Aerophagia

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
User avatar
Pugsy
Posts: 63941
Joined: Thu May 14, 2009 9:31 am
Location: Missouri, USA

Re: Aerophagia

Post by Pugsy » Wed Oct 05, 2022 2:17 pm

ejbpesca wrote:
Wed Oct 05, 2022 1:52 pm
What does the 95% on the Dashboard of SleepHQ represent for a pressure score?

95% numbers (either pressure or leak) just means that a person was AT OR BELOW that number for 95% of the night.
The "or below" part of the definition is real important to the overall numbers.
It is NOT an average where a person spends 95% of the night which is what a lot of people think it means.

95% numbers are easily elevated by relatively short periods of time at higher numbers. They are easily skewed.

_________________
Machine: AirCurve™ 10 VAuto BiLevel Machine with HumidAir™ Heated Humidifier
Additional Comments: Mask Bleep Eclipse https://bleepsleep.com/the-eclipse/
I may have to RISE but I refuse to SHINE.

If you want to try the Eclipse mask and want a special promo code to get a little off the price...send me a private message.

User avatar
robysue1
Posts: 897
Joined: Sun Sep 18, 2022 3:39 pm
Location: Buffalo, NY

Re: Aerophagia

Post by robysue1 » Wed Oct 05, 2022 2:42 pm

ejbpesca wrote:
Wed Oct 05, 2022 10:36 am
Here we go. Now I'm taking meds to help sleep, as expected, OA's are up. 18.8 AHI today. I was on a campaign to stop meds, I lost, meds won.
Don't beat yourself up for needing meds to help your sleep and pain: You've got some real significant health issues and there's nothing wrong with needing some medication to help you get the rest you need.
I have no blinking anything that will give an indication of a power outage that could have caused the off/on of my machine.
Does this mean you don't own anything that blinks if the power goes out? Or does it mean that the things that blink when the power goes out are not blinking?

When our power goes out we have blinking things all over the house: The bedroom alarm clock (yes, we still use one), the clock on the stove, the clock on the microwave are all blinking and screaming at us RESET RESET RESET. I seem to be the only member of the house that ever bothers to reset them though.
Yes, there is a possibility that I could have removed the mask then put it back on while asleep. I have sleepwalked, so I could have sleep mask removed then put back on, with no recollection of doing so. Mask off = auto shut down, mask on = auto start.
Since you can't verify or rule out a power failure, it could be that the power failure woke you up and disturbed you enough to keep you from getting soundly back to sleep for 2 hours I suppose.

Please remark on the following:

Reading your questions, should I answer them in a reply or just ask them to myself and ponder the answer?

I raised Min Pressure to 5.6 I am tempted to take it on up to 6.5... More power Scotty.
Given your aerophagia, I'd be really reluctant to make a jump from min pressure = 5.6 to min pressure = 6.5. Particularly since you say this about the acid reflux today:
Waking: No detection of aerophagia, acid symptoms down but rising,
You also write:
My current concept of therapy: (please check for accuracy)
Min pressure is to maintain a steady flow to prevent apneas. If an event occurs during Min pressure, pressure will rise in attempt to prevent more events, but immediate rise in pressure does not jump up fast to stop an event in progress.
While the gist of this is more-or-less correct, there are some misconceptions that we need to clear up.

1) Your machine can and will raise the pressure even if it is detecting no apneas and no hypopneas. Most of the time a Resmed APAP raises the pressure when it detects flow limitations and snoring. These can be precursors to the airway becoming blocked enough to cause a real hypopnea or a real obstructive apnea. So if the machine is not happy with the shape of your inhalations (i.e. it thinks there is a flow limitation), it will increase the pressure. Likewise, if the breathing pattern is characteristic of a snoring breathing. patter, the machine will assume you're snoring and raise the pressure.

2) The machine does not raise the pressure during the middle of an OA in an effort to "stop the event". Even at maximum pressure, our machines can't force an obstructed airway to open up. The machine will likely raise the pressure after the event is over, particularly if there have been two events in a short period of time or if the machine is detecting flow limited breathing patterns or snoring breathing patterns in the aftermath of the event. The idea is that the current pressure is not enough to keep the airway open and stable, but more pressure should help keep the airway open and stable. So by increasing the pressure, the machine hopes to prevent further events from happening. Once the machine is satisfied that your breathing has become steady, good quality sleep breathing and that your upper airway is now stable, the machine will start lowering the pressure back down until it detects flow limitations, snoring, or another event or two happens.

3) CPAP pressure is designed to make it harder for the airway to collapse in the first place. That's how it prevents events from happening. You eventually want your minimum pressure to be high enough to do a decent job of preventing most of your events. Ideally you also want little or no action in the Flow Limitation graph, and for most people that means setting the minimum pressure high enough to smooth out the flow limitations. But, and this is a BIG BUT, some people's airways react to higher pressures by becoming less stable. In other words, for some people, additional pressure never really smooths out the Flow Limitations and the machine can keep on increasing the pressure unnecessarily. And those unnecessary pressure increases do not usually result in better AHI numbers. And sometimes the AHI goes up, even though the pressure is high, specifically because the airway has somehow become unstable as a result of the pressure and that has then triggered really raggedy breathing patterns that the machine interprets as hypopneas and apneas.

