Obstructive sleep apnea

Obstructive sleep apnea is the most common sleep-related breathing disorder. It causes you to repeatedly stop and start breathing while you sleep.

There are several types of sleep apnea, but the most common is obstructive sleep apnea. This type of apnea occurs when your throat muscles intermittently relax and block your airway during sleep. A noticeable sign of obstructive sleep apnea is snoring.

Treatments for obstructive sleep apnea are available. One treatment involves using a device that uses positive pressure to keep your airway open while you sleep. Another option is a mouthpiece to thrust your lower jaw forward during sleep. In some cases, surgery might be an option too.

Symptoms

Signs and symptoms of obstructive sleep apnea include:

• Excessive daytime sleepiness
• Loud snoring
• Observed episodes of stopped breathing during sleep
• Abrupt awakenings accompanied by gasping or choking
• Awakening with a dry mouth or sore throat
• Morning headache
• Difficulty concentrating during the day
• Mood changes, such as depression or irritability
• High blood pressure
• Decreased libido

When to see a doctor

Consult a medical professional if you have, or if your partner observes, the following:

• Snoring loud enough to disturb your sleep or that of others
• Waking up gasping or choking
• Pausing in your breathing during sleep
• Having excessive daytime drowsiness, which may cause you to fall asleep while working, watching television or even driving a vehicle

Snoring doesn't necessarily indicate something potentially serious, and not everyone who snores has obstructive sleep apnea.

Be sure to talk to your doctor if you snore loudly, especially if your snoring is interrupted by periods of silence. With obstructive sleep apnea, snoring usually is loudest when you sleep on your back, and it quiets when you turn on your side.

Ask your doctor about any sleep problem that leaves you chronically fatigued, sleepy and irritable. Excessive daytime drowsiness may be due to other disorders, such as narcolepsy.

Causes

Obstructive sleep apnea occurs when the muscles in the back of your throat relax too much to allow normal breathing. These muscles support structures including the back of the roof of your mouth (soft palate), the triangular piece of tissue hanging from the soft palate (uvula), the tonsils and the tongue.

When the muscles relax, your airway narrows or closes as you breathe in, hampering your breathing for 10 seconds or longer. This can lower the level of oxygen in your blood and cause a buildup of carbon dioxide.

Your brain senses this impaired breathing and briefly rouses you from sleep so that you can reopen your airway. This awakening is usually so brief that you don't remember it.

You can awaken with shortness of breath that corrects itself quickly, within one or two deep breaths. You might make a snorting, choking or gasping sound.

This pattern can repeat itself five to 30 times or more each hour, all night long. These disruptions impair your ability to reach the deep, restful phases of sleep, and you'll probably feel sleepy during your waking hours.

People with obstructive sleep apnea might not be aware of their interrupted sleep. Many people with this type of sleep apnea don't realize they haven't slept well all night.

Risk factors

Anyone can develop obstructive sleep apnea. However, certain factors put you at increased risk, including:

• Excess weight. Most but not all people with obstructive sleep apnea are overweight. Fat deposits around the upper airway can obstruct breathing. Medical conditions that are associated with obesity, such as hypothyroidism and polycystic ovary syndrome, also can cause obstructive sleep apnea.
• Older age. The risk of obstructive sleep apnea increases as you age but appears to level off after your 60s and 70s.
• Narrowed airway. You might inherit naturally narrow airways. Or your tonsils or adenoids might become enlarged and block your airway.
• High blood pressure (hypertension). Obstructive sleep apnea is relatively common in people with hypertension.
• Chronic nasal congestion. Obstructive sleep apnea occurs twice as often in those who have consistent nasal congestion at night, regardless of the cause. This may be due to narrowed airways.
• Smoking. People who smoke are more likely to have obstructive sleep apnea.
• Diabetes. Obstructive sleep apnea might be more common in people with diabetes.
• Sex. In general, men are twice or three times as likely as premenopausal women to have obstructive sleep apnea. The frequency of obstructive sleep apnea increases in women after menopause.
• A family history of sleep apnea. Having family members with obstructive sleep apnea might increase your risk.
• Asthma. Research has found an association between asthma and the risk of obstructive sleep apnea.

