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gettingbetter - Therapy Thread
#1
gettingbetter - Therapy Thread
I've been on CPAP for 5 weeks.  During this time period, I've gotten the AHI down to an acceptable level.  In the initial stages, I had a few days of aerophagia that went away once I started taking Tagamet.  Unfortunately, now the aerophagia is back with a vengeance.  I'm waking up with a belly full of air that is causing heartburn, nausea, and reduced appetite.  I'm also having trouble moving the air through my system when I wake up in the mornings.  I need to at least find a way to make my belly more comfortable because I'm starting to lose weight, which isn't a good thing.  I need help in two areas:
 
1. reducing and/or eliminating the aerophagia
2. ways to move the air out of my system (until I figure out how to eliminate aerophagia).  The full belly (of air) doesn't wake me up, so if I could at least find a way to better move air out of my system in the mornings, this would be helpful.

Here are the things I've tried that haven't helped:
-Simethicone:  initially helped move air through my system but now doesn't seem as effective
-Tagamet or Pepcid 1 hour before bed:  initially helped but now isn't
-raising the head of my adjustable bed
-positional sleeping changes 
-cervical collar
-lowering pressure
-turning on EPR
-tried full face mask, which unfortunately increases AHI with me, so I use nasal mask
-taping mouth/not taping

My doctor prescribed a level of 4 cm in CPAP mode, however, I was waking up gasping for air.  So I switched to APAP mode (auto set for her).  Initially I switched to 6.0 max with EPR of 2.  Last night I went back to CPAP mode with pressure of 5.0 and EPR of 1.  Neither of these pressures helped with the aerophagia.  

I need to continue CPAP but in order to continue, I need to get the aerophagia under control.  I don't understand why it went away, only to come back with a vengeance.  I talked to the doctor about trialing a Bipap.  He said no.  I wondered if the algorithm of bipap might help the aerophagia.  I am beyond frustrated.  My doctor's response was to trial a dental device.  I attached an Oscar report from last night, in case that helps.


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#2
RE: terrible aerophagia - please help
When you tried the FFM did you adjust the mask setting in your autoset?
Do that then post the OSCAR shot with the FFM.

I agree that a BiLevel is not the solution. Until you go over 7 for pressure with EPR=3 BiLevel will not help.
EPR has to help, simply by having a lower average pressure. I'll agree that it is not effective enough.
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#3
RE: terrible aerophagia - please help
(07-31-2021, 10:03 AM)Gideon Wrote: When you tried the FFM did you adjust the mask setting in your autoset?
Do that then post the OSCAR shot with the FFM.

I agree that a BiLevel is not the solution. Until you go over 7 for pressure with EPR=3 BiLevel will not help.
EPR has to help, simply by having a lower average pressure.  I'll agree that it is not effective enough.

Thanks for your reply, Gideon.  Very early in my process I trialed Resmed Aircurve 10 vauto.  I attached an Oscar report from early June when using a FFM with higher IPAP pressure.  Very high AHI resulted.  I had trialed different pressures but couldn't get the AHI down with a ffm.  I quickly abandoned the ffm for a nasal mask, and my AHI went down immediately.  I know that is odd and ayptical.  I tried the ffm again a couple nights ago and had a very high AHI again, but forget to change the machine setting from nasal to ffm.  I actually would rather use a ffm this time of year but never have success with it lowering my ahi.  My doc thinks the pressure from the ffm retracts the lower, which further obstructs the airway.

I'm assuming the aerophagia is not related to wearing a nasal mask for me.?  I just desperately need ways to better manage the aerophagia to be more comfortable.

typo in my last post...I meant to saw "lower jaw"


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#4
RE: terrible aerophagia - please help
The VAuto problem in that shot is all positional apnea, and most likely chin tucking. The common fix for that is a soft cervical collar. There are very very few doctors that feel a cervical collar is any more than a witch doctor wish, but it works.
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#5
RE: terrible aerophagia - please help
Given that flow limit graph and your pressures, (which look a heck of a lot like mine only more so!) you need to seriously consider that you don't actually have "plain old sleep apnea" at all, but instead have something more like UARS. The bad news is that the PAP machine can help but not as much as it helps "plain old sleep apnea", the worse news is that most doctors/RTs don't even know UARS exists and will keep arguing with you that your wonderful AHI proves that your therapy is a smashing success and you should quit yer whining.

First piece of advice -- get your machine out of CPAP mode and into APAP mode. Even if you set both the min and max pressure the same, the machine will collect more data in APAP mode. There are people here who disagree with me, but I also say to set min and max at least a little different, even if it's just 0.2 -- because you can tell that if you are at 5.0 and the pressure stays at 5.0 vs rising to 5.1 then the algorithm is thinking different thoughts. Likewise if you are at 5.2 and falling to 5.1. The algorithms are very sophisticated looking at many things, and sometimes the behavior of the pressures will tell you subtle things.