With more events pressure keeps rising until it hits Max setting. If Max is not high enough, events will continue to occur until, for some reason, events stop anyway. Is that correct?
Again the gist of this is more-or-less right, but it's more subtle than whether the the max pressure setting high enough allow the machine to keep increasing the pressure until the last of the events stop.

Some people really cannot tolerate high pressures. Pressures over 10cm can sometimes trigger central apneas in some CPAPers. How many? I've seen estimates that maybe 15% of PAPers can have some problems with pressure-induced central apneas. For many of those affected, the problem more or less resolves itself after a while, but a few unlucky ones continue to have real problems with central apneas. Way back when (as in during the era of the Resmed S8 and PR M-Series machines), APAPs could not distinguish OAs from CAs, and the Resmed APAPs were programmed to not increase the pressure for apneas occurring when the pressure got above 10cm specifically because there was a chance those apneas were centrals rather than obstructives. And increasing the pressure in the presence of central apneas can increase the breathing instability and increase the number of centrals that get scored.

As for why the events can just "stop anyway": If a string of real events is triggered by REM sleep or supine sleep, the events will likely stop just as soon as the REM cycle is over or the person turns onto their side or their stomach. Sometimes a nasty cluster of events will just end because the person has finally aroused themselves enough to open the airway and as they go back to sleep, the airway simply remains stable. Sometimes the nasty cluster of events is sleep-wake-junk breathing and the machine is scoring a lot of events that would not actually be scored on a real sleep test because you're not actually fully asleep when they happen, and the cluster of events ends when you finally get into a real, honest sleep state and your breathing simply settles down into a real, steady sleep breathing pattern instead of the ragged SWJ pattern that has some characteristics of wake breathing, some characteristics of sleep breathing, and lots of weird transitions between the two that can make the machine score things as "events" when they're not real.
So the goal is to have a Min pressure setting that prevents apnea all night but does not cause aerophagia.
You don't need the min pressure to be so high that it prevents all the apneas from happening. You do need the minimum pressure to be high enough that the machine is not going to have to "chase" the events. By that I mean, you want the min pressure to be high enough that when events start to happen, the machine doesn't need to increase the pressure by 5 or 6 cm in 10 minutes in an effort to stabilize your airway and keep it open. By setting the min pressure a bit higher, you minimize the chance that a nasty cluster can get started. And you also make it easier for the machine to increase the pressure to an appropriate level to stabilize your airway if/when a small cluster of events occurs, and this can prevent a 3 or 4 event cluster from turning into a 20-30 event cluster.

Now factor in the aerophagia: You also need the minimum pressure to be low enough to not trigger the aerophagia. The more aerophagia you are dealing with, the worse your sleep becomes. The more restless you are because of the aerophagia, the more SWJ breathing creeps into your data. And the more likely you are to have breathing patterns that get (mis)-interpreted as flow limitations, which trigger pressure increases, which trigger more aerophagia and more arousals/mini-wakes and more SWJ breathing, all of which then has the potential to create a situation where a whole string of events gets scored that may not be real events.

So you've got to find a balance between aerophagia and the pressure needed to smooth out your flow limitation curve and prevent most of your events from happening. That means finding the highest Min Pressure setting your stomach can tolerate, particularly with the meds.

And finding the highest level you can set the Min Pressure setting means cautiously increasing your Min Pressure so that your stomach is not inundated with a significant pressure increase all at once.

So go slow. And accept that this is a process. Increase the Min Pressure in steps of 0.2 cm at a time instead of 1cm or more at a time. And after each increase in Min Pressure, leave the setting along for at least 3 days to see if the aerophagia really doesn't happen at that pressure. It if doesn't, then raise the pressure by 0.2 again and repeat.
That Min is now challenged by me resuming medications. Meds, I've taken for 30 years may be a major factor of OA events. I believe OA's are up due to meds resumed.
Why do you think the meds are increasing the OAs? If the meds were increasing the apnea in general, it seems to me we'd see a night-long increase in apneas rather than one bad cluster each night.
I think I could bump up that min to 8 as was the original one pressure setting from my first sleep test and bring AHI down. That may trigger aerophagia, maybe not. The culprit that causes the aerophagia may be the Max setting.
Yes, it could be the culprit that causes the aerophagia is the time you spend at pressures close above 10 or 11 or 12 cm. But you won't be able to tease that out if you keep switching both the Max and Min pressures at the same time. In order to figure out what's driving the aerophagia, you need to only change one variable at a time.

And you have reported that you had bad aerophagia when you had the machine set at 6-11 and no aerophagia at 4-9 and 5-9.

