Sleep-related breathing disorders, especially Obstructive Sleep Apnea Syndrome (OSAS), impair nighttime breathing and can significantly reduce quality of life. Typical symptoms such as loud snoring, daytime sleepiness, and difficulty concentrating should be taken seriously. Targeted diagnostics make it possible to determine the extent of the disorder, and individually tailored therapies help stabilize nighttime breathing and reduce long-term health risks. On this topic, the editorial team of the Leading Medicine Guide spoke with Prof. Dr. Bergmann and learned some remarkable insights.
Obstructive sleep apnea syndrome, or OSAS for short, goes beyond ordinary snoring and is characterized by recurrent pauses in breathing during sleep.
Affected individuals often snore very loudly, but unlike simple snoring, there are additional periodic breathing pauses accompanied by sometimes loud arousal reactions—so-called arousals. These interruptions lead to reduced oxygen supply to the body and disrupt the sleep cycle, so that despite sufficient sleep duration, those affected often feel exhausted and tired during the day. Typical accompanying symptoms include morning headaches, concentration problems, mood swings, and irritability.
„Obstructive sleep apnea is a serious sleep disorder that, unlike harmless snoring, is often not noticed by the affected person. While snoring is usually only bothersome for the bed partner, sleep apnea can have significant health consequences over many years. Typical symptoms perceived by the patient include pronounced daytime sleepiness, waking up unrefreshed, and increasing fatigue in everyday life.
In the background, complications in the cardiovascular system can develop—such as hypertension or cardiac arrhythmias—which often only become apparent after a longer period. In many cases, it is the bed partner who first notices the conspicuous snoring or breathing pauses and thereby prompts medical evaluation. For the physician, this is an important clue to distinguish between harmless snoring and the dangerous variant of sleep apnea. In people who live alone, however, the condition often goes undetected for many years because no one observes the nighttime breathing pauses.
In these cases, increased daytime sleepiness, difficulty concentrating, or a general feeling of exhaustion may be the first signs. At the same time, it must be considered that such symptoms can also have other causes—such as hormonal changes, which are common in women during menopause, or metabolic disorders. Therefore, if sleep problems are suspected, a comprehensive medical evaluation is always important to identify the actual cause and enable targeted treatment“, explains Prof. Dr. Bergmann at the beginning of our conversation, adding important information about specific anatomical factors:
„One of the most important contributing factors is overweight, as it leads to an increase in fatty tissue in the neck area. This fat presses from the outside on the pharyngeal airway, which already becomes narrower during sleep due to natural muscle relaxation. As a result, air can no longer flow freely—leading to snoring sounds and, in more severe form, to breathing arrests. To understand how these narrowings occur, it helps to look at the anatomy: The pharynx extends from the nasal cavity to the larynx and consists of several levels—the soft palate with the uvula, the palatine tonsils, the base of the tongue, and the epiglottis. In deep sleep or REM sleep, when muscle tone is particularly low, these structures can narrow and collapse, obstructing airflow. In people with increased body weight, the risk is particularly high because fat cells in the neck area enlarge and further constrict the pharynx. This also explains why many affected individuals have a thicker neck circumference. Nevertheless, the syndrome can also occur in people of normal weight, for example due to anatomical features, enlarged tonsils, or an unfavorable jaw and tongue position. Thus, body weight is a significant risk factor, but not the sole cause. It plays an important role in both the development and treatment of sleep apnea—weight reduction can significantly alleviate symptoms, but it does not replace medical evaluation and treatment“.
Many couples sleep separately because snoring or nighttime breathing pauses are disruptive. Often, only the snoring is noticed at first, but obstructive sleep apnea may be the underlying cause. It carries health risks such as hypertension or cardiovascular disease, which require early evaluation and treatment. Whereas normal snoring is usually caused merely by vibration of the soft tissues of the throat, OSAS is considerably more serious due to these repeated breathing arrests and the associated oxygen deprivation.
The diagnosis of obstructive sleep apnea syndrome (OSAS) proceeds in several steps to reliably identify the condition and determine its severity with precision.
„If a patient has been experiencing fatigue, exhaustion, or concentration problems over an extended period and suspects a link to their sleep, the evaluation begins with a detailed medical interview. This is the foundation of all further diagnostics to correctly categorize the symptoms.
