Aerophagia is going to make me quit...

I am glad to be here at the forum and appreciate all of the good information.

I will try and get to the point, but also be complete.

Over the years, my sleep quality deteriorated, with multiple awakenings and non-refreshing sleep. As a family doc, I considered sleep apnea, but I am not an overweight guy, and have a giant mouth, so didn't think it was likely. My wife started to observe me having apneas, and I was tired of waking up, not being able to go back to sleep and feeling crappy in the morning. I also had increasing headaches.

Sleep study was done at home with an AHI of 12, so not real severe, but it was quite severe when I was on my back. So I got my CPAP and ran with it. I quickly got used to the mask, it really did not bother me. My mouth usually falls open in sleep, so a full face mask seemed to be the ticket. Resmed Airsense V10 was given to me with settings of 5 cm and 11 cm. I quickly started to sleep through the night, and I felt better to some degree. Interestingly, my headache pattern has improved. It takes less migraine medication to take it away, and there has been a reduction in frequency and duration. It is not perfect, but I see improvement already after a couple of weeks, so I am happy about all that.

The main problem is that I am having a terrible time with aerophagia. Air gets into my gut and I wake up in pain, impressive flatulence, and after 2-3 hours I am finally feeling better. My sleep apnea doc has been great to work with, and we reduced the pressure. It became more mild, but still is severe enough that I didn't see myself continuing with CPAP unless something changed. I powered through it as I really think it is beneficial. My sleep doc suggested a change to Bipap, so I got the Bipap version of the Resmed machine (Aircurve V10 Auto) and used settings of 5 and 10 cm H20. I believe that thing was created by the demons of the underworld to torture me. I had the worst pain ever.

Interestingly, the app showed my AHI went through the roof with Bipap. With the CPAP, I had AHI that was consistently less than 5. Bipap gave me an AHI as high as 23. Doc was not convinced it was a pressure problem as most of my apneas were central. I finally found out about OSCAR and can see what they mean. So not only did Bipap make my aeorphagia worse, it worsened my apnea. I don't have the OSCAR data for the old machine, but the Resmed app said my AHI was less than 5.

Here is what else I have done:
I elevated the head of the bed 4 inches, not sure it has helped.
I use a chin strap and even tape my lips shut. That helped a little. I think I get plenty of air through my nose
I tried a nasal pillow mask and couldn't wear it for more than 10 minutes without feeling like I was suffocating, which I don't completely understand. I am going to try that again and see if I can tolerate that.
My sleep doc changed the Bipap to what he called 'almost like CPAP mode' with settings of just 3 cm and 7 cm H20 VPAP-S. My AHI immediately is back to less than 5, I slept all night again too. The apneas I do have are back to being obstructive.

Reading OSCAR, it looks like my machine just held tight at 7cm all night long last night. I am not sure what I was doing at 130-230, but I had nearly all of my apneas at that time, with AHI of 24, but I was just 4.4 for the night. I went as long as 40 seconds of apnea. Was I on my back? I mention this because I wonder if I gasp at that time and suck air into my esophagus then. Today I woke up with a lot of stomach pain and air like I usually do.

I really like the treatment so far, and want to continue. But I need help solving the Aerophagia, or it is going to be off to the ENT for surgery or dentist for an oral appliance.

Tallredrider wrote: ↑

Sat May 08, 2021 12:41 pm

it looks like my machine just held tight at 7cm all night long last night

Tallredrider wrote: ↑

Sat May 08, 2021 12:41 pm

My sleep doc changed the Bipap to what he called 'almost like CPAP mode' with settings of just 3 cm and 7 cm H20 VPAP-S.

These settings in S mode are going to be fixed all night. S mode can't vary at all so you have 7 cm on inhale and 3 on exhale all night long.
So we don't expect the machine to move off 7 cm...it can't.

I don't see an image of your detailed report but it does sound like you are having some obstructive clusters happening.
Might be related to being on your back and might be related to REM stage sleep which can also worsen OSA.

We don't want to go crazy with more pressure to deal with the obstructive stuff because more pressure is very likely going to make the aerophagia issues worse...and we can't get more crazy with added pressure support because it sounds like you are one of the people who get central apneas from pressure support (PS is just the difference between inhale and exhale so when you were using 5 exhale and 10 inhale your PS was 5. Sometimes PS of 5 just triggers centrals....so now the PS is reduced and the centrals have reduced.

I have a friend who gets about 18 centrals per hour with PS of 4 but rarely any centrals at all with PS of 3. Go figure that one but sometimes a small change in something ends up causing a big result.

Usually for obstructive stuff (OA/hyponea) we suggest more pressure. In your situation with history of centrals and aerophagia we are usually more conservative in our ideas. In your situation I would go small and just increase EPAP from 3 to 4 and leave everything else the same and see if that reduces the clustering you are seeing.