So, yes, you might be able to bump the min pressure up to 8 without triggering the aerophagia. But why risk it?

I'll look at your sleep data later tonight.
Joined as robysue on 9/18/10. Forgot my password & the email I used was on a machine that has long since died & gone to computer heaven.

Correct number of posts is 7250 as robysue + what I have as robysue1

Profile pic: Frozen Niagara Falls

User avatar
ejbpesca
Posts: 214
Joined: Tue Dec 10, 2013 12:09 pm
Location: Alabama

Re: Aerophagia

Post by ejbpesca » Wed Oct 05, 2022 4:35 pm

Does this mean you don't own anything that blinks if the power goes out? Or does it mean that the things that blink when the power goes out are not blinking?
Yes, that means I do not own anything that blinks if the power goes out. When power is out here, everything goes dark, no blinking of anything. Two devices will beep as they come back on but that may not wake me. There is no way for me detect a power outage while asleep, nor detect one has happened upon waking.

I recall VCRs blinking after a power outage, but that was way back.

_________________
MachineMask

User avatar
Pugsy
Posts: 63941
Joined: Thu May 14, 2009 9:31 am
Location: Missouri, USA

Re: Aerophagia

Post by Pugsy » Wed Oct 05, 2022 4:45 pm

consider a power out alarm to figure out if power went out....or mask came off.

https://www.cpap.com/productpage/relian ... m-powerout

_________________
Machine: AirCurve™ 10 VAuto BiLevel Machine with HumidAir™ Heated Humidifier
Additional Comments: Mask Bleep Eclipse https://bleepsleep.com/the-eclipse/
I may have to RISE but I refuse to SHINE.

If you want to try the Eclipse mask and want a special promo code to get a little off the price...send me a private message.

User avatar
robysue1
Posts: 897
Joined: Sun Sep 18, 2022 3:39 pm
Location: Buffalo, NY

Re: Aerophagia

Post by robysue1 » Wed Oct 05, 2022 5:16 pm

ejbpesca wrote:
Wed Oct 05, 2022 4:35 pm
Does this mean you don't own anything that blinks if the power goes out? Or does it mean that the things that blink when the power goes out are not blinking?
Yes, that means I do not own anything that blinks if the power goes out. When power is out here, everything goes dark, no blinking of anything. Two devices will beep as they come back on but that may not wake me. There is no way for me detect a power outage while asleep, nor detect one has happened upon waking.
Do those things that beep eventually quit beeping?

So you don't own a microwave with a clock that blinks after the power comes back on until you reset it?

Your stove's clock doesn't blink after the power comes back on until you reset it?
Joined as robysue on 9/18/10. Forgot my password & the email I used was on a machine that has long since died & gone to computer heaven.

Correct number of posts is 7250 as robysue + what I have as robysue1

Profile pic: Frozen Niagara Falls

User avatar
robysue1
Posts: 897
Joined: Sun Sep 18, 2022 3:39 pm
Location: Buffalo, NY

Re: Aerophagia

Post by robysue1 » Wed Oct 05, 2022 5:44 pm

Robysue's analysis of ejbpesca's data from the night of October 4 (Part 1)

First let's start with a picture of the whole night. Remember, I'm on EDT and you're on CDT. To keep things simple for you just use the time stamps I see in SleepHQ when talking about what I'm seeing in the data. When it's important, I'll include both Alabama time and Eastern time.

Here's an overview of the whole night's data that I've marked up with colored boxes that divide the night into different intervals:
Image

The first thing I want to point out is that in the blue boxes (#2, #4, and #6) represent good quality sleep breathing patterns for the most part. In #2 and #4 the leaks are very much under control. In #6, there is some leaking going on, but the unintentional leak rate is under 5 L/min and there is not much evidence that these leaks are actually disturbing your sleep.

Next, there are two obviously awful periods that I've outlined in red boxes (#3 and #5). Each one of these really bad periods has a rapid increase in pressure at the start of the period, the pressure maxes out during the period and stays at its max setting while the machine is flagging a heck of a lot of things as "OA"s. (More on that in a later post.). It's also worth noting that Flow Limitation graph and the Snore graph have a lot of activity. All of this indicates really ragged breathing. Finally it's also worth noting that while the leaks are almost always below 5 L/min, there's a heck of a lot of activity in that leak graph. As in there is evidence that you may be fiddling with the mask trying to get the leaks to stop. We obviously want to study these two regions of your data carefully in an effort to figure out what might be going on.

Finally I want to point out that there are also two intervals that I've outlined in green boxes (#1 and #7). Each of these intervals starts with significant pressure increase, but the breathing does not deteriorate the way it does in #3 and #5. The pressure spike in #1 is due to the machine detecting flow limitations and snoring just as soon as the ramp period ends. The pressure increase in #7 is caused by flow limitations. In #1, the flow limitations and snoring both end around the time the pressure reaches 8cm and the machine then immediately starts to reduce the pressure back down. In #7, the pressure maxes out at 9 while the flow limitations continue, but they never get as bad as they do in intervals #3 and #5.

