Obstructive Sleep Apnea

What is obstructive sleep apnea?

Obstructive sleep apnea (OSA) is when a blockage in your airway keeps air from moving through your windpipe while you’re asleep. The blockage and lack of airflow can cause your blood oxygen levels to drop, triggering a survival reflex in your brain that wakes you up just enough to breathe again.

While that reflex is key in keeping you breathing, it also disrupts your sleep. As more disruptions in your sleep happen, your sleep quality suffers. That can lead to a wide range of symptoms, many of which are disruptive or potentially dangerous.

Who does obstructive sleep apnea affect?

OSA can happen to anyone, but it’s more common under some circumstances and in some populations:

• Before age 50, it’s more common for people assigned male at birth (AMAB). After age 50, it affects people assigned female at birth (AFAB) at the same rate.
• People are more likely to develop it as they get older.
• Having excess weight or obesity strongly increases the risk of developing it.
• It’s more common in people who are of Black, Hispanic or Asian descent.

How common is obstructive sleep apnea?

OSA is uncommon but widespread. Experts estimate it affects about 5% to 10% of people worldwide. In older adults (age 65 and up), it’s much more common, climbing to 20% or more. However, it’s common for people not to realize that they have this condition, so experts aren’t certain about the true scope of this issue.

How does obstructive sleep apnea affect my body?

When learning about OSA, it’s helpful to know how the human sleep cycle works. The sleep cycle happens in multiple stages:

• Stage 1: Light sleep. This is a short stage that begins right after you fall asleep. It accounts for about 5% of your total sleep time.
• Stage 2: Deeper sleep. This stage is deeper and makes up about 45% to 50% of all the time you spend sleeping (this number goes up as you get older).
• Stage 3: Slow wave sleep. This is the deepest sleep stage, making up about 25% of the time you spend sleeping (this number goes down with age). It’s very hard to wake someone up in stage 3 sleep, and waking up directly from it usually causes “sleep inertia,” a state of “mental fog” and slowed thinking. Parasomnias like sleepwalking and sleep talking happen in this stage.
• REM sleep: REM stands for “rapid eye movement.” This stage is when you dream. When a person’s in REM sleep, you can see their eyes moving beneath their eyelids.

The stages of sleep also happen in a particular order. When you fall asleep, you typically enter stage 1 and then move into and cycle between stages 2 and 3. Then, you go into REM sleep and start dreaming. After the first REM cycle, you start a new cycle and go back into stage 1 or 2. One cycle normally takes about 90 to 110 minutes before another begins. Most people go through four or five cycles per night (assuming they get a full eight hours).

How sleep apnea causes poor sleep

The word “apnea” comes from Greek and means “breathless.” Obstructive sleep apnea means that it happens because of an obstruction or blockage. OSA happens most commonly because of how the muscles in your body relax as you move into some stages of sleep. As the muscles relax, the soft tissue around them settles downward because of gravity.

As soft tissues in your head and neck relax and sag downward, they can press on your windpipe, blocking air from passing through. Think of this as holding a straw between your thumb and index finger. The more pressure you put on the straw, the harder it is to pull liquid through it to drink. Likewise, air can’t pass through your windpipe if there’s enough downward pressure sealing it shut. That can cause either an apnea or a hypopnea:

• Apnea: This is when an airway blockage happens while you’re sleeping, which means you can’t breathe. It combines the Greek roots “a-,” which means “not” and “-pnea,” which refers to breathing.” Combined, it means “breathless.”
• Hypopnea: This is when you have an airway blockage, but it’s not severe enough to cause apnea. This combines Greek word roots “hypo-” and “-pnea.” The root “hypo” means “low” or “under.” Combining these roots means “under-breathing” or “low breathing,” which means you aren’t breathing enough to maintain oxygen levels in your blood.

Your brain can detect a drop in blood oxygen levels from apneas and hypopneas, and has a reflex that kicks in to keep you alive and breathing. That reflex wakes you up just enough for muscles in your head and neck to tense up slightly, taking the pressure off your windpipe.

