ACP issues recommendations on diagnosis of obstructive sleep apnea

Obstructive sleep apnea (OSA) is a relatively common disorder, especially among adults older than 60 years of age, and its prevalence is rising due to the growing epidemic of obesity.

Diagnosis and management of OSA is important in that the disorder can lead to daytime drowsiness with consequences of impaired function and increased risk for accidents and injuries.

A new guideline from the American College of Physicians provides recommendations on screening and diagnosis of OSA. The information is based on an Agency for Healthcare Research and Quality-sponsored comparative effectiveness review published in 2011, the 2007 Technology Assessment of Home Diagnosis of Obstructive Sleep Apnea-Hypopnea Syndrome, and a systematic review of English language peer-reviewed studies published between 1996 and May 2013.

The guideline makes two recommendations: 1) a sleep study should be performed in patients with unexplained daytime sleepiness; and 2) polysomnography should be used for diagnostic testing in patients suspected of having OSA. Portable sleep monitors are recommended for use as an alternative when polysomnography is not available in patients without serious comorbidities.

Limiting assessment for OSA to patients with unexplained daytime sleepiness is based on evidence that treatment of OSA with continuous positive airway pressure does not reduce coronary heart disease events and mortality in patients with OSA unaccompanied by daytime sleepiness. 

The recommendation on uses of a portable sleep monitor only in patients without serious comorbidities is based on the limited data available on the use of these devices in patients with comorbid conditions, such as chronic lung disease, congestive heart failure, or neurologic disorders.

The guideline summarizes findings from studies comparing different diagnostic tests for OSA. Based on its review, the guideline committee determined there was moderate-quality evidence showing that type II, III, and IV monitors may identify apnea-hypopnea index (AHI) scores. It was noted that type IV monitors cannot differentiate between obstructive and central apneas and appear to be less accurate than type III monitors based on indirect evidence.

Diagnostic utility of various sleep questionnaires was also assessed (Berlin Questionnaire, Epworth Sleepiness Scale, Multivariate Apnea Prediction Index, Pittsburgh Sleep Quality Index, and STOP-BANG Questionnaire), but it was noted they may not be applicable to the general population.

There was insufficient evidence to determine the effectiveness of phased testing for the diagnosis of OSA or the utility of preoperative screening for OSA to improve postsurgical outcomes.

The guidelines were published in the August 2014 issue of the Annals of Internal Medicine.