to use lower pressures and in an extremely tight range but her aerophagia was really bad if she didn't. She also had to compromise a bit and let a few apnea events slide because to try to kill them with higher pressures caused more problems than it fixed in terms of air in the belly issues.
I don't know if she talks about it much here at her blog but you might check it out or search her old posts here for the discussion.

http://adventures-in-hosehead-land.blog ... er_19.html

https://www.cpaptalk.com/search.php?aut ... 0&sr=posts

Her settings on the bilevel were like EPAP 4 with PS of 4 and max IPAP of 10 because her belly couldn't handle more.
Thanks Pugsy! I have a message into my doctor about trying a Bilevel, but I know what his answer is going to be. He's already recommended I trial a dental device. I'm just not ready to give up on PAP. It's too early in the game to do that. So I'll continue with experimentation!
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Re: general questions/therapy

Post by Pugsy » Fri Jul 30, 2021 8:07 am

1speechpick wrote:
Fri Jul 30, 2021 7:48 am
is the IPAP or EPAP most likely to aggravate aerophagia?
We really don't know but probably both. Remember YMMV thing.
My own personal thought is the longer we are at IPAP the greater the chance of the constant pressure against the LES (lower esophageal sphincter) pushing past the sphincter and entering the stomach causing the air in the belly issues.
The reason we advise EPR use...that reduces the time the machine is at the IPAP pressure.
And keeping EPAP as low as possible reduces the chance that EPAP against the LES will push past the sphincter.
1speechpick wrote:
Fri Jul 30, 2021 7:51 am
Are these levels of flow limits a problem?
They are for sure ugly and they are what is driving your pressure upwards. Are they a problem...depends on what they are caused from and are they disturbing your sleep. They aren't growing up to be hyponeas or OAs which is good.

I forget....do you have much nasal congestion going on? If you do then the FLs could be mainly from nasal issues and the fix isn't more pressure.

Just because the machine wants to go higher doesn't always mean we should let it go higher.
Sometimes it wants to go higher because of nasal issues and no amount of higher pressure will fix nasal issues.
Sometimes it wants to go higher but higher causes belly issues that cause more problems than it fixes.

What are your goals with trying more pressure...what are you wanting to fix?
It won't help with the centrals at all and other than the ugly flow limitation graph I don't see a need for more pressure since more pressure causes significant belly issues.
You are using the for Her mode...it always makes mountains out of mole hills when it comes to FLs.
Change over to regular auto mode for a night and see the difference. The FL graph will likely still be ugly but not as ugly.
If you are having any nasal congestion at all...we have to totally re-evaluate the FL graph and the pressure needs.
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Re: general questions/therapy

Post by 1speechpick » Fri Jul 30, 2021 8:37 am

Pugsy wrote:
Fri Jul 30, 2021 8:07 am
1speechpick wrote:
Fri Jul 30, 2021 7:48 am
is the IPAP or EPAP most likely to aggravate aerophagia?
We really don't know but probably both. Remember YMMV thing.
My own personal thought is the longer we are at IPAP the greater the chance of the constant pressure against the LES (lower esophageal sphincter) pushing past the sphincter and entering the stomach causing the air in the belly issues.
The reason we advise EPR use...that reduces the time the machine is at the IPAP pressure.
And keeping EPAP as low as possible reduces the chance that EPAP against the LES will push past the sphincter.
1speechpick wrote:
Fri Jul 30, 2021 7:51 am
Are these levels of flow limits a problem?
They are for sure ugly and they are what is driving your pressure upwards. Are they a problem...depends on what they are caused from and are they disturbing your sleep. They aren't growing up to be hyponeas or OAs which is good.

I forget....do you have much nasal congestion going on? If you do then the FLs could be mainly from nasal issues and the fix isn't more pressure.

Just because the machine wants to go higher doesn't always mean we should let it go higher.
Sometimes it wants to go higher because of nasal issues and no amount of higher pressure will fix nasal issues.
Sometimes it wants to go higher but higher causes belly issues that cause more problems than it fixes.

