Aerophagia

[palerider]

I understand <5 is okay.

< 5 is only "okay" for doctors and insurance companies that don't actually *care* about you or your health.

an AHI of 4 means that your sleep is interrupted *at least* every 15 minutes, on average, all night long. Do you really think you're going to get good rest like that?

[ejbpesca]

I understand <5 is okay.

< 5 is only "okay" for doctors and insurance companies that don't actually *care* about you or your health.

an AHI of 4 means that your sleep is interrupted *at least* every 15 minutes, on average, all night long. Do you really think you're going to get good rest like that?

The article I read claimed that apnea events are normal <5 per night. I do not know how valid that statement is.

Now that I'm paying attention to reports for the first time in 15 years of treatment, I am seeing a bit of a pattern that possibly links my events to REM sleep stage, not an all night every 15 minutes or more scenario. Either I don't have events or therapy works for much of sleep then a cluster of events appears on the graph.

[ejbpesca]

Ugh. Aerophagia back at min 6 max 11. Now min 6 max 10. Sleeping so few hours and feeling wiped out sick on waking around 3am. By 7am, I did a nap with no therapy. Was never a nap person till the past year. Naps for me are a very unpleasant few hours of not total sleep, but rather in and out, hoping to sleep.

In the past six months I have stopped taking many medications. This may have something to do with me feeling not well. I went from six meds ea. day to one, yet I do take some of the others on an as needed basis now.

AHI back down again, but today so not rested.

https://sleephq.com/public/c21fb8d7-b6c ... b3b597b533

[robysue1]

ejbpesca,

A criteria for OSA had to be set somewhere. And AHI < 5.0 was the decided cutoff.

Now palerider's computations are correct---if we assume that the obstructive events are equally distributed throughout the time asleep, that would in fact mean a person's sleep can be interrupted once every 12-15 minutes on average by a respiratory event and the person would still be considered "normal". But events are very rarely evenly spaced all night long for people who have very, very mild problems with apnea.

In your case the events that you were still experiencing while using your PAP were not equally distributed throughout the night when you are using a pressure range of 4-10. For most of the night, you had almost no events at all ---you had one or two here and there that are clearly far apart. But in the daily data that you posted for using 4-10 as the pressure range, there was always a very bad cluster of events that occurred sometime between 4:00 and 5:00 AM Alabama time. This cluster of events has a whole bunch of events---enough to skew the whole nightly AHI upward to around 4.0. And your machine maxed out at 10cm when these clusters were happening, so the machine could not increase the pressure any further to suppress additional events during that cluster. And your machine was typically using a pressure of about 5cm when the cluster starts, which indicates that you in theory you may need a higher minimum pressure setting to prevent that remaining nasty, nightly cluster of events.

It's the combination of all of those things, plus your need to minimize the aerophagia, that have to be taken into account when adjusting your pressure range.

Now you recently increased the pressure range to 6-11cm. And you write:

Ugh. Aerophagia back at min 6 max 11. Now min 6 max 10. Sleeping so few hours and feeling wiped out sick on waking around 3am. By 7am, I did a nap with no therapy. Was never a nap person till the past year. Naps for me are a very unpleasant few hours of not total sleep, but rather in and out, hoping to sleep.
...
AHI back down again, but today so not rested.

https://sleephq.com/public/c21fb8d7-b6c ... b3b597b533

The higher minimum pressure seems to have done its job in preventing the nasty cluster of events that have been occurring in the early AM when you were running at 4-11. But the cost of eliminating that last cluster of events appears to be unacceptable: You are sleeping less and the aerophagia has returned. And the result is that you are less rested than you were when using a pressure range of 4-10cm.

Notably too, you turned the machine off at around 3:10 AM Alabama time. What happened after you turned the machine off? Did you get up? Or did you go back to bed and sleep for a while without the mask on?

Because of the aerophagia and its known affect on your already severe acid reflux, its worth being extremely cautious when increasing your pressures in an effort to prevent that last, remaining nasty cluster of events that you seem to have in the wee hours of the morning every night when using 4-10 for the pressure range.

