Sleep Apnea: Common Sleep Disorders

In people who have sleep apnea (also referred to as sleep-disordered breathing), breathing briefly stops or becomes very shallow during sleep. This change is caused by intermittent blocking of the upper airway, usually when the soft tissue in the rear of the throat collapses and partially or completely closes the airway. Each breathing stop typically lasts 10–20 seconds or more and may occur 20–30 times or more each sleeping hour.

sleep apnea cycle

If you have sleep apnea, not enough air can flow into your lungs through the mouth and nose during sleep, even though breathing efforts continue. When this happens, the amount of oxygen in your blood decreases. Your brain responds by awakening you enough to tighten the upper airway muscles and open your windpipe. Normal breaths then start again, often with a loud snort or choking sound. Although people who have sleep apnea typically snore loudly and frequently, not everyone who snores has sleep apnea. (See Is Snoring a Problem?)

Because people who have sleep apnea frequently arouse from deeper sleep stages to lighter sleep during the night, they rarely spend enough time in deep, restorative stages of sleep. They are therefore often excessively sleepy during the day. Such sleepiness is thought to lead to mood and behavior problems, including depression, and such sleepiness more than triples the of being in a traffic or work-related accident.

The many brief drops in blood-oxygen levels can be associated with morning headaches and decreased ability to concentrate, think properly, learn, and remember. In sleep apnea, the combination of the intermittent oxygen drops and reduced sleep quality triggers the release of stress hormones. These hormones in turn raise your blood pressure and rate and boost the risk of heart attack, stroke, irregular heart beats, and congestive heart failure. In addition, untreated sleep apnea can lead to altered energy metabolism that increases the risk for developing obesity and diabetes.

Anyone can have sleep apnea. It is estimated that at least 12–18 million American have sleep apnea, making it as common as asthma. More than one-half of the people who have sleep apnea are overweight. Sleep apnea is more common in men. More than 1 in 25 middle-aged men and 1 in 50 middle-aged women have sleep apnea along with excessive daytime sleepiness. About 3 percent of children and 10 percent or more of people over age 65 have sleep apnea. This condition occurs more frequently in African Americans, Asians, Native Americans, and Hispanics than in Caucasians.

More than one-half of all people who have sleep apnea are not diagnosed. People who have sleep apnea generally are not aware that their breathing stops in the night. They just notice that they don't feel well rested when they wake up and are sleepy throughout the day. Their bed partners are likely to notice, however, that they snore loudly and frequently and that they often stop breathing briefly while sleeping. Doctors suspect sleep apnea if these symptoms are present, but the diagnosis must be confirmed with overnight sleep monitoring. (See How Are Sleep Disorders Diagnosed?) This monitoring will reveal pauses in breathing, frequent sleep arousals, and intermittent drops in levels of oxygen in the blood.

Like adults who have sleep apnea, children who have this disorder usually snore loudly, snort or gasp, and have brief stops in breathing while sleeping. Small children often have enlarged tonsils and adenoids that increase their risk for sleep apnea. But doctors may not suspect sleep apnea in children because, instead of showing the typical signs of sleepiness during the day, these children often become agitated and may be considered hyperactive. The effects of sleep apnea in children may include diminished school performance and difficult, aggressive behavior.

A number of factors can make a person susceptible to sleep apnea. These factors include:

  • Throat muscles and tongue that relax more than normal while asleep
  • Enlarged tonsils and adenoids
  • Being overweight—the excess fat tissue around your neck makes it harder to keep the throat area open
  • Head and neck shape that creates a somewhat smaller airway size in the mouth and throat area
  • Congestion, due to allergies, that can also narrow the airway
  • Family history of sleep apnea

If your doctor suspects that you have sleep apnea, you may be referred to a sleep specialist. Some of the ways to help diagnose sleep apnea include:

  • A medical history that includes asking you and your family questions about how you sleep and how you function during the day.
    Checking your mouth, nose, and throat for extra or large tissues—for example tonsils, uvula (the tissue that hangs from the middle of the back of the mouth), and soft palate (roof of your mouth in the back of your throat).
  • An overnight recording of what happens with your breathing during sleep (polysomnogram, or PSG).
  • A Multiple Sleep Latency Test (MSLT), usually done in a sleep center, is used to see how quickly you fall asleep at times when you would normally be awake. Falling asleep in only a few minutes usually means that you are very sleepy during the day. Being very sleepy during the day can be a sign of sleep apnea.

Once all the tests are completed, the sleep medicine specialist will review the results and work with you and your family to develop a treatment plan. Changes in daily activities or habits may help reduce your symptoms:

  • Sleep on your side instead of on your back. Sleeping on your side will help reduce the amount of upper airway collapse during sleep.
  • Avoid alcohol, smoking, sleeping pills, herbal supplements, and any other medications that make you sleepy. They make it harder for your airway to stay open while you sleep, and sedatives can make the breathing pauses longer and more severe. Tobacco smoke irritates the airways and can help trigger the intermittent collapse of the upper airway.
  • Lose weight if you are overweight. Even a little weight loss can sometimes improve symptoms.

These changes may be all that are needed to treat mild sleep apnea. However, if you have moderate or severe sleep apnea, you will need additional, more direct treatment approaches.

Continuous Positive Airway Pressure (CPAP) is the most effective treatment for sleep apnea in adults. CPAP delivers air into your airway through a specially designed nasal mask attached to a machine that acts as a pump. The mask does not breathe for you; the flow of air creates enough increased pressure to keep the airways in your nose and mouth more open while you sleep. The air pressure is adjusted so that it is just enough to stop your airways from briefly becoming too small during sleep. The pressure is constant and continuous. Sleep apnea will return if CPAP is stopped or if it is used incorrectly.

People who have severe sleep apnea symptoms generally feel much better once they begin treatment with CPAP. CPAP treatment can cause side effects in some people. Possible side effects include dry or stuffy nose, irritation of the skin on the face, bloating of the stomach, sore eyes, or headaches. If you have trouble with CPAP side effects, work with your sleep medicine specialist and support staff. Together, you can do things to reduce or eliminate these problems.

Currently, no medications cure sleep apnea. However, the prescription drug modafinil may help relieve the excessive sleepiness that sometimes persists even with CPAP treatment of sleep apnea.

Another treatment approach that may help some people is the use of a mouthpiece (oral or dental appliance). If you have mild sleep apnea or do not have sleep apnea but snore very loudly, your doctor or dentist may also recommend this. A custom-fitted plastic mouthpiece will be made by a dentist or an orthodontist—a specialist in correcting teeth or jaw problems. The mouthpiece will adjust your lower jaw and tongue to help keep the airway in your throat more open while you are sleeping. Air can then flow more easily into your lungs because there is less resistance to breathing. Following up with the dentist or orthodontist is important to correct any side effects and to be sure that your mouthpiece continues to fit properly.

Some people who have sleep apnea, depending on the findings of the evaluation by the sleep medicine specialist, may benefit from surgery. Removing tonsils and adenoids that are blocking the airway is done frequently, especially in children. Uvulopalatopharyngoplasty (UPPP) is a surgery for adults that removes the tonsils, uvula (the tissue that hangs from the middle of the back of the roof of the mouth), and part of the soft palate (roof of the mouth in the back of the throat). Tracheostomy is a surgery used rarely and only in severe sleep apnea when no other treatments have been successful. A small hole is made in the windpipe, and a tube is inserted. Air will flow through the tube and into the lungs, bypassing the obstruction in the upper airway.