If you're a snorer or share a bed with a snorer, you're all too familiar with the elbows and "ROLL OVER!"s that come with sleeping on your back, also known as supine sleeping. The fact is that most people with snoring and sleep apnea will have worse symptoms when they're on their backs. Why is this? The same reason that apple knocked Sir Isaac Newton in the head: gravity! To better understand this phenomenon, let's delve into the "pathophysiology," or abnormal anatomical process, that causes snoring and obstructive sleep apnea. Take a look at the diagrams below:
Anatomical relationship of structures in posterior upper airway in snoring and sleep apnea
As the soft palate starts to fall back and block the airway, snoring begins as a result of rapid airflow through a tiny tube, causing a vibratory effect. I often tell my patients that it's similar to what happens when you blow forcefully through a straw.
When you sleep on your back, gravity pushes your soft palate further down, blocking more of your airway, and leading to more frequent and loud snoring and, potentially, abnormal breathing episodes such as hypopneas ("reduced breathing") and apneas (complete cessation of breathing).
Interestingly, it turns out that, in addition to obstructive sleep apnea, central sleep apnea (the type of sleep apnea where the brain forgets to breathe) can be worse in the supine position as well. Research is ongoing to try to uncover the physiological reason.
Diagnosis: Positional Sleep Apnea
The diagnosis of sleep apnea requires a sleep study showing an "apnea-hypopnea index" (AHI), an average of the abnormal breathing events occurring per hour, of 5 or more. The governing body of sleep medicine, the American Academy of Sleep Medicine, defines positional sleep apnea as having a lower AHI in the nonsupine position (side and stomach sleeping) compared with the supine position. In practice, we sleep medicine doctors generally use the criterion of an AHI that is at least double in the supine versus nonsupine position to define clinical positional sleep apnea. For example, if your composite AHI for the entire study was 10, and your AHI supine was 20 or more, you have positional sleep apnea.
Treatment: CPAP, APAP and Alternatives Including Positional Therapy Devices
CPAP is considered the "gold standard" treatment for all types of sleep apnea. However, patients with positional sleep apnea often don't do well with fixed-pressure CPAP. This is because they usually need a very low pressure when they are sleeping in the nonsupine position but when they roll onto their backs, they need more pressure to keep the airway open. The machine, having been set to one consistent pressure, doesn't give it to them, and they often rip the mask off in a semi-groggy state and, the next morning, may remember a vague feeling that the mask made them feel "claustrophobic." This is a typical scenario that I frequently encounter in my clinic.
APAP to the Rescue
Autotitrating positive airway pressure or APAP, also known as AutoPAP or Auto-CPAP for short, can solve this problem by giving you pressure "on-demand" when you need it. For folks with positional sleep apnea, this means that you when you roll to your back during the night, the machine ramps the pressure up to match your body's needs. If you later roll to your side or stomach, the machine will decrease the pressure to the lowest pressure that you need to keep your airway open in those body positions. I have found that patients who suffer from positional sleep apnea often do much better on APAP.
Positional Devices for Snoring and Sleep Apnea
For those of you who would rather have a root canal without novacaine than wear a mask while sleeping, fortunately, there are other options out there.
First, some background: in order to be marketed for the "treatment of sleep apnea," products must undergo rigorous testing and be approved by the FDA. These products require a prescription from a licensed provider. Non-FDA approved products have not gone through the same testing and therefore can only be marketed for "snoring." Whether there is a substantive difference in efficacy between "FDA-approved" and "non-FDA approved" products is a matter for debate.
The longest standing remedy for positional snoring and sleep apnea has probably been sewing, or otherwise attaching, a tennis (or similar) ball to the back of a sleep shirt. Sleep doctors have been recommending this intervention since the dawn of sleep medicine, albeit with little long-term success. The failure rate is high with this method because it doesn't prevent you from rolling to your back, it simply wakes you when you do. You then roll onto your side, fall back asleep and a short while later, the same thing happens again. There is a common belief that you can permanently train yourself to sleep on your side with just a few weeks of the tennis ball method, which is a myth. Which leads me to the next subject...
Pillows & Body Pillows
Using pillows to prevent oneself from rolling onto the back sounds like an effective remedy, right? Wrong. More times than I can remember, I have had a variation of this conversation after recommending a trial of positional therapy:
Patient: Doc, I've figured out a system where I hug one pillow, then I put a pillow between my knees and have a body pillow behind me. I'm cured!
Me: Are you sure that you're not sleeping on your back at all anymore?
Patient: I'm 100% certain!
Me: OK, let's bring you back into the sleep lab for another study using your system. If it works, great. If not, we're trying something else.
Invariably, as I review the video from the previous night's sleep study, I see the patient roll onto his or her back shortly after falling asleep, scattering the pillows aside.
Now let's shift gears and discuss some more effective strategies...
Non-FDA Approved Devices
An air bladder in the rear compartment creates a wedge when filled that prevents supine sleep. At $89.95, the most affordable positional device. Larger folks may require an additional extension belt.
The inflatable "bumpers" add comfort to this well-received product that also acts as a physical barrier to prevent you from sleeping on your back. An affordable option.
FDA Approved Devices:
The Zzoma was one of the first products on the market for positional sleep apnea and remains one of the most popular non-CPAP solutions for this problem. FDA approved so it requires a prescription. The angular soft-foam wedge is designed to keep you sleeping on your side or stomach only.
The new kid on the block, it was released by Advanced Brain Monitoring in 2014. The NightShift is billed as the premium and most comfortable positional therapy device on the market. It promises to keep you off your back by using a built-in accelerometer to detect when you move onto your back. Then it gives gentle vibrations that escalate in intensity until you roll over. This device also requires a doctor's prescription.
Finally, a word about yet another form of treatment that may benefit those with positional snoring and obstructive sleep apnea -
Mandibular Advancement Devices (MAD):
As you can see from the diagram above, these retainer-like dental devices can hold the lower jaw in a forward position, preventing gravity's effect on the upper airway. They also come in two types: FDA approved for obstructive sleep apnea and non-FDA approved only for snoring. They are a good option for people who are not overweight or obese but have certain jaw structures, like retrognathia, shown below:
MADs can be quite pricey, often costing between $1500-2000. However, the ApneaRx is a new, more affordable option. Other downsides include TMJ dysfunction (or worsening of TMJ symptoms if you've already got them), as well as teeth movement that can affect the way your teeth come together, potentially causing other dental problems and headaches.
Positional snoring and obstructive sleep apnea are extraordinarily common problems. Fortunately, there are so many treatment options out there that there is bound to be one that suits you...or your noisy bedpartner!
Joseph Krainin, M.D., FAASM is the founder of Singular Sleep, the world's first online sleep center. He is a Fellow of the American Academy of Sleep Medicine and board certified in both sleep medicine and neurology. He has been practicing medicine for over 10 years.
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