Now the questions we need to ask are:
  • What happens near the start of each of the intervals where the pressure increases fairly rapidly?
  • Why does the pressure increase "work" (in the sense of no OAs and no Hs being scored) in the green boxes (#1 and #7)?
  • What goes wrong in the red boxes? Why doesn't the breathing stabilize in the red boxes (#3 and #5)?
  • Is there something more than just a coincidence between the pressure increases and the activity in the leak graph?
For that last question, it's critical to remember that the machine does not increase pressure because it detects a leak. But what we want to tease out is whether the leaks may be triggering enough arousals/mini-wakes where you are fiddling with the mask so that there's lots of SWJ mixed into the data during those intervals in the red boxes.

We'll look at these questions in future posts.
Joined as robysue on 9/18/10. Forgot my password & the email I used was on a machine that has long since died & gone to computer heaven.

Correct number of posts is 7250 as robysue + what I have as robysue1

Profile pic: Frozen Niagara Falls

User avatar
robysue1
Posts: 897
Joined: Sun Sep 18, 2022 3:39 pm
Location: Buffalo, NY

Re: Aerophagia

Post by robysue1 » Wed Oct 05, 2022 6:05 pm

Robysue's analysis of ejbpesca's data from the night of October 4 (Part 2)

We're now going to look at a snippet from one of the blue boxes:
Image

You should notice that the breathing in this window shows all of the breaths looking virtually identical in terms of the shape on the flow graph. The tops of the inhalations are nice and round and that indicates there is no flow limitation. You will also notice there is no activity at all in either the flow limitation graph or the snoring graph.

This is what your breathing looks like when you are soundly asleep and you are sleeping well in terms of the treated OSA.

Whenever your breathing looks like it does in this snippet, there is a very high probability that you are actually sleeping and sleeping soundly.

You'll also notice there's no activity in the leak graph: So there's no leaks to wake you up.

Now let's also look at a snippet from #6 where there are some leaks being recorded:
Image

What I want you to notice here is that the unintentional leaks are pretty constant during this time frame: Throughout the 6 minute window you had a small unintentional leak of 3 L/min. Now from the machine's point of view, that's an insignificant leak: It's nowhere near the Resmed Redline of 24 L/min.

But more importantly: Since your breathing pattern is nice, normal regular sleep breathing, that's an indication that you were sleeping soundly during the time this leak was happening: You're not tugging the mask around and you're not moving around in bed trying to fix the leak---you are sound asleep and the leak is not bothering you.

But keep in mind that just because this leak didn't bother you, that doesn't mean other leaks didn't bother you.
Last edited by robysue1 on Wed Oct 05, 2022 9:08 pm, edited 1 time in total.
Joined as robysue on 9/18/10. Forgot my password & the email I used was on a machine that has long since died & gone to computer heaven.

Correct number of posts is 7250 as robysue + what I have as robysue1

Profile pic: Frozen Niagara Falls

User avatar
robysue1
Posts: 897
Joined: Sun Sep 18, 2022 3:39 pm
Location: Buffalo, NY

Re: Aerophagia

Post by robysue1 » Wed Oct 05, 2022 7:22 pm

Robysue's analysis of ejbpesca's data from the night of October 4 (Part 3)

So now that you have an understanding of what decent, good quality sleep breathing looks like in the flow rate graph, it's time to start looking at the places where there is something actually going on in your data.

In this post, we're going to look at what happens in the green boxes of the overnight view of your data. Those are places where the pressure increases, but you don't wind up having a huge hoard of OAs scored.

Here is the first pressure increase of the night:
Image

This pressure increase happens very near the beginning of the night. To the left of the pressure increase, you are still in the ramp period. The red box contains the pressure increase itself. Note that there's a lot going on in that box: There's a possible arousal, there are flow limitations being scored, there snoring being scored, and there's a much larger, more noticeable leak than your very low background unintentional leak that doesn't seem to be bothering you.

At this scale, it's also clear that by the time the pressure reaches 8cm, your breathing stabilizes into nice, regular sleep breathing. But it's not yet completely clear what the sequence of events during that pressure increase might be. So let's zoom in on just the one-minute period right during which the pressure is actually increased from 5cm to 8 cm:
Image

During the ramp period, the machine is apparently programmed to not record flow limitations and it does not increase the pressure any faster than the ramp is increasing it even if there are flow limited breathing patterns in the flow rate graph and snoring is being detected and recorded in the snore graph.

But the instant the ramp finishes, the machine detects/records and responds to the flow limited breathing and the snoring by increasing the pressure. The pressure increase may (or may not) trigger an increase in the leaks. And it looks (to me) like the increased leak possibly triggers an arousal or a mini-wake where you wake up just enough to fix the leak. Once the leak is fixed and the pressure is around 8cm, your breathing returns to normal sleep breathing and the machine stops increasing the pressure.

