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Each night was like a wrestling match with her own airways. With the lights out, her children asleep and the house quiet, Melinda Mahlberg would begin to snore. Her husband, Troy, wore earplugs. He could still hear her. Her breathing sounded laboured as the snoring continued all night; the pair never started a day fully rested.<\/p>\n
Melinda was exhausted. Tests to find the cause of her fatigue had found nothing wrong. She wasn\u2019t just tired from being a mother of three and a receptionist with a busy social life; there was something else amiss. \u201cI\u2019m too young to be this tired,\u201d recalls the 45-year-old. \u201cAround my eyes was tense. And my brain was all foggy.\u201d<\/p>\n
Eventually, Melinda spent a night away from home \u2013 hooked up to monitors and breathing equipment at a clinic. They showed that, during at least some of her sleep, she stopped breathing, for seconds at a time, once every minute. \u201cIt was a bit of a shock.\u201d<\/p>\n
Sleep apnoea affects about 5 per cent of Australians; they will wake most days with the fuzziness of what Melinda calls a \u201ctired hangover\u201d. Fatigue can be dangerous, especially for drivers or people working with machinery. In the longer term, apnoea increases the risk of heart disease, high blood pressure and possibly even dementia.<\/p>\n
So what causes sleep apnoea? Who gets it? And how does someone with it (and their bed partner) get a good night\u2019s sleep?<\/p>\n
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Melinda Mahlberg was unsure why she felt so tired until a test revealed she has sleep apnoea. <\/span>Credit: <\/span>Edwina Pickles. Artwork Aresna Villanueva<\/cite><\/p>\n The snores of Kare Walkert, a Swede with sleep apnoea, reached a Guinness world record of 93 decibels in the 1990s, about the equivalent of a lawn mower. A British woman\u2019s snoring has since reportedly exceeded 111 decibels (as loud as someone shouting into another person\u2019s ear). Fortunately, most snoring volumes are usually around the level of a quiet conversation. About half of Australian adults snore, including most people with sleep apnoea.<\/p>\n But something extra happens with apnoea: a sleeper stops breathing for 10 seconds or more at least five times an hour. The word itself comes from the Greek for \u201cwithout breath\u201d. Cases range in severity. At one extreme, a woman with apnoea who also had a condition of the nervous system stopped breathing for 233 seconds in a hospital in the United States.<\/p>\n Starved of air, people with apnoea wake. \u201cI would have more minor [episodes] where you don\u2019t realise you\u2019re waking up,\u201d says public servant Susan Graham, a Melburnian who has managed her sleep apnoea for 15 years. \u201cThen you have really extreme ones where it sort of builds up and you jerk yourself awake.\u201d<\/p>\n Air travelling into our windpipes passes the base of the tongue, the tonsils, an area of muscular tube called the pharynx, and the voicebox, where vocal cords vibrate to produce sound. The muscles throughout this area, known as the upper airway, tend to relax as we sleep. If they become too floppy, our breathing can cause them to vibrate, causing snoring. But in some people, the muscles relax so much the usually moist inner surfaces of the sides of the pharynx can stick together blocking off the airway. \u201cIt\u2019s a bit like having a wet piece of paper against a glass window,\u201d says Associate Professor Megan Rees, head of respiratory and sleep disorders at the Royal Melbourne Hospital.<\/p>\n If the blockage is partial \u2013 a condition called hypopnea \u2013 it can cause slow and shallow breathing. Obstructive sleep apnoea is when the airway closes until the person\u2019s breathing response kicks in \u2013 the break point where it\u2019s believed our neurological and mechanical systems take over to make us gasp for air.<\/p>\n Anatomy is one cause: people with smaller pharynxes are more susceptible to apnoea. Others have an overbite that can crowd the soft tissue at the back of the airway. \u201cI come from a family of bad snorers,\u201d says Graham. \u201cI think it\u2019s sort of in the family genes to have quite a narrow airway.\u201d In fact, if an immediate family member has sleep apnoea it doubles a person\u2019s chance of having it.<\/p>\n When physicians first described sleep apnoea in the 1960s, they linked it to obesity. A patient had Pickwickian syndrome (obesity hypoventilation syndrome), a breathing condition named after a corpulent carriage driver in Charles Dickens\u2019 The Pickwick Papers<\/i> who would fall asleep running errands. The patient slept just a few hours because of a \u201ccyclic repetition of arousal and slumber\u201d.