Obstructive sleep apnea
An in-depth report about the causes, diagnosis, treatment, and prevention of obstructive sleep apnea.
Obstructive Sleep Apnea
Obstructive sleep apnea (OSA) is a common sleep disorder. It occurs when tissues in the upper airways come too close to each other during sleep, temporarily blocking the inflow of air.
Who Is At Risk
OSA can develop in anyone at any age but most often occurs in people who are:
Age 40 and older
Guidelines for Obstructive Sleep Apnea in Adults
Recent guidelines on diagnosis and treatment of adult OSA from the American College of Physicians recommend:
- Sleep tests should be reserved for patients who experience daytime sleepiness (the main symptom of OSA).
- Overnight sleep tests in a sleep center lab (polysomnography) are the best way to diagnose OSA. Home sleep tests using portable monitors are an option for patients who do not have access to sleep centers, but they are not appropriate for patients who have serious health conditions.
- Losing weight is an important first step for patients with OSA who are overweight or obese.
- Continuous positive airway pressure (CPAP) is the most effective treatment for moderate-to-severe OSA. Although these devices can take some time to get used to, most patients find that CPAP greatly improves their symptoms and quality of life.
- Mandibular advancement devices (MADs), a type of dental device, may be an alternative therapy for patients who cannot tolerate or use CPAP treatment.
Guidelines for Obstructive Sleep Apnea in Children
Recent guidelines from the American Academy of Pediatrics (AAP) recommend:
- Surgical removal of enlarged adenoids and tonsils (adenotonsillectomy) is the first-line treatment for childhood OSA.
- CPAP treatment is recommended if the sleep apnea persists.
- Intranasal corticosteroids are an option for children with mild obstructive sleep apnea.
- Weight loss is recommended in addition to other therapies for children who are overweight or obese.
New Nerve Stimulator Device Approved
In 2014, the FDA approved the Inspire Upper Airway Stimulator for select adult patients with moderate-to-severe OSA who cannot tolerate CPAP. The nerve stimulator is surgically implanted in the chest and controlled by the patient with a remote control. The device stimulates a nerve in the jaw that controls tongue movement to help keep the airways open during sleep.
Obstructive sleep apnea (OSA) is a disorder in which a person temporarily stops breathing during the night, perhaps hundreds of times. These gaps in breathing are called apneas. The word apnea means "absence of breath." An obstructive apnea episode is defined as the absence of airflow for at least 10 seconds.
Sleep apnea is usually accompanied by snoring, disturbed sleep, and daytime sleepiness. Many people with OSA do not even know they have the condition.
Obstructive Sleep Apnea
Obstructive sleep apnea (OSA) occurs when tissues in the upper throat relax and come together during sleep, temporarily blocking the passage of air. In general, OSA occurs as follows:
- On its way to the lungs, air passes through the nose, mouth, and throat (the upper airway).
- Under normal conditions, the back of the throat is soft and tends to collapse inward as a person breathes. Dilator (widening) muscles work against this collapse to keep the airway open.
- If the tissues at the back of the throat collapse and momentarily block the airway, apnea occurs. Apnea is when breathing is temporarily stopped. In most cases people are unaware of it, although sometimes they awaken and gasp for breath. Bed partners are often the first to notice the problem.
- In some cases, the interference is incomplete and causes continuous but slow and shallow breathing (hypopnea). In response, the throat vibrates and makes the sound of snoring. Snoring can occur whether a person breathes through the mouth or the nose. (Snoring often occurs without apnea.)
- Apnea decreases the amount of oxygen in the blood. This lack of oxygen triggers the brain to send extra activating signals to the breathing muscles to restart breathing.
- At this point, the sleeping person may make a gasping or snorting sound but does not usually fully wake up.
Obstructive sleep apnea is defined as five or more episodes of apnea or hypopnea per hour of sleep (called apnea-hypopnea index or AHI) in individuals who have excessive daytime sleepiness. Persons with 5 to 15 episodes of apnea or hypopnea per hour of sleep are considered to have mild sleep apnea, 15 to 30 episodes/hour is moderate sleep apnea, and more than 30 episodes indicates severe disease.
Other Types of Apnea
Central sleep apnea is much less common. It is caused by a problem in the central nervous system, most often a failure of the brain to signal the airway muscles to breathe. In such cases, oxygen levels drop abruptly and usually the sleeper wakes with a start. Often people with central sleep apnea recall waking up. Heart failure is a common cause of central sleep apnea.
Mixed apnea is the term used when central and obstructive sleep apneas occur together.
Upper airway resistance syndrome (UARS) is a condition in which patients snore, wake frequently during the night, and have excessive daytime sleepiness. However, patients do not have the breathing abnormalities that characterize sleep apnea and they do not show a reduction in blood oxygen levels. Treatments are similar to those for sleep apnea.
All of the muscles in the body relax during sleep. In people without obstructive sleep apnea, the throat muscles relax but do not block the airways. In patients with obstructive sleep apnea, the airways become temporarily blocked or narrowed during sleep, preventing air from flowing normally into the lungs.
Certain physical characteristics of the face, skull, and neck can affect the size of the airway.