Here's my suggestion: Set the minimum pressure at 5 cm. Set the maximum pressure at 10cm. I won't be surprised if the AHI goes back up because you wind up with a nasty cluster of events in the early AM. But the real question is whether your stomach can handle a minimum pressure of 5cm.

If the aerophagia gets better, keep using 5-10 for 3-5 days and post the daily data. If the clusters return, then there are two possible nexts steps---increasing the minimum pressure or increasing the maximum pressure, but because of the aerophagia issue, you will need to proceed more slowly and change only one pressure variable at a time.

If the aerophagia is still a big issue when using 5-10, then you're going to have to back off to 4-10 for a while and not worry about that nightly cluster of events for a bit. Once the aerophagia seems to be under control, you can then proceed more slowly to increase the pressures. And you will need to only increase one of the two pressure settings at a time.

In other words, I think the first task is to experiment until you know what minimum pressure triggers the aerophagia if the max pressure is left at 10 cm. Once you know what the highest minimum pressure you can tolerate is, then it will be time to see if increasing the maximum pressure can be done to help keep the AHI low while not triggering the aerophagia.

Finally you write:

In the past six months I have stopped taking many medications. This may have something to do with me feeling not well. I went from six meds ea. day to one, yet I do take some of the others on an as needed basis now.

Were any of those meds you've stopped taking prescribed for the acid reflux? And did the aerophagia problem start before or after you stopped taking many of the medications you were on?

In other words, we need the following information:

When you were using a pressure range of 10-20cm did you ever feel better?

How long ago did the aerophagia problem at 10-20cm start?

Did the aerophagia problem start before or after you stopped taking certain medications? If so, which medications did you stop taking before the aerophagia problem started? And how soon after you stopped taking the medication did the aerophagia problem start?

[robysue1]

Now that I'm paying attention to reports for the first time in 15 years of treatment, I am seeing a bit of a pattern that possibly links my events to REM sleep stage, not an all night every 15 minutes or more scenario. Either I don't have events or therapy works for much of sleep then a cluster of events appears on the graph.

Without knowing what your diagnostic sleep study indicated there is no way to answer the question of whether you simply don't have events for much of your sleep or therapy is working for much of your sleep.

If, like most of us, you had a diagnostic AHI = 20 or more, then the most likely scenario is that your CPAP therapy works well for most of your sleep each night. But when you either hit a prolonged REM cycle or you flip on your back (or both), the machine is having some trouble preventing the nasty cluster. But without PAP, the nasty cluster would be far worse: It would have more events and probably last longer than they do with PAP therapy.

The trick in your case will be to balance the pressure needed to fully eliminate that last cluster of events with the need to not trigger aerophagia and its affects on your total sleep time as well as your acid reflux. So you might never fully eliminate all clustering of events, but the goal would be to keep the clusters as short as possible and on as few nights per week as possible without triggering the aerophagia.

[ejbpesca]

In reply to RobySue:

Let's see if I have the concept right.

Min pressure will continue if there are no events. This means either the min pressure is preventing them, or the patient (me) is not having events.

When events occur, pressure increases on an APAP, and throttles towards the max setting to prevent more events, and give relief to the current event. Higher pressure will remain for some period of time, especially with more events as it tries to give therapy to those events.

Aerophagia could be caused by both min and max pressures, but I suspect it is the jump up to the max pressure setting that is causing aerophagia.

I am not sure of what I wrote above, but it is the current concept I have of what is happening.

Last night:
Once awake around 3am, I stayed up until 7am for 3 hours. I tried to get more sleep without therapy, but naps are some twilight zone that is not asleep and not totally awake. I think I may be drifting in and out, without knowing if I ever went to sleep. Miserable.

I discontinued 2 meds I had been taking daily for high blood pressure for ten years and two other meds for depression and anxiety I had taken for 30 years. I also discontinued potassium. My daily dose of a pain med was discontinued six years ago. So, that leaves only 1 med I take daily and that is Losartan for blood pressure. I do take other meds than the one, but they are on an as needed basis and some needed often.