Complications

Obstructive sleep apnea is considered a serious medical condition. Complications can include:

• Daytime fatigue and sleepiness. Because of a lack of restorative sleep at night, people with obstructive sleep apnea often have severe daytime drowsiness, fatigue and irritability. They might have difficulty concentrating and find themselves falling asleep at work, while watching TV or even when driving. This can put them at higher risk of work-related accidents.

  Children and young people with obstructive sleep apnea might do poorly in school and commonly have attention or behavior problems.

• Cardiovascular problems. Sudden drops in blood oxygen levels that occur during obstructive sleep apnea increase blood pressure and strain the cardiovascular system. Many people with obstructive sleep apnea develop high blood pressure (hypertension), which can increase the risk of heart disease.

  The more severe the obstructive sleep apnea, the greater the risk of coronary artery disease, heart attacks, heart failure and strokes.

  Obstructive sleep apnea increases the risk of abnormal heart rhythms (arrhythmias), which can lower blood pressure. If there's underlying heart disease, these repeated multiple episodes of arrhythmias could lead to sudden death.

• Complications with medications and surgery. Obstructive sleep apnea is also a concern with certain medications and general anesthesia. These medications, such as sedatives, narcotic analgesics and general anesthetics, relax your upper airway and can worsen your obstructive sleep apnea.

  If you have obstructive sleep apnea, having major surgery, especially after being sedated and lying on your back, can worsen breathing problems. People with obstructive sleep apnea might be more prone to complications after surgery.

  Before you have surgery, tell your doctor if you have obstructive sleep apnea or symptoms related to the condition. Your doctor might want you tested for obstructive sleep apnea before surgery.

• Eye problems. Some research has found a connection between obstructive sleep apnea and certain eye conditions, such as glaucoma. Eye complications can usually be treated.
• Sleep-deprived partners. Loud snoring can keep those around you from getting good rest and eventually disrupt your relationships. Some partners choose to sleep in another room.

People with obstructive sleep apnea may also complain of memory problems, morning headaches, mood swings or depression, and a need to urinate frequently at night.

Obstructive sleep apnea might be a risk factor for COVID-19. People with obstructive sleep apnea have been found to be at higher risk for developing a severe form of COVID-19 and needing hospital treatment than those who don't have obstructive sleep apnea.

Diagnosis

Your doctor will evaluate your condition based on your signs and symptoms, an examination, and tests. He or she might refer you to a sleep specialist for further evaluation.

During the physical examination, your doctor will examine the back of your throat, mouth and nose for extra tissue or abnormalities. Your doctor might measure your neck and waist circumference and check your blood pressure.

A sleep specialist can conduct additional evaluations to diagnose your condition, determine the severity of your condition and plan your treatment. The evaluation might involve staying at a sleep center overnight to monitor your breathing and other body functions as you sleep.

Tests

Tests to detect obstructive sleep apnea include:

• Polysomnography. During this sleep study, you're hooked up to equipment that monitors your heart, lung and brain activity, breathing patterns, arm and leg movements, and blood oxygen levels while you sleep.

  You might be monitored all night, or part of the night in a split-night sleep study.

  In a split-night sleep study, you'll be monitored during the first half of the night. If you're diagnosed with obstructive sleep apnea, staff may wake you and give you continuous positive airway pressure for the second half of the night.

  This sleep study can also help look for other sleep disorders that can cause excessive daytime sleepiness but require different treatments, such as leg movements during sleep (periodic limb movements) or sudden bouts of sleep during the day (narcolepsy).

• Home sleep apnea testing. Under certain circumstances, your doctor may provide you with an at-home version of polysomnography to diagnose obstructive sleep apnea. This test usually involves measurement of airflow, breathing patterns and blood oxygen levels, and possibly limb movements and snoring intensity.

Treatment

Lifestyle changes

For milder cases of obstructive sleep apnea, your doctor might recommend lifestyle changes:

• Lose weight if you're overweight.
• Exercise regularly.
• Drink alcohol moderately, if at all. Don't drink in the hours before bedtime.
• Quit smoking.
• Use a nasal decongestant or allergy medications.
• Don't sleep on your back.
• Avoid taking sedative medications such as anti-anxiety drugs or sleeping pills.

