Diagnosis for Sleep Apnea: Understanding Tests and Evaluations

If you suspect you might have sleep apnea, getting a proper diagnosis is the first crucial step towards better sleep and health. Your journey to diagnosis typically begins with your healthcare provider, who will assess your symptoms and sleep history. To aid this process, input from a bed partner or household member can be invaluable in providing a comprehensive picture of your sleep habits.

Often, your primary healthcare provider will refer you to a specialized sleep disorder center. Here, sleep specialists are equipped to conduct thorough evaluations and determine the necessity of further, more detailed testing. This evaluation frequently involves overnight monitoring at a sleep center, where your breathing and various bodily functions are carefully tracked as you sleep. In certain situations, home sleep testing might also be a viable alternative for initial assessment.

Several tests are employed to diagnose sleep apnea, each designed to monitor different aspects of your sleep and breathing patterns:

Nocturnal Polysomnography. This comprehensive sleep study is conducted overnight at a sleep center. During nocturnal polysomnography, you will be connected to sophisticated equipment that records a range of physiological data. This includes your heart rate and rhythm, lung and brain activity, breathing patterns (both effort and airflow), arm and leg movements, and blood oxygen saturation levels. Polysomnography provides a detailed overview of your sleep architecture and any disruptions caused by sleep apnea.
Home Sleep Tests. For a more convenient initial assessment, your healthcare provider may offer simplified sleep apnea tests that can be administered in the comfort of your own home. These home sleep tests typically monitor key indicators such as heart rate, blood oxygen level, airflow through your nose and mouth, and breathing patterns. It’s important to note that while home sleep tests are convenient, polysomnography in a sleep facility is generally recommended if central sleep apnea is suspected due to its ability to capture more nuanced data.

If the results from either type of sleep test are not clearly indicative of sleep apnea, or if they fall within a borderline range, your healthcare provider may still recommend further investigation, potentially including in-lab polysomnography. This is because portable monitoring devices used in home sleep tests can sometimes miss or underestimate the severity of sleep apnea. Conversely, if the test results are clearly positive for obstructive sleep apnea, your provider may be able to initiate therapy without requiring further testing.

For individuals diagnosed with obstructive sleep apnea (OSA), it is common for healthcare providers to recommend a consultation with an ear, nose, and throat (ENT) specialist. This referral is crucial to rule out any physical blockages in the nasal passages or throat that might be contributing to the OSA. In cases where central sleep apnea (CSA) is diagnosed or suspected, evaluation by a heart specialist (cardiologist) or a neurologist (a doctor specializing in the nervous system) may be necessary. These specialists can investigate underlying conditions related to the heart or nervous system that could be causing or contributing to central sleep apnea.

Continuous Positive Airway Pressure (CPAP)

One of the most common and effective treatments for sleep apnea, particularly obstructive sleep apnea, is Continuous Positive Airway Pressure (CPAP) therapy. A CPAP machine is designed to deliver a consistent stream of air pressure through a mask that you wear while sleeping. This continuous pressure is carefully calibrated to be just enough to keep your upper airway passages open, effectively preventing the collapse that leads to snoring and the pauses in breathing characteristic of sleep apnea.

For individuals with milder forms of sleep apnea, initial recommendations may focus on lifestyle adjustments. These often include strategies such as weight loss if overweight or obese, and smoking cessation for smokers. Changing sleep positions, particularly avoiding sleeping on your back, can also be beneficial. If nasal allergies are present, addressing and managing these allergies may also help to improve breathing during sleep.

However, if lifestyle modifications alone do not provide sufficient relief from symptoms, or in cases of moderate to severe sleep apnea, a range of other treatment options are available. These include various devices designed to maintain an open airway during sleep, and in some instances, surgical interventions may be considered.

Therapies for Obstructive Sleep Apnea (OSA)

Continuous Positive Airway Pressure (CPAP). As mentioned earlier, CPAP is a cornerstone therapy for moderate to severe obstructive sleep apnea. The machine delivers pressurized air via a mask, ensuring that the airway remains open throughout the night. While highly effective, some individuals may initially find CPAP cumbersome or uncomfortable. Perseverance is key; most people successfully adjust to CPAP therapy with practice. Fine-tuning the mask strap tension is important to achieve a comfortable and secure fit. Exploring different mask types and sizes is also often necessary to find the most suitable option. If you encounter difficulties with your CPAP machine, consulting your healthcare provider is essential. They can offer guidance on adjustments to improve comfort and address any ongoing issues, including persistent snoring despite treatment, which may indicate a need to adjust the pressure settings, especially if your weight has changed.
Other Airway Pressure Devices. Beyond standard CPAP, alternative airway pressure devices are available. Auto-CPAP machines automatically adjust the pressure level throughout the night based on your breathing needs, potentially enhancing comfort. Bilevel Positive Airway Pressure (BPAP) devices offer different pressure levels for inhalation and exhalation, which some users find more comfortable.
Oral Appliances. Another non-surgical treatment modality is oral appliances. These devices, custom-fitted by a dentist, are designed to keep the throat open during sleep. While CPAP generally demonstrates superior efficacy, oral appliances can be easier for some individuals to use and tolerate, particularly for mild to moderate OSA. Many oral appliances work by gently advancing the lower jaw forward, which can enlarge the airway and reduce snoring and mild sleep apnea. Finding the right oral appliance may require trying several different types. Once fitted, regular follow-up appointments with your dentist are crucial, especially in the first year and then periodically thereafter, to ensure proper fit, assess effectiveness, and make any necessary adjustments.

