Mandibular Advancement Devices: #1 Snoremate

If you've never seen one of these devices before, imagine it as a two gumshields stuck together, with the gumshield for the lower teeth fixed so that it forces the wearer to jut their jaw forward. The mandible is the jawbone, hence the term "Mandibular Advancement"

The idea behind this is that forcing the jaw forward creates more room in the airways by shifting muscles and fat forward slightly, reducing the likliehood and severity of airway obstruction.

Mandibular advancement (either by a specially made dental device, or by surgery) is a tried and tested concept of reducing snoring and sleep apnoea, so I'm not really putting that to the test, but rather I'm trying out the off the shelf concept, although my snoring is sleep-apnoea related, so unless the device can remedy the apnoea, I doubt that it will affect my snoring. 

SnoreMate

This is an off-the-shelf (but custom fit) mandibular advancement device (MAD).

The SnoreMate is made from a thermoplastic that you dip in hot water to make it soft, then bite into it to form a custom fit for your teeth. The SnoreMate can be adjusted by re-dipping it in hot water if you feel the need to advance your lower jaw more to increase the effectiveness of the mouthpiece, something that I did after a few nights of using it.

It was easy to mould, and is the most comfortable of the two mouthpieces that I've tried so far (the other device being the SomnoFit) which I found was too bulky to be comfortable for me). I was surprised that on the first night It stayed in place until around 2am, and on subsequent nights (to get used to it before I monitored it) it remained in place until the morning. It was actually quite easy to get used to. In fact it was surprisingly comfortable, so I purchased a second Snoremate and moulded that one slightly further forward rather than risk losing the comfortable positioning of the first one.

However, there are a couple of drawbacks to the mouthpiece, the main one is saliva build-up! I found myself waking at night just to swallow and clear my mouth. The other drawback is that my gums and a couple of teeth ached for a few of hours in the morning.

As far as snoring reduction went, using the method explained in this post, I was very surprised. I imagined that everything I used in addition to the Rematee would either improve on the Rematee's effect or make no change. I think that the graph shows why I was surprised...

The SnoreMate actually made my snoring louder! This would have been very annoying for anyone in the house as I managed to reach 98db (about the volume of a drill drilling!). This is an unacceptable volume when you consider that I was already sleeping on my side and wearing a mandibular advancement device. Although to be fair, it is an anti snoring device, and my snoring is more than snoring, it's related to sleep apnoea.

In the following clip it resembled a moose-call.

However, I had a lower AHI for the three nights (mean 2.05) with one of the nights using Snoremate with the Rematee giving me my lowest ever AHI of 0.77.

If I had to speculate as to why the snoring increased in volume (and sounded slightly different in tone) yet the AHI was lower, I'd have to say that it was probably due to the fact that, by design, it is impossible to breathe through your mouth with the SnoreMate, so the air has a to take a different path through the nasal passages, rather than through the open mouth of the snorer.

Even wilder speculation:  The SnoreMate was probably doing what it was intended to and tightening / stretching the muscles in the airways meaning that they were less prone to relaxing, hence less hypopneas. Again, further speculation, but it is possible that this also caused the snoring to be louder in the same way that in deflating a balloon a screech caused by keeping the neck taut is louder and higher pitched that if you were to let the neck relax causing a quieter lower-tone rapserry sound.

I was so intrigued by this hint that it was working, that I've made an appointment at my dentist to have a professional Mandibular Advancement Device constructed for me and I'm looking forward to being able to compare the results. My hope is that the professional device will allow me to further advance my jaw, keeping my airway muscles even tighter, elimating my apnoeas and maybe my hypopneas (and hopefully snoring too).

Sleeping Position - Supine AHI: A Baseline Measurement

Looking at my previous data for my 5-day mean AHI, you can see some variation on the day-by-day AHI measurements. 

It makes sense that each night will be slightly different but I still wanted to identify and eliminate some of these variables. Now that I know that my sleep-apnoea is positional (mainly when supine) I can attribute some of the night-by-night changes to my sleeping position.

Using the Black Shadow sleep monitor, I am able to automatically record my body position during the night. This is a recording of my sleep position for a single night.

