A single copy of this article may be reprinted for personal, noncommercial use only.
Obstructive sleep apneaBy Mayo Clinic staff
Original Article: http://www.mayoclinic.com/health/obstructive-sleep-apnea/DS00968
CLICK TO ENLARGE
|Obstructive sleep apnea|
Obstructive sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops and starts during sleep.
Several types of sleep apnea exist, but the most common type is obstructive sleep apnea, which occurs when your throat muscles intermittently relax and block your airway during sleep. The most noticeable sign of obstructive sleep apnea is snoring.
Anyone can develop obstructive sleep apnea, although it most commonly affects middle-aged and older adults and people who are overweight.
Obstructive sleep apnea treatment may involve using a device to keep your airway open or using a mouthpiece to thrust your jaw forward during sleep. Some people undergo a procedure to change the structure of their nose, mouth or throat.
Signs and symptoms of obstructive sleep apnea include:
- Excessive daytime sleepiness
- Loud snoring
- Observed episodes of breathing cessation during sleep
- Abrupt awakenings accompanied by shortness of breath
- Awakening with a dry mouth or sore throat
- Awakening with chest pain
- Morning headache
- Difficulty concentrating during the day
- Experiencing mood changes, such as depression or irritability
- Difficulty staying asleep (insomnia)
- Having high blood pressure
When to see a doctor
Consult a medical professional if you experience, or if your partner observes, the following:
- Snoring loud enough to disturb your sleep or that of others
- Shortness of breath that awakens you from sleep
- Intermittent pauses in your breathing during sleep
- Excessive daytime drowsiness, which may cause you to fall asleep while you're working, watching television or even driving a vehicle
Many people don't think of snoring as a sign of something potentially serious, and not everyone who snores has obstructive sleep apnea. However, be sure to talk to your doctor if you experience loud snoring, especially snoring that's punctuated 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.
CLICK TO ENLARGE
|Obstructive sleep apnea|
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 soft palate, the uvula — a triangular piece of tissue hanging from the soft palate, the tonsils and the tongue.
When the muscles relax, your airway narrows or closes as you breathe in and breathing may be inadequate for 10 to 20 seconds. This may lower the level of oxygen in your blood. 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 a transient shortness of breath that corrects itself quickly, within one or two deep breaths. You may 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 desired deep, restful phases of sleep, and you'll probably feel sleepy during your waking hours.
People with obstructive sleep apnea may not be aware that their sleep was interrupted. In fact, many people with this type of sleep apnea think they slept well all night.
Anyone can develop obstructive sleep apnea. However, certain factors put you at increased risk, including:
Being overweight. Around half of people with obstructive sleep apnea are overweight. Fat deposits around the upper airway may obstruct breathing. Also, people with obstructive sleep apnea tend to have a larger waist.
However, not everyone with obstructive sleep apnea is overweight and vice versa. Thin people can develop the disorder, too.
Having a large neck. The size of your neck may indicate whether you have an increased risk.
A thick neck may narrow the airway and may be an indication of excess weight. A neck circumference greater than 17 inches for men and 16 inches for women is associated with an increased risk of obstructive sleep apnea.
- Having high blood pressure (hypertension). Obstructive sleep apnea is relatively common in people with hypertension.
- Having a narrowed airway. You may inherit a naturally narrow throat. Or your tonsils or adenoids may become enlarged, which can block your airway.
- Having 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.
- Having diabetes. Obstructive sleep apnea may be more common in people with diabetes.
- Being male. In general, men are twice as likely to have obstructive sleep apnea.
- Being black. Among people under age 35, obstructive sleep apnea is more common in blacks.
- Being a certain age. Obstructive sleep apnea usually occurs in adults who are ages 18 to 60, but it can occur at any age.
- Having a family history of sleep apnea. If you have family members with obstructive sleep apnea, you may be at increased risk.
- Smoking. People who smoke are more likely to have obstructive sleep apnea.
- Using alcohol. Alcohol may worsen obstructive sleep apnea.
Obstructive sleep apnea is considered a serious medical condition. Complications may include:
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 attack, heart failure and stroke. In a study, men with obstructive sleep apnea appeared to be at risk of heart failure, but women with obstructive sleep apnea didn't appear to have a higher risk of heart failure.
People with obstructive sleep apnea are much more likely to develop abnormal heart rhythms (arrhythmias).
If there's underlying heart disease, these repeated multiple episodes of low blood oxygen (hypoxia or hypoxemia) could lead to sudden death from a cardiac event.
Daytime fatigue. The repeated awakenings associated with obstructive sleep apnea make normal, restorative sleep impossible. People with obstructive sleep apnea often experience severe daytime drowsiness, fatigue and irritability. They may have difficulty concentrating and find themselves falling asleep at work, while watching TV or even when driving.
