Switch from CPAP to APAP for aerophagia?

Hi all! I've already learned so much lurking here since I was diagnosed. I've finished my first week of CPAP and I've managed to sleep the first 2.5-4.5 hours each night with the machine. I've had some minor problems with the mask feeling prickly & itchy as the night goes on, and developing minor leaks (I've ordered a Padacheek liner), but the biggest hurdle is aerophagia, and it only seems to be getting worse.

At first, the ticklish sensation of air trickling down to my stomach woke me up each time, so I would wiggle around until I burped it up. Lots of sleep disruption, but no pain. Now I sleep through it, and don't wake up until my stomach is so full that it's painful and nauseating. (Last night it took five minutes of epic belches like rolling thunder to clear enough air out of my stomach that I could lie down again.)

I tried the falcon position and that did help, but I've never been a stomach sleeper befor, and it leaves my neck sore and stiff. Maybe yoga will get me there eventually, but it will be a long term process.

Right now I'm on straight CPAP at 10 cm. I'm very nervous about adjusting the pressure (and nervous about asking my doctor to do it), so I would love it if you guys could do some hand-holding here and walk me through the pros and cons.

My diagnosed AHI was 21.5, and I have reason to believe that's a worst-case scenario. My husband reports that I snore loudly from 3:00-7:00 AM nearly every night, but what happens in the first four hours is highly variable. Some nights I start sawing logs the second my head hits the pillow, while other nights there's only minor disturbances till 3:00. Colds & allergies makes a difference, and position of course (back is worst, but I do snore some on my sides), and PMS (I retain a TON of water during that one week each month, and I think all my soft tissues swell up a bit).

Just by coincidence, my sleep study happened to be scheduled on the day before my period, when I was recovering from a cold, and I didn't stop myself from back sleeping because I wanted them to see the whole picture.

So far, my AHI with the 10 cm has never been higher than 0.47, and several nights it's been zero. (Of course, I haven't managed to wear it yet during my zone of worst snoring.) Under these circumstances, does trying an APAP range like 6-10 or 7-10 seem like a reasonable experiment? Is there anything else you'd need to know before advising? Thanks!

I'd try the APAP 6-11 and see what happens. I know your AHI has been good with the setting of 10, but hopefully giving the machine some flexibility, you'll be able to wear it during the snoring episodes, too. It won't go up to 11 if it doesn't need to. What are you using for EPR settings?

I think people usually go from APAP to CPAP to limit how high the pressure goes to reduce aerophagia. I think I would try just reducing the pressure and/or an increase in EPR if that's an option.

Morchella wrote:Of course, I haven't managed to wear it yet during my zone of worst snoring.)

Which means your not being treated and we don't know what pressure is needed. By lowering the pressure, you may have to trade some AHI for a reduction in aeropagia which is a con, I suppose, of reducing the pressure. But some treatment is better than none.

You may find some benefit in a soft cervical collar to help keep your airway straighter and I found that a nasal mask produced less aeropahagia for me.

If you only need higher pressure a portion of the night, then going to APAP might work, we really need to see some SleepyHead charts to know what going on for sure.

I think your goal should be to sleep through the night under treatment, even if that means a substantial reduction in pressure and an increase in AHI temporarily.

Another overwhelming reason for APAP machines, no matter what.
Too many providers/suppliers "forget" that only APAPS are able to be run BOTH WAYS.
Single pressure can work for many, but if it doesn't, the patient is screwed.
It infuriates me that so many suppliers ASSume the only setting for apap is wide open (4-20).

Morchella wrote:Hi all! I've already learned so much lurking here since I was diagnosed. I've finished my first week of CPAP and I've managed to sleep the first 2.5-4.5 hours each night with the machine. I've had some minor problems with the mask feeling prickly & itchy as the night goes on, and developing minor leaks (I've ordered a Padacheek liner), but the biggest hurdle is aerophagia, and it only seems to be getting worse.

At first, the ticklish sensation of air trickling down to my stomach woke me up each time, so I would wiggle around until I burped it up. Lots of sleep disruption, but no pain. Now I sleep through it, and don't wake up until my stomach is so full that it's painful and nauseating. (Last night it took five minutes of epic belches like rolling thunder to clear enough air out of my stomach that I could lie down again.)

I tried the falcon position and that did help, but I've never been a stomach sleeper befor, and it leaves my neck sore and stiff. Maybe yoga will get me there eventually, but it will be a long term process.