 AHI = 9.30

As you can see from the above chart I spent a fair chunk of the night on either my right or left side. Those short spells on my back are when my sleep apnoea kicks in (or the snoring is so loud that it wakes me up). The reason that they are only short spells is that the apnoeas briefly wake me causing me to move onto my side for an hour or so before ending up on my back again (and beginning the cycle again). Towards the end of the sleep I remained on my back despite the apnoeas causing repeated micro awakenings (micro-arousals).

Prior to having access to accurate sleep position data I was aware that sleeping position (and other variables) could affect my AHI, so in my previous experiments I tried to eliminate its effects by recording 5 consecutive nights and calculating a mean AHI. Solely recording one night could have given a falsely low AHI because if by sheer chance I managed to spend the majority of the night on my side then my AHI would have been lower. This lower AHI would actually be masking my problem.

A recent paper by Sunnergren, Broström & Svanborg shows that "Position–dependent obstructive sleep apnea (POSA) was common both in subjects that by American Academy of Sleep Medicine classification had obstructive sleep apnea as well as those without. The severity of obstructive sleep apnea, as defined by American Academy of Sleep Medicine, could be dependent on supine time in a substantial amount of subjects".

This hints that people are slipping through the net and missing out on a diagnosis and treatment. 

It is for this reason that a sleep-study conducted in a sleep-lab or a hospital tries to have at least part of the night recorded with the patient sleeping on their back (and with some REM sleep too).

The Visi-Download software allows me to include/exclude portions of the night based upon custom criteria, so I manually selected only the times that I slept on my back and re-ran the analysis.

Using this method, my Supine AHI for the 9.30 night shown above was actually 12.73, for which I snored at a level of above 55db for 95.5% of the time! For the record, my lowest oxygen desaturation took me to 79%.

Using this method, my supine AHI is more stable, (although not completely the same every night) this demonstrates that this is actually a more consistent method of calculating my night-time AHI, although for others with non positional apnoea it may well be a different story.

I plan to carry out some further monitoring without the Rematee, so this is the method I will use to ensure a fairer compaison between nights.

Sleeping Position: Get off your back!

When you have a multi-channel sleep study, one of the "channels" that is examined is the position that you sleep in.

At first this may seem a strange thing to monitor, after all if you manage to achieve sleep, who cares how your inert body is positioned? 

Sleep position affects several aspects of our sleep, for example when I sleep on my back I find that:

• I experience more sleep paralysis
• I experience more body twitches as sleep begins

• It's also known that breathing is harder when sleeping flat on your back (supine), it is for this reason that patients with higher level spinal injuries are recommended to sleep with their head inclined and foot of their bed lowered as this can actually increase their vital capacity
• GERD / Acid Reflux / Heartburn is affected by sleeping position. Raising the head of your bed can prevent or at least reduce reflux episodes.

However, in this blog-post I'm going to concentrate on another major effect that supine sleeping has on the sleeper...

Supine sleeping can dramatically increase the number of obstructive apnoeas and hypopneas a sleeper has through the night!

The reason for this is that gravity has a greater effect on the muscles and soft tissues that relax in sleep and cause obstructive apnoeas. If you can lie on your side then gravity doesn't affect them in the same way, and can go some way to keeping the airways open during sleep.

Invariably we move around in our sleep so I needed a way to monitor my sleeping position as my monitor doesn't have this ability.

More sophisticated sleep study devices do this automatically, and there is actually an iPhone app that can do this for you too: Somnopose, after a couple of night of experimenting with the app you should be able to get a fairly accurate reading. You will probably be surprised how many times you actually turn over in your sleep.

This was actually quite easy for me to do manually as I already had my infra-red camera watching me for several nights during sleep. I then analysed the video to determine my sleep position. As well as recording continuously, the camera creates a new file every time it detects movement, so all I had to do was flick through the files and record the position on a chart alongside my oxygen desaturations. I did also plot a chart of body position against detected apnoeas, but the chart below shows things clearly enough.

 s=supine (back), p=prone (front), l=left down, r=right down

It was no surprise to see that the majority of my apnoeas and hypopneas occurred when I was sleeping on my back.

On several nights I deliberately began sleep on my side, but always woke to find myself flat on my back again and with a high AHI recorded. I needed a way to prevent myself from turning over in the night.

