Fact sheet: Obstructive sleep apnea

Everyone knows days like these: you cannot get any sleep at night due to noise, or else you only get a little sleep because you are nervous about taking a test the next day. The next day you feel tired and poorly rested. But what if you have actually gotten enough sleep and still feel absolutely beat the next morning?

That is what many people experience who have obstructive sleep apnea syndrome (OSAS): They do not get enough air while they are sleeping (usually without noticing), have breathing pauses, and are very sleepy during the day. Over the long term, this increases their risk of developing other diseases and can have a huge effect on quality of life. This fact sheet will tell you about the causes and repercussions of obstructive sleep apnea syndrome. And it will describe which treatments can help, and what you can do to get back to having more restful sleep.

What is obstructive sleep apnea?

People who have obstructive sleep apnea snore and regularly have phases of shallow breathing (hypopnea) and breathing pauses (apnea) that last longer than ten seconds while they are sleeping. Snoring itself is harmless; only when there are also breathing pauses is this described as sleep apnea.

Breathing pauses are caused by the muscles of the upper respiratory system relaxing and then collapsing. The airway in the throat is then narrowed or even completely blocked. As a result, the body does not get enough oxygen. Pulse and blood pressure fall, and the part of the brain responsible for breathing sets off an alarm and triggers a wake-up call. The sleeper then wakes up briefly, usually without realizing it. This interrupts the natural sleeping rhythm, and the heart starts beating faster and blood pressure rises. This brief response is also called “arousal”. If this occurs repeatedly over the course of one night, it may prevent someone from entering deep sleep, which is what is needed for getting restful sleep. Over the long term this can be bad for your health and wellbeing. 

The likelihood of developing obstructive sleep apnea increases constantly after the age of 45. Being very overweight and unusual features in the mouth and throat area are common causes. These unusual features include enlarged tonsils, a small lower jaw, the position of the tongue, a small soft palate, and in some cases obstructed nasal breathing. Sleeping on your back can promote snoring and other breathing difficulties, but it is rarely the sole cause.

Excessive consumption of alcohol and sleeping pills or sedatives can also make sleep apnea worse, because then the throat muscles relax even more. According to some estimates from the U.S., 4 out of every 100 middle-aged men and 2 out of every 100 middle-aged women have obstructive sleep apnea, that they are aware of. There are no reliable figures for Germany.

What are the effects of obstructive sleep apnea?

Obstructive sleep apnea can greatly affect quality of life. Sleeping poorly can make you feel tired and “beat” during the day. Some people involuntarily have what is called microsleep during the day as well. This mostly occurs during monotonous situations, for example on an evening out at the movies or the theater, during a meeting, while reading, or sitting in front of the television. But it could also happen while someone is behind the wheel of a car – with the added risk of an automobile accident. People who have sleep apnea and who are not getting restful sleep can also have trouble concentrating and remembering things. They sweat more often at night and frequently have to urinate. Those affected by sleep apnea sometimes wake up with a start and have shortness of breath and a racing heartbeat. The limited supply of oxygen to the brain during sleep and variations in blood pressure can also cause a headache, mostly in the morning. These very different types of effects are all part of what is collectively called obstructive sleep apnea syndrome.

Sleep that does not leave you feeling rested does not just have a short-term effect on your mood. It may also lead to generally not feeling as well as people who mostly get a good night’s sleep. It is possible that some people with sleep apnea are more likely to become depressed.

People with this condition more commonly have hypertension and other cardiovascular diseases. They are at an increased risk of having a heart attack, a stroke or heart rhythm problems.

Sleep apnea can affect a person’s relationship if loud snoring disturbs the other person’s sleep. This means that the sleeper’s partner can also end up feeling tired and irritated. The breathing pauses can also cause the partner to worry about him or her.

If someone does have breathing pauses, it does not automatically lead to other symptoms or health risks. If they only occur now and then, last only for a short time and do not cause tiredness during the day, there is usually no reason to worry. Yet it may be a good idea to watch any breathing difficulties and to have yourself examined if there are long-lasting symptoms.

How do doctors diagnose sleep apnea?

Doctors first ask about the severity of symptoms and a person’s habits and examine them. If the doctor suspects obstructive sleep apnea you may be given a portable measuring device. At night this machine records things like breathing, heart rate, blood oxygen levels, snoring and body position. If there are any irregularities, more testing in a sleep laboratory may be a good idea.

