While drifting off to sleep may be calm and restful for many, as muscles in the upper airway relax, some patients begin to experience breathing difficulty. Those who live with any of the more than 80 identified sleep disorders may experience disruptions in their sleep, threatening everything from energy and cognition to emotional and mental well-being as well as overall health.
Among the most common disorders are a group of respiratory conditions known as sleep-disordered breathing (SDB), a spectrum of diagnoses defined by the American Thoracic Society that includes sleep hypopnea (increased resistance to airflow through the upper airway, heavy snoring, and marked reduction in airflow) and sleep apnea (complete cessation of breathing).
As the clinical understanding of the relationship between sleep and respiratory health has become elucidated, pulmonologists and other respiratory care professionals are commonly collaborating with sleep health professionals in the diagnosis and treatment of SDB for patients of all ages and comorbidities.
“We now view sleep and respiratory not as separate systems, but as interconnected networks that influence each other,” Rupali Drewek, MD, a pediatric pulmonologist, sleep medicine specialist, and co-medical director of the sleep medicine program at Phoenix Children’s Hospital, Phoenix, said. “Another major discovery is how breathing interruptions during sleep raise stress hormones and inflammation that can lead to a multitude of problems, including worsening of underlying asthma. Understanding this connection is valuable for prevention and improved treatment.”
As education has advanced and treatments have evolved, Drewek and other clinicians are suggesting that screening and care planning continue to trend toward collaborative care planning.
Combined Complications
Approximately 50-70 million people in the US live with at least one sleep disorder, with an estimated 1 in 3 adults regularly not get the recommended amount of uninterrupted sleep to protect their health, according to the National Heart, Lung, and Blood Institute. Obstructive sleep apnea (OSA) is said to be the most common and severe form of SDB, affecting up to 1 billion adults globally, although some 40 million Americans are undiagnosed.
OSA is caused by a physical blockage within the airway while central sleep apnea is a condition in which the brain fails to appropriately signal muscles that control the body’s breathing. This inaccurate signaling is more common as people grow older. “Aging changes the body’s internal clock and sleep architecture,” explained Drewek. “It makes sleep lighter and causes nighttime awakenings.”
Women typically report worse sleep quality and more sleep disruption, with hormonal changes playing a significant role, according to the National Sleep Foundation. It’s also estimated that nearly half of all children will experience a sleep disorder at some point, according to findings by the Cleveland Clinic, Cleveland, with parasomnias, such as sleepwalking or night terrors, comprising a growing proportion of childhood cases that can be behavioral or respiratory related.
“Disrupted sleep or insufficient sleep can trigger parasomnias, and sometimes they happen for reasons that we don’t really understand,” said Drewek. “In children, the most common sleep problems are behavioral insomnia and OSA. Behavioral insomnia means that sleep difficulties are related to bedtime routine or inconsistent bedtime routines. OSA in children is most often related to having enlarged tonsils and adenoids.”
In the aging population, variations in the structure of the airways, muscle tone, and circadian rhythm are also contributing to sleep diagnoses, said Zergabachew Asfaw, MD, primary care physician at AZ Medical, Bronx, New York. “Our understanding has improved greatly because studies have helped us determine how closely sleep physiology and respiratory function are interrelated. We now realize that sleep is not a passive state and the change in muscle tone, neural control of the breathing process, and airway resistance during sleep can unmask or exacerbate underlying respiratory conditions such as asthma, chronic obstructive pulmonary disease (COPD), and SDB.”
Of pediatric patients diagnosed with SDB, adenotonsillar hypertrophy-causing OSA is also a common diagnosis, Asfaw said. “Behavioral insomnia, circadian rhythm problems in adolescents, and sleep problems associated with neurodevelopmental disorders, such as attention-deficit/hyperactivity disorder or autism, are also gaining attention and being treated sooner than was the case decades ago,” he said.
As recognition of sleep disorders increase, so does the finding that they are significantly influenced by a range of factors. These include underlying medical conditions and respiratory comorbidities such as asthma, interstitial lung disease, cystic fibrosis, and COPD, and lifestyle factors such as stress, diet and exercise, and sedentary behaviors, said Priya Shah, MD, a family medicine physician at Aylo Health Primary Care, Dawsonville, Georgia. “These disorders rarely exist in isolation and often overlap with cardiovascular, metabolic, neurologic, and respiratory health,” Shah explained. “A multidisciplinary approach allows us to address the root causes of sleep issues rather than simply managing symptoms.”
Respiratory and Sleep Health
Improved clinical awareness and increased diagnoses of SDB and respiratory diseases have necessitated physicians working collaboratively to manage disease. “In today’s world, we have a much deeper appreciation for the fact that the body’s systems do not operate in silos,” said Shah. “Advances in sleep diagnostics and long-term population data have helped us better understand how SDB impacts cardiovascular, metabolic, and cognitive health. Conditions such as OSA, COPD, and asthma clearly demonstrate how respiratory function and sleep quality influence one another.”
