Pressure vs Aerophagia (RNeil therapy)

[RNeil]

    Since I got my AHI below 1.0, I have been reluctant to make major changes. But I need to do something about aerophagia. Last night I woke up at 3:30 with stomach discomfort. I did a lot of burping. 

I have EPR set to 3 cmH2O, min pressure 8.2 and max pressure 16.2. Actual pressures were 9.7 med, 11.04 95% and 11.68 99.5%. The maximum looks like 11.92 right before I woke up. Does this mean I need to reduce the maximum from 16.2 to 11 or something? Should the min pressure be closer to the med, like 9.6?

I will attempt to attach my screen shot. 

Thanks for your help.

[Geer1]

Reducing max pressure to 11 would have barely affected your data that night since 95% of the time your pressure was below 11 already. If your average data is similar you would probably have to reduce max pressure to 10 cm or less before you would notice any difference. My gut feel is you would probably have to drop to something like min 7, max 9 before you might see a difference, the main question is if that change would affect treatment of apnea or flow limitations though.

Sometimes EPR can be part of the reason for aerophagia so you could try dropping it to 2 to see if that helps but I expect that would make your flow limitations worse and higher EPR is best for treating those.

[srlevine1]

Just saying anecdotally, my bout with aerophagia seems to have been reduced when I scaled back the time of my last meal and brought my GERD under control with a PPI (Proton Pump Inhibitor). Kept the same pressures 12-15.6 EPR=3.  

[RNeil]

Thanks for the responses. I will reduce the pressure.

I do have GERD. I take pantoprazol and eat dinner 4 hours before bed. I should stop the evening snacks.

[RNeil]

I hope Geer1 will forgive me for not following his advice to the letter. I thought I would phase in the changes. I kept my 8.2 min and reduced the max to 10. It did not seem to help the aerophagia. My AHI increased to 1.31, the worst in 40 days.

Tonight I will use Geer1's recommendation of 7 min and 9 max. I will keep the EPR at 3 and try 2 the next night.

I am still confused. I thought that only the max setting would affect aerophagia. Does the minimum also affect it? I don't know what the ramp pressure is. Mine is set for 8.

Thanks again.
   

[pholynyk]

My impression - and I hope somebody will correct me - is that the average pressure is what affects aerophagia. So the lower your EPAP (without increasing obstructives) and the lower the matching IPAP, the less chance of aerophagia.

So for an Autoset with a minimum pressure of 7 with EPR 3, your lowest EPAP will be 4 (the lowest possible), and the IPAP will be 7. The IPAP may rise, as required, to the maximum pressure you set, and the EPAP will also rise, always 3 lower that the current IPAP.

[Geer1]

Aerophagia can occur at any pressure but higher pressures are more often the issue.

Max pressure can be the culprit but more so in cases that have large pressure swings and extended periods at higher pressure. In this case max pressure is only slightly higher than min pressure so adjusting max pressure alone is less likely to reduce aerophagia so adjustment of both min and max may be required.

The downside is that such adjustments can cause apnea to worsen. Trying to treat both apnea and aerophagia is a game of compromise and you have to try to find the balancing point you find best.

[Gideon]

The intent with aerophagia is to lower pressures and minimize the aerophagia, perhaps going below the optimum therapy settings and hold for a period, then slowly, with fractional increments if possible increase pressures toward the optimized settings eventually getting there. The idea is to give the body time to adjust to each increment on the way back.

[RNeil]

Aerophagia is reduced, but not eliminated. But my sleep is worse. I plan to increase the maximum in 0.2 cm H2O increments and see what happens.

I have attached screenshots of last night and an overview with 13 nights. The overview shows that the last 3 nights with lower pressure resulted in a higher AHI. The reduced EPR (2) in last night had a higher flow limitation, but not compared with the previous night with unchanged (3) EPR. Geer1 suggested reducing EPR to 2, but Pholynyk says I need to reduce average pressure, which I think means a higher EPR. I am confused about EPR.

Thanks for everyone's help. This forum is the best.
   
   

[SarcasticDave94]

How are the other changes progressing? Things like cutting snacks, drinking, meals, several hours before bed, sleeping on your left side, small incline to the head of bed.