The physician—usually an ENT specialist, internist, pulmonologist, or cardiologist with additional training in sleep medicine—first clarifies whether the issue is an organic sleep-related breathing disorder, i.e., obstructive sleep apnea, or a non-organic sleep disorder such as insomnia, characterized by difficulty falling or staying asleep. Both forms often occur in combination, which is highly relevant for therapy planning.
The conversation explores the patient’s sleep behavior and lifestyle in detail: problems falling or staying asleep, nighttime awakenings, sleep rhythm, possible shift work, nocturia, or alcohol consumption, which can exacerbate snoring by relaxing throat muscles“, says Prof. Dr. Bergmann, continuing:
„To obtain an objective assessment, standardized, scientifically validated questionnaires are used—such as the Epworth Sleepiness Scale, which records daytime sleepiness, or the STOP-BANG test, which evaluates various risk factors like snoring, tiredness, blood pressure, and body measurements. If the patient exceeds certain thresholds, the suspicion of sleep apnea is strengthened. If insomnia is suspected, additional specific instruments are used to determine its severity.
This is followed by a physical examination, especially by the ear, nose, and throat specialist, who assesses the anatomical structures relevant to sleep-related breathing disorders—such as the soft palate, tonsils, tongue base, larynx, and nasal breathing. Impaired nasal breathing can exacerbate snoring and breathing pauses and must always be evaluated. Instrument-based diagnostics follow: Most commonly, polygraphy is performed first, also known as a home sleep test. This is an ambulatory measurement during sleep that records parameters such as snoring, body position, breathing pauses, oxygen saturation, and heart rate.
Modern devices can additionally determine sleep stages and the frequency of breathing pauses. If abnormalities are detected, a full polysomnography is arranged—the so-called comprehensive sleep lab study. This takes place either in an inpatient setting or on an outpatient basis and provides a comprehensive picture of breathing patterns, cardiovascular activity, sleep architecture, and oxygenation. Only on the basis of these data can the diagnosis of obstructive sleep apnea be confirmed and an individualized treatment plan be developed“.
Diagnostic testing in the sleep lab is typically conducted over one night, during which all relevant bodily functions are recorded during sleep. Only in special cases—such as when neurological causes are suspected—may the evaluation be extended over multiple nights. This measurement not only serves to detect a sleep-related breathing disorder but also to determine its severity, which is crucial for subsequent treatment planning.
Prof. Dr. Bergmann explains: „The extent of sleep apnea is described by the Apnea-Hypopnea Index (AHI). This value indicates how many breathing pauses (apneas) or episodes of shallow breathing (hypopneas) occur per hour. If the AHI is below 5 events per hour, the finding is considered normal. Mild sleep apnea is defined as 5 to 15 events, moderate as 15 to 30, and more than 30 breathing pauses per hour is categorized as severe sleep apnea.
In practice, values above 80 or 90 breathing pauses per hour are not uncommon. This classification is of great clinical importance because it is directly linked to the patient’s health risk. From moderate sleep apnea onward, the risk of cardiovascular diseases such as hypertension, myocardial infarction, or stroke increases several-fold. Obstructive sleep apnea is among the most common chronic conditions worldwide—estimates suggest that around 30% of the population is affected, many without knowing it. Given that cardiovascular diseases remain among the leading causes of death, timely diagnosis and treatment of this sleep disorder are of critical importance“.
Education is a crucial component in the treatment of sleep apnea. Many affected individuals do not realize that their symptoms may be due to a sleep-related breathing disorder—nor do many primary care or specialty physicians who are not regularly involved in sleep medicine.
„Therefore, professional societies in sleep medicine are working intensively on patient information, care pathways, and continuing education to raise awareness. Particularly in patients with hypertension, sleep apnea should always be considered and, if appropriate, further sleep diagnostics initiated. A major current issue in Germany is access to care: There are too few certified sleep labs, and waiting times in many places range from three to nine months.
The reasons are both the high costs associated with setting up and operating a sleep lab and the limited number of specialized physicians. Sleep medicine requires additional training for specialists in internal medicine, ENT, or pulmonology. Physicians without this qualification can, after a special four-day course, at least perform ambulatory polygraphy to provide an initial assessment and decide whether a referral to a sleep lab is necessary.
