Obstructive sleep apnoea

Sleep apnea is a common disorder that causes your breathing to stop or get very shallow. Breathing pauses can last from a few seconds to minutes. They may occur 30 times or more an hour.

The most common type is obstructive sleep apnea. It causes your airway to collapse or become blocked during sleep. Normal breathing starts again with a snort or choking sound. People with sleep apnea often snore loudly. However, not everyone who snores has sleep apnea.

You are more at risk for sleep apnea if you are overweight, male, or have a family history or small airways. Children with enlarged tonsils or adenoids may also get it.

Doctors diagnose sleep apnea based on medical and family histories, a physical exam, and sleep study results.

When your sleep is interrupted throughout the night, you can be drowsy during the day. People with sleep apnea are at higher risk for car crashes, work-related accidents, and other medical problems. If you have it, it is important to get treatment. Lifestyle changes, mouthpieces, surgery, and breathing devices can treat sleep apnea in many people.

NIH: National Heart, Lung, and Blood Institute

Source: MedlinePlus, U.S. National Library of Medicine

Classification

In the third edition of the International Classification of Sleep Disorders (ICSD-3), obstructive sleep apnea is classified amongst the sleep-related breathing disorders and is divided in two categories, namely adult OSA and pediatric OSA. Obstructive sleep apnea is differentiated from central sleep apnea (CSA), which is characterized by episodes of reduction or cessation in breathing attributable to decreased effort, rather than upper airway obstruction. The respiratory effort must then be assessed in order to correctly classify the apnea as obstructive given the specificity of the diaphragmatic activity in this condition: the inspiratory effort is continued or increased through the entire episode of absent airflow.

When hypopneas are present alongside apneas, the term obstructive sleep apnea-hypopnea is used. If it is associated with daytime sleepiness and other daytime symptoms, it is known as obstructive sleep apnea-hypopnea syndrome. To be categorized as obstructive, the hypopnea must meet one or more of the following symptoms: (1) snoring during the event, (2) increased oronasal flow flattening, or (3) thoraco-abdominal paradoxical respiration during the event. If none of them are present during the event, then it is categorized as central hypopnea.

Signs and symptoms

Common symptoms of obstructive sleep disorder syndrome include unexplained daytime sleepiness, restless sleep, frequent awakenings and loud snoring (with periods of silence followed by gasps). Less common symptoms are morning headaches; insomnia; trouble concentrating; mood changes such as irritability, anxiety, and depression; bruxism (teeth grinding), forgetfulness; increased heart rate or blood pressure; erectile dysfunction, unexplained weight gain; increased urinary frequency or nocturia; frequent heartburn or gastroesophageal reflux; and heavy night sweats.

Many people experience episodes of OSA transiently, for only a short period. This can be the result of an upper respiratory infection that causes nasal congestion, swelling of the throat, or tonsillitis that temporarily produces very enlarged tonsils. The Epstein-Barr virus, for example, is known to be able to increase the size of lymphoid tissue dramatically during acute infection, and OSA is fairly common in acute cases of severe infectious mononucleosis. Temporary spells of OSA syndrome may also occur in people who are under the influence of a drug (such as alcohol) that may relax their body tone excessively and interfere with normal arousal from sleep mechanisms.

Adults

The special symptom of OSA syndrome in adults is excessive daytime sleepiness. Typically, an adult or adolescent with severe long-standing OSA will fall asleep for very brief periods in the course of usual daytime activities if allowed to sit or rest. This behavior may be quite dramatic, sometimes occurring during conversations with others at social gatherings.

The hypoxia (absence of oxygen supply) related to OSA may cause changes in the neurons of the hippocampus and the right frontal cortex. Neuroimaging research revealed evidence of hippocampal atrophy in people with OSA. They found that OSA can cause problems in mentally manipulating nonverbal information, executive functions, and working memory. OSA may also be associated with an increased risk of a person developing Alzheimer's disease.

