Sleep apnea

Overview

Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops and starts. If you snore loudly and feel tired even after a full night's sleep, you might have sleep apnea.

The main types of sleep apnea are:

• Obstructive sleep apnea (OSA), which is the more common form that occurs when throat muscles relax and block the flow of air into the lungs
• Central sleep apnea (CSA), which occurs when the brain doesn't send proper signals to the muscles that control breathing
• Treatment-emergent central sleep apnea, also known as complex sleep apnea, which happens when someone has OSA — diagnosed with a sleep study — that converts to CSA when receiving therapy for OSA

If you think you might have sleep apnea, see your health care provider. Treatment can ease your symptoms and might help prevent heart problems and other complications.

Symptoms

The symptoms of obstructive and central sleep apneas overlap, sometimes making it difficult to determine which type you have. The most common symptoms of obstructive and central sleep apneas include:

• Loud snoring.
• Episodes in which you stop breathing during sleep — which would be reported by another person.
• Gasping for air during sleep.
• Awakening with a dry mouth.
• Morning headache.
• Difficulty staying asleep, known as insomnia.
• Excessive daytime sleepiness, known as hypersomnia.
• Difficulty paying attention while awake.
• Irritability.

When to see a doctor

Loud snoring can indicate a potentially serious problem, but not everyone who has sleep apnea snores. Talk to your health care provider if you have symptoms of sleep apnea. Ask your provider about any sleep problem that leaves you fatigued, sleepy and irritable.

Causes

Obstructive sleep apnea

This type of sleep apnea happens when the muscles in the back of the throat relax. These muscles support the soft palate, the triangular piece of tissue hanging from the soft palate called the uvula, the tonsils, the side walls of the throat and the tongue.

When the muscles relax, your airway narrows or closes as you breathe in. You can't get enough air, which can lower the oxygen level in your blood. Your brain senses that you can't breathe, and briefly wakes you so that you can reopen your airway. This awakening is usually so brief that you don't remember it.

You might snort, choke or gasp. This pattern can repeat itself 5 to 30 times or more each hour, all night. This makes it hard to reach the deep, restful phases of sleep.

Central sleep apnea

This less common form of sleep apnea occurs when your brain fails to send signals to your breathing muscles. This means that you make no effort to breathe for a short period. You might awaken with shortness of breath or have a difficult time getting to sleep or staying asleep.

Risk factors

Sleep apnea can affect anyone, even children. But certain factors increase your risk.

Obstructive sleep apnea

Factors that increase the risk of this form of sleep apnea include:

• Excess weight. Obesity greatly increases the risk of OSA. Fat deposits around your upper airway can obstruct your breathing.
• Neck circumference. People with thicker necks might have narrower airways.
• A narrowed airway. You might have inherited a narrow throat. Tonsils or adenoids also can enlarge and block the airway, particularly in children.
• Being male. Men are 2 to 3 times more likely to have sleep apnea than are women. However, women increase their risk if they're overweight or if they've gone through menopause.
• Being older. Sleep apnea occurs significantly more often in older adults.
• Family history. Having family members with sleep apnea might increase your risk.
• Use of alcohol, sedatives or tranquilizers. These substances relax the muscles in your throat, which can worsen obstructive sleep apnea.
• Smoking. Smokers are three times more likely to have obstructive sleep apnea than are people who've never smoked. Smoking can increase the amount of inflammation and fluid retention in the upper airway.
• Nasal congestion. If you have trouble breathing through your nose — whether from an anatomical problem or allergies — you're more likely to develop obstructive sleep apnea.
• Medical conditions. Congestive heart failure, high blood pressure and type 2 diabetes are some of the conditions that may increase the risk of obstructive sleep apnea. Polycystic ovary syndrome, hormonal disorders, prior stroke and chronic lung diseases such as asthma also can increase risk.

