Is hiatal hernia repair indicated for patients with aerophagia due to Continuous Positive Airway Pressure (CPAP) therapy?

Hiatal Hernia Repair for CPAP-Related Aerophagia

Hiatal hernia repair is not indicated as a primary treatment for aerophagia caused by CPAP therapy, as there is insufficient evidence supporting this surgical approach for this specific indication.

Understanding CPAP-Related Aerophagia

• CPAP-related aerophagia (C-aerophagia) is a recognized complication of CPAP therapy, occurring in approximately 7.2-16% of patients using CPAP for obstructive sleep apnea (OSA) 1, 2
• Symptoms include air swallowing, belching, abdominal distention, discomfort, and flatulence when using CPAP 2, 3
• Most patients with C-aerophagia already have some symptoms of aerophagia before starting CPAP therapy, with only mild worsening of flatulence and dry mouth during treatment 2

Risk Factors for CPAP-Related Aerophagia

• Higher CPAP pressure levels significantly increase the risk of aerophagia (odds ratio = 1.24) 1
• Pre-existing gastroesophageal reflux disease (GERD) is strongly associated with C-aerophagia (odds ratio = 2.52) 1
• Patients with C-aerophagia have a greater prevalence of GERD symptoms (29% vs. 10%) and nighttime GERD symptoms (9% vs. 2%) compared to those without aerophagia 3
• Lower age and lower BMI are also associated with increased risk of C-aerophagia 1

First-Line Management Approaches

• Adjust CPAP settings and interface:

  • Use the lowest effective pressure that controls OSA symptoms 4
  • Consider changing from full-face mask to nasal mask after initial stabilization, as full-face masks are associated with more air swallowing 4

• Address GERD if present:

  • Since GERD is strongly associated with C-aerophagia, treating underlying GERD should be prioritized before considering surgical interventions 1, 3
  • CPAP-induced aerophagia may precipitate or worsen GERD through gastric distension 3

• Consider behavioral techniques:

  • Techniques to reduce swallowing rate have shown some success in managing aerophagia in patients with hiatus hernia 5
  • However, symptomatic improvement may be short-lived 5

When to Consider Alternative Therapies

• For patients with persistent, severe C-aerophagia despite conservative measures:
  • Consider alternative OSA treatments such as mandibular advancement devices for mild to moderate OSA 4, 6
  • Weight loss should be recommended for all overweight or obese patients with OSA 6
  • Positional therapy may be considered, though it is clearly inferior to CPAP and has poor long-term compliance 4

Important Caveats and Contraindications

• Surgical interventions for OSA should generally be considered only when conservative treatments fail 4
• Current guidelines do not recommend hiatal hernia repair specifically for CPAP-related aerophagia 4
• Only 1% of patients with C-aerophagia symptoms abandon CPAP therapy due to these symptoms, suggesting that most cases can be managed conservatively 2
• Many patients with aerophagia symptoms do not report them to their physicians (only 44.4% report these symptoms), highlighting the importance of specifically asking about these symptoms during follow-up 1

Algorithm for Management

1. Confirm diagnosis of CPAP-related aerophagia through symptom assessment
2. Optimize CPAP settings (lower pressure if possible) 1
3. Consider changing mask type (from full-face to nasal if appropriate) 4
4. Evaluate and treat underlying GERD 1, 3
5. Consider behavioral techniques to reduce swallowing rate 5
6. For persistent severe symptoms affecting CPAP adherence, consider alternative OSA treatments 4, 6
7. Surgical interventions for hiatal hernia should be considered only when there are other indications for repair beyond CPAP-related aerophagia 4

In conclusion, while hiatal hernia and aerophagia may be associated, there is insufficient evidence to support hiatal hernia repair as a treatment specifically for CPAP-related aerophagia. Management should focus on optimizing CPAP settings, treating underlying GERD, and considering alternative OSA treatments when necessary.