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In the same local population study, in fact, 1 in 10 suffers from severe obstructive sleep apnea.
Obstructive sleep apnea (OSA) is a condition where people have partial or complete blockage of their breathing passage, leading to low oxygen levels, fragmented sleep and daytime sleepiness.
Obstructive sleep apnea is a chronic sleep disorder with serious health and daily life consequences. This is because obstructive sleep apnea has been shown to be connected to increased incidence of coronary heart disease, irregular heart rhythm, stroke and high blood pressure. It can also cause poor concentration and daytime fatigue, which can affect school and work performance.
Obstructive sleep apnea treatment has advanced over the last few decades. Whilst continuous positive airway pressure remains the standard treatment, other treatment options such as mandibular advancement device, positional therapy, bariatric surgery, upper airway soft tissue surgery, transoral robotic surgery, maxillomandibular advancement surgery, myofunctional therapy are also available as treatment strategies for suitable select patients.
In this 'Ask the Specialist' Q&A forum, Dr Phua Chu Qin, Consultant from the Department of Otolaryngology (ENT) at Sengkang General Hospital (SKH), a member of the SingHealth group, answers your questions or concerns about snoring and sleep apnea symptoms, diagnosis, non-invasive treatment options and modern surgical treatment techniques for sleep apnea.
This forum is open from 15 Mar to 18 Apr 2022.
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If you have problems posting your questions, please email your questions to marcom@healthxchange.com.sg
Kindly note: Your question will only go live / appear on this page after the doctor answers it
Hi Dr,
I have sleep apnea for many years. I have seeked treatment at SGH around 20 years ago and did a deviated septum surgery. I was asked by the doctor to try implant but I wasnt ready. Few years back I visited NTF hospital and was advised to try the CPAP but I could not sleep wearing the device, so I discontinued.
The past 2 years, my snoring became very bad and loud, my wife told me I got choked many times during my sleep and she got to shake me. I always woke up in the morning feeling very tired and my mental health affected. Please advise if there are any new non invasive treatment that I can try.
Answered by Dr Phua Chu Qin, Consultant, Department of Otolaryngology (ENT), Sengkang General Hospital (SKH)
Dear Sir, thank you for sharing your concerns and question. Your experience is one that is not uncommon, which I have seen in some of our patients as well. I can see that you have had some experience with previous treatment but you are still plight with the symptoms of sleep apnea.
There are few options available, however this would depend on your clinical suitability.
Hello Dr Phua, I currently on CPAP machine for my OSA for about 15 years. Initially when I use the CPAP for first few months, I felt life changes dramatically and felt so much fresher after woke up. As times goes by, my body expects more and seen like it was not satisfy with the CPAP machine from achieving optimal result which is the "feeling fresh" after woke up. And also I find it difficult to use CPAP to fall asleep because the air keep pushing in even at low level and make me not able to fall sleep with it so I had to somehow fall asleep first and woke up mayb 3 hours later then start put on CPAP when I in half awake mode. Therefore my usage is about 4 to 5 hours and my AHI is average reading betwwen 1 to 2. Although the reading is low but I still feel tired and I don't get that "feeling fresh" feel comparing to my initial use of CPAP.
Any advice or recommendation to improve my sleep quality? Thank you.
Dear Kenixora, sounds like you had some initial improvement of symptoms with CPAP and the effect seemed to have worn off.
If you have difficulty using CPAP to fall asleep and is finding it hard with the air pressure pushing in, it can be useful to see a Sleep technologist or sleep doctor to have your CPAP data downloaded and reviewed so they can help you troubleshoot. It is advisable for you to bring your masks and machine along as well so they can also check your mask fit and make adjustment to your machine as needed.
It might be also worth visiting a Sleep Surgeon as there can be some surgery such as nose surgery or tonsil surgery which can be done to help you use CPAP better and with more ease.
How do we know that we have OSA, and that it is serious enough for action to be taken?