Children and young people with obstructive sleep apnea may do poorly in school and commonly have attention or behavior problems.
Treatment of obstructive sleep apnea can improve these symptoms, restoring alertness and improving quality of life.
Complications with medications and surgery. Obstructive sleep apnea also is a concern with certain medications and general anesthesia. These medications, such as sedatives, narcotic analgesics and general anesthesia, relax your upper airway and may worsen your obstructive sleep apnea.
If you have obstructive sleep apnea, you may experience worse breathing problems after major surgery, especially after being sedated and lying on your back.
People with obstructive sleep apnea may be more prone to complications after surgery.
Before you have surgery, tell your doctor if you have obstructive sleep apnea or symptoms related to obstructive sleep apnea. If you have obstructive sleep apnea symptoms, your doctor may test you for obstructive sleep apnea prior to 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. It's not uncommon for a partner to choose to sleep in another room. Many bed partners of people who snore are sleep deprived as well.
People with obstructive sleep apnea may also complain of memory problems, morning headaches, mood swings or feelings of depression, and a need to urinate frequently at night (nocturia).
Preparing for your appointment
If you suspect that you have obstructive sleep apnea, you'll likely first see your family doctor or a primary care doctor. Your doctor may refer you to a sleep specialist.
It's a good idea to be well prepared for your appointment. Here's some information to help you get ready for your appointment, and what to expect from your doctor.
What you can do
- Be aware of any 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. You may be asked to record a sleep diary for one to two weeks.
- Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for your appointment.
- 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 that you're taking. Include anything you've taken to help you sleep.
- Take your bed partner along, if possible. Your doctor may want to talk to your partner to learn more about how much and how well you're sleeping.
- 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 is likely causing my symptoms?
- Other than the most likely cause, what are other possible causes for my symptoms?
- Is my condition likely temporary or chronic?
- What kinds of tests do I need?
- Should I go to a sleep clinic?
- What is the best course of action?
- What are the alternatives to the primary approach that you're suggesting?
- Are there any restrictions that I need to follow?
- I have other health conditions. How can I best manage them together?
Don't hesitate to ask other questions that occur to you.
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 begin experiencing symptoms?
- Have your symptoms been continuous or occasional?
- Do you snore? If so, does your snoring disrupt anyone else's sleep?
- How often do you snore? 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 ever seen you stop breathing during sleep?
- How refreshed do you feel when you wake up?
- Do you experience headache or dry mouth upon awakening?
- Are you tired during the day?
- Do you doze off or have trouble staying awake while sitting quietly or driving?
- Do you nap during the day?
- Do you use tobacco or drink alcohol?
- Do you worry about falling asleep or staying asleep?
- Do you have any family members with sleep problems?
- What medications do you take?
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 you may be abnormally sleepy, which can put you at higher risk of motor vehicle accidents. To be safe, schedule rest breaks. At times, a close friend or family member might tell you that you appear sleepier than you feel. If this is true, try to avoid driving.
Tests and diagnosis
To diagnose your condition, your doctor may make an evaluation based on your signs and symptoms, an examination, and tests. Your doctor may refer you to a sleep specialist in a sleep center for further evaluation.
You'll have a physical examination, and your doctor will examine the back of your throat, mouth and nose for extra tissue or abnormalities. Your doctor may measure your neck and waist circumference and check your blood pressure.
A sleep specialist may conduct additional evaluations to diagnose your condition, determine the severity of your condition and plan your treatment. The evaluation may involve overnight monitoring of your breathing and other body functions as you sleep. 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 may have a full-night study, in which you're monitored all night, or 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 test can help your doctor diagnose obstructive sleep apnea and adjust positive airway pressure therapy, if appropriate. This sleep study can also help rule out other sleep disorders, such as periodic limb movements of sleep or narcolepsy, which also can cause excessive daytime sleepiness, but require different treatment.
Oximetry. This test monitors and records your blood oxygen level while you're asleep and can be used a screening test for obstructive sleep apnea. If you have obstructive sleep apnea, the results of this test will often show drops in your blood oxygen level during apneas and subsequent rises with awakenings.
If the study reveals temporary drops in oxygen compatible with obstructive sleep apnea, a polysomnogram may follow to formally diagnose obstructive sleep apnea and determine appropriate therapy.
- Portable monitoring. 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.
Your doctor also may refer you to an ear, nose and throat doctor to rule out any anatomic blockage in your nose or throat.
Treatments and drugs
For milder cases of obstructive sleep apnea, your doctor may recommend lifestyle changes:
- Lose weight if you're overweight.