What are your goals with trying more pressure...what are you wanting to fix?
It won't help with the centrals at all and other than the ugly flow limitation graph I don't see a need for more pressure since more pressure causes significant belly issues.
You are using the for Her mode...it always makes mountains out of mole hills when it comes to FLs.
Change over to regular auto mode for a night and see the difference. The FL graph will likely still be ugly but not as ugly.
If you are having any nasal congestion at all...we have to totally re-evaluate the FL graph and the pressure needs.
Thanks for your response, Pugsy! My goal with more pressure had been to attempt to decrease the flow limitations. I do have some nasal congestion due to allergies. I use Nasacort, saline rinse, and an oral antihistamine. I tried Azelastine but had side effects. Some of the flow limitations could be from that. The nasal congestion is what drove me to try a ffm, and we know how that turned out. I'm disappointed about the ffm, as I find it comfortable. The nasal congestion should greatly improve in a couple of months after the first frost. Is there a chance the nasal congestion contributes to the aerophagia?
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Re: general questions/therapy

Post by Pugsy » Fri Jul 30, 2021 9:14 am

1speechpick wrote:
Fri Jul 30, 2021 8:37 am
Is there a chance the nasal congestion contributes to the aerophagia?
To be honest I don't know a definitive answer to that question.
Obviously the nasal congestion contributes to the machine wanting to go higher with the pressures and the higher pressures will sure contribute to the aerophagia but I don't know if just mouth breathing all by itself will do it. Mechanically I don't see how it would without cpap pressure being added.

Here are my thoughts about what I would do if I was seeing reports like yours and having the aerophagia issues complicate things.
I would deal with the nasal congestion issues first the best I could because it is entirely possible that the bulk of the ugly you see on that FL graph is nasal related and even if you could use 20 cm pressure...it would still be ugly.
At this point we just don't have any way to know how much of the ugly is nasal related and how much is airway related BUT we do know that aerophagia issues create a significant problem not matter what is causing the ugly FL graph.
If it were my report and I knew I had some nasal issues and was having aerophagia issues that were severe....I would put the FL graph on the back burner for now and quit worrying about increasing the pressure limits just because the machine wants to go there.

First of all there is no proof that more pressure will improve the FL graph because if it is mainly nasal related...more pressure won't ever fix the ugly....but we do know that more pressure causes problems.
There is no urgent need for more pressure....the central apneas won't respond or reduce with more pressure and the 2 items that might respond...the OAs and hyponeas aren't present in numbers that make for an urgent need to reduce them further with more pressure.

So in other words if I was seeing reports like yours and I knew that more pressure caused the aerophagia monster to set up shop....I would simply sit back and not worry about increasing the pressures for now to try to kill FLs that may or may not be killed anyway and accept the ugly FL graph and quite worrying about it. Maybe revisit FL graph worries after the worst of the allergy season is over and chances of nasal congestion impacting the FL graph are lessened.
Accept the fact that the FL graph is going to be ugly and you will have an occasional OA and hyponea which is no big deal and the centrals...we can't fix them with more pressure anyway and you aren't having enough of them to worry about anyway.
There comes a point where trying to get the AHI lower ends up causing more problems than it fixes.
Even people without the OSA diagnosis will have centrals, OAs, hyponeas and even flow limitations.

Just my opinion FWIW. I would quite worrying about killing everything with more pressure since more pressure creates a significant issue. Make an acceptable compromise and move on. Maybe revisit things later this fall or winter...not be in such a rush to kill something that I might not be able to kill anyway but the act of trying to kill it could cause me huge problems.
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Re: general questions/therapy

Post by 1speechpick » Fri Jul 30, 2021 9:53 am

Pugsy wrote:
Fri Jul 30, 2021 9:14 am
1speechpick wrote:
Fri Jul 30, 2021 8:37 am
Is there a chance the nasal congestion contributes to the aerophagia?
To be honest I don't know a definitive answer to that question.
Obviously the nasal congestion contributes to the machine wanting to go higher with the pressures and the higher pressures will sure contribute to the aerophagia but I don't know if just mouth breathing all by itself will do it. Mechanically I don't see how it would without cpap pressure being added.

Here are my thoughts about what I would do if I was seeing reports like yours and having the aerophagia issues complicate things.
I would deal with the nasal congestion issues first the best I could because it is entirely possible that the bulk of the ugly you see on that FL graph is nasal related and even if you could use 20 cm pressure...it would still be ugly.
At this point we just don't have any way to know how much of the ugly is nasal related and how much is airway related BUT we do know that aerophagia issues create a significant problem not matter what is causing the ugly FL graph.
If it were my report and I knew I had some nasal issues and was having aerophagia issues that were severe....I would put the FL graph on the back burner for now and quit worrying about increasing the pressure limits just because the machine wants to go there.

First of all there is no proof that more pressure will improve the FL graph because if it is mainly nasal related...more pressure won't ever fix the ugly....but we do know that more pressure causes problems.
There is no urgent need for more pressure....the central apneas won't respond or reduce with more pressure and the 2 items that might respond...the OAs and hyponeas aren't present in numbers that make for an urgent need to reduce them further with more pressure.