Large Neck. A large neck (17 inches or greater in men and 16 inches or greater in women) is a risk factor for sleep apnea. While some people’s necks are naturally larger than others, being overweight or obese can contribute to having a large neck.
Facial and Skull Characteristics. Structural abnormalities in the face and skull contribute to many cases of sleep apnea. These abnormalities include:
- Undersized lower jaw or chin (micrognathia)
- Receding lower jaw (retrognathia)
- Narrow upper jaw
- Enlarged tongue
- Enlarged tonsils
Soft Palate Characteristics. Some people have specific abnormalities in the soft area (palate) at the back of the mouth and throat that may lead to sleep apnea. These abnormalities include:
- The soft palate is stiffer, larger than normal, or both. An enlarged soft palate may be a significant risk factor for sleep apnea.
- The soft palate and the walls of the throat around it collapse easily.
Muscle Weakness. Abnormalities or weakness in the muscles that surround the airway can also contribute to obstructive sleep apnea.
Causes of Obstructive Sleep Apnea in Children
Sleep apnea occurs in about 2% of children and can occur even in very young children. The most likely causes include:
- Facial or skull abnormalities in infants such as brachycephaly, a birth defect in which the head tends to be shorter or wider than average. Facial abnormalities may be associated with congenital or genetic disorders such as Down syndrome.
- Overgrown tonsils, adenoids, or both in small children. Removal of the enlarged adenoids and tonsils (adenotonsillectomy) can free the airways and may correct the problem.
- Neuromuscular disorders such as cerebral palsy that affect the muscles in the airways.
More than 18 million Americans have sleep apnea. The incidence of obstructive sleep apnea has been increasing, due in part to rising rates of obesity.
Obstructive sleep apnea is more common in men than in women. Men tend to have larger necks and weigh more than women. However, women tend to gain weight and develop larger necks after menopause, which increases their risk of developing sleep apnea.
Female reproductive hormones appear to play a protective role in sleep apnea. Declining estrogen levels are another reason that postmenopausal women face more risk for sleep apnea than premenopausal women.
Sleep apnea is most common in adults ages 40 - 60 years old. Middle age is also when symptoms are worse. Nevertheless, sleep apnea can affect people of all ages, including children.
Race and Ethnicity
African-Americans face a higher risk for sleep apnea than any other ethnic group in the United States. Other groups at increased risk include Pacific Islanders and Mexicans.
People with a family history of obstructive sleep apnea are at increased risk of developing the condition.
Being overweight is a major risk factor for obstructive sleep apnea, especially when the fat distribution results in increased neck circumference. Excess weight may also contribute to sleep apnea when fat deposits increase tongue size or fill throat tissue. Even a moderate amount of weight gain can raise a child’s or adult’s chances of developing sleep apnea.
Smoking and Alcohol Use
Smoking. Smokers are at higher risk for apnea. Those who smoke more than two packs a day have a risk 40 times greater than nonsmokers.
Alcohol. Alcohol use may be associated with apnea. Patients diagnosed with sleep apnea are recommended not to drink alcohol before bedtime.
Medical Condition Risk Factors
Diabetes. Type 2 diabetes is associated with sleep apnea. It is not clear if there is an independent relationship between the two conditions or whether obesity is the common factor.
Gastroesophageal Reflux Disease (GERD). GERD is a condition caused by acid backing up into the esophagus. It is a common cause of heartburn. GERD and sleep apnea often coincide. Research suggests that the backup of stomach acid in GERD may produce spasms in the vocal cords (larynx), thereby blocking the flow of air to the lungs and causing apnea. Apnea itself may also cause pressure changes that trigger GERD. Obesity is common in both conditions, and more research is needed to clarify the association.
Hormonal Disorders. Hypothyroidism (underactive thyroid gland) and acromegaly (overactive pituitary gland) are endocrine disorders that increase the risk for obstructive sleep apnea. Polycystic ovary syndrome (PCOS), a disorder caused by imbalances in female hormones, is also highly associated with sleep apnea. Women with PCOS are also more likely to have diabetes and obesity, which are additional risk factors for sleep apnea.
Obstructive sleep apnea can lead to a number of complications, ranging from daytime sleepiness to possible increased risk of death. Sleep apnea has a strong association with several diseases, particularly those related to the heart and circulation.
Daytime Sleepiness, Accidents, and Quality of Life
Daytime sleepiness is the most noticeable, and one of the most serious, complications of sleep apnea. It interferes with mental alertness, social relations, and quality of life. People with obstructive sleep apnea are more likely to suffer from depression, and may be at risk for sexual dysfunction.
Daytime sleepiness can also increase the risk for accidents and related injuries. Many studies have shown that people with sleep apnea have a significantly increased risk for drowsy driving and car accidents. Untreated sleep apnea is a major risk factor for injury at factory and construction work sites.
Heart and Circulation Complications
Sleep-disordered breathing is very common among patients with heart problems such as high blood pressure, heart failure, pulmonary hypertension, stroke, heart attack, and atrial fibrillation. This link may be because both cardiovascular conditions and sleep apnea share a common risk factor of obesity. However, increasing evidence suggests that severe OSA is an independent risk factor that may cause or worsen a number of heart-related conditions.