Dear askachee,
In order to know if you have obstructive sleep apnoea (OSA), you will need to have a sleep study test done - ordered through a doctor. However, prior to that, you can do some self-screening using the ‘STOP BANG’ questionnaire.
S – Do you snore loudly?T – Do you often feel tired or sleepy during the daytime?O – Observed: has anyone observed that have you stopped breathing/choking/gasping?P – Pressure: Do you have high blood pressure?B – Body mass index of more than 35kg/mA – Age older than 50N – Neck size More than 40cmG – Male genderIf your answer is "yes" to five or more questions, you are considered high-risk for OSA and it is advisable that you see an ENT specialist/Sleep Centre/Respiratory Specialist/Sleep Specialist for evaluation.
During sleeping what is the oximeter reading?
In the event of central Apnea or arousal, what is the oximeter reading?
Dear Khoo K K, thank you for your question.
In a generally healthy population, the normal overnight average oxygen saturation is 96%. This value can decrease if there are any apnoea, underlying lung or heart problems, or any other sleep disorder.
In the event that there is any central apnoea, the oximeter reading would drop or decrease. However, it is not possible to predict what the oximeter would be as the oxygen saturation would differ between patients with various factors such as duration of the apnoea itself (the longer the apnoea, the worse the oximeter reading), any other associated lung or heart problem and so on. Arousals generally do not lead to a drop in oximeter reading
I always snore loudly when I sleep. How can I get this diagnosed to see whether I am suffering from OSA?
Dear ECKW1910, thank you for sharing your concerns.
It is good that you are aware of your condition and is keen to seek help. In order to have your snoring checked to see if you have OSA, it is best for you to arrange an appointment with an ENT specialist/ Respiratory Specialist/ Sleep Centre/Sleep Specialist for evaluation.
The usual process would involve the doctor asking you more questions about your sleep and daytime function, examining your weight, mouth, nose and sometimes throat to see if there are any areas of narrowing. It is also common that the doctor would organise a sleep study for you to evaluate for obstructive sleep apnoea.
I am told I snore loudly but I really don't think it's sleep apnoea! What can I do to cut down on the loud snoring?
Dear ASelviA, thank you for your question.
From snoring alone, it is difficult (not just for you but for doctors as well!) to decipher or predict if you have sleep apnoea. Sleep apnoea is often associated with other symptoms such as daytime tiredness, feeling sleepy, poor sleep quality at night, choking or gasping at night, waking up to pee at night frequently, dry mouth and more.
If you have any of these symptoms or are simply concerned about your snoring, it is worth seeing your polyclinic doctor/GP/ENT specialist/Respiratory Specialist/ Sleep Centre/Sleep Specialist for evaluation as the doctors can better advise if a sleep study is required after a more detailed evaluation.
To cut down on loud snoring, there are a few things you can potentially try. This involves:
However, again, it is advisable to consider seeing a doctor who can help you first ensure that you do not have an underlying sleep apnoea condition and they can personalise therapy for your snoring based on your weight and clinical examination findings (whether you have blocked nose, large tonsils etc.), and your usual sleep habits. A targeted therapy can be more effective.
Hi Dr, my question:
I have been on CPAP since 2009.
I stopped using it since CB in 2020 but recently resumed CPAP on advice of my doctor.
Since resumption, I did not enjoy the same quality of sleep when I was not using CPAP for the past 2 years.
Has my condition changed? For better or worse?
Please advise. Thank you.
Dear teomarcus71,
Thank you for your question on your CPAP usage. From what you have described, there can be a few reasons as to why your quality of sleep has changed despite therapy.
Mask issue – your mask might be old and might be causing leakage which can lead to your CPAP therapy being less than therapeutic (subtherapeutic).
Machine issue – it is said that generally, most CPAP machines can last 8 to 10 years. If your machine has been with you since 2009, perhaps it is worth bringing it to the vendor for them to check if it is still functioning normally.
Usage problem – your CPAP usage might have changed from before, if you are using CPAP for lesser hours, it might not be as effective.
