Aerophagia Help Needed: BiPAP at Very High Pressure (24 I / 17 E)

[kinganimal223]

Hi and thanks for taking the time to read this:

I started BiPAP therapy about 3 weeks ago - here is the rundown:

- ResMed AirCurve 10 S/T machine
- BiLevel S/T Pap Mode
- 24.0 IPAP
- 17.0 EPAP
- Currently using ResMed f40 hybrid nasal mask (I have also used ResMed AirFit P10 nasal pillows w/kinesiology mouth tape, and Fisher and Paykel Simplus full face mask) 
 
I cannot go an hour or more using my machine without experiencing uncomfortable and painful aerophagia symptoms that cause me to stop using BiPAP therapy for the night. These symptoms include bloating, stomach pain, farting, burping, and sometimes diarrhea.

The aerophagia has occurred with all 3 masks I have used, and symptoms start about 45 minutes to an hour after I start using my machine.

There are nights / days when the aerophagia symptoms are so bad, that my sleep is totally ruined (even when I try to get back to sleep without using my BiPAP) and the following day I spend the entire morning trying to get rid of the pain and bloating in my stomach.

I have tried nearly every aerophagia remedy suggested on Apnea Board, YouTube, and elsewhere - raise the head of the bed, chinstrap, mouth tape, wedge pillow, no eating before bed, soft cervical collar, side sleeping, taking Gas X or Pesto Bismol before bed, etc. - and nothing has helped.

The only 3 possible remedies available to me that I have yet to try are -

1) V-COM
2) A standard 22m /19m heated hose (I currently use 15m slimline)
3) Lowering the pressure settings

In general, my sleep when using BiPAP therapy is very minimal or nonexistent. I know I have fallen asleep during BiPAP therapy because I remember dreaming several times, but I am certain that I have only been asleep for a few minutes at a time. Every time I wake up, it is because of aerophagia symptoms. Even when I lay in bed and cannot fall asleep, after 45 minutes to an hour, I start getting aerophagia symptoms, so they are not just present after I wake up.

My mouth is always shut prior to falling asleep, and I can hear and feel the gurgling / rumbling in my stomach - the point being is that I don't consciously open my mouth and swallow air when I am awake that could be leading to aerophagia problems.

I have attached several OSCAR charts. I tried to focus in on the hypopnea and unclassified apnea events on the Flow Rate chart. Unfortunately, the Flow Limitations chart is not available for me to display.

I honestly do not know how to read the OSCAR results, but as I understand it, my hypopnea and unclassified apnea events are very few in number and within the normal limit.

I would like some help to interpret the results to try and determine what I could be doing when I am asleep that could be leading to all of my issues with aerophagia. Or perhaps there is some other root cause (ie my IPAP pressure is too high and needs to be lowered).

Can anyone please help me to try and diagnose the cause of my aerophagia and how to fix it? I am very frustrated and upset that aerophagia keeps occurring and prevents me from being successful with BiPAP therapy.

Any help or advice that can be offered would be greatly appreciated. Thank you!

[kinganimal223]

I took a couple of OSCAR screenshots that show a zoomed out Flow Rate chart for 4/7 and 4/1, to show the activity around the couple of apnea events. The previous screenshots were hyper-zoomed to show each individual event.

[jdougc]

Sorry you are having issues.
A few full night charts would be helpful.
Your settings are very, very high.

[kinganimal223]

Yes, I agree, I think my IPAP and EPAP settings are very, very high. I am very suspicious of the titration I had done at the sleep lab in late January that resulted in those settings. I see the sleep disorder specialist on Thursday and am going to address this with him.

Would it be at all helpful if I were to post the Poysomnography Report from my sleep lab titration that led to the 24.0 IPAP / 17.0 EPAP settings?

I have attached the whole night OSCAR charts from 4/7, 4/1, and 3/28 below.

[jdougc]

It would be at all helpful if you were to post the Poysomnography Report from my sleep lab titration

[kinganimal223]

The Polysomnography Report from the titration that I had done in the sleep lab that resulted in the 24.0 IPAP / 17.0 EPAP BiPAP pressure settings is attached below.

