Guideline sources The following summarized guidelines for the evaluation and management of obstructive sleep apnea (OSA) are prepared by our editorial team based on guidelines from the British Thoracic Society (BTS 2023), the American Diabetes Association (ADA 2023), the Oto-Rhino-Laryngological Society of Japan (ORLSJ/JADSM/JSSR/MHLW/JRS/JSPN/JCS/JSOH 2022), the Heart Failure Society of America (HFSA/AHA/ACC 2022), the European Respiratory Society (ERS 2021), the American Heart Association (AHA 2021), the American Academy of Sleep Medicine (AASM 2021; 2019; 2018; 2017), the United States Department of Defense (DoD/VA 2020), the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF 2019; 2017), the American Heart Association (AHA/HRS/ACC 2019), the American College of Preventive Medicine (ACPM/PCNA/ABC/ASPC/ASH/AAPA/AGS/AHA/NMA/ACC/APhA 2018), the American Thoracic Society (ATS 2018), the European Association for the Study of Obesity (EASO 2017), the U.S. https://web.pathway.md/diseases/recTKlOKFP9RKwbLb 1/14 6/30/23, 1:22 AM Obstructive sleep apnea Pathway Preventive Services Task Force (USPSTF 2017), the American Academy of Dental Sleep Medicine (AADSM/AASM 2015), the American Society of Anesthesiologists (ASA 2014), the American College of Physicians (ACP 2014; 2013), the Endocrine Society (ES 2013), the Obesity Society (OS/AACE 2013), and the American Association of Family Physicians (AAFP 2013). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 28 29 30 30 31 Definition OSA is a condition characterized by recurring episodes of upper airway obstruction during sleep, leading to cyclic reduction or cessation in airflow. 27 Epidemiology OSA is caused by recurrent periods of dynamic airway collapse during sleep. Factors that increase the risk of collapse include obesity, male sex, postmenopausal state, enlarged tonsils/adenoids, maxillary insufficiency, retrognathia, polycystic ovarian disease, androgen supplementation, hypothyroidism, and acromegaly. 29 30 Pathophysiology In the United States, the prevalence of moderate to severe OSA (apnea-hypopnea index 15) in adults (30-70 years of age) is estimated at 13% in men and 6% in women. 28 Disease course Key clinical manifestations of OSA include reduced sleep quality and daytime sleepiness. Long-term complications include arrhythmias, hypertension, cardiovascular events, stroke, impaired cognitive function, depression, and even premature death. 28 Prognosis and risk of recurrence Regular CPAP use is associated with an improvement in sleep apnea symptoms and health-related quality of life. Randomized studies have failed to demonstrate a benefit of CPAP for the prevention of adverse cardiovascular events. 30 31 Pathway Calculator Obstructive sleep apnea STOP BANG score for obstructiv Diagnosis and management Guidelines 1. Screening and diagnosis Risk factors: recognize that patients with higher BMI values are at a higher risk of OSA. B https://web.pathway.md/diseases/recTKlOKFP9RKwbLb 2/14 6/30/23, 1:22 AM Obstructive sleep apnea Pathway Show 2 more Indications for screening: As per AHA 2021 guidelines: Screen for OSA in patients with any of the following: resistant/poorly controlled hypertension pulmonary hypertension recurrent AF (after either cardioversion or ablation). E Consider obtaining sleep study if the following concerning signs/symptoms of sleep apnea are present: NYHA class II-IV HF symptoms tachycardia-bradycardia syndrome sick sinus syndrome VT survivors of sudden cardiac death stroke. E As per VA 2020 guidelines, consider assessing for sleep-disordered breathing in patients with a history of cardiovascular or cerebrovascular events, congestive HF, and long-term prescription opioid use. C As per ACC 2018 guidelines, obtain screening for obstructive apnea using the Berlin Questionnaire, Epworth Sleepiness Score, or overnight oximetry in patients with hypertension meeting any of the following criteria: resistant hypertension loss of normal nocturnal BP fall snoring, fitful sleep, breathing pauses during sleep daytime sleepiness obesity, Mallampati class III-IV. B As per AAO-HNSF 2017 guidelines, screen rhinoplasty candidates for comorbid OSA. Counsel rhinoplasty candidates with documented OSA about the impact of surgery on nasal airway obstruction and how OSA might affect perioperative management. B As