Snoring and feeling unrefreshed from sleep?

What you should know and what you can do about sleep-disordered breathing

Snoring and Obstructive Sleep Apnea (OSA) are the most common types of Sleep-Disordered Breathing (SDB).

In a recent global survey on snoring cities, Singapore was identified as one of the top three snoring cities in the world, after Dublin and Canberra that were ranked first and second, respectively.

Not only is snoring prevalent in Singapore, one in three has moderately-severe to severe OSA and is undiagnosed.

Undetected and consequently untreated severe OSA leads to:

Hence, snoring and Obstructive Sleep Apnea (OSA) are linked to serious unmet public health problems. The challenge is to gain public recognition for the need to diagnose the cause of snoring for the right treatment.

In this 'Ask the Specialist' Q&A forum, Dr Mimi Yow, Senior Consultant from the Department of Orthodontics at National Dental Centre Singapore (NDCS), and Dr Phua Chu Qin, Consultant from the Department of Otolaryntology (ENT) at Sengkang General Hospital (SKH), both members of SingHealth group, answers questions on common causes for snoring and sleep apnea, when it is a concern and treatments available (non-interventional and interventional).

This 'Ask the Specialist' forum has closed. Thank you for your interest and participation.   

1. Posted by H***********
Hello, Are tongue exercises beneficial to mitigate against OSA and if so, can you provide a link to learn more about these exercises? Is Invisalign beneficial in improving OSA if the teeth alignment is narrow rather than rounded? What are the options for a patient wanting to improve the symptoms of OSA? CPAP would not be an option I would consider. Thank you.

Answered by Dr Yow :
Hello Mr ***. Thank you for your questions. 

Research studies show that daily exercises involving muscles of the face, mouth, tongue and throat in orofacial myofunctional therapy can help to reduce snoring and the severity of OSA. This SGH video-link shows what orofacial myofunctional therapy looks like:-
https://www.sgh.com.sg/patient-care/conditions-treatments/Orofacial-Myofunctional-Therapy

Orthodontic bone-expanders broaden the palate (roof of the mouth), which is also the floor of the nose. Two outcomes are achieved by this bone expansion. Firstly, it opens up the nose to relieve nasal congestion for better breathing. Secondly, it increases space in the mouth for better placement of the tongue, which helps to reduce airway obstruction at the throat and the severity of OSA. The extra space can be used for alignment of teeth if they are initially crowded, or conversely, the extra space can cause teeth to become spaced. In either case, Invisalign removable braces or bonded braces can be used to align teeth or close the spaces between teeth in the wider jaw bone.

CPAP is by far the most effective treatment for OSA. It is understandable that not everyone can cope with daily use of CPAP and you are not alone. An audit at SGH showed that 60 to 70% patients reject or cannot tolerate CPAP treatment. There are non-surgical and surgical options to be considered after thorough examination and assessments by our sleep team doctors. Conservative or non-surgical treatment other than CPAP include:
◦Weight loss
◦Sleep posture
◦Management of nasal allergies and/or blocked nose
◦Orofacial myofunctional therapy with daily exercises involving the muscles of the face, mouth, tongue and throat
◦Mandibular Advancement Device
◦Tongue Stabilising Device

Surgical treatment is not a substitute for conservative treatment but provides options where non-surgical treatment has not worked. The different types of surgery are:
◦Surgery of the nose
◦Soft tissue surgery of the upper airway
◦Transoral robotic surgery of the tongue
◦Sleep apnea implant
◦Maxillomandibular advancement surgery of the jaws (MMA)
◦Bariatric or weight loss surgery

All the very best to you as you explore the options on the best way to manage your condition to improve your health and quality of life. 


2. Posted by m******
Dear Doctor Mimi Yow,
I'm male 60 year old on medications for HBP, High Cholesterol, Blood Thinner and Diabetic.
I snores whenever I sleep and have Sleep Apnea. Is there cure for Sleep Apnea such as surgery and would it eradicate Sleep Apnea. Other than surgery, any other medical help or treatment Sleep Apnea.
Thank you very much.

Answered by Dr Yow :
Hello M******. Thank you for our questions. 

I can understand your concerns with your snoring, sleep apnea and multiple medical conditions. I trust that you have seen a doctor and had a sleep study to confirm you have sleep apnea. Sleep apnea is a disorder that is treatable but not curable except for very mild sleep apnea. There are three different types of sleep apnea: 
1.Obstructive sleep apnea (OSA); 
2.Central sleep apnea (CSA); and 
3.Mixed OSA and CSA.

Diagnosis is important as it determines the type of treatment for you.
In Singapore, sleep studies reveal one in three of the community has moderately severe to severe OSA. More than 90% are unaware they have OSA and remain untreated. 

Individuals with untreated sleep apnea are at risk for multiple medical conditions with serious health and daily life consequences: hypertension, coronary artery disease, angina, heart attack, irregular heart rhythm, stroke, sudden death, diabetes, glaucoma, impaired neurocognition, depression, interrupted sleep, fatigue, daytime sleepiness, lack of vigilance at work or school, and increased risk of road traffic accidents by falling asleep at the wheel while driving.

