Sleep apnea

The typical screening process for sleep apnea involves asking patients about common symptoms such as snoring, witnessed pauses in breathing during sleep and excessive daytime sleepiness. There is a wide range in presenting symptoms in patients with sleep apnea, from being asymptomatic to falling asleep while driving. Due to this wide range in clinical presentation, some people are not aware that they have sleep apnea and are either misdiagnosed or ignore the symptoms altogether.{{cite journal |vauthors=El-Ad B, Lavie P |date=August 2005 |title=Effect of sleep apnea on cognition and mood |journal=International Review of Psychiatry |volume=17 |issue=4 |pages=277–82 |doi=10.1080/09540260500104508 |pmid=16194800 |s2cid=7527654}} A current area requiring further study involves identifying different subtypes of sleep apnea based on patients who tend to present with different clusters or groupings of particular symptoms.

OSA may increase risk for driving accidents and work-related accidents due to sleep fragmentation from repeated arousals during sleep. If OSA is not treated it results in excessive daytime sleepiness and oxidative stress from the repeated drops in oxygen saturation, people are at increased risk of other systemic health problems, such as diabetes, hypertension or cardiovascular disease. Subtle manifestations of sleep apnea may include treatment refractory hypertension and cardiac arrhythmias and over time as the disease progresses, more obvious symptoms may become apparent. Due to the disruption in daytime cognitive state, behavioral effects may be present. These can include moodiness, belligerence, as well as a decrease in attentiveness and energy.{{cite journal |vauthors=Aloia MS, Sweet LH, Jerskey BA, Zimmerman M, Arnedt JT, Millman RP |date=December 2009 |title=Treatment effects on brain activity during a working memory task in obstructive sleep apnea |journal=Journal of Sleep Research |volume=18 |issue=4 |pages=404–10 |doi=10.1111/j.1365-2869.2009.00755.x |pmid=19765205 |s2cid=15806274 |hdl-access=free |hdl=2027.42/73986}} These effects may become intractable, leading to depression.{{cite journal |vauthors=Sculthorpe LD, Douglass AB |date=July 2010 |title=Sleep pathologies in depression and the clinical utility of polysomnography |url=https://nrc-publications.canada.ca/eng/view/accepted/?id=31e80401-0de8-408d-90c5-1a593b660ea8 |url-status=live |journal=Canadian Journal of Psychiatry |volume=55 |issue=7 |pages=413–21 |doi=10.1177/070674371005500704 |pmid=20704768 |archive-url=https://web.archive.org/web/20240210170911/https://nrc-publications.canada.ca/eng/view/accepted/?id=31e80401-0de8-408d-90c5-1a593b660ea8 |archive-date=10 February 2024 |access-date=6 December 2023 |doi-access=free}}

Obstructive sleep apnea can affect people regardless of sex, race, or age.{{cite journal |vauthors=Rundo JV |date=2019 |title=Obstructive sleep apnea basics |url=https://www.ccjm.org/content/86/9_suppl_1/2 |url-status=live |journal=Cleveland Clinic Journal of Medicine |volume=86 |issue=9 Suppl 1 |pages=2–9 |doi=10.3949/ccjm.86.s1.02 |pmid=31509498 |archive-url=https://web.archive.org/web/20240206230109/https://www.ccjm.org/content/86/9_suppl_1/2 |archive-date=6 February 2024 |access-date=6 February 2024 |doi-access=free}} However, risk factors include:{{cite web |date=24 March 2022 |title=Sleep Apnea – Causes and Risk Factors {{pipe}} NHLBI, NIH |url=https://www.nhlbi.nih.gov/health/sleep-apnea/causes |url-status=live |archive-url=https://web.archive.org/web/20240206230109/https://www.nhlbi.nih.gov/health/sleep-apnea/causes |archive-date=6 February 2024 |access-date=6 February 2024}}

{{cols|colwidth=24em}}

• male sex{{cite web |title=Risk Factors |url=https://sleep.hms.harvard.edu/education-training/public-education/sleep-and-health-education-program/sleep-health-education-25 |url-status=live |archive-url=https://web.archive.org/web/20240206230110/https://sleep.hms.harvard.edu/education-training/public-education/sleep-and-health-education-program/sleep-health-education-25 |archive-date=6 February 2024 |access-date=6 February 2024}}
• obesity
• age over 40
• large neck circumference
• enlarged tonsils or tongue
• narrow upper jaw
• small lower jaw
• tongue fat/tongue scalloping
• a family history of sleep apnea
• endocrine disorders such as hypothyroidism
• lifestyle habits such as smoking or drinking alcohol

{{colend}}

Central sleep apnea is more often associated with any of the following risk factors:

• transition period from wakefulness to non-REM sleep
• older age
• heart failure
• atrial fibrillation
• stroke
• spinal cord injury

Obstructive sleep apnea

The causes of obstructive sleep apnea are complex and individualized, but typical risk factors include narrow pharyngeal anatomy and craniofacial structure. When anatomical risk factors are combined with non-anatomical contributors such as an ineffective pharyngeal dilator muscle function during sleep, unstable control of breathing (high loop gain), and premature awakening to mild airway narrowing, the severity of the OSA rapidly increases as more factors are present. When breathing is paused due to upper airway obstruction, carbon dioxide builds up in the bloodstream. Chemoreceptors in the bloodstream note the high carbon dioxide levels. The brain is signaled to awaken the person, which clears the airway and allows breathing to resume. Breathing normally will restore oxygen levels and the person will fall asleep again.{{cite book |last=Green |first=Simon |title=Biological Rhythms, Sleep and Hyponosis |date=8 February 2011 |publisher=Palgrave Macmillan |isbn=978-0-230-25265-3 |location=England |page=85}} This carbon dioxide build-up may be due to the decrease of output of the brainstem regulating the chest wall or pharyngeal muscles, which causes the pharynx to collapse.{{cite book |last=Purves |first=Dale |title=Neuroscience |date=4 July 2018 |publisher=Oxford University Press |isbn=978-1-60535-380-7 |edition=Sixth |location=New York |oclc=990257568}}{{page needed|date=March 2021}} As a result, people with sleep apnea experience reduced or no slow-wave sleep and spend less time in REM sleep.

Central sleep apnea

There are two main mechanism that drive the disease process of CSA, sleep-related hypoventilation and post-hyperventilation hypocapnia. The most common cause of CSA is post-hyperventilation hypocapnia secondary to heart failure. This occurs because of brief failures of the ventilatory control system but normal alveolar ventilation. In contrast, sleep-related hypoventilation occurs when there is a malfunction of the brain's drive to breathe. The underlying cause of the loss of the wakefulness drive to breathe encompasses a broad set of diseases from strokes to severe kyphoscoliosis.

OSA is a serious medical condition with systemic effects; patients with untreated OSA have a greater mortality risk from cardiovascular disease than those undergoing appropriate treatment.{{Cite journal |last1=Das |first1=Aneesa M. |last2=Chang |first2=Judy L. |last3=Berneking |first3=Michael |last4=Hartenbaum |first4=Natalie P. |last5=Rosekind |first5=Mark |last6=Ramar |first6=Kannan |last7=Malhotra |first7=Raman K. |last8=Carden |first8=Kelly A. |last9=Martin |first9=Jennifer L. |last10=Abbasi-Feinberg |first10=Fariha |last11=Nisha Aurora |first11=R. |last12=Kapur |first12=Vishesh K. |last13=Olson |first13=Eric J. |last14=Rosen |first14=Carol L. |last15=Rowley |first15=James A. |date=2022-10-01 |title=Enhancing public health and safety by diagnosing and treating obstructive sleep apnea in the transportation industry: an American Academy of Sleep Medicine position statement |journal=Journal of Clinical Sleep Medicine |language=en |volume=18 |issue=10 |pages=2467–2470 |doi=10.5664/jcsm.9670 |issn=1550-9389 |pmc=9516580 |pmid=34534065}} Other complications include hypertension, congestive heart failure, atrial fibrillation, coronary artery disease, stroke, and type 2 diabetes. Daytime fatigue and sleepiness, a common symptom of sleep apnea, is also an important public health concern regarding transportation crashes caused by drowsiness. OSA may also be a risk factor of COVID-19. People with OSA have a higher risk of developing severe complications of COVID-19.{{cite web |title=Obstructive sleep apnea – Symptoms and causes |url=https://www.mayoclinic.org/diseases-conditions/obstructive-sleep-apnea/symptoms-causes/syc-20352090 |url-status=live |archive-url=https://web.archive.org/web/20190811195722/https://www.mayoclinic.org/diseases-conditions/obstructive-sleep-apnea/symptoms-causes/syc-20352090 |archive-date=11 August 2019 |access-date=30 March 2022 |website=Mayo Clinic |language=en}}

