Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common sleep disorder in which the upper airway repeatedly narrows or becomes blocked during sleep. These interruptions in breathing can lower oxygen levels and disturb sleep, often without the person realizing it.

OSA can affect how we feel and function throughout the day. Common signs include loud snoring, gasping or pauses in breathing during sleep, and excessive daytime sleepiness. Some people also experience morning headaches, fatigue, or difficulty concentrating.

The good news is that OSA can be diagnosed and treated. Effective treatments can improve sleep quality and daytime wellbeing, while helping people manage the health risks associated with the condition.

This page focuses on adult OSA. Children and teens can also have OSA – see Sleep Apnea – Children and Teens.

During sleep, the muscles around our upper airway naturally relax. In people with OSA, this can cause the airway to become too narrow or temporarily blocked, reducing or stopping airflow.

When breathing is interrupted, the brain responds by briefly waking the person enough to restore normal breathing. These awakenings are often so short that they are not remembered. However, they can happen many times throughout the night, disrupting sleep and sometimes lowering oxygen levels.

Doctors measure the severity of OSA using the apnea-hypopnea index (AHI), which counts the average number of breathing interruptions per hour of sleep:

AHI below 5: Generally considered within the normal range

• Mild OSA: 5–14 events per hour
• Moderate OSA: 15–29 events per hour
• Severe OSA: 30 or more events per hour

The AHI is an important measure, but it doesn’t tell the whole story. Doctors also consider symptoms, oxygen levels, and other health conditions when deciding on appropriate treatment.

OSA symptoms vary from person to person. Some people experience noticeable breathing problems during sleep, while others mainly notice how they feel and function during the day.

Nighttime symptoms

Common nighttime signs of OSA include:

• Loud snoring: Frequent or disruptive snoring, sometimes interrupted by periods of silence.
  Breathing pauses: Breathing that repeatedly stops and starts, often noticed by a bed partner.
• Gasping or choking: Sudden gasping, choking, or snorting sounds as breathing resumes.
• Restless sleep: Frequent awakenings or movement during the night, sometimes without remembering waking up.
• Dry mouth or sore throat: Waking with a dry mouth or sore throat, often associated with breathing through the mouth.
• Waking short of breath: Suddenly waking with a feeling of breathlessness or needing to catch your breath

Not everyone who snores has OSA, and not everyone with OSA snores. A partner or family member may notice breathing interruptions before the person with OSA becomes aware of them.

Daytime symptoms

Repeated breathing interruptions can disrupt sleep and affect how we feel and function throughout the day. Common daytime symptoms include:

• Excessive daytime sleepiness: Feeling unusually sleepy during the day, even after spending enough time in bed.
• Fatigue and low energy: Feeling tired or lacking the energy needed for everyday activities.
• Difficulty concentrating: Problems with attention, memory, or decision-making.
• Mood changes: Increased irritability, low mood, or difficulty managing stress.
• Morning headaches: Headaches upon waking that often improve as the day progresses.
• Reduced daily functioning: Difficulty keeping up with work, social activities, or everyday responsibilities.

OSA cannot be diagnosed by symptoms alone. A sleep study is needed to confirm the diagnosis and understand the type and severity of sleep apnea.

Screening tools

Clinicians may use questionnaires to estimate the likelihood of OSA or daytime sleepiness. Examples include the STOP-Bang questionnaire, Epworth Sleepiness Scale, and Berlin Questionnaire. These tools can support decision-making, but they do not replace diagnostic testing. Diagnosis requires a sleep study or at-home sleep apnea test.

Sleep studies

An in-lab polysomnogram is an overnight sleep study performed in a sleep center. It records sleep stages, breathing, blood oxygen saturation levels, heart rhythm, body position, and movements. It can help diagnose OSA and identify other sleep disorders.

A home sleep apnea test is done at home with portable equipment. It usually measures breathing, oxygen levels, heart rate, and breathing effort. It can be appropriate for many adults when there is a strong suspicion of moderate to severe OSA and no major complicating conditions.

If a home test is negative, unclear, or does not match the person’s symptoms, further evaluation may be needed.

How to get help

A primary care physician is a good place to start for a sleep disorder evaluation. They can conduct preliminary screenings and recommend next steps for diagnosis. It can be helpful to bring information to an initial visit: try using WSCN’s Preparing to meet your new healthcare provider checklist.

Red flag: Seek emergency medical care if you experience severe shortness of breath, chest pain, fainting, sudden confusion, or new weakness or difficulty speaking.

Causes and risk factors

OSA develops when the upper airway repeatedly becomes too narrow or blocked during sleep. Several factors can increase the likelihood of this happening, and more than one may contribute. OSA can affect people of any age or body size.

Common risk factors include:

• Airway anatomy: A naturally narrow airway, a smaller or recessed jaw, or enlarged tissues around the throat can make the airway more likely to become blocked during sleep. Chronic nasal congestion can also contribute to breathing difficulties.
• Age and hormones: OSA becomes more common with age. Hormonal changes also influence risk, particularly in women after menopause.
• Body weight: Excess tissue around the upper airway can increase the risk of obstruction. However, people who are not overweight can also develop OSA.
• Family history: Having close relatives with OSA can increase your risk, partly because airway structure and other contributing traits can be inherited.
• Alcohol and certain medications: Alcohol and sedating medications can relax the muscles around the airway and make breathing interruptions worse. Opioid medications can also affect breathing during sleep.
• Sleeping position: For some people, sleeping on their back makes the airway more likely to become blocked. This is known as positional OSA.