Obesity is a major risk factor for OSA. In the severely obese, the risk for sleep apnea can be between 55 and 90%. However between 20 and 25% of patients with sleep apnea are not overweight. What is often unrecognized in primary care is that it is crucial to identify these patients because they are four times more likely to develop hypertension than obese individuals without OSA. And non-obese patients are at a higher risk for early atherosclerosis. In fact, approximately 2.7 times more than obese patients without OSA. This risk increases as the severity of the syndrome worsens. Factors in this population may include inherited anatomical features, instability of ventilatory control, neuromuscular inefficiency of the dilator muscles of the upper airways, or a lower threshold for awakening in response to respiratory stimuli.

Diagnosis of obstructive sleep apnea is significantly more common among people in relationships, who are alerted to their condition by being informed by their sleeping partner, since individuals with obstructive sleep apnea are often unaware of the condition. There is a stigma associated with loud snoring. It is not considered a feminine trait. Consequently, females are less likely to be told by their partners that they snore, or to admit it to themselves or doctors. Furthermore, CPAP (continuous positive airway pressure) machines are also perceived negatively by females. They are less likely to be utilized to their full extent in this group.

Children

Although this so-called "hypersomnolence" (excessive sleepiness) may also occur in children, it is not at all typical of young children with sleep apnea. Toddlers and young children with severe OSA instead ordinarily behave as if "over-tired" or "hyperactive"; and usually appear to have behavioral problems like irritability and an attention deficit.

Adults and children with very severe OSA also differ in typical bodily habitus. Adults are generally heavy, with particularly short and heavy necks. Young children, on the other hand, are generally not only thin but may have "failure to thrive", where growth is reduced. Poor growth occurs for two reasons: the work of breathing is intense enough that calories are burned at high rates even at rest, and the nose and throat are so obstructed that eating is both tasteless and physically uncomfortable. OSA in children, unlike adults, is often caused by obstructive tonsils and adenoids and may sometimes be cured with tonsillectomy and adenoidectomy.

This problem can also be caused by excessive weight in children. In this case, the symptoms are similar to those adults experience, such as restlessness and exhaustion. If adenotonsillar hypertrophy remains the most common cause of OSA in children, obesity can also play a role in the pathophysiology of upper airway obstruction during sleep which can lead to OSA, making obese children more likely to develop the condition. The recent epidemic increase of obesity prevalence has thus contributed to changes in the prevalence and in the characteristics of pediatric OSA, the severity of OSA is proportional to the degree of obesity.

Obesity leads to narrowing of the upper airway structure due to fatty infiltration and fat deposits in the anterior neck region and cervical structures. Alongside with the additional weight loading on the respiratory system, it increases the risk of pharyngeal collapsibility while reducing the intrathoracic volume and diaphragm excursion. Moreover, excessive daytime sleepiness resulting from sleep fragmentation can decrease physical activity and thus lead to weight gain (by sedentary habits or increased food intake to overcome somnolence). The obesity-related obstruction of upper airway structure has led some authors to distinguish between two types of OSA in children: type I is associated with marked lymphadenoid hypertrophy without obesity and type II is first associated with obesity and with milder upper airway lymphadenoid hyperplasia. The two types of OSA in children can result in different morbidities and consequences. Studies have shown that weight loss in obese adolescents can reduce sleep apnea and thus the symptoms of OSA.

Diagnosis

The diagnosis of OSA syndrome is made when the patient has recurrent episodes of partial or complete collapse of the upper airway during sleep, resulting in apneas or hypopneas, respectively. Criteria defining an apnea or a hypopnea vary. The American Academy of Sleep Medicine (AASM) defines an apnea episode as a reduction in airflow of ≥ 90% lasting at least 10 seconds. A hypopnea is defined as a reduction in airflow of ≥ 30% lasting at least 10 seconds and associated with a ≥ 4% decrease in pulse oxygenation, or as a ≥ 30% reduction in airflow lasting at least 10 seconds and associated either with a ≥ 3% decrease in pulse oxygenation or with an arousal.