Aerophagia can come from the pressure of the blowing air overwhelming your esophageal sphincters and pushing the air into your stomach. If pressures in the 4-5 level are enough that they are blowing through those muscles, then you need to be on special alert for all of the long-term damage that can come from GERD. Also it's odd that the gas isn't moving. Having been through things that look like gall bladder disease, the main thing that distinguishes gas from other things is that gas moves. If it's not moving maybe you need to figure out what's going on with your GI tract?

But, anyway, if you set the machine to min pressure of 5.0 and max pressure of 5.2 with an EPR of 1, then your EPAP is going to move between 4.0 and 4.2 and IPAP between 5.0 and 5.2. In other words, half the time your pressure is going to be lower than 5 and putting less pressure on your esophagus than what you are doing now. Especially if the gas was better at 4 than 5.

Next thing is your graphs... First thing to know is that you can drag the bottom of a graph up and down depending upon what the data is that's showing and how useful it is to see how much detail. You've consumed a tremendous amount of screen real estate to show that your pressure is 5, for example. The Events graph can be squished some and still tell you everything that you need to know. All you really need to know about leaks is none vs small vs medium vs large -- squish that and you can still see that. Your Flow Rate graph is so squished on auto-fit that it's really hard to see anything subtle. If you set the y-axis to go between 30 and -30 it will cut off the very tops and bottoms of when you are awake, but that's not the interesting part. It's enough to know that going above 30 or below -30 means you are moving and/or awake, and the exact levels above or below don't really matter.

Ok, the thing that is really sticking out at me from your July 30 graph is between about   2:46-2:54. At ~2:48 there's an arousal, followed by a decay into a lower flow rate, followed by an arousal at 2:52. If you show a zoom in between the two RERAs you will really be able to see it. Technically, the 2 minutes between 2:50-2:52 are probably a hypopnea, but at two minutes long "event" isn't really the right word. (I've got some that go on for 15-20 minutes, and I joke "that's not an event that's a lifestyle" LOL) And you look down to your Flow Limits curve and it's just screaming.


Now compare your June 12 graph. While your July 30 graph screams RERA, your June 12 graph screams chin-tucking positional apnea. (Did you feel like absolute sh** on June 13?!?) You really should have a recording pulse oximeter. (I have a contec 50F and others speak highly of the wellvue ring. I got my contec from walmart online store and their service was great.) Look at your total-time-in-apnea stat -- on June 12 you spent a freaking 25% of your sleep not breathing. Your oxygen must surely have dived! Basically the only way to cure positional apnea is to figure out what it is about your sleeping position is cutting off your airway and then figure out a way to stop it -- no cpap machine, no matter how expensive or sophisticated, can blow through positional apnea. Now July 30 shows no positional apnea -- if you don't KNOW how you fixed it, you need to figure it out. If you do know, just keep doing what you figured out and you won't have to worry about it. And if I'm right about the positional apnea, it's very likely that the biPAP was actually at least partially successful at fixing the flow limits and the positional apnea hid that success.


What I'm seeing in your graphs is like my graphs but even moreso -- that we probably don't have "plain old sleep apnea" at all, we have a combination of UARS and positional apnea. And the first problem is that "sleep medicine" revolves around "plain old sleep apnea" and they keep trying to shove us square pegs into their round hole. You know the old joke about how if the only tool you have is a hammer, every problem looks like a nail?

So we come to the crux of the issue: the only way that you are going to fix the flow limits is some pressure and more importantly some pressure support, and you can't tolerate the pressure that you have because the aerophagia is too severe long before you get to anything like a useful pressure setting for the flow limits. But from your description, this sounds like it might be something more than aerophagia. For most of us, aerophagia is more annoying than painful -- waking up and spending the first 15 minutes of your morning belching and farting. Because for most of us, the gas MOVES, and moves pretty quickly. If your gas isn't moving, then maybe you need a good GI workup to figure out that puzzle?
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#6
RE: terrible aerophagia - please help
cathyf:  Thank you so much for your knowledge and input!  It is greatly appreciated!  I have so much to learn!

When I had my initial At-Home sleep study (WatchPAT ONE) in early June, I had an ODI of 23 with 35 mins below spO2 of 88%.  I bought a Wellvue Ring.  I took a measure in early July which showed an ODI of .8/hr and 4 mins below spO2 of 88%.  So thankfully the oxygenation has greatly improved.  I've tried to import the Wellvue data into Oscar but I've not yet been successful with that (Mac user).