Worsening of condition – worsening of your sleep apnoea condition is a possible explanation. However, if your CPAP machine is still doing its job in providing effective therapy for you, your sleep quality should remain unchanged.
Other factors that affect sleep – work stress, sleep environment.
It is hard to be fully comprehensive here without details. It is therefore advisable that you see a sleep specialist and bring along your CPAP data card (each CPAP machine should have an SD card at the side that stores your usage data). They can help you troubleshoot your sleep habits, sleep hours, mask fit, machine readings, etc. to get to the root of the problem. You can also consider taking your CPAP machine for a check and servicing.
Hi Dr Phua,
Is it true that using Cpap machine is still the best option for severe OSA ?
If surgery to trim the palates is another option, how soon will it take for the palates to grow again?
How is the non invasive surgery done for OSA?
Please advise.
Thank you and Best Regards
Dear kkp008,
Thank you for your question. Yes, CPAP remains the gold standard recommendation worldwide for patients with sleep apnoea, particularly those with severe obstructive sleep apnoea, because when patients are able to tolerate CPAP therapy, CPAP therapy is more efficacious compared to other options.
However, we do appreciate that using CPAP is sometimes not very palatable to some patients or can be daunting for some. So we sometimes do help patients explore other options (when suitable), including upper airway surgery, dental appliance, positional therapy, weight loss surgery, myofunctional therapy and more. Equally, there are more and more efforts to help support patients through their CPAP therapy, so to increase their therapy success rates.
Palates do not re-grow following trimming. However, muscle laxity of the surrounding throat can get worse with age, which can lead to a recurrence of snoring and other sleep apnoea symptoms.
Minimally-invasive surgeries have been described for obstructive sleep apnoea. It includes procedures that apply radiofrequency (a heat-generating mechanism to reduce tissue volume and help it stiffen tissues) to the nose (turbinate), palate and tongue tissues, to reduce tissue volume and stiffen them, so to reduce airway obstruction and collapse during sleep.
However, in order for minimally-invasive surgeries to be effective, there are multiple considerations, including the patient’s weight, the severity of sleep apnoea, presence of a small chin and more.
Hi Dr, what are some preventive measures we can take to avoid developing sleep apnea? Are there certain sleeping postures we should adopt/avoid?
Dear Anonymous, thank you for your questions.
Prevention is indeed better than cure. For obstructive sleep apnoea, one of the things people can work on is to ensure weight control. Weight gain leads to fat deposition in the tongue and throat, which narrows the airway, and can lead to obstructive sleep apnoea. So if one is overweight, it is good to work on weight reduction. If one has a normal body weight, it is still advisable to perform regular exercise and eat a healthy diet to avoid any excessive weight gain.
If one has nasal allergies (sinus or allergic rhinitis condition), it is useful to have these controlled by avoiding the allergen or using medication such as intranasal steroid spray, to ensure a clear nasal passage for nasal breathing during sleep. This is because if the nose is blocked, it can lead to mouth breathing, which can lead to the tongue flopping backward which can make the upper airway narrower.
There are recommended sleep postures to recommend per se. In a patient with a normal airway, one should be able to sleep on their back or sides whenever they want. However, for patients who snore or have sleep apnoea, a subset of them have improved snoring and sleep apnoea when they lie on their sides. So this method can be used as part of the treatment options for snoring or sleep apnoea.
Why does my husband snore most of the time? Could there be an issue with the position or the height of his pillow?
Dear VYK, from a physical viewpoint, there are three main reasons why people snore. This includes being overweight, having a small chin or flat cheeks, or having soft tissue enlargement (large tonsils, blocked nose, large tongue).
These three factors can contribute to the narrowing of the upper airway. A narrow air passage can lead to turbulence in airflow, which then leads to the vibration of the upper airway tissue, creating the snoring sound that your husband makes.
Pillow height can be used to improve some (not all) patients’ snoring, whereby some patients do snore less when they sleep on a higher pillow.