There are several non-surgical ways of treatment:
◦Weight management
◦Sleep posture
◦Management of nasal allergies and/or blocked nose
◦Orofacial myofunctional therapy with daily exercises involving the muscles of the face, mouth, tongue and throat
◦Continuous Positive Airway Pressure (CPAP) Device
◦Mandibular Advancement Device
◦Tongue Stabilising Device

It is best for you to have a thorough examination by a sleep-trained doctor who can help you to determine the type and severity of sleep apnea you have and the appropriate treatment or combination of treatment that is best suited for your condition. All the very best to you in finding the best solution to manage your health and quality of life. 


3. Posted by R*********
How to prevent snoring?

Answered by Dr Yow :
Hello Mr R********. Thank you for your question. 

Snoring is caused by soft tissue vibrations in the upper airway. It can be due to a small and narrow airway or loose soft tissues in the airway or both. Narrowing of the nose and upper airway may be due to a number of reasons that may overlap: nasal allergy, swellings or polyps in the nose, deviated nasal septum, enlarged tonsils and/or adenoids, long and thick soft palate, big tongue, reduced muscle tone of the airway and tongue, and small jaws. 

Taking alcohol, antihistamines, sedatives and tranquillizers, smoking and nasal congestion can make snoring worse. To reduce snoring, avoid taking substances that make it worse, especially alcohol, in the evening and before going to bed. Sleep on the side rather than on the back, stop mouth breathing by clearing up nasal congestion and strengthen the tongue and throat muscles by daily myofunctional exercises. See a doctor to check if there is anything blocking your nose or pharynx (the airway behind the nose and tongue).

Listen out for family and friends who snore, it is a sign that they may need medical help. Before trying out self-remedies for snoring, it is important to check with a doctor to determine if snoring is a symptom of sleep apnea. 

Prevention is certainly better than cure and I wish you the best of health.


4. Posted by N*****
My ENT doctor believes I have sleep apnea and advises me to do a sleep apnea test. It is very expensive so I am not sure if it is really necessary. How would the test help me?

Answered by Dr Yow :
Hi Nezlo, your doctor is right. It is necessary to have a sleep study to confirm sleep apnea. 

A sleep study measures what happens to you while you sleep:
◦The duration of your sleep
◦How long do you sleep in each stage of the sleep cycle
◦How often is your brain aroused and at which stage of the sleep cycle
◦What is your sleep efficiency
◦Do you have limited airflow or pauses in breathing 
◦How often and how much does your blood oxygen level drop
◦What is your heart rate and rhythm
◦How much do you snore
◦What are your sleeping positions
◦Are there leg or jaw movements 
◦Are there other sleep disorders 

A home-based sleep study is less expensive and costs a few hundred dollars. However, it does not provide as much information as an in-hospital sleep study. If a home-based sleep study cannot rule out that you do not have sleep apnea, you may need to attend an in-hospital sleep study, which is the best available test to diagnose sleep apnea and any overlapping sleep disorder. An in-hospital sleep study can cost a few thousand dollars. If you have medical insurance or qualify for government subsidy, it can help to defray the cost of either a home-based or in-hospital sleep study.

Individuals with untreated sleep apnea are at risk for multiple medical conditions with serious health and daily life consequences such as hypertension, coronary artery disease, angina, heart attack, irregular heartbeats, stroke, sudden death, diabetes, glaucoma, impaired neurocognition, depression, interrupted sleep, fatigue, daytime sleepiness, lack of vigilance at work or school, and increased risk of road traffic accidents by falling asleep at the wheel while driving. Appropriate treatment and adequate follow-up are only possible with proper identification and confirmation of your condition. 

I wish you good health and may it be a priority in your life.


5. Posted by A*****
Hi Doctor,
How can I be sure that I have OSA? I do have the symptoms mentioned. Thanks.

Answered by Dr Yow : 
Hello A*****, you are indeed a wise man who listens to his body. 

You can determine the level of risk you have for OSA by self-screening using the STOP-BANG questionnaire. Screening establishes the level of suspicion for OSA but it does not replace the need for a sleep study. If you want to be absolutely sure if you have or do not have OSA, a sleep study is necessary.

Screening questionnaire: 

S – Do you snore loudly?
T – Do you often feel tired or sleepy during the daytime?
O – Has anyone observed that you have stopped breathing/choking/gasping for breath during sleep?
P – Pressure: do you have high blood pressure?

B – Body mass index (BMI) of more than 35kg/m (weight divided by the square of height)
A – Age older than 50
N – Neck circumference of more than 40cm
G – Male gender

If you have 3 to 4 "yes" answers, it is suggested that you see a doctor for further assessments to confirm if you have sleep apnea. 

If you have 5 or more "yes" answers, it indicates you are at high risk of sleep apnea. You are strongly advised to see a doctor to confirm the diagnosis of sleep apnea and treatment needed.

All the best of health to you.


6. Posted by A*****
Dear Doctor,

I have been wanting to see a doctor for my sleeping disorder and have it diagnosed and treated but I don't know where to start. I am experiencing the signs of snoring, constant tiredness that are mentioned.