So in other words if I was seeing reports like yours and I knew that more pressure caused the aerophagia monster to set up shop....I would simply sit back and not worry about increasing the pressures for now to try to kill FLs that may or may not be killed anyway and accept the ugly FL graph and quite worrying about it. Maybe revisit FL graph worries after the worst of the allergy season is over and chances of nasal congestion impacting the FL graph are lessened.
Accept the fact that the FL graph is going to be ugly and you will have an occasional OA and hyponea which is no big deal and the centrals...we can't fix them with more pressure anyway and you aren't having enough of them to worry about anyway.
There comes a point where trying to get the AHI lower ends up causing more problems than it fixes.
Even people without the OSA diagnosis will have centrals, OAs, hyponeas and even flow limitations.

Just my opinion FWIW. I would quite worrying about killing everything with more pressure since more pressure creates a significant issue. Make an acceptable compromise and move on. Maybe revisit things later this fall or winter...not be in such a rush to kill something that I might not be able to kill anyway but the act of trying to kill it could cause me huge problems.
Thanks so much for your perspective, Pugsy! I will work on targeting which pressure alleviates the aerophagia the most (lol if that even exists), then stay there a while so hopefully my system will get used to it. I'll only move in .2 increments (Zonker protocol), when/if changes are needed. For my future reference (after allergy season when I have a clear nose), what is an acceptable flow limit?

On a side note, I asked my doctor about trialing a bipap. He said "no". I was scolded for changing my pressure to 5.6, and told me not to do it again (even though I was waking up starving for air at his prescribed level of 4 on straight cpap setting). Perhaps he could be right about the bipap, we would only know if I tried one and it certainly wouldn't hurt to try. But, so much for feeling like my doctor and I are partnering in my health care. I get that from a stats perspective I don't need to go above above 6 cm for now, but 4 is just too low.
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Re: general questions/therapy

Post by zonker » Fri Jul 30, 2021 10:49 am

1speechpick wrote:
Fri Jul 30, 2021 7:48 am

If I'm understanding the Zonker protocol, tonight I should either stay at 5.6 max pressure, or perhaps try 5.4 to see if that gets rid of the aerophagia...stay at the most comfortable spot for a few nights, then bump up max pressure .2 to see how it is tolerated. Should I keep EPR on?

Thanks so much for your help. It seems like in your case the body just eventually adapted to the pressure, as long as you increased it very slowly over time.
you know, i honestly don't remember if i had epr on or not. i have a feeling that i did, simply to help with my breathing out smoothly thing. i say you should do as you see fit on the epr and we'll see.

yeah, eventually i got to the point where i could breath without having painful belly swelling on the machine. today, my pressures are 18 min and 20 max with no problem other than that "one off" that i mentioned. and that was prolly down to me stuffing myself like a pig at dinner. :lol:

now, when you start asking things like epap and ipap, i don't know nothin' about that. bilevel and such is pugsy's department and i see she is handling that in her usual good style.

good luck!
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Re: general questions/therapy

Post by 1speechpick » Fri Jul 30, 2021 11:31 am

zonker wrote:
Fri Jul 30, 2021 10:49 am
1speechpick wrote:
Fri Jul 30, 2021 7:48 am

If I'm understanding the Zonker protocol, tonight I should either stay at 5.6 max pressure, or perhaps try 5.4 to see if that gets rid of the aerophagia...stay at the most comfortable spot for a few nights, then bump up max pressure .2 to see how it is tolerated. Should I keep EPR on?

Thanks so much for your help. It seems like in your case the body just eventually adapted to the pressure, as long as you increased it very slowly over time.
you know, i honestly don't remember if i had epr on or not. i have a feeling that i did, simply to help with my breathing out smoothly thing. i say you should do as you see fit on the epr and we'll see.

yeah, eventually i got to the point where i could breath without having painful belly swelling on the machine. today, my pressures are 18 min and 20 max with no problem other than that "one off" that i mentioned. and that was prolly down to me stuffing myself like a pig at dinner. :lol:

now, when you start asking things like epap and ipap, i don't know nothin' about that. bilevel and such is pugsy's department and i see she is handling that in her usual good style.

good luck!
Thanks for the reply, Zonker! I'll keep EPR on for now and see how it goes. I'll keep my pressure moves to .2 and see how that goes, as well. It's amazing to me how each person has their thing that helps the aerophagia eventually.
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Re: general questions/therapy

Post by Pugsy » Fri Jul 30, 2021 12:04 pm

1speechpick wrote:
Fri Jul 30, 2021 9:53 am
what is an acceptable flow limit?
I guess it all depends on what is causing the FL first of all.
Quit worrying about numbers or graphs for now. The FLs aren't growing up to be OAs or hyponeas and that's the most important thing.
Yeah, it would be nice if your FL graph was unremarkable but right now it is something that can't be achieved for various reasons.

