Sleep apnoea (obstructive sleep apnoea, OSA)

Sleep apnoea means the breathing repeatedly stops while you are asleep. The soft tissues of the throat collapse as you breathe in, the airflow stops, the oxygen level in the blood drops, and the brain jolts you briefly out of deep sleep so that you take a breath. This can happen dozens or even hundreds of times a night, and hardly any of those arousals are remembered in the morning. Hence the paradox: someone is certain they slept for eight hours and still wakes up as though they never went to bed. The commonest form is the obstructive one, which is where the abbreviation OSA comes from. The key point is that this is not just loud snoring and not a personality trait. Left untreated for years, sleep apnoea keeps blood pressure high, unsettles the heart rhythm, worsens blood sugar control and makes a person dangerous behind the wheel.

What is heard at night and what is felt in the morning

The night-time half of the picture is invisible to the person it happens to: it is seen and heard by whoever sleeps beside them. From the outside it looks like this. The snoring is not steady but broken up; it suddenly stops dead for ten, twenty or thirty seconds while the chest carries on moving, and then comes a sharp gasp, as if the sleeper had choked and started breathing again. Sometimes they can be seen tossing about and changing position.

The person themselves comes to the doctor with quite different complaints:

• waking up wrung out, as though the night had never happened, however many hours were spent in bed;
• a headache immediately on waking, usually dull, easing after an hour or two;
• a dry mouth and a raw throat first thing;
• waking in the night with a pounding heart, a feeling of not getting enough air, or a start of fright;
• getting up to pass urine two or three times a night;
• daytime sleepiness: on public transport, in meetings, in front of the television;
• irritability, slow thinking, forgetfulness, low mood;
• reduced sex drive and, in men, erection problems.

If there is someone who can observe you, ask them to listen for a night or to record a few minutes of your sleep on a phone. A witness at the appointment saves months: the complaint "he stops breathing" and the complaint "I sleep badly" send a doctor down different paths.

Why this is a condition and not a quirk

Every pause in breathing means a dip in oxygen and a surge of stress hormones. Night after night the body spends its hours on alert, and the consequences add up:

• high blood pressure, including the kind that responds poorly to medication: the pressure fails to fall overnight as it should and is still high on waking;
• a raised risk of heart attack and stroke;
• rhythm disturbances such as atrial fibrillation, and pauses or slowing of the pulse at night; after an arrhythmia has been treated it comes back more often if the apnoea has been ignored;
• a worse course of heart failure;
• increasing insulin resistance and poorer control of type 2 diabetes;
• depression, anxiety and reduced performance at work;
• a higher risk of complications under anaesthetic, so the anaesthetist should be told about the apnoea in advance.

And one thing that is rarely said out loud: untreated apnoea wears out more than one person. A partner spends years not sleeping properly beside that snoring, couples end up in separate rooms, and treatment here mends considerably more than blood vessels.

Behind the wheel, other lives are at stake too

This needs saying plainly. The daytime sleepiness of sleep apnoea is not "feeling a bit drowsy" but sudden microsleeps lasting a few seconds that the person does not notice in themselves. At 90 km/h, four seconds is a hundred metres driven blind. A driver with untreated severe apnoea has a substantially raised risk of a crash, and they are not the only one who pays for it.

The practical rules are simple. Until the sleepiness is under control, do not drive, least of all on long journeys or at night. If your eyes start to close on the road, the only thing that works is pulling over and sleeping for twenty minutes; coffee, an open window and loud music push sleep back by a few minutes at most and create the false impression that you are coping. In most countries a driver has to report a confirmed diagnosis to the authority that issues the licence, and the requirements are stricter for professional drivers, so find out how this works where you live. The good news is that once treatment is working the sleepiness goes and driving is usually allowed again.

Why the throat closes in your particular case

• excess weight, especially fat around the neck and in the tongue; neck circumference says more than the number on the scales;
• being male, and age; in women, the years after the menopause, when the risk catches up with men's;
• anatomy: a small or set-back lower jaw, a large tongue, a narrow throat, a deviated septum and a chronically blocked nose;
• large tonsils and adenoids, which are the main cause in children; the picture in children is different, with snoring and pauses, mouth breathing and restless sleep, and by day not sleepiness but overactivity and difficulties at school;
• alcohol in the evening, sleeping tablets, tranquillisers and opioid painkillers, all of which relax the throat muscles;
• smoking, through swelling of the lining of the airway;
• sleeping on your back, when the tongue falls backwards;
• an underactive thyroid and, rarely, acromegaly;
• a family tendency.

