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Obstructions EXhaling during sleep, constant wake-ups from REM – It’s a thing! – iDunmed

I found multiple names for this on the internet. It’s known as:

  • Soft-palatal / palatal obstruction
  • Obstructive palatal prolapse (PP)
  • Retrograde palatal prolapse

TLDR: Insomniac for 10+ years, discovered I have this, done some research on it. I hereby want to share my newly acquired knowledge and possibly find other people who experience this. This is my second try at posting. Appearently I cannot post any links or the spam filter will delete my posts, so this time I removed all references.

Discovering that I’ve had this for probably at least a decade, was obviously a eureka moment for me, so I have started a self-help WhatsApp group about this topic as I am hell-bent on getting this treated. Plus, I found threads about it on several different insomnia-related internet forums where people describe that they are suffering from the same issue. Feel free to join my group: As I am not able to post any links I give you two hints: c u t t l y + ZrVxQ60 (c u t t l y being the URL shortening service)

Here’s my take on describing the condition: Upon expiration, the airstream moves the uvula and part of the soft palate tissue (velum) backwards into the nasopharynx, thereby sealing it off completely, resulting in a full obstruction of the nasopharynx. Some people refer to this full obstruction as “ballooning into the nasopharynx”.

Think of the velum and uvula acting as a “kickback valve”. When they shut off the nasopharynx (upon exhale), a small “plopping” sound can be heard, indicative of a sudden tight seal. This is sometimes audible, but doesn’t have to be (depending upon the strength of the exhalation). In some people though, the seal might not be perfect, which leads to snoring noises on expiration (as the velum flabs around in the airstream). Both forms can cause frequent arousals, which keep a person from sleeping well and deeply.

With a fully obstructed nasopharynx, the air leaves through the mouth upon exhalation, resulting in a “puff” sound as the mouth is opening and the air is venting out. Either that or your mouth stays shut and the air is not able to leave the lungs at all. Needless to say this will end in a wake-up reaction as oxygen levels fall.

Finally, some people (like me) can reproduce the EPO just by exhaling forcefully while relaxing throat muscles. For example it frequently happens to me when trying to blow my nose into a tissue. My nasal airway will become blocked and as a result air explodes out through my mouth.

My Story

I’ll try to keep it short. I’ve had trouble with insomnia for a long time and for the past few months things have been getting way worse – no more days where I feel rested, constant wake-ups, trouble to fall asleep in the evening and stay asleep (in the morning). I don’t want to go into detail about my whole story but, recently I began to re-evaluate, if I might have a form of sleep apnea. In the past, I never really looked into it as I am quite slim and thought it’s something only obese people develop. Well it seems, I was wrong.

After having read through scientific texts of Dr. Avram R. Gold (which is into sleep research and also upper airway resistence syndrom (UARS)), I began to form a better understanding of sleep apnea / UARS and its symptoms. This helped a lot, but it was only after reading on a sleep apnea related internet forum about this topic of EPO, that it finally clicked and everything made sense. I then came across the blog article (and poster) of Dr. Steven Park (mentioned above) which describes this form of expiratory sleep-disordered breathing very accurately.

Symptoms

  • Frequent wake-ups, especially during early morning REM sleep. I usually wake around 4 to 5 AM and have trouble falling back asleep. This seems to be because during early morning REM sleep, our throat muscles are especially flabby and lack the necessary muscle tone to keep the airway from collapsing. This is also a common problem in sleep apnea. I have the feeling that I can fall asleep at any point during early morning REM and at that point, I am still very tired, but the instant I fall asleep, the EPO happens and I wake – this cycle repeats indefinitely until I have to get up, leading to bad sleep quality and frequent arousals.
  • Difficulty exhaling forcefully (e.g. blow your nose into a tissue). Airflow will be cut-off or explode through the mouth.
  • Shifting back your head to maintain a straight posture seems to worsen the problem. This is especially interesting, because in the last year I have worked on my posture a lot – I might have exacerbated the EPO by doing that.
  • You don’t have to snore. (I don’t.)
  • Sleeping on your back (subpine position) exacerbates the problem.
  • Voiced nasal consonants [n], [ŋ] and [m] can be difficult to pronounce, since they rely on air leaving through your nasal airway – not possible during nasal obstruction.
  • Heightened sympathetic nervous system tone / hyper-arousal during day / stress as also seen in UARS (refer to Dr. Avram R. Gold’s work, he links UARS to sympathetic activation) ultimately leading to depression and/or anxiety throughout most of the day.
  • “Mini” panic attacks on sleep-onset when this happens, elevated heart rate
  • Palpitations (probably due to sleep deprivation and nervous system tone)