To define the severity of the condition, the Apnea-Hypopnea Index (AHI) or the Respiratory Disturbance Index (RDI) is used. While the AHI measures the mean number of apneas and hypopneas per hour of sleep, the RDI adds to this measure the respiratory effort-related arousals (RERAs). The OSA syndrome is thus diagnosed if the AHI is > 5 episodes per hour and results in daytime sleepiness and fatigue or when the RDI is ≥ 15 independently of the symptoms. Daytime sleepiness may be classified as mild, moderate, or severe depending on its impact on social life. Daytime sleepiness can be assessed using the Epworth Sleepiness Scale (ESS), a self-reported questionnaire on the propensity to fall asleep or doze off during the day. Screening tools for OSA itself comprise the STOP questionnaire, the Berlin questionnaire and the STOP-BANG questionnaire which has been reported as being a powerful tool to detect OSA.

Polysomnography

Nighttime in-laboratory Level 1 polysomnography (PSG) is the gold-standard diagnostic test. Patients are monitored with EEG leads, pulse oximetry, temperature or pressure sensors to detect nasal and oral airflow, respiratory impedance plethysmography or similar resistance belts around the chest and abdomen to detect motion, an ECG lead, and EMG sensors to detect muscle contraction in the chin, chest, and legs.

An "event" can be either an apnea, characterized by complete cessation of airflow for at least 10 seconds, or a hypopnea in which airflow decreases by 50 percent for 10 seconds or decreases by 30 percent if there is an associated decrease in the oxygen saturation or an arousal from sleep. To grade the severity of sleep apnea, the number of events per hour is reported as the apnea-hypopnea index (AHI). For adults, an AHI of less than 5 is considered normal, an AHI of [5–15) is mild, [15–30) is moderate, and ≥30 events per hour characterizes severe sleep apnea. For pediatrics, an AHI of less than 1 is considered normal, an AHI of [1–5) is mild, [5–10) is moderate, and ≥10 events per hour characterizes severe sleep apnea.

Home sleep test (HST) / home sleep apnea test (HSAT)

Sleep apnea can also be diagnosed using an in-home testing kit. The main advantage is that these record in the usual sleep environment and thus are more representative of their natural sleep than staying overnight at a lab. Home sleep testing is more accessible and less expensive than polysomnography due to long waiting periods for in-lab tests.

Home oximetry and peripheral arterial tone measurement

Home oximetry (a non-invasive method of monitoring blood oxygenation) used in concert with Peripheral Arterial Tone (PAT) technology has been approved by the FDA at-home sleep apnea diagnosis since November 2001 when Itamar Medical obtained 510(k) clearance for the Watchpat-100. Although PAT-based at-home sleep tests are not considered as accurate as polysomnography-based tests, their AHI or AHI-equivalent measurements are considered sufficient for coverage purposes in the United States by Medicare and private health insurance companies.

Criteria

According to the International Classification of Sleep Disorders, there are 4 types of criteria. The first one concerns sleep – excessive sleepiness, non-restorative sleep, fatigue, or insomnia. The second and third criteria are about respiration – waking with breath holding, gasping, or choking; snoring, breathing interruptions, or both during sleep. The last criterion revolved around medical issues such as hypertension, coronary artery disease, stroke, heart failure, atrial fibrillation, type 2 diabetes mellitus, mood disorder, or cognitive impairment. Two levels of severity are distinguished: the first is diagnosed by polysomnography or a home sleep apnea test demonstrating five or more predominantly obstructive respiratory events per hour of sleep; 15 or more events diagnose the higher level of severity. If the events occur fewer than 5 times per hour, no obstructive sleep apnea is diagnosed.

A considerable night-to-night variability further complicates the diagnosis of OSA. In unclear cases, multiple testing might be required to achieve an accurate diagnosis.