A rarer form deserves separate mention: central sleep apnoea. Here the airway stays open, but the brain stops sending the command to breathe for a while, and the chest does not move at all during the pause. It occurs in heart failure, after a stroke and in people taking opioids long term. The mechanism is different and so is the treatment, which is another reason a sleep study is needed.

The diagnosis is made with a sleep study

Apnoea is neither confirmed nor ruled out by looking at someone: a great many people snore without ever stopping breathing, and severe apnoea turns up in slim, almost silent sleepers. Sleepiness questionnaires are a way of deciding who should be investigated, not a diagnosis.

The study itself is usually done at home. You are given a small device to wear overnight that records airflow, chest movements, blood oxygen levels and pulse, and you return it in the morning. A full recording in a sleep laboratory, with electrodes on the head so that the stages of sleep can be seen as well, is kept for unclear cases or when another sleep disorder is suspected.

Severity is graded by the number of pauses and partial reductions in breathing per hour of sleep: roughly five to fifteen is mild, fifteen to thirty is moderate, and more than thirty is severe. The number matters, but the decision does not rest on it alone: with marked sleepiness, high blood pressure or an arrhythmia, treatment is started even at intermediate values.

CPAP works, but it is used badly

CPAP is a machine that delivers air at low pressure through a mask and stops the throat collapsing. In moderate and severe apnoea it is the most reliable treatment: the snoring and the pauses disappear on the very first night, and within a few weeks the daytime sleepiness and the morning headaches usually go too, while blood pressure is easier to control.

The difficulty lies elsewhere: a substantial proportion of people abandon the machine within the first months. The reasons are nearly always the same, and nearly all of them can be fixed:

• the mask presses or rubs, which almost always means the wrong size or the wrong type; there are several designs and getting it right takes a couple of fittings;
• air leaks round the edges, which again is a matter of fit rather than something to be endured;
• a dry nose and throat or minor nosebleeds, for which the humidifier is switched on or added and any nasal blockage is treated;
• difficulty breathing out against the flow, which is solved by setting a ramp so that the pressure rises gradually as you fall asleep;
• it feels strange and sleep will not come; the first weeks genuinely are hard, and it helps to wear the mask for an hour or two in the evening in front of the television, before going to bed.

The main rule is not to give up quietly. If the machine is not working out, go back to the sleep service and say so: almost everything is sorted out by adjustment and by trying alternatives. And CPAP only works on the nights it is worn, so it should be used every night and all night, including daytime naps and trips away.

What else helps, and what to expect honestly

Losing weight genuinely reduces the number of pauses and can sometimes turn a severe form into a mild one. But it cannot be promised as a replacement for treatment: in some people apnoea persists at a normal weight, and no diet changes the shape of the jaw and throat. Losing weight is worth doing; relying on it alone is not.

Sleeping on your side helps those whose pauses happen mainly on their back, which shows up on the sleep study recording. There are pillows and belts that make it hard to roll over. The advice to sew a tennis ball into your pyjamas has been circulating online for decades, but few people last more than a week sleeping like that.

A mandibular advancement splint, which holds the lower jaw forward, is a sensible alternative in mild and moderate apnoea and for people who cannot tolerate CPAP. It is made to measure by a dentist from an impression; the one-size-fits-all versions sold over the counter are useless.

Surgery does not suit everyone. In children, removing enlarged tonsils and adenoids often solves the problem completely. In adults, nasal surgery rarely cures apnoea, although it makes the mask far easier to tolerate, and operations on the soft palate give inconsistent results. There are also techniques such as hypoglossal nerve stimulation, which is specialist territory and is discussed with the sleep team.

Whatever is chosen, evening alcohol, unprescribed sleeping tablets and smoking work against the treatment, while a regular sleep schedule works for it.

Online consultation

A remote appointment covers the first step well: working out whether this looks like apnoea and whether a sleep study is needed. The doctor will go through exactly what your family hear at night, assess the daytime sleepiness, gather the risk factors and other conditions, and explain which tests are done at home, which need a sleep laboratory and how to prepare for them. It is particularly worthwhile for anyone who has already started treatment and cannot settle into it: an uncomfortable mask, dryness, being unable to fall asleep. All of that can be worked through in conversation, and there is nearly always something to put right. Driving and preparing for planned surgery can be discussed as well. The sleep study itself and the pressure settings, however, are done in person: a diagnosis is not made by message.

This material is for information only and does not replace medical advice.