How can OSA affect long-term health?

OSA does more than disrupt sleep. Repeated drops in oxygen levels and interruptions in breathing can place stress on the body. Over time, untreated OSA is associated with an increased risk of several health problems, including:

• Heart and blood vessel conditions: OSA can contribute to high blood pressure and is associated with heart disease, irregular heart rhythms such as atrial fibrillation, and stroke.
• Metabolic conditions: OSA is linked to insulin resistance, type 2 diabetes, and other problems with how the body regulates blood sugar.
• Brain and cognitive health: Research suggests that OSA is associated with problems involving memory and thinking. Scientists are also investigating possible connections with dementia, including Alzheimer’s disease.

These health risks vary between individuals and depend on several factors, including OSA severity and other existing health conditions. Effective treatment can improve breathing during sleep and reduce daytime symptoms. Managing OSA is also an important part of caring for overall health.

OSA treatment should be individualized. The goals are to improve breathing during sleep, reduce symptoms, support daytime function, lower safety risks, and address related health concerns.

OSA commonly occurs with other health conditions. Treating OSA does not guarantee prevention or reversal of other health conditions, but it can help in some circumstances.

Positive airway pressure therapy

Positive airway pressure, or PAP, is one of the most effective treatments for adult OSA, and is commonly the first treatment prescribed. PAP devices deliver pressurized air through a mask to help keep the airway open during sleep.

Types of PAP may include:

• CPAP: continuous positive airway pressure
• APAP: auto-adjusting positive airway pressure
• BiPAP or bilevel PAP: two pressure levels, used in select situations

PAP can reduce apnea/hypopnea events, improve oxygen levels, reduce snoring, and improve daytime alertness and quality of life for many people.

Some people adjust quickly to PAP therapy, while others need time and support to get comfortable. Common challenges include mask discomfort, air leaks, dryness, or difficulty tolerating the air pressure. Adjusting the mask, using a humidifier, or changing pressure settings can often help. Education and peer support can also make it easier to use PAP successfully over time.

Oral appliance therapy

Oral appliances may be an option for adults who cannot tolerate PAP therapy or prefer an alternative. They are often used for mild to moderate OSA, but may also be considered for some people with more severe OSA. A qualified dental sleep medicine provider should fit and monitor the device. Over-the-counter mouthguards are not a substitute for custom-made oral appliances designed to treat OSA.

Positional therapy

Some people have OSA mainly when sleeping on their back. Positional therapy uses pillows or other positioning devices to help the person sleep on their side or avoid back-sleeping. It may be helpful when sleep testing shows that OSA is strongly position-dependent, but it may not be enough for all people.

Weight loss support

For some people, weight loss can reduce the severity of OSA and improve symptoms. Depending on individual needs, treatment may include nutritional support, physical activity, behavioral approaches, or weight-management medications.

In December 2024, the U.S. Food and Drug Administration (FDA) approved tirzepatide (Zepbound) for moderate to severe OSA in adults with obesity, alongside a reduced-calorie diet and increased physical activity. This offers another treatment option for eligible patients.

Weight management should be individualized and supported by a healthcare professional. Even after significant weight loss, some people continue to need PAP therapy, an oral appliance, or another OSA treatment. OSA also affects people who are not overweight.

Surgery and hypoglossal nerve stimulation

Surgery may be an option when the structure of the upper airway contributes to OSA or when other treatments are not suitable or effective. Depending on the individual, procedures may involve removing or repositioning tissue that blocks the airway or adjusting the position of the jaw. The choice depends on the person’s anatomy and a specialist evaluation.

Hypoglossal nerve stimulation is an implanted treatment for selected adults with moderate to severe OSA who cannot tolerate PAP and meet specific clinical criteria. It works by stimulating muscles that help move the tongue forward during sleep.

Follow-up sleep testing is often needed after surgery or implanted therapy to assess whether OSA has improved.

Living with OSA and management over time

OSA treatment sometimes needs adjustments to remain comfortable and effective. Regular follow-up with a healthcare professional can help identify problems and determine whether changes to treatment are needed. Paying attention to symptoms and treatment experiences can also help. Useful things to track include:

• Sleep patterns: Bedtimes, wake times, and nighttime symptoms such as snoring or gasping.
• Daytime wellbeing: Sleepiness, fatigue, morning headaches, mood, and concentration.
• Treatment use: How regularly PAP therapy or an oral appliance is used and any difficulties with treatment.
• Daily habits: Changes in caffeine or alcohol consumption, medication use, and napping.
• Changes in health, body weight, or medications can affect treatment needs over time. Working with your healthcare team can help ensure that treatment continues to support better sleep and daytime wellbeing.

Research into OSA continues to improve our understanding of why the condition affects people differently and which treatments work best for each person.

Scientists are exploring new ways to treat OSA, including medications that target some of its underlying causes. Researchers are also studying how to make existing treatments more comfortable and effective, and how treating OSA affects long-term health.

These advances could lead to more personalized treatment options, helping people find approaches that work better for their individual needs.