Obesity

It is well known that children, adolescents, or adults with OSA are often obese. People with obesity show an increase in neck fat tissue, which potentiates respiratory obstruction during sleep.

However, people of all ages and sexes with normal body mass indices (BMIs) can also demonstrate OSA – and these people do not have significant measures of subdermal or intra-neck fat as shown on DEXA scans. It is speculated that they may have increased muscle mass or a tendency toward decreased muscle tone, potentiating airway collapse during sleep.

However, loss of muscle tone is a key feature of deep sleep, and whilst obesity seems a common association, it is not an invariable state of OSA.

Sleeping supine (on one's back) is also represented as a risk factor for OSA. Gravity and loss of tongue and throat tone as a person enters deep sleep are clear factors contributing to OSA development. But this explanation is also confounded by the presence of neck obesity.

The use of CPAP primarily expands a collapsed upper airway, allowing for nasal breathing. A positive response to CPAP confirms that airway collapse is the cause of OSA.

Throat lesions, particularly enlarged tonsils, are well recognized as aggravators of OSA, and removal may provide full, partial, or semi-permanent relief from OSA, which also indicates that enlarged tonsils may play a role in the pathogenesis of OSA.

Age

Old age is often accompanied by muscular and neurological loss of muscle tone in the upper airway. Decreased muscle tone is also temporarily caused by chemical depressants; alcoholic drinks and sedative medications are the most common. Permanent premature muscular tonal loss in the upper airway may be precipitated by traumatic brain injury, neuromuscular disorders, or poor adherence to chemical and or speech therapy treatments.

Muscle tone

Individuals with decreased muscle tone, increased soft tissue around the airway, and structural features that narrow the airway are at high risk for OSA. Men, whose anatomy is typified by increased mass in the torso and neck, are at increased risk of developing sleep apnea, especially in middle age and later. Typically, women experience this condition less frequently and to a lesser degree than do men, owing partially to physiology, but possibly also to differential levels of progesterone. Prevalence in post-menopausal women approaches that of men in the same age range. Women are at greater risk for developing OSA during pregnancy.

Medication and lifestyle

Lifestyle factors such as smoking may also increase the chances of developing OSA, as the chemical irritants in smoke tend to inflame the soft tissue of the upper airway and promote fluid retention, both of which can narrow the upper airway. Cigarettes may also have an impact due to a decline in blood nicotine levels, which alters sleep stability. Smokers thus show a higher risk of developing OSA, but the effect of cigarettes on increased OSA is reversible with the cessation of smoking. Children exposed to cigarette smoke may also develop OSA, as the lymphoid tissue will proliferate excessively in contact with the irritants. An individual may also experience or exacerbate OSA with the consumption of alcohol, sedatives, or any other medication that increases sleepiness as most of these drugs are also muscle relaxants. Allergic rhinitis and asthma have also been shown to be implicated in the increased prevalence of adenotonsillar hypertrophy and OSA.

Genetic

OSA also appears to have a genetic component; those with a family history of it are more likely to develop it themselves. This could be the result of both direct genetic contributions to OSA susceptibility. Or it could be from indirect contributions via 'intermediate' phenotypes such as obesity, craniofacial structure, neurological control of upper airway muscles, and of sleep and circadian rhythm sleep problems.

Several genes connected with sleep apnea have been identified, including DLEU1, DLEU7 CTSF, MSRB3, FTO, and TRIM66.

Craniofacial syndromes

Of substantial recent interest is the idea that there is a general human tendency towards developing short lower jaws (neoteny) is a major cause of OSA through a combined condition called glossoptosis. The posterior "normal" tongue is displaced backwards by a smaller "abnormal" anterior tongue and lower jaw. In much the same way, a narrow upper jaw will also contribute to OSA due to its relation to airway volume. A narrower upper jaw results in narrower nasal passages and a narrower throat; this also appears to be why so many OSA patients experience nasal congestion, especially while lying down.