Alzheimer's disease and severe obstructive sleep apnea are connected{{cite journal |last1=Andrade |first1=A. |last2=Bubu |first2=O. M. |last3=Varga |first3=A. W. |last4=Osorio |first4=R. S. |year=2018 |title=The relationship between Obstructive Sleep Apnea and Alzheimer's Disease |journal=Journal of Alzheimer's Disease |volume=64 |issue=Suppl 1 |pages=S255–S270 |doi=10.3233/JAD-179936 |pmc=6542637 |pmid=29782319}} because there is an increase in the protein beta-amyloid as well as white-matter damage. These are the main indicators of Alzheimer's, which in this case comes from the lack of proper rest or poorer sleep efficiency resulting in neurodegeneration.{{cite journal |last1=Jackson |first1=Melinda L. |last2=Cavuoto |first2=Marina |last3=Schembri |first3=Rachel |last4=Doré |first4=Vincent |last5=Villemagne |first5=Victor L. |last6=Barnes |first6=Maree |last7=O'Donoghue |first7=Fergal J. |last8=Rowe |first8=Christopher C. |last9=Robinson |first9=Stephen R. |title=Severe Obstructive Sleep Apnea Is Associated with Higher Brain Amyloid Burden: A Preliminary PET Imaging Study |journal=Journal of Alzheimer's Disease |date=10 November 2020 |volume=78 |issue=2 |pages=611–617 |doi=10.3233/JAD-200571 |pmid=33016907 |s2cid=222145149 |url=https://www.sciencedaily.com/releases/2020/11/201111104918.htm |url-access=subscription |access-date=26 February 2021 |archive-date=28 January 2021 |archive-url=https://web.archive.org/web/20210128005317/https://www.sciencedaily.com/releases/2020/11/201111104918.htm |url-status=live }}{{cite journal |last1=Weihs |first1=Antoine |last2=Frenzel |first2=Stefan |last3=Grabe |first3=Hans J. |date=13 July 2021 |title=The Link Between Obstructive Sleep Apnoea and Neurodegeneration and Cognition |url=https://pub.dzne.de/record/155442/files/19530.pdf |url-status=live |journal=Current Sleep Medicine Reports |publisher=Springer Science and Business Media LLC |volume=7 |issue=3 |pages=87–96 |doi=10.1007/s40675-021-00210-5 |issn=2198-6401 |s2cid=235801219 |archive-url=https://web.archive.org/web/20240206225000/https://pub.dzne.de/record/155442/files/19530.pdf |archive-date=6 February 2024 |access-date=6 February 2024 |doi-access=free}}{{cite journal |last1=Lee |first1=Min-Hee |last2=Lee |first2=Seung Ku |last3=Kim |first3=Soriul |last4=Kim |first4=Regina E. Y. |last5=Nam |first5=Hye Ryeong |last6=Siddiquee |first6=Ali T. |last7=Thomas |first7=Robert J. |last8=Hwang |first8=Inha |last9=Yoon |first9=Jee-Eun |last10=Yun |first10=Chang-Ho |last11=Shin |first11=Chol |date=20 July 2022 |title=Association of Obstructive Sleep Apnea With White Matter Integrity and Cognitive Performance Over a 4-Year Period in Middle to Late Adulthood |journal=JAMA Network Open |volume=5 |issue=7 |pages=e2222999 |doi=10.1001/jamanetworkopen.2022.22999 |pmc=9301517 |pmid=35857321 }} Having sleep apnea in mid-life brings a higher likelihood of developing Alzheimer's in older age, and if one has Alzheimer's then one is also more likely to have sleep apnea.{{cite journal |last1=Owen |first1=Jessica E |last2=Benediktsdottir |first2=Bryndis |last3=Cook |first3=Elizabeth |last4=Olafsson |first4=Isleifur |last5=Gislason |first5=Thorarinn |last6=Robinson |first6=Stephen R |title=Alzheimer's disease neuropathology in the hippocampus and brainstem of people with obstructive sleep apnea |journal=Sleep |date=21 September 2020 |volume=44 |issue=3 |pages=zsaa195 |doi=10.1093/sleep/zsaa195 |pmid=32954401 |url=https://www.sciencedaily.com/releases/2020/09/200928103416.htm |doi-access=free |access-date=1 March 2021 |archive-date=20 November 2020 |archive-url=https://web.archive.org/web/20201120140234/https://www.sciencedaily.com/releases/2020/09/200928103416.htm |url-status=live }} This is demonstrated by cases of sleep apnea even being misdiagnosed as dementia.{{cite news |first=Paul |last=Span |date=6 October 2010 |title=When Sleep Apnea Masquerades as Dementia |url=https://newoldage.blogs.nytimes.com/2010/10/06/when-sleep-apnea-masquerades-as-dementia/ |work=New York Times |url-status=live |archive-url=https://web.archive.org/web/20210309174427/https://newoldage.blogs.nytimes.com/2010/10/06/when-sleep-apnea-masquerades-as-dementia/ |archive-date=9 March 2021 |access-date=1 March 2021}} With the use of treatment through CPAP, there is a reversible risk factor in terms of the amyloid proteins. This usually restores brain structure and cognitive impairment.{{cite journal |last1=Liguori |first1=Claudio |last2=Chiaravalloti |first2=Agostino |last3=Izzi |first3=Francesca |last4=Nuccetelli |first4=Marzia |last5=Bernardini |first5=Sergio |last6=Schillaci |first6=Orazio |last7=Mercuri |first7=Nicola Biagio |last8=Placidi |first8=Fabio |date=1 December 2017 |title=Sleep apnoeas may represent a reversible risk factor for amyloid-β pathology |journal=Brain |volume=140 |issue=12 |pages=e75 |doi=10.1093/brain/awx281 |pmid=29077794 |doi-access=free}}{{cite journal |last1=Castronovo |first1=Vincenza |last2=Scifo |first2=Paola |last3=Castellano |first3=Antonella |last4=Aloia |first4=Mark S. |last5=Iadanza |first5=Antonella |last6=Marelli |first6=Sara |last7=Cappa |first7=Stefano F. |last8=Strambi |first8=Luigi Ferini |last9=Falini |first9=Andrea |date=1 September 2014 |title=White Matter Integrity in Obstructive Sleep Apnea before and after Treatment |url=https://aasm.org/brain-damage-caused-by-severe-sleep-apnea-is-reversible/ |url-status=live |journal=Sleep |volume=37 |issue=9 |pages=1465–1475 |doi=10.5665/sleep.3994 |pmc=4153061 |pmid=25142557 |archive-url=https://web.archive.org/web/20210304122831/https://aasm.org/brain-damage-caused-by-severe-sleep-apnea-is-reversible/ |archive-date=4 March 2021 |access-date=1 March 2021}}{{cite journal |last1=Cooke |first1=Jana R. |last2=Ayalon |first2=Liat |last3=Palmer |first3=Barton W. |last4=Loredo |first4=Jose S. |last5=Corey-Bloom |first5=Jody |last6=Natarajan |first6=Loki |last7=Liu |first7=Lianqi |last8=Ancoli-Israel |first8=Sonia |date=15 August 2009 |title=Sustained Use of CPAP Slows Deterioration of Cognition, Sleep, and Mood in Patients with Alzheimer's Disease and Obstructive Sleep Apnea: A Preliminary Study |journal=Journal of Clinical Sleep Medicine |publisher=American Academy of Sleep Medicine (AASM) |volume=05 |issue=4 |pages=305–309 |doi=10.5664/jcsm.27538 |issn=1550-9389 |s2cid=24123888 |doi-access=free}} Evidence continues to be found supporting there is an association between BMI and Alzheimer's.{{Cite journal |last1=Lee |first1=Eun Hye |last2=Yoo |first2=Heejin |last3=Kim |first3=Young Ju |last4=Cheon |first4=Bo Kyoung |last5=Ryu |first5=Seungho |last6=Chang |first6=Yoosoo |last7=Yun |first7=Jihwan |last8=Jang |first8=Hyemin |last9=Kim |first9=Jun Pyo |last10=Kim |first10=Hee Jin |last11=Koh |first11=Seong-Beom |last12=Jeong |first12=Jee Hyang |last13=Na |first13=Duk L. |last14=Seo |first14=Sang Won |last15=Kang |first15=Sung Hoon |date=2024-08-29 |title=Different associations between body mass index and Alzheimer's markers depending on metabolic health |journal=Alzheimer's Research & Therapy |volume=16 |issue=1 |pages=194 |doi=10.1186/s13195-024-01563-z |doi-access=free |issn=1758-9193 |pmc=11363444 |pmid=39210402}} There is also evidence of increased risk of developing Alzheimer's for those with a higher BMI in women ages 70 and above.{{Cite journal |last1=Gustafson |first1=Deborah |last2=Rothenberg |first2=Elisabet |last3=Blennow |first3=Kaj |last4=Steen |first4=Bertil |last5=Skoog |first5=Ingmar |date=2003-07-14 |title=An 18-Year Follow-up of Overweight and Risk of Alzheimer Disease |url=http://archinte.jamanetwork.com/article.aspx?doi=10.1001/archinte.163.13.1524 |journal=Archives of Internal Medicine |language=en |volume=163 |issue=13 |pages=1524–1528 |doi=10.1001/archinte.163.13.1524 |pmid=12860573 |issn=0003-9926|url-access=subscription }} While continuous positive airway pressure (CPAP) wasn't found to significantly improve cognitive performance, it was found to benefit other symptoms like depression, anxiety, etc.{{Cite journal |last1=Oliver |first1=Cerys |last2=Li |first2=Haoxuan |last3=Biswas |first3=Bijetri |last4=Woodstoke |first4=David |last5=Blackman |first5=Jonathan |last6=Butters |first6=Anneka |last7=Drew |first7=Cheney |last8=Gabb |first8=Victoria |last9=Harding |first9=Sam |last10=Hoyos |first10=Camilla M. |last11=Kendrick |first11=Adrian |last12=Rudd |first12=Sarah |last13=Turner |first13=Nicholas |last14=Coulthard |first14=Elizabeth |date=2024-02-01 |title=A systematic review on adherence to continuous positive airway pressure (CPAP) treatment for obstructive sleep apnoea (OSA) in individuals with mild cognitive impairment and Alzheimer's disease dementia |url=https://linkinghub.elsevier.com/retrieve/pii/S1087079223001259 |journal=Sleep Medicine Reviews |volume=73 |pages=101869 |doi=10.1016/j.smrv.2023.101869 |pmid=37924680 |issn=1087-0792}}

