Obstructive sleep apnea Diagnosis and management Initial sleep study AASM Q Does the patient have significant cardiorespiratory disease? Q Does the patient have potential respiratory muscle weakness due to a neuromuscular condition? Q Does the patient have awake hypoventilation or suspicion of sleep-related hypoventilation? Q Is the patient on chronic opioid medications? Q Does the patient have a history of stroke? Q Does the patient have severe insomnia? Yes to any Obtain polysomnography, rather than home sleep apnea testing, as a first-line test for OSA in patients with any of the following: significant cardiorespiratory disease potential respiratory muscle weakness due to a neuromuscular condition awake hypoventilation or suspicion of sleep-related hypoventilation chronic opioid medication use history of stroke severe insomnia. B No to all Obtain either polysomnography or home sleep apnea testing as the first-line investigation for patients with suspected OSA, in the absence of conditions that warrant using polysomnography as a first-line test. B Confirmatory sleep study Negative polysomnography Q Is an initial polysomnography negative? Q Is there still clinical suspicion of obstructive sleep apnea? Yes to all Consider obtaining a second polysomnography in patients with an initial negative polysomnography, if OSA is still clinically suspected. C No to any Positive airway pressure therapy ACP Q Do investigations confirm the diagnosis of obstructive sleep apnea? No Consider alternative diagnoses. Yes Initiate CPAP treatment as initial therapy in patients diagnosed with OSA. B Oral appliances ACP Q Does the patient refuse CPAP? Q Does the patient experience unacceptable adverse effects associated with CPAP? Yes to any Consider offering mandibular advancement devices as an alternative to CPAP in patients with OSA preferring mandibular advancement devices, or in patients with unacceptable adverse effects associated with CPAP treatment. C No to all Weight loss ACP Q Is the patient overweight or obese? Yes Advise all overweight and obese patients diagnosed with OSA to lose weight. B No Continue management and follow-up as clinically appropriate.