Maxillofacial surgeons see many effects of small lower jaws, including crowded teeth, malocclusions, as well as OSA – all of which are treatable by surgical operations that increase and normalise jaw size. Operations such as custom BIMAX, GenioPaully, and IMDO (in adolescence) offer a valid medical option that replaces all traditional forms of OSA treatment – including CPAP, Mandibular Advancement Splints, tonsillectomy, and UPPP. There are patterns of unusual facial features that occur in recognizable syndromes. Some of these craniofacial syndromes are genetic, and others are from unknown causes. In many craniofacial syndromes, unusual features involve the nose, mouth, and jaw, or resting muscle tone, and put the individual at risk for OSA.

Down syndrome is one such syndrome. In this chromosomal abnormality, several features combine to make the presence of obstructive sleep apnea more likely. The specific features of Down syndrome that predispose to obstructive sleep apnea include relatively low muscle tone, a narrow nasopharynx, and a large tongue. Obesity and enlarged tonsils and adenoids, conditions that occur commonly in the western population, are much more likely to be obstructive in a person with these features than without them. Obstructive sleep apnea occurs even more frequently in people with Down syndrome than in the general population. A little over 50% of all people with Down syndrome experience obstructive sleep apnea. Some physicians advocate routine testing of this group.

In other craniofacial syndromes, the abnormal feature may improve the airway, but its correction may put the person at risk for obstructive sleep apnea after surgery when it is modified. Cleft palate syndromes are such an example. During the newborn period, all humans are obligate nasal breathers. The palate is both the roof of the mouth and the floor of the nose. Having an open palate may make feeding difficult, but generally, it does not interfere with breathing; if the nose is very obstructed, then an open palate may relieve breathing. There are several clefting syndromes in which the open palate is not the only abnormal feature; additionally, there is a narrow nasal passage, which may not be obvious. In such individuals, closure of the cleft palate – whether by surgery or a temporary oral appliance – can cause the onset of obstruction.

Skeletal advancement to physically increase the pharyngeal airspace is often an option for craniofacial patients with upper airway obstruction and small lower jaws (mandibles). These syndromes include Treacher Collins syndrome and Pierre Robin sequence. Mandibular advancement surgery is one of the modifications needed to improve the airway; others may include reduction of the tongue, tonsillectomy, or modified uvulopalatoplasty.

Post-operative complication

OSA can also occur as a serious post-operative complication that seems to be most frequently associated with pharyngeal flap surgery as compared to other procedures for the treatment of velopharyngeal inadequacy (VPI). In OSA, recurrent interruptions of respiration during sleep are associated with temporary airway obstruction. Following pharyngeal flap surgery, depending on size and position, the flap itself may have an "obturator" or obstructive effect within the pharynx during sleep, blocking ports of airflow and hindering effective respiration. There have been documented instances of severe airway obstruction, and reports of post-operative OSA continues to increase as healthcare professionals (i.e. physicians, speech language pathologists) become more educated about this possible dangerous condition. Subsequently, in clinical practice, concerns of OSA have matched or exceeded interest in speech outcomes following pharyngeal flap surgery.

The surgical treatment for velopalatal insufficiency may cause obstructive sleep apnea syndrome. When velopalatal insufficiency is present, air leaks into the nasopharynx even when the soft palate should close off the nose. A simple test for this condition can be made by placing a tiny mirror on the nose and asking the subject to say "P". This p sound, a plosive, is normally produced with the nasal airway closed off – all air comes out of the pursed lips, none from the nose. If it is impossible to say the sound without fogging a nasal mirror, there is an air leak, reasonable evidence of poor palatal closure. Speech is often unclear due to the inability to pronounce certain sounds. One of the surgical treatments for velopalatal insufficiency involves tailoring the tissue from the back of the throat and using it to purposefully cause partial obstruction of the opening of the nasopharynx. This may actually cause OSA syndrome in susceptible individuals, particularly in the days following surgery, when swelling occurs (see below: Special Situation: Anesthesia and surgery).