Central sleep apnea

Risk factors for this form of sleep apnea include:

• Being older. Middle-aged and older people have a higher risk of central sleep apnea.
• Being male. Central sleep apnea is more common in men than it is in women.
• Heart disorders. Having congestive heart failure increases the risk.
• Using narcotic pain medicines. Opioid medicines, especially long-acting ones such as methadone, increase the risk of central sleep apnea.
• Stroke. Having had a stroke increases the risk of central sleep apnea.

Complications

Sleep apnea is a serious medical condition. Complications of OSA can include:

• Daytime fatigue. The repeated awakenings associated with sleep apnea make typical, restorative sleep impossible, in turn making severe daytime drowsiness, fatigue and irritability likely.

  You might have trouble concentrating and find yourself falling asleep at work, while watching TV or even when driving. People with sleep apnea have an increased risk of motor vehicle and workplace accidents.

  You might also feel quick-tempered, moody or depressed. Children and adolescents with sleep apnea might perform poorly in school or have behavior problems.

• High blood pressure or heart problems. Sudden drops in blood oxygen levels that occur during OSA increase blood pressure and strain the cardiovascular system. Having OSA increases your risk of high blood pressure, also known as hypertension.

  OSA might also increase your risk of recurrent heart attack, stroke and irregular heartbeats, such as atrial fibrillation. If you have heart disease, multiple episodes of low blood oxygen (hypoxia or hypoxemia) can lead to sudden death from an irregular heartbeat.

• Type 2 diabetes. Having sleep apnea increases your risk of developing insulin resistance and type 2 diabetes.
• Metabolic syndrome. This disorder, which includes high blood pressure, abnormal cholesterol levels, high blood sugar and an increased waist circumference, is linked to a higher risk of heart disease.

• Complications with medicines and surgery. Obstructive sleep apnea is also a concern with certain medicines and general anesthesia. People with sleep apnea might be more likely to have complications after major surgery because they're prone to breathing problems, especially when sedated and lying on their backs.

  Before you have surgery, tell your doctor about your sleep apnea and how it's being treated.

• Liver problems. People with sleep apnea are more likely to have irregular results on liver function tests, and their livers are more likely to show signs of scarring, known as nonalcoholic fatty liver disease.
• Sleep-deprived partners. Loud snoring can keep anyone who sleeps nearby from getting good rest. It's common for a partner to have to go to another room, or even to another floor of the house, to be able to sleep.

Complications of CSA can include:

• Fatigue. The repeated awakening associated with sleep apnea makes typical, restorative sleep impossible. People with central sleep apnea often have severe fatigue, daytime drowsiness and irritability.

  You might have difficulty concentrating and find yourself falling asleep at work, while watching television or even while driving.

• Cardiovascular problems. Sudden drops in blood oxygen levels that occur during central sleep apnea can adversely affect heart health.

  If there's underlying heart disease, these repeated multiple episodes of low blood oxygen — known as hypoxia or hypoxemia — worsen prognosis and increase the risk of irregular heart rhythms.

Diagnosis

Your health care provider may make an evaluation based on your symptoms and a sleep history, which you can provide with help from someone who shares your bed or your household, if possible.

You're likely to be referred to a sleep disorder center. There, a sleep specialist can help you determine your need for further evaluation.

An evaluation often involves overnight monitoring of your breathing and other body functions during sleep testing at a sleep center. Home sleep testing also might be an option. Tests to detect sleep apnea include:

• Nocturnal polysomnography. During this test, 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.

• Home sleep tests. Your health care provider might provide you with simplified tests to be used at home to diagnose sleep apnea. These tests usually measure your heart rate, blood oxygen level, airflow and breathing patterns. Your provider is more likely to recommend polysomnography in a sleep testing facility, rather than a home sleep test, if central sleep apnea is suspected.

  If the results aren't typical, your provider might be able to prescribe a therapy without further testing. Portable monitoring devices sometimes miss sleep apnea. So your health care provider might still recommend polysomnography even if your first results are within the standard range.

If you have obstructive sleep apnea, your health care provider might refer you to an ear, nose and throat specialist to rule out a blockage in your nose or throat. An evaluation by a heart specialist, known as a cardiologist, or a doctor who specializes in the nervous system, called a neurologist, might be necessary to look for causes of central sleep apnea.

