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Obstructive Sleep Apnea

Obstructive sleep apnea occurs when the upper airway repeatedly narrows or closes during sleep, disrupting sleep quality and breathing.[1]

Medical illustration of obstructive sleep apnea: a person lying on their back with the tongue and soft palate falling backward and blocking the airway
What happens in the airway. During normal sleep the throat muscles keep the airway open. In OSA, relaxed tissue collapses into the airway — breathing pauses, oxygen dips, and the brain briefly wakes you to reopen it, sometimes hundreds of times a night. Illustration via Wikimedia Commons (free license — see file page for author credit).

Common symptoms

  • Loud snoring, choking, or gasping during sleep
  • Witnessed pauses in breathing
  • Morning headaches, dry mouth, or unrefreshing sleep
  • Daytime sleepiness, fatigue, poor concentration, or irritability

Evaluation basics

Testing may include a home sleep apnea test or an in-lab polysomnography, depending on symptoms, medical history, and clinical context.[1]

Self-assessment

Do you have risk factors for obstructive sleep apnea?

The STOP-Bang questionnaire is a validated screening tool that estimates risk for obstructive sleep apnea.[2,3] It does not diagnose sleep apnea. A sleep study is needed to diagnose OSA.

S — Snoring: Do you snore loudly, louder than talking or loud enough to be heard through closed doors?

T — Tired: Do you often feel tired, fatigued, or sleepy during the daytime?

O — Observed: Has anyone observed you stop breathing, choke, or gasp during sleep?

P — Pressure: Do you have, or are you being treated for, high blood pressure?

B — BMI: Is your body mass index greater than 35 kg/m²?

A — Age: Are you older than 50?

N — Neck: Is your neck circumference greater than 16 inches / 40 cm?

G — Gender: Were you assigned male at birth?

Your result will appear here

Answer the questions above to estimate your OSA risk category.

Source: STOP-Bang questionnaire scoring categorizes 0–2 as low risk, 3–4 as intermediate risk, and 5–8 as high risk for obstructive sleep apnea in the general population.

STOP-Bang official scoring reference →
Sleepiness Assessment

Epworth Sleepiness Scale (ESS)

The Epworth Sleepiness Scale measures your general level of daytime sleepiness by asking how likely you are to doze off in 8 everyday situations.[7] Rate each situation from 0 (would never doze) to 3 (high chance of dozing). This does not diagnose a sleep disorder — it helps identify excessive sleepiness.

Sitting and reading

Watching TV

Sitting inactive in a public place (e.g., meeting, theater)

As a passenger in a car for an hour without a break

Lying down to rest in the afternoon

Sitting and talking to someone

Sitting quietly after a lunch without alcohol

In a car, while stopped for a few minutes in traffic

Your ESS score will appear here

0 = would never doze · 1 = slight chance · 2 = moderate chance · 3 = high chance

Scoring: 0–9 = normal daytime sleepiness · 10–15 = mild to moderate excessive sleepiness · 16–24 = severe excessive sleepiness. A score ≥ 10 suggests you should discuss your symptoms with a clinician.[7]

Risk factors

  • Obesity (BMI > 30 kg/m²) is the strongest modifiable risk factor[6]
  • Male sex and older age increase risk[2]
  • Large neck circumference (>17 inches in men, >16 inches in women)
  • Craniofacial features (retrognathia, enlarged tonsils, narrow airway)
  • Family history of sleep apnea
  • Nasal congestion, smoking, alcohol use near bedtime

Health consequences if untreated

Untreated OSA is associated with increased risk of hypertension, atrial fibrillation, heart failure, stroke, type 2 diabetes, motor vehicle accidents, and impaired quality of life.[6]

Evaluation

How is sleep apnea diagnosed?

