What are the diagnosis, treatment, and interventions for aerophagia in patients using Continuous Positive Airway Pressure (CPAP)/Bilevel Positive Airway Pressure (BiPAP)?

Diagnosis, Treatment and Interventions for Aerophagia in CPAP/BiPAP Patients

Diagnosis of CPAP-Related Aerophagia

CPAP-related aerophagia should be diagnosed when patients develop flatulence, eructation (belching), and abdominal bloating that clearly began or worsened after initiating positive airway pressure therapy. 1

Diagnostic Criteria

• Quantify symptom severity using a Visual Analog Scale (VAS), with scores ≥7 indicating definite discomfort requiring intervention 1
• The three cardinal symptoms are: flatulence, belching, and abdominal bloating with clear temporal relationship to PAP initiation 1
• Most patients (>50%) with aerophagia experience significant discomfort but only 44.4% spontaneously report these symptoms to their physician, so direct questioning is essential 1
• Prevalence ranges from 7.2% to 16% depending on diagnostic criteria used 2, 1

Risk Factors to Assess

• Higher CPAP pressure levels significantly increase aerophagia risk (OR = 1.24 per cm H₂O increase) 1
• Comorbid gastroesophageal reflux disease (GERD) more than doubles the risk (OR = 2.52) 1
• Younger age and lower BMI paradoxically increase risk 1
• Most patients reporting aerophagia with CPAP were already symptomatic before CPAP initiation, so baseline gastrointestinal symptoms should be documented 2

Treatment Algorithm

Step 1: Optimize Mask Fit and Equipment

Begin by ensuring proper mask fitting, as air leaks increase aerophagia likelihood regardless of device type. 3

• Assess for excessive mask leak using the 95th centile leak parameter from device data 4
• Consider nasal masks over full-face masks when clinically appropriate, as 39 of 56 patients with aerophagia in one study used full-face masks 4
• Add heated humidification to reduce nasal congestion that may promote mouth breathing and air swallowing 5, 6
• Nasal steroids can help relieve nasal obstruction that contributes to aerophagia 5

Step 2: Switch to Auto-Titrating PAP (APAP)

APAP therapy significantly reduces aerophagia symptoms compared to fixed CPAP while maintaining equivalent efficacy and compliance. 4

• APAP reduces median pressure and 95th centile pressure (P < .001) compared to fixed CPAP 4
• APAP specifically reduces bloating (P = .011), worst episodes of bloating (P = .040), flatulence (P = .010), and belching (P = .001) 4
• No differences in compliance, residual AHI, sleepiness scores, or quality of life between APAP and CPAP 4
• Set APAP range from 6-20 cm H₂O initially, then narrow based on download data 4

Step 3: Consider BiPAP if APAP Fails

BiPAP delivers lower pressure during exhalation, which can reduce air being forced into the digestive tract, though guidelines do not specifically recommend it for aerophagia alone. 3

• The American Academy of Sleep Medicine recommends considering BiPAP when patients cannot tolerate CPAP pressures >15 cm H₂O or experience significant pressure-related discomfort 3, 7
• Start with minimum IPAP of 8 cm H₂O and EPAP of 4 cm H₂O, with typical pressure differential of 4-6 cm H₂O 3
• Manual titration during attended polysomnography is the gold standard for determining optimal BiPAP settings 3
• Monitor for gastric distention and emesis, which are recognized complications of BiPAP 5

Step 4: Address Comorbid GERD

Treat underlying GERD aggressively, as it more than doubles aerophagia risk. 1

• Initiate proton pump inhibitor therapy for patients with GERD symptoms 1
• Elevate head of bed beyond what is already recommended for PAP therapy 1
• Consider gastroenterology referral for refractory cases 1

Important Clinical Caveats

When Aerophagia Leads to Treatment Abandonment

• Only 1% of patients abandon CPAP therapy due to aerophagia symptoms, so aggressive intervention to preserve therapy is warranted 2
• In the rare cases where symptoms are intolerable despite interventions, document failed attempts at APAP and BiPAP before discontinuing PAP therapy 2

Distinguishing Pre-Existing from Treatment-Related Symptoms

• Assess whether symptoms actually worsened with CPAP or were pre-existing, as most symptomatic patients had baseline gastrointestinal complaints 2
• Only flatulence and dry mouth show statistically significant increases with CPAP therapy (VAS increased from 24 to 34 for flatulence, P ≤ .001) 2
• Heartburn and belching may actually decrease with CPAP (P ≤ .001 and P = .018 respectively) 2

Monitoring and Follow-Up

• Initial follow-up within the first few weeks is essential to identify and address aerophagia before it becomes intolerable 6
• Objectively monitor CPAP usage data to detect declining compliance that may signal unaddressed aerophagia 6
• Longer-term follow-up yearly or as needed to address ongoing mask, machine, or usage problems 6
• Regular follow-up prevents facial complications and allows mask fit reassessment 5