Answered by Dr Yow :
Hello A*****. Good on you - you have taken the first step to find out what is the problem behind your snoring and constant daytime tiredness. 

Snoring is caused by soft tissue vibrations due to airflow in a small airway or loose soft tissues in the airway. Narrowing of the nose and upper airway can be caused by many factors: nasal allergy, swellings in the nose, deviated nasal septum, enlarged tonsils and/or adenoids, long and thick soft palate, big tongue or loose airway and tongue muscles, and small jaws.

A detailed examination of your nose, mouth, throat and jaws will be done to determine the possible causes of snoring where the airway is narrow. A sleep study will be necessary to confirm if the snoring and daytime sleepiness are associated with sleep apnea. The appropriate treatment will depend on the sleep study results and clinical assessments. 

You can see your own family doctor or a polyclinic doctor for a referral. An appointment can be made through Health Hub for the Singapore General Hospital, Changi General Hospital or Sengkang General Hospital Otolaryngology (ENT) Service.

All the best to you on your journey to good health.

Follow-up question posted by A*****

Dear Doctor
My sleeping problem is rather disturbing as I can only sleep soundly on my left side. For years I am unable to sleep on my right side as I would choke on my saliva or something else irritating my throat and would cause me to cough badly.
If I sleep face up the cough would also happen or otherwise I would snore after I fall asleep from exhaustion. This happens to me every night and for years.
I have an upcoming health screening at Changi General Hospital next month so am I able to get a referral from the health screening doctor?
I look forward to your reply.

Answered by Dr Yow :
Hello A*****. 
From what you describe, you seem to be choking in your sleep from upper airway obstruction. Yes, you can get a referral to the Integrated Sleep Service (ISS), which is also at the Changi General Hospital (CGH) where your health screening is done. 

The ISS at the CGH Specialist Clinics is a one-stop multidisciplinary clinic for comprehensive services to manage different types of sleep disorders including snoring, sleep apnea and insomnia by specialists from:
◦Otorhinolaryngology (ENT)
◦Respiratory Medicine
◦Dental
◦Psychological Medicine

Good to know that you are getting the medical help you need.


7. Posted by M***
Hi Dr Yow,
I was diagnosed with severe sleep apnea a few years ago, in my early 20s. I have more than 30 apnea events each hour when left untreated. To treat it, I am required to use a CPAP machine.

Unfortunately, I am not the best patient - I constantly fail to use it at night, and on average only put it on once a week. Is there any point of me using a CPAP machine if I am not compliant? What would the long term effects be if I still continue to use it this infrequently?

Answered by Dr Yow :
Hello M***. You have severe OSA and that is worrying. 

If you have untreated or inadequately treated sleep apnea, you are at risk for multiple medical conditions with serious long-term health and daily life consequences such as: hypertension, coronary artery disease, angina, heart attack, irregular heart rhythm, stroke, sudden death, diabetes, glaucoma, impaired neurocognition, depression, interrupted sleep, fatigue, daytime sleepiness, lack of vigilance at work or school, and increased risk of road traffic accidents by falling asleep at the wheel while driving.

Try your best to get used to sleeping with the CPAP device as it is proven to be the most effective among all the available treatment for OSA. Ideally, the CPAP device should be used for the entire duration of your sleep. Sleeping with the CPAP device for 4 to 5 hours improves daytime sleepiness but in order to reduce cardiovascular risks and hypertension associated with OSA, up to 6 hours of sleep with the CPAP device is advised. 

If you cannot use the CPAP device, there are other conservative, non-surgical ways to manage OSA:
◦Weight management
◦Sleep posture
◦Management of nasal allergies and/or blocked nose
◦Orofacial myofunctional therapy with daily exercises involving the muscles of the face, mouth, tongue and throat
◦Mandibular Advancement Device
◦Tongue Stabilising Device

There are also surgical options where conservative treatment does not work:
◦Surgery of the nose
◦Soft tissue surgery of the upper airway
◦Transoral robotic surgery of the tongue
◦Sleep apnea implant
◦Maxillomandibular advancement surgery of the jaws (MMA)
◦Bariatric or weight loss surgery

Please take your health issues related to OSA seriously as you are still young. Do take action to treat the severity of your OSA. I wish you a long life ahead with many healthy years.


8. Posted by E***
Dear Dr Mimi, Good day.
I read with interest about SDB, whether snoring or OSA and in particular the Non-invasive treatment.
Would appreciate your sharing about the non-invasive treatment:
◦Is this a day surgery one-off treatment?
◦Patient will be put under LA or GA?
◦What is the success rate?
◦What is the cost amount?
◦Specifically, what will be done to the patient?

Answered by Dr Yow :
Hello E***. Thank you for your questions. 

