More than 10% of adults in the United States have diagnosed sleep apnea, meaning they stop breathing multiple times every hour while they sleep.
And there’s likely a significant undercount for the true toll of sleep apnea since medical experts estimate that more than 80% of people with the breathing ailment don’t know they have it.
In addition to triggering exhaustion, sleep apnea can cause noisy snoring and increased risk for cardiovascular illnesses including hypertension, stroke, heart disease and cardiac arrhythmia, also known as an irregular heartbeat.
Green is the medical director at the UCHealth Sleep Medicine Clinic on the Anschutz Medical Campus as well as the UCHealth Sleep Lab in Central Park. She’s also is an assistant professor at the University of Colorado School of Medicine.
Green is an ear, nose and throat specialist — an otolaryngologist — who also has formal fellowship training in both sleep medicine and sleep surgery. She was the first surgeon in Denver to implant a device called Inspire which is an alternative to using traditional CPAP (continuous positive airway pressure) machines for obstructive sleep apnea.
Schell is also an assistant professor of otolaryngology at the CU School of Medicine. Like Green, she has formal fellowship training in both sleep medicine and sleep surgery.
What is sleep apnea? I hear it’s common, but many people don’t know they have it.
“Sleep apnea occurs when a person’s airway closes and they frequently stop breathing during sleep,” Green said. “It’s normal for people to have occasional pauses in breathing during sleep, but people who stop breathing more than five times per hour have sleep apnea.”
The condition is quite common and, since apnea occurs while people are sleeping, many people don’t realize they have it. And it can cause other health problems, Green said.
What are the other health problems associated with sleep apnea? Why should I be concerned if I might have it?
“Sleep apnea prevents you from getting deep, healthy sleep. And it makes your heart work harder due to the lack of oxygen,” Green said.
Untreated sleep apnea can also cause high blood pressure.
When a patient repeatedly stops breathing, the body springs into action with a natural stress response. In addition to being exhausted, patients’ hearts can be working overtime all night, responding every few seconds to a temporary loss of oxygen.
“We think about 15% of all cases of high blood pressure are due to sleep apnea,” Green said. “The sleep apnea triggers your fight or flight response and you have all of this stimulation. Untreated sleep apnea increases the risk of heart attack, stroke and congestive heart failure. And, it increases the risk of sudden cardiac death during sleep or falling asleep while driving.”
Along with physical problems, sleep apnea can leave people feeling hopeless.
“It can affect mood and energy, leading to depression, anxiety, poor concentration and memory impairment. The poor sleep quality associated with sleep apnea also has direct effects on work or school performance,” Green said. “These are serious downstream effects of sleep apnea that we don’t want to ignore.”
I hear there are two types of sleep apnea. What are they and what’s the difference?
There are two types: obstructive sleep apnea and central sleep apnea.
“Obstructive is much more common and is caused by a blockage in breathing while a person is asleep, usually from the throat muscles collapsing and narrowing your airways,” Green said. “These blockage events cause your oxygen to drop during sleep and disrupt your sleep quality.”
Central sleep apnea is less common in the entire population. But it’s more common at higher elevations than it is in people who live at sea level and lower elevations.
“Especially in Colorado, because of high altitude, we need to pay much more attention to central sleep apnea. The vast majority of sleep apnea cases in our country relate to obstructive sleep apnea. But up to 20% of sleep apnea cases at higher elevation are related to central sleep apnea,” Green said.
“The basic CPAP machine may be ineffective for central sleep apnea,” she said.
The causes of the two types of sleep apnea also vary. Central sleep apnea can afflict people who already have had a heart attack or a stroke. With central sleep apnea, the brain is failing to tell your body to breathe.
Both obstructive and central sleep apnea can be severe, and both can lead to serious health consequences (see above).
What are the common symptoms of sleep apnea?
“The common symptoms that you or your partner should look for are snoring, gasping or choking in your sleep. All of these can be signs of underlying obstructive sleep apnea,” Green said. “If you can fall asleep, but can’t stay asleep, that may be a sign of sleep apnea.”
There are also many symptoms people may experience when they’re awake.
“Waking with a headache or waking up and not feeling refreshed or feeling tired throughout the day, even to the point of dozing off, all can be signs of sleep apnea,” Green said.
How do you know if you have sleep apnea?
A simple at-home test can determine if you have sleep apnea. Green encourages anyone with concerns to get tested.
“If you are doing all the right things and you don’t feel refreshed by the sleep you are getting, or if you are having trouble staying asleep, it’s time to talk to a sleep doctor,” Green said.
What’s it like to do an at-home sleep test?
Years ago, people who needed to be tested for sleep apnea had to spend a night at a sleep lab so experts could monitor them while they slept. Now, many monitoring devices are portable and most patients can do a sleep test at home.
If you have the symptoms of sleep apnea, your doctor may arrange for you to get monitoring devices that will measure your breathing and heart rate overnight.
While it may be awkward to sleep with these monitors for a single night, you should be able to get some sleep and the data that the monitors will provide to your doctor will be invaluable. The monitors make it possible for doctors to definitively determine whether or not you have sleep apnea.