So, each day with meds is different and yes, some do affect sleep. A nerve pain med can induce sleep. I have many permanent injuries that give me chronic pain that can leap to level 9 in an instant. The pain is part of why I do not sleep well.

Thank you.

[lynninnj]

Ugh. Aerophagia back at min 6 max 11. Now min 6 max 10. Sleeping so few hours and feeling wiped out sick on waking around 3am. By 7am, I did a nap with no therapy. Was never a nap person till the past year. Naps for me are a very unpleasant few hours of not total sleep, but rather in and out, hoping to sleep.

In the past six months I have stopped taking many medications. This may have something to do with me feeling not well. I went from six meds ea. day to one, yet I do take some of the others on an as needed basis now.

AHI back down again, but today so not rested.

https://sleephq.com/public/c21fb8d7-b6c ... b3b597b533

your leak rate was really good and then all hell broke loose. seems like everything happened at one time.

Edit: your highest pressure was just above nine but it never actually made it to 10 until the league started. I am half tempted to believe that the leaks are why the pressure is going so high and causing the aerophagia.

You’re gonna figure this out

[Pugsy]

I am half tempted to believe that the leaks are why the pressure is going so high and causing the aerophagia.

Get over the temptation. Leaks don't cause pressure increases. Don't even go suggesting that idea because someone will snap it up for a legit reason and it's simply not a viable idea.

Pressure increases are from any/or combination of
Snores
Flow Limitations
OAs flagged
hyponeas flagged

Now could someone experience a big leak and the machine also responding to whatever (snores, FLs, OAs, hyponeas) at the same time????
Of course but that doesn't mean that the leak caused the pressures to increase.

In most situations when faced with a big leak and time...these machines will actually reduce the pressure in an effort to get leaks under better control.

[lynninnj]

I am half tempted to believe that the leaks are why the pressure is going so high and causing the aerophagia.

Get over the temptation. Leaks don't cause pressure increases. Don't even go suggesting that idea because someone will snap it up for a legit reason and it's simply not a viable idea.

Pressure increases are from any/or combination of
Snores
Flow Limitations
OAs flagged
hyponeas flagged

Now could someone experience a big leak and the machine also responding to whatever (snores, FLs, OAs, hyponeas) at the same time????
Of course but that doesn't mean that the leak caused the pressures to increase.

In most situations when faced with a big leak and time...these machines will actually reduce the pressure in an effort to get leaks under better control.

thank you for the gentle explainer.

I learn something new every day.

What do you think is going on?

[ejbpesca]

ejbpesca,

In other words, we need the following information:

When you were using a pressure range of 10-20cm did you ever feel better?

How long ago did the aerophagia problem at 10-20cm start?

Did the aerophagia problem start before or after you stopped taking certain medications? If so, which medications did you stop taking before the aerophagia problem started? And how soon after you stopped taking the medication did the aerophagia problem start?

1. I have had good and bad days with 10-20cm.
2. Aerophagia started about two months ago.
3. I have stopped/started so many medications (10) in the past few months I am not sure
which or when any of them is associated with aerophagia.
4. Yes, I take acid reducer as needed, and needed has been continuously for 3 months. It has not been effective. (I guess for now that makes two meds I am certain to take each day, but sometimes I take 6.)

[ejbpesca]

It just dawned on me, a possible cause of the aerophagia. Due to severe acid pain an endoscope was used to examine my esophagus and stomach. It was sometime after that procedure the aerophagia began. Scope could have damaged something. It was so rough on me, I cancelled the second scoping. I think aerophagia may happen while awake too, but not as bad.

I do know, that with a drastic reduction in APAP pressures the daily upon waking aerophagia was reduced to zero, then it came back when I added more pressure in order to take down the AHI that seemed to be produced by the lesser pressure. Maybe there is a happy medium.

[robysue1]

In reply to RobySue:

Let's see if I have the concept right.

Min pressure will continue if there are no events. This means either the min pressure is preventing them, or the patient (me) is not having events.

When events occur, pressure increases on an APAP, and throttles towards the max setting to prevent more events, and give relief to the current event. Higher pressure will remain for some period of time, especially with more events as it tries to give therapy to those events.