There are three types of sleep apnea. OSA accounts for 84%, CSA for 0.9%, and 15% of cases are mixed.{{cite journal |last1=Morgenthaler |first1=Timothy I. |last2=Kagramanov |first2=Vadim |last3=Hanak |first3=Viktor |last4=Decker |first4=Paul A. |title=Complex Sleep Apnea Syndrome: Is It a Unique Clinical Syndrome? |journal=Sleep |date=September 2006 |volume=29 |issue=9 |pages=1203–1209 |doi=10.1093/sleep/29.9.1203 |pmid=17040008 |url=https://www.sciencedaily.com/releases/2006/09/060901161349.htm |doi-access=free |access-date=28 February 2018 |archive-date=9 September 2017 |archive-url=https://web.archive.org/web/20170909052221/https://www.sciencedaily.com/releases/2006/09/060901161349.htm |url-status=live |url-access=subscription }}

{{Main|Obstructive sleep apnea}}

File:ObstructiveApnea.png

File:New_no_obstruction.png

File:Airway_obstruction.png

In a systematic review of published evidence, the United States Preventive Services Task Force in 2017 concluded that there was uncertainty about the accuracy or clinical utility of all potential screening tools for OSA,{{cite journal |display-authors=6 |vauthors=Jonas DE, Amick HR, Feltner C, Weber RP, Arvanitis M, Stine A, Lux L, Harris RP |date=January 2017 |title=Screening for Obstructive Sleep Apnea in Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force |journal=JAMA |volume=317 |issue=4 |pages=415–433 |doi=10.1001/jama.2016.19635 |pmid=28118460 |doi-access=free}} and recommended that evidence is insufficient to assess the balance of benefits and harms of screening for OSA in asymptomatic adults.{{cite journal |display-authors=6 |vauthors=Bibbins-Domingo K, Grossman DC, Curry SJ, Davidson KW, Epling JW, García FA, Herzstein J, Kemper AR, Krist AH, Kurth AE, Landefeld CS, Mangione CM, Phillips WR, Phipps MG, Pignone MP, Silverstein M, Tseng CW |date=January 2017 |title=Screening for Obstructive Sleep Apnea in Adults: US Preventive Services Task Force Recommendation Statement |journal=JAMA |volume=317 |issue=4 |pages=407–414 |doi=10.1001/jama.2016.20325 |pmid=28118461 |doi-access=free}}

The diagnosis of OSA syndrome is made when the patient shows recurrent episodes of partial or complete collapse of the upper airway during sleep resulting in apneas or hypopneas, respectively.{{cite journal |vauthors=Franklin KA, Lindberg E |date=August 2015 |title=Obstructive sleep apnea is a common disorder in the population-a review on the epidemiology of sleep apnea |journal=Journal of Thoracic Disease |volume=7 |issue=8 |pages=1311–1322 |doi=10.3978/j.issn.2072-1439.2015.06.11 |pmc=4561280 |pmid=26380759}} Criteria defining an apnea or a hypopnea vary. The American Academy of Sleep Medicine (AASM) defines an apnea 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.Berry RB, Quan SF, Abrue AR, et al.; for the American Academy of Sleep Medicine. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications. Version 2.6. Darien, IL: American Academy of Sleep Medicine; 2020.

To define the severity of the condition, the Apnea-Hypopnea Index (AHI) or the Respiratory Disturbance Index (RDI) are 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).{{cite journal |vauthors=Kapur VK, Auckley DH, Chowdhuri S, Kuhlmann DC, Mehra R, Ramar K, Harrod CG |date=March 2017 |title=Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline |journal=Journal of Clinical Sleep Medicine |volume=13 |issue=3 |pages=479–504 |doi=10.5664/jcsm.6506 |pmc=5337595 |pmid=28162150}} 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.{{cite journal |last1=Thurnheer |first1=R. |date=September 2007 |title=Diagnosis of the obstructive sleep apnea syndrome |url=https://www.minervamedica.it/en/journals/minerva-pneumologica/article.php?cod=R16Y2007N03A0191 |journal=Minerva Pneumologica |volume=46 |issue=3 |pages=191–204 |s2cid=52540419 |access-date=21 March 2024 |archive-date=23 October 2020 |archive-url=https://web.archive.org/web/20201023215006/https://www.minervamedica.it/en/journals/minerva-pneumologica/article.php?cod=R16Y2007N03A0191 |url-status=live }} According to the American Association of Sleep Medicine, daytime sleepiness is determined as mild, moderate and severe depending on its impact on social life. Daytime sleepiness can be assessed with the Epworth Sleepiness Scale (ESS), a self-reported questionnaire on the propensity to fall asleep or doze off during daytime.{{cite journal |vauthors=Crook S, Sievi NA, Bloch KE, Stradling JR, Frei A, Puhan MA, Kohler M |date=April 2019 |title=Minimum important difference of the Epworth Sleepiness Scale in obstructive sleep apnoea: estimation from three randomised controlled trials |journal=Thorax |volume=74 |issue=4 |pages=390–396 |doi=10.1136/thoraxjnl-2018-211959 |pmid=30100576 |s2cid=51967356 |doi-access=free}} Screening tools for OSA comprise the STOP questionnaire, the Berlin questionnaire and the STOP-BANG questionnaire which has been reported as being a powerful tool to detect OSA.{{cite journal |display-authors=6 |vauthors=Chiu HY, Chen PY, Chuang LP, Chen NH, Tu YK, Hsieh YJ, Wang YC, Guilleminault C |date=December 2017 |title=Diagnostic accuracy of the Berlin questionnaire, STOP-BANG, STOP, and Epworth sleepiness scale in detecting obstructive sleep apnea: A bivariate meta-analysis |journal=Sleep Medicine Reviews |volume=36 |pages=57–70 |doi=10.1016/j.smrv.2016.10.004 |pmid=27919588}}{{cite journal |vauthors=Amra B, Javani M, Soltaninejad F, Penzel T, Fietze I, Schoebel C, Farajzadegan Z |date=2018 |title=Comparison of Berlin Questionnaire, STOP-Bang, and Epworth Sleepiness Scale for Diagnosing Obstructive Sleep Apnea in Persian Patients |journal=International Journal of Preventive Medicine |volume=9 |issue=28 |page=28 |doi=10.4103/ijpvm.IJPVM_131_17 |pmc=5869953 |pmid=29619152 |doi-access=free}}

According to the International Classification of Sleep Disorders, there are 4 types of criteria.{{cite book | chapter-url=https://link.springer.com/chapter/10.1007/978-1-4939-6578-6_27 | doi=10.1007/978-1-4939-6578-6_27 | chapter=International Classification of Sleep Disorders | title=Sleep Disorders Medicine | date=2017 | pages=475–484 | isbn=978-1-4939-6576-2 | vauthors=Thorpy M | access-date=10 October 2024 | archive-date=11 May 2021 | archive-url=https://web.archive.org/web/20210511100659/https://link.springer.com/chapter/10.1007/978-1-4939-6578-6_27 | url-status=live }}{{Cite book |url=https://aasm.org/wp-content/uploads/2019/05/ICSD3-TOC.pdf |title=International Classification of Sleep Disorders, Third Edition|year=2014|publisher=American Academy of Sleep Medicine|location=Darien, IL|access-date=10 October 2024|isbn=978-0991543403}}{{page needed|date=September 2020}} The first one concerns sleep – excessive sleepiness, nonrestorative sleep, fatigue or insomnia symptoms. 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 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 one is determined by a polysomnography or home sleep apnea test demonstrating 5 or more predominantly obstructive respiratory events per hour of sleep and the higher levels are determined by 15 or more events. If the events are present less than 5 times per hour, no obstructive sleep apnea is diagnosed.

