Sleep Apnea Signs and Symptoms
The cardinal signs and symptoms of sleep apnea include excessive daytime sleepiness (EDS) and loud snoring, with additional key features being observed breathing pauses during sleep, choking or gasping on awakening, morning headaches, and nocturia. 1
Primary Clinical Presentation
Most Common Symptoms
The two most frequent presenting symptoms are:
- Excessive daytime sleepiness (EDS) - characterized by falling asleep easily in non-stimulating environments (watching television, reading, riding in or driving a car) despite adequate sleep time 1
- Loud snoring - typically loud enough to be heard through a closed door 1
Additional Nocturnal Symptoms
- Observed apneas - witnessed pauses in breathing during sleep (requires bed partner or caregiver observation) 1
- Choking or gasping - awakening from sleep with choking sensation 1
- Frequent arousals - repeated awakenings from sleep 1
- Morning headaches 1
- Nocturia - frequent nighttime urination 1
Daytime Manifestations
- Fatigue despite adequate sleep duration 1
- Poor concentration and neurocognitive impairment 1
- Irritability 2
- Forgetfulness 2
Physical Characteristics and Risk Factors
Predisposing Physical Features
- BMI ≥35 kg/m² in adults 1
- Neck circumference ≥17 inches in men or ≥16 inches in women 1
- Craniofacial abnormalities affecting the airway 1
- Anatomical nasal obstruction 1
- Enlarged tonsils - nearly touching or touching in the midline 1
Important caveat: While most younger OSA patients are obese, elderly patients with OSA may not necessarily be obese, making diagnosis more challenging in this population 1
Diagnostic Algorithm for Clinical Suspicion
A patient likely has OSA if they have signs or symptoms in two or more of the following three categories: 1
- Predisposing physical characteristics (any of the features listed above)
- History of airway obstruction during sleep (two or more nocturnal symptoms, or one if patient lives alone)
- Somnolence (one or more daytime symptoms)
If only one category is severely abnormal (e.g., markedly increased BMI, respiratory pauses frightening to observers, patient falls asleep within minutes when unstimulated), treat as severe sleep apnea even without meeting the two-category threshold 1
Pediatric-Specific Presentations
Children present differently than adults with distinct features: 1
Nighttime Symptoms in Children
- Snoring and excessive sweating 1
- Restless sleep with mouth breathing 1
- Labored breathing and witnessed apneas or gasping 1
- Hyperextension of the neck during sleep 1
- Intermittent vocalization during sleep 1
- Night terrors 1
- Unusual sleep positions 1
- New onset enuresis (bedwetting) 1
Daytime Symptoms in Children
- Behavioral and mood problems - may be misdiagnosed as attention deficit hyperactivity disorder 1
- Poor concentration and difficulty focusing 1
- Excessive aggression or irritability 1
- Difficulty arousing at usual awakening time 1
- Failure to thrive 1
Associated Comorbidities That Should Raise Suspicion
Clinicians should maintain high suspicion for OSA in patients with: 1
- Cardiovascular disease - particularly heart failure, atrial fibrillation, stroke, and difficult-to-control hypertension 1
- Hypothyroidism (especially in women) 1
- Diabetes mellitus and insulin resistance 1
- Depression (common comorbidity in women with OSA) 1
Critical Clinical Pitfalls
Do not dismiss sleep apnea in non-obese elderly patients - the typical obesity pattern seen in younger patients may be absent in older adults, yet OSA prevalence reaches up to 70% in older men and 56% in older women 1
Do not overlook OSA in women - there is significant underdiagnosis due to provider and patient bias toward seeking the disease preferentially in men, despite male-to-female prevalence ratios being only 3:1 to 2:1 1
Obtain collateral history - whenever possible, interview bed partners or caregivers, as patients are often unaware of their nocturnal symptoms, particularly observed apneas and snoring severity 1