There are different types of non-invasive treatment to manage sleep-disordered breathing. Being non-invasive, there is no surgery involved. Non-invasive therapies include:
◦Weight management
◦Sleep posture
◦Management of nasal allergies and/or blocked nose
◦Orofacial myofunctional therapy with daily exercises involving the muscles of the face, mouth, tongue and throat
◦Continuous Positive Airway Pressure or CPAP Device
◦Mandibular Advancement Device
◦Tongue Stabilising Device

Invasive treatment to manage sleep-disordered breathing requires surgery with general anaesthesia. Surgery is not a substitute for non-invasive therapies but provides options where conservative treatment has not worked. There are different types of surgery:
◦Surgery of the nose
◦Soft tissue surgery of the upper airway
◦Transoral robotic surgery of the tongue
◦Sleep apnea implant
◦Maxillomandibular advancement surgery of the jaws (MMA)
◦Bariatric or weight loss surgery

The success of treatment varies as OSA can be due to different causes that require a combination of treatment. Individual compliance and response to treatment are also unpredictable factors that affect treatment outcomes. 

The cost for devices varies as they are supplied by different vendors. This will be discussed at the time of assessment and selection of the appropriate device. 

For invasive treatment, assessments by the surgeon are necessary to determine the risks and benefits of surgery compared with other non-surgical management of your condition. The cost of surgical intervention depends on the indications of the type or combination of surgical procedures, choice of ward and duration of hospitalisation. The attending surgeon will discuss this with you after an assessment of your condition during the consultation. 

Good health to you, take care and stay well.


9. Posted by S****
Hi Dr,
Can you talk about Inspire sleep apnea implants? Is it approved in Singapore and if yes, what is the cost like.
I did surgery for OSA years ago and it came back in two years. I am very interested in the Inspire implants.

Answered by Dr Yow :
Hi S****. Thank you for your question. It is good to know that you are keeping checks on your condition, which can worsen by aging, weight gain from increased body fat and loss of muscle tone. 

Yes, the Inspire device is approved in Singapore for use in selected patients with OSA. SGH is currently the only public health institution with ENT surgeons accredited to perform Inspire implant surgery. 

The Inspire hypoglossal nerve stimulator (HGNS) device delivers electrical stimuli to the nerves in the tongue by sensing respiratory effort. The tongue is activated to move forward together with other muscles in the throat to open and stabilise the airway. 

A thorough assessment by the surgeon is necessary to determine the risks and benefits of the implantable sleep apnea device and whether it is suitable for you. The cost depends on indications of the device, the surgical procedure, choice of ward and duration of hospitalisation. This will be discussed with you by the attending ENT surgeon.

All the very best of health to you.

Follow-up question posted by S****
Thank you for your reply Dr Yow.

Can you let me know about your experience with this?
How are the patients doing after the surgery?
Are there significant improvements in sleep quality and snoring?
Assuming the surgery is performed and staying in a class B ward, what is the ballpark figure on the cost?
How can I schedule an appointment with ENT for this?

Answered by Dr Yow :
Hello S****. Thank you for your questions.

The Inspire implant accredited ENT surgeon is the best person to answer your questions and advise you. To schedule an appointment as a private patient, you can contact the SGH Patient Liaison Service, by email: [email protected] or by phone: (65) 6326-5656. Should you wish to be seen as a subsidised patient, please make an appointment with a doctor at any Polyclinic who can assess you before referring you to the SGH ENT Centre.

All the very best to you.


10. Posted by I****
Dear Dr, 
I was diagnosed by an ENT surgeon in SGH as having mild to moderate OSA about 7-8 years ago.

Upon her advice I bought a CPAP but I didn't really like to use it because it limits my movement, that is turning to the right or left. I cannot be lying in a recumbent position. Because of this restriction, I used the device about 4- 5 hours nightly.

The question I would like to ask is would seeing a Dental Surgeon help with the OSA? I would be happy if I don't have to use the device.

Answered by Dr Yow :
Hello I****. I am very sorry to learn of your frustrations in sleeping with the CPAP device. It is understandable that not everyone can cope with the daily use of CPAP and you are not alone. An audit at SGH showed that 60 to 70% patients reject or cannot tolerate CPAP treatment.

The most effective treatment for OSA is CPAP. Ideally, the CPAP device should be used for the entire duration of sleep. Sleeping with the CPAP device for 4 to 5 hours improves daytime sleepiness but in order to reduce cardiovascular risks and hypertension associated with OSA, up to 6 hours of sleep with CPAP device is advised. 

Do try out the newer, smaller and softer models of CPAP straps/nose mask or nasal pillows for side-sleepers or active sleepers, to see if they work for you. However, if you really cannot sleep properly with the CPAP device, you can explore other options of treatment or combinations of treatment. 

The conservative, non-surgical ways to manage OSA other than CPAP are:
◦Weight management
◦Sleep posture
◦Management of nasal allergies and/or blocked nose
◦Orofacial myofunctional therapy with daily exercises involving the muscles of the face, mouth, tongue and throat
◦Mandibular Advancement Device
◦Tongue Stabilising Device

There are also surgical options where conservative treatment does not work:
◦Surgery of the nose
◦Soft tissue surgery of the upper airway
◦Transoral robotic surgery of the tongue
◦Sleep apnea implant
◦Maxillomandibular advancement surgery of the jaws (MMA)
◦Bariatric or weight loss surgery

It is best for you to have a thorough examination by a sleep team who can help you to determine the appropriate treatment or combination of treatment. All the very best to you in finding the best solution to manage your condition for good sleep and good health.