It’s important to be discerning when considering advertised sleep apnea treatments, particularly those promoted online or on television. Always discuss any potential treatment with your healthcare provider before trying it to ensure its appropriateness and safety for your specific condition.

Surgery for Obstructive Sleep Apnea (OSA)

Surgical intervention for OSA is generally considered when other, less invasive treatments have been unsuccessful. Typically, a trial period of at least three months with other treatment options is recommended before considering surgery. However, in a small subset of individuals with specific jaw structure abnormalities, surgery may be considered as a primary treatment option.

Surgical options for OSA include:

Tissue Removal (Uvulopalatopharyngoplasty – UPPP). This procedure involves the surgical removal of tissue from the back of the mouth and the upper part of the throat. Often, the tonsils and adenoids are also removed during UPPP. While UPPP can be effective in reducing snoring by addressing vibrations of throat structures, it is generally less effective than CPAP and is not considered a first-line treatment for OSA. Radiofrequency ablation, which uses radiofrequency energy to remove tissue in the back of the throat, is another tissue removal option that may be considered for patients who cannot tolerate CPAP or oral appliances.
Tissue Shrinkage (Radiofrequency Ablation). This less invasive procedure uses radiofrequency energy to shrink tissue in the rear of the mouth and back of the throat. It may be suitable for mild to moderate sleep apnea. Studies suggest that tissue shrinkage via radiofrequency ablation can have similar effects to tissue removal with potentially fewer surgical risks.
Jaw Repositioning (Maxillomandibular Advancement – MMA). This more complex surgical procedure involves moving the upper and lower jaws forward relative to other facial bones. MMA significantly enlarges the space behind the tongue and soft palate, dramatically reducing the likelihood of airway obstruction.
Implants. This procedure involves surgically implanting small, soft rods, typically made of polyester or plastic, into the soft palate. The aim of these implants is to stiffen the soft palate and reduce airway collapse. However, further research is needed to definitively determine the long-term effectiveness of palatal implants.
Nerve Stimulation (Hypoglossal Nerve Stimulation). This more recent surgical approach involves implanting a stimulator that targets the hypoglossal nerve, which controls tongue movement. By stimulating this nerve, the tongue is prompted to move forward, helping to maintain an open airway. Like implants, more research is ongoing to fully evaluate the efficacy and long-term outcomes of hypoglossal nerve stimulation for OSA.
Tracheostomy. In cases of severe, life-threatening sleep apnea that have not responded to any other treatments, a tracheostomy may be necessary. This procedure involves creating a surgical opening in the neck and inserting a tube directly into the trachea (windpipe). During the day, the opening is typically covered, but at night, uncovering it allows air to bypass any upper airway obstruction and flow directly into and out of the lungs.

Other surgical procedures that may indirectly aid in OSA treatment by improving airflow include:

Surgery to remove enlarged tonsils or adenoids, particularly in children with OSA.
Bariatric surgery (weight-loss surgery) for individuals with obesity-related OSA.

Therapies for Central Sleep Apnea (CSA)

Treatment for Associated Medical Problems. Central sleep apnea is often linked to underlying medical conditions such as heart disorders or neuromuscular diseases. Addressing and treating these underlying conditions is often the first step in managing CSA. Additional therapies that may be used for CSA include supplemental oxygen, CPAP, BPAP, and Adaptive Servo-Ventilation (ASV).
Medicine Changes. Certain medications can affect breathing patterns and potentially worsen central sleep apnea. If medications, such as opioid pain relievers, are suspected to be contributing to CSA, your healthcare provider may adjust or change your medication regimen. In some cases, medications like acetazolamide may be prescribed to help regulate breathing.
Supplemental Oxygen. Using supplemental oxygen during sleep can be beneficial for some individuals with central sleep apnea. Various oxygen delivery systems are available to provide oxygen to the lungs throughout the night.
Adaptive Servo-Ventilation (ASV). ASV is a more advanced airflow device specifically designed for central sleep apnea and complex sleep apnea. ASV machines use sophisticated algorithms to learn and monitor your individual breathing patterns. During sleep, the machine automatically adjusts the pressure support to regulate your breathing, preventing pauses and irregularities. While ASV can be effective for certain types of CSA, including treatment-emergent central sleep apnea, it is generally not recommended for individuals with predominant central sleep apnea and advanced heart failure due to potential risks. Moreover, ASV is contraindicated for those with severe heart failure.