OSA diagnosis requires a sleep study. Screening tools like STOP-Bang estimate risk, but a sleep study is needed to confirm the diagnosis and determine severity.[1]

Home sleep apnea test (HSAT)
  • A portable device worn at home during one or more nights of sleep.
  • Typically measures airflow (nasal cannula), breathing effort (chest belt), oxygen saturation (finger probe), and body position.
  • Appropriate for patients with a high pretest probability of moderate-to-severe OSA without significant comorbidities.[1]
  • Does not measure sleep stages, so it cannot detect sleep fragmentation or distinguish sleep from wakefulness.
  • A negative or inconclusive HSAT does not rule out OSA — in-lab polysomnography may be needed.
In-lab polysomnography (PSG)
  • An overnight monitored study in a sleep laboratory, considered the gold standard for diagnosing sleep disorders.[1]
  • Measures brain activity (EEG), eye movements (EOG), muscle tone (EMG), airflow, breathing effort, oxygen saturation, heart rhythm (ECG), leg movements, body position, and snoring.
  • Determines the apnea-hypopnea index (AHI), which counts how many times breathing pauses or becomes shallow per hour of sleep.
  • OSA severity: mild (AHI 5–14), moderate (AHI 15–29), severe (AHI ≥ 30).[1]
  • Recommended when HSAT is negative or inconclusive, or when other sleep disorders (e.g., central sleep apnea, narcolepsy, parasomnias) are suspected.
Treatment

Treatment options for OSA

Treatment depends on severity, symptoms, anatomy, preferences, and other medical conditions. The goal is to keep the airway open during sleep, improve sleep quality, and reduce health risks.

Positive airway pressure (PAP)

PAP therapy is the first-line treatment for moderate-to-severe OSA.[4] A machine delivers pressurized air through a mask worn during sleep, keeping the airway open.

  • CPAP (continuous positive airway pressure) delivers a fixed pressure throughout the night.
  • APAP (auto-adjusting PAP) automatically adjusts pressure within a set range based on detected events.
  • BiPAP (bilevel PAP) provides higher pressure during inhalation and lower pressure during exhalation, sometimes used for comfort or certain conditions.
  • Mask types include nasal, nasal pillow, and full-face masks. Finding the right fit is important for comfort and adherence.

Oral appliance therapy

Custom-fitted dental devices (mandibular advancement devices) hold the lower jaw forward during sleep, opening the airway.[5]

  • An option for mild-to-moderate OSA, or for patients who cannot tolerate PAP.
  • Must be custom-fitted by a qualified dentist, not over-the-counter devices.
  • Follow-up sleep testing is recommended to confirm effectiveness.
  • Side effects may include jaw discomfort, bite changes, or excess salivation.

Lifestyle and behavioral

  • Weight loss: Even modest weight loss (10–15%) can improve AHI and symptoms in overweight patients.[6]
  • Positional therapy: Sleeping on one's side instead of the back can reduce events in position-dependent OSA.
  • Alcohol and sedatives: Avoiding alcohol and sedating medications near bedtime can reduce airway collapse.
  • Sleep hygiene: Maintaining regular sleep schedules and adequate sleep duration.

Surgical and procedural

  • Tonsillectomy/adenoidectomy: Often first-line in children; considered in adults with large tonsils.
  • Hypoglossal nerve stimulation: An implanted device that stimulates the tongue muscle during sleep (for selected patients who cannot use PAP).[6]
  • Uvulopalatopharyngoplasty (UPPP): Soft tissue surgery to widen the airway.
  • Maxillomandibular advancement: Jaw surgery for selected cases with craniofacial contributors.
Detailed guide to CPAP alternatives →

Trusted resources

Learn more from AASM Sleep Education.

AASM: Obstructive Sleep Apnea →

Related topics

Drowsy driving can be dangerous. If sleepiness affects driving or safety, seek medical advice promptly.

References

  1. Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13(3):479-504. doi:10.5664/jcsm.6506
  2. Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108(5):812-821. doi:10.1097/ALN.0b013e31816d83e4
  3. Chung F, Subramanyam R, Liao P, et al. High STOP-Bang score indicates a high probability of obstructive sleep apnoea. Br J Anaesth. 2012;108(5):768-775. doi:10.1093/bja/aes022
  4. Patil SP, Ayappa IA, Caples SM, Kimoff RJ, Patel SR, Harrod CG. Treatment of adult obstructive sleep apnea with positive airway pressure: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2019;15(2):335-343. doi:10.5664/jcsm.7640
  5. Ramar K, Dort LC, Katz SG, et al. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med. 2015;11(7):773-827. doi:10.5664/jcsm.4858
  6. Epstein LJ, Kristo D, Strollo PJ Jr, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009;5(3):263-276. doi:10.5664/jcsm.27497
  7. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991;14(6):540-545. doi:10.1093/sleep/14.6.540