LPR or Sleep Apnea ?

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LPR or Sleep Apnea ?

Postby Ronnie47 » Fri Feb 25, 2011 11:57 pm

So, I just came up from the ENT surgeon's office and he looked through my nose, soft palate, tongue etc and found everything to be normal. No deviated septum, no large soft palate, no large tongue base. He saw acid in my voice box and little redness due to the reflux. So he thinks the real problem is that the acid at back of my thorat could be causing throat spasms at night making it harder to breathe. Also, he mentioned that acid might be seeping into the airway causing the blockage while sleeping. When asked about the repeating cycle of waking up with a jolt right at the moment of falling asleep, and the need to consciously keep breathing during the day/night, he is attributing that to anxiety + acid in the back of the throat

I am really confused. My sleep study said that I have servere Obstructive Sleep Apnea where in there was a complete or partial blockage of breathing for a total of 31 times in an hour. My ENT says, that my OSD is not the problem, but it is LPR. He asked me to get a second sleep study done.

Can OSD be confused with LPR? Has anyone here faced a similar situation?

I have had LPR since 3 years, but it was always under control with PPIs.
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Postby librarylady » Sat Feb 26, 2011 12:18 pm

I have BOTH LPRD and OSA. The LPRD was diagnosed between my baseline study and my titration study, and the titration study, with treatment of the LPRD underway, still required a pressure of 11 to control the OSA. I was referred to the ENT because my voice was becoming more and more raspy and I talk for a living--I take a PPI twice a day. On the occasion that I have missed a day or two, the raspy quality of my voice comes right back.

I had a night a few months ago when the electricty went out and I had to TRY to sleep without my CPAP, but I would almost nod off and would begin gasping for breath--so treating my LPRD has made no difference in the OSA since my LPRD is under control. I would definitely not rule out treating the OSA based on what the ENT thinks might be happening. The sleep study pretty much tells the tale. Have you had a titration study yet? What does your sleep specialist say?
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Re: LPR or Sleep Apnea ?

Postby Todzo » Sat Feb 26, 2011 1:27 pm

Ronnie47 wrote:So, I just came up from the ENT surgeon's office and he looked through my nose, soft palate, tongue etc and found everything to be normal. No deviated septum, no large soft palate, no large tongue base. He saw acid in my voice box and little redness due to the reflux. So he thinks the real problem is that the acid at back of my thorat could be causing throat spasms at night making it harder to breathe. Also, he mentioned that acid might be seeping into the airway causing the blockage while sleeping. When asked about the repeating cycle of waking up with a jolt right at the moment of falling asleep, and the need to consciously keep breathing during the day/night, he is attributing that to anxiety + acid in the back of the throat

I am really confused. My sleep study said that I have servere Obstructive Sleep Apnea where in there was a complete or partial blockage of breathing for a total of 31 times in an hour. My ENT says, that my OSD is not the problem, but it is LPR. He asked me to get a second sleep study done.

Can OSD be confused with LPR? Has anyone here faced a similar situation?

I have had LPR since 3 years, but it was always under control with PPIs.


Hi Ronnie!

The symptom of "waking up with a jolt right at the moment of falling asleep" is common enough to have the name "hypnic jerk". One thing they say about it may be familiar to you, it is common amongst those whose sleep schedules are irregular.

My severe Obstructive Sleep Apnea (OSA) was diagnosed in 2003. It greatly contributed to the end of a carrier I loved for over 20 years. Crawling up out of that hole with some retraining I was slammed down again by being attacked with a knife coming home from getting a treat at my local AM-PM two little blocks from my house. Now I am still treating the OSA while also dealing with panic attacks (for me long times when my body is hypervigilant - six to 48 hours of it!). Seeing a return of symptoms (sleepiness, high blood pressure, high blood sugar in the morning (8+ hours fasting), cognitive decline and emotional liability) I started looking for possible causes. One doctor mentioned that gastroesophageal reflux disease (GERD) is, in his experience, common amongst those with OSA (GERD has heartburn as one of it's main symptoms, in Laryngopharyngeal reflux (LPR) only 50% experience heartburn - both are caused by acid moving up from the stomach and into the airway). He theorizes that the GERD is due to the low pressures created by the increased respiratory effort due to the airway obstructions of the apnic events causing low pressure in the airway which tends to draw juices out of the stomach due to the vacuum.

