Aerophagia and low pressures and high heart rate in sleep

[manacles]

Hi everyone, I've been on CPAP since March 2022 and have been dealing with issues from it for the entire time. Mainly, I have pretty severe aerophagia, and will wake up very gassy, often at least 3 times a night. Usually my first wake up is after about 4-5 hours of sleep and I will wake up about every hour or two after. It definitely has a very bad effect on my sleep, and I will often sleep a total of 9+ hours a night without feeling rested at all. Even at low pressures, such as 6-7, I can even feel the air being forced into my esophagus while laying awake in bed, causing me to immediately burp it up.

In addition, I wear an Apple watch during my sleep and the heart rate tracker will often show that my average heart rate actually increases in my sleep, going to ~90 bpm while sleeping even though when I'm just laying down awake I will consistently be in the 50's-60's. So my three main issues are aerophagia, frequent wakings, and high heart rates and I'm not sure what the causality is or how to tackle these issues.

For the past year, I've been experimenting with different CPAP settings, such as constant pressures ~6 or APAP between 5 and 10, but the problems remained. I recently met with a new sleep doctor who suggested I do APAP from 5-7 but even that is still causing the same issues. I've attached the last few days of OSCAR data on these pressure settings if anyone can provide some advice. Even though my AHI values are apparently low there seems to be something going wrong for me.

https://imgur.com/a/MX6CjtD

[Pugsy]

Have you turned EPR on and used it?
If not, give it a try set to 2 or 3.

[manacles]

Should I use EPR with a higher max/min pressure or the current settings I'm using?

[Pugsy]

I wouldn't increase either of those pressure settings at this time until I saw some reports with EPR turned to see if more pressure is needed to compensate for the drop during exhale when using EPR.

The use of EPR is an effort to reduce your aerophagia issues first before we worry about the other stuff.

[manacles]

I've been trying EPR 2 for the past couple of days but it feels very disruptive for my sleep, i've noticed that when the APAP pressure goes down with EPR I start getting very agitated in my sleep. I've thought about setting a static pressure of 7 instead and seeing hwo that would go.

[manacles]

I think I came across a breakthrough recently with my therapy. I found a thread online about someone who had similar issues with very severe aerophagia even low pressures, with the same story of the air forcing open their esophagus. They were able to resolve it by simply applying external pressure to their throat just below their adam's apple. Apparently it may be due to a condition called silent reflux. As someone who gets sore throats and coughs after eating in addition to my CPAP troubles I wonder if I may have that myself. I tried applying pressure using a soft collar and for the past week my aerophagia is pretty much gone.

In addition, I am now able to raise my max pressures to my original prescription values (5-15) with no aerophagia problems, and my average sleeping hr's are within the 60's-70's, which is still slightly higher than my resting HR but much much better now. I've also found that sleeping on my right side works better than my left, which seems to contrast with others dealing with reflux/aerophagia. I still wake up once or twice a night but that's also a big improvement, and generally feel more energized during the day.

I'm always looking to make improvements and adjustments, and I've posted my last night's data with oximetry if anyone has advice. I was a bit concerned about those disturbances between 2-4 am and wonder what those could be in particular.

https://imgur.com/a/mlcfMXH

[jkossis]

That’s awesome that you came across a breakthrough, manacles.

Any chance you could share what collar you used to achieve this relief?

[manacles]

The actual collar I bought from amazon isn't available anymore but it's quite similar to this one:

https://www.amazon.com/Velpeau-Brace-Fo ... B072Q9QG68

I wear it just tight enough to where I can feel it touching the bottom of my throat and it's enough to keep me from swallowing air. I actually wear mine upside down to what's instructed by the manufacturer as I find it conforms with my neck better

There's also a device called the reflux band that is unfortunately no longer sold, but can be pretty simply improvised. I've seen people recommend that for aerophagia as well

[jkossis]

I appreciate you passing along that link, manacles.

I’m probably missing the obvious here, but when you say it is touching the bottom of your throat, is the collar not a uniform tightness across your entire throat? Or should it be looser at the top/tighter at the bottom? I went ahead and purchased the collar! Hoping I can find some relief as well.

All the best,
Jason

[ozij]

Thank you for coming back to update!

Reflux - silent or otherwise - should be treated. It means you upper esophageal sphincter is inflamed by the acid, and not closing properly - you've clearly found a mechanical solution for you nighttime CPAP problem, but that's not enough. Contact your PC doctor about those other symptoms - cough after you eat, soar throat, etc.

I looked at your charts, but couldn't see the what you mean by "disturbances between 02:00 and 04:00.
If you mean the pulse changes, consider the following:
According the chart you posted, you spend at 50% of your time at a pressure of 8 or more. It looks like you have more flow limitations when the pressure drops too low, and concurrently, you have changes in your pulse rate and oxygenation.

Take medical are of your reflux, and try raising your minimum pressure slowly and gradually when that's been taken care of.

[manacles]

Thank you for the advice, I was just at my primary but I think I'll have to call him again. I'll work on gradually increasing pressure as well.

It seems that my aerophagia problems are still resolved for now, but I'm still having other issues, mainly with waking up multiple times a night and getting a strange feeling in my chest, like my heart was beating very fast. I've been wearing an o2ring and it does show some periods of elevated heart rate, though my averages are decently in the 60-70s range. However, I will have moments sometimes where I will wake up feeling very short of breath and be gasping for breath in the morning, I'll feel like I'm not breathing enough air and I have to really breathe very deeply. My mouth will also be hanging open and I'm unable to close it (even though i normally breathe through my nose). I don't know what's causing it and not sure how to address it, considering my SpO2 and AHI values are very good. Does anyone else have similar experiences or advice? Would increasing min pressure be of any help?

https://imgur.com/a/cdQbVEt

[manacles]

I decided to try a 9cm constant pressure as I was concerned that the pressure increases and drops on APAP may have been causing some of my disturbances as well as some of the breathing troubles I've been having at low pressures.It's also possible that at low pressure I may be swallowing air or gasping before the machine can adjust. I've been on it for a week or so and it's felt better than APAP, and while I'd like to increase my pressure gradually I'm still working on aerophagia as below.

I'm still having some aerophagia that mostly just leads to burping, but not bad enough to cause any pain. I've decided to shelve the collar for now, as it was kind of challenging to wear it correctly every night. There was a thin margin for me between putting enough pressure on my throat to stop myself from swallowing air and having it too tight and messing with my airflow. I'm lining up an appointment with a GI doc to help me figure out my situation with possible GERD/LPR but it takes a few months to get a visit. 9.0 seems like a good value to settle on for now until I can figure out how to better deal with my aerophagia. (conventional advice like not eating before bed, left side sleeping, and incline sleeping didn't help)

My main concern now is just trying to figure out why my heart rates fluctuate so much through the night even though SpO2 values are decent. While some of my spikes I've seen on my O2Ring are most likely artifacts, I'll consistently have moments lasting up to an hour where my heart rate is continually elevated. I've attached the last three nights of OSCAR data with the O2Ring oximetry where I've tried to find correlations between the recorded spikes with my flow rates. It looks like the flow does look different when my heart rates are low vs high, but I couldn't identify any consistent patterns. I don't experience anything like this during the day so I feel it does have something to do with my CPAP settings rather than a heart condition but I'm really out of ideas. Would really appreciate any insight, and can provide additional charts or zooms as requested.

https://imgur.com/a/F6e5BBj