Not coincidentally, there is a growing need for multidisciplinary care in sleep medicine because conditions are understood to be far more complex, said Drewek. “They overlap with problems in pulmonology, cardiology, neurology, psychiatry, and endocrinology,” she said. “For example, OSA can affect the heart and cause systemic or pulmonary hypertension. It can cause metabolic syndrome, including rises in blood glucose levels. No single specialist can address all the contributing and confounding factors. Multidisciplinary care ensures patients receive comprehensive care and experience better long-term outcomes.”
At Phoenix Children’s, where she helped launch the sleep program, Drewek said there’s a robust referral network where many of the patients whom she sees are referred by subspecialists within the hospital system. “For example, if we have a pulmonologist who brings in a patient who has asthma and is snoring, they’ll be referred to our sleep department,” she said. “We also receive a lot of referrals from the general pediatrics department and endocrinologists. And when I see patients who have a concurrent respiratory issue or we’re worried about metabolic syndrome, I can refer. There’s this bidirectional relationship that creates this very cohesive, comprehensive care plan.”
Collaborative personalized care planning also extends to treatment of children. “For children who have OSA, the first line of treatment would be consideration toward adenotonsillectomy, and in children who have no other risk factors, that surgical intervention usually is curative,” said Drewek. “If a patient is not a candidate for adenotonsillectomy or has already undergone that surgical intervention, the next line of treatment would be using continuous positive airway pressure (CPAP). And we always couple that with improving sleep hygiene and good sleep habits.”
Care plans might include more innovative therapies such as hypoglossal nerve stimulation, an implantable device that stimulates the tongue to move it forward during sleep to prevent airway obstruction. Additionally, auto-titrating CPAP machines can be prescribed to intelligently deliver the pressure needed to maintain airway clearance. “This not only optimizes treatment but adds to the comfort of patients,” Drewek said.
More comprehensive collaboration reduces the likelihood of fragmented treatment while improving adherence for more sustainable results in sleep quality and general health, said Asfaw. “By engaging pulmonologists, sleep specialists, neurologists, behavioral health providers, and primary care clinicians, care planning is more coordinated and patient-centered,” he said.
Other interventions that can also be considered include surgical procedures, oral appliances, weight management, and positional therapy, a noninvasive treatment that “trains” patients to side-sleep to maintain an open airway, primarily for snoring and positional OSA, a form of sleep apnea typically affecting those who sleep on their backs, said Drewek.
“In addition, progress in sleep studies, home sleep testing, and respiratory monitoring has enabled clinicians to better detect subtle patterns of hypoventilation, oxygen desaturation, and sleep fragmentation,” said Asfaw. “This has led to earlier diagnosis and more precise treatment, improving outcomes for previously undiagnosed or undertreated patients.”
Screening and Treatment Best Practices
Despite progress in collaboration and care planning, Drewek still sees sleep health as one that’s “underrated” and in need of better screening practices and prioritization. “From a lot of different areas, we need more recognition of sleep disorders and treatments because, on both sides, people take sleep for granted,” said Drewek, who said she initially became interested in practicing sleep health alongside pulmonology and pediatrics during her clinical rotations. “The intersection between pulmonology and sleep is fascinating,” she said. “I’ve always thought it would be a good way to branch off into a field that I really wanted to help improve.”
Drewek believes screening for sleep issues has become more robust over time with better multidisciplinary involvement, and screening for SDB at the time of an initial asthma evaluation will occur together. Patients experiencing low lung volumes will also receive earlier emphasis on the potential for hypoventilation or SDB. She suggested that a lung volume of 30% or lower warrants screening with a sleep study.
Potential of Artificial Intelligence (AI)
AI may offer an aid as it can be used to identify high-risk patients for sleep apnea screening earlier based on BMI, blood pressure, comorbid diagnoses, and prescribed medications, said Shah. “AI has tremendous potential to enhance sleep medicine by identifying patterns in large datasets, improving diagnostic accuracy of sleep study results, and helping predict treatment response,” she said. “When used thoughtfully, AI can support more personalized, data-driven care while enhancing clinical judgement and allowing providers to spend more time focused on patient connection and health outcomes.”
Algorithms are also being trained to analyze data from sleep studies and wearable devices and provide clinically relevant information to providers and patients, leading to early detection and treatment, said Drewek. From a post-care perspective, the technology can more effectively monitor CPAP adherence and identify risks for complications. As tools mature, there is an opportunity to improve clinical decision-making, design treatment plans that are more individualized, and improve outcomes while reducing overall healthcare system burden, said Asfaw.
Drewek, Asfaw, and Shah reported no related financial disclosures.