Finally, patients with OSA are at an increased risk of many perioperative complications when they are present for surgery, even if the planned procedure is not on the head and neck. Guidelines to reduce the risk of perioperative complications have been published.

Management

Numerous treatment options are used in obstructive sleep apnea. Avoiding alcohol and smoking is recommended, as is avoiding medications that relax the central nervous system (for example, sedatives and muscle relaxants). Weight loss is recommended in those who are overweight. Continuous positive airway pressure (CPAP) and mandibular advancement devices are often used and found to be equally effective. Physical training, even without weight loss, improves sleep apnea. There is insufficient evidence to support widespread use of medications. In selected patients, e.g., with tonsillar hyperplasia, tonsillectomy is recommended. In patients failing CPAP and oral appliances, surgical treatment with conservative uvulopalatopharyngoplasty (UPPP) as salvage surgery is recommended. UPPP has a positive effect on nocturnal respiration and excessive daytime sleepiness.

Physical intervention

The most widely used therapeutic intervention is positive airway pressure whereby a breathing machine pumps a controlled stream of air through a mask worn over the nose, mouth, or both. The additional pressure holds open the relaxed muscles. There are several variants:

Continuous positive airway pressure (CPAP) is effective for both moderate and severe disease. It is the most common treatment for obstructive sleep apnea.

Variable positive airway pressure (VPAP) (also known as bilevel (BiPAP or BPAP)) uses an electronic circuit to monitor the patient's breathing and provides two different pressures, a higher one during inhalation and a lower pressure during exhalation. This system is more expensive and is sometimes used with patients who have other coexisting respiratory problems or who find breathing out against an increased pressure to be uncomfortable or disruptive to their sleep.

Nasal EPAP, which is a bandage-like device placed over the nostrils that utilizes a person's own breathing to create positive airway pressure to prevent obstructed breathing.

Automatic positive airway pressure, also known as "Auto CPAP", incorporates pressure sensors and monitors the person's breathing.

A 5% reduction in weight among those with moderate to severe OSA may decrease symptoms similarly to CPAP.

Encouraging people with moderate to severe OSA to use CPAP devices can be challenging, as their use often requires a behavioural change in sleeping habits. 8% of people who use CPAP devices stop using them after the first night, and 50% of people with moderate to severe OSA stop using their devices in the first year. Educational initiatives and supportive interventions to help improve compliance with CPAP therapy have been shown to improve the length of time people who need CPAP therapy use their devices.

Many people benefit from sleeping at a 30-degree elevation of the upper body or higher, as if in a recliner. Doing so helps prevent the gravitational collapse of the airway. Sleeping on a side as opposed to sleeping on the back ("supine position") is also recommended.

Some studies have suggested that playing a wind instrument (such a didgeridoo, for example) may reduce snoring and apnea incidents. This may be especially true of double reed instruments.

Medications

Evidence is insufficient to support the use of medications to treat obstructive sleep apnea directly. This includes the use of fluoxetine, paroxetine, acetazolamide, and tryptophan among others.

Recent studies are trying to investigate cannabinoids as a treatment for OSA, especially dronabinol, which is a synthetic form of THC (delta-9-tetrahydrocannabinol). Cannabis is known to influence sleep; for example, it can reduce sleep latency. However, results are not consistent. Studies about dronabinol have shown positive impact on the OSA, as they observed a reduced AHI (Apnea-Hypopnea Index) and an increased self-reported sleepiness (the objective sleepiness being unaffected). However, more evidence are needed as many effects of those substances remain unknown, especially the effects of a long-term intake. The effects on sleepiness and weight gain are particularly of concern. Due to uncertainty about its effects and a lack of consistent evidence, medical cannabis is not recommended for the treatment of OSA.

There are multiple drugs approved for managing the excessive daytime sleepiness associated with OSA, but not the underlying cause. These include solriamfetol, modafinil, and armodafinil.

