Just after finishing a tonsillectomy on a 13 year old boy, I watched as the anesthesiologist removed the breathing tube easily. He was then moved to the stretcher, but after a few seconds, he became combative and started sitting up and flailing his arms and legs. It took two anesthesiologists, two OR nurses and myself to keep the him down on the stretcher, to prevent him from falling off the stretcher. I then remembered that during the sleep endoscopy portion of the case, his tongue fell back almost completely, in addition to his enlarged tonsils (which were removed). I instructed everyone to turn him onto his side, and immediately, he calmed down.
There are countless books and articles that claims to reveal your best sleep position, correlating various positions with certain personality types. However, none of these resources correlate your sleep position with your ability to breathe, especially at night when you’re sleeping.
Before I explain further, a brief anatomy lesson is in order. Just after birth, your soft palate and the top of your voice box (the epiglottis) overlaps. This allows for babies to suckle and breathe at the same time. But around 3-4 months of age, the voice box slowly drops down and separates away from the soft palate, leaving a gap called the oropharynx. It’s been stated that only humans have a true oropharynx. You can see the oropharynx by looking inside your mouth. It’s the space between your soft palate and tongue. Evolutionary biologists have also said that this unique anatomy is also what allows for complex speech and language. It’s also why only humans have so many choking and swallowing problems. (For a great description of this process, please see Dr. Davidson’s paper.)
As I’ve described in past articles and podcasts, modern humans messed up everything by changing our diets and infant feeding habits, among other things. This lead to an epidemic of dental crowding and narrowed airways. Having smaller facial bones and jaw structures leaves less room for the normal-sized soft tissues like your tongue and soft palate. This also can lead to a deviated nasal septum, where the septum buckles as it grows since the roof of your mouth doesn’t drop appropriately.
Additionally, the tongue can fall back into the oropharynx more easily, especially when on our backs. Even worse, during deeper levels of sleep, the tongue relaxes even more due to muscle relaxation. This is why many of you prefer not to, or absolutely can’t sleep on your back. No wonder why the boy I mentioned earlier couldn’t stay on his back. With anesthesia onboard, and being forced to lie flat on his back, he was literally suffocating. Only after switching to his side was he able to breathe again. His mother relayed later on that he only slept on his side or stomach.
Sleep studies can sometime reveal dramatic differences in the severity of apneas on or off your back. It can be as dramatic as having an AHI of 1 when on your side, vs. and AHI of 15 when on your back. This is also why people know to avoid back sleeping if you snore.
Here are 4 situations that I see regularly regarding sleep position that can dramatically alter your ability to breathe and sleep:
1. In my book, Sleep, Interrupted, I recounted my experience as a surgical intern, when I had 3 patients that had heart attacks between 3 to 5 AM. At that time, I just chalked it up to bad luck. Now in retrospect, it’s likely that they possibly had undiagnosed obstructive sleep apnea, and after major abdominal surgery, being forced to sleep on their backs tipped them over the edge. Another common event after surgery is that they’re given narcotic medications, which can significantly lower muscle tone and drive to breathe. Three to 5 AM is also when you go into longer periods of REM sleep. REM sleep is when you dream, and your muscles are most relaxed.
2. Similar to point #1, if you undergo any type of surgical procedure, or if you get injured, there’s a high possibility that your sleep position may be altered. Whether it’s a hernia or a knee operation, many procedures will force you to sleep on your back. A back or neck injury can definitely affect your sleep quality. Even if you can sleep on your side, it may be uncomfortable for you to turn comfortably from side to side.
3. Once in a while, a woman will come see me for various symptoms (such as headaches or fatigue) that started a few months ago. Looking at the airway, it’s clear that she can’t sleep on her back. She tells me that she sleeps on her back, but I don’t believe her. When queried further, she states that her dermatologist told her to sleep on her back to avoid facial wrinkles. As expected, she changed sleep positions just before her symptoms began.
4. Pediatricians have touted the Back to Sleep campaign as a public health success story in lowering sudden infant death syndrome (SIDS) by about 50%. No doubt that it made a big difference, but a number of problems with this recommendation has been proposed. Since the campaign started in the early 1990s, the number of infants sleeping on their backs has gone from a small minority to the vast majority. The problem with this recommendation is that it’s been shown that many babies generally sleep much better on their tummies. Mothers will swear by it. Research studies have shown that back sleeping leads to less deep sleep and many more arousals. There’s even been speculation that the Autism epidemic began to increase a few years after the Back to Sleep campaign started. As an unintended consequence of preventing around 2000 cases of SIDS deaths every year in the US, we’re likely sleep depriving the vast majority of our children. This is clearly a controversial issue, but it’s one that needs updated research attention.
Now that I’ve gotten your attention about the importance of sleep position, what can you do? Ultimately, your best sleep position is what you’re more comfortable sleeping in, before you had your surgery, injury, or dermatology recommendation. However, for some of you, you may be asking, “Knowing all this, how can I sleep better?”
1. Re-evaluate and confirm your favorite sleep position and make every effort to stay in the position to the best of your ability. Some people can sleep on their sides or tummy naturally, but many people need help. There’s the tennis ball sewn into the back of your pajamas, but in my opinion, this has limited results. You may want to look into more aggressive sleep positioners, such as Slumberbump or Anti-snore shirt. A large wedge pillow or mattress topper can help some people. Rarely, I have patients that can only sleep in a recliner. I’ve even had patients invest and sleep on a massage table, sleeping face-down through the hole.
2. Unstuff your stuffy nose, if your nose is stuffy. Think about sucking through a flimsy straw. If you pinch the tip as you breathe in, the middle part of the straw will cave in. This is what may happen to your throat structures if your nose is stuffy. This is why it’s important to do everything possible to breathe optimally through your nose. For more information about how to deal with nasal congestion, please see my free e-book, Unstuff Your Stuffy Nose.
3 There’s a reason why the first A in the ABC of CPR is airway. This means tilting the head back, which opens the airway. Whenever I’m able to look at the airway with a fiberoptic camera, extending the head back can oftentimes make a dramatic difference in the opening of your airway. If you like to sleep on your back, the best way to tilt your head back is to use a contour pillow, which provides more support behind your neck and less support under your head. Side sleepers have reported using a soft neck collar to prevent the head from bending forward.
4. If the above conservative options don’t help to improve your sleep quality, consider seeing a doctor and get tested for obstructive sleep apnea. If you’re found to have sleep apnea, consider getting formally treated with CPAP or a mandibular advancement device.
5. Go into space. This may sound like a joke, but it’s true. Studies have shown that OSA diminished significantly in astronauts who go into space. Lack of gravity can have a profound impact on obstructive sleep apnea.
So the next time you see an article on sleep position, skip the test on personality types and go straight to your most optimal sleep position so you can breathe better and sleep better.
If you had to suddenly alter your sleep position from side/stomach to your back due to surgery, an injury, or someone’s recommendation, how did it affect your sleep quality?