High Blood Pressure. Moderate-to-severe sleep apnea definitely increases the risk for high blood pressure (hypertension) even when obesity is not a factor. Studies suggest that CPAP may help reduce blood pressure, especially when combined with weight loss in overweight patients.
Coronary Artery Disease and Heart Attack. Sleep apnea appears to be associated with heart disease regardless of the presence of high blood pressure or other heart risk factors. Studies suggest that patients with moderate-to-severe obstructive sleep apnea have a higher risk for heart attack.
Stroke. Sleep apnea may increase the risk of death in patients who have previously had a stroke.
Heart Failure. Up to a third of patients with heart failure also have sleep apnea. Central sleep apnea often results from heart failure. Obstructive sleep apnea can cause heart damage that worsens heart failure and increases the risk for death.
Atrial Fibrillation. Sleep apnea may be a cause of atrial fibrillation (irregular heartbeat).
Other Adverse Effects on Health
Untreated obstructive sleep apnea is associated with higher incidence or complication of many medical conditions including:
- Insulin Resistance. Obstructive sleep apnea can lead to insulin resistance, a condition that increases the risk for type 2 diabetes and prediabetes. Insulin resistance is closely related to metabolic syndrome, a major risk factor for heart disease. Metabolic syndrome is marked by large waist circumference, abnormal cholesterol levels, high triglyceride levels, high blood pressure, and high blood sugar (glucose) levels.
- Asthma. Sleep apnea may worsen asthma symptoms and interfere with the effectiveness of asthma medications. Treating the apnea may help asthma control.
- Seizures. There may be an association between seizures and obstructive sleep apnea, especially in older adults. Some studies have shown treatment of obstructive sleep apnea may help in the control of refractory seizures.
- Headaches. Sleep disorders, including apnea, may be the underlying causes of some chronic headaches. In some patients with both chronic headaches and apnea, treating the sleep disorder may cure the headache.
- High-risk pregnancies. Sleep apnea may possibly increase the risk of pregnancy complications, including gestational diabetes and high blood pressure.
Effects on Bed Partners
Because sleep apnea often includes noisy snoring, the condition can adversely affect the sleep quality of the bed partner. Spouses or partners may also suffer from sleeplessness and fatigue. In some cases, the snoring can disrupt relationships. Diagnosis and treatment of sleep apnea in the patient can help eliminate these problems.
Effects in Infants and Children
Failure to Thrive. Small children with undiagnosed sleep apnea may "fail to thrive," that is, they do not gain weight or grow at a normal rate and they have low levels of growth hormone. In severe cases, this may affect the heart and central nervous system.
Behavior and Learning Problems. Poor sleep and sleep-related breathing disturbances can cause behavioral and cognitive issues. Problems in attention and hyperactivity are common in children with sleep apnea. There is some evidence that such children may be misdiagnosed with attention-deficit hyperactivity disorder. Even children who snore and do not have sleep apnea may be at higher risk for poor concentration.
People with sleep apnea usually do not remember their snoring, restless sleep, or sudden brief waking during the night.
Symptoms in Adults
Symptoms may include:
Excessive daytime sleepiness. Excessive daytime sleepiness and fatigue are the hallmark symptoms of obstructive sleep apnea. Patients risk falling asleep during the day while performing routine activities such as reading, watching TV, sitting inactively, lying down, or riding in or even driving a car. Usually, these brief episodes of sleep do not relieve their overall sense of sleepiness.
Restless or unrefreshing sleep. Patients often wake up feeling unrefreshed despite having a full night’s sleep. Some patients experience morning headaches, dry mouth, or sore throat after awakening.
Impaired mental or emotional functioning. Patients may have trouble with concentration, attention, or memory. They may feel irritable or depressed. Some patients experience a reduced sex drive.
Snoring. Bed partners may report very loud and interrupted snoring, especially when patient is lying on back. Patients have frequent pauses in breathing (apneas) that last 10 to 30 seconds followed by gasping or choking that suddenly and briefly awakens them. The snoring often occurs in a crescendo pattern with the loudest noises occurring right before the gasping sounds.
Symptoms in Children
Children with obstructive sleep apnea share certain symptoms with adults such as snoring and restless sleep, but they tend not to exhibit daytime sleepiness. Children often have symptoms that differ from adults, including:
- More effort in breathing (flaring nostrils, heaving chests, sweating). The chest may have an inward motion during sleep (paradoxical breathing).
- Behavioral difficulties without any obvious cause, such as hyperactivity and aggressiveness
- Nighttime sweating or strange sleep positions
- Daytime mouth breathing, stuffy nose, nasal speech
- Failure to grow and gain weight
In diagnosing obstructive sleep apnea, the doctor will ask about your medical and sleep history, and conduct a physical exam. If symptoms suggest obstructive sleep apnea or another sleep disorder, further diagnostic testing may be performed. Your doctor may recommend you have a sleep study (polysomnography) performed at a sleep disorders center or do a sleep study at home wearing a portable monitor.