Sleep laboratories are places where people can spend one or several nights while their sleep is monitored using different recording devices and a video camera. Breathing, pulse, the oxygen levels in the blood and blood pressure are all measured, for example. Eye and leg movements occurring during sleep are also recorded, as are brainwaves. These measurements are used to look at the different stages of sleep. This is done to find out how long and how well someone has slept, whether there was enough time spent in deep sleep and dreaming, and whether there is an actual sleeping disorder. In people with sleep apnea, the machines can record how often breathing pauses occur, how long they last and what type they are. It is also possible to tell the stage of sleep and the body position a person is in when the breathing pauses occur, and how they affect the cardiovascular system and blood oxygen levels.

What can you do on your own to relieve sleep apnea?

You can first try to relieve symptoms by making changes in your lifestyle. There is unfortunately not much research on whether these types of changes in behavior can help if you have obstructive sleep apnea. There are different ways to improve your general sleep habits that will have a positive effect on your sleep, but that will not automatically reduce breathing pauses:

• Stimulants like coffee and tea, as well as large meals in the evening can affect your sleep. So it is worth trying to avoid these things 4 to 6 hours before going to sleep.
• Evening use of alcohol or nicotine can also result in a poor night’s sleep. You might sleep more soundly if you refrain from smoking and drinking alcohol in the evening.
• A quiet, dark, and most importantly comfortable place to sleep that is kept at a pleasant temperature could also help you get restful sleep.

You can find more information about what could help you sleep better here.

Sleeping pills and sedatives can have many adverse effects when taken long term, and can make your sleep apnea worse. This means that there may be an advantage in avoiding these kinds of drugs or in getting some medical advice. Drinking less alcohol also seems to be a good idea if you have sleep apnea: alcohol causes the throat muscles to become even more relaxed, which can make sleep apnea symptoms worse.

Overweight people are more likely to have sleep apnea. The main reason for this is most likely that abdominal fat makes breathing more difficult. They will also have somewhat more fat tissue in the throat area. If you weigh a lot, losing weight can generally have a positive influence on your health. You can find out more about the health benefits of permanent weight loss here. Sleep apnea also improves if weight is lost, even if it only rarely goes away completely.

Snoring and breathing problems are more common when you sleep on your back because your tongue falls further back into your throat. If sleep apnea only occurs while sleeping on your back, there are different ways of maintaining a sleeping position on your side. Some people, for instance, sew a tennis ball onto the back of their pajamas or they place a pillow behind their back. Sometimes even something as simple as raising the position of your head can help to make breathing easier while lying on your back.

There is also a wide range of products that aim to improve sleep and minimize snoring. These include nasal strips, belts, support pillows, sprays and liquids for gargling. Whether any of these have a benefit is not clear, because there has not been any conclusive scientific testing on these products.

How can obstructive sleep apnea be treated?

There are many different treatment options that aim to relieve sleep apnea symptoms. These include machines that support breathing during the night, surgery, medication, and other special aids. For some of these treatments there is scientific evidence that they can help people with sleep apnea.

CPAP – nighttime breathing with continuous, pressurized air

CPAP therapy is very often used to treat obstructive sleep apnea – it is seen as standard therapy. CPAP stands for “continuous positive airway pressure”. In this type of treatment, the person wears a mask during sleep. Depending on the model, the mask covers either both the mouth and nose or just the nose. There also so-called nasal pillows where two soft plastic end pieces are inserted directly into the nostrils. 

In breathing therapy pressurized air taken from the immediate surroundings is blown into the airways while you are sleeping. A small pump that produces the pressure is attached to the mask by a tube. This incoming air stops the relaxed muscles from collapsing, which keeps the upper airways free. This considerably decreases the amount of breathing pauses, increases blood oxygen levels, and improves the quality of sleep. It also usually ends snoring problems.

Special types:

• APAP – auto-CPAP): APAP, in contrast to CPAP, does not produce continuous pressure. The pressure of the air to be breathed in is determined by the machine for each breath so that it is adjusted to the person’s breathing. APAP may be an option for people who do not respond well to the continuous pressure of the CPAP machine or who have sleep apnea that only occurs when they sleep in certain positions.
• BiPAP – bi-level PAP: BiPAP machines lower the pressure every time you exhale. They are mostly used if there are problems breathing out against the pressure created by CPAP. These machines are also better suited for people who have obstructive lung disease.

Trials show that by doing breathing therapy people are less tired during the day and can achieve clear improvement in their quality of life. The treatment can also help lower elevated blood pressure levels.

Breathing therapy cannot heal obstructive sleep apnea, it can only relieve its symptoms. If treatment is stopped, the symptoms usually appear again right away.

Dealing with the CPAP machine

Wearing a mask takes getting used to, and some find CPAP therapy to be unpleasant and constrictive. Some people also get a stuffy nose and/or a dry throat from the therapy. Then you can try changing the pressure of the air or using an air humidifier. Modern CPAP machines are quiet when running and are hardly bothersome. The valve on the mask is what is audible instead. Wearing a mask at night is so uncomfortable for some people that they stop the therapy altogether. Others put on the mask for only a few hours a night, which may mean that not all of the benefits of treatment are being fully tapped. It is recommended to use CPAP machines for at least five hours a night.