[Sleepster]

Lower the pressure, even if it compromises your therapy. Therapy at too low a pressure is better than no therapy at all, or even painful therapy.

Hopefully, as you adapt the aerophagia will subside, but you will never adapt if you don't use the machine.

And keep your pressure support high.

[kinganimal223]

What lowered pressure settings should I try? A reduction of 1 cmH2O? 2 cmH2O? 3 cmH2O? I'm unsure how to self-titrate.

What is pressure support? Is this a specific setting on the AirCurve 10?

If anyone could please give me some guidance on this I would greatly appreciate it because I really don't know how to go about this. Thanks.

[Sleepster]

What lowered pressure settings should I try? A reduction of 1 cmH2O? 2 cmH2O? 3 cmH2O? I'm unsure how to self-titrate.

Well, this is hard to answer because it depends on how your body responds. I would say try lowering both the IPAP and the EPAP by 3 cm. Try that for at least 2-3 nights and see if it helps the aerophagia. If not, reduce them each by at least 1 cm and again leave those settings there for 2-3 days, hoping for relief. Keep going until the aerophagia becomes at least tolerable. Monitor your AHI. If the obstructive apnea (OA) index or hypopnea (H) index is too high, and you are getting at least some relief from the aerophagia, try raising the the IPAP and EPAP by at least 1 cm and hope that the aerophagia doesn't get worse. If it does, lower them back down again. Insufficient treatment is better than no treatment.

If you have an elevated central apnea (CA) index, also called the clear-airway apnea index, let us know. The solution for that is to lower either the pressures or the pressure support (PS), but seeing your OSCAR charts may help us make an informed guess. Often we just have to try one attempted solution and if it doesn't work try the other.

And try doesn't mean just one night, the settings have to be left alone for at least 2-3 nights, preferably a week, as long as you are not suffering too badly.

What is pressure support?

Simply the difference between the IPAP and the EPAP.

If anyone could please give me some guidance on this I would greatly appreciate it because I really don't know how to go about this. Thanks.

Don't worry, we got you. Keep in mind that for the vast majority of us, aerophagia subsides as we adapt to CPAP therapy. But to adapt, we must use the machine as much as possible. For me that means using the machine whenever I sleep, all the time I am sleeping. Even for a nap.

Know that I have suffered my way through this malady and conquered it. You will too.

Keep trying different sleeping positions. There are two theories on this. I'm not a biologist but my understanding is that in your throat two tubes pass through, one for breathing (the airway) and one for swallowing (the esophagus). For an aerophagia sufferer the pressurized CPAP air is being forced through the esophagus instead of (or probably in addition to) the airway.

One theory is that the correct sleeping position is to keep the neck aligned with the body and head, keeping the airway open, so using a soft cervical collar is one way to achieve this (they are available on Amazon, for example). I think this is by far the more successful solution.

The other theory is less popular, but it was the one that worked for me. It is the opposite of the first theory. I had to keep my chin tucked against my chest to pinch off the esophagus. I know, a very uncomfortable position and one that's hard to sustain. But I persisted.

Eventually the aerophagia subsided. Now I have a machine that auto-adjusts the pressure and delivers bilevel therapy. Auto-adjusting the pressure means I can keep the pressure lower, and the machine will automatically raise it when needed to ward of OA's and H's. Bilevel simply means an adjustable PS. I need to keep the PS low to ward off OA's.

I know this all sounds complicated, but you can learn it if you immerse yourself in it and pay attention. Some people won't do this. They just leave it to the care providers, who are rarely diligent, and if it doesn't work they put the CPAP machine in a closet and never use it. They end up leading a miserable sleep-deprived life riddled with ailments, and raise their risk of an early death due to stroke or cardiovascular disease. You don't have to be that person.

[SarcasticDave94]

What lung disease are you treating, besides Apnea? The ST is for Apnea with lung disease. Your sleep study has some Central Apnea reported, is that why you're using ST? The ResMed AirCurve 10 or 11 ASV would be better for that CA treatment.

With ST, you're getting timed and spontaneous breathing but it's a static exhale to inhale only. You get no range at all.

A VAuto might be OK, except for the moderate level of Central Apnea at 14 to 66 Obstructive Apnea.