per USPSTF 2017 guidelines, insufficient evidence to assess the balance of benefits and harms of screening for OSA in asymptomatic adults. I As per ES 2013 guidelines: Screen for OSA in adolescent and adult female patients with PCOS. B Consider screening for symptoms suggestive of OSA in overweight/obese adolescent and adult female patients with PCOS. Obtain polysomnography to make a definitive diagnosis. Refer patients with obstructive sleep to an institution offering appropriate treatment. C As per AACE 2013 guidelines, consider obtaining standardized screening for OSA (with confirmatory polysomnography if screening tests are positive) in patients considered for bariatric https://web.pathway.md/diseases/recTKlOKFP9RKwbLb 3/14 6/30/23, 1:22 AM Obstructive sleep apnea Pathway surgery. C Screening questionnaires: As per VA 2020 guidelines, consider using the STOP questionnaire to stratify risk for OSA in patients reporting sleep symptoms. C As per AASM 2017 guidelines, do not diagnose OSA in adult patients using clinical tools or questionnaires, in the absence of polysomnography or home sleep apnea testing. D 2. Diagnostic investigations Physical examination: Recognize that neck circumference, tongue size, and nasal and oropharyngeal airway structures are morphologic markers that may be associated with OSA. B Recognize that tonsil size may be associated with disease severity, as measured by apnea- hypopnea indices, in adult patients with OSA. B Initial sleep study: As per VA 2020 guidelines, consider obtaining a manually scored type III home sleep apnea test (unattended portable monitor) using an event index (such as respiratory disturbance index, apnea-hypopnea index) 15 events/hour to establish the diagnosis of moderate-to-severe OSA in patients with a high pretest probability of OSA. C As per AASM 2017 guidelines: 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 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 As per ACP 2014 guidelines: Obtain a sleep study in patients with unexplained daytime sleepiness. B Obtain polysomnography as the first-line diagnostic test in patients with suspected OSA. Use portable sleep monitors in patients without serious comorbidities as an alternative to polysomnography, if the latter is not available. B Confirmatory sleep study, negative home testing: As per DoD/VA 2020 guidelines, obtain repeated testing (home sleep apnea testing or laboratory-based polysomnography) for OSA in patients with a high pretest probability of OSA https://web.pathway.md/diseases/recTKlOKFP9RKwbLb 4/14 6/30/23, 1:22 AM Obstructive sleep apnea Pathway and a nondiagnostic home sleep apnea test (technically inadequate or apnea-hypopnea index < 5 events/hour). A As per AASM 2017 guidelines, obtain follow-up polysomnography in patients with a single negative, inconclusive, or technically inadequate home sleep apnea test. B Confirmatory sleep study (negative polysomnography): consider obtaining a second polysomnography in patients with an initial negative polysomnography, if OSA is still clinically suspected. C Actigraphy: consider obtaining using integrated with home sleep apnea test devices to estimate total sleep time during recording (in the absence of alternative objective measurements of total sleep time) in adult patients with suspected sleep-disordered breathing. C Echocardiography: obtain echocardiography to evaluate pulmonary arterial pressures in patients with obesity, OSA, and edema. B 3. Respiratory support Positive airway pressure therapy: As per JRS 2022 guidelines, initiate CPAP as first-line therapy in patients with strong clinical symptoms, such as daytime sleepiness due to OSA, and for moderate-to-severe cases. A As per ERS 2021 guidelines, consider initiating CPAP therapy over offering mandibular advancement devices in adult patients with OSA. C As per VA 2020 guidelines, advise patients with OSA receiving positive airway pressure therapy to use this treatment for the entirety of their sleep periods. A Show 4 more As per AASM 2019 guidelines, initiate positive airway pressure therapy in patients with OSA based on a diagnosis established using objective sleep apnea testing. B Show 10 more As per ACC 2018 guidelines, insufficient evidence regarding the effectiveness of CPAP to reduce BP in adult patients with OSA and hypertension. I