What if my partner snores a lot? Could they have sleep apnea?
Yes. Many people who have sleep apnea snore, but there also are other causes of snoring aside from sleep apnea. Most people who snore have no idea that they’re snoring. Green encourages people to talk openly with their partners and to help them seek help if necessary. Snoring can be disturbing to a sleep partner. It also can be a sign of a sleep apnea or another health problem.
How do you determine the severity of a person’s sleep apnea?
Sleep experts measure the severity of sleep apnea based on how many times a person stops breathing per hour.
Here’s how the measurements stack up:
- Adults who temporarily stop breathing fewer than five times per hour as they sleep do not have sleep apnea.
- Those who stop breathing between five and 15 times per hour have mild sleep apnea.
- Adults who stop breathing between 15 and 30 times per hour have moderate sleep apnea.
- People who stop breathing more than 30 times per hour have severe sleep apnea.
Can children have sleep apnea?
Yes. In kids, enlarged tonsils are the leading cause of sleep apnea. Adults also can have enlarged tonsils that may cause sleep apnea.
Do children have different symptoms than adults if they have sleep apnea?
Yes, Green said.
“Kids with sleep apnea are very rarely tired during that day. That’s very different from adults with obstructive sleep apnea,” Green said. “Most of the time, sleep apnea in children presents with ADHD-like symptoms: acting out, emotional lability (exaggerated mood swings) or poor school performance.”
If parents notice their children snoring and witness episodes when kids stop breathing, Green encourages them to talk with their pediatricians. Further evaluation may be wise.
IIs sleep apnea more common as people age? And is it true that more men than women have sleep apnea?
Yes. Sleep apnea gets more common as people age. About 24% of men and 9% of women have symptoms of sleep apnea, according to the American Academy of Sleep Medicine. One study of older veterans estimated that sleep apnea may affect as many as 38-to-68% of people older than age 60.
While more men have been diagnosed with sleep apnea, the condition likely is underdiagnosed in women.
“Many studies show that after menopause the risk of sleep apnea is probably equal in men and women. It may be a driver of insomnia in women. There is probably less of gender discrepancy than previous data showed,” Green said.
Is obesity connected with sleep apnea?
Yes. A much higher percentage of people in the U.S. are now overweight and obese than in previous decades. And people who are overweight or obese are more likely to suffer from sleep apnea.
But Green says it’s a myth that sleep apnea is always linked to weight.
“Being overweight or obese definitely impacts sleep apnea. For some people, weight loss can be curative. But people of all body types have sleep apnea. I see people who are stick skinny who have severe sleep apnea,” Green said.
“It all comes down to the size, shape and configuration of the airways and how your bones are structured,” she said. “Anyone can have sleep apnea. It tends to run in families. If you have family members who have sleep apnea, you may as well. It’s very common and severely underdiagnosed.”
Along with men and people who are overweight or obese, who else is more likely to have sleep apnea?
The following groups of people are more likely to have sleep apnea:
- People who smoke
- Those suffering from nocturnal nasal congestion
- Men and women who have large neck sizes
- Ethnic and racial minorities
- Adults and children with Down Syndrome
- People with larger tonsils and adenoids
- Anyone with a family history of sleep apnea
- People with endocrine disorders including acromegaly and hypothyroidism
What are the treatments for sleep apnea?
A CPAP machine is by far the most effective and least invasive cure for sleep apnea, Green said.
“The gold-standard treatment for sleep apnea is the CPAP machine. If you can wear it, it’s 100% effective. If you can sleep with a CPAP machine, it can provide a 100% correction,” Green said.
Using a CPAP machine requires getting fitted with a mask that fits over your nose and mouth (or just your nose for some people). The mask connects to an air hose, which connects to the CPAP machine. The machine then delivers pressurized air through the hose and mask into your airway, preventing episodes of halted breathing by supporting the airway from the inside out.
Is it possible to have other sleep disorders along with sleep apnea?
Yes. Some people have sleep apnea and another disorder like restless leg syndrome.
“For some people, that’s why a CPAP is uncomfortable. If other sleep conditions are not being addressed at the same time, a person may not do well,” Green said. “Often these conditions occur together. We don’t want to treat one in isolation and ignore others.”
If a person uses a CPAP machine, will they stop snoring?
Yes, a CPAP machine will always completely eliminate snoring. No matter how disruptive or loud the snoring is, when people use CPAP machines, they will become silent sleepers.
Does a CPAP machine disturb a person’s bed partner?
A CPAP machine makes some noise while it runs (a little like a fan or white noise machine), but new models are incredibly quiet. Most of the time, bed partners find that the CPAP is much, much quieter than snoring from untreated sleep apnea.
I hear some people have trouble getting used to a CPAP machine. Is that true?
Yes, that’s true.
Some people have not found a mask that fits them well. Others are only able to use their CPAP machine for a couple of hours a night or struggle to fall asleep while wearing it.
Without adequate support, about 20 to 60% of people comfortably use their CPAP machines every night.
