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Which pressure setting most affects aerophagia?
#1
Which pressure setting most affects aerophagia?
Greetings and thanks in advance for any help...

I met with a new sleep doctor today who thinks my sleep apnea has been treated inappropriately for the last eleven years. He thinks the EP was never high enough to give me relief. He proposed raising the EPAP and lowering the IPAP (which often maxed out). I was worried that increasing the EPAP might cause problems as I had a lot of trouble with aerophagia in the past. He asked me if I thought is was from too much air coming in when I took a breath or not being able to exhale enough air. I really did not know.

My question here is general ....
Which setting most determines aerophagia problems?  EPAP or IPAP?

All comments welcome!
Thanks
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#2
RE: Which pressure setting most affects aerophagia?
If I can remember correct, I lowered my EPAP Max to work on aerophagia when I first started the ASV therapy.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#3
RE: Which pressure setting most affects aerophagia?
That seems right. 

I had one night on the increased EPAP and woke with dreadful aeropagia. In the morning I had a sore chest and upper ribs as well. That was just going from 9 to 12. I don't see how I'm going to get to 15. 

Thanks for the input
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#4
RE: Which pressure setting most affects aerophagia?
I would say both can be significant factors. For example I have noticed I get more aerophagia when trying higher EPAP with my autoset, my PS stays the same so increasing EPAP/IPAP is obviously the contributing factor to my aerophagia. I have noticed that many users have aerophagia issues when changing to ASV from cpap/bilevel even though they and they often used higher EPAP without issues before doing so, the higher PS (and therefore IPAP) and the addition of backup rate are clearly factors that also influence aerophagia.

Your doctor is only correct that higher EPAP will help if your issue is obstructive apnea and your airways aren't stinted open. If it is central apnea then increasing EPAP is going to decrease your max PS available and decrease the machines ability to treat your central apnea.

I tried finding some recent OSCAR data but don't see any. I saw the following thread had some from over a year ago. I would be interested to see results before and after the recent EPAP change. For now I am going to theorize based on the old data.

http://www.apneaboard.com/forums/Thread-...y-AM-hours

This attachment made me wonder if doctor was onto something about this being obstructive and potentially positional based. I see comments were made about positional apnea in that thread and it sounds like you unsuccessfully have tried to treat positional apnea. I say unsuccessfully but is that because it didn't treat your positional apnea or because you don't have positional obstructive apnea?

http://www.apneaboard.com/forums/attachm...?aid=21883

This zoomed in attachment made me question the idea that these are obstructive. Although these don't appear to be obvious central apnea as we often see with treatment emergent cases the one thing that really stood out to me is how every single pressure wave gets transferred through to your flow rate chart similar to how the forced oscillation technique transposes onto flow rate in central apneas when using a autoset or vauto. Imo the reason your spikes in flow rate are that visible for each pressure spike is because your airways are open which means there is a significantly larger volume of airway/lung space to compress which requires more air flow. If this was obstructive then the only air to be compressed would be that in the hose and your upper airway and I don't believe you would see such large flow rates.

http://www.apneaboard.com/forums/attachm...?aid=21885

I read through a little bit of your old posts and see that your main issue has always been central apneas, potentially due to an injury. Imo this original diagnosis was probably correct and you primarily suffer from central apnea. Imo this machine is trying to force you to breath but the backup rate and pressure support aren't able to kick start your spontaneous breathing effort like they are trying to do.

If this theory is correct then your machine (ASV) may not be ideal for your situation. ASV relies on spontaneous breathing effort and is not indicated for use in chronic hypoventilation which you clearly have hence the required oxygen use. ASV + oxygen may be enough to maintain your oxygen levels but you would need a recording oximeter to confirm (if you don't have one you should imo). If central apnea is the problem then decreasing your EPAP to get more max PS could actually help as long as the lower EPAP doesn't allow airway to collapse causing obstructions. The current idea to try higher EPAP will make treatment worse if the issue is central in nature.

The machine that is probably more indicated for your use would be ST-A with IVAPS. This machine acts similar to ASV but targets a minimum level of ventilation (ASV targets a fraction of your previous spontaneous ventilation) and has a different more square shape waveform that can supply more air/ventilation even if you aren't spontaneously breathing. Unfortunately I think it could also make your aerophagia worse due to the square shape/more forceful air supply.

Have you ever had a titration study done? Would like to know the results if so.
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#5
RE: Which pressure setting most affects aerophagia?
any pressure above a certain cmw, whether epap or ipap, gives me aerophagia. my epap is set to the minimum necessary to treat out most of my obstructives and that's lower than the threshold over which I swallow air. restricting max ipap to lower than that threshold solves my aerophagia problem. otherwise, all my machines - apap, vauto, asv - tend to raise pressure on me to whatever max is set.
  Shy   I have no particular qualifications or expertise with respect to the apnea/cpap/sleep related content of my posts beyond my own user experiences and what I've learned from others on this site. Each of us bears the burden of evaluating the validity and applicability of what we read here before acting on it.  
 
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#6
RE: Which pressure setting most affects aerophagia?
For me, the PS and IPAP didn't seem to affect aerophagia so much, as they seemed to only go up to attack CA, and it was more a brief burst than the more constant EPAP.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#7
RE: Which pressure setting most affects aerophagia?
Thank you for your reply, Greer1, and others too ...

I am two nights out on the increased EPAP (12). It did cause more aerophagia the first night and settled down a little the second night. My AHI has averaged around 20 (ranging from about 10 to about 30) for the last year. This is with ASV treatment. The last two nights, it came down to 8 and 6. This new doctor thinks I only have obstructive apnea and don't need the 4-LPM oxygen (but I opted to stay on it for now). In a week or two he wants to try to push the EPAP from 12 to 15. He is hoping it will bring my AHI down further. I would opt for this being quite gradual as I'm sure it will bring on more aerophagia. I have to say when I woke up this morning, colors seemed brighter, objects seemed more defined, and some of the brain fog has lifted. Could it be I've finally got a treatment that works?

What I don't get is how it's possible to be treated for sleep apnea for over ten years, by three different doctors, with sleep studies all along the way including three in the last six months, and have every one of them get it wrong. ??? Really???

Yet my AHI is dramatically lower. So what do I know???
I suppose it's possible this new doctor just hasn't yet run up against something the other doctors knew.
But I have supplied him with ALL my previous sleep studies.

You may be as curious as me, so I will keep you all posted.

PS, thanks for going the extra mile for me, Greer1. I really just had a simple question, but I am always impressed by how much effort some people are willing to go to in order to help others on this board in a personal way. You get a gold star, for sure.
Thanks
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#8
RE: Which pressure setting most affects aerophagia?
If AHI is dropping that is a good sign it might be helping. There could be an obstructive aspect (like I say from zoomed out view that was first thought), I imagine there could be some way higher pressure could affect centrals as well. Without seeing a lot of detailed data too difficult to know what exactly is going on. You should post some examples before and after changes so we can give a bit more analysis/thoughts rather then guessing what is going on.

You mention multiple sleep studies, were some of these with PAP/ASV (titration studies)? Seeing some titration study results should help understand the obstructive vs central aspect.
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#9
RE: Which pressure setting most affects aerophagia?
Oh I forgot, on aerophagia and my GERD issues, and also due to high back pain, I've slept a lot in my left side with a small head/torso bed incline.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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