Right now I'm on straight CPAP at 10 cm. I'm very nervous about adjusting the pressure (and nervous about asking my doctor to do it), so I would love it if you guys could do some hand-holding here and walk me through the pros and cons.

My diagnosed AHI was 21.5, and I have reason to believe that's a worst-case scenario. My husband reports that I snore loudly from 3:00-7:00 AM nearly every night, but what happens in the first four hours is highly variable. Some nights I start sawing logs the second my head hits the pillow, while other nights there's only minor disturbances till 3:00. Colds & allergies makes a difference, and position of course (back is worst, but I do snore some on my sides), and PMS (I retain a TON of water during that one week each month, and I think all my soft tissues swell up a bit).

Just by coincidence, my sleep study happened to be scheduled on the day before my period, when I was recovering from a cold, and I didn't stop myself from back sleeping because I wanted them to see the whole picture.

So far, my AHI with the 10 cm has never been higher than 0.47, and several nights it's been zero. (Of course, I haven't managed to wear it yet during my zone of worst snoring.) Under these circumstances, does trying an APAP range like 6-10 or 7-10 seem like a reasonable experiment? Is there anything else you'd need to know before advising? Thanks!

Are you monitoring your therapy with software......like Sleepyhead?

If you have lots of Flow Limitations or Snores (which it sounds like you do), that's going to drive your pressures up.
Are you using EPR? If so, what setting and have you tried turning it off?

With that AHI, it sounds like your therapy is doing pretty good, with the exception of the aerophagia.
Chances are, if you used a range with 10 being the top pressure, it would keep going up to 10 and staying there all night anyway.

You can always TRY those ranges to satisfy your curiosity. It's YOUR therapy.

Over the years, this subject has come up often and there is no definitive answer.......it depends on the individual user.
Sometimes straight pressure works, sometimes ranges work, sometimes just turning off EPR or whatever exhale relief the machine has, eating schedules, and any number of other things.


Den

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Morchella,

I think your plan is sound.

When I was a newbie 5.5 years ago, I was started off on a Resmed S9 APAP set in CPAP mode at 9cm (with EPR = 3). The stomach problems started almost immediately and I have particularly bad memories of waking up one morning from a dream where I was a goose being force fed for fois gras, and I had a rock hard, swollen belly. By the end of two weeks, my husband insisted calling the sleep doc's office, and I had the first of many "semi-emergency squeeze you in appointments" with a PA. And the first thing she did was switch me to APAP (wide open) to see if I'd been over titrated at the titration study. A week later she was looking at the data, and suggesting a (slight) lowering of pressure. Since I'd had a fewer problems with aerophagia on APAP, I was able to talk her into leaving me on APAP with a pressure range of 4-8cm. It helped some with the aerophagia, but since I continued to have problems with it, the PA eventually recommended a switch to BiPAP, and helped even more.

In your case, I'd suggest starting with an APAP range of 6-10, or even 6-9. And if you are not using EPR, I'd suggest turning EPR on as well. If the aerophagia continues to be as painful as you describe after you switch to APAP, you really should contact the sleep doc's office and let them know that the pain is severe enough to keep you from getting back to sleep after you wake up and that you have had to resort to sleeping without the mask after waking up in agony from the stomach pain.

In case it turns up anything interesting, here is a SleepyHead read-out from a couple nights ago. (I picked this one because it has one apnea and one snore -- most of the other nights are really boring.)



The EPR is currently set to 1 cm. I see people have posted recommendations to turn it off, and to increase it. Can someone go into more detail about why either strategy might affect the air swallowing?

Thank you all for the advice so far!

Morchella wrote:In case it turns up anything interesting, here is a SleepyHead read-out from a couple nights ago. (I picked this one because it has one apnea and one snore -- most of the other nights are really boring.)

The EPR is currently set to 1 cm. I see people have posted recommendations to turn it off, and to increase it. Can someone go into more detail about why either strategy might affect the air swallowing?

Thank you all for the advice so far!

Not really. But it's just another one of the "tweaks" that some have found over the years that CAN affect (help) aerophagia.
Keep in mind that in some cases, aerophagia can have a link to GERD or a weak LES. So, whatever may affect swallowing air may be connected to any of those things.


Den

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Morchella wrote:In case it turns up anything interesting, here is a SleepyHead read-out from a couple nights ago. (I picked this one because it has one apnea and one snore -- most of the other nights are really boring.)