11. Posted by W******
Good evening Dr,
My husband snores really loud and it's affecting my sleep. We have changed so many pillows thinking that might be the problem. But apparently not. 

Sometimes after a period of snoring loudly, he quietens down, and seems like he's not breathing. Then after a few seconds, he starts snoring again. It's something I observe when I can't sleep. He refuses to see a doctor about it. Please advise. Thank you.

Answered by Dr Yow :
Hello W******. 
It must be distressing for you to witness your loved one suffering from sleep-disordered breathing. What you have observed is partial collapse of the upper airway that limits airflow and causes snoring. When the upper airway collapses completely there is no noise as there is no airflow - what follows is the brain waking up briefly to restore airflow.

Snoring is common but just because it is common does not mean that it is normal. Snoring, with or without sleep apnea, is harmful. To the person who is snoring, he is unaware of it as he is unconscious. To you the bed-partner, the noise from snoring keeps you awake. If this happens night after night, you become sleep deprived. Loud snoring can be more than 100 decibels in intensity – similar to the sound level at a rock concert or from the car speaker that is at maximum volume. Loud sounds create powerful vibrations. Recurrent strong vibrations inflict damage to the snorer’s soft palate and pharynx (the airway behind the nose and tongue). Repeated trauma causes inflammation and swelling of the soft palate and pharynx, which are prevented from healing by constant vibrations from the snoring. The damaged pharynx becomes collapsible and prone to snoring and sleep apnea. 

It is good that you know what is happening and can help him. He may be unaware or fearful of the health consequences or both. Give him plenty of support and time to understand that snoring is a health issue for the both of you. If your sleep is fragmented by the noise and you are experiencing symptoms of sleep deprivation - excessive daytime tiredness, headaches, irritability, reduced vigilance with daytime tasks or have problems thinking and remembering, please see a doctor and ask your husband to accompany you. The doctor can advise him on how to help you by getting treatment.

All the best of health and happiness to you and your husband.


12. Posted by C****
Hi Dr Yow 
I have done sleep study (which I didn’t slept well) which shows AHI of 5.7. Sleep Doctor say I have no sleep apnea (at least of no concern) and only insomnia and delay sleep syndrome and given some pills to help with falling asleep. 

However, I still feel unrefreshed and on several occasion noticed I can’t breath and the tongue is blocking my airway when I’m half awake. It gets worse when I am tired and on my back. 

Is there any other discipline which I can request to check on my condition if I am told do not fit into the AHI / sleep apnea model but still feel tired and lack of oxygen/unrefreshed?

Answered by Dr Yow :
Hi C****. I can understand your concerns with sleep-disordered breathing, unrefreshing sleep and daytime tiredness. 

You are right in that there are some individuals with upper airway resistance who have sleep apnea type symptoms but the sleep study does not confirm sleep apnea. If you still do not breathe or sleep well, you should have another assessment and do take your sleep study report along to have it reviewed by a sleep-trained doctor.

To schedule an appointment as a private patient, you can contact the SGH Patient Liaison Service, by email: [email protected] or by phone: (65) 6326-5656. Should you wish to be seen as a subsidised patient, please make an appointment with a doctor at any Polyclinic who can assess you before referring you to the SGH ENT Centre. All the very best.


13. Posted by C**
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 :
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.

1.Consider retrying CPAP: I know you might not have had a good experience with it previously, but hear me out. A few reasons to consider retrying CPAP is that - mask designs and machine features have evolved significantly over the last few years to help patients counter the discomforts you might have experienced with the mask or machine. What you might have found difficult in the past when using CPAP, might be resolvable with current technologies. Additionally, our sleep technologist can help support you through your journey of CPAP trial by helping you troubleshoot your discomforts and provide adjustments either on machines or mask, or provide other recommendations. CPAP is by far still the most effective treatment option available. 
2.Mandibular advancement device - or Dental appliance can be worn during sleep to advance your jaw, pull your tongue and palate forward, and opens up your airway space. 
3.Surgery - Sometimes some surgery (such as nose surgery) can unblock your nose, making it a lot easier for you to tolerate CPAP. 
4.Positional therapy - Some patient’s snoring and sleep apnea improves with sleeping on the side. This is usually reflected in your sleep study or your partner may notice that your snoring/choking improves when you lie on your side. 
5.Myofunctional therapy - these are sets of tongue and throat exercises that can help tone up the tongue and throat to reduce your upper airway collapse during sleep. This does require regular daily exercises of at least 10 - 15 mins, and tends to work better for people with mild sleep apnea. 
6.Weight loss - weight loss can potentially help with your snoring and choking if you are overweight and that weight is contributing to your sleep apnea.


14. Posted by K*******
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.

Answered by Dr Phua :
Dear K*******, 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.


15. Posted by a*******
How do we know that we have OSA, and that it is serious enough for action to be taken?

Answered by Dr Phua :
Dear a*******, 
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/m
A – Age older than 50
N – Neck size More than 40cm
G – 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.


16. Posted by k**********
During sleeping what is the oximeter reading?
In the event of central Apnea or arousal, what is the oximeter reading?

Answered by Dr Phua :
Dear 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.