The devices used for sleep studies can measure the number of apnea (stopped breathing) or hypopnea (shallow or slow breathing) events that occur during sleep. Based on these measurements, a sleep specialist doctor will evaluate the apnea-hypopnea index (AHI) to determine if you have obstructive sleep apnea and, if so, whether it is mild, moderate, or severe. Obstructive apnea is diagnosed when a patient has at least 15 events per hour with or without other symptoms, or 5 events per hour with symptoms.
Symptoms or signs that may indicate sleep apnea include:
- Daytime sleepiness is the main symptom of obstructive sleep apnea. According to the American College of Physicians, patients who do not have daytime sleepiness do not need to have a sleep study
- Loud snoring (however, not everyone who snores has sleep apnea)
- Periods of breath holding during sleep, followed by gasps or snorts
- Restless sleep
Medical and Sleep History
To help determine the presence of obstructive sleep apnea, the doctor may ask the following questions:
- Do you ever feel tired, feel sleepy, or lack energy during the day?
- If so, how often during the day? When does this usually occur?
- How restful is sleep?
- Do you frequently have morning headaches?
- Are you taking any medications that may affect sleep?
- Are you taking or withdrawing from stimulants, such as coffee or tobacco?
- How much alcohol do you drink each day?
- Do you have any problems with mental or emotional functioning?
- What is your normal sleeping position (back, side, or stomach)?
- If you have a bed partner, does he or she complain about your snoring, thrashing, or gasping for breath?
- Do you fall asleep almost as soon as your head hits the pillow? (May be a sign of sleep deprivation.)
The doctor will check for physical indications of sleep apnea, including:
Ruling out Other Disorders
The doctor will also consider conditions other than sleep apnea that may cause daytime sleepiness including:
- Other sleep disorders (narcolepsy, insomnia, or restless legs syndrome)
- Medical conditions (chronic pain, hypothyroidism, gastroesophageal reflux disease, respiratory disorders)
- Medications (tranquilizers, sleeping pills, antihistamines beta blockers, many others)
- Occupational and lifestyle factors (night or varying shift work, alcohol abuse)
Polysomnography and Sleep Lab Tests
Polysomnography (PSG) is the technical term for an overnight sleep study that involves recording brain waves and other sleep-related activity. Polysomnography is typically performed at a sleep center. The patient sleeps in a room that resembles a hotel room but is equipped with a video camera and monitoring station. Polysomnography conducted in a sleep lab is the gold standard for diagnosing sleep apnea.
The patient arrives about 2 hours before bedtime without having made any changes in daily habits. A trained technician places electrodes (similar to the sticky pads used for electrocardiograms) on the patient’s face and head, a sensor on the finger, and a sensor in the nose. Special belts are placed around the waist to monitor breathing activity. These devices are all painless. They are used to collect data on eye movements, brain activity, heart rate, and oxygen levels.
Wires attached to these devices transmit data to the technician in the monitoring room. The technician will score the sleep pattern data throughout the night as the patient passes through the various sleep stages. The patient is discharged in the morning. A sleep specialist doctor will later evaluate the data that was collected and send a report to your doctor.
If you show signs of moderate-to-severe sleep apnea during your sleep, the technician may wake you up during the night to perform split-night polysomnography. In split-night polysomnography, during the second part of the night patients are fitted with a CPAP mask and receive a CPAP titration study to adjust the amount of air flow coming through the mask. In centers that do not perform split-night polysomnography, patients may need to return for a second overnight sleep study to have CPAP titration performed.
Portable Monitors and Home Sleep Tests
Diagnostic testing at home with portable monitors may be an option for patients who have a high likelihood of moderate-to-severe obstructive sleep apnea, do not have access to a sleep laboratory, and do not have any other major medical disorders. Portable monitors are not appropriate for people who have serious conditions such as chronic lung disease, heart failure, or neurological disorders (such as seizures). Patients with these conditions are at higher risk for central sleep apnea. Many portable monitors cannot distinguish between central and obstructive sleep apnea. Portable monitors are also not recommended for patients who may have other sleep disorders, such as narcolepsy.
There are different types of portable home monitors. They are classified as type II, type III, or type IV. (Sleep lab-based polysomnography is classified as type 1.) Type II monitors are the most similar to an overnight PSG study conducted in a sleep center. The main difference is that there’s no technician present. Type III monitors record fewer variables than type II or type I studies, but usually evaluate several respiratory channels, heart rate, and oxygen saturation. However, they cannot distinguish between sleep and wake states. Type IV monitors are the least sophisticated devices. Type III and type IV portable monitors do not measure the apnea-hypopnea index, but can provide estimates.
Portable monitors usually come with an air-flow sensor that goes under the nose, an oxygen clip that’s attached to a finger, and a belt monitor that goes around the chest. The data is collected through wireless transmission. Depending on the device, the patient may pick up the monitor at a local hospital and receive instructions from a technician, or the monitor may be shipped in the mail to the patient’s home.
Some insurance companies prefer home studies with portable monitors because they are cheaper than sleep lab studies, which require a technician to be present. However, sleep experts consider lab-based polysomnography at a sleep center to be the best option for diagnosing sleep apnea.