If this is a non-boring night, then there are people here who would kill for your data. Of course, they might reconsider when they realize it comes with dealing with your aerophagia.

The EPR is currently set to 1 cm. I see people have posted recommendations to turn it off, and to increase it. Can someone go into more detail about why either strategy might affect the air swallowing?

Dealing with aerophagia is a lot like dealing with nasal congestion: What works for one person doesn't work for another. And what works for one person might actually make another person's aerophagia worse rather than better.

So with regards to EPR: Some people find they swallow more air if there is any change in the pressure at all. So turning EPR off helps. Other people find they swallow more air if they are having even the smallest problems exhaling against the pressure. So turning EPR up as far as possible helps.

Lots of other "tips" for aerophagia that can go both ways:

Some people find sleeping on their backs help. Others find sleeping on their backs makes the aerophagia worse.

Some people say they have fewer problems if they keep their chin far away from the chest and the neck as straight as possible. For me? That position definitely causes me to swallow more air.

Some people find out that their aerophagia is minimized if they do a lot of things that are suggested for dealing with GERD: Raise the head of the bed. Sleep on an inclined wedge. Don't eat too close to supper. Others? These tips make little or no difference.

For me, the biggest thing that influences the amount of aerophagia I get is restlessness: The more I wake up for any reason, the more likely I am to get aerophagia. Which in turn causes more arousals/wakes and even more aerophagia. It can be a really bad feedback loop once it gets started. So for me, it's important to try to minimize the number of things that cause me to wake up in the first place.

robysue wrote: So with regards to EPR: Some people find they swallow more air if there is any change in the pressure at all. So turning EPR off helps. Other people find they swallow more air if they are having even the smallest problems exhaling against the pressure. So turning EPR up as far as possible helps.

Lots of other "tips" for aerophagia that can go both ways...

Oh joy... more experimentation. Backstory: I was diagnosed last year with a rare and bizarre allergy that took months of experimentation and data collection on my part before I could even get referred to the right specialist. But at least I have the skills now to do the same thing with my sleep. I cannot tell you how excited I was when I saw all the data that I could access through Sleepyhead. Copious data! On the most mysterious part of daily life!

Have set the machine to Auto, 6-10, and I'm leaving the EPR at 1 for now.

I personally think turning up the EPR will give you a better chance to exhale and minimize aerophagia. I would try 6-11 with EPR 3. I don't know why you're so set on maxing it at 10 when you're not even wearing the CPAP during your snoring periods.

I just prefer to change one variable at a time when I'm trouble-shooting anything. But I will definitely try your additional suggestions if this first change doesn't get me to where I want to be!

Well, night one on APAP was an improvement, but not a home run. Slept for 4.5 hours. I have worn the mask for 4.5 hours before, but there was a lot of awake time in that; this was the first time that it was mostly sleep. (I do remember changing position 3-4 times.) When I woke up I was uncomfortably full, but it wasn't overtly painful and there wasn't any burping. I got up to rinse a bunch of drool out of my mask and then was too awake to get back to sleep.



I feel like for the sake of thoroughness I should give this a couple more nights, but the temptation to tweak another variable is strong...

Morchella wrote:Well, night one on APAP was an improvement, but not a home run. Slept for 4.5 hours. I have worn the mask for 4.5 hours before, but there was a lot of awake time in that; this was the first time that it was mostly sleep.

That's great progress and the data looks exceptionally good.

I feel like for the sake of thoroughness I should give this a couple more nights, but the temptation to tweak another variable is strong...

I'd give it a couple more nights before changing any of the settings.
Out of curiosity, what variable are you wanting to tweak next?

Last night I slept over 7 hours without taking off the mask! Just had a few burps worth of air when I woke up. It was the cervical collar that made the difference!

On the second night of adjustable pressure, my pressure was around 7 most of the night and only jumped to 10 once, yet the aerophagia was worse, so clearly pressure wasn't the whole story.

What seemed to be different was that the more relaxed I got, the more time I spent in my favorite sleeping position (curled into a little ball) and the more my jaw fell open. So I tried a cervical collar and BOOM! Success. I even slept on my back for a while, which has been impossible so far. Somehow the collar even stopped the mask fit problems that I was having on my back.

An all that with an AHI of 0.17.

So now that I've got that worked out... when do I start feeling more like a superhero and less like a zombie?