17. Posted by E*******
I always snore loudly when I sleep. How can I get this diagnosed to see whether I am suffering from OSA?

Answered by Dr Phua :
Dear E*******, 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.


18. Posted by A******
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?

Answered by Dr Phua :
Dear A******, 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: 
◦Sleeping on your side (this can work for some patients but not all)
◦Sleeping on a higher pillow (again, this might work for some patients but not all
◦Losing weight
◦Reducing alcohol intake before sleep time
◦Oral myofunctional therapy exercise (a set of tongue and throat exercises that can help tone up your tongue and throat and encourage nasal breathing to reduce your snoring). 

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.


19. Posted by t**********
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.

Answered by Dr Phua :
Dear t**********, 
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. 


20. Posted by k*****
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

Answered by Dr Phua :
Dear k*****, 
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.

     
21. Posted by Anonymous
Hi Dr, what are some preventive measures we can take to avoid developing sleep apnea? Are there certain sleeping postures we should adopt/avoid?

Answered by Dr Phua :
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. 


22. Posted by V**
Why does my husband snore most of the time? Could there be an issue with the position or the height of his pillow?
Please advise. Thank you.

Answered by Dr Phua :
Dear V**, 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. 


23. Posted by Anonymous
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.

Answered by Dr Phua :
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.


24. Posted by B******
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?

Answered by Dr Phua :
Dear B******, 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. 


25. Posted by G**********
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?

Answered by Dr Phua :
Dear G**********, 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. 

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). 


26. Posted by l****@ymail.com
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?

Answered by Dr Phua :
Dear l****, 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. 


27. Posted by a********
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.

Answered by Dr Phua :
Dear a********, 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.


28. Posted by L*****
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?

Answered by Dr Phua :
Dear L*****, 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.


29. Posted by s**********
Hi Dr, how can OSA be correctly diagnosed without visiting the doctors? 
Are there non surgical methods that can improve sleep and rid OSA?

Answered by Dr Phua :
Dear s**********, 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/m
A – Age older than 50
N – Neck size more than 40cm
G – 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.


30. Posted by B***********
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 :)

Answered by Dr Phua :
Hi B***********, 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.

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/m
A – Age older than 50
N – Neck size more than 40cm
G – 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. 
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.


31. Posted by O*****
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.

Answered by Dr Phua :
Dear O*****, 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.


32. Posted by l********
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?

Answered by Dr Phua :
Dear W*****, 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. 


33. Posted by u**********@yahoo.com
Good afternoon Doc. I recently got Covid and I started seeing a strange pattern in my sleep. Usually every alternate day I wake up between 2-4am(early morning) feeling breathless. I know I can breathe but my mind tells something else. 
Not sure if this is a COVID effect or something related to OSA. THANKS

Answered by Dr Phua :
Dear u**********, I can see why you are concerned. COVID-19 infection is an infection that can affect your upper airway, with most patients experiencing symptoms similar to a common cold during the initial infection. Some of these symptoms can persist for weeks as a post-viral illness, with patients experiencing prolonged cough, asthma-like symptoms and feeling out of breath. 

The good news is that most of these usually resolve after a few weeks. However, if it does not or if you are concerned, it is advisable for you to visit an ear nose and throat doctor for a review and further evaluations. 


34. Posted by A********
I snore very loudly at night and often stopped breathing before snoring again. How do I get assessed if I have obstructive sleep apnea?

Answered by Dr Phua :
Dear A*********, thank you for your question. In order to get checked on whether you have obstructive sleep apnoea, you can obtain a polyclinic referral to the hospital’s Ear Nose and Throat Surgery department, respiratory department or sleep clinic. In these clinics, the doctor will evaluate your symptoms, do a physical examination and arrange a sleep study for you, which will be the best assessment of whether you have obstructive sleep apnoea. 


35. Posted by D********
My husband snores when sleeping on his back but he doesn't when he sleeps on his side. Why is this so? But he can't sleep on his side. I can't sleep when he snores. Help!!

Answered by Dr Phua :
Dear D********, this is commonly described. When your husband lies on his back, it is likely that his tongue and soft palate would flop backward, causing the narrowing of his upper airway, leading to snoring. For some people, this snoring can improve when they lie on their side. 

I can think of a few ways that can help with your situation. You can find sleeping aids such as the pregnancy pillow or tennis ball t-shirt or zzoma pillow which are useful aids to help your husband sleep on his side. Alternatively, some comfortable earplugs for yourself can help.

However, what can be useful is for your husband to see an ENT doctor/respiratory physician or sleep clinic to get evaluated for his snoring. Sometimes, there can be certain conditions, such as a sensitive nose, which can be treated with medications. However, if his condition is more severe, a sleep study and further treatment may be necessary. Hope this helps!


36. Posted by J*****
Hi Dr Phua,
May I know is OSA can be treated and recovered totally without relapse? Thanks and best regards.

Answered by Dr Phua :
Hi J****,
Unfortunately, at the present day, it is difficult to guarantee a full cure without relapse for sleep apnoea. We have many patients where symptoms improved remarkably with continuous positive airway pressure therapy (CPAP), but the underlying condition does not change. We also have patients who had undergone surgery with an improvement of symptoms and reduction of sleep apnoea severity. 