A considerable night-to-night variability further complicates diagnosis of OSA. In unclear cases, multiple nights of testing might be required to achieve an accurate diagnosis.{{Cite journal |last1=Tschopp |first1=Samuel |last2=Wimmer |first2=Wilhelm |last3=Caversaccio |first3=Marco |last4=Borner |first4=Urs |last5=Tschopp |first5=Kurt |date=2021-03-30 |title=Night-to-night variability in obstructive sleep apnea using peripheral arterial tonometry: a case for multiple night testing |journal=Journal of Clinical Sleep Medicine |language=en |volume=17 |issue=9 |pages=1751–1758 |doi=10.5664/jcsm.9300 |issn=1550-9389 |pmc=8636340|pmid=33783347 |s2cid=232420123}} Since sequential nights of testing would be impractical and cost prohibitive in the sleep lab, home sleep testing for multiple nights can not only be more useful, but more reflective of what is typically happening each night.{{cite journal |last1=Punjabi |first1=Naresh |title=Variability and Misclassification of Sleep Apnea Severity Based on Multi-Night Testing |journal=Chest Journal |date=18 February 2020 |volume=158 |issue=1 |pages=365–373 |doi=10.1016/j.chest.2020.01.039 |pmid=32081650 |pmc=7339240 }}

Nighttime in-laboratory Level 1 polysomnography (PSG) is the gold standard test for diagnosis. Patients are monitored with EEG leads, pulse oximetry, temperature and 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. A hypopnea can be based on one of two criteria. It can either be a reduction in airflow of at least 30% for more than 10 seconds associated with at least 4% oxygen desaturation or a reduction in airflow of at least 30% for more than 10 seconds associated with at least 3% oxygen desaturation or an arousal from sleep on EEG.{{cite journal |author=Slowik |first=Jennifer M. |author2=Collen |first2=Jacob F. |date=2020 |title=Obstructive Sleep Apnea |journal=StatPearls |pmid=29083619}} {{CC-notice|cc=by4|url=https://www.ncbi.nlm.nih.gov/books/NBK459252/}}

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.{{cite journal |date=August 1999 |title=Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The Report of an American Academy of Sleep Medicine Task Force |journal=Sleep |volume=22 |issue=5 |pages=667–689 |doi=10.1093/sleep/22.5.667 |pmid=10450601 |doi-access=free}} To grade the severity of sleep apnea, the number of events per hour is reported as the apnea-hypopnea index (AHI). An AHI of less than 5 is considered normal. An AHI of 5–15 is mild; 15–30 is moderate, and more than 30 events per hour characterizes severe sleep apnea.

{{Main|Central sleep apnea}}

The diagnosis of CSA syndrome is made when the presence of at least 5 central apnea events occur per hour.{{Cite journal |last1=Roberts |first1=Erin Grattan |last2=Raphelson |first2=Janna R. |last3=Orr |first3=Jeremy E. |last4=LaBuzetta |first4=Jamie Nicole |last5=Malhotra |first5=Atul |date=2022-07-01 |title=The Pathogenesis of Central and Complex Sleep Apnea |url=https://doi.org/10.1007/s11910-022-01199-2 |journal=Current Neurology and Neuroscience Reports |language=en |volume=22 |issue=7 |pages=405–412 |doi=10.1007/s11910-022-01199-2 |issn=1534-6293 |pmc=9239939 |pmid=35588042}} There are multiple mechanisms that drive the apnea events. In individuals with heart failure with Cheyne-Stokes respiration, the brain's respiratory control centers are imbalanced during sleep.{{cite journal |vauthors=Yumino D, Bradley TD |date=February 2008 |title=Central sleep apnea and Cheyne-Stokes respiration |journal=Proceedings of the American Thoracic Society |volume=5 |issue=2 |pages=226–36 |doi=10.1513/pats.200708-129MG |pmid=18250216}} This results in ventilatory instability, caused by chemoreceptors that are hyperresponsive to CO2 fluctuations in the blood, resulting in high respiratory drive that leads to apnea. Another common mechanism that causes CSA is the loss of the brain's wakefulness drive to breathe.

File:CentralApnea.png

CSA is organized into 6 individual syndromes: Cheyne-Stokes respiration, Complex sleep apnea, Primary CSA, High altitude periodic breathing, CSA from medication, CSA from comorbidity. Like in OSA, nocturnal polysomnography is the mainstay of diagnosis for CSA. The degree of respiratory effort, measured by esophageal pressure or displacement of the thoracic or abdominal cavity, is an important distinguishing factor between OSA and CSA.

Some people with sleep apnea have a combination of both types; its prevalence ranges from 0.56% to 18%. The condition, also called treatment-emergent central apnea, is generally detected when obstructive sleep apnea is treated with CPAP and central sleep apnea emerges. The exact mechanism of the loss of central respiratory drive during sleep in OSA is unknown but is most likely related to incorrect settings of the CPAP treatment and other medical conditions the person has.{{cite journal | vauthors = Khan MT, Franco RA | title = Complex sleep apnea syndrome | journal = Sleep Disorders | volume = 2014 | pages = 1–6 | year = 2014 | pmid = 24693440 | pmc = 3945285 | doi = 10.1155/2014/798487 | doi-access = free }}

The treatment of obstructive sleep apnea is different than that of central sleep apnea. Treatment often starts with behavioral therapy and some people may be suggested to try a continuous positive airway pressure (CPAP) device. Many people are told to avoid alcohol, sleeping pills, and other sedatives, which can relax throat muscles, contributing to the collapse of the airway at night. The evidence supporting one treatment option compared to another for a particular person is not clear.{{cite journal |last1=Pinto |first1=Ana Carolina Pereira Nunes |last2=Rocha |first2=Aline |last3=Drager |first3=Luciano F |last4=Lorenzi-Filho |first4=Geraldo |last5=Pachito |first5=Daniela V |date=24 October 2022 |editor-last=Cochrane Airways Group |title=Non-invasive positive pressure ventilation for central sleep apnoea in adults |url= |journal=Cochrane Database of Systematic Reviews |language=en |volume=2022 |issue=10 |pages=CD012889 |doi=10.1002/14651858.CD012889.pub2 |pmc=9590003 |pmid=36278514 }}

More than half of people with obstructive sleep apnea have some degree of positional obstructive sleep apnea, meaning that it gets worse when they sleep on their backs.{{cite journal |last1=Omobomi |first1=Olabimpe |last2=Quan |first2=Stuart F. |date=May 2018 |title=Positional therapy in the management of positional obstructive sleep apnea-a review of the current literature |url=https://dash.harvard.edu/bitstream/1/35427798/1/2017%20Omobomi%20and%20Quan%2c%20Positional%20therapy....pdf |journal=Sleep & Breathing = Schlaf & Atmung |volume=22 |issue=2 |pages=297–304 |doi=10.1007/s11325-017-1561-y |issn=1522-1709 |pmid=28852945 |s2cid=4038428 |access-date=30 December 2023 |archive-date=8 March 2024 |archive-url=https://web.archive.org/web/20240308031052/https://dash.harvard.edu/bitstream/handle/1/35427798/2017%20Omobomi%20and%20Quan,%20Positional%20therapy....pdf?sequence=1 |url-status=live }} Sleeping on their sides is an effective and cost-effective treatment for positional obstructive sleep apnea.

File:Cpapanwender.jpg

File:CPAP device on a nightstand.jpg

{{see also|Continuous positive airway pressure}}

For moderate to severe sleep apnea, the most common treatment is the use of a continuous positive airway pressure (CPAP) or automatic positive airway pressure (APAP) device.{{cite web |url=http://www.nhlbi.nih.gov/health/dci/Diseases/SleepApnea/SleepApnea_Treatments.html |title=How Is Sleep Apnea Treated? |publisher=National Heart, Lung, and Blood Institute |url-status=live |archive-url=https://web.archive.org/web/20071013043521/http://www.nhlbi.nih.gov/health/dci/Diseases/SleepApnea/SleepApnea_Treatments.html |archive-date=13 October 2007 }} These splint the person's airway open during sleep by means of pressurized air. The person typically wears a plastic facial mask, which is connected by a flexible tube to a small bedside CPAP machine.

Although CPAP therapy is effective in reducing apneas and less expensive than other treatments, some people find it uncomfortable. Some complain of feeling trapped, having chest discomfort, and skin or nose irritation. Other side effects may include dry mouth, dry nose, nosebleeds, sore lips and gums.

Whether or not it decreases the risk of death or heart disease is controversial with some reviews finding benefit and others not.{{cite journal | vauthors = Yu J, Zhou Z, McEvoy RD, Anderson CS, Rodgers A, Perkovic V, Neal B | title = Association of Positive Airway Pressure With Cardiovascular Events and Death in Adults With Sleep Apnea: A Systematic Review and Meta-analysis | journal = JAMA | volume = 318 | issue = 2 | pages = 156–166 | date = July 2017 | pmid = 28697252 | pmc = 5541330 | doi = 10.1001/jama.2017.7967 }} This variation across studies might be driven by low rates of compliance—analyses of those who use CPAP for at least four hours a night suggests a decrease in cardiovascular events.{{cite journal | vauthors = Gottlieb DJ | title = Does Obstructive Sleep Apnea Treatment Reduce Cardiovascular Risk?: It Is Far Too Soon to Say | journal = JAMA | volume = 318 | issue = 2 | pages = 128–130 | date = July 2017 | pmid = 28697240 | doi = 10.1001/jama.2017.7966 }}