As per ACP 2013 guidelines, initiate CPAP treatment as initial therapy in patients diagnosed with OSA. B Supplemental oxygen: As per JRS 2022 guidelines, consider offering oxygen therapy in patients unable to use CPAP or oral appliances. C As per VA 2020 guidelines, avoid administering oxygen therapy as a standalone treatment in patients with OSA unable to tolerate other recommended therapies. D 4. Medical management https://web.pathway.md/diseases/recTKlOKFP9RKwbLb 5/14 6/30/23, 1:22 AM Obstructive sleep apnea Pathway Anti-obesity medications: consider offering anti-obesity pharmacotherapy, if not contraindicated (including no active CVD), in patients with OSA with a BMI 27 kg/m failed to improve weight with a comprehensive weight-loss lifestyle intervention program. C Carbonic anhydrase inhibitors: consider administering carbonic anhydrase inhibitors only in the context of an RCT. C Nasal corticosteroids: avoid using topical nasal corticosteroids for the sole purpose of improving positive airway pressure adherence in patients without nasal congestion. D Hypnotics: do not use hypnotics initially in the treatment of patients with OSA and insomnia. Prioritize treatment of OSA. D Consider offering hypnotics if insomnia is present despite the proper use of CPAP. D 5. Nonpharmacologic interventions Weight loss: As per JRS 2022 guidelines, offer weight loss in patients with OSA and obesity. B As per ATS 2018 guidelines, advise overweight or obese patients with OSA participating in a comprehensive lifestyle intervention program including a reduced-calorie diet, exercise/increased physical activity, and behavioral counseling. B As per ACP 2013 guidelines, advise all overweight and obese patients diagnosed with OSA to lose weight. B Oral appliances: As per JRS 2022 guidelines, consider offering oral appliances in patients with mild-to-moderate OSA if CPAP is not indicated or cannot be used. C As per VA 2020 guidelines, consider offering mandibular advancement devices, fabricated by a qualified dental provider, as an alternative to positive airway pressure therapy in appropriate patients with mild-to-moderate OSA (apnea-hypopnea index < 30 events/hour). C As per AASM 2015 guidelines, offer oral appliances in adult patients requesting treatment of primary snoring (without OSA). B Show 5 more As per ACP 2013 guidelines, 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 Myofunctional therapy: Avoid offering myofunctional therapy as a standard/regular treatment of OSA, reserving only for specific cases seeking alternative treatments and reluctant to undertake surgical or mechanical strategies. D Consider initiating CPAP instead of offering myofunctional therapy in adult patients with OSA. C Positional therapy: https://web.pathway.md/diseases/recTKlOKFP9RKwbLb 6/14 6/30/23, 1:22 AM Obstructive sleep apnea Pathway As per JRS 2022 guidelines, consider instructing patients regarding sleeping position, upon confirming that apnea can be reduced in the lateral position, in patients with mild disease and patients having difficulty with CPAP. C As per ERS 2021 guidelines: Consider offering either positional therapy using vibratory devices or CPAP in adult patients with mild or moderate position-dependent OSA as defined by a supine apnea-hypopnea index at least twice as high as the nonsupine apnea-hypopnea index and no relevant nonsupine apnea-hypopnea index (< 15 events/hour). C Consider offering either vibrational positional therapy or mandibular advancement devices in patients with mild positional OSA. C As per ASA 2014 guidelines, advise adult patients with nonsurgical OSA to sleep in the lateral, prone, or sitting positions, rather than the supine position, to improve apnea-hypopnea index scores. B 6. Therapeutic procedures Hypoglossal nerve stimulation: As per ERS 2021 guidelines: Avoid performing hypoglossal nerve stimulation as first-line treatment in patients with OSA. D Consider offering hypoglossal nerve stimulation as a salvage treatment in patients with symptomatic OSA unable to be sufficiently treated with positive airway pressure treatment (CPAP, bilevel positive airway pressure) or mandibular advancement device, and having an apnea-hypopnea index < 50 events/hour and a BMI < 32 kg/m . C As per VA 2020 guidelines, consider obtaining evaluation for surgical treatment