Fragmented REM or Aerophagia on Bi-Level

[jrcifani5005]

I've been on CPAP/BiPaP since 2006.  Was originally given a low CPAP pressure of 6.  Many many changes since then trying to find something that worked.  Have probably tried every type of approach out there (APAP, Auto Bi-Level, CPAP, Bi-Level, etc.), and every type of pressure (Pressure support of 1, 2, 3, 4 and even 5).  I seem to be in a rare category of people that need some kind of pressure - but not too much.  Some kind of pressure support, but not too much.  I'm have the N20 Airfit nasal which has been really great, and use a chinstrap.  My AHI is typically below 1.0 and often 0, but I can see many many awakenings in REM of less than 8 seconds in my Flow Data on OSCAR.

At 7 over 5 I have horribly fragmented REM sleep.  At 9 over 5 I have slightly improved REM sleep but horrible horrible aerophagia that creates visceral pain from the distention in the intestines that lasts for days.  Anything higher than that I start to get Centrals and more aerophagia.  I feel like I have to choose between poor REM sleep, or extreme aerophagia in order to get better REM sleep.  I recognize that the pressure needs are higher as we get into REM, and auto-adjusting algorithims (APAP, Auto Bi-Level) haven't worked for me (they don't adjust quickly enough up and down).  If I wear Hypafix Mouth tape the aerophagia gets even worse (the air has no where to go if not out the mouth).  Without some kind of CPAP therapy -- sleep is even worse.

I seem to have a high high sensitivity to wakefullness when in REM when the throat collapses slightly and have RERAs during REM that aren't tracked by the machine or reported as part of AHI.

I've been to 5 different sleep Drs in the Cincinnati area -- and always the same answer ("your AHI is great!....nothing needs to change here").  Fed up with the reluctance to look at OSCAR Flow data together and problem solve this.

The Lanky Lefty (AXG Diagnostics) has tried to help - but just can't find something to address this.  Fragmented REM sleep over time is starting to create a mental health crisis (and yes I'm working with a psychiatrist to try drug therapy as well -- but that's not getting to the root cause of the RERAs during REM).

I'm fairly desparate here -- not sure what to do.  I'm working on getting an oral appliance, but have been told that isn't going to solve the need for some kind of CPAP therapy in addition. 

Does anyone have any thoughts about this situation?  I've been told by several that this is rare to not be able to increase pressure enough to handle apnea events because of aerophagia being so severe.

Thanks all!
JR

[gainerfull]

1. What are you doing to keep your nose / nasal passageways as open as possible every night? What is your routine?

2. Have you explored smaller increments of pressure over a longer period of time?

3. What is your typicaly 95% and 99.5% flow limit rate?

4. Have you considered ASV? Can be tough to adapt to but works.

[PeaceLoveAndPizza]

Please post some OSCAR charts for analysis. Folks can take it from there and offer suggestions.

[jrcifani5005]

1. What are you doing to keep your nose / nasal passageways as open as possible every night? What is your routine?

I use two BreathRite strips; nasal dilators, Flonase daily to keep nasal passages open.  Have a small septal deviation.  Those three seem to be effective used together.


2. Have you explored smaller increments of pressure over a longer period of time?

I've titrated manually for a while - EPAP up 0.2 until I stopped at 5.4 to try to clear OSAs.  I've really struggled with the same approach for IPAP -- can't find a pressure setting that handles RERAs and Hypopneas but doesn't induce major aerophagia.  Been as high as 9 and as low as 6.6

3. What is your typicaly 95% and 99.5% flow limit rate?  

I have to confess that I've tried to get OSCAR to report against that category, but never see anything but "0s" in the Flow Limitation chart.  Could use help on that setting.

4. Have you considered ASV? Can be tough to adapt to but works.

I've been told by several sleep Drs that I am not a candidate for ASV - that my sleep apnea is "controlled".  I have up on the sleep care industry back 2013 and then re-engaged recently to try again and am ending up with the same "non-helpful" answers.  "Your AHI is fine.....it's depression...or anxiety" - etc.  However, I can see on OSCAR the frequent arrousals in REM

[jrcifani5005]

                                1st night; Oct 31 - horrible horible aerophagia; chinstrap + mouth tape used

2nd night; Nov 1 - bad aerophagia; no mouth tape; used chinstrap

3rd night; Nov 2 - aerophagia; no mouth tape; used chinstrap

[Sleeprider]

When posting charts, be sure monthly calendar is minimized and no pie chart. All the useful respiratory and PAP performance data is out of sight farther down that left column. Lots of duplicate images in this installment. You have essentially no apnea events and without the respiratory stats these charts all look the same to me. We may need to get some zoomed images to see these arousals and respiratory disruptions.

[jrcifani5005]

1st night; Oct 31 - horrible horible aerophagia; chinstrap + mouth tape used

2nd night; Nov 1 - bad aerophagia; no mouth tape; used chinstrap  (charts attached)            

3rd night; Nov 2 - aerophagia; no mouth tape; used chinstrap

[Sleeprider]

All charts above are for Nov 1. We can't reduce EPAP lower than 4 to help aerophagia, so maybe try IPAP 7.0. The UF events are really nothing to be concerned with and CA is not very prevalent in your results. You can try changing trigger sensitivity to high to see if it helps with these minor events. Respiratory statistics are excellent.

[jrcifani5005]

What does Trigger Sensitivity do? 

Also would it help to change from Easy Breath setting ON and use Rise Time of 900 milliseconds (i don't know what the equivalent milliseconds Easy Breath is set at)

Thanks so much for the quick reply!!

[jrcifani5005]

Also this snapshot is an example of an "event" where aerogphagia occurs....and just not sure what's happening?  not enough pressure?  too much?