Home

Search

Pathway AI

Account ⋅ Sign Out

Table of contents

Obstructive sleep apnea

Definition
OSA is a condition characterized by recurring episodes of upper airway obstruction during sleep, leading to cyclic reduction or cessation in airflow.
1
Pathophysiology
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.
3
4
Epidemiology
In the US, 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.
2
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.
2
Prognosis and risk of recurrence
Regular CPAP use is associated with an improvement in sleep apnea symptoms and health-related QoL. Randomized studies have failed to demonstrate a benefit of CPAP for the prevention of adverse cardiovascular events.
4
5
Key sources
The following summarized guidelines for the evaluation and management of obstructive sleep apnea are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2023), the British Thoracic Society (BTS 2023), the Oto-Rhino-Laryngological Society of Japan (ORLSJ/JADSM/JSSR/MHLW/JRS/JSPN/JCS/JSOH 2022), the U.S. Preventive Services Task Force (USPSTF 2022), the Heart Failure Society of America (HFSA/AHA/ACC 2022), the American Academy of Sleep Medicine (AASM 2021; 2019; 2018; 2017), the European Respiratory Society (ERS 2021), the American Heart Association (AHA 2021), 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 Thoracic Society (ATS 2018), the American College of Preventive Medicine (ACPM/PCNA/ABC/ASPC/ASH/AAPA/AGS/AHA/NMA/ACC/APhA 2018), the European Association for the Study of Obesity (EASO 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 American Academy of Family Physicians (AAFP 2013), the Endocrine Society (ES 2013), and the Obesity Society (OS/AACE 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
29
30
31

Guidelines

1.Screening and diagnosis

Indications for screening: as per USPSTF 2022 guidelines, insufficient evidence to assess the balance of benefits and harms of screening for OSA in the general adult population.
I
Create free account

More topics in this section

  • Screening questionnaires

2.Classification and risk stratification

Risk factors: recognize that patients with higher BMI values are at a higher risk of OSA.
B
Show 2 more

3.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

More topics in this section

  • Initial sleep study

  • Confirmatory sleep study (negative home testing)

  • Confirmatory sleep study (negative polysomnography)

  • Actigraphy

  • Echocardiography

4.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

More topics in this section

  • Supplemental oxygen

5.Medical management

Anti-obesity medications: consider offering anti-obesity pharmacotherapy, if not contraindicated (including no active CVD), in patients with OSA with a BMI ≥ 27 kg/m² failed to improve weight with a comprehensive weight-loss lifestyle intervention program.
C

More topics in this section

  • Carbonic anhydrase inhibitors

  • Nasal corticosteroids

  • Hypnotics

6.Nonpharmacologic interventions

Weight loss: as per JRS 2022 guidelines, offer weight loss in patients with OSA and obesity.
B

More topics in this section

  • Oral appliances

  • Myofunctional therapy

  • Positional therapy

7.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/m².
C

8.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

More topics in this section

  • Postoperative supplemental oxygen

  • Postoperative monitoring

9.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/m² intolerant to or not accepting positive airway pressure.
A
Show 2 more

More topics in this section

  • Bariatric surgery

10.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

More topics in this section

  • Pediatric patients (questionnaires)

  • Pediatric patients (pulse oximetry and cardiorespiratory sleep studies, without comorbidities)

  • Pediatric patients (pulse oximetry and cardiorespiratory sleep studies, with comorbidities)

  • Pediatric patients (pulse oximetry and cardiorespiratory sleep studies, technical considerations)

  • Pediatric patients (CO2 monitoring)

  • Pediatric patients (home monitoring)

  • Pediatric patients (tonsillectomy)

  • Patients with bradycardia and conduction disorders

  • Patients with HF

  • Patients with Cheyne-Stokes respiration

11.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