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Table of Contents

Magill’s Medical Guide, 9th Edition

Sleep apnea

by Zuha Anwar, , OMS-III

Category: Disease/Disorder

Also known as: Obstructive sleep apnea

Anatomy or system affected: Respiratory system

Specialties and related fields: Otorhinolaryngology, pulmonary medicine

Definition: A sleep disorder characterized by intermittent cessation of airflow through the upper airway.

Key terms:

apnea: lack of airflow for more than ten seconds

hypopnea: a decrease in airflow greater than 50 percent

oxygenation: the process of getting oxygen into the bloodstream

CAUSES AND SYMPTOMS

Obstructive sleep apnea (OSA) is caused by repetitive upper airway obstruction. Soft tissue in the back of the mouth collapses during sleep and temporarily obstructs airflow into the lungs. Generally, OSA is due to obstruction or collapse of the nasopharynx, oropharynx and/or the hypopharynx. People with sleep apnea experience many periods of apnea and hypopnea. During such periods, the oxygen level in the bloodstream can decline significantly. Since these episodes occur throughout the night, the sleep cycle is interrupted, resulting in the person feeling sleepy during the day. Symptoms of OSA can be divided based on the time of day. Daytime symptoms can include morning headaches, fatigue, poor concentration, and daytime sleepiness (somnolence). The person might doze off while watching television, reading, or, more dangerously, driving. Nighttime symptoms include dry mouth, choking during sleep, and snoring. While the person may not be aware of apnea or the resultant snoring, a sleeping partner will frequently notice these symptoms. It should be noted, however, that snoring alone, without apnea, is very common and does not indicate sleep apnea.

Risk factors for the development of OSA include older age, obesity, a small jaw, a deviated septum of the nose, a big tongue, or enlarged tonsils. Smokers are also at higher risk of developing sleep apnea.

If OSA is left untreated, significant medical complications may result, including increased risks of hypertension, heart failure, strokes, and pulmonary hypertension. In pulmonary hypertension, the lungs become stiff and fail to provide normal oxygenation. OSA can also increase the risk of perioperative complications, especially respiratory failure. Therefore, it is extremely important to recognize and treat sleep apnea.

While the clinical triad of snoring, apneic episodes, and daytime somnolence suggests OSA, testing must be performed for a definitive diagnosis to be made. This diagnosis can be made at home by using Home Sleep Apnea testing (HSAT) or an overnight oximeter. An oximeter is a noninvasive device worn over a finger that measures the oxygen level in the bloodstream. It can be worn overnight at home and is useful for detecting any drop in oxygen level caused by apneic or hypopneic episodes. It must be noted however, that overnight desaturations using overnight pulse oximetry alone is not enough to diagnose OSA. The gold standard for OSA diagnosis is a formal sleep study known as “polysomnography.”

Polysomnography requires an overnight observation in a sleep center where multiple monitors record brain waves, heart rate, breathing rate, abdominal muscle movement, and oxygen level. Based on these measurements, an apnea-hypopnea index (AHI), the average number of apneic and hypopneic episodes in one hour, is reported. An AHI of respiratory events per hour of sleep is normal, five to fourteen is considered mild sleep apnea, fifteen to thirty is moderate, and an AHI of greater than greater is considered severe.

An illustration depicting a sleep apnea monitor.

MMG2022_p2671_001.tif

Image by BruceBlaus, via Wikimedia Commons.

Information on Sleep Apnea

Causes: Upper airway obstruction; risk factors include obesity, small jaw, deviated septum, big tongue, enlarged tonsils, smoking

Symptoms: Periods of apnea and hypopnea during sleep, interrupting sleep pattern and resulting in snoring, daytime sleepiness, morning headaches, fatigue, difficulty with concentration; complications may include hypertension, heart failure, strokes, pulmonary hypertension

Duration: Chronic with acute episodes

Treatments: Lifestyle changes (weight loss, smoking cessation, avoidance of sedating medications and alcohol); continuous positive airflow pressure machine; in severe cases, surgery (removal of excess soft tissue, moving of tongue and jaw forward, tracheostomy)

TREATMENT AND THERAPY

Obese individuals with OSA should lose weight, quit smoking, and avoid sedating medications and alcohol as they may impair breathing even further.