<\/p>\n Today, 58 per cent of people with moderate to severe sleep apnoea are believed to be obese. Fat in the tongue and neck can cause the airway to collapse. <\/b><\/p>\n Sleep apnoea is about three times more common in men than women. Some of this could be due to under-diagnosis in women but also to how body weight is distributed. \u201cIf you\u2019re carrying excess body weight in a central area and around your neck, you\u2019ll be more at risk of sleep apnoea. Whereas women who are overweight often carry that extra weight below their waist,\u201d Rees says.<\/p>\n \u2018They start to snore a bit in their 30s and then snore loudly in their 40s and have sleep apnoea in their 50s.\u2019<\/p>\n Still, in both women and men, age tends to make apnoea worse. \u201cEverything gets saggier, so the muscular tube in the back of the airway just gets floppier,\u201d says David Cunnington, clinical chair of the Australasian Sleep Association. \u201cThey start to snore a bit in their 30s and then snore loudly in their 40s and have sleep apnoea in their 50s.\u201d<\/p>\n In fewer than 1 per cent of cases, people have no airway blockage, but the brain stops telling them to breathe \u2013 called central sleep apnoea. \u201cThere is a pause and the person does not make any effort to breathe,\u201d says Dr Kirk Kee, a sleep and respiratory physician at the Royal Melbourne Hospital. \u201cThat\u2019s until their carbon-dioxide level gets high enough that their brain goes, \u2018Whoops, I need to breathe again.\u2019 \u201d The most common reason for this is severe heart disease, but stroke and opiates can also cause it.<\/p>\n Gina Bundle, who got tested for apnoea, with sleep scientist Serhan Kalistu.<\/span>Credit: <\/span>Photo: Paul Jeffers. Artwork Aresna Villanueva<\/cite><\/p>\n It\u2019s 9pm and patients toss and turn. Some watch TV, others scroll their phones, but it\u2019s hard to ignore the weirdness of being in a sleep laboratory. Gina Bundle has 22 electrodes attached to pads stuck mostly on her face and head. Wires neatly run behind her back, keeping her from getting tangled, then into a monitor recording every breath and blink. \u201cYou feel it all over,\u201d she says.<\/p>\n She can\u2019t remember her last good night\u2019s sleep. A thyroid condition then long COVID made her exhausted. She\u2019s spending the night in the Royal Melbourne Hospital to test whether sleep apnoea has also been in the mix. \u201cWhen you get home from work, you sit and take your shoes off. Well, I didn\u2019t even get that far; I\u2019d be out like a light,\u201d she says.<\/p>\n Sleep scientist Serhan Kalistu calculates Gina\u2019s body mass index (BMI), checks her blood pressure and measures the width of her neck \u2013 anything unusually wide carries a greater chance of apnoea. Bands around her chest and abdomen measure her diaphragm moving, as does a CPAP machine (continuous positive airway pressure) that blows air at gentle pressure into her nose. Scientists adjust the pressure during the night. \u201cIf you have sleep apnoea, you\u2019re not actually breathing, so on the system there will be a flatline for a few seconds,\u201d Kalistu says.<\/p>\n Her test results were \u2018through the roof\u2019, showing she stopped breathing 110 times every hour.<\/p>\n How severe a person\u2019s sleep apnoea is depends on how often they stop breathing in an hour, a scale known as the apnoea hypopnea index or AHI. Five to 15 events is considered mild; 15 to 30 moderate; and more than 30 severe. (Susan Graham says her test results were \u201cthrough the roof\u201d, showing she stopped breathing 110 times every hour, or nearly once every 30 seconds.)<\/p>\n Computers in the next room chart the patients\u2019 breathing, eye movements, heartbeat and brain waves. Some lines become more squiggly as the patient enters the deeper stages of sleep known as slow wave and rapid eye movement. The monitors also record snoring, which Kalistu has seen exceed 70 decibels, roughly the rumble of a washing machine. \u201cIn terms of the snore itself, it generally happens in our deeper sleep stages,\u201d he says. But sleep apnoea also limits people from reaching deeper sleep. \u201cAs a result, they always wake up feeling groggy.\u201d<\/p>\n It can be a patient\u2019s bed partner, who has lost sleep listening to the silences between their companions\u2019 bursts of snoring, who persuades them to seek a sleep test. But long gaps between breaths aren\u2019t always noticeable or distinguishable from snoring. And for people who sleep alone, the signs of apnoea might be just tiredness, headaches or waking with a dry mouth.<\/p>\n The long-term effects of apnoea (we\u2019ll get to them in a minute) worry Gina \u2013 \u201cI\u2019m nearly 60, I\u2019m an Aboriginal woman, I\u2019m in the danger zones for just about everything\u201d \u2013 but being in a hospital similar to where she works has brought a sense of calm. \u201cMaybe it\u2019s because there are people around me.