Sleep Apnea

Overview

Sleep apnea is when your breathing repeatedly stops and starts or becomes shallow during sleep. These breathing pauses are known as apneas, while shallow breathing periods are known as hypopneas.

During a sleep apnea episode, air is either blocked or partially blocked from reaching our lungs, which in turn may cause blood oxygen levels to drop. As a result, your brain briefly wakes you to restart breathing, which is called a microarousal.

People with sleep apnea might have from a few to hundreds of apneas per night, leading to fragmented and non-restorative sleep. At the same time, fluctuations in oxygen stress the body, leading to excessive daytime sleepiness, fatigue, and poor concentration, which can cause secondary hypersomnia.

There are three primary types of sleep apnea: 

• Obstructive sleep apnea (OSA): The most common type of sleep apnea, obstructive sleep apnea causes the throat muscles to relax during sleep, in turn causing the airway to narrow or collapse and block airflow. Loud and chronic snoring, gasping or choking during sleep, and repeated awakenings are key indicators of obstructive sleep apnea. 
• Central sleep apnea (CSA): In central sleep apnea, the brain temporarily fails to send the proper signals to the breathing muscles, and breathing stops. While it has similar key indicators, central sleep apnea snoring is less loud and chronic than in obstructive sleep apnea. Central sleep apnea is less common than OSA.
• Mixed (complex) sleep apnea: A combination of both obstructive and central sleep apnea, mixed sleep apnea starts as obstructive sleep apnea and later progresses to central sleep apnea. Doctors most often diagnose this type of sleep apnea during sleep studies.

The causes of obstructive sleep apnea can include: 

• Obesity: Being overweight is a common risk factor for obstructive sleep apnea because excess fat around the neck and mid-section can narrow the anatomical structures connecting your mouth and nose to those deeper in the airway, increasing the likelihood that it will temporarily collapse during sleep. 
• Airway anatomy and structure: A naturally small airway, enlarged tonsils or adenoids, a thick neck or excess tissue around the throat, and certain jaw shapes, like a recessed jaw, can increase your risk of developing obstructive sleep apnea. 
• Muscle relaxation during sleep: Your throat muscles naturally relax during sleep, but in some individuals, they relax too much and allow the airway to collapse.
• Alcohol and sedatives: By further relaxing airway muscles, these substances can make breathing interruptions more likely.
• Sleeping position: Sleeping on your back can allow your tongue and soft tissues to fall backward, obstructing the airway.

The causes of central sleep apnea can include: 

• Brain signaling problems: Common underlying causes of the brain failing to regulate breathing during sleep can include stroke, traumatic brain injury (TBI), neurological diseases, and medications that reduce activity in the part of the brain responsible for regulating breathing.
• Heart conditions: Heart failure and atrial fibrillation are strongly associated with a specific pattern of central sleep apnea. 
• Other contributing factors: Being male, older age, smoking, living in higher altitudes, and having nasal congestion or chronic airway inflammation can increase your odds of developing central sleep apnea. So, too, can genetic predisposition.

Nighttime symptoms of sleep apnea can include:

• Loud, chronic snoring: Frequent and loud snoring interrupted by breathing pauses is one of the most common signs of obstructive sleep apnea.
• Pauses in breathing during sleep: Breathing may stop for seconds at a time.
• Gasping, choking, or snorting during sleep: Since the brain briefly wakes the body to restart breathing, sudden gasping or choking sounds can occur multiple times throughout the night (though you might not recall them).
• Restless or fragmented sleep: You may toss and turn or wake up frequently without realizing why, leaving you feeling as though you aren’t sleeping well. 
• Night sweats: Due to repeated stress on the body from low oxygen levels, you may wake up sweating.
• Frequent nighttime urination: Waking up multiple times to use the bathroom can result from hormonal changes during disrupted sleep.
• Waking up with a dry mouth or sore throat: Breathing through the mouth during sleep can leave your mouth and throat dry or irritated in the morning.

