Sleep-Disordered Breathing

The spectrum of sleep-disordered breathing

When you sleep, the muscles that hold the throat open relax. In some people, the airway narrows or collapses, or the brain's breathing control becomes unstable. The main categories, as defined by the American Academy of Sleep Medicine, are:

Obstructive sleep apnea is by far the most common serious form. See sleep apnea for a comparison of obstructive and central types.

Symptoms in adults

• loud, habitual snoring
• pauses in breathing, snorting or gasping noticed by a bed partner
• waking with a choking feeling
• frequent waking to urinate at night
• unrefreshing sleep and daytime sleepiness
• morning headaches and dry mouth
• poor concentration, irritability and low mood
• reduced sex drive and erectile dysfunction

Women more often report insomnia, fatigue and morning headaches than classic snoring.

Sleep-disordered breathing in children

SDB affects children differently. The most common cause is enlarged tonsils and adenoids (adenoid hypertrophy), usually between ages 2 and 8. Obesity, allergies, Down syndrome, facial differences and neuromuscular conditions also raise the risk.

Signs include:

• snoring 3 or more nights a week
• mouth breathing and a stuffy nose
• labored breathing, pauses or gasps during sleep
• restless sleep, sweating and unusual sleep positions (such as neck extended)
• bedwetting after being dry
• hyperactivity, inattention, irritability and learning problems, which can be mistaken for ADHD
• morning headaches and, in some, poor growth

Unlike adults, children are often not sleepy in the day. The American Academy of Pediatrics recommends that doctors ask about snoring at every routine checkup.

Causes and risk factors

• Excess weight, especially around the neck
• Anatomy: large tonsils, a small or set-back jaw, a large tongue, narrow airway
• Nasal obstruction: allergic rhinitis, a deviated septum, nasal polyps
• Male sex and older age; risk rises in women after menopause
• Alcohol, sedatives and opioids, which relax throat muscles and dampen breathing drive
• Sleeping on your back
• Heart failure, stroke and kidney failure (central sleep apnea)
• Pregnancy, hypothyroidism and acromegaly

Diagnosis

Screening questions

Doctors use questionnaires such as STOP-BANG (snoring, tiredness, observed apnea, blood pressure, BMI, age, neck size, gender) and the Epworth Sleepiness Scale.

Sleep studies

• Home sleep apnea test: measures airflow, breathing effort and oxygen levels at home. Suitable for many adults suspected of moderate to severe OSA without major heart or lung disease.
• In-lab polysomnography: the full overnight test, also recording brain waves, leg movements and heart rhythm. It is used for children, suspected central apnea, hypoventilation or when a home test is negative but symptoms persist.

What the results mean

The apnea-hypopnea index (AHI) counts breathing pauses (apneas) and shallow breaths (hypopneas) per hour of sleep:

In children, an AHI above 1 is considered abnormal, and above 10 is usually considered severe.

Treatment

Treatment depends on the type and severity.

For adults

• Weight loss: losing even 10% of body weight can reduce OSA severity substantially. GLP-1 based medicines such as tirzepatide have been approved for moderate to severe OSA in adults with obesity.
• CPAP (continuous positive airway pressure): a mask delivers gentle air pressure that holds the throat open. It is the most effective treatment for moderate to severe OSA.
• Oral appliances: custom mouthguards from a dentist that move the lower jaw forward, for mild to moderate OSA or people who cannot use CPAP.
• Positional therapy: devices that prevent sleeping on the back, when apnea occurs mainly in that position.
• Nasal treatment for allergies or blockage, which improves comfort and CPAP tolerance.
• Hypoglossal nerve stimulation: an implanted device that moves the tongue forward during sleep, for selected people who cannot use CPAP.
• Surgery on the throat, nose or jaw in selected cases.
• Central sleep apnea: treat heart failure, reduce opioids, and use specialized ventilation devices or, in some cases, a phrenic nerve stimulator.
• Hypoventilation: bilevel positive airway pressure (BiPAP) and weight loss.

For children

• Adenotonsillectomy (removing the tonsils and adenoids) is first-line treatment for children with OSA and enlarged tonsils, and improves breathing, sleep and behavior in most.
• Nasal steroid sprays and sometimes montelukast for mild cases.
• CPAP if surgery is not suitable or symptoms persist.
• Weight management and orthodontic treatment in some children.

Lifestyle steps for everyone

• avoid alcohol and sedatives in the evening
• keep a regular sleep schedule
• stop smoking
• raise the head of the bed if you snore mainly on your back

Why it matters

Untreated moderate to severe SDB is linked to:

• high blood pressure, especially treatment-resistant hypertension
• atrial fibrillation, heart failure and stroke
• type 2 diabetes
• car and work accidents from sleepiness
• depression and memory problems
• in children, behavior problems, poor school performance and slowed growth

Treatment improves sleepiness and quality of life, and lowers blood pressure in many people.

Frequently asked questions

Is sleep-disordered breathing the same as sleep apnea?

Not exactly. Sleep-disordered breathing is the umbrella term for all breathing problems during sleep, from simple snoring to upper airway resistance, obstructive and central sleep apnea, and hypoventilation. Sleep apnea is one, more severe, part of that spectrum.

What are the signs of sleep-disordered breathing in children?

Signs include snoring three or more nights a week, mouth breathing, pauses or gasps during sleep, restless sleep, bedwetting, morning headaches and daytime behavior problems such as hyperactivity or poor attention. Children are often not sleepy during the day. Enlarged tonsils and adenoids are the most common cause.

Is snoring always a sign of sleep apnea?

No. Many people snore without any breathing pauses or oxygen drops, which is primary snoring. However, loud snoring most nights, especially with gasping, witnessed pauses, daytime sleepiness or high blood pressure, should be checked with a sleep study.

What AHI is considered sleep apnea?

In adults, an apnea-hypopnea index of 5 or more events per hour with symptoms, or 15 or more without symptoms, indicates obstructive sleep apnea. Mild is 5 to 14, moderate 15 to 29 and severe 30 or more. In children, an AHI above 1 is abnormal.

Can sleep-disordered breathing be cured?

Sometimes. Removing enlarged tonsils and adenoids cures most childhood cases. In adults, significant weight loss, jaw surgery or treating the cause of central apnea can resolve it. Otherwise, treatments such as CPAP or oral appliances control it effectively as long as they are used.