APAPs will increase the pressure when it detects snoring, flow limitations, RERAs, hypopneas and obstructive apneas. The most common reason a Resmed APAP is going to increase pressure is flow limitations: In other words, if the machine is not happy with the way you are breathing and it thinks the breathing pattern indicates the airway is at risk of collapsing or partially collapsing, it will increase the pressure in an effort to prevent the serious events (hypopneas and obstructive apneas) from occurring the first place.

Trying to determine why the minimum pressure is maintained during a certain time period requires knowing about your untreated apnea: If your untreated apnea was significantly worse during REM or on your back, then the minimum pressure might be maintained because you just aren't having events during that time period. But it could also be that the minimum pressure is enough to prevent events from occurring during the parts of your sleep when the apnea is not at its worst. Without knowing what your diagnostic sleep study said about when your events were occurring before you started PAPing, there's no way to tell.

Aerophagia could be caused by both min and max pressures, but I suspect it is the jump up to the max pressure setting that is causing aerophagia.

It's a reasonable hypothesis to think that the aerophagia might be caused by the sudden increase in pressure when the machine decides to increase the pressure in response to a deteriorating breathing pattern. But in this case, we would expect that increasing the minimum pressure from 4 to 6 should have not triggered a return of the aerophagia since the jump in pressure would have been less severe.

In general, the higher the minimum pressure is, the smaller the increase the machine needs to make in order to stabilize your breathing when it detects things are starting to go down hill. To try to make this clearer:

If your minimum pressure is at 4cm and your machine has not increased pressure in response to anything AND you go into REM and the breathing deteriorates rapidly, the machine may increase the pressure from 4 to your max of 11 in a matter of 5 or 10 minutes. That's in increase of 7cm over a relatively small amount of time.

On the other hand, if your minimum pressure is at 8 cm your machine has not increased pressure in response to anything AND you go into REM and the breathing deteriorates rapidly, the machine may increase the pressure from 8 to your max of 11 in a matter of 5 or 10 minutes. That's in increase of only 3 cm over the same amount of time.

It's also a reasonable hypothesis that your particular sphincter value is super-sensitive to pressure in the first place, and in that case you might do better with a lower minimum pressure since the lower minimum pressure seems to keep most of your apnea under control. The question then becomes what is the highest setting for the minimum pressure that your stomach can tolerate. And given that minimum pressure setting, how much additional pressure can the stomach take for shorter periods of time to try to prevent nasty clusters of events from occurring?

The way to tease out which of the two hypotheses better fits you and your stomach is to cautiously change only one thing at a time from the baseline 4-10cm range that did not seem to trigger the aerophagia problems and gather enough data at each pressure setting to be sure that you're not just looking at one particularly good or bad night in terms of both the apnea and the aerophagia.

Last night:
Once awake around 3am, I stayed up until 7am for 3 hours. I tried to get more sleep without therapy, but naps are some twilight zone that is not asleep and not totally awake. I think I may be drifting in and out, without knowing if I ever went to sleep. Miserable.

What happens if you try to nap with the machine? More aerophagia?

I discontinued 2 meds I had been taking daily for high blood pressure for ten years and two other meds for depression and anxiety I had taken for 30 years. I also discontinued potassium. My daily dose of a pain med was discontinued six years ago. So, that leaves only 1 med I take daily and that is Losartan for blood pressure. I do take other meds than the one, but they are on an as needed basis and some needed often.

Do any of those medications have known affects on your acid reflux problems?

So, each day with meds is different and yes, some do affect sleep. A nerve pain med can induce sleep. I have many permanent injuries that give me chronic pain that can leap to level 9 in an instant. The pain is part of why I do not sleep well.

It may be worth keeping a log to see if the chronic pain and bad sleep issues corollate with the worst of the aerophagia.

In other words, it's worth asking:

Is your aerophagia less severe (or absent) on the nights where the chronic pain doesn't leap up to a level 9 in an instant?

Is your aerophagia worse on the nights where the chronic pain flairs up significantly? Is it worse on the nights where the chronic pain's background level is higher?

Is your aerophagia less severe (or absent) on the nights where you subjectively feel you have gotten as decent of a night's sleep as you are capable of getting?