\u201d<\/p>\n A sleep study can also be done at home, but the findings are not as granular, says David Cunnington. He will recommend these for people who are unlikely to have further underlying health problems. \u201cIt\u2019s not that much simpler. But you go home then sleep the night and the next day you drop your equipment back.\u201d In 2019, people aged between 65 and 74 were the most likely to do a laboratory study while those aged 45 to 64 were most likely to do a home test.<\/p>\n Gina Bundle, wired up in a sleep lab: \u201cI would love normal, whatever normal is.\u201d<\/span>Credit: <\/span>Paul Jeffers <\/cite><\/p>\n Melinda Mahlberg could barely find the energy to make dinner for her family in south-west Sydney. \u201cI just wanted to lie on the lounge and go to sleep.\u201d She was making \u201csilly mistakes\u201d at work such as tripping over, once getting a black eye.<\/p>\n It\u2019s well known that a poor night\u2019s sleep can reduce our cognitive performance and ability to manage emotions. But Angela D\u2019Rozario, a research leader at the Woolcock Institute of Medical Research, says the way sleep apnoea affects cognition can differ between people, with some still able to perform tasks that others can\u2019t. \u201cIt\u2019s so difficult to separate people; but we think part of that is they recruit other brain regions to maintain a level of performance.\u201d<\/p>\n For most people though, the risks remain, including to others. Drivers with sleep apnoea are 2\u00bd times more likely to have an accident, says Andrew Vakulin, of the Adelaide Institute of Sleep Health. In August, a Victorian coroner found a truck driver\u2019s undiagnosed sleep apnoea possibly contributed to his failure to stop at an intersection in Corio in Geelong; he collided with a 27-year-old driver who died as a result. State licensing authorities generally follow Austroads\u2019 Assessing Fitness to Drive guidelines, which require people with sleep disorders to report them, depending on their symptoms. Health professionals can also advise the licensing authority of someone\u2019s incapacity to drive.<\/p>\n Untreated sleep apnoea doubles the risk of heart failure, and increases the risk of stroke.<\/p>\n In some cases, intoxication from drugs or alcohol can blunt the reflex of people with sleep apnoea to breathe, says Cunnington. \u201cIf you already have sleep apnoea, a smaller drug overdose might be more dangerous for you.\u201d (A Los Angeles coroner found sleep apnoea contributed to Star Wars <\/i>star Carrie Fisher\u2019s death at age 60 in 2016, although they could not state the effect of multiple drugs found in her system.)<\/p>\n But it\u2019s the longer-term consequences of sleep apnoea that are a worry, too. In 2018, it played a role in 1066 deaths in Australia, accompanying heart disease in more than one-third of those cases. Untreated sleep apnoea doubles the risk of heart failure, and increases the risk of stroke. Each time a person with apnoea wakes, a stress response is triggered in their body, Cunnington says. \u201cIf you just get repeated stress responses every single night, over time that baseline is just a bit higher and blood pressure sits at just a bit higher level. The heart muscle can be weakened over the years as well.\u201d<\/p>\n Sleep serves many restorative functions, too, including cleaning neurotoxins in the brain. Emerging evidence suggests sleep apnoea interrupts this, putting people at greater risk of dementia. \u201cOne of the things that\u2019s known about the cleaning process is that if you have elevated blood pressure at night, for example, the cleaning process is somewhat compromised,\u201d says Craig Phillips, of the Woolcock Institute and Macquarie University, who is researching dementia\u2019s links to sleep apnoea.<\/p>\n Melinda Mahlberg, and with her CPAP mask on.<\/span>Credit: <\/span>Photo Edwina Pickles. Artwork Aresna Villanueva<\/cite><\/p>\n The labourer\u2019s apnoea was so severe he would fall asleep on scaffolding at work. It was 1980 and Sydney physician Colin Sullivan recommended the man have a procedure called a tracheoscopy, in which a tube is inserted to allow breathing through the throat. But the man refused. So Sullivan offered to do an experiment.<\/p>\n At the time, it wasn\u2019t known whether sleep apnoea was due to muscles in the airway tensing or relaxing. If the latter, Sullivan had an idea: a gentle stream of pressurised air <\/strong>holds the airway open during sleep. \u201cInitially, I thought this would be a rescue therapy that someone like this man, who came in with really serious complications, could use to get them on treatment,\u201d he says. \u201cIt was absolutely spectacular. In the morning, he woke up and he was bright and alert.