Initial OSA treatment consists of a nasal continuous positive airflow pressure (CPAP) machine. A triangular mask fits over the nose and is hooked up to a machine that pushes pressured air into the upper airway to keep it open. A repeat sleep study using a CPAP machine can determine the level of pressure necessary to prevent apneic and hypopneic episodes. Such a device can be very effective in treating OSA. Side effects may include anxiety from using the mask, nasal congestion, nosebleeds, dry mouth, and irritation of the skin from the mask.

Some individuals require surgical treatment, especially those who cannot tolerate the use of a CPAP machine. The most common surgery performed for OSA is a procedure called “uvulopalatoplasty,” which involves surgical removal of excess soft tissue including the tonsils in the back of the mouth. Laser-assisted uvulopalatoplasty, in which a laser is used to remove the soft tissue, can be performed in the office. Other surgeries, including maxillary and mandibular advancement can move the tongue and jaw forward to open up the airway in the back of the mouth. For very severe cases of sleep apnea, an opening can be made in the trachea (the windpipe in the upper neck) to bypass the obstruction in the mouth and nose; this procedure is known as a “tracheostomy.” Since there is not a single “cure all” treatment for OSA, a complete surgical evaluation should include a proper physical exam, nasopharyngeal endoscopy and radiographic imaging to develop an individualized plan based on the severity and classification of an individual’s OSA.

PERSPECTIVE AND PROSPECTS

Accounts of what may have been sleep apnea date back to 305 to 30 BCE and involve eleven members from seven generations of the Egyptian royal family. These individuals were obese and were reported by contemporary philosophers and historians to have a tendency toward falling asleep during social and political events.

Sleep apnea has sometimes made an appearance in literature. In the late sixteenth century, symptoms of OSA are suggested in characters created by William Shakespeare for this plays Richard II and Henry IV. In Richard II, the obese Sir John Falstaff snores and sleeps much of the day, interrupted by an apneic breathing pattern. In Henry IV, King Henry IV has trouble sleeping, with periods of not breathing in his sleep. Lewis Carroll described a character with sleep apnea in his book Alice’s Adventures in Wonderland (1865). At the Mad Hatter’s tea party, the Dormouse suffers from daytime sleepiness. The other characters try to help the Dormouse by putting him into a tight teapot, which would serve as a positive pressure to assist his breathing.

The famous composer Johannes Brahms (1833-97) was thought to have developed sleep apnea in his later years when he gained weight. He was known to his friends to snore loudly at night. He also fell asleep during a performance by another famous composer, Franz Liszt.

See also: Apnea; Asphyxiation; Cyanosis; Hypoxia; Lungs; Obesity; Pulmonary diseases; Pulmonary medicine; Pulmonary medicine, pediatric; Respiration; Resuscitation; Sleep; Sleep disorders.

For Further Information:

1 

Goldman, Lee, and Dennis Ausiello, editors. Cecil Textbook of Medicine. 23rd ed., Saunders/Elsevier, 2007.

2 

Lavie, Peretz. Restless Nights: Understanding Snoring and Sleep Apnea. Translated by Anthony Berris. Yale UP, 2003.

3 

Mason, Robert J., et al., editors. Murray and Nadel’s Textbook of Respiratory Medicine. 5th ed., Saunders/Elsevier, 2010.

4 

Randerath, Winfried J., Bernd M. Sanner, and Virend K. Somers, editors. Sleep Apnea: Current Diagnosis and Treatment. S. Karger, 2006.

5 

Rock, Peter, editor. Obesity and Sleep Apnea. Saunders/Elsevier, 2005.

6 

Terris, David J., and Richard L. Goode, editors. Surgical Management of Sleep Apnea and Snoring. Taylor & Francis, 2005.

7 

Salman, Salam O., editor. Modern Management of Obstructive Sleep Apnea. Springer Nature, 2019.

Citation Types

Type
Format
MLA 9th
Anwar, Zuha. "Sleep Apnea." Magill’s Medical Guide, 9th Edition, edited by Anubhav Agarwal,, Salem Press, 2022. Salem Online, online.salempress.com/articleDetails.do?articleName=MMG2022_1249.
APA 7th
Anwar, Z. (2022). Sleep apnea. In A. Agarwal, (Ed.), Magill’s Medical Guide, 9th Edition. Salem Press. online.salempress.com.
CMOS 17th
Anwar, Zuha. "Sleep Apnea." Edited by Anubhav Agarwal,. Magill’s Medical Guide, 9th Edition. Hackensack: Salem Press, 2022. Accessed September 16, 2025. online.salempress.com.