Causes

  • Palatal prolapse has been identified as a cause, where excess palatal tissue (big uvula / elongated velum) is dangling around in your throat which is pressed into the nasopharyngal opening upon expiration leading to partial or full obstruction.
  • A high Mallampati score (3 – 4) seems NOT to help the condition (I am a 4.)

Possible solutions

  • CPAP therapy: Some people have found that enabling the expiratory pressure relief (EPR) (C-Flex on Philips) setting on your CPAP machine makes things worse for EPO. This makes sense, since pressure is the thing that is keeping your excess tissue in place upon exhalation. Unfortunately that means, that people that suffer from EPO cannot use this setting. Obviously CPAP relies on a closed loop system and this only works if you can keep a good seal. If you are using a nasal mask and your mouth keeps opening, look into mouth-taping. I’m not sure yet, if a full face mask will do good for EPO, but I remain skeptical, because you’d want the pressure behind your velum / tongue area and not in front of it for it to stay out of the nasopharynx. APAP, BiPAP, ASV are probably not a good solution because of the same problem (like EPR), but that’s just my personal opinion. I have not experimented with these. – currently looking into it using my Resmed AutoSet 10 with nasal mask.
  • Nasal stents: AlaxoStent / Nastent – not tried ’em yet.
  • MAT Body positioning system / Massage table with face cradle – not tried, either. Might be worth a try.
  • Mandibular advancement devices – Haven’t tried one, but if I move my lower jaw forward, I can still very reliably reproduce the EPO – so I suspect it’s of no good use for this special problem.
  • Velumount / Ronchex (german): These are basically clips made of wire in silicone tubing that are supposed to stabilizing your velum and uvula during sleep – currently looking into this!
  • Shifting your sleep position: Sleeping on your side (lateral position) seems to be better. This makes sense to me, because gravity will not additionally pull your uvula/velum back into your throat (like in subpine position). As long as I remember, I haven’t been able to fall asleep in subpine position, ever.
  • Playing Didgeridoo (combined with ‘circular breathing’) is said to help as this trains muscles in the respective areas. Might look into this.
  • Surgery options: Radiofrequency treatment of the soft palate and uvula (uvulopalatopharyngoplasty (UPPP)), also the ‘pillar Procedure’. Both very promising – pillar procedure seems to be reversible, even.

Unfortunately I have not resolved this yet, but I just discovered it and I am quite euphoric that I did so after years of searching for a solution to my insomnia – imagine that I may have had this for at least a decade (albeit not as severe as now, as I am getting older and tissues are getting saggy – you know the drill…) This is a big find for me and now only a matter of time until I get this resolved. Finding a solution means that I’d ultimately get my old life back where didn’t feel like a zombie every day. I really am hell-bent on solving this and as of now am putting a lot of effort into it, even if it means surgery. Again, if you have this or think that you have this, please consider joining my WhatsApp group.

If you made it up to here – thanks for reading. I am currently waiting for my sleep study due in march and will report on the findings. If you found a way to treat this condition successfully, please let me know.

Discussions about this topic on other internet forums

Sorry, no more links here…

Scientific stuff (You’ll have to use Google)

  • Palatal prolapse as a signature of expiratory flow limitation and inspiratory palatal collapse in patients with obstructive sleep apnea
  • Dr. Steven Park made a poster describing the condition on his blog – search for it!
  • The association of somatic arousal with the symptoms of upper airway resistance syndrome

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