Years ago, a solution to positional obstructive sleep apnoea was to "sew a tennis ball into the back of your pyjamas", this had a "Princess and the Pea" type effect on the sleeper and caused them to be uncomfortable if they turned over and slept on their back.

Nowadays there are more sophisticated solutions, and the one that I put to the test is called the "REMATEE Bumper Belt". It's a neoprene belt that velcro fastens around your chest. At the back of the belt are pockets into which you place inflatable "bumpers". Sounds strange?

It may be clearer if I show you a photo of what I'm describing. Rather then subjecting you to a screen-capture from my camera, I'll use a product photo instead (click for a larger version).

It's surprising how quickly you get used to it.

My belt also has shoulder straps to stop it turning round in the night although when it first arrived I was slightly daunted by the idea of being strapped in, so I decided to tuck the shoulder straps into the pouches that held the bumpers.

I found that if the belt was tight enough then I didn't need to use the shoulder straps, but it does take a few nights of trial and error to get used to how tight to wear it and how much air to put in the bumpers.

When the belt first arrived I tried it out for a few nights without monitoring my breathing and found that it did affect my Zeo stats. It increased my REM sleep. It also reduced the number of awakenings that I had through the night.

Initially, it seemed to decrease Deep (SWS) Sleep but this stopped and my SWS actually increased after a few nights of using it. (See graphs below).

Then I began my five nights of recording my breathing...

Again I followed my rules for determining my 5-night mean data with the obvious exception of not beginning the night by sleeping on my back. I also didn't take any of the supplements discussed in this blog, and I stopped the vitamins and minerals on the Friday beforehand to try to eliminate the effects of those on my sleep.

The results were clear:

The REMATEE belt kept me off my back and reduced my oxygen desaturations:

 s=supine (back), p=prone (front), l=left down, r=right down

My AHI each night was dramatically reduced:

This brought my 5-day mean AHI down to 1.70.

This makes the REMATEE the most effective method that I've found so far to reduce my AHI. 

The reduction in respiratory events (reflected by the reduced AHI) also had a positive knock-on effect on my Zeo data...

Considering that most of my respiratory events happen in REM sleep, it makes sense that when the number of events was reduced, my REM increased (because it was not being broken by me waking up to breathe). As already discussed, my Slow Wave Sleep (deep) also increased.

Will I carry on using the REMATEE? Definitely.

As a follow up, I plan to combine the REMATEE belt with my 5-HTP routine as both seem to reduce my AHI through different mechanisms. Maybe their combined effect will be greater than as individual methods.

Additional Links

The REMATEE Bumper Belt is available in the UK from Intus Healthcare: 
http://www.eu-pap.co.uk/rematee-neoprene-bumper-belt.html

REMATEE http://www.antisnoreshirt.com/

5-HTP, Serotonin and Sleep

 

For the last 5 days I've been taking 5-HTP.

5-HTP is a precursor to serotonin (that is, it becomes serotonin once metabolised by the body).

I've previously used 5-HTP for experimenting with my sleep composition, and to try to reliably trigger lucid dreams. The dosage that I was taking then was 50 - 100mg at night.

This time I tried a brand that contained "co-factors". These are associated vitamins and minerals that help the body to metabolise the 5-HTP into serotonin. 

I decided on 200mg each night about 10 minutes before getting into bed. 100mg is the recommended maximum daily dose of this brand, although I have seen others that give a maximum daily dose as 300mg.

I have also seen medical literature that cites doses of 150mg-300mg as a daily dose (as a trial for treating depression), so toxicity at this dose seemed unlikely.

Why did I take 5-HTP?

The rather lazy answer is that (as I mentioned above) I've taken it before without ill effect, and that it is mentioned to have a positive effect on sleep, even being cited as having a positive effect on a severe case of insomnia 

A rather cheeky and over-simplified answer is that I have already shown that a depressant (alcohol) increases my AHI, so I wondered if something that has antidepressant properties would have the opposite effect and reduce my AHI.

I have also seen medical literature that suggests a link between depression and sleep apnoea (both as a cause and effect of sleep apnoea). 

Depression is more complicated that just having low serotonin levels, but low serotonin does play a part. Serotonin is a neurotransmitter (it is used in the body's sending and receiving of nerve impulses), so I wondered if increasing my levels would mean that I would have stronger signals to breathe during sleep and that the muscle tone in my airways would be that much "sharper".

