Intestinal gas problems

[Sleeprider]

I agree with your conclusion the increasing flow limitation is positional. It is futile and uncomfortable to try to manage that with pressure. You have excellent results with lower pressure, and you should continue to manage the positional issue with other aids.

[marklang]

Just an update.   I continue to work on the gas problem.  As could be seen from my recent screenshots from Oscar, I seem to do pretty well with pressures from 11-18 cm or even 10-18 cm with a PS of 5.  However, I still need to be very careful with my head position.  With my best efforts, I have periods where the machine holds the lower pressures 10-15 or 11-16 without any serious problem.  But I also have periods there flow restriction causes the pressures to rise.  With an upper limit of 18, it does not always remove the flow limit, but it does seem to keep my incidents low. 

I wanted to try further positioning changes to see if I can get more time without any flow limit problems.  It seems like any pillow that lifts my head even a small amount causes issues.  The fancy cervical pillow with the pocket in the center was much worse that my normal routine.  I went back to the Popitz pillow that I acquired a while ago but never really used.  The Popitz pillow actually raises my upper body a bit, and then lets my head hang back down below level in a down-sloping pocket.  This is supposed to be designed for the optimal position, and it is similar to what I get in my normal pillow position.  Unfortunately, I woke up after about a hour, and had an AHI of 2.4.  That is not too bad, but worse than my normal routine.  Also, the gas seemed worse.  I went back to the normal pillow.  However, this time I raised my adjustable bed a bit to retain about the same upper body lift.  After another about 2.5 hours I woke up again.   This time the AHI dropped suggesting I had no more incidents (the machine only shows the average over the entire evening).  Nevertheless, the gas was very bad - similar to what I have had for a while at the higher pressures.  At that point, I lowered the bed to very slightly above level and used my normal pillow arrangement.  The rest of the night went well for the apnea, but the gas was already so bad I had an uncomfortable night and morning. 

I am pretty much at a loss to think of anything else I can try to eliminate the remaining positional issues.  My current pillow arrangement, again a COOP foam pillow adjusted to be pretty flat with my shoulders on the pillow and head hanging down over the top of the pillow, comes as close as I have gotten -- but still allows flow restriction at some times.  I also now seem to know that the gas problem is worse if my upper body is elevated, even if the pressures are in the lower range.  I will continue to try slight differences with the COOP pillow and my body level to see if I can get more consistent.  At least with this arrangement the gas seems to be better, more tolerable, at least most of the time. 

Again, I appreciate all the advice.  I clearly have made some progress with the gas problem if not gotten completely beyond it.

[Sleeprider]

Whatever you were doing at the end of the night would be what I recommend you pick up with next time. I want to emphasize once again, that capping your maximum pressure at a level you tolerate is crucial to your success. If that is 16, then do that, and continue to work on sleep position to minimize the flow limits. I'm a fan of a simple down pillow which offers a lot of flexibility in any position without a lot of loft.

[Cpapian]

This might be a long shot but ....

One think that I find helps with swallowing air is my tongue position.   Keeping my tongue at the top of my mouth and a little bit back from my teeth,  blocks air from getting into my mouth.  When air gets into my mouth it has two places to go, swallow or through my lips.

To test for the right spot, with machine on, put your tongue in place and open your mouth.  Shift your tongue around until no escapes.

[marklang]

What I was doing at the end of last evening (3-15) is what I noted is my "normal position," e.g. with my shoulders on my relatively flat pillow and my head hanging down to the bed over the top of the pillow, and also with my body almost flat (very slight upper body elevation).   That is the same thing I did all night, for example, on 3-9-2021 as noted previously.  This works fairly well, but apparently I twist my head or do something else that initiates flow restriction without being aware of it.  I have not been able to reliably correct that.  I will continue to try to make minor adjustments to that to see if I can get more consistent, but I am not sure I can really achieve that since it is not clear what else I can do. 

I appreciate the comments from Cpapian about my tongue.  My tongue is probably part if not the major factor in my flow restriction.   However, I am not sure I can get it to stay in any given position after I go to sleep.  I will experiment, however.  I use a full face mask.

[marklang]

This is just an update on my situation.  I have experimented with positional changes quite a bit.  The big breakthrough was finding that I am affected not just by head position issues.  I have for many years raised my upper body using an adjustable bed to deal with back problems.  At this point, I only have it raised very slightly, around 2 inches at the head.  Of course, the bed angles up from its center.  For back issues, I wanted the lift at approximately the waist so that my upper body is angled up relative to my hips and legs to take pressure off the nerves in the lumbar region.  I discovered that I have apnea flow issues in that position.  I must move my body higher, so that my entire rear end is above where the lift begins and my hips are in line with my back.  I am not sure what this does, but it clearly makes a big difference in helping me lower my pressures without issues.  Also, rather than position my shoulders on the pillow with my entire head hanging down above the pillow, I adjusted slightly so that my head hangs down right at the upper edge of the pillow.  I manually form a small pocket in the pillow under my head so it rests down on the bed below within that pocket.  This seems to provide some side support to keep my head from turning as much during the night.  That was a lesser impact than the lower back, but still helps. 

With all those changes, I have achieved what seems like stable apnea results with the EPAP set to 8 cm, with a PS of 5.0.  I leave the machine in auto mode with a maximum of 16 to deal with the remaining positional issues.  When I am careful to insure this positioning, I get pretty good results, as the attached recent example from 4/16/2021 shows.         I still get occasional flow restrictions, but modest rises up to 16 cm seem to deal with them most of the time.  You can see on the graph that there are small flow restrictions noted by the machine, but usually not enough to cause it to up the pressure.   When I lower the EPAP even 1 more to 7 cm, the machine starts lifting the pressure so often that my average pressures are higher than with the 8 to 13 cm range, as in the attached example from 4/13/2021.      

With these settings, I still get some gas issues.  However, I seem to be able to pass more of what gas remains, so it is not nearly as bad as I have been having.  This seems to be about as low as I can go with the pressures to deal with the apnea.  I will try these settings for a while to see how things go. 

Thanks again for all the help.  If anyone has any further suggestions, please let me know.