I used a small camera to photograph the back of my throat each morning and did indeed find that I had redness and swelling back there after nights that showed bad sleep quality (measured by a Zeo), apneas (measured by my CPAP) and blood oxygen desaturations (measured by my recording pulse oximeter). In my case the reflux is probably contributed to by my use of Selective Serotonin Reuptake Inhibitors (SSRIs) along with the fact that the hypervigilance upsets my tummy and tends to make me want to gag a bit sometimes.

Then I remembered that a doctor many years ago told me I should raise the head of my bed (I think he noticed my LPR). The experiment was cheap, less than five dollars spent to purchase a couple of 6"x6"x8" concrete blocks. The results I am still finding out. My 30 day and 7day Apnea-Hypopnea Indexes (AHIs) are less than two per hour. Sleep quality is good, regulation of blood pressure and blood sugar and blood oxygen are good. I have more energy more of the time and my hearing seems to be improving. The back of my throat looks a lot better. For me this little thing helped a lot!

All of my research, which included that mentioned above and audio recordings of my sleep times, has led me to believe that my often hyperviligant state makes me more sensitive to my breathing obstructions and that I consequently have many more Respiratory Effort Related Arousals (RERAs). Even these have become less after raising the head of the bed. I hope that as summer approaches I can get back a bit more to living a life.

In regard to your question "Can OSD be confused with LPR?" did you mean to write OSA instead of OSD? If so, I think that your doctor is having trouble believing that you have OSA since he can find none of the "usual (physical) suspects". Just as many doctors have trouble believing that skinny people have OSA (about 20% of those with OSA are of normal body mass index) yours has not yet made the connection between GERD and OSA that other doctors have. Me, well, I am not a doctor but I do read, think a lot, and have experience with OSA so I wonder if GERD would tend to cause OSA by desensitizing the nerves in the airway such that the air flow monitoring does not make it to the brain and the muscles have more trouble receiving the signals that do make it back from the brain. Along with the swelling of the airway tissues I think that if I were an ENT I would tend to suspect OSA if I saw LPR or GERD. But, that is just me.

May God Help Us!

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Postby Ronnie47 » Sat Feb 26, 2011 2:35 pm

@librarylady No, I have not yet had that titration study. My problem has been that I did not notice any improvements in my breathing after using CPAP for 4 days. I would feel that I am able to breathe, but the air is not reaching the lungs. The same shortness of breath would continue throughout the day, giving me the feeling that I need to consciously keep breathing. And once you start thinking about breathing, it kind of messes you up. Last night, I took an extra PPI in the evening and I slept for 7 hours without the CPAP. I woke up once with a choking sensation in the night and acid taste in my mouth, then went back to sleep. So, I am thinking my ENT might be right after all. Since, LPR is also notorious is causing the blockage of the breathing passage and asthma like symptoms (http://heartburn.about.com/od/gastrictr ... is_LPR.htm), that is what might be causing my breathing problems at night. The sleep study just mentioned that I have partial or complete blockage of breathing, but it does not say why.

@Todzo
I think I should also try raising the foot of the bed so that I sleep at an incline. My reflux had been in control using PPIs, so I never tried it. But looks like t might have recently come back for unknown reasons. Regarding that feeling of waking up right at the moment of going to sleep, I am thinking it might be psychological. You are continuously worrying about not being able to breathe properly and that might cause it.

All said and done, yesterday I was able to sleep for the first time in 6 days for over 6 hours. So I am feeling better. I am planning to manage my acid reflux first, before I start thinking about OSA.

I will keep you guys posted.
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Postby librarylady » Sat Feb 26, 2011 3:00 pm

I am confused. You say that your LPRD is under control using your PPI. If that is the case, why do you suspect it is the cause of your apneas? Or other breathing issues. If it is truly under control, it should not be giving you any types of problems. I also have asthma, and using my CPAP has helped that tremendously as well. I know mine is under control because I go to the ENT every 6 months to have it scoped, which is no fun at all! Other than the raspy voice, I have never had any other symptoms from the LPRD.