All patients with obstructive sleep apnea who are overweight or obese should attempt to lose weight. Weight loss reduces snoring and apnea/hypopnea episodes in many people, and may even in some cases cure obstructive sleep apnea. Weight loss may also help improve sleep and reduce daytime sleepiness.
Smoking, Alcohol, and Drugs
- Smokers should quit, since smoking worsens apnea
- Avoid alcohol within 4 hours of sleep
- Avoid sedatives and sleeping medications
Body position has some effect on obstructive sleep apnea, with at least twice as many apneas occurring in people who lie on their back as in those who sleep on their side. This may be due to the effects of gravity, which cause the throat to narrow when a person lies on the back. Sleeping on the back also increases the chances of snoring.
Positional therapy can help relieve snoring. However, simply trying to treat snoring will not treat sleep apnea. (Remember that snoring does not necessarily indicate sleep apnea.) Changing body position may help with mild apnea but it has little effect on severe sleep apnea.
As a first step, simply try sleeping on your side. Other suggestions for maintaining a low-risk sleeping position include:
- Sew a small pocket to the back of the pajamas and place a tennis ball or other small ball into it.
- A special pillow that helps to stretch the neck may reduce snoring and improve sleep for people with mild sleep apnea.
- Sleeping in an upright position may improve oxygen levels in overweight people with sleep apnea. Elevating the head of the bed may help.
It is important for patients to treat obstructive sleep apnea (OSA) as they would any chronic disease. OSA needs to be taken seriously given its long-term complications and its association with high blood pressure, heart problems, stroke, and diabetes. Ideally, OSA should be treated by a doctor who specializes in sleep disorders.
The American College of Physicians recommends the following treatments for obstructive sleep apnea:
- Weight loss is the most important first lifestyle step for patients who are overweight.
- Continuous positive airway pressure (CPAP) is the most effective medical treatment. CPAP uses a device that delivers slightly pressurized air to keep the airways in the throat open during the night. [See CPAP section in this report.]
- Dental devices are an alternative treatment for patients who cannot tolerate CPAP. They are not as effective as CPAP but are an option. For dental devices, the American College of Physicians recommends the mandibular advancement device (MAD). [See Dental Devices section in this report.]
Medications. The American College of Physicians does not find evidence to support the use of medications for treatment of obstructive sleep apnea. In general, drugs are not very helpful except for specific situations. Medications that treat accompanying disorders associated with sleep apnea may be helpful. For example, thyroid hormone may help improve sleep apnea in patients who have an underactive thyroid gland (hypothyroidism). Intranasal corticosteroids may be helpful in some cases for children with sleep apnea.
Modafinil (Provigil), which is also used to treat narcolepsy, is the only drug approved by the FDA to treat the sleepiness associated with obstructive sleep apnea. However, modafinil is meant to be used in combination with -- not as a substitute for -- CPAP. Sleep doctors stress that patients who take modafinil should adhere to CPAP treatment as the drug treats only the symptom of sleepiness, not the underlying cause of obstructive sleep apnea.
Patients with sleep apnea should be aware that sedatives, narcotics, and anti-anxiety drugs can actually worsen the breathing disturbances that occur with this condition. These medications may cause the soft tissues in the throat to sag and diminish the body's ability to inhale. Patients with sleep apnea should never use sleeping pills or tranquilizers. If undergoing surgery, be sure to inform your surgeon, anesthesiologist, and other doctors of your condition so that they can determine which sedatives, anesthetics, or pain medications are safe and appropriate.
Surgery. Surgery should never be used as an initial treatment for obstructive sleep apnea. Surgical treatments for sleep apnea have a number of risks, and there is limited evidence as to their benefit. However, surgery may be an appropriate option for select patients who cannot tolerate or comply with CPAP therapy. [For more information, see Surgery section in this report.]
Continuous Positive Airway Pressure (CPAP)
The best treatment for obstructive sleep apnea is a system known as continuous positive airway pressure (CPAP). It is safe and effective for people of all ages, including children.
Patients with obstructive sleep apnea who use CPAP feel better rested, have less daytime sleepiness, and have improved concentration and memory. In addition, CPAP may potentially reduce the risks for heart problems such as high blood pressure. For maximum benefit, CPAP should be used for at least 6 to 7 hours each night.
CPAP works in the following way:
- The device itself is a machine weighing about 3 pounds that fits on a bedside table.
- A mask containing a tube connects to the device and fits over the mouth and nose or just over the nose.
- The machine supplies a steady stream of air through a tube and applies sufficient air pressure to prevent these tissues from collapsing during sleep
The standard CPAP machine delivers a fixed, constant flow of air. Variations on CPAP include:
- Autotitrating positive airway pressure (APAP) devices automatically respond to changes in the sleeper’s breathing patterns by adjusting and varying the air pressure flow throughout the night. Some patients find this makes CPAP easier to tolerate.
- Bilevel positive airway pressure (BPAP) systems deliver two different pressures, a higher one for inhalation (breathing in) and a lower one for exhalation (breathing out).
Side Effects and Getting Used to the Device
CPAP works well, but it can take some time to get used to, especially for the first few nights. Here are some tips to help you adjust:
- Masks are available in many different styles ranging from full face masks with adjustable straps to half masks with nasal pillows. Masks also come in different sizes. When choosing a mask, try on different styles and sizes to see which feels most comfortable.