Excess body weight is thought to be an important cause of sleep apnea.{{cite journal |last1=Young |first1=Terry |last2=Peppard |first2=Paul E. |last3=Gottlieb |first3=Daniel J. |title=Epidemiology of Obstructive Sleep Apnea: A Population Health Perspective |journal=American Journal of Respiratory and Critical Care Medicine |date=May 2002 |volume=165 |issue=9 |pages=1217–1239 |doi=10.1164/rccm.2109080 |pmid=11991871 |s2cid=23784058 }} People who are overweight have more tissues in the back of their throat which can restrict the airway, especially when sleeping.{{cite news |last1=Watson |first1=Stephanie |title=Weight loss, breathing devices still best for treating obstructive sleep apnea |url=https://www.health.harvard.edu/blog/weight-loss-breathing-devices-still-best-for-treating-obstructive-sleep-apnea-201310026713 |work=Harvard Health Blog |date=2 October 2013 |access-date=21 October 2019 |archive-date=3 July 2019 |archive-url=https://web.archive.org/web/20190703145118/https://www.health.harvard.edu/blog/weight-loss-breathing-devices-still-best-for-treating-obstructive-sleep-apnea-201310026713 |url-status=live }} In weight loss studies of overweight individuals, those who lose weight show reduced apnea frequencies and improved apnoea–hypopnoea index (AHI).{{cite journal | vauthors = Tuomilehto HP, Seppä JM, Partinen MM, Peltonen M, Gylling H, Tuomilehto JO, Vanninen EJ, Kokkarinen J, Sahlman JK, Martikainen T, Soini EJ, Randell J, Tukiainen H, Uusitupa M | title = Lifestyle intervention with weight reduction: first-line treatment in mild obstructive sleep apnea | journal = American Journal of Respiratory and Critical Care Medicine | volume = 179 | issue = 4 | pages = 320–7 | date = February 2009 | pmid = 19011153 | doi = 10.1164/rccm.200805-669OC }} Weight loss effective enough to relieve obesity hypoventilation syndrome (OHS) must be 25–30% of body weight. For some obese people, it can be difficult to achieve and maintain this result without bariatric surgery.{{cite journal |last1=Mokhlesi |first1=Babak |last2=Masa |first2=Juan Fernando |last3=Brozek |first3=Jan L. |last4=Gurubhagavatula |first4=Indira |last5=Murphy |first5=Patrick B. |last6=Piper |first6=Amanda J. |last7=Tulaimat |first7=Aiman |last8=Afshar |first8=Majid |last9=Balachandran |first9=Jay S. |last10=Dweik |first10=Raed A. |last11=Grunstein |first11=Ronald R. |last12=Hart |first12=Nicholas |last13=Kaw |first13=Roop |last14=Lorenzi-Filho |first14=Geraldo |last15=Pamidi |first15=Sushmita |last16=Patel |first16=Bhakti K. |last17=Patil |first17=Susheel P. |last18=Pépin |first18=Jean Louis |last19=Soghier |first19=Israa |last20=Tamae Kakazu |first20=Maximiliano |last21=Teodorescu |first21=Mihaela |title=Evaluation and Management of Obesity Hypoventilation Syndrome. An Official American Thoracic Society Clinical Practice Guideline |journal=American Journal of Respiratory and Critical Care Medicine |date=1 August 2019 |volume=200 |issue=3 |pages=e6–e24 |doi=10.1164/rccm.201905-1071ST |pmid=31368798 |pmc=6680300 }}

{{see also|Palatal expansion}}

In children, orthodontic treatment to expand the volume of the nasal airway, such as nonsurgical rapid palatal expansion is common. The procedure has been found to significantly decrease the AHI and lead to long-term resolution of clinical symptoms.{{cite journal |last1=Villa |first1=Maria Pia |last2=Rizzoli |first2=Alessandra |last3=Miano |first3=Silvia |last4=Malagola |first4=Caterina |title=Efficacy of rapid maxillary expansion in children with obstructive sleep apnea syndrome: 36 months of follow-up |journal=Sleep and Breathing |date=1 May 2011 |volume=15 |issue=2 |pages=179–184 |doi=10.1007/s11325-011-0505-1 |pmid=21437777 |s2cid=4505051 }}{{cite journal |last1=Machado-Júnior |first1=Almiro-José |last2=Zancanella |first2=Edilson |last3=Crespo |first3=Agrício-Nubiato |title=Rapid maxillary expansion and obstructive sleep apnea: A review and meta-analysis |journal=Medicina Oral, Patología Oral y Cirugía Bucal |date=2016 |volume=21 |issue=4 |pages=e465–e469 |doi=10.4317/medoral.21073 |pmid=27031063 |pmc=4920460 }}

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.{{cite journal |last1=Li |first1=Qiming |last2=Tang |first2=Hongyi |last3=Liu |first3=Xueye |last4=Luo |first4=Qing |last5=Jiang |first5=Zhe |last6=Martin |first6=Domingo |last7=Guo |first7=Jing |title=Comparison of dimensions and volume of upper airway before and after mini-implant assisted rapid maxillary expansion |journal=The Angle Orthodontist |date=1 May 2020 |volume=90 |issue=3 |pages=432–441 |doi=10.2319/080919-522.1 |pmid=33378437 |pmc=8032299 |doi-access=free }}{{cite journal |last1=Abdullatif |first1=Jose |last2=Certal |first2=Victor |last3=Zaghi |first3=Soroush |last4=Song |first4=Sungjin A. |last5=Chang |first5=Edward T. |last6=Gillespie |first6=M. Boyd |last7=Camacho |first7=Macario |title=Maxillary expansion and maxillomandibular expansion for adult OSA: A systematic review and meta-analysis |journal=Journal of Cranio-Maxillofacial Surgery |date=1 May 2016 |volume=44 |issue=5 |pages=574–578 |doi=10.1016/j.jcms.2016.02.001 |pmid=26948172 }} Changes are permanent with minimal complications.

File:Cautérisation des parties molles - apnée du sommeil.svg

Several surgical procedures (sleep surgery) are used to treat sleep apnea, although they are normally a third line of treatment for those who reject or are not helped by CPAP treatment or dental appliances. Surgical treatment for obstructive sleep apnea needs to be individualized to address all anatomical areas of obstruction.

Often, correction of the nasal passages needs to be performed in addition to correction of the oropharynx passage. Septoplasty and turbinate surgery may improve the nasal airway,{{cite journal |last1=Sundaram |first1=Supriya |last2=Lim |first2=Jerome |last3=Lasserson |first3=Toby J |last4=Lasserson |first4=TJ |title=Surgery for obstructive sleep apnoea in adults |journal=Cochrane Database of Systematic Reviews |date=19 October 2005 |issue=4 |pages=CD001004 |doi=10.1002/14651858.CD001004.pub2 |pmid=16235277 }} but has been found to be ineffective at reducing respiratory arousals during sleep.{{cite journal |last1=Li |first1=Hsueh-Yu |last2=Wang |first2=Pa-Chun |last3=Chen |first3=Yu-Pin |last4=Lee |first4=Li-Ang |last5=Fang |first5=Tuan-Jen |last6=Lin |first6=Hsin-Ching |title=Critical Appraisal and Meta-Analysis of Nasal Surgery for Obstructive Sleep Apnea |journal=American Journal of Rhinology & Allergy |date=January 2011 |volume=25 |issue=1 |pages=45–49 |doi=10.2500/ajra.2011.25.3558 |pmid=21711978 |s2cid=35117004 }}

Tonsillectomy and uvulopalatopharyngoplasty (UPPP or UP3) are available to address pharyngeal obstruction.

File:UPPP. 4 figures..png

The "Pillar" device is a treatment for snoring and obstructive sleep apnea; it is thin, narrow strips of polyester. Three strips are inserted into the roof of the mouth (the soft palate) using a modified syringe and local anesthetic, in order to stiffen the soft palate. This procedure addresses one of the most common causes of snoring and sleep apnea — vibration or collapse of the soft palate. It was approved by the FDA for snoring in 2002 and for obstructive sleep apnea in 2004. A 2013 meta-analysis found that "the Pillar implant has a moderate effect on snoring and mild-to-moderate obstructive sleep apnea" and that more studies with high level of evidence were needed to arrive at a definite conclusion; it also found that the polyester strips work their way out of the soft palate in about 10% of the people in whom they are implanted.{{cite journal | vauthors = Choi JH, Kim SN, Cho JH | title = Efficacy of the Pillar implant in the treatment of snoring and mild-to-moderate obstructive sleep apnea: a meta-analysis | journal = The Laryngoscope | volume = 123 | issue = 1 | pages = 269–76 | date = January 2013 | pmid = 22865236 | doi = 10.1002/lary.23470 | s2cid = 25875843 }}

Base-of-tongue advancement by means of advancing the genial tubercle of the mandible, tongue suspension, or hyoid suspension (aka hyoid myotomy and suspension or hyoid advancement) may help with the lower pharynx.

Other surgery options may attempt to shrink or stiffen excess tissue in the mouth or throat, procedures done at either a doctor's office or a hospital. Small shots or other treatments, sometimes in a series, are used for shrinkage, while the insertion of a small piece of stiff plastic is used in the case of surgery whose goal is to stiffen tissues.