In other words, this pressure increase stabilized your upper airway and improved the shapes of your inhalations. You may have had a very brief wake in the middle of the pressure increase when the leak got bigger, but you were able to fix the leak and hence your brain was able to immediately return sleep.

Another pressure increase that happens near the end of the night in the box that I labeled as #7 in my first post also doesn't disturb your sleep. Here's the pressure increase from box #7 in my first post:
Image

This pressure increase is a lot less "busy" than the first one we looked at in this post: The only reason the pressure is increased is the machine is detecting some flow limitations. These flow limitations are milder than the ones in the earlier snippet and at this zooming level they basically look close to normal sleep breathing. (It can be very hard to figure out why one stretch of breathing is considered a mild flow limitation and another is not.) Notably this 2cm increase over a 2 minute window does not trigger any additional leaks. It also doesn't improve the flow limitations all that much if you look at the flow limitation graph. But the pressure is capped at 9cm and so it is not allowed to go any higher in an effort to smooth out the last bit of flow limitation.

Now a good question to consider is this: Would your sleep in this part of the night have really been any better if the had been able to increase the pressure further? No one can answer that definitively, but I would hazard a guess that the answer is, "No, your sleep would not have been any better if the pressure had gone up to 10 or 11cm in an effort to smooth out the last of the flow limitations."

A final comment: Basically these snippets show how a major part of the APAP algorithm is supposed to work: The machine detects flow limitations that show the airway may be compromised and may be in danger of collapsing. So it increases the pressure and the airway stabilizes and thus becomes much less likely to collapse. And because your airway stabilizes, no apneas or hypopneas occur during the time you are asleep.
Last edited by robysue1 on Wed Oct 05, 2022 11:20 pm, edited 2 times in total.
Joined as robysue on 9/18/10. Forgot my password & the email I used was on a machine that has long since died & gone to computer heaven.

Correct number of posts is 7250 as robysue + what I have as robysue1

Profile pic: Frozen Niagara Falls

lynninnj
Posts: 1267
Joined: Mon Jul 25, 2022 8:56 am

Re: Aerophagia

Post by lynninnj » Wed Oct 05, 2022 8:40 pm

All I can say is: Robysue- WOW! that was amazing.

Appreciate the explainer.

_________________
Machine: AirSense 11 Autoset
Mask: ResMed AirFit N30 Nasal CPAP Mask with Headgear
Additional Comments: Newbie who loves her machine!
Beware the schoolyard bullies, mean girls, and fragile male egos. Move along if you can’t be kind.

User avatar
robysue1
Posts: 897
Joined: Sun Sep 18, 2022 3:39 pm
Location: Buffalo, NY

Re: Aerophagia

Post by robysue1 » Wed Oct 05, 2022 8:50 pm

Robysue's analysis of ejbpesca's data from the night of October 4 (Part 4)

Now we're finally going to look at the stuff you're most worried about: Those two awful clusters where the machine is scoring OAs seemingly right on top of each other. I've put this off until last because I've wanted you to have a good sense of what sleep breathing should look like so that you understand why the breathing patterns in those nasty clusters look so weird.

Here is a shot that shows the whole of the first cluster, but since the first cluster goes on for 80 minutes it's hard to see much detail:
Image
But even at this level, you should be able to see that there's a weird, somewhat repetitive breathing pattern going on: An apnea gets scored, there's a few large recovery breaths, the breathing shallows out and then the next OA is scored. Over and over for 80 minutes.

And 80 minutes is far too long to assume that this is a REM episode. Maybe you flipped on your back? But then the question is: On your diagnostic sleep study, was your AHI substantially higher on your back than in other positions? I don't know.

So let's also notice a few more things in this image: There's a lot of activity in the leak graph, the snore graph, and the flow limitation graph. Clearly all that activity in the snore graph and the flow limitation graph as well as all the OAs is making the machine want to increase the pressure further, but it can't because you've got Max Pressure set to 9cm. But an important question that has to be asked is: Why doesn't the breathing improve even marginally?

There's no way to definitively answer that question. But we can start trying to at least partially answer the question by looking much more closely at what's going on in that cluster.

Let's start by zooming in on the very beginning of the cluster:
Image
Before this cluster starts, it appears you may have had some kind of an arousal. There was then some kind of new or bigger leak that may have caused you to arouse/wake even more in an effort to stop the leak. Then there's an OA scored where the leak drops down to a pretty insignificant level. As soon as the apnea is over, the leak rate goes back up. And then there's another apnea, and the leak rate goes down. And the pattern seems to repeat: I've stepped through the whole of the 80 minute episode and this pattern is almost always present between the apneas that are scored very close to each other. The hypopneas, on the other hand, look more "real" in that they seem to be preceded by a few "sleep breathing" inhalations with a low leak rate followed by the characteristic decrease in flow rate (and often an increase in flow limitation). But the hypopneas and the OAs that are far enough out to have some "sleep breathing" inhalations between them combined with a low leak rate are far fewer than OAs with a flat leak rate followed by a few inhalations with a larger leak rate and the next OA with the pattern repeating for several OAs in a row.

