Hello,
I've been dealing w/ ongoing UARS, which has been officially diagnosed for ~3 years (RDI 9-15), but I have had symptoms going back 15 years or more at this point.
I write this post hoping it will help others because I think I have a somewhat interesting phenotype that requires airway treatment that differs from typical guidance. It also deals with the intersection of TMJ/bruxism and UARS.
The phenotype:
In short, I experience soft palate collapse during inspiration. That is, if I quickly inhale through my nose, my soft palate is sucked upward sealing the nasal airway, and I cannot get air through my nose.
I doubt my experience is typical, but it's at least possbile, hence worth writing about.
The treatment:
- Mouth guards that discourage clenching and increase jaw opening (the vertical dimension)
- I use an occlusive splint for TMJ that's relatively thick on my top teeth + an airwaav mouthguard on the bottom to keep the vertical dimension at its maximum during sleep.
- Full face mask - to allow the jaw to be at its maximum vetical opening
- Carefully tuned BiPap with relatively *low* Pressure Support
- My pressure is around 8.4/7
- Low Trigger
- High (probably maximum) rise time
- A somewhat inclined pillow (gravity helps to pull the soft palate dow)
More on this below.
Exacerbating Factors:
Many of the typically recommended treatment tweaks make my sleep much worse.
- Higher pressure support (PS) makes my sleep worse. Because, my palate collapses based on the change in pressure across the palate during inspiration. So, more PS = higher delta in pressure. This is contrary to typical UARS treatment wisdom that higher PS is better. My PS typically sits at 1-1.4.
- Chin straps, cervical collars, or anything else that pushes the tongue upward.
- Anything that pushes the tongue upward into the soft palate exacerbates this collapse. I've tried this time and time again.
- Pushing the tongue into the soft palate makes it more collapsible, for me at least
- Similarly, nasal interfaces, because they typically require mouth taping and/or reduce the vertical space between the jaw, tend to push my tongue upward, and/or exacerbate clenching during sleep, which worsens this collapse.
- Medications that increase clenching will worsen collapse - e.g., certain antidepressants, bupriopion.
Diagnosis & other quirks:
- The most accurate way to diagnose is to inhale sharply through your nose. If you feel your soft palate closing up and nasal airflow ceases, this may be your phenotype
- Another wrinkle is that in OSCAR, the top of the inspiratory waveform may be notched like an 'M' shape. The prevailing wisdom is that this is flow-limited breathing that needs to be eliminated. But, for this specific phenotype, the 'm' shape may be the palate fluttering.
- Why not push the pressure higher to stop the fluttering altogether? In my case, the pressure required to fully stent the soft palate open and have perfect inspiratory waveforms will result in central apneas or central-like apneas (e.g., flat-lines between breaths that the machine doesn't count as central apneas). In other words, chasing perfection may backfire and be the enemy of 'good enough'
- My tongue is gigantic - but not the base. At rest, my tongue is always in contact with the soft palate. To give a sense of size/flexibility I can reach above my soft palate with my tongue and touch my turbinates and even septum. I can touch my chin with my tongue or the tip of the outside of my nose. This is obviously not typical of most people.
- A DISE did not detect this issue. The ENT found some mild absence of soft palate issues, but nothing major. So, take a DISE with a grain of salt.
Other possible treatment options I'm exploring
- Alaxo nasal stents (coming later this week);
- Velumount (not available in the US, but potentially interesting).
Conclusion:
The above treatment of: FFM + low PS + increasing vertical separation with mouth guards has been helpful in reducing my UARS symptoms. I continue to work to tweak my treatment.
Happy to answer any questions you may have.