Okay, so how did the 5 days go?

I noticed the following effects (sleep related and non-sleep related):

• I wasn't as tired in the evenings, so went to bed later
• I found it easier to wake up
• I didn't feel as hungry during the day, generally ate once at 2pm, then didn't eat in the evening.

Throughout these experiments, I go to bed when I am tired.

I calculated my average bedtime using the Zeo data. As I am doing these 5-day comparisons on weekdays (except the alcohol test - see separate blog for that), the time that I had to wake up was the same each day, hence later to bed meant less time in bed, which oddly with the 5-HTP didn't feel like a bad thing.

 

I wondered if my body "needed" more sleep, afterall I am used to roughly an extra hour (and still crave more), but on two mornings of the week (Fri and Sat) I can have a bit of a lie-in if I need to but I didn't want to lie in when taking 5-HTP at night (It's Saturday and I'm typing this at 7am, after waking up at my normal weekday time of 6:30am)!

It is known that some anti-depressants can decrease the amount of REM sleep that you have, so I suspected that my percentage of REM would decrease.

As percentages, the figures do not show this. In fact they show an increase in the percentage of deep sleep, along with a slight increase in REM and wake...

However, as REM is more abundant at the end of the night, it follows that the less time one spends in bed, the less opportunity there is for REM sleep, hence my actual 5-day-mean time in REM fell by 11 minutes from my baseline of 98 minutes, although it put it more inline to the average for my age of 90 minutes.

My actual time in slow-wave sleep (deep) rose by a mean of 3 minutes.  My mean deep sleep (34 minutes) is still way below the average for my age (69 minutes) but within limits, so I am pleased with this small increase.

I'm not sure if these changes are actually significant, perhaps a longer trial may reveal more?

So, even if 5-HTP didn't affect my AHI, it still had positive effects on several aspects of my sleep composition. 

However, it did have a positive effect on my AHI and it was much more noticeable... 

I've graphed my 5-day-mean AHI alongside the other 5-day-mean AHIs for alcohol and my baseline.

It brings my mean AHI down to a level that puts me in the "normal" category (<5 AHI = normal). Maybe this is the reason for not wanting to sleep so early and finding it easier to wake in the mornings.

For the sake of showing that this is a consistent effect, I also graphed the data on a night by night basis... 

For now, this seems too good to be true: 

• Lower AHI
• Normal bedtimes
• Less time in bed
• Increase in slow-wave sleep

So what now? Keep on taking the tablets?

Based on my limited data, I wouldn't dare go so far as to claim that this is a effective treatment for mild (very mild) obstructive sleep apnoea, nor would I suggest that it would work for others, but it is intriguing and does need looking at further.

It leaves me wanting to know more about the mechanism behind this effect. Yes, it's good that it has helped me as far as my AHI is concerned, but I want to know how. In a previous post, I noted that my sleep apnoea seems to be REM related. Serotonin related activity drops dramaticaly during REM sleep, so maybe the higher levels due to 5-HTP reduced that effect?

Is my pseudo-science hypothesis correct, or is there more to it than that?

I'd be interested to see if this effect carried on, or if my body got used to the 5-HTP and the effect faded.

I'd also like to try this with a lower dose of 5-HTP (after all, why take a high dose if you don't need to)? I'd also like to see if sustained-release 5-HTP is more effective.

I was planning to try the mandibular advancement device next, but after such a positive effect, I think I'll stay with 5-HTP for a while and see if I can improve on the results even more. I'd like to bring my sleep latency (time to sleep onset) down.

Yes, this is good news but I can't help feeling a little like Lizzy in "Drop Dead Fred", she knows that she's taking a pill that will stop her seeing things that others can't. Will taking 5-HTP, increasing my serotonin levels and bringing my AHI down stop me from having sleep paralysis, lucid dreams and seeing/hearing the sleep-wake border imagery that I have grown so used to? 

I hope not.

I'll explain how and why I came to like sleep paralysis in an upcoming blog-post. Hopefully it may be of use to anyone that fears it as I used to.

I have to say that this is a test with a tiny sample size, and of limited duration. I am not suggesting that anybody should try this, and certainly not use it in place of recognised treatments. 