Regarding the stay in a sleep lab, many patients initially find the unfamiliar environment and attached sensors unusual. However, studies show that the quality of diagnostics is hardly affected— even if sleep is somewhat shorter or more restless, the recordings provide reliable results. An alternative approach is ambulatory polysomnography, in which the evaluation takes place in the familiar sleep environment—at home or even in a hotel bed.
This option is particularly recommended for patients without severe preexisting conditions, while individuals with a history of heart attack, severe obesity, or complex cardiovascular or metabolic diseases should be admitted to an inpatient sleep lab. However, statutory health insurers generally cover inpatient evaluations only when medical criteria are met. Ambulatory polysomnography is often billed privately, but thereby becomes available to more patients seeking prompt and uncomplicated diagnostic clarification“, emphasizes sleep medicine specialist Prof. Dr. Bergmann.
In obstructive sleep apnea syndrome (OSAS), several physiological mechanisms lead to repeated breathing pauses during sleep. The central cause is instability of the upper airway.
Treatment of obstructive sleep apnea includes both conservative and, in select cases, surgical approaches. The gold standard is nighttime positive airway pressure therapy, the so-called nPAP therapy (nighttime positive airway pressure therapy).
Prof. Dr. Bergmann clarifies: „In this therapy, the patient wears a mask that sits either on the nose or on both the nose and mouth. The mask is connected via a tube to a small, quiet machine that continuously blows air into the patient’s airways. The increased air pressure keeps the airways open, effectively reducing breathing pauses and snoring.
This therapy is especially important for patients with severe sleep apnea. In the past, CPAP therapy was common, in which a constant air pressure is set by the device (C stands for ‘continuous’). Today, there is also APAP therapy, where the device automatically detects how much pressure the patient needs to prevent breathing pauses. This increases acceptance and improves long-term adherence. Nevertheless, patients often find it uncomfortable to wear such a mask, and after three years, only about 50% of patients use the mask regularly.
Through telemedicine solutions, therapy can be monitored and adjusted, which can increase adherence to as much as 80%. Another important aspect is body weight. If the body mass index is above the normal range, weight reduction should be pursued. There is no official nutrition counseling available by prescription, but primary care physicians or internists can refer to their network of dietitians. Even without formal counseling, targeted weight optimization can be recommended, as it can significantly improve sleep apnea“.
For patients who cannot tolerate or do not wish to use the mask, a mandibular advancement device (MAD)—a dental splint that prevents the tongue from falling back and blocking the airway at night—is available.
_Mattes, CC BY-SA 2.0.jpg "Prof. Dr. med. Christoph Bergmann")
„This method is less effective than positive airway pressure therapy but still far better than no treatment. In mild or moderate forms of sleep apnea, it can even be used as a first-line therapy. In patients with significant obesity and moderate sleep apnea, however, positive airway pressure therapy is usually still recommended. It is important to know that these therapies are aids, comparable to eyeglasses or hearing aids—they do not correct the underlying cause but compensate for the problems. When anatomical factors such as excess weight are involved, improvement can occur through weight optimization, but this only happens over the long term, so positive airway pressure or oral appliance therapy remains necessary in the meantime“, stresses Prof. Dr. Bergmann.
Surgical interventions are considered when the patient has mild to moderate sleep apnea, or severe sleep apnea that, for specific reasons, cannot be treated with a mask.
„In such cases, a drug-induced sleep endoscopy may first be performed. The patient is brought into a sleep-like state so the physician can assess the upper airways in a way that approximates how they behave during sleep at home. This makes it possible to identify where in the throat a collapse occurs and where breathing pauses originate. At the same time, it can be tested whether the patient would benefit from a dental splint or whether narrowings of the soft palate, tongue base, or epiglottis are present that are better treated surgically.
If, for example, the palatine tonsils are significantly enlarged, a tonsillectomy may be appropriate. Surgical procedures on the soft palate are also possible. A newer, highly effective option—though not suitable for all patients—is hypoglossal nerve stimulation (‘tongue pacemaker’). An electrode is implanted in the tongue musculature, similar to a cardiac pacemaker, combined with a sensor under the skin that monitors blood oxygen levels.