However, the downside of these events is that they also disrupt your sleep cycle. These usually happen during stage 3 and REM sleep, and it’s extremely common for people not to remember these events. Your body will try to resume your sleep cycle as soon as blood oxygen levels return to normal, which means your muscles will relax again. If that causes another event, this process will repeat itself.

The apnea/hypopnea index (AHI) is the average hourly number of apnea or hypopnea events — times when a person stops breathing. The AHI is the main factor determining the severity of sleep apnea. The higher a person’s apnea index, the more severe their OSA. The severity breaks down like so:

• Mild sleep apnea: This level means a person has an AHI between 5 and 15. That means they have between 5 and 15 apnea or hypopnea events per hour. However, healthcare providers also consider symptoms at this level. If you don’t have other symptoms, they may not consider it severe enough to treat.
• Moderate sleep apnea: People with moderate sleep apnea have between 15 and 29 events per hour. That means a person who sleeps eight hours stops breathing and/or wakes up between 120 and 239 times.
• Severe sleep apnea: People with severe sleep apnea wake up 30 or more times in an hour. That means they stop breathing and/or wake up 240 times or more during a full eight hours of sleep.

What are the symptoms of obstructive sleep apnea?

OSA has many symptoms. Some of these happen while a person’s awake, while others happen when a person’s asleep.

Awake-centered symptoms include:

• Feeling tired or even exhausted when waking up. People often notice this feeling because of how tired they feel even though they slept eight hours or more.
• Daytime sleepiness. In more severe cases, this can cause drowsiness during driving, working or other activities.
• Mood changes. Depression and anxiety are common symptoms of sleep apnea.
• Disruptions in brain function. These can include memory loss, trouble concentrating or other brain-related problems.
• Headaches. These are often very noticeable when waking up.
• Insomnia.
• Sexual dysfunction.

Sleep-centered symptoms include:

• Snoring. This is a common feature with sleep apnea (but it isn’t something that happens in all cases). You can also have sleep apnea without snoring at all.
• Waking up in the middle of the night. This symptom might be harder to notice because people usually don’t remember waking up or why. People who do this often remember waking up for another reason, like heartburn or needing to go to the bathroom.
• Pauses in breathing while asleep that others witness. A spouse, partner or other loved one may notice these symptoms while you’re asleep.
• Night sweats and feeling restless in your sleep.
• Waking up feeling short of breath or like you’re choking.

Sleep apnea in children

While OSA is more common as people age, it’s still possible in children. The symptoms of OSA in children are mostly similar to those in adults, with a few exceptions. The childhood symptoms include:

• Hyperactivity or trouble focusing or performing poorly in school. This can look like symptoms of attention-deficit/hyperactivity disorder (ADHD).
• Loud snoring.
• Bedwetting.
• Frequent arm or leg movements while asleep.
• Sleeping in unusual positions or sleeping with their neck extended.
• Reflux (heartburn) or night sweats.

What causes obstructive sleep apnea?

OSA is the more common form of sleep apnea, and many factors can contribute to it or be the sole reason for it. Some of these happen on their own, while others can happen in combinations. The following are factors that can contribute to or cause OSA:

• Excess weight and obesity. Excess body weight can increase how much tissue presses on your windpipe while you’re asleep. OSA can also disrupt metabolism and other body systems, causing more weight gain.
• Structural causes: Having an underbite (retrognathia, pronounced “retro-nath-ee-uh”) or an unusually small lower jaw (micrognathia) can increase the risk of having OSA. Other structural issues include having a large tongue, large tonsils or adenoids, or having a neck circumference greater than 16 inches (40 centimeters).
• Genetic conditions. This includes conditions that affect the shape of your head and neck, such as Down syndrome or Prader-Willi syndrome.

