Breathing-Related Sleep Disorders

Learning Objectives

  • Describe sleep apnea and other breathing-related sleep disorders

Sleep Apnea

Sleep apnea is defined by episodes during which a sleeper’s breathing stops. Sleep apnea episodes can last 10–20 seconds or longer and often are associated with brief periods of arousal. While individuals suffering from sleep apnea may not be aware of these repeated disruptions in sleep, they do experience increased levels of fatigue. Many individuals diagnosed with sleep apnea first seek treatment because their sleeping partners indicate that they snore loudly and/or stop breathing for extended periods of time while sleeping (Henry & Rosenthal, 2013).

Sleep apnea is much more common in people who are overweight and it may exacerbate cardiovascular disease (Sánchez-de-la-Torre, Campos-Rodriguez, & Barbé, 2012). While sleep apnea is less common in people who are thin, anyone, regardless of their weight, who snores loudly or gasps for air while sleeping, should be checked for sleep apnea.

While people are often unaware of their sleep apnea, they are keenly aware of some of the adverse consequences of insufficient sleep. One person explained that the sleep apnea affected his daily life saying, “I’m in a job where there’s a premium on being mentally alert. I was really sleepy . . . and having trouble concentrating. . . . It was getting to the point where it was kind of scary” (Henry & Rosenthal, 2013, p. 52).

There are two main types of sleep apnea: obstructive sleep apnea, listed as obstructive sleep apnea hypopnea (OSAH) in the DSM-5, and central sleep apnea. Obstructive sleep apnea occurs when an individual’s airway becomes blocked during sleep and air is prevented from entering the lungs. It is diagnosed if a person has at least five obstructive apneas per hour of sleep combined with breathing disturbances such as snoring and daytime sleepiness or at least fifteen obstructive apneas per hour of sleep without other symptoms. The apnea is characterized by at least ten-second disturbances in breathing. In central sleep apnea (CSA), disruption in signals sent from the brain that regulate breathing cause periods of interrupted breathing (White, 2005). Central sleep apnea is less common than obstructive sleep apnea hypopnea (OSAH) and is more commonly associated with illnesses.

Approximately 2%-9% of adults in the United States have obstructive sleep apnea and about 0.9% of adults over the age of 40 are diagnosed with central sleep apnea, but many cases are estimated to be undiagnosed. Both are more common in men than women. There are multiple factors that contribute to being at risk for sleep apnea, including obesity, hormonal imbalances, smoking cigarettes, family history, and the size and positioning of the jaw, throat, and tongue.[1]

Watch It

Watch this video to learn about sleep apnea, including its causes, symptoms, diagnosis, treatment, and pathology.

You can view the transcript for “Sleep apnea – causes, symptoms, diagnosis, treatment, pathology” here (opens in new window).

Treatment

One of the most common treatments for sleep apnea involves the use of a special device during sleep. A continuous positive airway pressure (CPAP) device includes a mask that fits over the sleeper’s nose and mouth, which is connected to a pump that pumps air into the person’s airways, forcing them to remain open, as shown in Figure 1. Some newer continuous positive airway pressure (CPAP) masks are smaller and cover only the nose. This treatment option has proven to be effective for people suffering from mild to severe cases of sleep apnea (McDaid et al., 2009). However, alternative treatment options are being explored because consistent compliance by users of continuous positive airway pressure (CPAP) devices is a problem. EPAP (excitatory positive air pressure) device has shown promise in double-blind trials as one such alternative (Berry, Kryger, & Massie, 2011). Treatment of sleep apnea also involves treading comorbid medical conditions, sometimes through surgery or medications.

Photograph A shows a CPAP device. Photograph B shows a clear full face CPAP mask attached to a mannequin's head with straps.

Figure 1. (a) A typical CPAP device used in the treatment of sleep apnea is (b) affixed to the head with straps and a mask that covers the nose and mouth.

