Is this a SBD? What can I do to test it myself?

[Trimochio]

Hi all. I've been experiencing middle of the night awakenings since late August last year. I'm currently in the process of trying to get a sleep lab study done but the earliest appointment is 3 whole months away and if possible I'd like to get the issue addressed much sooner than that. What bothers me is that I've been doing a lot of reading on related topics within the past year and the common sleep breathing disorder symptoms don't seem to align with what I'm experiencing. When I wake up, I'm not gasping for air or needing to use the toilet. I don't wake up with headaches, although I tend to get headaches later into the day. Past the MotN awakenings, I also tend to wake up too early in the morning, tired but unable to fall back asleep, even when I don't have to get up early. The most noteworthy aspect imo is how seemingly "nothing" is waking me up and I simply wake up without any stimuli like pain. I'll be listing as much relevant information as I can to see if anything jumps out to you.


-I've always had poor sleep quality. Being started on Mirtazapine (15 mg) early last year made me realize just how poor my general sleep quality was. Even though in the past mid-night disruptions weren't common, the quality of sleep was such that I'd regularly feel tired every day. 
-2 things I can think of happened roughly around the time the sleep problems started: I finished my Invisalign sets and switched to retainers, and I was converting from stomach sleeping to back sleeping to address my back and neck pain. Noticing the possibility, I've tried switching back to stomach sleeping a few nights and no dice.
-I consulted an ENT doctor who identified nasal abnormalities (concha bullosa, deviated septum, enlarged turbinates and adenoids) that would suggest sleeping issues. We tried Montelukast which subjectively seemed to make an improvement. That, alongside how congestion was seemingly causing me to wake up when I was sick, made me really think that was it so I had sinus surgery. It's been 2 months since and while I do think there's been improvement in the quality of rest, I've still been waking up.
-Post-operation I've been using Mometasone and Mupirocin ointment in my left nostril. Even though it's not supposed to have this effect, I feel like my sleep quality is better when I have it applied compared to the nights I didn't. This makes me suspect that maybe the ointment is catching allergens, but it's only my left nostril, w
-I had a home sleep study which returned inconclusive. It showed low (2.6) AHI but snoring the whole time.
-I was started on Trazodone (50 -> 100 mg) to combat the sleep issue. It does seem to improve quality of rest but again, doesn't stop me from waking up.
-I've tried switching over to side sleeping, favoring my right side. Recently I've been wearing a drawstring bag stuffed so that I can't roll over onto my back. The result...is that I'd still wake up on my side at least but with a strong urge to roll over or at least switch sides and the bag really gets in the way of that. Initially my theory was that I'd start sleeping on my side and the wake up happens at some point after I inevitably roll onto my back, but now it seems like that's not the case? 
-Just in case, I'm young enough that age-related sleep changes shouldn't be a factor and I exercise regularly too, which doesn't seem to have a direct effect. 

Pretty much the only thing I haven't tried yet (other than a CPAP which I can't get) is a wedge pillow and/or soft neck brace. I'm not above shelling out for either of those as I'm desperate for relief, but I also don't want to stretch myself too thin between all these things I'm trying. Not to mention that I'd imagine either of those could negatively impact my sleep quality at least initially when adjusting to them.

[PeaceLoveAndPizza]

First, we are not doctors, just CPAP users helping other CPAP users. 

You certainly have a lot going on there. The only way to know if you have SDB is to be tested either in a home or lab study. 

My recommendation is to see a sleep doctor and get tested. That would remove all doubt.

[Trimochio]

I understand that I can't rely on internet strangers for a clinical diagnosis, which is why I mentioned the pending actual sleep lab study. This is just me trying whatever I can in the meanwhile and hoping something happens. Get some extra perspectives and/or affirmations and all that.

[PeaceLoveAndPizza]

Some of us are more strange than others. A moniker we wear proudly.

The best you can do in the meantime would be to try using a flatter pillow and maybe mouth tape or a soft cervical collar. Some have found using a wedge pillow helps as well.

Outside of that I’ll let others with more experience offer suggestions.

[Trimochio]

I've been conflicted about wedge pillows because on one hand I hear about how elevation helps SBD and on the other hand I hear about how chin-tucking is a potential cause of SBD and I wasn't sure which one to believe. I only just now realized the two points are not contradictory and wedge pillows are supposed to give your head elevation without angling your head into your neck, right? That sounds like a solid lead.

[BoxcarPete]

Your experience is not terribly different from mine. I got a diagnosis of mild OSA back in 2020 after complaining about constant tiredness, with overall AHI of 5.6, but REM clusters of 25+ and no events otherwise. Your home test report may not include information like clustering, so an in-lab study might still be worth looking at. After several years of trying different things, I ended up with a triple nasal surgery this past January (septum, turbinates, and adenoids). Follow-up home study had me around 3.4 (and still occurring in ~20-minute long clusters) but I requested an in-lab to correlate to the original test because it's pretty well-established that home tests aren't great for mild cases, and it came back squeaky clean.