Mixed/complex sleep apnea

Central sleep apnea is when there’s a problem in your brain or nervous system that keeps your body from breathing while you’re asleep. While it’s different than OSA, a person can develop a form that starts with central sleep apnea and then develops the obstruction symptom of OSA. Experts call this mixed sleep apnea or complex sleep apnea.

Is obstructive sleep apnea contagious?

OSA isn’t contagious, so you can’t give it to or catch it from someone else.

How is obstructive sleep apnea diagnosed?

Two main tests can help diagnose OSA. One is more common and is a definitive way to diagnose this condition. The other is a way to diagnose cases that aren’t severe or to confirm that a person still has OSA after certain medical procedures or body changes. The tests are:

• Overnight sleep study (polysomnogram). This is an overnight test where you sleep in a medical facility (often known as a “sleep lab”) that’s specially equipped to be as comfortable as possible while still monitoring your sleep. This test involves sensors that monitor your heart rate, breathing, blood oxygen levels, brain waves and more. Experts consider this test the gold standard for diagnosing all forms of sleep apnea.
• Home sleep apnea testing. This form of testing allows a person to complete a sleep study from home. It’s similar to an overnight sleep study but doesn’t involve brain wave monitoring and other types of sensors. This test can also help determine if a person still has or no longer has OSA after an initial diagnosis. An at-home sleep apnea test isn’t usually an option when a person may have mixed sleep apnea, if a provider suspects a person has moderate to severe OSA or if a person has other sleep disorders or medical conditions. Often when a home study doesn’t show sleep apnea, experts recommend confirming this with an overnight sleep study.

How is obstructive sleep apnea treated, and is there a cure?

There are many approaches to treating OSA, depending on how severe it is and what exactly causes it. None of these are cures, but they can prevent apnea events or reduce how often they happen.

Possible treatments include:

• Conservative (nonmedical) treatments.
• Positive airway pressure and adaptive ventilation devices.
• Oral appliances (mouthpieces).
• Nerve stimulators.
• Surgery.

Conservative treatments

These nonmedical treatments or approaches can improve OSA or resolve it. They aren’t cures, but they can reduce OSA to the point where it stops happening or isn’t severe enough to cause symptoms. These include:

• Weight loss. A 10% decrease in body weight can significantly improve OSA for people with excess weight or obesity.
• Position changes while sleeping and sleep aid items. Sleeping on your back makes sleep apnea more likely to happen. Special support pillows and similar items can help change the position in which you sleep, keeping you off your back so soft tissue doesn’t press on your windpipe and block breathing.
• Nasal sprays, adhesive strips, etc. These over-the-counter (OTC) products improve breathing by making it easier for air to travel through your nose. While they can’t help moderate or severe OSA, they can sometimes help snoring and mild OSA.

Positive airway pressure (PAP) and adaptive ventilation

Positive airway pressure is a method that uses a specialized device to increase the air pressure inside your airway while you inhale. This method can treat sleep apnea.

Pushing pressurized air down your windpipe keeps it open so you can breathe. These devices push air through a hose that attaches to a special mask you wear on your face while you sleep. Masks can cover your nose, mouth or both, and many different types and styles are available.

The best-known PAP device is the Continuous Positive Airway Pressure (CPAP) machine. However, there are other types of PAP machines, too. These devices increase the air pressure inside your airway and lungs when you inhale, keeping surrounding tissue from pressing your airway shut.

Oral devices

OSA happens when soft tissue in your head or neck — especially around your mouth and jaw — presses downward on your windpipe. Special mouthpiece devices can help hold your jaw and tongue in a position that keeps pressure off your windpipe. Dentists and sleep medicine specialists often work together to make these for people who need them.

Nerve stimulators

The hypoglossal nerve (the name comes from Greek and means “under the tongue”) is what controls your tongue’s movements. A nerve stimulator attached to the hypoglossal nerve can stimulate that nerve, pushing your tongue slightly forward when you breathe while you’re sleeping. That keeps your tongue from relaxing and pressing backward on your windpipe while you sleep, which is one of the ways that OSA happens.