I will try your suggested switch to APAP with your suggested settings and see how it goes.  Hopefully that will help with the aerophagia.  I just had my gallbladder removed and recently had a colonoscopy, so I think the GI tract is okay.  I do have very occasional GERD but was able to quit meds once I cleaned up my diet.  I was not having ANY GI difficulty or GERD until I started CPAP, so I suspect it's the culprit.  If it continues, I will get a GI consult.  Hopefully this aerophagia is just a newbie stage and my body will adjust.

Thanks for guidance on the graphs.  I will make adjustments for future postings.  

I was hoping that my flow limitations were temporarily related to some nasal congestion due to allergies.  If that were the case though, would the flow limit be a more constant value?  Does my wide variance of flow limitations point more towards UARS and eventually needing more pressure, once the aerophagia has cleared?  Are you suggesting that I could benefit from a Bipap?   Is aerophagia ever present because pressures are too low?  Sorry for all the questions!

Thanks again for all of your input!!!
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#7
RE: terrible aerophagia - please help
(07-31-2021, 02:33 PM)cathyf Wrote: Given that flow limit graph and your pressures, (which look a heck of a lot like mine only more so!) you need to seriously consider that you don't actually have "plain old sleep apnea" at all, but instead have something more like UARS. The bad news is that the PAP machine can help but not as much as it helps "plain old sleep apnea", the worse news is that most doctors/RTs don't even know UARS exists and will keep arguing with you that your wonderful AHI proves that your therapy is a smashing success and you should quit yer whining.


Cathy:  In my last post, I didn't phrase one question to you very well.  So here's the question rephrased.   Is it even remotely possible that if someone has UARS, they get aerophagia from too low of a pressure to address flow limitations? 
Thanks
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#8
RE: terrible aerophagia - please help
Quote:Is it even remotely possible that if someone has UARS, they get aerophagia from too low of a pressure to address flow limitations?

I'm not positive -- I tend to find those really low pressures uncomfortable, and I know lots of us do. Maybe your body might be doing something to try to get more air that's actually causing you to swallow air more than you otherwise would?

I will say that I went through a period where I thought I was suffering from aerophagia and I was not really. I would wake up with the typical cpap user's annoying but not really serious problem of belching/farting impressively, but I was also getting attacks of upper-right-quadrant pain. I had all of the symptoms of gall bladder attacks, but all the tests came back negative, and after a couple of years they stopped happening. My gastro's theory was that I might be having plain old muscle spasms in the intestine near the gall bladder, and that maybe the gas going by could be a trigger.

But my gastro also talked about various procedures that we could do if it turned out to be some functional problem with the gall bladder drainage and it got worse. He warned me that there is a surgery that they sometimes do that has a pretty high risk of pancreatitis. You said that you recently had your gall bladder out. Is it possible that what you are experiencing is not aerophagia but  pancreatitis? That would explain why it doesn't move! Or what about costochondritis? (I went off APAP for 3 months after a sleep study and the specialist said that I didn't have apnea any more -- long gruesome story detailed elsewhere. I ended up with costochondritis 2 weeks later. It's a fairly common symptom of arthritis, so it might not have had anything to do with apnea, but maybe it did?)
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#9
RE: terrible aerophagia - please help
(08-01-2021, 12:56 AM)cathyf Wrote: I'm not positive -- I tend to find those really low pressures uncomfortable, and I know lots of us do. Maybe your body might be doing something to try to get more air that's actually causing you to swallow air more than you otherwise would?

I will say that I went through a period where I thought I was suffering from aerophagia and I was not really. I would wake up with the typical 

Thanks for your response, cathyf!  I've had costochondritis before, and this stomach gas seems too low to be costo (I think).  Pancreatitis could certainly be a possibility.  I have a history of IBS, so it could also be that.  At any rate, if it doesn't subside soon, a trip to the doctor is in order.
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#10
RE: terrible aerophagia - please help
I've been studying waveforms on the Apneaboard information link.  Last night I slept with a soft cervical collar and adjustable bed elevated to about 45 degrees (head of bed).  I also lowered my IPAP a bit to 4.8 and kept EPAP at 4 (via EPR).  Aerophagia was slightly better, and the air that is present is moving a little better today.  I will stay at this pressure for a bit until my body gets used to it.

I attached a graph from last night zeroing in on the waveform form.  To me this looks like waveform "class 4"..."peak during the initial phase followed by a plateau"..."initial opening indicates effective upper airway dilation".   I'm trying to understand what this means.  

Can anyone explain what this means in everyday laymen's terms?
Is my waveform okay, or will I eventually need more pressure?
Does anything else noteworthy stand out?

Thanks, in advance, for all replies.  I'm trying to get ideas of how to optimize my therapy after the aerophagia has settled.


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