Waking up in the middle of the night and realizing that you were gasping for air during sleep can be scary and something you shouldn’t ignore. It can be a sign of a serious health problem. And if you do find yourself waking feeling short of breath, don’t assume right away that it’s sleep apnea. “Gasping at night can be caused by a lot of things,” says otolaryngologist Omar G. Ahmed, MD, who specializes in treating sleep disorders at Houston Methodist Hospital.
The key to finding out what’s causing your nighttime gasping is to see a sleep specialist, who will perform a physical exam and ask a lot of questions. How long have you been gasping at night? How often does it happen? Have you gained weight lately? Do you have any major health problems?
A sleep specialist may suspect sleep apnea as the cause of your gasping, but you might be surprised by the variety of other potential causes.
Obstructive Sleep Apnea
Obstructive sleep apnea (OSA), the most common form of this nighttime breathing disorder, occurs if your tongue and other tissues in the mouth fall backward and block your airway when you lie down for a snooze. Each time that happens, you stop breathing for up to a minute or more, and it can happen hundreds of times per night. You may not wake up, but a bed partner will likely be wide-eyed at your snoring, as well as frequent gasps for air.
If a doctor suspects you may have sleep apnea, they will order a sleep study, which can be done at home, though tests conducted in hospital sleep clinics provide more information. While you sleep, you’ll be connected to various monitors that measure your breathing, oxygen levels, body movements, and other factors that offer clues that you have sleep apnea. “We want to find out if obstructive sleep apnea is occurring, and if so, how severe it is,” Ahmed says.
If you are diagnosed with OSA and you’re carrying some extra pounds, “the most important thing you can do is lose weight,” says sleep specialist Priyanka Yadav, DO, of the Robert Wood Johnson University Hospital Comprehensive Sleep Center, in Hillsborough, NJ. Dropping 10% of your body weight, she says, can reduce episodes of sleep apnea by up to 50%.
The current “gold standard” treatment for OSA is continuous positive airway pressure (CPAP), which uses a mask-like device that fits over the nose and mouth and is attached by a tube to a motor that blows air. “CPAP creates pressure in your airways so they don’t collapse while you sleep,” Ahmed says. CPAP is first-line therapy for people with moderate to severe OSA, which makes up 80% of the 22 million Americans who have sleep apnea, according to the American Sleep Apnea Association.
Many of Yadav’s patients with mild cases of OSA benefit from special mouthguard-like devices that prevent the airway from being compressed by moving the lower jaw forward; they work best for back sleepers.
A relatively new device approved by the Food and Drug Administration, called Inspire, is for people with moderate to severe OSA. Inspire is implanted in the chest and senses when you breathe, then stimulates nerves to keep your airways open. “Patients do really well with it,” says Ahmed, who has implanted the device in many. Inspire is approved for patients who fail on or can’t tolerate CPAP and isn’t available for very obese people. If all else fails, Ahmed and other surgeons can perform procedures that widen the airway.
Central Sleep Apnea
Less common than OSA, central sleep apnea (CSA) is not caused by blocked airways. Instead, signals from the brain that normally maintain breathing during sleep go haywire, resulting in periods where there is little or no air flowing into the lungs. CSA can also be brought on by certain medical conditions or drugs, as well as sleeping at high altitude. CPAP is the usual treatment for CSA.
Anxiety and Nocturnal Panic Attacks
It’s possible that your psyche is triggering your nighttime respiratory problems. “Some patients will say, I’m not snoring, but I wake up gasping at night,” Yadav says. If she rules out sleep apnea and other potential physiological causes, Yadav often discovers that a patient is most likely gasping during sleep due to anxiety or nocturnal panic attacks.
Everybody knows what anxiety feels like. A nocturnal panic attack is a nighttime version of a panic attack, which is the sudden onset of overwhelming fear and worry, often accompanied by a pounding heart, perspiration, and shortness of breath. Some people who have a panic disorder primarily experience attacks when they’re asleep. Choking and shortness of breath are common in people who experience nocturnal panic attacks.
People who have sleep-time gasping and other symptoms related to anxiety and nocturnal panic attacks often have a history of insomnia, Yadav says. If you wake up gasping, the sheets are soaked, your heart is pounding, and you’re scared out of your wits, you may be experiencing one of these problems. Yadav suspects that the number of people worldwide who experience these attacks has probably risen during the COVID-19 pandemic. She refers patients to a psychotherapist or psychiatrist for counseling and, possibly, medication.