An electrode attaches to the nerve under your jaw and connects to a device implanted under the skin in your chest. You can turn the stimulator on before you sleep and turn it off after you wake up. The electrical current is strong enough to keep your tongue from relaxing too much but mild enough that it’s not uncomfortable.

Surgery

Surgeries on your nose, mouth and throat can help prevent blockages of your nose, throat and windpipe. However, the impact of these in adults is usually limited and varies from person to person. These surgeries include:

• Somnoplasty: This procedure uses radiofrequency (RF) to reduce soft tissue around the upper parts of your windpipe.
• Tonsillectomy/adenoidectomy: Removing your tonsils and adenoids can widen the opening where your mouth, throat and nasal passages connect. That makes it easier for air to pass through and reduces soft tissue blocking your breathing. This procedure is most helpful for children with OSA.
• Uvulopalatopharyngoplasty (UPPP): This procedure removes your uvula (the teardrop-shaped soft tissue that hangs at the back of your mouth). It also removes soft tissue from your soft palate and pharynx. These widen the area where your mouth and throat meet, making it easier for air to pass through.
• Jaw surgery: Different surgery procedures can subtly change the position of your jaw so that soft tissue can’t easily press back on your airway. These procedures are especially helpful for people with OSA for structural reasons like micrognathia.
• Nasal surgery: One common form of nasal surgery is septoplasty, which straightens the soft tissue in your nose, making it easier for air to travel through your nose and nasal passages.

What can or can’t I eat or drink with sleep apnea?

People with OSA should avoid heavy drinking, frequent use of sleeping pills or other drugs (recreational and otherwise) that cause heavy sedation. These can make OSA worse. Your healthcare provider can talk to you about drugs that can cause that and how you can avoid the effects.

Complications/side effects of the treatment

The complications and side effects of the treatments depend on many factors, especially the treatments themselves. Your healthcare provider is the best source of information for what you can do to minimize the side effects or prevent them when possible.

How can I take care of myself/manage symptoms?

OSA can severely disrupt your life and even create the potential for life-threatening complications and events (see more about these under the Outlook/Prognosis section below). That means you shouldn’t try to self-diagnose or self-treat it. If you think you have OSA, you should schedule an appointment with a specialist or ask a primary care provider to refer you to one.

How you can help with diagnosis

If you suspect you or a loved one has OSA, you might be able to help a healthcare provider diagnose it. Video and audio recordings of a person sleeping, especially where you can hear breathing, can give a provider key evidence they need to speed up the diagnostic process.

How soon after treatment will I feel better?

Many factors can affect how long it takes to recover or feel better when you have sleep apnea. The type of treatment you receive, especially if it’s an ongoing treatment like nightly use of a PAP device, can also make a difference.

For some people, treatment may be enough for them to feel better very quickly. To see the full benefits, others may need three to six months of consistent nightly treatment. Your healthcare provider can tell you more about the timeline for your recovery and when you should expect to feel better.

Positive airway pressure devices can sometimes bring very fast results. Older devices may take some tweaking and adjusting (a process known as “titration”) of their settings, but many newer PAP devices can often adjust their settings automatically.

While some people may need to get used to wearing a mask to sleep, most people can overcome that fairly quickly. If you find yourself struggling with this, you aren’t alone. Many people struggle to acclimate to the masks. You can talk to your provider for tips on how to get used to wearing a mask or for recommendations on different types of masks that might work better for you.

How can I reduce my risk or prevent obstructive sleep apnea?

While OSA is sometimes preventable, it isn’t always something people can avoid. An example of this is how some people who have a healthy body weight or below-healthy weight can still develop OSA. For those individuals, the cause of their OSA is usually related to their head and neck structure, so they can’t prevent it.