Maxillomandibular advancement is considered the most effective surgery for people with sleep apnea, because it increases the posterior airway space.{{cite journal | vauthors = Prinsell JR | title = Maxillomandibular advancement surgery for obstructive sleep apnea syndrome | journal = Journal of the American Dental Association | volume = 133 | issue = 11 | pages = 1489–97; quiz 1539–40 | date = November 2002 | pmid = 12462692 | doi = 10.14219/jada.archive.2002.0079 }} However, health professionals are often unsure as to who should be referred for surgery and when to do so: some factors in referral may include failed use of CPAP or device use; anatomy which favors rather than impedes surgery; or significant craniofacial abnormalities which hinder device use.{{cite journal |author=MacKay, Stuart |title=Treatments for snoring in adults |journal=Australian Prescriber |volume=34 |issue=34 |pages=77–79 |date=June 2011 |doi=10.18773/austprescr.2011.048 |doi-broken-date=7 November 2024 |doi-access= }}

Several inpatient and outpatient procedures use sedation. Many drugs and agents used during surgery to relieve pain and to depress consciousness remain in the body at low amounts for hours or even days afterwards. In an individual with either central, obstructive or mixed sleep apnea, these low doses may be enough to cause life-threatening irregularities in breathing or collapses in a patient's airways.{{cite book |first1=T. Scott |last1=Johnson |first2=William A. |last2=Broughton |first3=Jerry |last3=Halberstadt |title=Sleep Apnea – The Phantom of the Night: Overcome Sleep Apnea Syndrome and Win Your Hidden Struggle to Breathe, Sleep, and Live |publisher=New Technology Publishing |year=2003 |isbn=978-1-882431-05-2 |url-access=registration |url=https://archive.org/details/sleepapneaphanto0000john }}{{Page needed|date=September 2010}} Use of analgesics and sedatives in these patients postoperatively should therefore be minimized or avoided.

Surgery on the mouth and throat, as well as dental surgery and procedures, can result in postoperative swelling of the lining of the mouth and other areas that affect the airway. Even when the surgical procedure is designed to improve the airway, such as tonsillectomy and adenoidectomy or tongue reduction, swelling may negate some of the effects in the immediate postoperative period. Once the swelling resolves and the palate becomes tightened by postoperative scarring, however, the full benefit of the surgery may be noticed.

A person with sleep apnea undergoing any medical treatment must make sure their doctor and anesthetist are informed about the sleep apnea. Alternative and emergency procedures may be necessary to maintain the airway of sleep apnea patients.{{cite web |url=http://www.nhlbi.nih.gov/health/dci/Diseases/SleepApnea/SleepApnea_LivingWith.html |title=What is Sleep Apnea? |year=2012 |website=National Heart, Lung, and Blood Institute |publisher=National Institutes of Health |access-date=15 February 2013 |url-status=live |archive-url=https://web.archive.org/web/20110828030048/http://www.nhlbi.nih.gov/health/dci/Diseases/SleepApnea/SleepApnea_LivingWith.html |archive-date=28 August 2011}}

Diaphragm pacing, which involves the rhythmic application of electrical impulses to the diaphragm, has been used to treat central sleep apnea.{{EMedicine|article|1970348|Diaphragm Pacing}}{{cite journal | vauthors = Yun AJ, Lee PY, Doux JD | title = Negative pressure ventilation via diaphragmatic pacing: a potential gateway for treating systemic dysfunctions | journal = Expert Review of Medical Devices | volume = 4 | issue = 3 | pages = 315–9 | date = May 2007 | pmid = 17488226 | doi = 10.1586/17434440.4.3.315 | s2cid = 30419488 }}

In April 2014, the U.S. Food and Drug Administration granted pre-market approval for use of an upper airway stimulation system in people who cannot use a continuous positive airway pressure device. The Inspire Upper Airway Stimulation system is a hypoglossal nerve stimulation implant that senses respiration and applies mild electrical stimulation during inspiration, which pushes the tongue slightly forward to open the airway.{{cite web |url=https://www.fda.gov/medicaldevices/productsandmedicalprocedures/deviceapprovalsandclearances/recently-approveddevices/ucm398321.htm |title=Inspire Upper Airway Stimulation – P130008 |work=FDA.gov |publisher=Food and Drug Administration |date=11 January 2016 |access-date=9 March 2016 |url-status=dead |archive-url=https://web.archive.org/web/20160311075714/https://www.fda.gov/medicaldevices/productsandmedicalprocedures/deviceapprovalsandclearances/recently-approveddevices/ucm398321.htm |archive-date=11 March 2016 }}

There is currently insufficient evidence to recommend any medication for OSA.{{cite journal |last1=Gaisl |first1=Thomas |last2=Haile |first2=Sarah R. |last3=Thiel |first3=Sira |last4=Osswald |first4=Martin |last5=Kohler |first5=Malcolm |title=Efficacy of pharmacotherapy for OSA in adults: A systematic review and network meta-analysis |journal=Sleep Medicine Reviews |date=August 2019 |volume=46 |pages=74–86 |doi=10.1016/j.smrv.2019.04.009 |pmid=31075665 |s2cid=149455430 }} This may result in part because people with sleep apnea have tended to be treated as a single group in clinical trials. Identifying specific physiological factors underlying sleep apnea makes it possible to test drugs specific to those causal factors: airway narrowing, impaired muscle activity, low arousal threshold for waking, and unstable breathing control.{{cite journal |last1=Dolgin |first1=Elie |date=29 April 2020 |title=Treating sleep apnea with pills instead of machines |url=https://knowablemagazine.org/article/health-disease/2020/treating-sleep-apnea-pills-instead-machines |url-status=live |journal=Knowable Magazine |doi=10.1146/knowable-042820-1 |archive-url=https://web.archive.org/web/20220530121424/https://knowablemagazine.org/article/health-disease/2020/treating-sleep-apnea-pills-instead-machines |archive-date=30 May 2022 |access-date=9 May 2022 |doi-access=free}}{{cite journal |last1=Wellman |first1=Andrew |last2=Eckert |first2=Danny J. |last3=Jordan |first3=Amy S. |last4=Edwards |first4=Bradley A. |last5=Passaglia |first5=Chris L. |last6=Jackson |first6=Andrew C. |last7=Gautam |first7=Shiva |last8=Owens |first8=Robert L. |last9=Malhotra |first9=Atul |last10=White |first10=David P. |title=A method for measuring and modeling the physiological traits causing obstructive sleep apnea |journal=Journal of Applied Physiology |date=June 2011 |volume=110 |issue=6 |pages=1627–1637 |doi=10.1152/japplphysiol.00972.2010 |pmid=21436459 |pmc=3119134 }} Those who experience low waking thresholds may benefit from eszopiclone, a sedative typically used to treat insomnia.{{cite journal |last1=Eckert |first1=Danny J. |last2=Owens |first2=Robert L. |last3=Kehlmann |first3=Geoffrey B. |last4=Wellman |first4=Andrew |last5=Rahangdale |first5=Shilpa |last6=Yim-Yeh |first6=Susie |last7=White |first7=David P. |last8=Malhotra |first8=Atul |title=Eszopiclone increases the respiratory arousal threshold and lowers the apnoea/hypopnoea index in obstructive sleep apnoea patients with a low arousal threshold |journal=Clinical Science |date=7 March 2011 |volume=120 |issue=12 |pages=505–514 |doi=10.1042/CS20100588 |pmid=21269278 |pmc=3415379 |url=https://doi.org/10.1042/CS20100588 |access-date=10 May 2022 |issn=0143-5221 |archive-date=8 March 2024 |archive-url=https://web.archive.org/web/20240308031502/https://portlandpress.com/clinsci/article-abstract/120/12/505/68829/Eszopiclone-increases-the-respiratory-arousal?redirectedFrom=fulltext |url-status=live }} The antidepressant desipramine may stimulate upper airway muscles and lessen pharyngeal collapsibility in people who have limited muscle function in their airways.{{cite journal |last1=Taranto-Montemurro |first1=Luigi |last2=Sands |first2=Scott A. |last3=Edwards |first3=Bradley A. |last4=Azarbarzin |first4=Ali |last5=Marques |first5=Melania |last6=Melo |first6=Camila de |last7=Eckert |first7=Danny J. |last8=White |first8=David P. |last9=Wellman |first9=Andrew |title=Desipramine improves upper airway collapsibility and reduces OSA severity in patients with minimal muscle compensation |journal=European Respiratory Journal |date=1 November 2016 |volume=48 |issue=5 |pages=1340–1350 |doi=10.1183/13993003.00823-2016 |pmid=27799387 |pmc=5437721 |url=https://erj.ersjournals.com/content/48/5/1340 |access-date=10 May 2022 |language=en |issn=0903-1936 |archive-date=8 August 2022 |archive-url=https://web.archive.org/web/20220808100210/https://erj.ersjournals.com/content/48/5/1340 |url-status=live }}