Worry about your sleep quality and how you feel during the day and keeping the belly issues from not making your life miserable. You might have the most perfect FL graph in the world and sleep like crap and feel like death during the day and that pretty FL graph is meaningless. Same thing about AHI...perfect AHI numbers don't guarantee that we feel like superwoman. The best judge of how effective your therapy is....your own body as to how you sleep and feel in general.

Quit looking at numbers or graphs that you can't really change at this point anyway.
And while your FL graph is ugly...I have seen much worse.

I don't do FL numbers as guides. I go by the big picture which includes overall activity AND subjective findings in terms of sleep and how we feel. FL numbers are too easily screwed with from nasal issues that aren't apnea issues which makes for FL graph evaluation being less than accurate. Why worry about something that has a high probability of being related to something you can't fix with pressure changes anyway.
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Re: general questions/therapy

Post by 1speechpick » Fri Jul 30, 2021 3:52 pm

Thank you so much, Pugsy!
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Re: general questions/therapy

Post by 1speechpick » Sat Aug 07, 2021 5:22 pm

zonker wrote:
Fri Jul 30, 2021 10:49 am
1speechpick wrote:
Fri Jul 30, 2021 7:48 am

If I'm understanding the Zonker protocol, tonight I should either stay at 5.6 max pressure, or perhaps try 5.4 to see if that gets rid of the aerophagia...stay at the most comfortable spot for a few nights, then bump up max pressure .2 to see how it is tolerated. Should I keep EPR on?

Thanks so much for your help. It seems like in your case the body just eventually adapted to the pressure, as long as you increased it very slowly over time.
you know, i honestly don't remember if i had epr on or not. i have a feeling that i did, simply to help with my breathing out smoothly thing. i say you should do as you see fit on the epr and we'll see.

yeah, eventually i got to the point where i could breath without having painful belly swelling on the machine. today, my pressures are 18 min and 20 max with no problem other than that "one off" that i mentioned. and that was prolly down to me stuffing myself like a pig at dinner. :lol:

now, when you start asking things like epap and ipap, i don't know nothin' about that. bilevel and such is pugsy's department and i see she is handling that in her usual good style.

good luck!

Zonker:

Just checking in to let you know the "Zonker protocol" seems like it is starting to work. I went back to a really low pressure, but have been going up by .2 every few days. I'm now up to IPAP of 5, EPAP 4. I will continue to experiment. I'm still intermittently a little air but it's much better than it was. Thank you for the great advice.
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Re: general questions/therapy

Post by zonker » Sat Aug 07, 2021 6:39 pm

1speechpick wrote:
Sat Aug 07, 2021 5:22 pm

Zonker:

Just checking in to let you know the "Zonker protocol" seems like it is starting to work. I went back to a really low pressure, but have been going up by .2 every few days. I'm now up to IPAP of 5, EPAP 4. I will continue to experiment. I'm still intermittently a little air but it's much better than it was. Thank you for the great advice.

Image

not to mention-

Image

seriously, thanks for letting me know cuz it makes me happy.

so many people here on the forum helped me(and continue to help me) over the years and i'm really quite pleased to know when i can help someone else.
the two great unwritten rules of life are-
1.
2.
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Re: general questions/therapy

Post by 1speechpick » Sat Aug 07, 2021 7:23 pm

zonker wrote:
Sat Aug 07, 2021 6:39 pm
1speechpick wrote:
Sat Aug 07, 2021 5:22 pm

Zonker:

Just checking in to let you know the "Zonker protocol" seems like it is starting to work. I went back to a really low pressure, but have been going up by .2 every few days. I'm now up to IPAP of 5, EPAP 4. I will continue to experiment. I'm still intermittently a little air but it's much better than it was. Thank you for the great advice.

Image

not to mention-

Image

seriously, thanks for letting me know cuz it makes me happy.

so many people here on the forum helped me(and continue to help me) over the years and i'm really quite pleased to know when i can help someone else.

Zonker: Starting back at ground zero (4 cm) and inching up in .2 increments made the difference in being able to tolerate CPAP (versus giving up). Many, many thanks! Right now, straight CPAP mode (with use of EPR) also seem to help manage aerophagia. I seemed to have more aerophagia in APAP mode, though I'm unsure why. I will have try APAP mode again in a few weeks.
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