Now there's no good reason to suspect that a leak is going to fix itself during an apnea that just happens to occur right after the leak starts, and then the leak reappears when the apnea is over. So what else might be going on?

Well here's one hypothesis: You're not actually asleep during all those apneas. It's just possible that you're lying in bed fighting with the leak and every time you think you have the leak fixed and start to relax back into sleep, the leak starts up again and you start fiddling with the leak. Of course this doesn't explain why the machine is scoring an OA when the leak is "fixed". But here's something for you to think about: When we are awake (or sort of awake) and we're concentrating on something (like fixing a pesky leak), we sometimes have a tendency to unconsciously hold our breath for a few seconds. And we hold our breath long enough, the machine will score it as an apnea. And if we close our epiglottis while we're holding our breath trying to fix that pesky leak, the FOT algorithm may very well decide our airway is blocked (because the epiglottis is, in fact, blocking our airway.

And this raises the question that Pugsy raised several pages back: Are these long episodes occurring during real sleep? or are they occurring in SWJ episodes?

Now you have mentioned leaks bothering you in previous posts. So it's also important to ask: How bad did the leaks subjectively feel on this night? And did you think you were fighting to get the leaks under control for a lengthy period of time during the night?

Because if these OAs are occurring in extended SWJ episodes, the fix is to figure out how to reduce the SWJ. And if you are aware of lengthy periods where you feel like you are fighting leaks, then I think figuring out how to refit the mask quickly in the middle of the night when you spring a leak will go a long way towards reducing these kinds of clusters.


But if my hypothesis is wrong and if these events really are occurring in real sleep, the questions become:

Would a higher minimum pressure help? Before this cluster starts, you are at your minimum pressure of 5 cm. After the first OA is scored, the machine increases the pressure to 8cm, but the breathing does not stabilize and the machine scores a second OA. The machine increases the pressure again, this time to 9cm, but the breathing still does not stabilize and we're off to the races with the events coming fast and furious for the next 80 minutes. It's possible that if the pressure had been higher at the start of the cluster, maybe the breathing would have stabilized after the first pressure increase. Or it's possible that if the pressure had not been allowed to drop all the way to 5cm, the first event might never have happened.

Would a higher maximum pressure help? It's possible that even if your minimum pressure were higher than 5cm that you'd still have a cluster that gets started and needs more pressure to stabilize the airway.

Is the problem that your airway simply is not responding to the increased pressure as the machine expects? There are times when a person's airway can become unstable when too much pressure is applied. In other words, it's also possible that regardless of why the cluster starts, the extended time at your maximum pressure is simply not stabilizing your airway and hence not stabilizing your breathing. This itself can result in additional arousals, and then that brings us back to SWJ---how many of the events are "real" and how many are artifacts of SWJ breathing being mis-scored by your machine as sleep disordered breathing events, which by definition, can only occur during sleep.

Finally, I've stepped through this whole 80 minute long cluster with a 3 or 4 minute window so that I can see the breath pattern quite clearly. And it seems to me that a lot of these OAs might be caused by breath holding while you are in a mini-wake trying to fix a leak. And a bunch more of these events might be normal sleep-transition central apneas/hypopneas mis-scored as OAs. (These would not be scored on a sleep test because it's normal to have a CA while transitioning to sleep.) And some of these events are likely real---i.e. they occurred while you were actually asleep.
Last edited by robysue1 on Wed Oct 05, 2022 11:24 pm, edited 1 time in total.
Joined as robysue on 9/18/10. Forgot my password & the email I used was on a machine that has long since died & gone to computer heaven.

Correct number of posts is 7250 as robysue + what I have as robysue1

Profile pic: Frozen Niagara Falls

User avatar
robysue1
Posts: 897
Joined: Sun Sep 18, 2022 3:39 pm
Location: Buffalo, NY

Re: Aerophagia

Post by robysue1 » Wed Oct 05, 2022 10:46 pm

Robysue's analysis of ejbpesca's data from the night of October 4 (Part 5)

We're now going to look at the second bad cluster of events..

Here's the overview of the whole Bad Cluster #2:
Image

Even at this level of zooming we can tell that there are two distinctly different looking halves to this cluster: The stuff to the left of the first blue line looks quite different from the stuff to the right of the second blue line. The stuff between the two lines is a transition area from the first "half" of the cluster to the second "half" of the cluster.

To the left of the first blue line, there are lots of OAs being scored and once again it appears that the activity in the leak graph corresponds to the periods between the apneas. (Rather like what was going on in the first cluster that we examined in the last post.) It's also worth noting that there is very little activity in the flow limitation and snore graphs.

To the right of the second blue line, the events thin out---i.e. they become further apart. And we see hypopneas being scored instead of OAs. Moreover, there is less activity in the leak graph. And there's a whole lot of activity in the flow limitation graph, indicating the machine is detecting patterns that it believes indicate pretty the airway may be in danger of collapsing. The snore graph is also busy during this part of the cluster.

