Snoring or sleep apnoea? How to tell the difference

This is the question that brings most people to my clinic when sleep is the issue. Usually a partner has said something, or the person has read about sleep apnoea and recognised themselves in it, and they want to know whether the snoring is simply an irritating noise or a sign of something that needs treating.

It is a good question, and the honest answer is that you cannot reliably work it out from home. But you can work out whether you need to find out — and that is genuinely worth doing, because the two conditions have very different implications.

What is physically happening in each

Snoring happens when the airway is narrowed. Air has to travel faster to get through the same space, and fast air moving past loose tissue makes it flutter. The soft palate, the uvula, the tonsils and the base of the tongue are the usual culprits. The airway is narrow, but air is still getting through.

Obstructive sleep apnoea is what happens when the same airway narrows past the point of collapse. Instead of vibrating, the tissues meet and airflow stops entirely — an apnoea — or falls dramatically — a hypopnoea. You go on trying to breathe; the chest and abdomen keep working, often harder and harder, but nothing moves. Oxygen levels fall by three or four per cent, sometimes far more, and the brain responds by lifting you briefly out of deep sleep so that muscle tone returns and the airway reopens. You take a deep breath, settle back down, and because nothing has changed, it happens again.

In severe cases this can occur every thirty seconds throughout the night. Almost nobody remembers a moment of it.

One spectrum, not two conditions

It helps to think of sleep-disordered breathing as a continuum rather than a set of separate diseases.

The same person can move along this spectrum over time. Loss of muscle tone with age, weight gain, alcohol, sedating medication, the menopause and worsening nasal blockage all narrow the margin. This is why a normal sleep study five years ago is not a guarantee about today.

The clues that point towards apnoea

None of these is diagnostic on its own. Together they shift the probability enough to justify testing.

What the snoring sounds like

Volume matters less than pattern. Continuous, even snoring is more likely to be simple snoring. Snoring that builds, stops abruptly, is followed by ten or twenty seconds of silence, and then resumes with a snort or a gasp is the sound of an apnoea and its termination. If your partner can describe that rhythm, take it seriously.

Recording yourself is genuinely useful here. A phone left running overnight, or one of the snore-recording apps, will not diagnose anything — but hearing the interruptions for yourself is often what prompts people to act.

What you notice in the day

Waking unrefreshed after seven or eight hours; needing caffeine to function rather than to enjoy; nodding off in front of the television, in meetings, or as a passenger; word-finding difficulty and forgetfulness; irritability and short temper that are out of character. In simple snoring, daytime function is generally normal.

What you notice at night and first thing

Getting up two or three times to pass urine. A very dry mouth or sore throat on waking. Headache on waking that eases within the first hour. Night sweats. Reflux, throat clearing or hoarseness. These are the ones people rarely connect to their breathing, and they are often the most telling.

What else is going on medically

Blood pressure that needs three or more medicines. Atrial fibrillation. Type 2 diabetes with stubborn control. Unexplained fatigue that has been investigated without an answer. Low mood that has not responded fully to treatment. Any of these alongside snoring raises the priority considerably.

Why symptoms alone cannot settle it

This is the part I find myself explaining most often, and it cuts both ways.

People with significant sleep apnoea frequently feel fine. Because the condition develops over years, the tiredness becomes the baseline and gets attributed to work, age or family life. A person can have thirty events an hour and score entirely normally on the Epworth Sleepiness Scale. In one study of drivers with sleep apnoea, nearly one in five had objective impairment on formal testing while reporting no subjective sleepiness at all.

Equally, plenty of people who are convinced they have sleep apnoea do not. Poor sleep has many causes — insomnia, shift work, anxiety, alcohol, restless legs, perimenopause, thyroid disease, iron deficiency, and simply not spending enough hours in bed. Testing is as useful for ruling out as for ruling in, and knowing that your breathing is fine redirects attention to whatever is actually responsible. My article on whether sleep hygiene actually works covers some of that ground.

What a smartwatch or ring can and cannot tell you

Consumer wearables infer sleep from movement and from an optical heart rate sensor. They do not measure airflow. They do not measure the effort you are making to breathe. Most do not measure blood oxygen across the night in a way that has been validated for diagnosis. Someone with moderate or severe sleep apnoea can produce an entirely unremarkable sleep score, because the device is blind to the mechanism causing the problem.

They are not useless — trends in resting heart rate and total sleep duration over weeks are reasonably reliable, and they are good at prompting people to take sleep seriously. But a reassuring score is not reassurance. I have written about this in detail in can your sleep tracker detect sleep apnoea?.

Screening questionnaires

Two are worth knowing about.

STOP-BANG asks eight yes-or-no questions: loud Snoring, daytime Tiredness, Observed apnoeas, high blood Pressure, BMI over 35, Age over 50, Neck circumference over 40cm, and male Gender. A score of 0–2 suggests low risk, 3–4 intermediate, and 5–8 high risk. It is deliberately over-inclusive: it is designed to catch nearly everyone who has the condition, accepting that it will also flag people who do not. An intermediate or high score is a reason to have a sleep study, not a diagnosis.

The Epworth Sleepiness Scale asks how likely you are to doze in eight everyday situations, scoring each 0–3. Above 10 is generally taken as excessive sleepiness. As above, a normal score does not exclude anything — it measures how sleepy you feel, not how alert you actually are.

The test that does settle it

A sleep study measures what a questionnaire cannot: airflow, breathing effort, oxygen saturation, pulse, snoring intensity, body position, and — on the more detailed devices — sleep stage. It produces an apnoea-hypopnoea index: the number of times per hour your breathing stopped or became significantly shallower. Under 5 is normal, 5 to 14 mild, 15 to 29 moderate, 30 or more severe.

NICE recommends home respiratory polygraphy as the first-line test, with full polysomnography reserved for cases where a simpler negative test does not fit the symptoms. In practice a home study is also the better test for most people, because a first night in a hospital sleep laboratory in an unfamiliar bed is rarely representative.

I can arrange the whole range — a straightforward posted single-night screen, multi-night recordings that capture how much your breathing varies from night to night, advanced studies that add body position and REM data, full home polysomnography set up at your home by a sleep technologist, and detailed manual analysis for suspected upper airway resistance syndrome. Which one is right depends on the question we are trying to answer.

If it turns out to be snoring

That is good news, and it does not mean nothing can be done. Snoring responds well to a systematic approach: opening the nose properly with a steroid spray used at the right dose and with the right technique, sleeping on your side, reducing evening alcohol, losing weight where relevant, daily throat and tongue exercises, and — where the tongue is the problem — a dental device made by a dentist trained in sleep medicine. The full sequence is in how to stop snoring.

If it turns out to be sleep apnoea

Then the priority is treating it, and doing so in a sensible order. Nasal blockage and large tonsils should be assessed and dealt with first, because they undermine every other treatment — CPAP in particular. NICE says this explicitly, and it is the step most often skipped; I have given it its own article for that reason. After that, treatment depends on severity, on where in the airway the problem is, and on what you can actually live with: CPAP, a custom mandibular advancement device, positional therapy, weight loss, myofunctional therapy, or a combination.

A minority of people need surgical assessment — usually those with moderate or severe disease who cannot tolerate CPAP or a dental device. That begins with a drug-induced sleep endoscopy, a short procedure under light sedation in which a fine camera is used to watch the airway collapse in real time, showing exactly which structure is responsible. It is the only way to target surgery properly rather than guess.