Aerophagia Help Needed: BiPAP at Very High Pressure (24 I / 17 E)

[kinganimal223]

Hi and thanks for taking the time to read this:

I started BiPAP therapy about 3 weeks ago - here is the rundown:

- ResMed AirCurve 10 S/T machine
- BiLevel S/T Pap Mode
- 24.0 IPAP
- 17.0 EPAP
- Currently using ResMed f40 hybrid nasal mask (I have also used ResMed AirFit P10 nasal pillows w/kinesiology mouth tape, and Fisher and Paykel Simplus full face mask)

I cannot go an hour or more using my machine without experiencing uncomfortable and painful aerophagia symptoms that cause me to stop using BiPAP therapy for the night. These symptoms include bloating, stomach pain, farting, burping, and sometimes diarrhea.

The aerophagia has occurred with all 3 masks I have used, and symptoms start about 45 minutes to an hour after I start using my machine.

There are nights / days when the aerophagia symptoms are so bad, that my sleep is totally ruined (even when I try to get back to sleep without using my BiPAP) and the following day I spend the entire morning trying to get rid of the pain and bloating in my stomach.

I have tried nearly every aerophagia remedy suggested on Apnea Board, YouTube, and elsewhere - raise the head of the bed, chinstrap, mouth tape, wedge pillow, no eating before bed, soft cervical collar, side sleeping, taking Gas X or Pesto Bismol before bed, etc. - and nothing has helped.

The only 3 possible remedies available to me that I have yet to try are -

1) V-COM
2) A standard 22m /19m heated hose (I currently use 15m slimline)
3) Lowering the pressure settings

In general, my sleep when using BiPAP therapy is very minimal or nonexistent. I know I have fallen asleep during BiPAP therapy because I remember dreaming several times, but I am certain that I have only been asleep for a few minutes at a time. Every time I wake up, it is because of aerophagia symptoms. Even when I lay in bed and cannot fall asleep, after 45 minutes to an hour, I start getting aerophagia symptoms, so they are not just present after I wake up.

My mouth is always shut prior to falling asleep, and I can hear and feel the gurgling / rumbling in my stomach - the point being is that I don't consciously open my mouth and swallow air when I am awake that could be leading to aerophagia problems.

I have attached several OSCAR charts. I tried to focus in on the hypopnea and unclassified apnea events on the Flow Rate chart. Unfortunately, the Flow Limitations chart is not available for me to display.

I honestly do not know how to read the OSCAR results, but as I understand it, my hypopnea and unclassified apnea events are very few in number and within the normal limit.

I would like some help to interpret the results to try and determine what I could be doing when I am asleep that could be leading to all of my issues with aerophagia. Or perhaps there is some other root cause (ie my IPAP pressure is too high and needs to be lowered).

Can anyone please help me to try and diagnose the cause of my aerophagia and how to fix it? I am very frustrated and upset that aerophagia keeps occurring and prevents me from being successful with BiPAP therapy.

Any help or advice that can be offered would be greatly appreciated. Thank you!

[Pugsy]

What was your original diagnosis that earned you the ST machine?

How did they come up with the 24/17 pressure settings? Did you have a titration sleep study (using the machine) to determine optimal pressures?

They pressure is the culprit for the aerophagia problem.....I have my doubts as to whether anything other than lowering the pressures is going to reduce the aerophagia problem but you are of course welcome to try.

[kinganimal223]

Thanks for the reply and interest in my situation.

I have attached the Polysomnography Titration Report that was provided after my sleep lab test, and what resulted in the 24 cmH2O IPAP / 17 cmH2O EPAP.

From everything I've seen and read, I agree with you that my pressure settings are too high and the cause of my aerophagia.

However, I do not know how to self-titrate and adjust my pressure settings - should I decrease by 1 cmH2O to begin with? Or 2 cmH2O or 3 cmH2O?

Any advice would be greatly appreciated - I really don't know where to start with fixing this, but I know I cannot live with the aerophagia anymore, even if it means less effective therapy (at least initially).

[kinganimal223]

Sorry I forgot to add my original diagnosis was severe OSA.

[Pugsy]

Okay....so you had a small handful of central apneas and a truckload of obstructive apneas and they decided to nuke the OAs with ST mode and high pressures and force you to breathe every breath at a god awful high pressure and it's blowing you up like a puffer fish.

A better choice for a machine would have been the ASV model. IMHO It is designed to deal with both the obstructive stuff and when a central crops up it will force you to breathe but only if you need it.

I doubt that you need 24 inhale and 17 exhale to deal with the OAs.

Anyone who knows me knows that I am not a fan of ST mode machines unless someone has central apnea only. It does a great job for someone with central apnea. Sucky therapy for someone with mainly obstructive apnea....and the higher pressures are a recipe for disastrous aerophagia issues.

We have to find pressure settings that won't feed the aerophagia monster and can still deal with the OAs and cross our fingers the centrals stay in low numbers.
You really, really need to be alerting your sleep doctor to the aerophagia problem.

The graph showing pressures tried and AHI results don't help and to me they don't make a lot of sense so I have no idea what to try in a DIY self titration.
How about S mode try????
I have no idea where your aerophagia threshold is so I will throw out something to try just to see if it causes the aerophagia problems and not worry so much about the therapy results at this time
S mode
EPAP 10
IPAP 13
It's a lower fixed pressure and will be gentler....see if it helps or not.