  • Tongue Surgery
    • This procedure involves advancing one of the main tongue muscles, the genioglossus muscle, forward, thereby limiting the backward fall of the tongue during sleep. This procedure addresses the same sites of potential obstruction as the hyoid advancement, and numerous studies have shown a high success rate. 
  • Nasal Surgery
    • Both daytime nasal obstruction and nocturnal nasal congestion have been shown as risk factors for sleep-disordered breathing. Therefore, the treatment of nasal obstruction plays an important role in sleep apnea surgery. Three anatomic areas of the nose that may contribute to obstruction are the septum, the turbinates, and the nasal valve. The most common nasal surgical procedure consists of straightening out the septum and reducing the size of the turbinates, which creates more room in the nose and allows air to pass smoothly and without effort.
  • Tongue Surgery
    • The tongue has an established role in obstruction in sleep apnea. One treatment involves moving one of the main tongue muscles, the genioglossus muscle, forward; thereby limiting the backward fall of the tongue during sleep. This procedure addresses the same sites of potential obstruction as the hyoid advancement, and numerous studies have shown a high success rate. Another effective surgical treatment to reduce is to reduce the amount of tissue at the tongue base.
  • UPPP
    • UPPP, or in full, uvulopalatopharyngoplasty, has been the most common sleep apnea surgical procedure performed during the past 25 years. This procedure was developed to remove excess tissue from the soft palate and pharynx to remove the obstruction from the upper airwayPatients who suffer from snoring gain a great deal of improvement from this procedure as snoring is often due to the reverberation of the soft palate with the back wall of the pharynx.
  • Hyoid Advancement
    • The hyoid bone is a small bone in the neck where the muscles of the tongue base and pharynx attach. Patients with sleep apnea often have a large tongue base. During the deep stages of sleep, normal muscle tone is relaxed, and the base of the tongue falls back and can make contact with the back wall of the pharynx resulting in obstruction. Through a very minimally invasive procedure, the hyoid bone is surgically repositioned anteriorly by placing a suture around it and suspending it to the front of the jaw bone. This procedure results in an expansion of the airway and prevents collapse.
  • Lower Jaw Advancement
    • Abnormality of the maxillofacial skeleton is a well-recognized risk factor of obstructive sleep apnea. Sleep apnea patients usually have small, narrow jaws that result in diminished airway dimension, which leads to nocturnal obstruction. Maxillomandibular advancement achieves enlargement of the entire upper airway through the expansion of the skeletal framework that encircles the airway.
  • Tracheostomy
    • Tracheostomy is a technique that creates a passageway for air to get to the lungs directly from the trachea in the neck. This technique bypasses any potential sites of obstruction from the upper airway. Permanent tracheostomy as a long-term treatment of obstructive sleep apnea remains an option when all other forms of non-surgical and surgical treatments have failed. Though it may seem excessive, it is an extremely effective surgical option reserved for the very sick patient.[2]

Key Takeaways: Sleep Apnea

SIDS

The “Safe to Sleep” campaign logo shows a baby sleeping on his back and the words “safe to sleep.”

Figure 2. The Safe to Sleep campaign educates the public about how to minimize risk factors associated with SIDS. This campaign is sponsored in part by the National Institute of Child Health and Human Development.

In sudden infant death syndrome (SIDS), an infant stops breathing during sleep and dies. Infants younger than 12 months appear to be at the highest risk for SIDS, and boys have a greater risk than girls. A number of risk factors have been associated with SIDS, including premature birth, smoking within the home, and hyperthermia. There may also be differences in both brain structure and function in infants that die from SIDS (Berkowitz, 2012; Mage & Donner, 2006; Thach, 2005).

The substantial amount of research on SIDS has led to a number of recommendations to parents to protect their children (Figure 2). For one, research suggests that infants should be placed on their backs when put down to sleep, and their cribs should not contain any items that pose suffocation threats, such as blankets, pillows, or padded crib bumpers (cushions that cover the bars of a crib). Infants should not have caps placed on their heads when put down to sleep in order to prevent overheating, and people in the child’s household should abstain from smoking in the home. Recommendations like these have helped to decrease the number of infant deaths from SIDS in recent years (Mitchell, 2009; Task Force on Sudden Infant Death Syndrome, 2011).

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Glossary

central sleep apnea: sleep disorder with periods of interrupted breathing due to a disruption in signals sent from the brain that regulate breathing

continuous positive airway pressure (CPAP): device used to treat sleep apnea; includes a mask that fits over the sleeper’s nose and mouth, which is connected to a pump that pumps air into the person’s airways, forcing them to remain open

obstructive sleep apnea: sleep disorder defined by episodes when breathing stops during sleep as a result of blockage of the airway

sleep apnea: sleep disorder defined by episodes during which breathing stops during sleep

sudden infant death syndrome (SIDS): infant (one-year-old or younger) with no apparent medical condition suddenly dies during sleep


  1. Sleep Apnea - Causes & Symptoms. Sleep Foundation. (2020, September 25). https://www.sleepfoundation.org/sleep-apnea.
  2. Sleep Apnea - Treatment Options. Sleep Foundation. (2020, September 25). https://www.sleepfoundation.org/sleep-apnea.