Is your aerophagia worse on nights when you subjectively feel you have gotten a rotten night's sleep for whatever reason?

[robysue1]

It just dawned on me, a possible cause of the aerophagia. Due to severe acid pain an endoscope was used to examine my esophagus and stomach. It was sometime after that procedure the aerophagia began. Scope could have damaged something. It was so rough on me, I cancelled the second scoping. I think aerophagia may happen while awake too, but not as bad.

I do know, that with a drastic reduction in APAP pressures the daily upon waking aerophagia was reduced to zero, then it came back when I added more pressure in order to take down the AHI that seemed to be produced by the lesser pressure. Maybe there is a happy medium.

This is why I think you need to go back to the 4-10 cm pressure range you tried for a while.

You need to get the stomach happy at least for a few days. Then you need a plan to more cautiously work on finding the happy medium that of preventing the nasty cluster of events that appears to be REM related while not triggering the aerophagia and destroying your sleep.

Another question pertaining to both the acid reflux and the aerophagia: What position do you tend to sleep in? Some sleeping positions are more prone to allowing acid to escape from the stomach. And those positions can also be more prone to allowing air from the PAP to get into the stomach.

[Pugsy]

What do you think is going on?

My crystal ball is cloudy....again.

The cluster of events where the pressure is maxed out....it's going to be either REM stage sleep or supine sleeping or maybe a combination of both. That's really the only 2 choices with the exception of maybe some sort of chin tucking thing going on...need the crystal ball.

Last night's slight increase in both minimum and maximum seems to have done a decent job preventing that sort of clustering but a the price of the return of the aerophagia discomfort and sacrificing of sleep quality and feeling decent today.
Not an acceptable compromise IMHO. I wouldn't accept it if it were me.

The flow limitation graph shows use pretty much what is driving the pressure (for majority of the time)...not leaks.
AND....if I look at the flagged events that preceded the spike in pressure and leak spike....doesn't look like asleep breathing to me.
I think some sort of arousal was the culprit....the machine increased the pressure in response to arousal/awake breathing irregularities.

Now what caused the arousal/awake breathing???? Again I need the crystal ball which is still broken.

Looks like a quick reseating of the mask at the leak spike to over 100 L/min but once completed the leak was never totally tamed since we see the leak line graph slightly off 0.0 line.

At this point though the leak isn't the problem (assuming it isn't waking OP up) and instead we have to concentrate of figuring out where the line in the sand for opening the door for the aerophagia monster to come and set up shop.

Main goal....decent sleep quality and feel decent during the day and if aerophagia complicates things then we sit back and re-evaluate our goals. Without good quality sleep....the rest of the numbers don't really mean much.

That one pressure increase where you see the spike.....related to arousal/awake breathing irregularities...and to fix that you have to try to figure out what caused the arousal and then fix it. Not an easy task.

These machines do NOT ever try to fix a leak with more pressure...just won't happen.
Now does the machine sometimes get it wrong and it increases the pressure because of arousal breathing irregularities and that pressure maybe make leaks worse...you bet your sweet behind it can but the original culprit starting the cascading problems is the arousal in the first place.

Back to letting RobySue help the OP try to figure out the line in the sand that can keep the aerophagia monster at bay.

[Pugsy]

BTW....I am not convinced that the cluster of events on Oct 1 that everyone is so worried about is a real asleep cluster.
The breathing prior to the onset of the cluster....very irregular to my eye which makes me suspect the validity of those flagged events and the machine's response.

So....someone went trying to kill some maybe arousal flagged events with more pressure....and that opened the door for the aeophagia monster to sneak in. Just because a machine might want to go higher doesn't always mean that the reason it wants to go higher is a valid reason and even if a valid reason it doesn't mean that it won't create a problem going higher.

If it had been me I wouldn't have changed anything based on that one night with some maybe not so asleep flagged events driving the pressure up. If not asleep....doesn't count.

I would have waited and got more concrete data and looked for trends and patterns.
I am not so sure that more pressure was the way to go because I am not so sure that the flow rate points to for sure asleep breathing.