Do you know how to changes the settings yourself???

[robysue1]

As someone who fought the aerophagaia monster for months (at even low pressures) when I was first starting out, I want to second everything that Pugsy has said.

It's critically important for you to report (and keep reporting) the aerophagia problem to the sleep doc. Don't let them brush it off as "you just have to get used to it." When you are waking up with severe bloating before you even complete a full sleep cycle, that really does destroy any chance of getting any meaningful sleep for the night.

Like Pugsy, I question the need for you being on an ST machine at such high pressures. Now, it is possible that you really do need a significant amount of pressure to prevent the obstructive stuff, but, like Pugsy, I just don't think the number of CAs on your titration study was enough to justify putting you on an ST machine---the "T" part of the ST mode along with the very high pressures is likely aggravating the aerophagia---when you don't inhale "in time", the machine decides to force a whole lot more air down your throat in an effort to "trigger" an inhalation, and my guess is that you're swallowing all that extra air. (It's worth remembering that for many people who do have some treatment emergent centrals, the problem resolves itself after a few weeks or months without the need to put the patient on an ST machine in ST mode.)

Personally I think Pugsy's suggestions of using S mode at IPAP 13, EPAP = 10 for a week or two is great place to start. And during that time frame, I'd be more interested in seeing if that helps minimize the aerophagia and I wouldn't worry a whole lot (immediately) about the treated AHI at the start of the experiment.

The idea is to find out three things:

1) Does significantly lower pressure eliminate or at least minimize the aerophagia?
2) Do central apneas start appearing in large enough numbers during the time you are likely asleep to warrant changing back to ST mode?
3) Just how many obstructive events wind up occuring during the time you are likely asleep?

If using lower pressure fixes the aerophagia problem, that should help you sleep better with the machine. And once you are actually sleeping with the machine, it will be time to reevaluate whether IPAP = 13, EPAP = 10 is enough pressure to treat the OSA stuff as well as reevaluating whether its (unfortunately) high enough to trigger a boatload of CAs when you are asleep.

If using lower pressure does fix the aerophagia problem, but too many obstructive events continue to occur but you're not seeing a lot of centrals, that may mean you should push for a VAuto instead of the much more expensive ASV machine. If you see both too many obstructive events and too many centrals when using S mode at IPAP = 13, EPAP = 10, then it's time to push for an ASV machine.

[Pugsy]

Unfortunate the damn ST machine can't/won't tell us if someone is having a central apnea or obstructive apnea.
Not in any mode. Both those go into the UA or unknown/unclassified apnea basket. There is no FOT available on the ST (or even ASV) models.

[robysue1]

Unfortunate the damn ST machine can't/won't tell us if someone is having a central apnea or obstructive apnea.
Not in any mode. Both those go into the UA or unknown/unclassified apnea basket. There is no FOT available on the ST (or even ASV) models.

Thanks for reminding me of that fact.

I really think this poster would have been better off being given an AutoSet or a VAuto machine. The number of those centrals was just not that high and they may very well have resolved after a few weeks of CPAP/APAP/VAuto therapy.

[Pugsy]

Unfortunate the damn ST machine can't/won't tell us if someone is having a central apnea or obstructive apnea.
Not in any mode. Both those go into the UA or unknown/unclassified apnea basket. There is no FOT available on the ST (or even ASV) models.

Thanks for reminding me of that fact.

I really think this poster would have been better off being given an AutoSet or a VAuto machine. The number of those centrals was just not that high and they may very well have resolved after a few weeks of CPAP/APAP/VAuto therapy.

I couldn't tell if those centrals were from starting cpap or if they were part of original diagnosis.
At any rate even if they were occurring pre cpap they might have resolved or lessened even with plain old fix cpap.
Miracles do happen....I have seen a couple of times where I thought that no way in hell would cpap fix it....but it did.

Like you I would have thought starting with conventional models to start with would have been a better option....but no one asked us.

My first thought though.....try to fix the aerophagia problem if at all possible because if it isn't fixed the machine is going to end up in the closet. May have to consider some compromising but the aerophagia monster has to be evicted.

If we see a truckload of UAs with lower pressures....cross that bridge when we come to it....and cuss ResMed all the way for not including FOT in the models designed specifically for central or complex apnea.

[robysue1]

My first thought though.....try to fix the aerophagia problem if at all possible because if it isn't fixed the machine is going to end up in the closet. May have to consider some compromising but the aerophagia monster has to be evicted.

My thoughts exactly: Painful aerophagia of the sort that the OP describes makes it nearly impossible to stick with treatment specifically because it makes you so miserable you can't sleep, as I know all too well from my own early days.

If we see a truckload of UAs with lower pressures....cross that bridge when we come to it....and cuss ResMed all the way for not including FOT in the models designed specifically for central or complex apnea.

Yep to both points. You'd think that Resmed would not have been so stupid as to omit the FOT on models designed specifically to treat central and complex sleep apnea since those are the folks who really need to know whether the apneas that are still occurring with a clear air or obstructed airway.