Hi Dr, senior citizens above 70, like me have OSA and wonder if surgery can be an option to be considered if it is not high risk and does improve the breathing. Will it be made affordable considering the relatively high medical costs.
Dear Anonymous, thank you for your question. Surgery for obstructive sleep apnoea can be an option for senior citizens like yourself. When medically indicated, sleep apnoea surgery is MediSave deductible, which usually helps most of our patients cover the cost.
When deciding on surgery, considerations do have to be given to the risks of general anaesthesia, risks of surgery, the potential benefit from the surgery, as well as risks and benefits of other alternatives.
Hi I was diagnosed with moderate (almost bordering on severe) sleep apnea after a home sleep test and have been using a cpap machine for 2 years. Will my condition reverse or will I be dependent on it forever? Now I feel that I don't dare to sleep unless I have the cpap machine on. Otherwise I wake up feeling even more tired than before resting. Also sometimes I wake up when I forgot to use the cpap machine, feeling like i forgot to breath. Is that the same as obstructive sleep apnea?
Dear Blubber, thank you for your question. Sleep apnoea for adults is usually hard to reverse, and a large number of patients do have to use the CPAP machine long-term. The concept of wearing CPAP is akin to a short-sighted person wearing glasses – they are able to see when they wear the glasses and are unable to see clearly when they don’t. The same goes for CPAP- it provides a mechanical force to open up your airway when you sleep. Your airway is open when you wear it and collapses when you are sleeping if you don’t.
That said, there are instances where patients are able to achieve a cure or a milder form of obstructive sleep apnoea, such that they can get off CPAP. However, these usually require significant weight loss in a patient whose weight is the main contributor to their sleep apnoea, or in some patients who have undergone surgery such as maxillomandibular advancement surgery (surgery to advance the cheek and jaw to increase the upper airway space). Some patients with mild obstructive sleep apnoea can also potentially improve sufficiently by doing myofunctional therapy regularly (tongue and throat exercises to tone the upper airway).
When you wake up after forgetting to use the CPAP machine, with the feeling like you forgot to breathe, that is likely because your obstructive sleep apnoea is causing your airway to close shut when you sleep. When you feel tired after not using CPAP, this is also likely to be due to your sleep apnoea condition itself. This is because when you are not wearing CPAP, your sleep apnoea condition means that your air passage is likely to be narrowing again during sleep. This usually leads to the reduction of oxygen levels in your body, which stresses your body and causes your body to react - making you slightly awake, so you would breathe again to get oxygen. When this happens, there is a mini-arousal, which means that you are slightly awake, but you might not have remembered the episode. However, if this happens frequently, it gives you very fragmented and poor sleep, which can cause you to be tired.
It is therefore advisable for you to continue using your CPAP particularly if you are deriving benefit from it (less tired). Whilst the idea of using CPAP long-term can sound dreary, you might be able to think of it as an investment for your health. By using CPAP therapy regularly when you have sleep apnoea, you have better sleep and more energy to do things during the day. It can also potentially reduce the risks of other sleep apnoea-related complications such as high blood pressure, heart attack, stroke, irregular heart rhythm and more.
Hi Dr, I was diagnosed with Servere OSA after a sleep study and have been using a CPAP for many years.
Is this treatment lifelong?
When can I stop using the CPAP?
When should I go for another sleep study?
I have lost some weight and have been exercising everday. Will this help in my OSA?
Dear Greenpepper, thank you for your question on CPAP therapy. Yes, unfortunately, for adults, most obstructive sleep apnoea is not reversible, and CPAP therapy does have to be lifelong. The concept of wearing CPAP is akin to a short-sighted person wearing glasses – they are able to see when they wear the glasses and are unable to see clearly when they don’t. The same goes for CPAP- it provides a mechanical force to open up your airway when you sleep. Your airway is open when you wear it and collapses when you are sleeping if you don’t.