Daytime symptoms of sleep apnea can include: 

• Excessive sleepiness: Feeling very sleepy during the day and struggling to stay awake during routine, everyday activities is a hallmark symptom of sleep apnea. 
• Difficulty concentrating or reduced mental capacity: Trouble focusing, slower thinking, memory issues, and a feeling of brain fog are also common symptoms.
• Morning headaches: Disrupted sleep and low oxygen levels during the night can lead to a dull headache upon waking.
• Changes in mood: Experiencing poor sleep can lead to irritability, mood swings, anxiety, or symptoms of depression.
• Low energy or fatigue: Feeling constantly drained or lacking energy is also common.
• Decreased libido: Hormonal and energy changes from poor, fragmented sleep can reduce overall interest in sex.
• Hypertension: A less obvious but important symptom of sleep apnea is high blood pressure, known as hypertension. Sleep apnea is strongly linked to blood pressure that’s higher than normal.
• Falling asleep unintentionally: In more severe cases of sleep apnea, you may doze off during conversations, while watching TV, or while driving.

If you experience some or all of the symptoms outlined above, please reach out to a healthcare professional to initiate a sleep apnea diagnosis. 

Sleep specialists use the following exams, tools, and sleep studies to diagnose sleep apnea:

• Physical and neurological exam: A detailed conversation with a healthcare professional will help identify specific sleep apnea symptoms like snoring, daytime sleepiness, witnessed pauses in breathing, and morning headaches. Your doctor will also check for physical features that may increase your risk, like a large neck circumference, enlarged tonsils, and an abnormal jaw structure. Finally, a neurological exam will evaluate your reflexes, coordination, balance, and cognitive function to help identify signs of neurological disorders that can affect sleep regulation.
• Sleep questionnaires: These standardized forms are used to help assess your sleep apnea risk and severity. Common questionnaires include the Epworth Sleepiness Scale, which measures daytime sleepiness, and the STOP-BANG questionnaire, which screens for sleep apnea risk. 
• Overnight sleep study: The gold standard for diagnosing sleep apnea, an overnight sleep study in a sleep laboratory involves sensors placed on your scalp, face, chest, and legs to monitor brain waves, breathing, heart rate, oxygen levels, and body movements during sleep. A sleep study can also exclude other sleep disorders that may cause excessive sleepiness. 
• Home sleep apnea test (HSAT): An HSAT is a simplified sleep study you can do at home using a portable device that measures your breathing effort, airflow, and oxygen levels. Although it’s less detailed, an HSAT is more convenient than a lab study, and specialists often use them in cases of suspected moderate or severe obstructive sleep apnea.
• Oxygen saturation monitoring: Often included in both laboratory and home sleep tests, oxygen saturation monitoring measures how much oxygen is in your blood during sleep. Drops in oxygen levels suggest significant breathing interruptions. 
• Actigraphy: Actigraphy uses a watch-like device worn on the wrist to track your movements and light exposure. It also continuously records your sleep-wake activity for days or weeks to provide an objective view of your circadian rhythm.
• Maintenance of Wakefulness Test (MWT): This test measures how well you can stay awake sitting quietly in a dim room for several sessions throughout the day. It gauges the severity of daytime sleepiness or evaluates whether a specific treatment is working.
• Multiple Sleep Latency Test (MSLT): An MSLT measures how quickly you fall asleep during daytime naps. In this test, you’ll take a scheduled nap every two hours, and how quickly you fall asleep and whether you enter REM sleep faster than normal will be measured. An MSLT is most often used to diagnose narcolepsy or hypersomnia, or if these symptoms overlap with sleep apnea.
• Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) scan: If a neurological cause or structural abnormality is suspected—for example, a brain tumor—your doctor might order an MRI or CT scan of your brain or your airway. 

An important scoring tool for diagnosing sleep apnea includes the Apnea–Hypopnea Index (AHI), which measures the number of breathing interruptions per hour of sleep. This index helps classify the severity of sleep apnea: 

• Mild sleep apnea: Ranges from 5-14 apnea events per hour
• Moderate sleep apnea: Between 15-29 apnea events per hour
• Severe sleep apnea: More than 30 apnea events per hour

In addition to weight loss, doctors commonly recommend the following nonsurgical treatments: 