\u201d<\/p>\n Colin Sullivan with his early CPAP machine in 1984. About 1000 patients used the machine. <\/span>Credit: <\/span>Paul Matthews <\/cite><\/p>\n Now known as the CPAP machine, Sullivan\u2019s invention is the most common treatment for sleep apnoea. Joe Biden is one user, the White House said in June after indentations were visible on the president\u2019s face from the mask one morning. The mask can cover both airways or just the nose and attaches to a small, box-shaped machine that sits at the bedside, as quiet as a desktop computer. An expert will recommend an air pressure depending on the severity of apnoea, typically after a sleep study.<\/p>\n It\u2019s \u201cdefinitely not sexy\u201d, says Susan Graham of her machine. Still, Megan Rees swears they help more relationships than they harm. \u201cI have certainly seen relationships blossom when people start being treated and the snoring and gasping stops.\u201d<\/p>\n Melinda Mahlberg\u2019s snoring was a source of tension for her and her husband. \u201cWe\u2019ve got friends who sleep in separate rooms and I thought, well, maybe that\u2019s where we\u2019re headed … because I can\u2019t just choose to stop snoring,\u201d she says. Troy says he sometimes rolled over to disturb Melinda to stop the snoring. \u201cI would feel guilty for that, she would feel guilty for snoring; we were all in this big guilt cycle.\u201d<\/p>\n Now Melinda is using CPAP, they\u2019re both sleeping better, but she still has a big \u201csleep debt\u201d to repay. \u201cI\u2019ve only been using CPAP for two months, so I\u2019m still looking forward to the benefits.\u201d<\/p>\n \u2018I would love normal, whatever normal is. It would be nice to go to bed and just go straight to sleep.\u2019<\/p>\n In milder cases, a kind of mouth guard called a mandibular advancement splint, which repositions the jaw and tongue, can stop the airway collapsing. A specialist dentist will usually fit the device. \u201cSome people find these more comfortable than CPAP, and they have good research to support their use,\u201d says Cunnington. \u201c[But] if you try to push the jaw too far, it can cause discomfort. It can also cause the teeth to shift over time.\u201d Surgery can also help widen airways in some cases, such as for children with large tonsils. \u201cThere\u2019s no uniform surgery; it\u2019s an individualised approach.\u201d<\/p>\n And losing weight is an option for many, although exhaustion can make you less inclined to exercise and more likely to seek out sweet snacks for energy. Several hormones that affect appetite and metabolic rate also need the deeper stages of sleep to be properly regulated. \u201cYou end up being in a vicious cycle,\u201d says Rees. Still, one study showed people who lost 10 per cent of their body weight had a 26 per cent drop in how many times they stopped breathing while asleep.<\/p>\n Weight-loss drugs could be a new frontier, but the evidence is still emerging. Trials overseas of the drug, Wegovy, and a similar drug called tirzepatide with two active ingredients, have found body weight dropped by about 15 per cent and 20 per cent respectively. \u201cWe actually think it\u2019s going to be a game-changer,\u201d says Craig Phillips, who has evaluated the potential of the drugs. Tirzepatide is being trialled for its ability to make sleep apnoea less severe. Gastrointestinal side effects are one sticking point, but these can be offset by gradually increasing the dosage, Phillips says.<\/p>\n Different drugs also still in trials could prevent muscles in the throat from relaxing during sleep. If successful, these could complement existing treatments, Cunnington says. \u201cA mouth guard plus medication might well prevent them needing to go on to CPAP.\u201d<\/p>\n Sullivan isn\u2019t concerned his machines will be displaced just yet though. \u201cSleep apnoea is not simply weight; [many] people probably have a relatively small airway that puts them at risk,\u201d he says. \u201cI honestly don\u2019t believe we\u2019re going to find the silver bullet.\u201d Graham is one patient who believes she would suffer from sleep apnoea for life without CPAP. \u201cIt\u2019s not instantaneous that you feel better; it takes a while for your body to get used to actually getting sleep again,\u201d she says. \u201cNow, I can\u2019t sleep without it.\u201d<\/p>\n As Gina Bundle waits for the results of her sleep test, she just wants to know what a good night\u2019s sleep is. \u201cI would love normal, whatever normal is. It would be nice to go to bed and just go straight to sleep.\u201d<\/p>\nWhat\u2019s sleep apnoea?<\/h3>\n
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How do you know you\u2019ve got sleep apnoea?<\/h3>\n
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How does sleep apnoea affect your health?<\/h3>\n
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How is sleep apnoea treated (and what\u2019s a CPAP machine)?<\/h3>\n
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