There is limited evidence for medication, but 2012 AASM guidelines suggested that acetazolamide "may be considered" for the treatment of central sleep apnea; zolpidem and triazolam may also be considered for the treatment of central sleep apnea,{{cite journal |last1=Lambert |first1=Mara |title=Updated Guidelines from AASM for the Treatment of Central Sleep Apnea Syndromes |journal=American Family Physician |date=15 November 2012 |volume=86 |issue=10 |pages=968–971 |url=https://www.aafp.org/afp/2012/1115/p968.html |access-date=10 May 2022 |issn=0002-838X |archive-date=10 May 2022 |archive-url=https://web.archive.org/web/20220510120148/https://www.aafp.org/afp/2012/1115/p968.html |url-status=live }} but "only if the patient does not have underlying risk factors for respiratory depression".{{cite journal | vauthors = Aurora RN, Chowdhuri S, Ramar K, Bista SR, Casey KR, Lamm CI, Kristo DA, Mallea JM, Rowley JA, Zak RS, Tracy SL | title = The treatment of central sleep apnea syndromes in adults: practice parameters with an evidence-based literature review and meta-analyses | journal = Sleep | volume = 35 | issue = 1 | pages = 17–40 | date = January 2012 | pmid = 22215916 | pmc = 3242685 | doi = 10.5665/sleep.1580 }} Low doses of oxygen are also used as a treatment for hypoxia but are discouraged due to side effects.{{cite web |url=http://www.psychologytoday.com/conditions/sleep-apnea |title=Sleep Apnea |work=Diagnosis Dictionary |publisher=Psychology Today |url-status=live |archive-url=https://archive.today/20130408080751/http://www.psychologytoday.com/conditions/sleep-apnea |archive-date=8 April 2013 }}{{cite journal |last1=Mayos |first1=M. |last2=Hernández Plaza |first2=L. |last3=Farré |first3=A. |last4=Mota |first4=S. |last5=Sanchis |first5=J. |title=Efecto de la oxigenoterapia nocturna en el paciente con síndrome de apnea-hipopnea del sueño y limitación crónica al flujo aéreo |trans-title=The effect of nocturnal oxygen therapy in patients with sleep apnea syndrome and chronic airflow limitation |language=es |journal=Archivos de Bronconeumología |date=January 2001 |volume=37 |issue=2 |pages=65–68 |doi=10.1016/s0300-2896(01)75016-8 |pmid=11181239 }}{{cite journal | vauthors = Breitenbücher A, Keller-Wossidlo H, Keller R | title = Transtracheale Sauerstofftherapie beim obstruktiven Schlafapnoe-Syndrom |trans-title=Transtracheal oxygen therapy in obstructive sleep apnea syndrome | language = de | journal = Schweizerische Medizinische Wochenschrift | volume = 119 | issue = 46 | pages = 1638–1641 | date = November 1989 | pmid = 2609134 |oclc=119157195 }}

In December 2024, the FDA approved tirzepatide, an anti-diabetic and weight loss medication, as a component in the combination treatment of adults with obesity suffering from moderate to severe obstructive sleep apnea. Other components of the therapy are a reduced-calorie diet and increased physical activity.{{Cite web |last=Commissioner |first=Office of the |date=2024-12-20 |title=FDA Approves First Medication for Obstructive Sleep Apnea |url=https://www.fda.gov/news-events/press-announcements/fda-approves-first-medication-obstructive-sleep-apnea |archive-url=https://web.archive.org/web/20241220234436/https://www.fda.gov/news-events/press-announcements/fda-approves-first-medication-obstructive-sleep-apnea |url-status=dead |archive-date=20 December 2024 |access-date=2024-12-25 |website=FDA |language=en}}

An oral appliance, often referred to as a mandibular advancement splint, is a custom-made mouthpiece that shifts the lower jaw forward and opens the bite slightly, opening up the airway. These devices can be fabricated by a general dentist. Oral appliance therapy is usually successful in patients with mild to moderate obstructive sleep apnea.{{cite journal | vauthors = Machado MA, Juliano L, Taga M, de Carvalho LB, do Prado LB, do Prado GF | title = Titratable mandibular repositioner appliances for obstructive sleep apnea syndrome: are they an option? | journal = Sleep & Breathing = Schlaf & Atmung | volume = 11 | issue = 4 | pages = 225–31 | date = December 2007 | pmid = 17440760 | doi = 10.1007/s11325-007-0109-y | s2cid = 24535360 }}{{cite journal | vauthors = Chen H, Lowe AA | title = Updates in oral appliance therapy for snoring and obstructive sleep apnea | journal = Sleep & Breathing = Schlaf & Atmung | volume = 17 | issue = 2 | pages = 473–86 | date = May 2013 | pmid = 22562263 | doi = 10.1007/s11325-012-0712-4 | s2cid = 21267378 }} While CPAP is more effective for sleep apnea than oral appliances, oral appliances improve sleepiness and quality of life and are often better tolerated than CPAP.

Nasal EPAP is a bandage-like device placed over the nostrils that uses a person's own breathing to create positive airway pressure to prevent obstructed breathing.{{cite journal | vauthors = Riaz M, Certal V, Nigam G, Abdullatif J, Zaghi S, Kushida CA, Camacho M | title = Nasal Expiratory Positive Airway Pressure Devices (Provent) for OSA: A Systematic Review and Meta-Analysis | journal = Sleep Disorders | volume = 2015 | pages = 734798 | date = 2015 | pmid = 26798519 | pmc = 4699057 | doi = 10.1155/2015/734798 | doi-access = free }}

Oral pressure therapy uses a device that creates a vacuum in the mouth, pulling the soft palate tissue forward. It has been found useful in about 25% to 37% of people.{{cite journal | vauthors = Nigam G, Pathak C, Riaz M | title = Effectiveness of oral pressure therapy in obstructive sleep apnea: a systematic analysis | journal = Sleep & Breathing = Schlaf & Atmung | volume = 20 | issue = 2 | pages = 663–71 | date = May 2016 | pmid = 26483265 | doi = 10.1007/s11325-015-1270-3 | s2cid = 29755875 }}{{cite journal | vauthors = Colrain IM, Black J, Siegel LC, Bogan RK, Becker PM, Farid-Moayer M, Goldberg R, Lankford DA, Goldberg AN, Malhotra A | title = A multicenter evaluation of oral pressure therapy for the treatment of obstructive sleep apnea | journal = Sleep Medicine | volume = 14 | issue = 9 | pages = 830–7 | date = September 2013 | pmid = 23871259 | pmc = 3932027 | doi = 10.1016/j.sleep.2013.05.009 | url = http://www.escholarship.org/uc/item/3cd5x9qk | access-date = 7 October 2018 | archive-date = 24 January 2019 | archive-url = https://web.archive.org/web/20190124152318/https://escholarship.org/uc/item/3cd5x9qk | url-status = live }}

Death could occur from untreated OSA due to lack of oxygen to the body.{{cite web|url=https://www.effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=731|title=Diagnosis and Treatment of Obstructive Sleep Apnea in Adults|publisher=AHRQ Effective Health Care Program|date=8 August 2011|url-status=dead|archive-url=https://web.archive.org/web/20161231230122/https://www.effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=731|archive-date=31 December 2016}}. A [https://www.effectivehealthcare.ahrq.gov/ehc/products/117/1534/sleep-apnea-surveillance-130502.pdf 2012 surveillance update] {{webarchive|url=https://web.archive.org/web/20170125113854/http://www.effectivehealthcare.ahrq.gov/ehc/products/117/1534/sleep-apnea-surveillance-130502.pdf |date=25 January 2017 }} found no significant information to update.

There is increasing evidence that sleep apnea may lead to liver function impairment, particularly fatty liver diseases (see steatosis).{{cite journal | vauthors = Aloia MS, Sweet LH, Jerskey BA, Zimmerman M, Arnedt JT, Millman RP | title = Treatment effects on brain activity during a working memory task in obstructive sleep apnea | journal = Journal of Sleep Research | volume = 18 | issue = 4 | pages = 404–10 | date = December 2009 | pmid = 19765205 | doi = 10.1111/j.1365-2869.2009.00755.x | hdl = 2027.42/73986 | s2cid = 15806274 |hdl-access=free }}{{cite journal | vauthors = Ahmed MH, Byrne CD | title = Obstructive sleep apnea syndrome and fatty liver: association or causal link? | journal = World Journal of Gastroenterology | volume = 16 | issue = 34 | pages = 4243–52 | date = September 2010 | pmid = 20818807 | pmc = 2937104 | doi = 10.3748/wjg.v16.i34.4243 | doi-access = free }}{{cite journal | vauthors = Singh H, Pollock R, Uhanova J, Kryger M, Hawkins K, Minuk GY | title = Symptoms of obstructive sleep apnea in patients with nonalcoholic fatty liver disease | journal = Digestive Diseases and Sciences | volume = 50 | issue = 12 | pages = 2338–43 | date = December 2005 | pmid = 16416185 | doi = 10.1007/s10620-005-3058-y | s2cid = 21852391 }}{{cite journal | vauthors = Tanné F, Gagnadoux F, Chazouillères O, Fleury B, Wendum D, Lasnier E, Lebeau B, Poupon R, Serfaty L | title = Chronic liver injury during obstructive sleep apnea | journal = Hepatology | volume = 41 | issue = 6 | pages = 1290–6 | date = June 2005 | pmid = 15915459 | doi = 10.1002/hep.20725 | doi-access = free }}