Finally, it's worth pointing out that at the end of this cluster, there is another area where the breathing pattern changes and the leaks get worse. It looks to me like this might be another area of SWJ breathing, probably triggered by fighting with leaks again.

This is what the beginning of Bad Cluster #2 looks like:
Image
Notice we have the same kind of beginning that the first cluster had: There's a probable arousal and a large leak that happens just before the first OA is scored. And for the first several OAs in the cluster we have the same pattern that the leaks are worse between the apneas and magically get better during the apneas. Once again, I think you are actually awake during these events and unconsciously holding your breath while concentrating on fixing the leak. And you think you've got it fixed, you quit holding your breath and just as you're starting to doze off, the leak starts back up again. That pattern continues all the way to the place I marked with the first blue line in the overview of the cluster.

And notably this time your pressure was already close to 7cm at the beginning of the cluster. (There were flow limitations in that sleep breathing period that were causing the machine to increase the pressure just before the big leak & arousal happen.) So after the first OA ends, the machine increases the pressure almost to your max, and the max is reached after the second OA is scored. But again, the breathing does not stabilize at all. My hypothesis is, again, that this part of the cluster is most likely SWJ (or mostly W) where you are fighting to get the leak to stop.

But if we look at what happens in the transition part of this cluster---the stuff between and just outside my two blue lines, we see this:
Image
The size of the leaks is less than it was and it looks (to me) like you are just about ready to fall back asleep. But you've got one more time when the leak seems to trigger an arousal before you really get back to sleep. Those OAs in the green circle might be SWJ. Or they could be sleep transition CAs mis-scored as OAs. But the breathing in the red circle, even though its ragged, looks more like sleep breathing that is showing evidence of sleep disordered breathing---i.e. those hypopneas look more real than any of the apneas in this cluster do.

And if we look at some of the events that are well to the right of the second blue line that I drew in the overview image, we see this:
Image
I believe the three events in this snippet of data are very likely two real hypopneas followed by a real OA. Notice that the breathing between the events, even though it has a lot of flow limitations, still looks more or less regular. And we can see a few almost normal sleep breathing inhalations mixed into the flow limitation breathing. There also don't seem to be any arousals that precede these events.

So the upshot of this is that you very likely do have some real events mixed into these dense clusters. But it seems unlikely that all of the events scored during these periods are real. The question really is: How much SWJ is there during your worst clusters?

More pressure is not going to fix SWJ events because these event are not "real" sleep disordered breathing events; rather SWJ events are typically either wake breathing (which is less regular than sleep breathing) or transition to sleep/wake events (which are normal and are not scored on a sleep test.) And under some circumstances, more pressure can create increase SWJ periods and that can cause more SWJ events to be scored.

Add your aerophagia to this, and there's a good reason to be cautious about increasing your pressures in the hopes of breaking up these clusters of events that may very well be SWJ events instead of real events.
Joined as robysue on 9/18/10. Forgot my password & the email I used was on a machine that has long since died & gone to computer heaven.

Correct number of posts is 7250 as robysue + what I have as robysue1

Profile pic: Frozen Niagara Falls

User avatar
ozij
Posts: 10120
Joined: Fri Mar 18, 2005 11:52 pm

Re: Aerophagia

Post by ozij » Thu Oct 06, 2022 3:14 am

robysue1 wrote:
Wed Oct 05, 2022 8:50 pm
But if my hypothesis is wrong and if these events really are occurring in real sleep, the questions become:

Would a higher minimum pressure help? Before this cluster starts, you are at your minimum pressure of 5 cm. After the first OA is scored, the machine increases the pressure to 8cm, but the breathing does not stabilize and the machine scores a second OA. The machine increases the pressure again, this time to 9cm, but the breathing still does not stabilize and we're off to the races with the events coming fast and furious for the next 80 minutes. It's possible that if the pressure had been higher at the start of the cluster, maybe the breathing would have stabilized after the first pressure increase. Or it's possible that if the pressure had not been allowed to drop all the way to 5cm, the first event might never have happened.
I think we have a number of nights with clusters, and they look pressure related to me, not necessarily SWJ.
Oct. 1
https://sleephq.com/public/f701bfbc-31f ... 4c6b842017
The cluster here come with flow limitations and snores - and starts at a pressure of about 5.2
Not at all leak related.

Sept 29: you can see the flow getting worse as the pressure drops.
https://sleephq.com/public/d4940f98-0dd ... 2649e6ebf5

Another cluster, not related to leaks but related to lower pressure happens on Oct.3 -- accompanied again by flow limitations and snores.
https://sleephq.com/public/27b528a0-648 ... 1a4b332af7

Acciording to your results, AHI dropped, and aerophagia returned when your raised both min and max , min to 6 max to 11
And then your response, ejbpesca, was to drop both min and max -- and AHI mounted, and clusters returned.