Also, if you have not had a titration study, your pressure may not be optimal and you may not be any benefit yet. If your pressure is just a guess, it may too low to stop the apneas. Can you access any of your data to see what the CPAP is actually doing for you?
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Postby Ronnie47 » Sat Feb 26, 2011 4:02 pm

Well, I thought my LPR was under control. But something has happened, which may have triggered it again. I am not sure what. I have this occasional feeling of tightness in my chest and a mild annoying pain at the back of my throat (just under the voice box), which might very well be due to the reflux. Initially I thought, it was due to the stress of not sleeping for days due to the sleep apnea.

As for the CPAP, my pressure was 5 - 8. When using CPAP, if the pressure actually goes up, I feel uncomfortable, but the shortness of breath remains. I end up pushing that button on the CPAP machine to reduce the pressure.

So I am planning to take care of my reflux at the moment, making sure that feeling at the back of my throat is gone. Once that is done, I will see if my breathing problems are resolved. If not, I will visit the sleep center again to have my CPAP machine checked out and talk to the sleep specialist.
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Postby Janknitz » Sat Feb 26, 2011 9:14 pm

There is a growing body of evidence that LPR and Sleep apnea go hand in hand. When you're obstructed and struggling to breathe, it creates a vacuum effect in the throat that pulls acids from the stomach and esophagus up into the larnx. The acid, in turn, irritates the lining of the larynx, causing edema, which can increase the obstructive apena. I don't think they're certain which causes which in the first place--a bit of a chicken and the egg theory. Knowledgeable sleep specialist treat BOTH when both are present.

You said that your ENT suggested that you get a second sleep study done now that you are treating the LPR. What he did NOT say is to stop the CPAP, and if he did say that he was being irresponsible. Most likely you need to treat both, and the ONLY safe way to judge if the treatment of LPR is effective enough to forgo CPAP is with a second sleep study. Otherwise you are taking your life in your hands with such severe OSA. If you think the treatment of the LPR alone is scucessful, you owe it to yourself to prove it with a new sleep study without CPAP.

You mention that you knew you had LPR for three years and have been treating it with PPI's, and you STILL have severe OSA--that should tell you something. The fact that you are now having LPR again without the CPAP is further evidence. Untreated obstructive apnea will cause LPR!

Some people become more aware of LPR or GERD when they first start CPAP for two reasons--one is the CPAP is hard to sleep with at first, so you feel the reflux episodes you otherwise might have slept throug, and the second is that the aerophagia people sometimes have with CPAP can induce reflux in some people. There are things to help the aerophagia, most importantly keeping your tongue on the roof of your mouth because that will seal off the mouth from the nasal pharnyx and reduce the air that goes into your esophagous and stomach.
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Postby Ronnie47 » Sat Feb 26, 2011 11:08 pm

@librarylady - Sorry, I did not know this word - titration, so I did not know what titration study was. I checked my sleep study report, and it was actually done, and the pressure for the CPAP adjusted to 8 based on that.

@Janknitz - Cant OSA be caused by inflammation of the airway caused by LPR? LPR is known to cause the blocking of the breathing passage and cause upper sensory airway impairment. In that case would it help to use the CPAP? I thought CPAP would only be useful if your soft palate or tongue is blocking the airway. The reason I say this is, I tried sleeping with the CPAP for 4 days and did not notice any difference in the quality of my sleep. Yesterday I took a 2nd PPI in the evening on the advice of my ENT and I slept for 7 hours without the CPAP.

Read this (Search for LPR) - http://bluesleep.com/news/Developments_ ... _Apnea.pdf

Do you guys think I should still use the CPAP or talk to the sleep specialist to adjust the pressure but still use it?
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Postby Janknitz » Sun Feb 27, 2011 12:28 am

Do you guys think I should still use the CPAP or talk to the sleep specialist to adjust the pressure but still use it?


You MUST continue to use the CPAP until a new PSG confirms that you no longer need it!!!!!!

Yes, it's possible that some OSA could be caused by LPR, but your OSA is SEVERE and unlikely that it is caused solely by the LPR, if at all. It's more likely that the OSA is causing your LPR. The fact that the ENT didn't perceive any structural reason for the OSA on his exam doesn't mean that you don't have OSA. A physical exam is NOT the standard for diagnosis and treatment of OSA--otherwise all the sleep labs would go out of business.