Thank you for the response.

And I forgot to ask if there is a way for me to hack the machine and change the settings myself? I hate to bother the doc with multiple small changes, but I guess that is why he gets the big bucks.

I will do an overnight oximetry or even an entire sleep study once I think I have it dialed in, so it isn't a case of me not being invested in solving the problem.

Yes...changing the settings is easy. Just a matter of knowing the secret handshake or combination of button pushing to get you into the clinical setup menu area.

This manual is for the AirSense model and you now have the AirCurve but the secret handshake is the same for both models.

https://www.respshop.com/manuals/ResMed ... %20her.pdf

page 14 explains how to access the setup menu area. That secret handshake...

Pugsy wrote: ↑

Sat May 08, 2021 1:41 pm

Yes...changing the settings is easy. Just a matter of knowing the secret handshake or combination of button pushing to get you into the clinical setup menu area.

This manual is for the AirSense model and you now have the AirCurve but the secret handshake is the same for both models.

https://www.respshop.com/manuals/ResMed ... %20her.pdf

page 14 explains how to access the setup menu area. That secret handshake...

You mean that I should read the manual? Uggggh, I really thought it was some secret thing only the sleep doc could do. Thank you!

Between that and the data from OSCAR, I have a lot to play with. It looks like it has a CPAP mode also, if I want to go back to that.

Isn't S mode supposed to lower the pressure in between breaths? OSCAR shows a constant pressure of 7 cm, without any variation.

Tallredrider wrote: ↑

Sat May 08, 2021 4:17 pm

Isn't S mode supposed to lower the pressure in between breaths? OSCAR shows a constant pressure of 7 cm, without any variation.

Are you sure it is showing 7 without variation down to 3??? The 3 cm pressure line might not be easily seen but it should be there.
How about a screen shot of what you are seeing?
viewtopic/t158560/How-to-post-images-for-review.html

CPAP mode is limited to EPR (backwards PS) of 3....S mode lets you have more than 3 pressure support and normally that comes in very handy when people are having aerophagia issues.

But yes cpap mode is very similar to S mode except for that difference in PS availability.

And yes...might be a good idea to read the manual and learn about what the machines do...but I did make it easier for you in that I told you the page number for the secret handshake.

I am familiar with both the machine you are currently using (I use it myself) as well as the AirSense 10 models.
You have a sweet little machine there. Too bad we have the aerophagia monster mucking things up as well as potentially having PS itself being a problem but that's something that could maybe be dealt with later. Maybe 5 cm causes a lot of centrals and 4 cm won't...we don't know yet.

For OAs though...your EPAP setting is going to be your most critical setting to tweak.

Let's see if this works. Looks like the machine is stuck on 7 cm all the time.

Here I have selected the worst hour of sleep. Lots of obstructive apneas going on here. You can see from the summary at the top that I had very few apneas the rest of the night.

There are other interesting tidbits that couldn't all fit on one screen, like between apneas, it looks like I took very deep and quick breaths. My Tidal volume increased substantially and so did flow rate. Am I gulping air into my stomach during those times?

It's not "stuck" on 7 the entire time. EPAP is 3 cm which is the bottom line and this is what you see when using S mode.......I think anyway.
Let me go do a little experiment with my machine and see if mine shows the same sort of pressure graph.
I think if we zoomed in on masked pressure graph it should more clearly show 7 inhale and 3 exhale.
I think the reason it looks like only one pressure is because the EPAP pressure line is overlaying the axis bottom line of the pressure graph.
EPAP at 3 cm is as low as the machine will go...it's 3 cm in S mode and 4 cm in the VAuto mode...and if in cpap mode it would be 4 cm .

The statistics show 7 inhale and 3 exhale with PS of 4 but it's just not easily seen on the pressure graph.
The pressure is going to be constant though.....constantly 7 inhale and 4 exhale.

pugsy?

before i start running my yap about something (yeah, i know, big change! ), is the resmed vauto similar to the apap in that the pressures can be raised/lowered by .2 increments?

my thought is if so, then the op can make changes by those .2 increments, as i did on apap, and not feel the blast of aerophagia so much.

or is that not how one deals with it on a vauto?

Note the area that I circled.
My EPAP is 4 so the pressure line is super imposed over the 4 baseline.
My IPAP is 8 because PS is 4. It looks fixed because it is but I did have the drop to 4 with each breath.
Stayed fixed probably until I fell asleep and the airway started to try to collapse so then the machine went to work increasing the pressure as it sensed the need.
Yours is doing the same thing but with inhale 7 and exhale 3 and the 3 part is simply hidden all night because it is super imposed over the baseline pressure line.