What's also similar is that we both wake up in the night for no apparent reason. Once I got my 0-event PSG it started getting better (see point two, below). The doctor gave the biggest shoulder shrug possible using medical lingo about the awakenings in my report. I also often get the strong urge to change sleep positions when this happens, especially early in the morning.

Now, my questions for you:

1. You had a "sinus surgery" a couple months ago. What exactly was done? If septum, turbinates and/or adenoids were not touched, I would recommend going back for whichever of those did not get addressed if you can.

2. Are you overly stressed? I had a bunch of issues along my path which could be explained by sleep problems or other issues, but I kept it in my head that there was no problem I had that was incompatible with excess stress. Taking up Brazilian Jiu Jitsu has done wonders for me on that front. There's nothing quite like getting on the mats and engaging in some primal ape-on-ape grappling to clear out all the pent-up stress that we inevitably accumulate in this modern world of ours. I mention this because I get the impression from your post that you're in the under-40 crowd with no other medical issues of note. I started last year in my 30s and am glad I did.

3. As far as wedge pillows go, I tried one and it made everything worse. I'm glad I didn't throw it away because I used it twice since then (when I injured my shoulder at BJJ and after nasal surgery to elevate my head), but it's horrible for me in general sleep. Those two points are in fact not contradictory, but as I understand it the sleep elevation is better for "classic" sleep apnea patients with loose flesh in their necks that can sag down, rather than younger fitter people who tend to have firmer airway obstructions that are structural in nature. For me, prior to my second adenoid removal, I could tuck my chin to my chest and block 80%+ airflow even against my full conscious effort, but after surgery the tucking of my chin has no effect whatsoever.

4. One more question: how firm is your mattress? I always suspected that my in-lab study was not as bad as a normal night, and my second round of testing indicates that that might yet be the case. They have firmer mattresses at the sleep lab than I have at home, and I also usually get really good sleep in hotels with firm mattresses. Best sleep I ever get though is camping where my hips literally have nothing to sink into. It's a different form of positional apnea which I am starting to find for me connects to hip-shoulder alignment; the wedge pillow will do the opposite of good for that if it's part of your problem.

$0.02

[Trimochio]

Thanks for sharing your experience! To answer your questions:

1) The complete procedure was to address the nasal issues I listed, so there was septoplasty, adenoidectomy, and crushing of the concha bullosa (air bubble). I'll have to double check the extent of the procedures because my doc did mention that the septum was greatly improved/straightened but not all the way because of just how crooked it was before, and she advised against going further. 

2) The only stress I've been having lately entirely stems from the sleep issues because of how persistent they are and how they came out of nowhere. Before this started, I'd actually say I was in a very good spot because the Mirtazapine was working miracles for my general sleep quality and mood/energy levels. I don't practice martial arts but I make it a goal to hit up the gym for half an hour daily of mostly cardio (stairs walking). I've been trying to go in the morning before work rather than after work because exercise improves sleep and supposedly the earlier you exercise the better the effects. In truth, I can't say I've noticed a positive correlation between any amount of exercise at any point in the day with an improvement in sleep quality but it's healthy so whatever.

3) This is a really interesting point! Since the issue was chin-tucking, did you try a soft neck brace and if so, did it help? 

4) I'll have to do some research to figure out how firm or soft my mattress would be considered. All I really know is that it is memory foam and that I've been using it for years already. I didn't consider it as a potential factor because it wasn't a new element and I slept extremely well during the period between starting Mirtazapine and before the mid-night awakenings started. I suspect my mattress is on the softer end so I guess trying a firm topper is a potential direction. Fwiw, I did sleep on a firmer/thinner mattress for a night and there wasn't an improvement, but at the same time it was also a crappy mattress so lack of comfort might've canceled out the hypothetical upsides of going from a soft mattress to a firm one.

[BoxcarPete]

1. That's good to hear. I had mine done in January, and I'm still feeling improvements come in now that allergy season is coming to a close. I hate it when doctors tell me this, but give it some more time and you might continue to breathe easier.

2. Chronic stress is insidious and pervasive because stress makes the body more sensitive to stressors. You may think sleep problems are the only thing stressing you out, but even if you're right, that might be enough to keep you in a stress trap. Gym workouts are enough for my wife, but she goes every day and sometimes twice. I personally wouldn't get enough out of a little simple cardiac agony; I need to do something competitive to really clear my head. You may need to do something bigger to get ahead of the problem, then your stated routine might be enough to maintain a healthy level once you've cleared it.

3. I tried it, found that it gave me some limited benefit, and somehow lost track of the thing. I think my wife may have thrown it out.

4. Firm topper on a soft mattress generally doesn't work that well, unfortunately. Much more effective to go the other way. You can try something like laying on the couch with pillows wedged below your hips and/or shoulders, and try breathing gently in each position to see if it might even make any kind of difference to you at all. I have a hybrid spring/memory foam bed and it's about 10 years old now. It's a little wallowed where I lay down, so if I move a little bit I sag back toward my default bed position, so it's time for a new one.