For adults with obesity and moderate-to-severe OSA, during a 52-week study tirzepatide (brand name Zepbound) substantially reduced apneic-hypopnic events, body weight, hypoxic burden, hsCRP concentration, and systolic blood pressure, and improved sleep-related patient-reported outcomes, all presumably mediated via induced weight loss of 18–20% from baseline. Subsequently, the FDA approved the drug for treatment of OSA in December 2024, and Medicare and many insurers began covering the drug specifically for treatment of OSA in 2025.

Dental appliances

Mandibular advancement splints (mandibular advancement devices) are designed to hold the lower jaw slightly down and forward relative to the natural, relaxed position. This position keeps the tongue farther away from the back of the airway and may be enough to relieve apnea or improve breathing. This device is a mouthguard similar to those used in sports to protect the teeth. Mandibular advancement splints are used for snoring and for mild to moderate obstructive sleep apnea. They are most suitable for people with AHI < 25, BMI < 30, and good dentition.

Where appropriate, they are considered a good therapy choice as they are non-invasive, easily reversible, and quiet. They are generally well-tolerated because they are less uncomfortable. However, they may not be as effective as CPAP. Oral devices have been shown to treat OSA successfully. These include the polysomnographic indexes of OSA, subjective and objective measures of sleepiness, blood pressure, aspects of neuropsychological functioning, and quality of life. The focus of improvement in appliance design is in reducing bulk, permitting free jaw movement (i.e., yawning, speaking, and drinking), and allowing the user to breathe through their mouth (early "welded gum shield"-type devices prevented oral breathing).

Tongue repositioning (retaining) devices are made of soft acrylic and cover the upper and lower teeth, creating a seal with the lips. They have a "bulb" or "bubble" which sticks out of the front of the mouth. This creates negative suction pressure by holding the tongue in a forward position and increasing the airway space behind the tongue. Hybrid devices combine mandibular advancement with the tongue restraint. These devices have been used for snoring and obstructive sleep apnea. Tongue retaining devices have not been well-received as a therapy choice since they are invasive, and the acclimation period is long. The devices have shown high success rates for therapy.

Soft-palate lifters are devices that lift the soft palate. They are useful for people who have weak muscles in the region.

Evidence to support oral appliances/functional orthopedic appliances in children is insufficient, with very low evidence of effect. However, the oral appliances/functional orthopedic appliances may be considered in specified cases as an auxiliary in the treatment of children with craniofacial anomalies, which are risk factors for apnea.

Rapid Palatal Expansion

In children, orthodontic treatment to expand the volume of the nasal airway, such as nonsurgical rapid palatal expansion, is common.

Since the palatal suture is fused in adults, regular RPE using tooth-borne expanders cannot be performed. Mini-implant-assisted rapid palatal expansion (MARPE) has been recently developed as a non-surgical option for the transverse expansion of the maxilla in adults. This method increases the volume of the nasal cavity and nasopharynx, leading to increased airflow and reduced respiratory arousals during sleep. Changes are permanent with minimal complications.

Surgery

Sleep surgery is a range of surgical treatments to modify airway anatomy. They are varied and are tailored to the specific location and nature of the airway obstruction for each individual. Surgery is not considered a first-line treatment for obstructive sleep apnea in adults. For people with obstructive sleep apnea who are unable or unwilling to comply with first-line treatment, surgical intervention is adapted to an individual's specific anatomy and physiology, personal preference, and disease severity. Uvulopalatopharyngoplasty (UPPP) with or without tonsillectomy is the most common surgery for OSA. It is effective in selected patients failing conservative treatment. In Tonsillectomy, the benefit of the surgery increases with tonsil size. However, there is little randomized clinical trial evidence for other types of sleep surgery. There are many different procedures which may be performed, including:

Septoplasty is a corrective surgical procedure for nasal septum deviation in which the nasal septum is straightened.

