New to the forum- questions about aerophagia

[Littledreamer]

Hello,

I am new to this forum after just discovering it this week. I have recently tried nasal pillows (p10) after only using a FFM. It seems I am experiencing aerophagia for the first time while trying the pillows. I really don’t know what to do from here. I don’t want to go back to a FFM at all but this is painful. I use an ASV AirCurve 10, so I really don’t see how I can tweak pressures at all. My EPR is at 5. What am I missing and what can I try, change, etc to alleviate this? Thanks for your help!

[Miss Emerita]

Welcome! I’m not familiar with the ASV machine you use; could you tell me whether it has a setting for mask type? What are your minimum and maximum pressures?

And it would be really great if you could use the Oscar software and share a daily chart. You’d need a laptop or desktop computer, an SD card in your machine, and a way to read the card, e.g., a plug in card reader. What do you think?

Finally, could you let us know why you’re using an ASV machine?

[Pugsy]

ASV machines don't use EPR. They have what is called pressure support that does what EPR does (cause a drop in pressure during exhale) and usually the Pressure support setting has a minimum and maximum....do your settings show a range for PS/pressure support.

EPR comes off your IPAP pressure setting.
Pressure support gets added to your minimum EPAP setting.

So what are all your settings? There's a lot more than just Pressure Support.
Depending on why you are using ASV and what those other settings are and your results at those settings you might be able to tweak the settings a little bit so that you aren't having so much aerophagia.

[Littledreamer]

Thank you both for responding! I had my sleep test three years ago. I failed at CPAP titration and bilevel. My 4th study was with ASV and my AHI was immediately under 2 that night. Baseline Sleep study results were like 6 OA, 5 CA, 1 mixed and 170 hypopneas. AHI was 42 and RAI 0.7. I was told I could not use anything but a FFM (I had crappy care). I ended up quitting because I couldn't tolerate the silicone in my mask. Then recently I discovered I could in fact use a nasal mask and so here I am trying to give it a go again. My OSCAR data seems great. I don't have any events usually at all. It's just been this horrible aerophagia since trying the P10 the last 2 1/2 weeks. I do have more leakage with the pillows in OSCAR. I tried taping but I couldn't tolerate it. I think too many changes at once. I have noticed that after I wake up from sleeping 3-4 hours I have trouble going back to sleep. Sometimes it is pressure which isn't a big deal with the FFM because I can give it a big blow and it backs off. It's hard to do that with the nasal pillows. I am using straight up ASV and there is a setting for min EPAP. So my settings are by the clinical standards- EPAP at 5, PS 5-15. Before I adjusted it, the DME had my EPAP set at 8. Oh, and yes it has settings for what type of mask I use and I did change that when I switched. Hose is also on correct setting. I attached two OSCAR shots. One is with F20 full face mask and other P10 pillows.

[Pugsy]

I attached two OSCAR shots.

Where are the reports?
You will have to host the images elsewhere on the internet.
See this
viewtopic/t183806/Attachment-storage-is ... MENTS.html

Might be able to limit max PS a little bit and still get your centrals taken care of. That's what PS does...goes up real fast if it thinks you aren't breathing because of a central apnea.

Need to see those reports to see just how much PS the machine is giving you.

[Littledreamer]

https://imgur.com/waNNbyH
https://imgur.com/TaZKvLj


Oops! I uploaded them on the site. Let me know if this doesn't work!

[Pugsy]

The correct mask type setting for the P10 is "pillows" and not "nasal". Minor detail but I seriously doubt that is the cause of the problem.

I am scratching my head here because I don't know why using the P10 has seemed to invite the aerophagia monster into your house.

You don't happen to have any of that paperwork about your first sleep study and/or the follow up that earned you the ASV?
Would be nice if we knew what the original problem was in terms of diagnosis and the problem that caused the need for ASV because that would affect what we might reduce to help kick the aerophagia monster to the curb yet still effectively (or maybe very minor compromise) treat whatever problem earned you the ASV.

Pressure support is needed to be fairly big to effectively force you to breathe when you have a central apnea.
I assume that you had some sort of problem with central apneas (and maybe obstructive apneas as well) that caused you to "fail" cpap. Either you had too many centrals at the first sleep study or you developed centrals once you were on cpap that wouldn't go away for some reason.

So.....we really need more details but at this time they might not be easily available and your available options to change are severely limited.
1...you could reduce EPAP to 4 cm (from the 5) but I don't know if that would be all that helpful....but it's a very minor change and sometimes little changes bring big results.
2...you could limit PS max but then we start affecting how well any central apneas are dealt with and you rarely made use of over 10 anyway. I would be real nervous about limiting PS max though. I think to help the aerophagia issues you would need to drop PS below 10 and that makes me nervous about the chance of central apneas not being effectively dealt with.

If it were me and I were in your shoes....I would try Option number 1.

Do you have any history of GERD symptoms or disease? Looking at your reports the nasal pillow report actually seems to show less pressure used overall than you used with the FFM...which makes no sense since it is the pressure that is leaking into the stomach causing the aerophagia issues. I wonder why higher pressures overall doesn't cause a problem and lower pressures overall does.

Wonder if it has to do with taping the mouth shut...do you still get the aerophagia if you don't tape your mouth with the P10?

[Pugsy]

Nearing midnight and past my bedtime. Any further response by me will be tomorrow.