Hi Dr, I am using a ResMed CPAP Airsense 10 Autoset with full face mask. My pressure setting is between 4 and 18. I have set the Ramp Time at 4. I noticed that the pressure climbs up to almost 17 in the early hours of the morning.
Is it correct to say the high pressure is due to my slow breathing?
Dear lowhl, thank you for your question. I can only postulate based on the information you gave. One of the possible explanations for your higher pressure in the early hours is as follows.
Usually, later into the night or early morning hours, most of us go into a longer REM sleep. REM sleep is also known as rapid eye movement sleep. This is a stage of sleep where we have reduced muscle tone in most of our body muscles, including the muscles of our upper airway.
As a result of this reduced tone, it can make your sleep apnoea worse during REM sleep. The CPAP machine is therefore likely to sense that you require a higher pressure during this stage of sleep (which usually happens more in the early hours of the morning), and therefore provides you with higher pressure.
Hello Dr Phua,every morning when I woke up I feel my throat dry and at night during sleep I'm snoring. I've been trying to sleep on the side but it's hard to stay at that position. I would like to get advice from you. Thank you.
Dear angie1990, thank you for your question. If you are experiencing snoring and dry throat during sleep, sometimes this can be due to a nose blockage issue such as a sensitive nose causing nose blockage. It can be useful if you were to see a doctor about your nose, as sometimes using nasal spray for nose blockage, can help you avoid breathing through your mouth while sleeping and can reduce your snoring as well.
For sleeping aids to help you sleep in side positions, you can consider a few options:
Tennis ball therapy – sew a tennis ball to the back of a t-shirt and wear it while sleeping. The idea is that when you lie on your back with that tennis ball, you will feel the object (tennis ball) there, which then makes you lie on your side instead.
Pregnancy pillow - Alternatively, the pregnancy pillow (U-shaped pillow) available on most online stores, can help you sleep on the side.
Hi Dr, how does sleep apnoea cause stroke?
Do all types of irregular heart rhythms related to sleep apnea cause stroke or only if its atrial fibrillation?
Dear Ling00, thank you for your question. The mechanisms of sleep apnoea leading to stroke are not fully known. One of the common explanations include a drop in blood oxygen level during apnoea episodes, leading to the inflammation and production of reactive oxygen species, which can increase the clotting in blood vessels, leading to stroke.
Various types of irregular heart rhythm can lead to stroke. However, atrial fibrillation (a heart rhythm disorder) is by far the most common.
Hi Dr, how can OSA be correctly diagnosed without visiting the doctors?
Are there non surgical methods that can improve sleep and rid OSA?
Dear sunandsea1, in order to know if you have obstructive sleep apnoea (OSA), you will need to have a sleep study test done ordered through a doctor. However, prior to that, you can do some self-screening using the ‘STOP BANG’ questionnaire to evaluate your risk factor for sleep apnoea. However, this sort of screening does not replace a sleep study, which is the gold standard to achieve a diagnosis.
S – Do you snore loudly?T – Do you often feel tired or sleepy during the daytime?O – Observed: has anyone observed that have you stopped breathing/choking/gasping?P – Pressure: Do you have high blood pressure?
B – Body mass index of more than 35kg/mA – Age older than 50N – Neck size more than 40cmG – Male gender
If your answer is "yes" to five or more questions, you are considered high-risk for OSA and it is advisable that you see an ENT specialist/Sleep Centre/Respiratory Specialist/Sleep Specialist for evaluation.
Non-surgical methods for treatment of sleep apnoea include continuous positive airway pressure therapy (CPAP), mandibular advancement device, positional therapy, weight loss, treatment of nasal allergies, and oral myofunctional therapy. These treatments can be used as a standalone therapy or in combination. Suitability for the various therapy does require information such as how severe your sleep apnoea might be or whether there is any improvement seen in different sleep positions, which are information that can be obtained from a sleep study.