But sleep specialists can help people dramatically boost their comfort.
“With adjustments, we can improve CPAP compliance to about 70-to-75%,” Green said. “If your CPAP machine arrived and you watched one YouTube video and tried wearing it for a short time and sent it back, for most people, we can do better.”
While she is a surgeon, Green always tries to help her patients achieve success with the least invasive option.
“I spend a lot of time talking people out of surgery,” she said.
But for the estimated 25-to-30% of people who don’t do well with a CPAP, doctors can provide other options.
I’ve heard about a large recall of CPAP devices made by Philips Respironics. What if people have gotten used to a CPAP machine, but their device has been recalled?
Philips Respironics issued a voluntary recall last year for an estimated 4 million ventilator devices. As patients wait for a new device, Green encourages many of these people to keep using their current CPAP machine.
“For most patients, the risk of untreated sleep apnea is higher than risks being reported with the recall,” Green said. “I have counseled patients who feel better with their CPAPs to keep using them. It is complex, and we hope all of the machines are going to be replaced in the next couple of months.”
What are oral appliances?
Oral appliances are another type of therapy that doctors use to treat sleep apnea.
“They look like mouth guards. They pull the lower jaw and tongue muscles forward. In general, most patients find these appliances to be comfortable and compliance is higher than it is with a CPAP,” Green said.
“They are most effective for primary snoring or people with mild to moderate sleep apnea. Often this can be a good first alternative to consider,” Green said. “But their success rate is much more variable than with CPAP, and for many people the oral appliances may not completely eliminate snoring or sleep apnea.”
Can weight loss or bariatric surgery reduce the need for a CPAP or other sleep apnea treatment?
Yes. “The cure rate with bariatric surgery can be as high as 78%,” Green said.
What are other surgical options for people with sleep apnea?
Some surgeries help people adapt better to a CPAP machine or an oral appliance, Schell said.
“Not all surgery is meant to throw out or replace the CPAP or oral appliance,” Schell said.
Sometimes, surgeons are able to alter a person’s anatomy so they will do better.
“There are interventions for the nose that could allow a patient to use a less-intrusive mask. We sometimes do surgery to help reduce the pressure of your machine,” she said. “Or if you have huge tonsils, we can get those out of the way. That might open your upper airway.”
What is Uvulopalatopharyngoplasty surgery, also known as UPPP or UP3?
These procedures date back to the 1980s. Surgeons remove tissue in the throat to make it easier for patients to breathe.
Schell said the surgery originally was a “one-size-fits-all” approach. And it didn’t work well for all patients.
“It entailed removing structures in the throat to make more space,” Schell said. “If you think of the throat as a room with a lot of furniture, the idea of this surgery is to remove some of the overstuffed chairs, like the tonsils and the soft part of the roof of the mouth.”
In theory, the concept was good. In reality, Schell said the success rate was poor — only about 40%. And, the surgery was extremely painful.
In recent years, surgeons have modified the surgery.
“In patients with large tonsils, we’ve been able to approach an 80% success rate,” Schell said. “If you have big tonsils, taking them out seems to work.”
The recovery is still very difficult.
“Patients will have two to three weeks of very bad throat pain,” Schell said.
What about jaw surgery?
Patients with severe sleep apnea and a particular anatomy of their upper and lower jaws may do well with what’s known as a maxillomandibular advancement surgery or MMA.
“If you think of the UP3 surgery as rearranging the furniture, the MMA surgery is like busting out the walls and rearranging the space,” Schell said.
“Both of the jaws are moved forward. It’s a big surgery with quite an extensive recovery. The success rates are quite high, as high as 80-to-95%. Usually this surgery is for a person who has structural jaw abnormalities and it’s for people with very severe sleep apnea,” she said.
What is the Inspire device?
“The Inspire is a surgically implanted device that moves your tongue muscles forward. It can open up your airways,” Schell said.
“This surgery has been FDA-approved since 2014 and now a more routine option in the sleep surgeon’s toolbox,” she said. “This surgery often doesn’t require strong pain medication post-operatively. Usually people can get back to non-strenuous activities within a few days.”
Schell said the best candidates for the Inspire device are those with moderate to severe sleep apnea who are not significantly overweight.
“In general, a person’s BMI (or body mass index) has to be lower than 32-to-35,” Schell said. “As BMI goes up, it’s harder to achieve success with this surgery.”
(The same is true for all upper airway surgeries like palate surgeries. Success for upper airway surgeries goes down significantly if a person’s BMI is over 35.)
“For those who are eligible, about 70% are able to get their breathing pauses to a place where we are comfortable eliminating the CPAP,” she said “A similar percentage have subjective improvement in their sleep symptoms.
“About 94% of people report a positive experience with this surgery,” Schell said. “And usage is better than it is with CPAP. The odds of success go up as we age and for people with lower body mass indices.”
Overall, both sleep experts encourage people to consult with a doctor if they are not sleeping well.
“We can do something about sleep apnea. We have a lot of treatments,” Green said.
“Sleep is a quality of life issues. Good sleep quality can make a dramatic difference in absolutely everything.”