Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops and starts. You may have sleep apnea if you snore loudly and you feel tired even after a full night’s sleep.
There are two main types of sleep apnea:
• Obstructive sleep apnea, the more common form that occurs when throat muscles relax
• Central sleep apnea, which occurs when your brain doesn’t send proper signals to the muscles that control breathing
Treatment is necessary to avoid heart problems and other complications.
Why it Occurs
Causes of obstructive sleep apnea
Obstructive sleep apnea occurs when the muscles in the back of your throat relax. These muscles support the soft palate, the triangular piece of tissue hanging from the soft palate (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, and you can’t get an adequate breath in. This may lower the level of oxygen in your blood. Your brain senses this inability to breathe and briefly rouses you from sleep so you can reopen your airway. This awakening is usually so brief that you don’t remember it.
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, some people with this type of sleep apnea think they sleep well all night.
Causes of central sleep apnea
Central sleep apnea, which is much less common, occurs when your brain fails to transmit signals to your breathing muscles. You may awaken with shortness of breath or have a difficult time getting to sleep or staying asleep. Like with obstructive sleep apnea, snoring and daytime sleepiness can occur. The most common cause of central sleep apnea is heart failure and, less commonly, a stroke. People with central sleep apnea may be more likely to remember awakening than are people with obstructive sleep apnea.
Obstructive sleep apnea
• Excess weight. Fat deposits around your upper airway may obstruct your breathing. However, not everyone who has sleep apnea is overweight. Thin people develop this disorder, too.
• Neck circumference. People with a thicker neck may have a narrower airway.
• A narrowed airway. You may have inherited a naturally narrow throat. Or, your tonsils or adenoids may become enlarged, which can block your airway.
• Being male. Men are twice as likely to have sleep apnea. However, women increase their risk if they’re overweight, and their risk also appears to rise after menopause.
• Being older. Sleep apnea occurs significantly more often in adults older than 60.
• Family history. If you have family members with sleep apnea, you may be at increased risk.
• Race. In people under 35 years old, African Americans are more likely to have obstructive sleep apnea.
• Use of alcohol, sedatives or tranquilizers. These substances relax the muscles in your throat.
• Smoking. Smokers are three times more likely to have obstructive sleep apnea than are people who’ve never smoked. Smoking may increase the amount of inflammation and fluid retention in the upper airway. This risk likely drops after you quit smoking.
• Nasal congestion. If you have difficulty breathing through your nose — whether it’s from an anatomical problem or allergies — you’re more likely to develop obstructive sleep apnea.
Central sleep apnea
• Being male. Males are more likely to develop central sleep apnea.
• Being older. People older than 65 years of age have a higher risk of having central sleep apnea, especially if they also have other risk factors.
• Heart disorders. People with atrial fibrillation or congestive heart failure are more at risk of central sleep apnea.
• Stroke or brain tumor. These conditions can impair the brain’s ability to regulate breathing.
The signs and symptoms of obstructive and central sleep apneas overlap, sometimes making the type of sleep apnea more difficult to determine. The most common signs and symptoms of obstructive and central sleep apneas include:
• Excessive daytime sleepiness (hypersomnia)
• Loud snoring, which is usually more prominent in obstructive sleep apnea
• Episodes of breathing cessation during sleep witnessed by another person
• Abrupt awakenings accompanied by shortness of breath, which more likely indicates central sleep apnea
• Awakening with a dry mouth or sore throat
• Morning headache
• Difficulty staying asleep (insomnia)
• Attention problems
Consult a medical professional if you experience, or if your partner notices, the following:
• Snoring loud enough to disturb the sleep of others or yourself
• 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
Many people don’t think of snoring as a sign of something potentially serious, and not everyone who has sleep apnea snores. But be sure to talk to your doctor if you experience loud snoring, especially snoring that’s punctuated by periods of silence. Ask your doctor about any sleep problem that leaves you chronically fatigued, sleepy and irritable. Excessive daytime drowsiness (hypersomnia) may be due to other disorders, such as narcolepsy.
For milder cases of sleep apnea, your doctor may recommend only lifestyle changes, such as losing weight or quitting smoking. If these measures don’t improve your signs and symptoms or if your apnea is moderate to severe, a number of other treatments are available. Certain devices can help open up a blocked airway. In other cases, surgery may be necessary. Treatments for obstructive sleep apnea may include:
• Continuous positive airway pressure (CPAP). If you have moderate to severe sleep apnea, you may benefit from a machine that delivers air pressure through a mask placed over your nose 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 methods of treating sleep apnea, some people find it cumbersome or uncomfortable. Many people give up on CPAP, but with some practice, most people learn to adjust the tension of the straps to obtain a comfortable and secure fit. You may need to try more than one type of mask to find one that’s comfortable. Some people benefit from also using a humidifier along with their CPAP system.