If these measures don't improve your sleep or if your apnea is moderate to severe, then your doctor may recommend other treatments. Certain devices can help open up a blocked airway. In other cases, surgery may be necessary.

Therapies

• Positive airway pressure. If you have obstructive sleep apnea, you may benefit from positive airway pressure. In this treatment, a machine delivers air pressure through a piece that fits into your nose or is placed over your nose and mouth while you sleep.

  Positive airway pressure reduces the number of respiratory events that occur as you sleep, reduces daytime sleepiness and improves your quality of life.

  The most common type is called continuous positive airway pressure, or CPAP (SEE-pap). With this treatment, the pressure of the air breathed is continuous, constant and somewhat greater than that of the surrounding air, which is just enough to keep your upper airway passages open. This air pressure prevents obstructive sleep apnea and snoring.

  Although CPAP is the most consistently successful and most commonly used method of treating obstructive sleep apnea, some people find the mask cumbersome, uncomfortable or loud. However, newer machines are smaller and less noisy than older machines and there are a variety of mask designs for individual comfort.

  Also, with some practice, most people learn to adjust the mask to obtain a comfortable and secure fit. You may need to try different types to find a suitable mask. Several options are available, such as nasal masks, nasal pillows or face masks.

  If you're having particular difficulties tolerating pressure, some machines have special adaptive pressure functions to improve comfort. You might also benefit from using a humidifier along with your CPAP system.

  CPAP may be given at a continuous (fixed) pressure or varied (autotitrating) pressure (APAP). In fixed CPAP, the pressure stays constant. In autotitrating CPAP, the levels of pressure are adjusted if the device senses increased airway resistance.

  Bilevel positive airway pressure (BPAP), another type of positive airway pressure, delivers a preset amount of pressure when you breathe in and a different amount of pressure when you breathe out.

  CPAP is more commonly used because it's been well studied for obstructive sleep apnea and has been shown to effectively treat obstructive sleep apnea. However, for people who have difficulty tolerating fixed CPAP, BPAP or APAP might be worth a try.

  Don't stop using your positive airway pressure machine if you have problems. Check with your doctor to see what adjustments you can make to improve its comfort.

  In addition, contact your doctor if you still snore despite treatment, if you begin snoring again, or if your weight goes up or down by 10% or more.

• Mouthpiece (oral device). Though positive airway pressure is often an effective treatment, oral appliances are an alternative for some people with mild or moderate obstructive sleep apnea. It's also used for people with severe sleep apnea who can't use CPAP. These devices may reduce your sleepiness and improve your quality of life.

  These devices are designed to keep your throat open. Some devices keep your airway open by bringing your lower jaw forward, which can sometimes relieve snoring and obstructive sleep apnea. Other devices hold your tongue in a different position.

  If you and your doctor decide to explore this option, you'll need to see a dentist experienced in dental sleep medicine appliances for the fitting and follow-up therapy. A number of devices are available. Close follow-up is needed to ensure successful treatment and that use of the device doesn't cause changes to your teeth.

Surgery or other procedures

Surgery is usually considered only if other therapies haven't been effective or haven't been appropriate options for you. Surgical options may include:

• Surgical removal of tissue. Uvulopalatopharyngoplasty (UPPP) is a procedure in which your doctor removes tissue from the back of your mouth and top of your throat. Your tonsils and adenoids may be removed as well. UPPP usually is performed in a hospital and requires a general anesthetic.

• Upper airway stimulation. This new device is approved for use in people with moderate to severe obstructive sleep apnea who can't tolerate CPAP or BPAP.

  A small, thin impulse generator (hypoglossal nerve stimulator) is implanted under the skin in the upper chest. The device detects your breathing patterns and, when necessary, stimulates the nerve that controls movement of the tongue.

  Studies have found that upper airway stimulation leads to significant improvement in obstructive sleep apnea symptoms and improvements in quality of life.

• Jaw surgery (maxillomandibular advancement). In this procedure, the upper and lower parts of your jaw are moved forward from the rest of your facial bones. This enlarges the space behind the tongue and soft palate, making obstruction less likely.

• Surgical opening in the neck (tracheostomy). You may need this form of surgery if other treatments have failed and you have severe, life-threatening obstructive sleep apnea.