CPAP therapy is in fact the treatment that can best help people who have sleep apnea. So it may be worth it to find ways to make it easier to use the CPAP machine. Trials show that some people use the machine more at night and continue therapy for a longer time if they always have someone they can talk to about any problems they encounter during treatment. It is especially important to get a lot of support during the first few weeks of using the machine. A specific type of psychotherapy – cognitive behavioral therapy – may also be of help. You can read more about the benefits of long-term specific support for CPAP breathing therapy here.

If you are having practical problems dealing with the CPAP machine or if you just cannot get used to breathing therapy, it is a good idea to get professional help. Maybe you have not yet found the right type of mask – then it is worth it to try out some alternatives. The humidifier on the machine may be the solution if your airways are dry. You can find more information about dealing with common problems arising in CPAP therapy here.

Medications

Up to now, medication has not played any role in the treatment of sleep apnea. The benefits of available drugs have not been proven so far.

Surgery

There are different types of surgery for permanently improving breathing for people who have sleep apnea. These operations mostly aim to free up the airways by either tightening or removing tissue.

• In a special operation (uvulopalatopharyngoplasty or UPPP) the uvula is tightened and soft tissue on the palate is surgically removed. These tissues narrow the airways in people who have sleep apnea. During this procedure the adenoids may also be removed or reduced in size.
• By using a special technique – radiofrequency ablation (RFA) – a small probe is used to remove tissue from the palate, the nasal cavity or tonsils. This leaves scars, which cause the tissue to pull together, tightening the tissue.
• The palate tissue can also be tightened using a laser. This method (laser-assisted uvulopalatopharyngoplasty or LAUP) is rarely used today because it is so painful, among other things.
• An operation on the nasal cavities is done to improve ventilation through the nose.
• Some people have a deviated nasal septum, which can make breathing through the nose difficult. This can be corrected.
• Enlarged tonsils can sometimes cause sleep apnea in children. In these cases the tonsils can be surgically removed.
• In some cases, the jawbone is surgically moved forward. This is done in people whose jawbone is positioned far back, which can make breathing difficult.

It is not easy to determine what the benefits of the individual procedures are and who can be helped by them – except for removing enlarged tonsils in children. There are only very few and very small-scale trials on this. Whether a particular operation can help, essentially depends on how the airways are narrowed.

Each of the procedures described above also carries risks. Besides bleeding and pain, problems swallowing can also result, for example. These risks depend on the type of procedure. Before any surgical procedure doctors are required to explain any associated adverse effects that might occur.

Mandibular splints

Some people who have sleep apnea wear a plastic mandibular splint in their mouth at night. This makes sure that the jaw is moved forward. This can prevent the tongue from moving back and narrowing the airways. Trials show that this helps some people to breathe better at night and to feel more rested during the day.

Mandibular splints are less effective than using a CPAP machine. But they are an option for treating milder forms of sleep apnea. They can also be used as an alternative for people who cannot get used to the CPAP machine. Yet some also find wearing a mandibular splint at night unpleasant. It may cause increased flow of saliva, a dry mouth, and sensations of pressure or pain in the jaw (temporomandibular) joint. But how this therapy affects the jaw joint over the long term is not yet well known.

Mandibular splints are fitted by dentists and orthodontists. In Germany, the costs for these mandibular splints are usually not covered. There are also freely available pre-adjusted splints – but due to possible adverse effects it is a good idea to have them personally fitted at the dentist’s office. Only for personalized mandibular splint is there enough reliable evidence that they are effective.

Living with sleep apnea

Living with obstructive sleep apnea and its associated symptoms is not always easy. And CPAP therapy, which is best able to relieve symptoms, is itself difficult to get used to. It might help you to join a self-help group where you can talk with others who also have sleep apnea. There are now self-help groups for people with sleep apnea in many cities in Germany. Our interviews can also give you an impression of how others deal with both this condition and therapy for it. The most important thing is to be patient and get the support you need. Then you can succeed in making breathing therapy a part of your daily routine and really improve your quality of life.

Other options for support and help

In Germany, you can find more information on regional support and help services at the Independent Patient Counselling Germany (in German: Unabhängige Patientenberatung – UPD). Click here to read more (in German, Turkish and Russian).


Author: German Institute for Quality and Efficiency in Health Care (IQWiG)


Next planned update: September 2014. You can find out more about how our health information is updated here.

© IQWiG (Institute for Quality and Efficiency in Health Care)