The best things you can do to reduce your risk of sleep apnea include:

• Reaching and maintaining a healthy weight.
• Practicing good sleep hygiene.
• Managing any existing health conditions, such as high cholesterol, high blood pressure and Type 2 diabetes.
• Seeing your healthcare provider at least once a year for a checkup.

What can I expect if I have obstructive sleep apnea?

OSA can severely disrupt your life, and it increases your risk for life-threatening complications and events that are medical emergencies. Even if you don’t develop life-threatening or dangerous problems, people with sleep apnea can’t get restful sleep, so they constantly feel tired. In the worst cases, this condition can make them so tired that they may fall asleep during the day, leading to accidents, problems with work, hobbies, social activities, etc.

Dangerous complications of obstructive sleep apnea

OSA is a dangerous condition because it can cause several different complications, many of which are severe or life-threatening. These include:

• Heart damage and heart failure. OSA increases the pressure in your heart and the surrounding blood vessels. That puts a strain on your heart, ultimately damaging the heart muscle.
• Chronic health conditions. The effects of OSA can also contribute to or worsen high blood pressure (hypertension) or Type 2 diabetes.
• Arrhythmias, especially atrial fibrillation. Atrial fibrillation (called a-fib for short) is a dangerous arrhythmia because it disrupts how blood flows through the upper left chamber of your heart. A-fib causes blood to pool and linger for too long, resulting in blood clots. Those clots can then exit your heart and travel directly to your brain, causing a stroke.
• Sudden cardiac death. OSA can cause arrhythmias that are severe enough to stop your heart. When this happens, it’s a life-threatening condition known as sudden cardiac death.
• Daytime drowsiness. Feeling sleepy during the daytime can be dangerous if you’re driving or doing something that needs your full, undivided attention. If you nod off while using power tools, operating machinery or driving, that can have deadly consequences for you or others.

How long does obstructive sleep apnea last?

OSA is a chronic (long-term) condition. For some people, it’s possible to resolve it by reducing their weight or undergoing certain treatments. For others, it may be a life-long issue.

The outlook for obstructive sleep apnea

The outlook for OSA depends on many factors. The severity and type of sleep apnea do make a difference. However, sticking to your treatment method once you find one that works is usually the biggest determining factor in how this condition will affect you.

It’s critical to adhere to treatment closely. Using and sticking with treatments — especially ongoing ones like positive airway pressure devices — can make a huge difference. Many people stick with treatments for a month or so but then stop using them. That can increase the risk of complications and a negative outcome, so it’s essential that you keep on using them as long as you have sleep apnea.

How do I take care of myself?

There are several things you can do to help you manage OSA:

• Make lifestyle changes as best you can. Changing how you live your life, especially regarding diet and physical activity, can be a challenge. Don’t feel ashamed to talk to your healthcare provider about these struggles. These are VERY common, and your healthcare provider can probably help you overcome or adapt to these issues.
• Stick to your treatment plan closely. Ultimately, people who adhere to the treatments and make them a part of their routine — never or rarely missing a night — are more likely to have good outcomes and avoid severe or dangerous complications.
• Talk to your provider about what you’re experiencing. You should talk to your provider if you struggle to stick to treatment because of issues with a PAP device. It’s common for people to have issues with how a PAP device mask fits, pressure settings, etc. Your provider can help you remedy these issues, stick to your treatments and get a good night’s sleep.
• See your provider as recommended. Follow-up visits can be crucial, especially early on, to make sure your treatments are working as they should.

When should I go to the ER?

You should go to the ER if you notice any of the symptoms of a heart attack or stroke, both of which are more likely to happen with sleep apnea.

A note from Cleveland Clinic

Obstructive sleep apnea is a widespread condition that affects the sleep quality of millions of people around the world. This condition keeps you from getting enough quality sleep, leaving you feeling fatigued and drained. This condition also increases your risk of developing life-threatening heart and circulatory problems, including stroke. However, with treatment, you can adapt to or even overcome this condition, letting you get the restful sleep you need.