What is the risk of aerophagia with positive airway pressure (PAP) therapy for obstructive sleep apnea and how can it be prevented or managed?

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Last updated: February 17, 2026 • View editorial policy

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Risk of Aerophagia with PAP Therapy

Aerophagia occurs in approximately 7-8% of patients on PAP therapy and is characterized by air swallowing that causes flatulence, belching, and abdominal bloating—symptoms that can be severe enough to cause treatment discontinuation in about 1% of cases. 1, 2

Prevalence and Clinical Impact

  • The reported prevalence of CPAP-related aerophagia ranges from 7.2% to 16% across observational studies, with the most rigorous diagnostic criteria yielding a 7.2% rate. 1, 2

  • More than half of patients with aerophagia experience significant discomfort (VAS ≥7), yet only 44.4% report these symptoms to their physician, making this an underrecognized complication. 1

  • Flatulence is the most disturbing symptom, with median VAS scores increasing from 24 before CPAP to 34 during CPAP therapy (p ≤ 0.001). 2

  • While aerophagia symptoms are the primary reason for abandoning CPAP in only 1% of patients, this represents a preventable cause of treatment failure. 2

Risk Factors for Developing Aerophagia

Higher CPAP pressure levels significantly increase aerophagia risk (OR = 1.24 per cm H₂O increase), making this a dose-dependent side effect. 1

  • Comorbid gastroesophageal reflux disease (GERD) more than doubles the risk of developing CPAP-related aerophagia (OR = 2.52). 1

  • Younger age increases susceptibility (OR = 0.76 for each year increase), suggesting older patients have protective factors. 1

  • Lower body mass index increases risk (OR = 0.88 per kg/m² increase), with higher BMI appearing protective against aerophagia. 1

Prevention and Management Strategies

Primary Prevention Measures

Use nasal interfaces preferentially over oronasal masks, as the American Academy of Sleep Medicine recommends nasal interfaces to reduce side effects. 3

  • Add heated humidification at PAP initiation to minimize nasal congestion and mouth breathing, which can promote air swallowing. 3, 4

  • Ensure proper mask fitting during acclimatization to minimize air leaks that may cause compensatory swallowing. 5

Management of Established Aerophagia

Reduce CPAP pressure to the minimum effective level by reassessing titration results, as higher pressures directly correlate with aerophagia risk. 1

  • Consider switching from CPAP to bilevel PAP (BiPAP) with lower expiratory pressure (EPAP) to reduce the pressure gradient promoting air entry into the esophagus, particularly when therapeutic pressures exceed 12-15 cm H₂O. 6, 1

  • Optimize humidification settings to prevent nasal congestion that leads to mouth breathing and increased air swallowing. 4

  • Treat underlying GERD aggressively with proton pump inhibitors or H2-blockers, as GERD independently promotes aerophagia during PAP therapy. 1

  • Evaluate for and correct mask leaks by reviewing device data for sudden increases in leak rates, as leaks can trigger compensatory swallowing. 5

Clinical Assessment Algorithm

Directly ask about flatulence, belching, and abdominal bloating at follow-up visits, as patients frequently do not volunteer these symptoms despite significant discomfort. 1

  • Use quantitative assessment (VAS 0-10) to gauge symptom severity and establish whether symptoms began or worsened after PAP initiation. 1

  • Review PAP device download data for average pressure levels, 95th percentile pressures, and leak patterns. 5

  • Assess for comorbid GERD symptoms including heartburn and regurgitation. 1

Important Clinical Caveats

Most patients reporting aerophagia symptoms with CPAP were already symptomatic before therapy initiation, so establish temporal relationship carefully before attributing symptoms to PAP. 2

  • Do not assume aerophagia is an inevitable consequence of PAP therapy—it is a correctable side effect in most cases through pressure adjustment, interface changes, or switching to BiPAP. 1, 2

  • Heartburn and belching may actually decrease with CPAP therapy (median VAS from 12 to 10 for heartburn, p ≤ 0.001), so worsening of these symptoms should prompt evaluation for other causes. 2

  • The American Academy of Sleep Medicine emphasizes that adequate follow-up with troubleshooting is essential to identify and address PAP-related problems including aerophagia. 3

References

3
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

4
Guideline

Benefits of Heated Tubing with PAP Therapy

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

5
Guideline

New Oral Odor After Starting PAP Therapy in OSA Patients

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

6
Guideline

First‑Line Positive Airway Pressure Therapy for Uncomplicated Obstructive Sleep Apnea

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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