Tonsillectomy or adenoidectomy in an attempt to increase the size of the airway.

Removal or reduction of parts of the soft palate and some or all of the uvula, such as uvulopalatopharyngoplasty (UPPP) or laser-assisted uvulopalatoplasty (LAUP). Modern variants of this procedure sometimes use radiofrequency waves to heat and remove tissue.

Turbinectomy is a surgical procedure in which all or some of the turbinate bones are removed to relieve nasal obstruction.

Reduction of the tongue base, either with laser excision or radiofrequency ablation.

Genioglossus advancement, in which a small portion of the lower jaw that attaches to the tongue is moved forward, to pull the tongue away from the back of the airway.

Hyoid suspension, in which the hyoid bone in the neck, another attachment point for tongue muscles, is pulled forward in front of the larynx.

Prognosis

Stroke and other cardiovascular diseases are related to OSA, and those under the age of 70 have an increased risk of early death. Persons with sleep apnea have a 30% higher risk of heart attack or death than those unaffected. In severe and prolonged cases, increased in pulmonary pressures are transmitted to the right side of the heart. This can result in a severe form of congestive heart failure known as cor pulmonale. Diastolic function of the heart also becomes affected. Elevated arterial pressure (i.e., hypertension) can be a consequence of OSA syndrome. When OSA causes hypertension, it is distinctive in that, unlike most cases (so-called essential hypertension), the readings do not drop significantly when the individual is sleeping (non-dipper) or even increase (inverted dipper).

Without treatment, the sleep deprivation and lack of oxygen caused by sleep apnea increases health risks such as cardiovascular disease, aortic disease (e.g., aortic aneurysm), high blood pressure, stroke, diabetes, clinical depression, weight gain, obesity, and even death.

OSA is associated with cognitive impairment, including deficits in inductive and deductive reasoning, attention, vigilance, learning, executive functions, and episodic and working memory. OSA is associated with increased risk for developing mild cognitive impairment and dementia, and has been associated with neuroanatomical changes (reductions in volumes of the hippocampus, and gray matter volume of the frontal and parietal lobes) which can however be at least in part reversed with CPAP treatment.

Epidemiology

Until the 1990s, little was known regarding the frequency of OSA. A recent meta-analysis of 24 epidemiological studies on the prevalence of OSA in the general population aged 18 and older revealed that for ≥ 5 apnea events per hour, OSA prevalence ranged from 9% to 38%, specifically ranging from 13% to 33% in men and 6% to 19% in women, while in the population aged 65 and older, OSA prevalence was as high as 84%, including 90% in men and 78% in women. Nevertheless, for ≥ 15 apnea events per hour, OSA prevalence ranged from 6% to 17%, and almost 49% prevalence in the older population aged 65 and older. Moreover, a higher BMI is also linked to a higher prevalence of OSA, where a 10% increase in body weight led to a 6-fold risk of OSA in obese men and women.

However, OSA is underdiagnosed as it is not always accompanied by daytime sleepiness which can leave the sleep-disordered breathing unnoticed. The prevalence of OSA with daytime sleepiness is thus estimated to affect 3% to 7% of men and 2% to 5% of women, and the disease is common in both developed and developing countries. OSA prevalence increases with age and is most commonly diagnosed in individuals over 65 years old, with estimations ranging from 22.1% to 83.6%. The prevalence has drastically increased in recent decades due to the incidence of obesity.

Men are more affected by OSA than women, but the phenomenology differs between the genders. Snoring and witnessed apnea are more frequent among men but insomnia for example is more frequent among women. The OSA frequency increase with age for the women, and is in particular linked to the onset of menopause and associated hormonal changes. The mortality is higher for women.

If studied carefully in a sleep lab by polysomnography (formal "sleep study"), it is believed that approximately 1 in 5 American adults would have at least mild OSA. In the US, some studies report that it is more frequent among the Hispanic and African American population than among the white population.

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