- Exercise regularly.
- Drink alcohol moderately, if at all, and don't drink several hours before bedtime.
- Quit smoking.
- Use a nasal decongestant.
- Don't sleep on your back.
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.
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 the nose or is placed over the 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.
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 also may benefit from using a humidifier along with your CPAP system.
CPAP may be given at a continuous (fixed) pressure or varied (autotitrating) pressure. 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 autotitrating CPAP may 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 changes.
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. 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 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.
- Medications. If you continue to experience daytime sleepiness after treatment for your obstructive sleep apnea, your doctor may prescribe medications to reduce sleepiness.
Surgery or other procedures
The goal of surgery for obstructive sleep apnea is to prevent blockage of the upper airway during sleep. 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 are commonly removed as well.
UPPP usually is performed in a hospital and requires a general anesthetic.
Doctors sometimes remove tissue from the back of the throat with a laser (laser-assisted uvulopalatoplasty) or with radiofrequency energy (radiofrequency ablation) to treat snoring. These procedures don't treat obstructive sleep apnea, but they may reduce snoring.
Jaw surgery. In this procedure, called maxillomandibular advancement, 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.
This procedure often requires an oral surgeon and possibly an orthodontist. Complications could include numbness of the mouth, bleeding, infection, removal of hardware or temporomandibular joint problems.
Surgical opening in the neck. You may need this form of surgery if other treatments have failed and you have severe, life-threatening obstructive sleep apnea.
In this procedure, called 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.
- Implants. The Pillar procedure is a minimally invasive treatment that involves placement of three tiny polyester rods in the soft palate. These inserts stiffen and support the tissue of the soft palate and reduce upper airway collapse and snoring. This treatment is recommended only for people with mild obstructive sleep apnea.
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 nasal 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 slight loss of excess weight may help relieve constriction of your airway. Losing weight can also improve your health and quality of life, and may reduce your sleepiness during the day.
- Exercise. Exercising, such as aerobic exercise and strength training, can help improve your condition. Aim to exercise about 150 minutes per week, and generally try to exercise four or more days per week.
- Avoid alcohol and medications such as tranquilizers and sleeping pills. Alcohol can worsen obstructive sleep apnea and sleepiness and may lead to you gaining weight. Certain medications also can worsen your sleep.
- 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 prevent sleeping on your back, try sewing a tennis ball in the back of your pajama top.
- 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 only be recommended for short-term use.
- What is sleep apnea? National Heart, Lung, and Blood Institute. http://www.nhlbi.nih.gov/health/health-topics/topics/sleepapnea/. Accessed April 17, 2013.
- Kline LR. Clinical presentations and diagnosis of obstructive sleep apnea in adults. http://www.uptodate.com/home. Accessed April 4, 2013.
- Strohl KP. Overview of obstructive sleep apnea in adults. http://www.uptodate.com/home. Accessed April 4, 2013.
- Tamisier R, et al. Cardiovascular effects of obstructive sleep apnea. http://www.uptodate.com/home. Accessed April 4, 2013.
- Kryger MH. Management of obstructive sleep apnea in adults. http://www.uptodate.com/home. Accessed April 4, 2013.
- Paruthi S. Evaluation of suspected obstructive sleep apnea in children. http://www.uptodate.com/home. Accessed April 16, 2013.
- Olson E. Surgical risk and the preoperative evaluation and management of adults with obstructive sleep apnea. http://www.uptodate.com/home. Accessed April 16, 2013.
- Collop N. Portable monitoring in obstructive sleep apnea in adults. http://www.uptodate.com/home. Accessed April 16, 2013.
- Millman RP, et al. Polysomnography in obstructive sleep apnea in adults. http://www.uptodate.com/home. Accessed April 16, 2013.
- Dave NB. Initiation of positive airway pressure therapy for obstructive sleep apnea in adults. http://www.uptodate.com/home. Accessed April 12, 2013.
- Jacobson RL, et al. Treating obstructive sleep apnea: The case for surgery. American Journal of Orthodontics and Dentofacial Orthopedics. 2012;142:435.
- Grover DP. Obstructive sleep apnea and ocular disorders. Current Opinion in Ophthalmology. 2010;21:454.
- Rosario IC. Obstructive sleep apnea: A review and update. Minnesota Medicine. 2011;94:44.
- Find a sleep center near you. American Academy of Sleep Medicine. http://www.sleepcenters.org/. Accessed April 4, 2013.
- U.S. News best hospitals 2012-2013. U.S. News & World Report. http://health.usnews.com/best-hospitals/rankings. Accessed April 4, 2013.
- Olson EJ (expert opinion). Mayo Clinic, Rochester, Minn. April 29, 2013.