Now your cluster...might have been when you were on your back. Might also be REM related as that big cluster corresponds with just about when we would expect the first REM stage to happen after sleep onset. Heck, might be a combination of REM and supine sleeping.

Usually we would just say "go to auto mode and let the machine increase the pressure and sort it all out" but more pressure for you very well could open the door for the aerophagia monster to sneak in.

So we have to maybe try some other way to better prevent that cluster (or at least make it a smaller cluster) no matter what the cause.
Usually more baseline pressure is the first thing to try when we can't really just go to auto mode and open it up and let the machine just figure it out.

Now if we knew what the trigger for the aerophagia was...we could maybe use a tight range in auto mode. Like if IPAP at 10 cm triggered the aerophagia then we might try a range to maybe 9 cm and let the machine try to sort it out.
It's hard to know at what pressure the aerophagia is triggered...could be EPAP that is also the trigger.

Just a suggestion on the aerophagia issue. Experiment a bit and see if your sleep position makes any difference. I can tell a difference from side to side, and even whether my shoulder is rolled all the way forward or if my arm is resting on my side, opening my chest area. May not resolve the problem but mitigating the symptoms enough to avoid misery would be a win. My aerophagia was horrible for a while, but this thread has made me realize it hasn't been a problem for a very long time. Maybe the fact that I can sleep only on my right side due to pain issues has had a fringe benefit. Good luck with things.

Yes the machine is adjustable in 0.2 increments. @zonker

Last night I dropped it from 7 cm to 6 cm and today woke up with no pain, Yayyyy!

My AHI was nearly identical to the previous night, however. It is not quite enough to call it a trend, but the last 2 nights my apneas went from nothing to severe exactly 2.5 hours after falling asleep. It seems I should have entered REM sleep prior to that. My AHI was over 30 during the next 90 minutes on both nights. And 90 minutes seems like a long time for a REM stage to last. Then my events go back to nothing the rest of the night.

Would I be too weird if I rigged up a camera to document my position during the night? Together with the machine and OSCAR data, it starts to put together a poor man's sleep study, if you will.

Tallredrider wrote: ↑

Sun May 09, 2021 10:11 am

Would I be too weird if I rigged up a camera to document my position during the night?

Not weird at all. Lots of people on the forum have done it. If it helps you answer questions and helps you figure out how to best deal with your problem....win win.

Normally REM stage sleep begins approx 90 minutes after sleep onset and the first REM stage is usually fairly brief and as the night progresses REM will come on and last longer with the greatest amount of REM occurring in the wee hours of the night right before we normally wake up.
So if you see only one ugly cluster during the night then I would be more apt to think supine sleeping is the culprit because chances are you would have more than 1 REM stage during the night. REM clusters tend to go along with normal REM cycles. You can google Sleep Stages and look at the normal hypnograms to get an idea as to when REM normally occurs. I am very familiar with REM worse OSA myself. Documented 5 time worse in REM with my OSA....and in my case supine sleeping really doesn't change things all that much but some people will have substantial worsening with supine position and maybe no real change during REM.

Sometimes when aerophagia is a big problem people have to make compromises in therapy just so they aren't totally miserable or ill from the aerophagia.....meaning maybe allow a cluster of ugly events here and there because to increase the pressure to deal with things causes a worse problem.

Sometimes they just let the ugly clusters happen for now and maybe revisit more pressure at a later time in hopes that whatever was causing the extreme aerophagia issues as abated and is no longer causing problems.

We have to get the sleep first and then we also have to try to have getting that sleep not cause other problems. Most people won't have a problem but occasionally a few people have some extra challenges they have to sort through.

Tallredrider wrote: ↑

Sun May 09, 2021 10:11 am

Yes the machine is adjustable in 0.2 increments. @zonker

good.

i found that when i went through my own profound aerophagia is that the .2 increments were the key. i went back to the settings that worked without the pain, no aerophagia at all. then i increased the lower(minimum) pressure by .2. if that didn't work, i backed off. then on again. then off.

once i got used to that minimum with no aerophagia, i started all over again and raised by .2, off and on. and again. and so on.

this literally took me weeks, but i managed to train my body to get used to the pressure with no aerophagia. today, i can happily sleep at a minimum pressure of 18 and a mx of 20.

have no idea if this will work for you. just saying this mainly as encouragement.

good luck!

Last night was a good night, and didn't have a lot of events, but the events I had were all in 2 separate clusters. Camera captured me lying flat on my back, chin up when the cluster of apneas happened. So it appears positional. I previously learned that I can increase the settings to overcome the apnea, but that results in bad air in the stomach. I will work on gradually increasing the pressure, seeing if I can find a happy medium that solves the apnea, but doesn't quite make me swallow air.

I have seen several threads on how to prevent back sleeping. Frankly, I like sleeping on my back, but it looks like I have to pick my poison.