And, you cannot judge sleep apnea by the quality of your sleep--it's very common to think you are sleeping fine, but snoring and PSG testing tell a different story. Think about all the time leading up to your PSG. You probably thought you were sleeping OK AND you were treating the LPR, but then you STILL had SEVERE OSA.

What you are describing is some difficulty getting used to the CPAP. It does disturb sleep at first, but that's something that you overcome with some careful tweaking to get rid of the things that are bothering you and giving yourself some time to get used to having a chunk of plastic strapped to your face and blowing air into it all night. It's no wonder you slept better the night without it--or at least you think you did, but the LPR you experienced tells a different story.

Personally, I think the ENT did you a great disservice by telling you that the LPR was your problem and not the sleep apnea. He totally ignored the severity of the OSA and the fact that it is very dangerous for you to ignore it.

Call your sleep doctor first thing Monday and see what HE has to say about stopping CPAP.

And if you tell us about what made it uncomfortable for you, we can help.
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Postby Ronnie47 » Sun Feb 27, 2011 12:40 am

Well, even with the CPAP, what I am experiencing is that the moment I am transtioning into sleep, I have this weird chest tightness and some kind of a feeling of spasm in my throat below my voice box and it wakes me up. This cycle continues over and over again and the end result is I dont sleep. I saw a cardiologist as well and he did not find anything wrong with me. I am not sure if this is due to the fact that there is less oxygen. But if it was due to lack of oxygen, then wouldnt't CPAP resolve it?

Yesterday was the only night I slept well, and so I was trying to talk myself out of wearing/needing a CPAP :cry:

Anyways, I think I will try CPAP today and tomorrow. If this weird thing continues, then I will call my sleep specialist on Monday.
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Postby Janknitz » Sun Feb 27, 2011 12:48 am

The ramp feature on machines is designed to start the pressure at its lowest setting (usually 4 cm) and gradually increase to your full titrated pressure over a period of time. The idea is that you will be asleep by the time full pressure is reached, and that you will be more comfortable while still awake on a lower pressure. That's the IDEA, but the reality is very different.

If you are using a ramp feature on your CPAP or it is an autoset with a wide pressure range, it could very well be that when you are falling asleep there is not yet enough pressure to keep your airway open. It's very common to have apneas right a that "transitional" stage of sleep. The ramp is a "comfort measure" intended to help you get used to the pressure, but it often sets newbies up for failure because your body quickly figures out that that's not enough pressure. And an auto CPAP starting with a pressure too far below your titrated pressure can do the same thing. Furthermore, your early stages of lighter sleep can be disturbed by the pressure changes from the ramp or the auto features (when the auto is set too low).

If you tell us what machine you are using and the settings, that might help us help you. If the ramp feature is on, you can try shortening it, raising the starting pressure of the ramp (assuming they have not locked you out of the patient controls for this feature) or turn the ramp off altogether if the full pressure doesn't bother you.

Most of us chuck the ramp after the first few days. The manufacturers make a big deal of this feature, but I personally think it is a major factor in why a lot of newbies don't have success with CPAP in the first place.
Last edited by Janknitz on Sun Feb 27, 2011 1:15 am, edited 1 time in total.
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Postby Ronnie47 » Sun Feb 27, 2011 1:14 am

I have a Phillips Respironics Remstar AFlex. The lessors is 5-8. There is a button to reduce the pressure, but none to increase it.
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Postby Ronnie47 » Sun Feb 27, 2011 1:15 am

I meant pressure is 5-8
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Postby Janknitz » Sun Feb 27, 2011 1:32 am

That's a good, narrow range.

Does it start at 4 or 5? What was your titrated pressure?

And what are your AHI's? (scroll to info, scroll to AHI).
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Postby Ronnie47 » Sun Feb 27, 2011 1:43 am

"CPAP pressure was started at 5cm/H2O and titrated up to 8cm/H2O with 3cm of C-flex. Initial AHI - 30.2 / hour. AHI After CPAP - 0.2 AHI" - This is what the sleep study says.

The Big question - Why dont I get any sleep :cry: I dont mind using the CPAP, only if I get some god damn sleep...
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