It has been revealed that people with OSA show tissue loss in brain regions that help store memory, thus linking OSA with memory loss.{{cite journal | vauthors = Kumar R, Birrer BV, Macey PM, Woo MA, Gupta RK, Yan-Go FL, Harper RM | title = Reduced mammillary body volume in patients with obstructive sleep apnea | journal = Neuroscience Letters | volume = 438 | issue = 3 | pages = 330–4 | date = June 2008 | pmid = 18486338 | doi = 10.1016/j.neulet.2008.04.071 | s2cid = 207126691 }} Using magnetic resonance imaging (MRI), the scientists discovered that people with sleep apnea have mammillary bodies that are about 20% smaller, particularly on the left side. One of the key investigators hypothesized that repeated drops in oxygen lead to the brain injury.{{cite journal | vauthors = Kumar R, Birrer BV, Macey PM, Woo MA, Gupta RK, Yan-Go FL, Harper RM | title = Reduced mammillary body volume in patients with obstructive sleep apnea | journal = Neuroscience Letters | volume = 438 | issue = 3 | pages = 330–4 | date = June 2008 | pmid = 18486338 | doi = 10.1016/j.neulet.2008.04.071 | s2cid = 207126691 | url = http://newswise.com/articles/view/541519/ | url-access = subscription | access-date = 12 June 2008 | archive-date = 15 June 2008 | archive-url = https://web.archive.org/web/20080615014142/http://www.newswise.com/articles/view/541519/ | url-status = live }}

The immediate effects of central sleep apnea on the body depend on how long the failure to breathe endures. At worst, central sleep apnea may cause sudden death. Short of death, drops in blood oxygen may trigger seizures, even in the absence of epilepsy. In people with epilepsy, the hypoxia caused by apnea may trigger seizures that had previously been well controlled by medications.{{cite journal |vauthors=Devinsky O, Ehrenberg B, Barthlen GM, Abramson HS, Luciano D |date=November 1994 |title=Epilepsy and sleep apnea syndrome |journal=Neurology |volume=44 |issue=11 |pages=2060–4 |doi=10.1212/WNL.44.11.2060 |pmid=7969960 |s2cid=2165184}} In other words, a seizure disorder may become unstable in the presence of sleep apnea. In adults with coronary artery disease, a severe drop in blood oxygen level can cause angina, arrhythmias, or heart attacks (myocardial infarction). Longstanding recurrent episodes of apnea, over months and years, may cause an increase in carbon dioxide levels that can change the pH of the blood enough to cause a respiratory acidosis.{{medical citation needed|data=February 2024|date=February 2024}}

{{Globalize|section|date=August 2016}}

The Wisconsin Sleep Cohort Study estimated in 1993 that roughly one in every 15 Americans was affected by at least moderate sleep apnea. It also estimated that in middle-age as many as 9% of women and 24% of men were affected, undiagnosed and untreated.{{cite journal |last1=Young |first1=Terry |last2=Palta |first2=Mari |last3=Dempsey |first3=Jerome |last4=Skatrud |first4=James |last5=Weber |first5=Steven |last6=Badr |first6=Safwan |title=The Occurrence of Sleep-Disordered Breathing among Middle-Aged Adults |journal=New England Journal of Medicine |date=29 April 1993 |volume=328 |issue=17 |pages=1230–1235 |doi=10.1056/NEJM199304293281704 |pmid=8464434 |s2cid=9183654 |doi-access=free }}{{cite journal | vauthors = Lee W, Nagubadi S, Kryger MH, Mokhlesi B | title = Epidemiology of Obstructive Sleep Apnea: a Population-based Perspective | journal = Expert Review of Respiratory Medicine | volume = 2 | issue = 3 | pages = 349–364 | date = June 2008 | pmid = 19690624 | pmc = 2727690 | doi = 10.1586/17476348.2.3.349 }}

The costs of untreated sleep apnea reach further than just health issues. It is estimated that in the U.S., the average untreated sleep apnea patient's annual health care costs $1,336 more than an individual without sleep apnea. This may cause $3.4 billion/year in additional medical costs. Whether medical cost savings occur with treatment of sleep apnea remains to be determined.{{cite journal |last1=Kapur |first1=Vishesh |last2=Blough |first2=David K. |last3=Sandblom |first3=Robert E. |last4=Hert |first4=Richard |last5=de Maine |first5=James B. |last6=Sullivan |first6=Sean D. |last7=Psaty |first7=Bruce M. |title=The Medical Cost of Undiagnosed Sleep Apnea |journal=Sleep |date=September 1999 |volume=22 |issue=6 |pages=749–755 |doi=10.1093/sleep/22.6.749 |pmid=10505820 |doi-access=free }}

Sleep disorders including sleep apnea have become an important health issue in the United States. Twenty-two million Americans have been estimated to have sleep apnea, with 80% of moderate and severe OSA cases undiagnosed.{{cite web |date=13 January 2017 |title=Sleep Apnea Information for Clinicians |url=https://www.sleepapnea.org/learn/sleep-apnea-information-clinicians/ |url-status=live |archive-url=https://web.archive.org/web/20220409152513/https://www.sleepapnea.org/learn/sleep-apnea-information-clinicians/ |archive-date=9 April 2022 |access-date=30 March 2022 |website=www.sleepapnea.org |language=en-US}}

OSA can occur at any age, but it happens more frequently in men who are over 40 and overweight.

A type of CSA was described in the German myth of Ondine's curse where the person when asleep would forget to breathe.{{cite book|last1=Yentis|first1=Steven M.|last2=Hirsch|first2=Nicholas P.|last3=Ip|first3=James|title=Anaesthesia and Intensive Care A-Z: An Encyclopedia of Principles and Practice|date=2013|publisher=Elsevier Health Sciences|isbn=978-0-7020-5375-7|page=428|url=https://books.google.com/books?id=Te7TAAAAQBAJ&pg=PA428|access-date=11 September 2017|archive-date=14 January 2023|archive-url=https://web.archive.org/web/20230114064201/https://books.google.com/books?id=Te7TAAAAQBAJ&pg=PA428|url-status=live}} The clinical picture of this condition has long been recognized as a character trait, without an understanding of the disease process. The term "Pickwickian syndrome" that is sometimes used for the syndrome was coined by the famous early 20th-century physician William Osler, who must have been a reader of Charles Dickens. The description of Joe, "the fat boy" in Dickens's novel The Pickwick Papers, is an accurate clinical picture of an adult with obstructive sleep apnea syndrome.{{cite journal | vauthors = Kryger MH | title = Fat, sleep, and Charles Dickens: literary and medical contributions to the understanding of sleep apnea | journal = Clinics in Chest Medicine | volume = 6 | issue = 4 | pages = 555–62 | date = December 1985 | doi = 10.1016/S0272-5231(21)00394-4 | pmid = 3910333 }}

The early reports of obstructive sleep apnea in the medical literature described individuals who were severely affected, often presenting with severe hypoxemia, hypercapnia and congestive heart failure.{{medical citation needed|data=February 2024|date=February 2024}}

The management of obstructive sleep apnea was improved with the introduction of continuous positive airway pressure (CPAP) machines, first described in 1981 by Colin Sullivan and associates in Sydney, Australia.{{cite journal | vauthors = Sullivan CE, Issa FG, Berthon-Jones M, Eves L | title = Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares | journal = Lancet | volume = 1 | issue = 8225 | pages = 862–5 | date = April 1981 | pmid = 6112294 | doi = 10.1016/S0140-6736(81)92140-1 | s2cid = 25219388 }} The first models were bulky and noisy, but the design was rapidly improved and by the late 1980s, CPAP was widely adopted. The availability of an effective treatment stimulated an aggressive search for affected individuals and led to the establishment of hundreds of specialized clinics dedicated to the diagnosis and treatment of sleep disorders. Though many types of sleep problems are recognized, the vast majority of patients attending these centers have sleep-disordered breathing. Sleep apnea awareness day is 18 April in recognition of Colin Sullivan.{{cite web|last=Sichtermann|first=Lori|title=Industry Recognizes Sleep Apnea Awareness Day 2014|date=19 April 2014|url=http://www.sleepreviewmag.com/2014/04/sleep-apnea-awareness-day-2014/|publisher=Sleep Review|access-date=30 April 2014|url-status=live|archive-url=https://web.archive.org/web/20140430083056/http://www.sleepreviewmag.com/2014/04/sleep-apnea-awareness-day-2014/|archive-date=30 April 2014}}

{{Portal|Medicine}}

{{div col|colwidth=20em}}

• Congenital central hypoventilation syndrome
• Modes of mechanical ventilation
• Periodic breathing
• Obesity hypoventilation syndrome
• Respiratory disturbance index (RDI)
• Upper airway resistance syndrome

{{div col end}}

{{Reflist}}

{{Medical resources

| DiseasesDB =

| ICD11 = {{ICD11|7A40}}, {{ICD11|7A41}},

| ICD10 = {{ICD10|G47.3}},{{ICD10|P28.3}}

| ICD9 = {{ICD9|327.23}}, {{ICD9|780.57}}

| ICDO =

| OMIM =

| MedlinePlus = 000811

| MedlinePlus_mult = {{MedlinePlus2|003997}}

| eMedicineSubj = ped

| eMedicineTopic = 2114

| MeshID = D012891

}}

{{Sleep}}

{{Authority control}}

{{DEFAULTSORT:Sleep Apnea}}

Category:Breathing abnormalities

Category:Medical conditions related to obesity

Category:Sleep disorders

Category:Sleep physiology

Category:Wikipedia medicine articles ready to translate

Category:Wikipedia neurology articles ready to translate

Category:Otorhinolaryngology