I don't follow your logic, ejbpesca - why did you raise the max, and then when aerophagia returned, why did you not bring it down to 10?

If I understand correctly, a max of 10 did not give you aerophagia, a max of 11 did.
My suggestion is based on that understanding,
If those were my results, (and I'm repeating my suggestion from before)
I'd leave the max at 10.
Put the min at 6
Try that for few nights, unless aerophagia returns.
And if that happens, the only thing I'd do is drop the min gradually to where you have no aerophagia, see what happens to your sleep and AHI, and proceed based on the results.
I would also make sure that the ramp, if I need it, would not be lower than my minimum pressure.

Most of your clusters, when they happen, have snores, flow limitations and apnea - all indicating a collapsing airway, and that has to be prevented otherwise, as robysue said,"were off to the races"... and I will add: it's a race we lose.

_________________
Mask: AirFit™ P10 Nasal Pillow CPAP Mask with Headgear
Additional Comments: Machine: Resmed AirSense10 for Her with Climateline heated hose ; alternating masks.
And now here is my secret, a very simple secret; it is only with the heart that one can see rightly, what is essential is invisible to the eye.
Antoine de Saint-Exupery

Good advice is compromised by missing data
Forum member Dog Slobber Nov. 2023

User avatar
Rubicon
Posts: 1678
Joined: Sun Feb 20, 2022 6:59 am

Re: Aerophagia

Post by Rubicon » Thu Oct 06, 2022 3:26 am

IYAM, there's no question that most of those events are real.

That said, DWing might not be the best approach, nor would shooting the Therapy Cannon (cervical collar and/or BiPAP).

That said2, a downloadable oximeter would be a good way to confirm the hypothesis. SWJ-related stuff has hyperventilation-associated events that wouldn't (shouldn't?) desaturate.

Also a specific list of all medications and when tooken (if that's not a word, it should be). Drug name and dose ("nerve-pain med" doesn't help. If you're loading up on Oxy before bedtime that's gonna be an issue). Consider spreadsheet to monitor everything.

If you have
Cognitive function impaired
from taking all those pharmaceuticals then ooops gotta go...
Freeze this moment a little bit longer.
Make each sensation a little bit stronger.
Experience slips away.

User avatar
ozij
Posts: 10120
Joined: Fri Mar 18, 2005 11:52 pm

Re: Aerophagia

Post by ozij » Thu Oct 06, 2022 4:46 am

Rubicon,
Years ago (many years ago....) you had a "not so good" opinion of pulse oxymeters. Would you say nowadays that any of those OSCAR works with can be useful? Is there one (or more?) that you consider worth buying?
Rubicon wrote:
Thu Oct 06, 2022 3:26 am
DWing might not be the best approach,
Would you agree that since the OP was about to give up on entirely, because of major aerophagia and reflux, some reduction in his pressure was worth trying?

Oh... and question three:
That pattern of "no leak when an apnea happens" which robysue poitned at - can we trust it? I mean, could be be at artifact to the machines ability to register event? And if we can trust it, do you have an idea what it means?

_________________
Mask: AirFit™ P10 Nasal Pillow CPAP Mask with Headgear
Additional Comments: Machine: Resmed AirSense10 for Her with Climateline heated hose ; alternating masks.
And now here is my secret, a very simple secret; it is only with the heart that one can see rightly, what is essential is invisible to the eye.
Antoine de Saint-Exupery

Good advice is compromised by missing data
Forum member Dog Slobber Nov. 2023

User avatar
Rubicon
Posts: 1678
Joined: Sun Feb 20, 2022 6:59 am

Re: Aerophagia

Post by Rubicon » Thu Oct 06, 2022 5:28 am

ozij wrote:
Thu Oct 06, 2022 4:46 am
Years ago (many years ago....) you had a "not so good" opinion of pulse oxymeters. Would you say nowadays that any of those OSCAR works with can be useful? Is there one (or more?) that you consider worth buying?
Yeah, I think there was a discussion about sampling rate resulting in very coarse signals. Currently, I don't know what is "good" or "not so good" out there so I have no opinion.
Would you agree that since the OP was about to give up on entirely, because of major aerophagia and reflux, some reduction in his pressure was worth trying?
Desensitization is always a valuable tool. Clearly a lot better than quitting.
That pattern of "no leak when an apnea happens" which robysue poitned at - can we trust it? I mean, could be be at artifact to the machines ability to register event? And if we can trust it, do you have an idea what it means?
Lotta references about leaks on this page (72 AAMOF) but if you're referencing this one:

Image

IMO those are SWJ leaks (patient moves, leak sneaks out); overall there are no leaks that would affect machine performance in the data provided; if one is asleep and leaks are <24 L/M who cares; and machines are pretty good about compensating for leaks so while they can be concerning IMO one shouldn't necessarily become obsessed with getting a -0- leak line (i.e., cost vs benefit).
Freeze this moment a little bit longer.
Make each sensation a little bit stronger.
Experience slips away.