• Continuous positive airway pressure (CPAP) therapy: As a frontline treatment for moderate to severe obstructive sleep apnea, CPAP is a bedside machine that delivers steady air pressure through a mask to help your airway stay open during sleep. It begins working immediately, although it may take some time to get comfortable with the mask. 
• Advanced PAP devices (APAP or BiPAP): A variation of CPAP, an auto-adjusting positive airway pressure (APAP) device adjusts pressure automatically. In contrast, a bilevel positive airway pressure (BiPAP) uses different pressures for inhalation and exhalation. These advanced PAP devices address specific cases of central sleep apnea or complex apnea, along with CPAP therapy intolerance.
• Oral appliance therapy: Similar to a retainer, a small custom-fitted mouthpiece can help gently move your lower jaw forward and keep your airway open. Oral appliance therapy is used in mild to moderate obstructive sleep apnea cases and for those who can’t tolerate CPAP therapy. 
• Positional therapy: This approach encourages you to sleep on your side rather than on your back using wearable devices, specialized pillows, or alarms that prompt repositioning. 
• Oxygen therapy: In some cases, supplemental oxygen is used during sleep to maintain healthy oxygen levels, often alongside another treatment, like CPAP therapy. Oxygen therapy is not a standalone treatment.
• Myofunctional therapy: In cases of mild to moderate sleep apnea, strengthening airway muscles with throat and tongue exercises may help keep your airway more stable. The goal of myofunctional therapy is to improve the function of the throat and tongue muscles to support your airway better, and it works best when paired with other nonsurgical treatments.

• Medication: While medication cannot fix the airway collapse that causes most types of sleep apnea, it can be a useful additional treatment. Examples include wakefulness-promoting medications for daytime sleepiness, such as armodafinil and solriamfetol; acetazolamide and theophylline for central sleep apnea; and nasal steroids and decongestants for nasal congestion, allergies, and blockages. Recently, tirzepatide, a GLP1 agonist, was approved for the treatment of moderate to severe OSA. More medications are being investigated through clinical trials and may become available in the future. 
• Regular exercise: Staying physically active will help regulate your breathing, improve your sleep quality, and reduce other risk factors, like obesity and cardiovascular disease.
• Upgrading your sleep hygiene: Improving your nighttime habits can support better overall sleep quality. Keeping a consistent bedtime schedule, optimizing your sleep environment—keeping your bedroom cool and dark—and avoiding screens an hour before bed are proven sleep hygiene practices. 

If your treatment plan includes CPAP, APAP, or BiPAP, it’s important to incorporate a healthy dose of patience as you start, since finding the right mask and pressure may take time and require adjustments. 

Ultimately, consistency matters more than anything: Even the best sleep apnea treatment only works if you use it regularly. Your treatment may also evolve due to changes in weight, aging, or new health conditions.

Surgical Treatments

In general, surgical treatments for sleep apnea are tailored to the site where the airway collapses, like the tongue, palate, jaw, or nose. Additionally, some sleep apnea patients may require a combination of procedures.

Doctors might suggest the following surgical treatments when other options don’t work or aren’t well tolerated:

• Hypoglossal nerve stimulation: Hypoglossal nerve stimulation is a treatment for obstructive sleep apnea that helps keep the airway open by stimulating the hypoglossal nerve, which controls the tongue, via a small, implanted device, much like a pacemaker.
• Uvulopalatopharyngoplasty (UPPP): This surgical procedure removes or reshapes tissue at the back of the throat, like the uvula and part of the soft palate, to widen the airway and reduce its collapse during sleep. 
• Maxillomandibular advancement (MMA): As one of the most effective surgical options for moderate to severe sleep apnea, an MMA moves the upper and lower jaw forward and permanently enlarges the airway. However, this procedure is a major surgery and involves a longer recovery time.
• Glossectomy: Also known as a tongue-reduction surgery, this procedure removes or reduces part of the tongue to create more space in the airway if the tongue is a major source of obstruction.
• Tonsillectomy and adenoidectomy: Removal of enlarged tonsils and/or adenoids is highly common and often very effective in children with sleep apnea.
• Radiofrequency ablation (RFA): This minimally invasive surgical procedure uses controlled heat energy to shrink and stiffen the tongue or soft palate, in turn reducing the risk of collapse during sleep.
• Palatal implants: In this procedure, tiny implants are placed in the soft palate to stiffen it, thereby reducing vibration and palate collapse. Doctors typically use this approach for mild sleep apnea.
• Nasal surgeries: Often used alongside other treatments, nasal surgery reduces swollen nasal tissues or straightens a deviated septum to improve airflow through the nose and make breathing easier.

As with any procedure, follow-up care is critical—in fact, your care team will likely prescribe additional sleep studies to confirm your treatment is working.