Snoring is routinely a nuisance, particularly for people who share a bed with a light sleeper. For some, though, snoring can be a sign of a more serious health problem: sleep apnea. Once a barely known condition, there are several treatments now available for sleep apnea and more are coming down the pipeline. But many sufferers are still in the dark about their apnea and not getting the help they need.
The word “apnea” simply means the pausing of breathing, which can happen for lots of reasons, including a good sob. Sleep apnea is defined by having multiple and sustained (10 seconds or longer) episodes of no breathing throughout the night—anywhere from 5 to 100 times a hour. It primarily comes in two forms: central and obstructive sleep apnea (OSA). OSA happens when airway muscles physically block a person’s breathing, while central apnea is when the actual muscles used to breathe stop working, often due to a lack of signaling from the brain (a third complex form has both types). Of the two, OSA is far more common, with roughly 12% of American adults estimated to have the condition compared to less than 1% of adults estimated to have central sleep apnea.
While snoring might be the symptom most associated with sleep apnea, it doesn’t guaranteed that you have it, since about 25% to 50% of people snore at least occasionally. Other signs of it include trouble sleeping, waking up with a dry mouth, and feeling sleepy during the day. Over time, sleep apnea can steadily affect our health for the worse, possibly raising the risk of other conditions like heart disease, diabetes, brain damage, and even an earlier death.
“The harm is twofold. One, when you pause in your breathing, your oxygen levels drop, and having low oxygen levels makes the heart and the brain less happy, and from there they can sustain injuries from repetitive decreases in oxygen,” Douglas Kirsch, a sleep medicine physician and spokesperson for the American Academy of Sleep Medicine, told Gizmodo over the phone. “As well, when we start breathing again, because we always start breathing again, our blood pressure and our heart rate climb up, and that repetitive climb of blood pressure after every episode, night after night, again and again, that too can cause problems for the heart and the brain,” he added.
Once a Mysterious Ailment
For how common sleep apnea is, it’s only recently that we’ve begun to learn much about it. The condition was only formally named sleep apnea in 1965, though written reports of it might date back thousands of years (before sleep apnea became widely used, cases were sometimes referred to as “Pickwickian syndrome”—a reference to a character in Charles Dickens’ The Pickwick Papers who displayed many of the telltale symptoms). In the first few decades after its discovery, the go-to treatment for sleep apnea was far from gentle. Doctors would commonly perform a tracheostomy, cutting a hole and inserting a permanent tube in the windpipe that’s opened up at night so air could still flow through (the surgery is sometimes still used today, though only for the most severe cases).
But in the early 1980s, doctors Eliot Philipson and Colin Sullivan developed the first continuous positive airway pressure (CPAP) machine, an invention partly inspired by Sullivan’s research on dogs with their own breathing problems. To this day, CPAP machines remain the gold standard of apnea treatment, though sometimes a misunderstood one, according to Oliver Sum-Ping, a sleep disorder clinician and researcher at Stanford University.
“There are some common misconceptions about CPAP, like that it’s specifically giving you oxygen, or that it’s breathing for you,” Sum-Ping told Gizmodo over the phone. “There are variations, but basic CPAP uses air pressure just to help dilate your airway, kind of like how blowing air into a balloon helps separate the walls of the balloon.”
CPAP can be highly effective for sleep apnea, but it has its limitations. Though they’ve gotten less cumbersome to wear over time, for instance, many people still have trouble using them long-term or have a medical condition that prevents their use. There are now other options, such as upper airway stimulation devices, which are implanted in the chest and neck to send electricity to the hypoglossal nerve, helping control tongue movement.
During sleep, the device senses a person’s breathing and uses stimulation to keep the tongue from blocking the airways. The only explicitly approved device of this kind is the Inspire implant, approved in 2014 by the Food and Drug Administration. While these devices are less intrusive on a daily basis, they’re not for everyone according to Sum-Ping. There are also dental devices that try to reposition the jaw or tongue, though these aren’t considered widely effective either. And as we covered before, mouth-taping might be the latest sleep health trend on TikTok, but there’s next to little evidence for its use with sleep apnea.
“With CPAP, you could try it for almost anybody with sleep apnea. That’s not to say that it’s going to work perfectly for everybody, but it’s broadly applicable. With something like hypoglossal nerve stimulation, it’s more important to carefully select patients, and even then, the results are often not quite as good as CPAP would be,” Sum-Ping said. “But for patients who can’t use CPAP for one reason or another, it can be a reasonable alternative.”
Drugs for Sleep Apnea
In the near future, we may see approved medications specifically for treating apnea. In April, Eli Lilly announced the early results of two Phase III trials testing its diabetes and obesity drug tirzepatide for people with both obesity and obstructive sleep apnea. As other research has shown, people on tirzepatide lost a substantial amount of weight, up to 20% of their baseline weight compared to a placebo. But they also tended to experience a significant reduction in apnea, with the frequency of episodes reduced by up to two thirds, or about 30 fewer episodes an hour. The company has already submitted for an expanded FDA approval of tirzepatide that would cover sleep apnea, which could arrive as early as late this year.
As pivotal as this approval could be, Kirsch points out that tirzepatide and similar drugs won’t be a cure-all for apnea. Obesity is the one of the most common risk factors for this condition, but it isn’t the only one, and people without obesity can develop it. Since the drug’s effect on apnea seems to mostly come from its weight loss effect, that means it won’t do much of anything for many sufferers. Even in the clinical trial data, slightly less than half of the patients on tirzepatide experienced a reduction significant enough for their apnea to be considered resolved.
“I think it’s important to recognize that it’s part of a good practice to try and help all our patients with sleep apnea with their weight, when that is an issue. But it’s probably not going to be a replacement therapy for one of these other types of devices alone in all people,” Kirsch said. That said, there are other drugs far along the development pipeline that directly aim to address the mechanisms behind apnea, like pills designed to keep people’s airways open at night.
Unfortunately, no matter the drug or device, many people aren’t getting any relief for their apnea, thanks to a consistent lack of awareness. Studies have estimated that up to 80% of sleep apnea cases go undiagnosed, a disparity that may even be worse in more disadvantaged populations, like those living in poverty (people in lower-income neighborhoods also appear to be less likely to begin treatment even once diagnosed).
Sum-Ping is encouraged by the development of technologies that can more easily screen for sleep apnea, such as wearables and “nearables.” Just this past February, the Samsung Galaxy Watch became the first such device in the U.S. to have a feature for detecting sleep apnea approved by the FDA, which is done by measuring blood oxygen levels. And Kirsch notes that it’s gotten easier over time to formally diagnose apnea, thanks to simpler tests.
“A lot of people I see didn’t want to come to see a sleep doctor because they didn’t want to do a sleep test in a laboratory. But now we can do those in the home, in some cases. Or people don’t want to necessarily see a sleep doctor because they don’t want to think about using a CPAP machine. And I tell them all the time that before we worry about the kind of treatment, let’s figure out how bad of a problem you have, because the severity of the problem sometimes changes how we think about the treatment” Kirsch said.
The future of sleep apnea treatment is looking bright, but perhaps the most important goal is to make sure that people who have it know about it in the first place.