There is a minority where sleep apnoea does get cured, however, this is few and far between. Even if the cure is achieved, it is impossible to guarantee no relapse as we are fighting the inevitable muscle/tissue laxity as we age, as well as the general weight gain when people age.

That said, not all hope is lost. Even in the absence of a complete cure or guarantee against relapse, most patients are able to achieve significant symptom control, with an improvement of their snoring and daytime sleepiness, which these patients do report to be life-changing for them, as they now can concentrate at work better, and enjoy time with their families better. Hope that the answers are useful.


37. Posted by C**
Hi Dr, 
I have sleep apnoea for many years. I seeked treatment at a hospital around 20 years ago and did a deviated septum surgery. I was asked by the doctor to try implant but I wasn’t ready. Few years back I visited another hospital and was advised to try the CAPA 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. Thank you.

Answered by Dr Phua :
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 apnoea.

There are a few options available. However, this would depend on your clinical suitability. 

1.Consider retrying CPAP: I know you might not have had a good experience with it previously, but hear me out. A few reasons to consider retrying CPAP is that – the mask designs and machine features have evolved significantly over the last few years to help patients counter the discomfort you might experience with the mask or machine. What you might have found difficult in the past when using CPAP, might be resolvable with the current technologies. In addition, our sleep technologist can help support you through your journey of CPAP trial by helping you troubleshoot regarding your discomfort and provide adjustments either on machines or masks or provide other recommendations. CPAP is by far still the most effective treatment option available. 
2.Dental appliance
3.Surgery
4.Positional therapy
5.Myofunctional therapy
6.Weight loss regime or surgery


38. Posted by P******
Hi Dr, 
I have seen a specialist and eceived feedback that I may have slight sleep apnoea. I am weighing around 67kg and height is 1.69cm.
But about a year and half ago my snoring seem to be getting worse. At times during that week or two, whenever I woke up my mouth is dry. 
The specialist mentioned I am considered fit and not fat at all. And I don't drink or smoke also. But the specialist suggested me to go for uvulopalatopharyngoplasty and tonsillectomy surgery if things don't improve or is disturbing me. 
But these 2 surgery I find is not considered small surgeries to me. I wonder is it a must to do these 2 surgery. Need your advice. Thanks.

Answered by Dr Phua :
Hi P******, without the benefit of your actual sleep study results or your physical evaluation findings (for example, do you have large tonsils, are your soft palate long and low lying, do you have a small chin etc.), it is difficult to advise further. 

The surgery of uvulopalatopharyngoplasty and tonsillectomy do come with their own risks and benefits. It can potentially improve your snoring, if that is the main cause of your upper airway narrowing. But, it does come with its own sets of potential complications such as bleeding, regurgitation of fluids into the nose and sometimes some potential problems in swallowing. That said, most of our patients who undergo the surgery do report improvement in symptoms and most operation sequelae are well-tolerated. 

If you are bothered about your symptoms, you can consider seeing us at the Sleep Surgery clinic along with your sleep study results. We can re-discuss options based on your sleep study results and clinical evaluation. There are other non-surgical options too such as dental appliances, continuous positive airway pressure therapy, positional therapy, myofunctional therapy as well if you are worried about surgery being invasive. That said, each of the therapy do come with their own pros and cons. This discussion is better done in person, with more information at hand. 


39. Posted by L******
Hi Dr,
I was told by my family that I snored very loud. Could that be one of the causes for hypertension? In addition, I feel tired during the day. Any remedies? Thanks.

Answered by Dr Phua :
Dear L******, snoring loudly does not cause hypertension. However, sleep apnoea can. You have symptoms such as snoring and feeling tired during the day, which could be suggestive of obstructive sleep apnoea. It is advisable for you to see a doctor to consider a sleep study for the evaluation of sleep apnoea. And if you do have sleep apnoea, treatment can potentially alleviate your snoring and daytime tiredness. 

Until you see a doctor, a few things can be done to see if they can help with your symptoms. You can consider sleeping on a higher pillow or sleeping on the side, which can sometimes improve your snoring and tiredness. You can also optimise your sleep hours and sleep hygiene, ensure you have at least 7-8 hours of sleep per night, in a dark, quiet room with a cooling temperature and comfortable bedding with no noise distractions (phones, pets etc.).


40. Posted by S****
Dear Dr, my question on obstructive sleep apnoea is:
At times while I am having breakfast, I doze off without realising it till my family members called me. Also, my family members complain that I am very noisy while sleeping, and I feel tired during the day.
May I know whether I suffer from sleep disorder? How can I seek medical advice? Thank you.

Answered by Dr Phua :
Dear S****, dozing off at the breakfast table is indeed a little concerning. Your symptoms of feeling tired and being noisy while asleep can indeed be suggestive of obstructive sleep apnoea. In order to know if you suffer from obstructive sleep apnoea, you would need to do a sleep study for diagnosis and confirmation. To get this done, it is best you consider a polyclinic referral to the hospital’s ENT, respiratory or sleep clinics for evaluation and sleep study to be arranged. 