Treatment

For milder cases of sleep apnea, your health care provider may recommend only lifestyle changes, such as losing weight or quitting smoking. You may need to change the position in which you sleep. If you have nasal allergies, your provider may recommend treatment for your allergies.

If these measures don't improve your symptoms or if your apnea is moderate to severe, a number of other treatments are available.

Certain devices can help open a blocked airway. In other cases, surgery might be necessary.

Therapies for OSA

• Continuous positive airway pressure (CPAP). If you have moderate to severe obstructive sleep apnea, you might benefit from using a machine that delivers air pressure through a mask while you sleep. With CPAP (SEE-pap), the air pressure is somewhat greater than that of the surrounding air and is just enough to keep your upper airway passages open, preventing apnea and snoring.

  Although CPAP is the most common and reliable method of treating sleep apnea, some people find it cumbersome or uncomfortable. Some people give up on the CPAP machine. But with practice, most people learn to adjust the tension of the straps on the mask to obtain a comfortable and secure fit.

  You might need to try more than one type of mask to find one that's comfortable. Don't stop using the CPAP machine if you have problems. Check with your health care provider to see what changes can be made to increase your comfort.

  Additionally, contact your provider if you're still snoring or begin snoring again despite treatment. If your weight changes, the pressure settings of the CPAP machine might need to be adjusted.

• Other airway pressure devices. If using a CPAP machine continues to be a problem for you, you might be able to use a different type of airway pressure device that automatically adjusts the pressure while you're sleeping (auto-CPAP). Units that supply bilevel positive airway pressure (BPAP) also are available. These provide more pressure when you inhale and less when you exhale.

• Oral appliances. Another option is wearing an oral appliance designed to keep your throat open. CPAP is more reliably effective than oral appliances, but oral appliances might be easier to use. Some are designed to open your throat by bringing your jaw forward, which can sometimes relieve snoring and mild obstructive sleep apnea.

  A number of devices are available from your dentist. You might need to try different devices before finding one that works for you.

  Once you find the right fit, you'll need to follow up with your dentist repeatedly during the first year and then regularly after that to ensure that the fit is still good and to reassess your symptoms.

You'll likely read, hear or see TV ads about different treatments for sleep apnea. Talk with your health care provider about any treatment before you try it.

Surgery for OSA

Surgery may be an option for people with OSA, but usually only after other treatments have failed. Generally, at least a three-month trial of other treatment options is suggested before considering surgery. However, for a small number of people with certain jaw structure problems, surgery is a good first option.

Surgical options might include:

• Tissue removal. During this procedure (uvulopalatopharyngoplasty), a surgeon removes tissue from the rear of your mouth and top of the throat. Your tonsils and adenoids usually are removed as well.

  This type of surgery might be successful in stopping throat structures from vibrating and causing snoring. It's less effective than CPAP and isn't considered a reliable treatment for obstructive sleep apnea.

  Removing tissues in the back of the throat with radiofrequency energy (radiofrequency ablation) might be an option for those who can't tolerate CPAP or oral appliances.

• Tissue shrinkage. Another option is to shrink the tissue at the rear of the mouth and the back of the throat using radiofrequency ablation. This procedure might be used for mild to moderate sleep apnea. One study found this to have effects similar to that of tissue removal, but with fewer surgical risks.
• Jaw repositioning. In this procedure, the jaw is moved forward from the remainder of the face bones. This enlarges the space behind the tongue and soft palate, making obstruction less likely. This procedure is known as maxillomandibular advancement.
• Implants. Soft rods, usually made of polyester or plastic, are surgically implanted into the soft palate after numbing with a local anesthetic. More research is needed to determine how well implants work.
• Nerve stimulation. This requires surgery to insert a stimulator for the nerve that controls tongue movement (hypoglossal nerve). The increased stimulation helps keep the tongue in a position that keeps the airway open. More research is needed.

• Creating a new air passageway, known as tracheostomy. You may need this form of surgery if other treatments have failed and you have severe, life-threatening sleep apnea. In this procedure, your surgeon makes an opening in your neck and inserts a metal or plastic tube through which you breathe.

