What is the current recommended standard for evaluation and treatment of sleep-disordered breathing and obstructive sleep apnea (OSA)?
Background: There is lack of consensus about diagnostic protocols for OSA in adults. This multicenter, multispecialty clinical guideline summarizes the best evidence and makes a series of clinical recommendations, with associated strength of recommendation depending on the underlying supportive evidence.
Study Design: Consensus clinical guideline
Synopsis: This guideline is rich with helpful algorithms and lists of important criteria and can serve as a reference. Key recommendations are as follows:
Key screening questions are history of snoring and daytime sleepiness. Screening examination should include evaluation for obesity, retrognathia or hypertension. Positive screening findings should lead to comprehensive evaluation, including snoring, witnessed apnea, gasping/choking episodes and excessive sleepiness.
There is no clinical model that consistently predicts the severity of OSA. Diagnostic testing, therefore, is required. This can include in-laboratory polysomnography (PSG) or at-home testing with a portable monitor (PM). PMs can be used in patients with a high pretest likelihood of moderate or severe OSA; however, because the denominator is total recording time rather than total sleep time, PMs are likely to underestimate the severity of OSA. PSG testing is indicated in patients with possible mild apnea, with any comorbidity or before bariatric surgery.
Treatment of OSA is complicated and multifactorial and should include some combination of behavioral options, positive airway pressure, oral appliances or surgical treatment. Surgical treatment tends to be more effective at improving non-PSG outcomes, such as sleepiness, quality of life and functional status, but often does not result in resolution of OSA by PSG criteria.
Bottom Line: OSA should be screened and tested for. The diagnosis is dependent on a combination of symptoms and sleep study findings. In some circumstances, an unattended at-home study is adequate for diagnosis of OSA.
Citation: Epstein LJ, Kristo D, Strollo PJ II, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009;5(3):263-276.
—Reviewed by Michael G. Stewart, MD, MPH