with hypoglossal nerve stimulation therapy in patients with OSA with an apnea-hypopnea index of 15-65 events/hour and a BMI < 32 kg/m unable to adhere to positiver airway pressure therapy. C 7. Perioperative care Perioperative CPAP: As per EASO 2017 guidelines, continue CPAP or bilevel positive airway pressure therapy immediately after surgery in patients with OSA, and for 3-6 months post-surgery. Review patients thereafter by a respiratory physician in order to determine whether the CPAP/bilevel positive airway pressure therapy pressures need to be adjusted and if a new sleep-respiratory assessment should be undertaken. B As per ASA 2014 guidelines: Consider offering preoperative at-home CPAP to decrease frequencies of serious postoperative complications, including cardiac events, complications needing ICU transfer or urgent respiratory support. C Initiate postoperative CPAP to improve ventilatory function in patients with OSA. A https://web.pathway.md/diseases/recTKlOKFP9RKwbLb 7/14 6/30/23, 1:22 AM Obstructive sleep apnea Pathway Postoperative supplemental oxygen: insufficient evidence to recommend postoperative supplemental oxygen administration in patients with OSA. I Postoperative monitoring: consider obtaining continuous postoperative monitoring with pulse oximetry to increase the detection of hypoxemic events. C 8. Surgical interventions Upper airway surgery: As per AASM 2021 guidelines, discuss referral to a sleep surgeon as part of a patient-oriented discussion of alternative treatment options in adult patients with OSA and BMI < 40 kg/m intolerant to or not accepting positive airway pressure. A Show 2 more As per ERS 2021 guidelines, consider performing maxillomandibular osteotomy or initiating CPAP in adult patients with OSA. C As per VA 2020 guidelines: Consider obtaining evaluation for nasal surgery in patients with anatomical nasal obstruction as a barrier to positive airway pressure. C Consider obtaining evaluation for alternative treatment with maxillomandibular advancement surgery in patients with severe OSA unable to tolerate or being not appropriate candidates for other recommended therapies. C Bariatric surgery: As per AASM 2021 guidelines, discuss referral to a bariatric surgeon as part of a patient- oriented discussion of alternative treatment options in adult patients with OSA and obesity (class II/III, BMI 35 kg/m ) intolerant to or not accepting positive airway pressure. A As per ERS 2021 guidelines, consider evaluating adult patients with obesity and OSA for bariatric surgery rather than advising a weight-reducing diet when weight has not improved despite participating in a comprehensive weight reduction program and if there are no contraindications. C As per ATS 2018 guidelines, consider referring patients with OSA with a BMI 35 kg/m failed to improve weight with a comprehensive weight-loss lifestyle intervention program for bariatric surgery evaluation, if not contraindicated. C As per AACE 2013 guidelines, consider offering bariatric surgery in patients with a BMI 35 kg/m and OSA. B 9. Specific circumstances Pediatric patients (screening): screen pediatric patients with diabetes mellitus for symptoms of sleep apnea at each visit and refer them to a pediatric sleep specialist for evaluation and polysomnography if indicated. B https://web.pathway.md/diseases/recTKlOKFP9RKwbLb 8/14 6/30/23, 1:22 AM Obstructive sleep apnea Pathway Pediatric patients (questionnaires): consider using the SRBD-PSQ (with a cut-off of 0.33) or the OSA-18 questionnaire (with a cut-off of 0.60) for diagnosing moderate-to-severe sleep- disordered breathing in 2 years old pediatric patients with no comorbidities. Obtain further tests, such as pulse oximetry, cardiorespiratory sleep studies, or polysomnography, if a test questionnaire is inconsistent with clinical features or if a higher degree of diagnostic certainty is required. C Show 5 more Pediatric patients (pulse oximetry and cardiorespiratory sleep studies, without comorbidities): consider obtaining pulse oximetry as a first-line diagnostic test in pediatric patients with suspected sleep-disordered breathing. Consider obtaining a higher level of investigation, such as a cardiorespiratory sleep study, if the test result is inconsistent with the clinical picture. C Show 7 more Pediatric patients (pulse oximetry