Even If You Don't Snore: Who Should Get Tested for Sleep Apnea

Originally written in Korean and adapted for international readers.

You may learn about snoring or changes in your breathing during sleep from someone else^[1]. But not snoring does not rule out sleep apnea. Women may have fatigue, insomnia, or morning headaches without snoring^[2]. This article covers symptoms you may notice yourself and situations in which to discuss testing.

Why not snoring does not rule out sleep apnea

The apnea–hypopnea index (AHI), the number of apneas and hypopneas per hour, is used to assess sleep apnea severity. In a 2010 study of 49 newly diagnosed, untreated patients, scores for sleepiness, sleep quality, depression, and anxiety showed no statistically significant correlation with AHI^[3]. This was a small group without major coexisting illnesses, so the findings do not establish that symptoms and test results are always unrelated.

A lack of daytime sleepiness does not rule out sleep apnea. The diagnostic criteria described in the American Academy of Sleep Medicine (AASM) guideline include people without symptoms whose sleep study results meet a specified threshold^[4]. Symptoms and their severity need to be assessed alongside the test results and medical history.

A 2019 analysis estimated that about 936 million adults aged 30–69 worldwide had at least mild obstructive sleep apnea. The authors noted that most cases remained undiagnosed and untreated, even in developed countries^[5].

Signs you can notice yourself

Sleep apnea can cause the symptoms below. Treat them as information to discuss at an appointment, rather than a way to diagnose yourself^[4][1].

• Waking up unrefreshed
• Daytime sleepiness or fatigue
• Waking often at night to urinate (nocturia)
• Waking up gasping or choking
• Waking frequently or having trouble falling asleep (insomnia)
• Morning headaches
• A dry mouth
• Difficulty concentrating because you feel sleepy during the day

Women may also experience depression or anxiety, as well as insomnia and fatigue. The National Heart, Lung, and Blood Institute (NHLBI) advises women to discuss these symptoms or risk factors with a healthcare provider even if they do not snore^[2].

One study at a Turkish sleep clinic compared 589 patients with moderate-to-severe sleep apnea (AHI ≥15). Women reported morning headaches (50.0% vs 28.4%), depressed mood (49.0% vs 19.5%), nocturia, and restless legs symptoms more often than men^[6]. Fatigue was reported by 72.9% of women and 65.3% of men, but that difference was not statistically significant (p=0.156). The chart below shows results for this study's moderate-to-severe sleep apnea group.

Self-reported snoring can also differ from measured snoring. In a separate study of patients referred for sleep testing, 28% of women and 6.9% of men described themselves as non-snorers. Among those women, 36.5% were found to snore heavily^[7]. A woman's report of whether she snores should therefore not be the only consideration when assessing her symptoms.

Sleep apnea can occur without obesity

Body size alone cannot rule out sleep apnea. A study comparing Chinese patients in Hong Kong with White patients in Australia found that, at a similar level of sleep apnea severity, the White patients had a higher BMI, while the Chinese patients had more restricted craniofacial bone structure^[8]. This comparison involved patients at two clinics. It does not explain the anatomy or causes of sleep apnea in all East Asian populations, including Koreans.

A Korean study assessed 383 people tested for suspected sleep apnea. In this group, the BMI cutoffs for predicting sleep apnea were about 23 for women and 25 for men; the neck circumference cutoffs were 34.5 cm for women and 38.75 cm for men^[9]. These cutoffs were calculated to distinguish patients with and without sleep apnea within that study. The authors cautioned against applying the results to the general population because they had included only high-risk patients with suspected sleep apnea^[9]. Weight or neck circumference alone cannot determine whether you need testing.

When to discuss screening with your doctor

Sleep apnea is common in people with cardiovascular disease. Its prevalence has been reported as high as 40–80% in groups of patients with hypertension, heart failure, coronary artery disease, pulmonary hypertension, atrial fibrillation, and stroke^[10]. Screening recommendations and the conditions for further assessment differ between these groups.

The American Heart Association recommends screening for sleep apnea in patients with the following conditions^[10]:

• Resistant or poorly controlled hypertension
• Pulmonary hypertension
• Atrial fibrillation that recurs after cardioversion or ablation

For heart failure, the recommendation is conditional. A formal sleep assessment is considered reasonable in people with New York Heart Association (NYHA) class II–IV heart failure who also have suspected sleep-disordered breathing or excessive daytime sleepiness^[10]. The statement describes continuing uncertainty about routine screening and treatment after stroke^[10]. If you have a coexisting condition, discuss your symptoms and history with the clinician managing it.

For US prevalence, a study published in 2013 estimated that 13% of men and 6% of women aged 30–70 had moderate-to-severe sleep-disordered breathing (AHI ≥15) in 2007–2010^[11]. It estimated that 26% of adults in that age range had at least mild sleep-disordered breathing (AHI ≥5)^[11]. These are estimates for that period, not current US prevalence figures.

A screening tool: STOP-Bang

STOP-Bang is a questionnaire used to assess sleep apnea risk. Chung and colleagues validated it in patients awaiting surgery. It covers eight items: snoring, daytime tiredness, observed apnea, and high blood pressure (STOP), plus BMI, age, neck circumference, and male sex (Bang)^[12].

To calculate your score — STOP-Bang Score calculator (MDCalc) →

A 2022 meta-analysis of patients awaiting surgery used a score of 3 or more as a positive screen. Sensitivity was 85% for all sleep apnea, 88% for moderate-to-severe sleep apnea, and 90% for severe sleep apnea^[13]. These results apply to the surgical patient populations studied. The score alone cannot diagnose or rule out sleep apnea. If you have symptoms, tell your healthcare provider regardless of your score so they can assess whether testing is needed^[4].

How testing works

Diagnosis requires an assessment of symptoms and medical history, along with an objective sleep test. For adults without complicating conditions whose signs and symptoms indicate an increased risk of moderate-to-severe sleep apnea, the AASM recommends polysomnography or a home sleep apnea test (HSAT) using a technically adequate device^[4]. If a home test is negative, inconclusive, or technically inadequate, the guideline recommends polysomnography^[4].

Polysomnography is recommended over home testing for people with significant heart or lung disease, possible respiratory muscle weakness due to a neuromuscular condition, a history of stroke, or severe insomnia. The same recommendation applies to chronic opioid use, hypoventilation while awake, or suspected sleep-related hypoventilation^[4].

If you have these symptoms, discuss them with your healthcare provider even if you do not snore. Your symptoms and medical history help determine whether testing is needed and which test is appropriate^[1].

This article is general information, not individual medical advice. Talk to a sleep specialist about your own symptoms and history.