- Make sure your doctor or CPAP service provider shows you how to adjust the mask for the best fit. A poor-fitting mask can cause skin irritation or sores. Let your doctor know if you develop any skin problems.
- When beginning CPAP treatment, it may help to wear your mask for short periods while you are awake so you get used to how it feels. For the first few nights of treatment, begin with low air pressure and then use the ramp setting to gradually increase the pressure.
- Patients on CPAP often complain of nasal congestion and dry mouth. Many CPAP machines now come with a heated humidifier attachment. Chin straps (to keep the mouth closed) and nasal saline sprays can also help with these problems.
- To help ensure a good night of sleep, follow sleep hygiene practices such as avoiding alcohol and caffeine before bedtime.
- Be sure to clean and maintain your equipment and mask on a daily basis. Your doctor may need to periodically readjust the air pressure settings.
Oral appliances, also called dental appliances or devices, may be an option for patients who cannot tolerate CPAP. The American Academy of Sleep Medicine recommends dental devices for patients with mild-to-moderate obstructive sleep apnea who are not appropriate candidates for CPAP or who have not been helped by it. (CPAP should be used for patients with moderate-to-severe sleep apnea whenever possible.)
Several different dental devices are available. A trained dental professional such as a dentist or orthodontist should fit these devices. Devices include:
- Mandibular advancement device (MAD). This is the most widely used and most recommended dental device for sleep apnea. It is similar in appearance to a sports mouth guard. MAD forces the lower jaw forward and down slightly, which keeps the airway open.
- Tongue retraining device (TRD). This is a splint that holds the tongue in place to keep the airway as open as possible.
Patients fitted with one of these devices should have a check-up early on to see if it is working; short-term success usually predicts long-term benefits. It may need to be adjusted or replaced periodically.
Benefits of Dental Devices. Dental devices seem to offer the following benefits:
- Significant reduction in apneas for those with mild-to-moderate apnea, particularly if patients sleep either on their backs or stomachs. They do not work as well if patients lie on their side. The devices may also improve airflow for some patients with severe apnea.
- Improvement in sleep in many patients
- Improvement and reduction in the frequency of snoring and loudness of snoring in most (but not all) patients
- Few or no complications
Disadvantages of Dental Devices. Dental devices are not as effective as CPAP therapy. They are often expensive, and since they are custom-made they cannot be returned. Side effects associated with dental devices include:
- Nighttime pain, dry lips, tooth discomfort, and excessive salivation. In general, these side effects are mild, although over the long term they cause nearly half of patients to stop using dental devices. Devices made of softer materials may produce fewer side effects.
- Permanent changes in the position of the teeth or jaw can sometimes occur with long-term use. Patients should have regular visits with a health professional to check the devices and make adjustments.
- In a small number of patients, the treatment may worsen apnea.
An orthodontic treatment called rapid maxillary expansion, in which a screw device is temporarily applied to the upper teeth and tightened regularly, may help patients with sleep apnea and a narrow upper jaw. This nonsurgical procedure helps to reduce nasal pressure and improve breathing.
Surgery is sometimes recommended, usually by ear, nose, and throat specialists, for severe obstructive sleep apnea. A patient should be sure to seek a second opinion from a specialist in sleep disorders. Few randomized clinical trials, the gold standard of medical research, have been conducted to verify the long-term efficacy of sleep apnea surgery.
The Procedure. Surgery known as uvulopalatopharyngoplasty (UPPP) removes soft tissue on the back of the throat. Such tissue includes all or part of the uvula (the soft flap of tissue that hangs down at the back of the mouth) and parts of the soft palate and the throat tissue behind it. If tonsils and adenoids are present, they are removed. The surgery typically requires a stay in the hospital.
The Goal of Surgery. The goals of UPPP are to:
- Increase the width of the airway at the throat's opening
- Block some of the muscle action in order to improve the ability of the airway to remain open
- Improve the movement and closure of the soft palate
Success Rates. The American Academy of Sleep Medicine (AASM) does not endorse UPPP as a sole procedure for treating OSA. The AASM recommends that patients considering this surgery first try CPAP or dental devices.
There is limited evidence as to the effectiveness of UPPP. Studies suggest that success rates for sleep apnea surgery are rarely higher than 65% and often deteriorate with time, averaging about 50% or less over the long term.
Few studies have been conducted on which patients make the best candidates. Some studies suggest that surgery is best suited for patients with abnormalities in the soft palate. Results are poor if the problems involve other areas or the full palate. In such cases, CPAP is superior and should always be tried first. Many or most patients with moderate or severe sleep apnea will likely still require CPAP treatment after surgery.
Complications. UPPP is among the most painful treatments for sleep apnea, and recovery takes several weeks. The procedure also has a number of potentially serious complications including:
- Impaired function in the soft palate and muscles of the throat (called velopharyngeal insufficiency), which can make it difficult to keep liquids out of the airway
- Mucus in the throat
- Changes in voice frequency
- Swallowing problems
- Regurgitation of fluids through the nose or mouth
- Impaired sense of smell
- Failure and recurrence of apnea. In such cases, CPAP is often less effective afterward.