Many CPAP Mask Options Available

Continuous Positive Airway Pressure (CPAP) masks and headgear are available in a wide array of styles, sizes, and designs to ensure comfortable and effective sleep apnea treatment. Recognizing that individual needs, preferences, and facial features vary significantly, it is often necessary to try several different mask styles and brands to find the optimal fit and functionality.

Mask sizing can also vary across different styles and manufacturers. A particular size in one mask style does not guarantee the same size will be appropriate in another. Proper mask sizing is critical for both comfort and the therapeutic effectiveness of CPAP therapy.

Here’s an overview of common CPAP mask styles and their potential benefits:

Nasal Pillow Mask

Nasal pillow masks feature small, soft cushions that fit directly into the nostrils (nares) to deliver pressurized air.

Nasal pillow masks might be a good choice if:

You experience claustrophobia with masks that cover a larger portion of your face.
You prefer an unobstructed field of vision for activities like reading or watching television before bed.
You need to wear eyeglasses while using CPAP.
You have facial hair that interferes with the seal of other mask types.

Nasal Masks

Nasal masks cover the entire nose and deliver air pressure through this interface.

Nasal masks might be a good choice if:

Your doctor has prescribed a higher air pressure setting for your CPAP therapy.
You tend to move around frequently during sleep.

Full-Face Masks

Full-face masks cover both the nose and mouth, delivering air pressure to both airways.

Full-face masks might be a good choice if:

You experience nasal obstruction or congestion that makes breathing through your nose difficult.
You tend to breathe through your mouth at night, even after trying a nasal mask or nasal pillow in combination with a heated humidifier or chin strap (or both) to encourage mouth closure.

Lifestyle and Home Remedies

In addition to medical treatments, certain lifestyle adjustments and home remedies can play a significant role in managing both obstructive and central sleep apnea.

Lose Excess Weight. Even modest weight loss can alleviate pressure on your throat and upper airway. In some instances, sleep apnea may resolve entirely with weight loss, although it can recur if weight is regained.
Exercise Regularly. Regular physical activity can improve the symptoms of obstructive sleep apnea, even without significant weight loss. Aim for at least 30 minutes of moderate-intensity exercise, such as brisk walking, on most days of the week.
Avoid Alcohol and Certain Medications. Alcohol, tranquilizers, and sleeping pills can relax the muscles in the back of your throat, potentially worsening sleep apnea by further obstructing airflow.
Sleep on Your Side or Abdomen. Sleeping on your back can encourage the tongue and soft palate to fall back against the throat, narrowing or blocking the airway. To help maintain a side-sleeping position, consider sewing a tennis ball into the back of your pajama top. Alternatively, commercially available devices vibrate gently when you roll onto your back during sleep.
Don’t Smoke. Smoking irritates and inflames the airways, exacerbating sleep apnea. If you smoke, seek resources and support to help you quit.

Preparing for Your Appointment

If you or your sleep partner suspect sleep apnea, scheduling an appointment with your primary care provider is the first step. In some cases, you may be referred directly to a sleep specialist.

To make the most of your appointment, consider the following preparation tips:

What You Can Do

When scheduling, ask if there are any pre-appointment instructions, such as dietary modifications or keeping a sleep diary.
Compile a comprehensive list of:
- Your symptoms, including any that may seem unrelated to sleep, noting when they began.
- Key personal information, including any family history of sleep disorders.
- All medications, vitamins, and supplements you currently take, including dosages.
- Questions you want to ask your doctor.
If possible, bring a family member or friend to the appointment to assist with remembering information. Ideally, your bed partner should accompany you, as they can provide valuable firsthand observations of your sleep habits and symptoms.

Questions to Ask Your Doctor about Sleep Apnea:

What is the most likely cause of my symptoms?
What diagnostic tests are needed? Do these tests require any special preparation?
Is my condition likely to be temporary or chronic?
What treatment options are available?
Which treatment approach do you recommend for me?
I have other health conditions. How can sleep apnea and my other conditions be managed together effectively?
Should I consult a sleep specialist?
Are there any educational brochures or reliable websites you recommend for further information?

What to Expect From Your Doctor

Your healthcare provider is likely to ask you a series of questions to better understand your symptoms and medical history. Be prepared to discuss:

The nature of your symptoms: Are they continuous, or do they come and go?
The severity of your symptoms.
How your bed partner describes your sleep symptoms.
Whether you are aware of stopping breathing during sleep, and if so, how frequently per night.
Any factors that seem to alleviate your symptoms.
Factors that may worsen your symptoms, such as sleep position or alcohol consumption.

What You Can Do in the Meantime

While awaiting your appointment or test results, consider these self-care measures:

Try to sleep on your side.
Avoid alcohol for at least 4 to 6 hours before bedtime.
Refrain from taking sedatives or medications that induce drowsiness unless specifically prescribed by your doctor.
If you experience excessive daytime sleepiness, avoid driving or operating heavy machinery.