  You keep the opening covered during the day. But at night you uncover it to allow air to pass in and out of your lungs, bypassing the blocked air passage in your throat.

Other types of surgery may help reduce snoring and contribute to the treatment of sleep apnea by clearing or enlarging air passages:

• Surgery to remove enlarged tonsils or adenoids.
• Weight-loss surgery, also known as bariatric surgery.

Therapies for CSA

• Treatment for associated medical problems. Possible causes of central sleep apnea include heart or neuromuscular disorders, and treating those conditions might help. Other therapies that may be used for CSA include supplemental oxygen, CPAP, BPAP, and adaptive servo-ventilation (ASV).
• Medicine changes. You may be prescribed medicine to help manage your breathing, such as acetazolamide. If medicines are worsening your CSA, such as opioids, your health care provider may change your medicines.
• Supplemental oxygen. Using supplemental oxygen while you sleep might help if you have central sleep apnea. Various forms of oxygen are available with devices to deliver oxygen to your lungs.

• Adaptive servo-ventilation (ASV). This more recently approved airflow device learns your typical breathing pattern and stores the information in a built-in computer. After you fall asleep, the machine uses pressure to regulate your breathing pattern and prevent pauses in your breathing.

  ASV may be an option for some people with treatment-emergent central sleep apnea. However, it might not be a good choice for people with predominant central sleep apnea and advanced heart failure. And ASV is not recommended for those with severe heart failure.

Lifestyle and home remedies

In some cases, self-care might be a way for you to deal with obstructive sleep apnea and possibly central sleep apnea. Try these tips:

• Lose excess weight. Even a slight weight loss might help relieve constriction of your throat. In some cases, sleep apnea can resolve if you return to a healthy weight, but it can recur if you regain the weight.
• Exercise. Regular exercise can help ease the symptoms of obstructive sleep apnea even without weight loss. Try to get 30 minutes of moderate activity, such as a brisk walk, most days of the week.
• Avoid alcohol and certain medicines such as tranquilizers and sleeping pills. These relax the muscles in the back of your throat, interfering with breathing.
• Sleep on your side or abdomen 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 keep from rolling onto your back while you sleep, try attaching a tennis ball to the back of your pajama top. There are also commercial devices that vibrate when you roll onto your back in sleep.
• Don't smoke. If you're a smoker, look for resources to help you quit.

Preparing for an appointment

If you or your partner suspects that you have sleep apnea, contact your primary care provider. In some cases, you might be referred immediately to a sleep specialist.

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

What you can do

When you make the appointment, ask if there's anything you need to do in advance, such as modify your diet or keep a sleep diary.

Make a list of:

• Your symptoms, including any that may seem unrelated to the reason for which you scheduled the appointment, and when they began.
• Key personal information, including family history of a sleep disorder.
• All medicines, vitamins or supplements you take, including doses.
• Questions to ask your doctor.

Take a family member or friend along, if possible, to help you remember the information you receive. Because your bed partner might be more aware of your symptoms than you are, it may help to have your partner along.

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

• What's the most likely cause of my symptoms?
• What tests do I need? Do these tests require special preparation?
• Is my condition likely temporary or long lasting?
• What treatments are available?
• Which treatment do you think would be best for me?
• I have other health conditions. How can I best manage these conditions together?
• Should I see a specialist?
• Are there brochures or other printed material that I can have? What websites do you recommend?

What to expect from your doctor

Your health care provider is likely to ask you questions, including:

• Have your symptoms been continuous, or do they come and go?
• How severe are your symptoms?
• How does your partner describe your symptoms?
• Do you know if you stop breathing during sleep? If so, how many times a night?
• Is there anything that has helped your symptoms?
• Does anything make your symptoms worse, such as sleep position or alcohol consumption?

What you can do in the meantime

• Try to sleep on your side.
• Avoid alcohol for 4 to 6 hours before bed.
• Don't take drugs that make you sleepy.
• If you're drowsy, avoid driving.