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Obstructive sleep apnea

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Updated 2023 BTS guidelines for the diagnosis and monitoring of sleep-disordered breathing in pediatric patients.

Background

Overview

Definition
OSA is a condition characterized by recurring episodes of upper airway obstruction during sleep, leading to cyclic reduction or cessation in airflow.
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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.
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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.
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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.
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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.
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Guidelines

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 Academy of Family Physicians (AAFP 2024,2022,2013), the American Diabetes Association (ADA 2024), the European Society of Cardiology (ESC/EACTS 2024), the British Thoracic Society (BTS 2023), the Heart Failure Society of America (HFSA/AHA/ACC 2022), the Oto-Rhino-Laryngological ...
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Screening and diagnosis

Indications for screening: as per AAFP 2022 guidelines, use the STOP-Bang criteria to screen for OSA in patients with chronic bilateral lower extremity edema.
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  • Screening questionnaires

Classification and risk stratification

Risk factors: as per ASA 2014 guidelines, recognize that patients with higher BMI values are at a higher risk of OSA.
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Diagnostic investigations

Physical examination
As per ASA 2014 guidelines:
Recognize that neck circumference, tongue size, and nasal and oropharyngeal airway structures are morphologic markers that may be associated with OSA.
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Recognize that tonsil size may be associated with disease severity, as measured by apnea-hypopnea indices, in adult patients with OSA.
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  • Initial sleep study

  • Confirmatory sleep study (negative home testing)

  • Confirmatory sleep study (negative polysomnography)

  • Actigraphy

  • Echocardiography

Respiratory support

Positive airway pressure therapy: as per JADSM/JCS/JRS/JSOH/JSPN/JSSR/MHLW/ORLSJ 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.
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  • Supplemental oxygen

Medical management

Anti-obesity medications: as per ATS 2018 guidelines, 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.
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  • Carbonic anhydrase inhibitors

  • Nasal corticosteroids

  • Hypnotics

Nonpharmacologic interventions

Weight loss: as per JADSM/JCS/JRS/JSOH/JSPN/JSSR/MHLW/ORLSJ 2022 guidelines, offer weight loss in patients with OSA and obesity.
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  • Oral appliances

  • Myofunctional therapy

  • Positional therapy

Therapeutic procedures

Hypoglossal nerve stimulation
As per ERS 2021 guidelines:
Avoid performing hypoglossal nerve stimulation as first-line treatment in patients with OSA.
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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.
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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.
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  • Postoperative supplemental oxygen

  • Postoperative monitoring

Surgical interventions

Upper airway surgery: as per AAFP 2024 guidelines, consider referring patients with moderate-to-severe OSA and a BMI < 32 kg/m² nonadherent to positive airway pressure therapy for hypoglossal nerve stimulation surgery.
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  • Bariatric surgery

Specific circumstances

Pediatric patients, screening: as per ADA 2024 guidelines, 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. Treat OSA when documented.
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  • 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 AF

  • Patients with bradycardia and conduction disorders

  • Patients with HF

  • Patients with Cheyne-Stokes respiration

Follow-up and surveillance

Follow-up sleep study: as per AASM 2021 guidelines, do not obtain follow-up polysomnography or home sleep apnea test for routine reassessment of asymptomatic patients with OSA on positive airway pressure therapy.
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