In general, only a small percentage of patients experience serious complications. Many of these complications can be avoided with proper technique and experienced surgeon. A patient's health status, including presence of obesity and other health conditions, may also affect outcomes.
Laser-Assisted Uvulopalatoplasty (LAUP)
A variation on UPPP called laser-assisted uvulopalatoplasty (LAUP) is being increasingly performed to reduce snoring. It removes less tissue at the back of the throat than UPPP and can be done in a doctor's office. At this time, however, long-term success rates in the treatment of obstructive sleep apnea with LAUP are very modest, particularly for reducing apneas. Some doctors, in fact, are concerned that if LAUP eliminates snoring, they may miss a diagnosis of apnea in patients who have the more serious condition.
More than half of patients complain of throat dryness after surgery. Throat narrowing and scarring have also been reported. In a minority of patients, snoring becomes worse afterward.
According to guidelines from the American Academy of Sleep Medicine (AASM), LAUP is not routinely recommended as treatment for obstructive sleep apnea. According to the AASM, this surgery generally does not help improve symptoms and may actually worsen the condition.
Pillar Palatal Implant
The pillar palatal implant is a noninvasive surgical treatment for mild-to-moderate sleep apnea and snoring. However, the main focus of the procedure is a reduction in snoring. The implant helps reduce the vibration and movement of the soft palate. In this procedure, a doctor inserts 3 short pieces of polyester string into the soft palate.
The procedure can be performed in a doctor’s office and takes about 10 minutes. Unlike uvulopalatopharyngoplasty (UPPP), the pillar procedure requires only local anesthesia and has less pain and quicker recovery time. There is still not enough evidence to determine whether it is an effective treatment for obstructive sleep apnea.
Upper Airway Stimulator
Approved in 2014 , the Inspire Upper Airway Stimulator is a nerve stimulation device that is surgically implanted in a patient’s chest. The device senses the patient’s breathing patterns and stimulates the hypoglossal nerve, which controls tongue movement, to help keep the airways open. The patient turns the device on and off, before and after sleep, using a remote control.
The FDA approved this nerve stimulator device for a subset of adult patients with moderate-to-severe obstructive sleep apnea who cannot tolerate CPAP therapy. The device is not appropriate for patients who have mixed and central sleep apneas, certain anatomical abnormalities of the soft palate, or certain neurological conditions.
In a small study of patients, the device helped reduce breathing pauses and drops in blood oxygen levels. However, some patients experienced a worsening of their sleep apnea. The long-term risks and benefits of this device are not yet known.
Tracheostomy used to be the only treatment for sleep apnea. It is quite straightforward:
- The surgeon makes an opening through the neck into the windpipe and inserts a tube.
- It is almost 100% successful, but it requires a quarter-size opening in the throat. This produces a number of medical and psychological problems associated with recovery.
Today, this operation is performed rarely, usually only if sleep apnea is life threatening.
Other surgical procedures may be appropriate to correct facial abnormalities or obstructions that cause sleep apnea. They may be used alone or combined with each other or with UPPP. Most are invasive and reserved for patients with severe sleep apnea who fail to respond to or comply with CPAP. Overall, there is limited evidence as to their effectiveness in treating OSA. These procedures include:
- Radiofrequency ablation (RFA) for tongue or palate reduction.
- Maxillomandibular advancement (MMA), which moves the upper (maxilla) or lower (mandible) jawbone forward.
- Genioglossus (tongue advancement), in which an opening is cut where the tongue joins the jawbone and the area is pulled forward.
- Genioplasty, which is plastic surgery on the chin.
- Hyoid advancement surgery, in which the movable bone underneath the chin is moved forward, pulling the tongue muscle along with it.
- Surgery for nasal obstructions (such as a deviated septum) that contribute to snoring and other symptoms.
Removing Adenoids and Tonsils in Children
Adenotonsillectomy, or surgical removal of the tonsils and adenoids, is a first-line treatment for children and adolescents with sleep apnea proven by sleep studies. It cures or improves the condition in most patients.
Complications include respiratory illness, which occurs in about 25% of children after the surgery. The highest risk for respiratory complications is associated with:
- Age under 3 years old
- Severe sleep apnea
- Heart complications
- Failure to thrive
- Recent lung infections
- Certain facial structures
- Neuromuscular disease
The procedure may fail to improve apnea in some patients, such as those with very severe disease. Such children are candidates for continuous positive airway pressure (CPAP) therapy.
Removal of the tonsils and adenoids alone is not an effective treatment for adults with sleep apnea, although the procedure may be effective when combined with UPPP surgery.
Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine; Epstein LJ, Kristo D, Strollo PJ Jr, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009;5(3):263-276.
Aurora RN, Casey KR, Kristo D, et al. Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. Sleep. 2010;33(10):1408-1413.
Barbé F, Durán-Cantolla J, Sánchez-de-la-Torre M, et al. Effect of continuous positive airway pressure on the incidence of hypertension and cardiovascular events in nonsleepy patients with obstructive sleep apnea: a randomized controlled trial. JAMA. 2012;307(20):2161-2168.