  During a tracheostomy, your surgeon makes an opening in your neck and inserts a metal or plastic tube through which you breathe. Air passes in and out of your lungs, bypassing the blocked air passage in your throat.

Other types of surgery may help reduce snoring and sleep apnea by clearing or enlarging air passages, including:

• Nasal surgery to remove polyps or straighten a crooked partition between your nostrils (deviated septum)
• Surgery to remove enlarged tonsils or adenoids

Lifestyle and home remedies

In many cases, self-care may be the most appropriate way for you to deal with obstructive sleep apnea. Try these tips:

• Lose weight. If you're overweight or obese, even a moderate loss of excess weight may help relieve constriction of your airway. Losing weight can also improve your health and quality of life and might reduce your daytime sleepiness.
• Exercise. Exercising, such as aerobic exercise and strength training, can help improve your condition. Aim to exercise about 150 minutes a week, and generally try to exercise most days of the week.
• Avoid alcohol and medications such as anti-anxiety drugs and sleeping pills. Alcohol, some anti-anxiety medications, and some sleeping pills can worsen obstructive sleep apnea and sleepiness.

• Sleep on your side or stomach rather than on your back. Sleeping on your back can cause your tongue and soft palate to rest against the back of your throat and block your airway.

  To prevent sleeping on your back, try sewing a tennis ball in the back of your pajama top or place pillows behind you while you sleep on your side.

• Keep your nasal passages open while you sleep. If you have congestion, use a saline nasal spray to help keep your nasal passages open. Talk to your doctor about using nasal decongestants or antihistamines, because some medications may be recommended for only short-term use.

Preparing for an appointment

If you suspect that you have obstructive sleep apnea, you'll likely first see your primary care doctor. Your doctor might refer you to a sleep specialist.

Here's some information to help you get ready for your appointment.

What you can do

• Be aware of pre-appointment requests. When you make your appointment, ask if there's anything you need to do in advance, such as keeping a sleep diary.

  In a sleep diary, you record your sleep patterns — bedtime, number of hours slept, nighttime awakenings and awake time — as well as your daily routine, naps and how you feel during the day.

• Write down your symptoms, including any that may seem unrelated to the reason for your appointment, and when they began.
• Write down key personal information, including new or ongoing health problems, major stresses or recent life changes.
• Bring a list of all medications, vitamins or supplements you take, including doses. Include anything you've taken to help you sleep.
• Take your bed partner along, if possible. He or she can provide information about how much and how well you're sleeping. If you can't bring your partner with you, ask him or her about how well you sleep and whether you snore.
• Write down questions to ask your doctor. Preparing a list of questions can help you make the most of your time with your doctor.

For obstructive sleep apnea, some basic questions to ask your doctor include:

• What's the most likely cause of my symptoms?
• What tests do I need? Do I need to go to a sleep clinic?
• What treatments are available and which do you recommend for me?
• I have other health conditions. How can I best manage these conditions together?

Don't hesitate to ask other questions.

What to expect from your doctor

A key part of the evaluation of obstructive sleep apnea is a detailed history, meaning your doctor will ask you many questions. These may include:

• When did you first notice symptoms?
• Have your symptoms been off and on, or do you always have them?
• Do you snore? If so, does your snoring disrupt anyone else's sleep?
• Do you snore in all sleep positions or just when sleeping on your back?
• Do you ever snore, snort, gasp or choke yourself awake?
• Has anyone seen you stop breathing during sleep?
• How refreshed do you feel when you wake up? Are you tired during the day?
• Do you have a headache or dry mouth when you awaken?
• Do you doze off or have trouble staying awake while sitting quietly or driving?
• Do you nap during the day?
• Do you have family members with sleep problems?

What you can do in the meantime

• Try to sleep on your side. Most forms of obstructive sleep apnea are milder when you sleep on your side.
• Avoid drinking alcohol close to bedtime. Alcohol worsens obstructive sleep apnea.
• If you're drowsy, avoid driving. If you have obstructive sleep apnea, daytime sleepiness can put you at higher risk of motor vehicle accidents. To be safe, schedule rest breaks. If a close friend or family member ever tells you that you appear sleepier than you feel, try to avoid driving.

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