41. Posted by M***
Hi Dr Phua Chu Qin, I have the following questions to ask:
1.Is sleep apnoea a risk for Optic Nerve Damage?
2.Does sleep Apnoea contribute to increased Glaucoma risk?
Thank you

Answered by Dr Phua :
Dear M***, thank you for your questions. Studies showed that obstructive sleep apnoea does predispose one to optic nerve ischaemia (lack of blood supply) and glaucoma. The actual mechanism of how it causes the damage is not fully known but it is postulated that sleep apnoea causes low blood oxygen (hypoxia), which subjects the retinal blood vessels (eye blood vessels) and optic nerve to various oxidative stress, hemodynamic changes (blood pressure changes), inflammation and dysregulation.


42. Posted by K******
Good morning, Dr Phua
If you sleep 
◦from 11.33pm to 2.40am for about 3 hours (186.7min), 
◦wake up from 2.40am to 4.20am for about 1 hour 40 min(99.6min), 
◦and sleep again from 4.20am to 5.47am for about 1 hour 25min (85 min):

1.What would be the actual total hours used to diagnose if you have OSA?
2.How many continuous sleep hours would be sufficient to diagnose if you have OSA
3.Would the above fragmented sleep affect the diagnosis of the sleep study?
4.If you have mild OSA(AHI:12.4/hr) from the above Sleep but if you could sleep longer, say continuously from 11.30pm to 5am uninterrupted, would your mild OSA progress to Moderate or Severe since it is only 2.6/hr away to Moderate(15-30/hr)?
5.Would one night of sleep study be sufficient for the diagnosis? Or do we need further sleep studies to be conclusive?
6.Would OSA worsen over time from mild to moderate or severe if untreated or when you age?

I would appreciate if you could advise. Thank you and looking forward to hearing from you soon.

Answered by Dr Phua :
Dear K*****, 
Truthfully, your questions would be more accurately answered if your sleep study result is made available, though I can understand it is difficult in this setting of a forum. I will try my best to answer based on the information available but it would be better if you could visit a sleep clinic to have a discussion with the doctor. 

From the sleep time you mentioned – a total of 186.7 mins and 85 mins, these add up to 271.7 mins which is equivalent to more than 4 hours. By convention, interpretation of sleep study requires a minimum of 4 hours of total sleep time recording. Hence, based on your total sleep hours of 4.5 hours, this is sufficient for interpretation. Continuous sleep hours are not criteria required for the diagnosis of OSA. Fragmented sleep or disrupted sleep architecture such as insufficient REM sleep (deep sleep), can potentially affect the sleep study. It depends on the sleep architecture you have in your sleep study. If your current sleep study shows insufficient deep sleep, had you slept longer and spend more time in deep sleep, yes, it can potentially alter your apnea-hypopnea index (AHI) – the number of apneas or hypopneas recorded during the study per hour of sleep and OSA diagnosis. 

For most patients, one night of sleep study is usually sufficient for study. Of course, the more nights of sleep studies done, it can increase the data collected and can potentially improve the accuracy of the data. However, sleep studies are costly and have limited slots available. So it is not common practice for repeated nights of sleep studies. However, in your case, if you have doubts about the results of your sleep study, you can have a discussion with your sleep doctor about whether it is worth repeating the sleep study. Again, this is better done with your current sleep study at hand. 

Based on current research, OSA indeed can worsen over time up to the age of 60, when left untreated. This is especially true if one has weight gain when one ages. 

Hope this helps!


About Dr Mimi Yow

Dr Mimi Yow is a senior consultant in orthodontics. She has more than three decades of experience in multidisciplinary practice with the SingHealth Sleep, Cleft and Craniofacial, and Orthognathic Surgery teams.

Dr Yow is the Director of Sleep Clinical Services of the SingHealth Duke-NUS Disease Centre for the management of sleep disorders. The SingHealth Duke-NUS Disease Centres (SDDCs) are located at the Singapore General Hospital (SGH), KK Women's and Children's Hospital (KKH), Changi General Hospital (CGH) and Sengkang General Hospital (SKH) campuses.

The Sleep SDDC brings together multidisciplinary expertise into dedicated SingHealth Sleep Centres to offer patient-centric settings for optimised patient-outcomes through integrated clinical care.

ABOUT DR PHUA CHU QIN

Dr. Phua Chu Qin graduated from the University of Edinburgh and completed her Otolaryngology Residency Training in Singapore. She obtained further professional qualification of Fellowship of the Royal Colleges of Surgeons (FRCS) in Otolaryngology with the Royal College of Surgeons of Edinburgh.

She has a distinct interest in the subspecialty of Sleep Disordered Breathing. She seeks to alleviate symptoms associated with obstructive sleep apnea and to reduce its associated adverse sequelae. She is in the constant pursuit to help patients improve their sleep-related quality of life.

Dr Phua has immense enthusiasm for patients and junior doctors’ education. She believes in empowering patients by enhancing their understanding of their own conditions and equipping patients with strategies to manage their conditions. She is passionate about helping medical students and residents develop their potential. She was awarded the NHG-NUS Medicine Junior Doctor Teaching Award in 2016 as a recognition of her accomplishment in undergraduate education.

Ref: J22