Hello Dr Phua, would like to ask how do I know if I have sleep apnea? My dad has sleep apnea and he has to use cpap machine to sleep. Hence, I am worried that I might have sleep apnea too. I do not know if I snore during my sleep, as I sleep alone. I wake up with a dry mouth in the morning, as I tend to use my mouth to breathe. Is there anything that I can do now, so that I can prevent myself from having sleep apnea issues? Thank you :)
Hi Beatricechia, thank you for your question. I can see why you are concerned. If sleep apnoea runs in your family, you are at risk of sleep apnoea. In order to know if you have obstructive sleep apnoea (OSA), you will need to have a sleep study test done - ordered through a doctor.
However, prior to that, you can do some self-screening using the ‘STOP BANG’ questionnaire.
To try and reduce risk factors for snoring or sleep apnoea, there are a few efforts that can be made
Avoid weight gain, or if you are overweight, consider weight loss
Avoid alcohol before bed
If you have nasal allergy causing nasal blockage, consider getting it treated
Regular tongue and throat exercises (oral myofunctional therapy) can be considered to tone up the tongue and throat to prevent collapse
However, that said and done, if you are concerned about your sleep and snoring, it is best to visit a doctor to get a diagnosis and treatment, as that can allow a more targeted and effective solution to your concerns.
Hello Dr Phua, My fitbit app said my blood oxygen saturation during sleep at times with high variations. And this can be linked to breathing issues. Would this be classified as having sleep apnea? Thank you.
Dear OPTOUT, thank you for your question. There is a lot of interest in sleep wearables and how they can be used to improve our sleep. It is something that I see a lot of potential with for the future.
However, at present, as per the American Academy of Sleep Medicine Position Statement, sleep wearables like Fitbit cannot be utilised for the diagnosis of sleep apnoea as yet. If your Fitbit app has prompted that you have a drop in blood oxygen and high variation, it may suggest potential sleep breathing issues such as obstructive sleep apnoea.
However, likewise, it could be a wide variety of other reasons. It would still be advisable to see a doctor and consider a sleep study for diagnosis.
In my first sleep test I was diagnosed with moderate OSA with a predominant CA. In my second sleep test which was 6 months apart. I was diagnosed with mild OSA. I sorted treatment using the CPAP. While my OSA was resolved with CPAP but my CA is going wild. In average my OSA is below 5, my CA can reach up to 22 and I observed CSR events are starting to appear more and more reguarly in my CPAP report. I have been on CPAP for 2 months+.
My questions are, (1) is there a concern if the CA continue to at this level. (2) could it be an inaccurate titration or the setting pressure of the CPAP machine that resulted a high CA?
Dear Winnie, thank you for your questions. We do need more information, for instance, the two sleep tests that were done for you, are they the same type of in-hospital sleep study or are they different? Also, did anything change during that 6 months? For instance, did you lose weight or did you have any surgery done?
I will try my best to answer your questions based on the available information. However, it is best to consider a follow-up at a Sleep/Respiratory Specialist clinic as there are a few possible explanations for your condition, and it might require more information and further evaluation to ensure the right treatment is administered.
If your OSA symptoms resolved with CPAP, but the central apnoea index has gone wild, this could be suggestive of a condition called "Treatment-Emergent Central Sleep Apnoea" or "complex sleep apnoea". This is a unique sleep disorder that occurs when there is an emergence or persistent central apnoea during the treatment of obstructive sleep apnoea. This treatment-emergent central sleep apnoea tends to resolve spontaneously over time with ongoing treatment CPAP. However, if the central sleep apnoea component persists, you may need other treatment approaches such as adaptive servo-ventilation. This requires monitoring and review from the Sleep/Respiratory specialist.
That said, if your initial sleep test showed a central apnoea component, it might be that your central apnoea is not treated. The treatment for Central sleep apnoea does require an evaluation of the cause of your central sleep apnoea. For instance, did you have any pre-existing conditions such as heart failure or stroke which can potentially lead to central apnoea? In summary, your condition is a tad complicated and it is highly advisable you see a sleep/respiratory specialist for further management. Referral can be obtained from the polyclinic.