This common problem can cause nighttime gasping, too, particularly if you happen to have heavy nasal congestion. When a congested person lies down at night, Ahmed says, thick drainage can drip from the nasal passages and into the nasopharynx, or upper part of the throat behind the nose, and then into the oropharynx, or the portion of the throat at the back of the mouth. “That can cause people to feel like, Hey, I suddenly can’t breathe!” Ahmed says. Post-nasal drip can also cause coughing and the need to spit out thick mucus.
Post-nasal drip occurs due to various forms of rhinitis and sinusitis, which are inflammation and swelling of the mucous membrane of the nose and the sinuses, respectively, Ahmed says. Some people have chronic rhinitis, though the common cold and seasonal allergies can produce similar symptoms. Also, a condition called vasomotor rhinitis simply causes people to produce large amounts of nasal mucous fluid, she says.
Various medications such as antihistamines, nasal steroids, and others can help relieve rhinitis and sinusitis. If medications don’t help, various other procedures may offer relief. If you have chronic rhinitis, cryotherapy can deliver extremely cold temperatures that “freeze” a nerve in the nasal passage that’s causing you to produce too much discharge.
Endoscopic sinus surgery is an option for people with hard-to-treat sinusitis. “The goal of this procedure is to open up the sinus passages, as wide as possible, so they can drain easily,” Ahmed says. Widening the sinus passages also makes it easier to treat ongoing inflammation that’s causing post-nasal drip in the first place.
Can that cheeseburger you had for dinner trigger a nighttime gasping episode? Most of us get a touch of heartburn now and then, and if you get a burning sensation in your chest routinely you may have gastroesophageal reflux disease (GERD). Nighttime gasping and other discomfort can be caused by a related problem, called laryngopharyngeal reflux (LPR), Ahmed says. As in GERD, acidic juices from the stomach leak out and creep back up the windpipe in LPR. But instead of causing classic heartburn symptoms, Ahmed explains, the acidic fluid instead irritates the throat in LPR (it’s sometimes called “silent reflux” since it seems to sneak past the chest). “That can produce the sensation that you have something stuck in your throat,” he says, which can cause you to wake up feeling like you need to clear your throat so you can take a breath.
You may be particularly likely to have a flareup of either GERD or LPR soon after you fall asleep, resulting in a gasp attack, since the body’s peak production of stomach acid occurs between 10 p.m. and 2 a.m., Yadav says.
Fortunately, a number of preventive measures can help with both. Avoiding fried or fatty foods is wise for many reasons and may ease acid reflux. You also should watch your evening consumption of highly acidic foods and beverages, such as tomato sauce, orange juice, and coffee. Take an acid reducer such as famotidine (Pepcid) a half hour before dinner, Yadav suggests, or ask your doctor about using a related medicine, called a proton-pump inhibitor, such as esomeprazole (Nexium) or omeprazole (Prilosec). Finally, elevating the head of your bed slightly (special risers are available) or using a lot of pillows can let gravity keep stomach acid in its place.
A common cardiovascular condition, heart failure, which affects over 6 million Americans, can leave you short of breath, which can limit your activities by day and wake you up at night. This condition occurs when the heart is unable to pump adequate supplies of blood to the body’s other organs, depriving them of oxygen. Blood backs up when your heart cannot pump it forward properly. This back up can leak into your lungs. “And that gets worse when you lie down flat,” Ahmed explains.
People with inadequately managed heart failure often wake up abruptly, struggling to breathe. Propping up your head may help, but if you have heart failure and wake up short of breath often, tell your cardiologist. If you haven’t been diagnosed with heart failure but have shortness of breath at night or by day, especially if it’s accompanied by swelling in the legs or feet, see a doctor as soon as possible.
If you have asthma and it’s not well controlled with medication, that may explain why you often wake up gasping. When you breathe, oxygen-rich air travels down your windpipe and into your lungs, where it passes through a tree-like formation of tubes with ever-tinier branches called bronchioles. It turns out that bronchioles have a daily cycle. They’re most open around 4 p.m. in the afternoon, Yadav says, but most constricted (or closed) around 4 a.m. “That means there’s more airway resistance at night when you’re sleeping, which can make underlying asthma worse,” Yadav says, which could lead to a predawn fit of wheezing and shortness of breath.