and cardiorespiratory sleep studies, with comorbidities): consider obtaining cardiorespiratory sleep studies for diagnosing sleep-disordered breathing in pediatric patients with neuromuscular disorders or Down syndrome predisposing to sleep- disordered breathing. C Show 6 more Pediatric patients (pulse oximetry and cardiorespiratory sleep studies, technical considerations): use an oximeter with a software algorithm to minimize the influence of motion artifacts. B Use a short pulse oximetry averaging time of 2-3 seconds. E Show 9 more Pediatric patients (carbon dioxide monitoring): do not obtain CO monitoring in addition to pulse oximetry for diagnosing sleep-disordered breathing in pediatric patients without comorbidities. D Show 4 more Pediatric patients (home monitoring): consider obtaining home cardiorespiratory sleep studies for diagnosing sleep-disordered breathing in pediatric patients without comorbidities where the patients and/or carers are deemed appropriate for implementing a home sleep study. Offer a repeat study, and consider obtaining it as an inpatient, if a test result is inconsistent with the clinical picture or data are incomplete. C Show 4 more Pediatric patients (tonsillectomy): Perform tonsillectomy in pediatric patients with OSA documented by overnight polysomnography. B Obtain overnight, inpatient monitoring in pediatric patients after tonsillectomy if they are < 3 years of age or have severe OSA (apnea-hypopnea index 10 obstructive events/hour, oxygen saturation nadir < 80% or both). B Patients with bradycardia and conduction disorders: screen for symptoms of OSA with subsequent confirmatory testing directed by clinical suspicion in patients with documented or suspected bradycardia or conduction disorder during sleep. B https://web.pathway.md/diseases/recTKlOKFP9RKwbLb 9/14 6/30/23, 1:22 AM Obstructive sleep apnea Pathway Show 2 more Patients with heart failure: Consider obtaining a formal sleep assessment in patients with HF and suspicion of sleep- disordered breathing to confirm the diagnosis and differentiate between obstructive and central sleep apnea. C Consider offering CPAP to improve sleep quality and decrease daytime sleepiness in patients with HF and OSA. C Patients with Cheyne-Stokes respiration: initiate CPAP for Cheyne-Stokes breathing associated with CVDs, such as HF, if the Cheyne-Stokes breathing remains at a moderate or higher level even after treatment of the underlying disease is optimized. B Show 3 more 10. Follow-up and surveillance Follow-up sleep study: do not obtain follow-up polysomnography or home sleep apnea test for routine reassessment of asymptomatic patients with OSA on positive airway pressure therapy. D Show 6 more Clinical findings Symptoms Past medical history Erectile dysfunction Asthma Excessive daytime sleepiness Diabetes mellitus Frequent nighttime awakenings Hypertension Irritability Obesity Memory impairment Pulmonary hypertension Morning headache Social history Nasal congestion Night sweats Cigarette smoking Nocturia Vascular exam Nocturnal apnea Nocturnal choking or nocturnal gasping Peripheral edema Nonrefreshing sleep Head and neck exam Snoring Trouble concentrating Enlarged uvula Macroglossia Family history Pharyngeal narrowing Retrognathia Sleep apnea Tonsillar hypertrophy Vital signs Mallampati score https://web.pathway.md/diseases/recTKlOKFP9RKwbLb 10/14 6/30/23, 1:22 AM Obstructive sleep apnea Pathway Hypertension Neurological exam Mood alteration Hematological findings blood Hgb Likelihood Ratios Pertinent positives The following findings increase the probability of obstructive sleep apnea in adults. 31 Finding LR+ Value History of nocturnal choking or nocturnal gasping 3.3 (2.1-4.6) History of morning headache* 2.6-3.8 Increased STOP-Bang score (> 2)* 1.8 (1.5-2.3) Increased Mallampati score (> 2)* 1.6 (1.1-2.3) for AHI threshold 5 for AHI threshold 10 Show 7 more Pertinent negatives The following findings decrease the probability of obstructive sleep apnea in adults. 31 Finding LR- Value No history of snoring* 0.12-0.45 STOP-Bang score not increased ( 2)* 0.23 (0.15-0.35) NAMES-2 score not increased ( 2)* 0.36 (0.26-0.51) Berlin score not increased ( 1)* 0.43 (0.33-0.55) for AHI threshold 5 for AHI threshold 10 Show 7 more References 1. 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