Aerophagia is Something to Lose Sleep Over
Aerophagia or air swallowing is an occasional side effect from the pressurized air of PAP therapy. Scant research has examined this unpleasant and not uncommonly painful symptom, usually felt as bloating in the stomach. Less common but very annoying is the release of gas through belching or farting after taking off the mask in the morning.
Most causes of aerophagia can be diagnosed and treated with various degrees of success. Solutions may be as simple as mask adjustments or the use of medications for specific conditions that might trigger aerophagia.
Surprisingly, periodic limb movements (PLMD, the sleeping version of RLS) or leg jerks may be the single most unrecognized cause of aerophagia. Almost nothing is written about this phenomenon in the scientific literature, so the mechanism remains unclear. Speculation suggests that arousals in the brain caused by leg jerks lead to very brief waking episodes, which then trigger a swallow, the end result being the pressurized air entering the stomach.
The treatment of leg jerks in aerophagia patients has resulted in so much overwhelming success, often the complete elimination of the symptoms, it's difficult to imagine leg jerks were not the underlying issue. As further corroboration, when we see these patients back in the sleep lab to retest their pressure settings, it is usually clear their leg jerks diminished in frequency with the start of a medication to treat these leg movements of sleep.
The treatment of leg jerks has its own complexities that will be dealt with in other posts. A key point, however, needs to be mentioned here: there are many reasons why a leg jerk medication might not work, so if the aerophagia does not resolve in such cases, don’t presume the problem isn’t leg jerks. Instead, more detective work is needed to figure out how to solve leg jerks, if indeed they are the presumed cause of air swallowing.
Another frequent cause aerophagia is directly related to mask issues. Someone using a full face mask but still mouth breathing can swallow air. When leak occurs during full face mask use (or actually any type of mask) the PAP machine has a built-in system to compensate with bursts of pressurized air. That is, the device gauges that not enough air is keeping the airway open (because too much leaked out), so it sends a new burst of air to compensate, which is extremely annoying, unpleasant and actually traumatizing to some individuals. With these bursts a person often wakes up completely. However in other instances a person doesn't awaken but swallows more air because of the burst. Often, both problems of mouth breathing and mask leak need to be solved, and it’s not unusual for the individual to need a full face mask and a chin strap. I know it sounds very bulky to use a full face mask and a chin strap together, yet it is remarkable to see such huge benefits from this combination and how many people find it relatively easy to adapt to.
In another area, we've worked with patients with severe esophageal diseases including dilation of the esophagus or chronic reflux. Many of these patients need medications, changes in diet, weight loss and some may require surgeries. Nonetheless, even in such patients a chin strap and a better fitting mask may actually solve the problems or at least provide more substantive relief than anticipated given the severity of the esophageal disease.
Additional mask issues causing aerophagia can be related to nasal pillows or over the nose masks. In this instance, some will resort to mouth taping (sounds strange, I know) or chin straps or both. As you can imagine we’re moving in directions that require a lot of hands-on work with your sleep professionals, due to adding in all these “extras” that could lead to claustrophobic feelings. I have tried all these combinations at various times in my use of PAP and have been very appreciative of the benefits from doing so. I was fortunate at various times to receive a lot of coaching from my own sleep technologists at our sleep center on how to apply these steps. Overall, the bottom line on mask is that fitting, comfort, leak, and mouth breathing must be closely attended to if your air swallowing persists.
Another large factor in evaluating aerophagia is rhinitis, including a sometimes peculiar relationship between reflux and rhinitis. Reflux on its own is an obvious trigger to aerophagia, but many people do not realize they have reflux, which is why an ENT examination is essential. With the fiber-optic scope the ENT can diagnose a condition known as silent reflux where the patient is asymptomatic but the upper esophagus still shows erosions indicating stomach contents or secretions are irritating the lining of the esophagus. Then, it turns out this irritation extends upwards into the bottom of the throat, which triggers its own rhinitis symptoms commonly known as non-allergic rhinitis. Of practical interest, it's very common for someone who effectively treats reflux from whatever cause to experience a virtual elimination of the aerophagia.
The more common type of rhinitis is the allergic variety, and many people suffer from this condition often called seasonal allergies or hay fever. Whether a person has allergic or non-allergic rhinitis, these problems must be aggressively addressed since the mucus build-up can lead to excessive swallowing during sleep, creating an obvious catalyst for aerophagia. We've seen a lot of improvements in these conditions with assorted nasal sprays such as Sensimist, Astelin, Astepro, Atrovent, and the newer Xylitol nasal spray. I strongly encourage you to discuss these options with your Health Care Professionals if you are persuaded your aerophagia is caused by chronic nasal congestion. And of course you would receive the added benefit of improving nasal airflow to further enhance your capacity to adapt to and use PAP therapy.
For more about rhinitis, please check out my six-part, free video series, The Nose Knows on my website:
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Last, it is important to reiterate aerophagia can be so bad it will cause somebody to stop using PAP therapy or prevent the patient from ever receiving an optimal response. Although little research is available to tell us how often people suffer from this problem, my sense is aerophagia is largely overlooked or underestimated at sleep clinics. It appears the only attention is given to mask issues; there does not seem to be much focus leg jerks or rhinitis or even reflux.
Discuss these options with your sleep professionals to you can decreased aerophagia to manageable levels or preferably eliminate entirely.