Update on Saturday, May 12, 2012 at 7:54PM by Hypnagogia Blog

I've also found that 5-HTP helped reduced residual snoring after lowering my AHI with positional therapy.

Snoring Remedies? Results for 5-HTP

Apnoeas, me? My Baseline AHI

I'm going to be exploring some of the sensible and not so sensible suggestions in order to bring down my AHI (see my post "What is an Apnoea?" for an explanation).

To do that I needed reliable data, so I decided on a 5 day mean with a few basic rules:

• No coffee after 3pm
• Monday - Friday monitoring only (to ensure routine sleep and wake times)
• No alcohol
• No other supplements known to affect sleep
• Begin sleep on my back (supine)
• Motion detection IR camera (for verification of events if needed)
• The same apnoea / hypopnea scoring criteria will be used throughout

I could use the IR camera to detect sleep position, but that would take a lot more time, so until I have a system that can detect that reliably then I won't include that data, and I may re-evaluate some weeks using that ability.

I did initially check the camera to see if I attempted to breathe when the system was detecting apnoeas. I did make some respiratory effort, so I will make the presumption (for now) that my apnoeas are obstructive in nature.

I also noticed that when the oxygen desaturations due to apnoeas were compared to the Zeo hypnogram, that like my son's, they were clustered around REM sleep.  

The top line is my oxygen level.

It does look like I'm awake for those periods, but the black line is a more detailed Zeo hypnogram (data calculated on a 30 second basis). Zeo has a scoring system and shows the highest scoring sleep stage as being the dominant one. "Wake" scores the highest; this makes sense, as being awake is probably the most important thing to show when you are supposed to be sleeping.

The 30 second graph shows why the main Zeo graph shows a lot of wakefulness during the night... I have oxygen desaturations which in turn wake me up, hence Zeo shows "wakefulness for the whole 5 minute epoch. However, when you see Zeo's calculations of time spent in each sleep stage, these are based on the more detailed 30 second data.

Sleep apnoea can run in families. Whether that is a factor or not, my diagnosis (albeit a self-diagnosis) doesn't surprise me. I sometimes snore, I wake up with headache a lot, and I could do with losing a bit of weight.

I have long suffered with sleep paralysis, and I suspect that being disturbed in REM sleep is a major factor in that, if not the sole cause.

So, how is this a problem?

My average AHI (number of apnoeas and hypopneas per hour) is 7, hence I am classified as having "Mild Obstructive Sleep Apnoea".

The classification ranges are:  

<5      -    Normal (unless symptomatic)
5-15   -    Mild
15-30 -    Moderate 
30+    -    Severe 

The REM element brings the name to "Mild REM-Related Obstructive Sleep Apnoea"

I will say that this "diagnosis" is an amateur one, it may not correlate with a professional one in a sleep lab, but if I use the same equipment throughout this experiment the results will still be valid, just relative to my original numbers.

So, what if I don't want to have that diagnosis, what if I want to be "normal" (says the man who sleeps with electrodes on his head, prongs up his nose and a camera watching him)?

Standard advice:

• Lose weight if you are overweight (even a small amount can make a difference)

That's all very well, and something that I will do, but that won't help me fix my sleep tonight will it?

Other advice includes:

• Prop the head of your bed up by 4-6 of inches (takes the weight off your neck)
• Cut down on alcohol (see this blog entry on alcohol)
• Quit smoking
• Use a mandibular advancement device (pushes the bottom jaw forward to hold the airway open)
• Use a CPAP device (see this blog entry on NIV)
• Avoid caffeine and heavy meals within two hours of bed
• Use a nasal dilator (keeps the nostrils open)
• Try a nasal saline spray
• Throat exercises
• Surgery

I'll evaluate some of these (plus a few more ideas that I have) and back up the findings with a 5 day mean AHI and sleep graphs.

Let's face it, we're all looking for quick-fix solutions, and I'm not trying to cut corners, but I am trying to help myself whilst on the journey to losing a bit of weight.

So that I don't confuse the issue I will not intentionally lose weight until I have tried some of the other methods.

So, in essence I am looking for some way of bringing my AHI down, along with the time that I spend awake at night.

...but before I do that, how about trying to INCREASE my AHI? Next blog post.