Can exposure to Aqueous Film Forming Foam (AFFF) and Perfluoroalkyl and Polyfluoroalkyl Substances (PFAS) cause sleep apnea?

Association Between PFAS/AFFF Exposure and Sleep Apnea

There is currently no established scientific evidence linking exposure to Aqueous Film Forming Foam (AFFF) or Per- and Polyfluoroalkyl Substances (PFAS) to the development of sleep apnea.

Current Understanding of PFAS Health Effects

• PFAS are synthetic compounds widely used in industrial processes and household products, including firefighting foams (AFFF), with exceptional chemical stability and persistence in the environment 1
• PFAS exposure has been associated with several health concerns, but sleep apnea is not among the established health effects documented in current scientific literature 1
• The primary health concerns associated with PFAS exposure include:
  • Decreased antibody response to vaccination or infection (sufficient evidence) 1
  • Increased risk of certain cancers, including thyroid, kidney, bladder, testicular, prostate, and colon cancer 2
  • Effects on lipid levels that may increase cardiovascular disease risk 1
  • Potential ulcerative colitis (limited suggestive evidence) 1

Sleep Apnea Etiology and Risk Factors

Obstructive Sleep Apnea (OSA)

• The principal risk factors for OSA are:
  • Obesity (70% of OSA patients are obese) 3
  • Increased neck circumference (>17 inches in men, >16 inches in women) 3
  • Upper airway abnormalities 3
  • Male sex (OSA is more prevalent in men than women) 3
  • Advanced age (incidence increases between ages 40-65 years) 3
  • Postmenopausal status in women 3
  • Medication use (opioids, testosterone therapy, medications that induce weight gain) 3
  • Medical comorbidities (cardiovascular conditions, endocrine disorders) 3

Central Sleep Apnea (CSA)

• Primary etiologies of CSA include:
  • Heart failure (most common cause with characteristic Cheyne-Stokes respiration pattern) 4
  • Neurological disorders such as stroke 4
  • Atrial fibrillation 4
  • Pulmonary hypertension 4
  • Renal failure 4
  • Medication effects, particularly opioids 4
  • Treatment-emergent central sleep apnea (occurs in approximately 1% of patients starting CPAP therapy) 4

PFAS Exposure Research Related to Sleep

• A 2023 study analyzing NHANES 2005-2014 data found no evidence suggesting that exposure to four legacy PFAS worsened self-reported sleep health among U.S. adults 5
• Some inverse associations between serum PFAS and trouble sleeping or sleep disorder were observed, particularly for PFOS, but these findings may be influenced by self-selection and uncontrolled confounding biases 5

Occupational Exposure to AFFF

• Firefighters have been found to have elevated serum levels of long-chain PFAS, most notably from exposure to PFAS-containing AFFF 2
• The highest levels of PFOS and PFHxS in firefighters were one order of magnitude higher compared to the general population in Australia and Canada 6
• Despite documented elevated PFAS levels in firefighters, no specific association with sleep apnea has been established in the scientific literature 2, 6

Clinical Implications

• For patients with known PFAS exposure concerned about sleep issues:
  • Standard sleep apnea risk assessment should focus on established risk factors (obesity, neck circumference, etc.) 3
  • Polysomnography remains the gold standard for diagnosing sleep apnea, regardless of potential environmental exposures 4
  • Management should follow established guidelines for OSA or CSA based on the specific diagnosis 1, 4

Conclusion

Based on current scientific evidence, there is no established link between PFAS/AFFF exposure and sleep apnea. Healthcare providers should focus on known risk factors and established diagnostic and treatment protocols when evaluating patients with suspected sleep apnea, regardless of potential PFAS exposure.