If the oxygen level drops during a breathing pause, the electrode delivers a small, barely perceptible electrical impulse that moves the tongue to reopen the airway. This is an innovative surgical option that can bring marked improvement in sleep apnea, particularly for selected patients“, says Prof. Dr. Bergmann, adding:
„Not every patient is a candidate for surgery. Patients with a very high number of breathing pauses or with severe obesity are generally unsuitable, as the lateral pharyngeal collapse is too pronounced, and even hypoglossal nerve stimulation is not sufficiently effective. Suitability can, however, be assessed well using the diagnostic methods described above—namely, sleep lab studies and drug-induced sleep endoscopy.
These operations are performed in specialized centers. The success rate of soft palate tightening can be quantified: One should never assume a 100% effect, but the recommended measures generally lead to a significant reduction in symptoms. Surgical treatment of the soft palate, with or without simultaneous tonsillectomy, initially shows a success rate of just under 90%. Over the following years, this value drops to about 60%, as soft tissues can change over time.
Many people who had their tonsils removed in childhood have a lower risk of developing sleep apnea later in life. For these patients, treatment of the soft palate alone has a success rate of around 30%. Therefore, the physician must decide individually which therapy is optimal for the respective patient. Surgical measures are generally suitable only for patients with mild to moderate sleep apnea, because when breathing pauses are very frequent, even surgical procedures cannot relieve symptoms as reliably as positive airway pressure therapy“.
Device-based therapies such as CPAP (Continuous Positive Airway Pressure) and BiPAP (Bilevel Positive Airway Pressure) are central treatment methods for obstructive sleep apnea syndrome (OSAS), particularly in moderate to severe forms of the condition. Their mechanism of action is to keep the upper airways open during sleep to prevent repeated breathing pauses.
If you want to take preventive steps against a sleep-related breathing disorder, maintaining a normal body weight is key. Beyond that, it is important to seek medical evaluation if there are indications of possible breathing problems.
„Many of the supposedly sleep-enhancing products offered online—such as nasal strips, mouth tapes, or special pillows—are generally not scientifically evaluated, meaning their effectiveness has not been proven. Pragmatic measures can be useful in individual cases: If diagnostics show, for example, that snoring or the breathing disorder occurs only in the supine position, the patient can be advised to avoid sleeping on their back.
There are now digital aids for this, such as devices that discourage supine sleep or ergonomic side-sleeper pillows. Another important point is nasal breathing. Allergies, such as to house dust mites, can block the nose at night and thus promote snoring or breathing pauses. Here, too, those affected should seek medical advice rather than rely on uncontrolled self-measures.
Digital tools can also provide support. Modern wearables such as the Apple Watch from Series 9 onward, Garmin or Samsung watches, as well as specialized smart rings can provide clues to nighttime breathing pauses or abnormalities in blood pressure. If deviations are detected over several nights, this is an indicator to have the situation evaluated medically“, explains Prof. Dr. Bergmann, adding:
„In my practice, I offer a comprehensive spectrum of measures: from ambulatory or inpatient sleep lab diagnostics to fitting positive airway pressure therapy to surgical procedures (with the exception of hypoglossal nerve stimulator implantation, which is handled by specialized centers). Examination of the nose is also an important component, as free nasal breathing has a significant—albeit indirect—impact on sleep-related breathing disorders. In this way, patients can be managed both preventively and in a targeted manner before serious consequences arise“.
- Specialist in otorhinolaryngology (ENT), private ENT practice & Head of ENT Department, RKM740 Düsseldorf
- Focus areas: nasal & paranasal sinus surgery, functional & aesthetic rhinoplasty, allergology, sleep medicine, eustachian tube disorders, laryngopharyngeal reflux, pediatric ENT
- Combination of conservative & surgical therapies, state-of-the-art diagnostics such as cone-beam CT, innovative therapies such as longevity infusions
- Immunology research at the University of Pittsburgh, international fellowships, over 72 publications
- Professor at the University of Duisburg-Essen, involvement in AeDA Düsseldorf, EAACI Working Group, examination board & continuing education committee
- Recipient of the Anton von Tröltsch Prize and the Plester Prize
- Holistic, patient-centered care that integrates precision, science, and quality of life