[Littledreamer]

https://i.imgur.com/nMiHvJu.jpg Here's OSCAR with EPAP 6 and pillows from two weeks ago
https://i.imgur.com/f5TPTac.jpg. and one with EPAP 4

I noticed I had setting incorrect and switched to pillows after a couple nights. I also noticed the pressure being lower with the pillows too! You know a lot more than me but I thought it was weird too. I looked through and found one night with the full mask that had something similar but that was it.

YES, I do have my studies printed out. You saw results from baseline study in my first post. I was put through 5 studies in three weeks. CPAP and bilevel created a lot of centrals. My RAI went from 0.7 at baseline to 37.7 with CPAP. When they got me to 15 to stop OAs, I started having centrals and still had hypopneas. They maxed me out at 18. Next study was bilevel which was similar. Conclusion was unsuccessful bilevel titration with pressure of 17/12 due to unresolved sleep disordered breathing- CAs and OAs. Couldn't move to bilevel ST during the night apparently b/c I didn't have a 50% CA and OA ratio. THEN, I had to do a separate study with ST which I essentially failed but the tech kept me two extra hours to "pass" me because he told me there were no other options after ST. The note literally says, patient had severe sleep onset events that would occur post-arousal. This would happen back to back in a seemingly never ending cycle. Tech maxed out machine but pt still had pressure-supported events back to back. Then says successful titration at 25/21 with timed insp of 2.0 and breathing rate of 11. I never saw the doc at this point, only a NP. She basically said at the follow up this was the best we could do and I was sent home with the ST. Then I found apnea board and those good folks said I needed an ASV. So I was finally sent to the doctor after asking for an ASV, who said I had to fail at the ST first for insurance. So I suffered through that for two weeks and then had a study with the ASV which was extremely successful.

I have some mild reflux, lots of allergies and I do have asthma. Those are the only issues to really note, I believe. I use a regular inhaler twice a day for asthma, I've been receiving allergy shots for 4 years and I do have two nasal sprays as well. I hope I answered all of your questions. Thanks so much for helping.

[Pugsy]

Was the aerophagia present after the night with EPAP at 4 cm?

It was late last night and I wasn't thinking totally but there is another option that might help the aerophagia issue and that is reducing PS minimum.
Since PS is added to EPAP that creates a consistent higher baseline IPAP even before PS increases in response to centrals.
Usually it's some form of higher pressure that causes aerophagia and when we can reduce the pressure in some manner (and not negatively impact therapy effectiveness) then there is a chance aerophagia can be reduced.

So maybe reduce PS minimum from 5 to say 3....and leave max PS alone.
Keep EPAP at 4.
This would give you a baseline IPAP of 7 instead of 9 or 10 (depending on the EPAP).

Watch your reports and how you sleep and feel as well. Your body has a say in this as well.

YES, I do have my studies printed out. You saw results from baseline study in my first post.

Maybe I am blind but I just went back to your other posts and I don't see the diagnostic sleep study results anywhere.
But your explanation of the progression to ASV pretty much explains what happened and you aren't alone.
Someone gets diagnosed with plain OSA but when they start cpap treatment emergent centrals muddy up the treatment.
Swapped apnea events and still have a problem and it's called Complex Sleep Apnea which is where people can have a problem with both obstructive apnea events and central apnea events and obstructive vs central require 2 different approaches.
This happens to a fairly small percentage of people put on cpap.

[Julie]

Just wondering if your allergy and asthma meds are having effects on your sleep - they normally tend to interfere and you might want to talk to your MD about them, or even possibly a counteracting one like a small dose of melatonin before bed (couple of hrs before).

[Littledreamer]

That’s a great idea about changing PS min! I will give it a try. Yeah, I still had aerophagia with the EPAP set at 4. What’s weird is I didn’t experience the first two nights when I first tried the pillows. I think the first night my EPAP was still at 8! The P10 are not a good option for me, I tried all the sizes, so I need to figure out what’s next.

My diagnostic study was AHI of 42. RAI of 0.7. I had 1 mixed event, 5 centrals, 6 OAs and 170 hypopneas. 95% of time I think 02 stats were between 90-95%. I’ll have to look when I am home for my info than that.

[ozij]

I ended up quitting because I couldn't tolerate the silicone in my mask.

What do you mean by that? the P10 is also made of silicone.
Do you mean you couldn't stand the sensation of so much silicone on your face? If so, you should try cloth mask liners.

My OSCAR data seems great. I don't have any events usually at all.

That's to be expected with an ASV. You are titrated up to the pressure that keeps you from having obstructive events, and the ASV takes care of hypopneas and central apneas.

[Littledreamer]

I wasn’t very clear about the silicone comment. My face ends up itching a lot with the silicone FFM. I’m fine until I wake up after 3-4 hours.

[Pugsy]

If you end up going back to the full face mask and it causes itching you might consider adding a mask liner to keep a barrier of sorts between your skin and the mask material.
Padacheek makes some really nice ones and special attention to several of the models.
https://www.padacheek.com/

Let's see if reducing minimum PS makes any change in the aerophagia issues.

If you end up trashing the P10 and still want a nasal mask...look at the ResMed AirFit N30 under the nose cushion.
You might like it. Silent like the P10 but of course with the under the nose cushion it might suit you better.
BTW...I think the N30 calls for the "pillows" setting despite it technically being a "nasal" mask.
There's more to the mask setting than just the type of mask but I don't have time to go into the details of the what.
Some behind the scenes stuff is all I have time to offer at this time.