Don’t just stop using the CPAP machine if you experience problems. Check with your doctor to see what modifications can be made to make you more comfortable. Additionally, contact your doctor if you are still snoring despite treatment or begin snoring again. If your weight changes, the pressure settings may need to be adjusted.
• Adjustable airway pressure devices. If CPAP continues to be a problem for you, you may be able to use a different type of airway pressure device that automatically adjusts the pressure while you’re sleeping. For example, units that supply bilevel positive airway pressure (BPAP) are available. These provide more pressure when you inhale and less when you exhale.
• Expiratory positive airway pressure (EPAP). This is the most recent treatment approved by the Food and Drug Administration (FDA). These small, single-use devices are placed over each nostril before you go to sleep. The device is a valve that allows air to move freely in, but when you exhale, air must go through small holes in the valve. This increases pressure in the airway and keeps it open. The device helped reduce snoring and daytime sleepiness when compared to a sham device. And, it may be an option for some who can’t tolerate CPAP.
• 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 may 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 may need to try different devices before finding one that works for you. Once you find the right fit, you’ll still need to follow up with your dentist at least every six months during the first year and then at least once a year after that to ensure that the fit is still good and to reassess your signs and symptoms.
Surgery is usually only an option after other treatments have failed. Generally, at least a three-month trial of other treatment options is suggested before considering surgery. However, for those few people with certain jaw structure problems, it’s a good first option. The goal of surgery for sleep apnea is to enlarge the airway through your nose or throat that may be vibrating and causing you to snore or that may be blocking your upper air passages and causing sleep apnea. Surgical options may include:
• Tissue removal. During this procedure, which is called uvulopalatopharyngoplasty (UPPP), your doctor removes tissue from the rear of your mouth and top of your throat. Your tonsils and adenoids usually are removed as well. This type of surgery may be successful in stopping throat structures from vibrating and causing snoring. However, it may be less successful in treating sleep apnea because tissue farther down your throat may still block your air passage. UPPP usually is performed in a hospital and requires a general anesthetic.
Removing tissues in the back of your throat with a laser (laser-assisted uvulopalatoplasty) isn’t a recommended treatment for sleep apnea. Radiofrequency energy (radiofrequency ablation) may be an option for people who can’t tolerate CPAP or oral appliances.
• Jaw repositioning. In this procedure, your jaw is moved forward from the remainder of your face bones. This enlarges the space behind the tongue and soft palate, making obstruction less likely. This procedure, which is known as maxillomandibular advancement, may require the cooperation of an oral surgeon and an orthodontist, and at times may be combined with another procedure to improve the likelihood of success.
• Implants. Plastic rods are surgically implanted into the soft palate while you’re under local anesthetic. This procedure may be an option for those with snoring or milder sleep apnea who can’t tolerate CPAP.
• Creating a new air passageway (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:
• Nasal surgery to remove polyps or straighten a crooked partition between your nostrils (deviated nasal septum)
• Surgery to remove enlarged tonsils or adenoids.
Treatments for central and complex sleep apnea may include:
• Treatment for associated medical problems. Possible causes of central sleep apnea include heart or neuromuscular disorders, and treating those conditions may help. For example, optimizing therapy for heart failure may eliminate central sleep apnea.
• Supplemental oxygen. Using supplemental oxygen while you sleep may help if you have central sleep apnea. Various forms of oxygen are available as well as different devices to deliver oxygen to your lungs.
• Continuous positive airway pressure (CPAP). This method, also used in obstructive sleep apnea, involves wearing a pressurized mask over your nose while you sleep. The mask is attached to a small pump that forces air through your airway to keep it from collapsing. CPAP may eliminate snoring and prevent sleep apnea. As with obstructive sleep apnea, it’s important that you use the device as directed. If your mask is uncomfortable or the pressure feels too strong, talk with your doctor so that adjustments can be made.
• Bilevel positive airway pressure (BPAP). Unlike CPAP, which supplies steady, constant pressure to your upper airway as you breathe in and out, BPAP builds to a higher pressure when you inhale and decreases to a lower pressure when you exhale. The goal of this treatment is to assist the weak breathing pattern of central sleep apnea. Some BPAP devices can be set to automatically deliver a breath if the device detects you haven’t taken one after so many seconds.
• Adaptive servo-ventilation (ASV). This more recently approved airflow device learns your normal breathing pattern and stores the information in a built-in computer. After you fall asleep, the machine uses pressure to normalize your breathing pattern and prevent pauses in your breathing. ASV appears to be more successful than other forms of positive airway pressure at treating central sleep apnea in some people.
Along with these treatments, you may read or hear about different treatments for sleep apnea, such as implants. Although a number of medical devices and procedures have received Food and Drug Administration clearance, there’s limited published research regarding how useful they are, and they aren’t generally recommended as sole therapies.