Basner RC. Continuous positive airway pressure for obstructive sleep apnea. N Engl J Med. 2007;356(17):1751-1758.
Bradley TD, Floras JS. Obstructive sleep apnoea and its cardiovascular consequences. Lancet. 2009;373(9657):82-93.
Campos-Rodriguez F, Martinez-Garcia MA, de la Cruz-Moron I, Almeida-Gonzalez C, Catalan-Serra P, Montserrat JM. Cardiovascular mortality in women with obstructive sleep apnea with or without continuous positive airway pressure treatment: a cohort study. Ann Intern Med. 2012 Jan 17;156(2):115-122.
Caples SM, Rowley JA, Prinsell JR, et al. Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis. Sleep. 2010;33(10):1396-1407.
Chan AS, Lee RW, Cistulli PA. Dental appliance treatment for obstructive sleep apnea. Chest. 2007;132(2):693-699.
Chirinos JA, Gurubhagavatula I, Teff K, et al. CPAP, weight loss, or both for obstructive sleep apnea. N Engl J Med. 2014;370(24):2265-2275.
Collop NA, Anderson WM, Boehlecke B, et al. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Portable Monitoring Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. 2007;3(7):737-747.
Franklin, KA, Anttila H, Axelsson S, Gislason T, Maasilta P, Myhre K I, et al. Effects and side-effects of surgery for snoring and obstructive sleep apnea--a systematic review. Sleep. 2009 Jan 1;32(1):27-36.
Hirshkowitz M. The clinical consequences of obstructive sleep apnea and associated excessive sleepiness. J Fam Pract. 2008;57(8 Suppl):S9-S16.
Ishman SL. Wakefield TL, Collop NA. Sleep apnea and sleep disorders. In: Flint PW, Haughey BH, Lund VJ, et al, eds. Cummings Otolaryngology: Head and Neck Surgery. 5th ed. Mosby; 2010:252-270.e4.
Kasai T, Bradley TD. Obstructive sleep apnea and heart failure: pathophysiologic and therapeutic implications. J Am Coll Cardiol. 2011;57(2):119-127.
Marcus CL, Brooks LJ, Draper KA, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130(3):576-584.
Marcus CL, Moore RH, Rosen CL, et al. A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med. 2013;368(25):2366-2376. 2012 May 23;307(20):2169-76.
Marin JM, Agusti A, Villar I, et al Association between treated and untreated obstructive sleep apnea and risk of hypertension. JAMA. 2012;307(20):2169-2176.
Marshall NS, Wong KK, Liu PY, Cullen SR, Knuiman MW, Grunstein RR. Sleep apnea as an independent risk factor for all-cause mortality: the Busselton Health Study. Sleep. 2008;31(8):1079-1085.
Martínez-García MA, Capote F, Campos-Rodríguez F, et al. Effect of CPAP on blood pressure in patients with obstructive sleep apnea and resistant hypertension: the HIPARCO randomized clinical trial. JAMA. 2013;310(22):2407-2415.
Morgenthaler TI, Aurora RN, Brown T, et al. Practice parameters for the use of autotitrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome: an update for 2007. An American Academy of Sleep Medicine report. Sleep. 2008;31(1):141-147.
Pien GW, Pack AI. Sleep-disordered breathing. In: Mason RJ, Broaddus VC, Martin TR, et al, eds. Murray and Nadel’s Textbook of Respiratory Medicine. 5th ed. Saunders; 2010:1881-1913.
Qaseem A, Dallas P, Owens DK, Starkey M, Holty JE, Shekelle P. Diagnosis of Obstructive Sleep Apnea in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2014;161(3):210-220.
Qaseem A, Holty JE, Owens DK, Dallas P, Starkey M, Shekelle P. Management of Obstructive Sleep Apnea in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2013;159(7):471-483.
Somers VK. Sleep apnea and cardiovascular disease. In: Bonow RO, Mann DL, Zipes DP, Libby P, Braunwald E, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Saunders; 2011:1771-1778.
Somers VK, White DP, Amin R, et al. Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing. J Am Coll Cardiol. 2008;52(8):686-717.
Sterni LM, Tunkel DE. Obstructive sleep apnea syndrome. In: Flint PW, Haughey BH, Lund VJ, et al, eds. Cummings Otolaryngology: Head and Neck Surgery. 5th ed. Mosby; 2010:2849-2853.
Strohl KP, Brown DB, Collop N, et al. An official American Thoracic Society Clinical Practice Guideline: sleep apnea, sleepiness, and driving risk in noncommercial drivers. An update of a 1994 Statement. Am J Respir Crit Care Med. 2013;187(11):1259-1266.
Strollo PJ Jr, Soose RJ, Maurer JT, et al. Upper-airway stimulation for obstructive sleep apnea. N Engl J Med. 2014;370(2):139-149.
- Last reviewed on 9/10/2014
- David A. Kaufman, M.D., Section Chief, Pulmonary, Critical Care & Sleep Medicine, Bridgeport Hospital-Yale New Haven Health System, and Assistant Clinical Professor, Yale University School of Medicine, New Haven, CT. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Isla Ogilvie, PhD, and the A.D.A.M. Editorial team.
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