SUMMARY 

Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder and has been rising in prevalence in the past few decades, with an estimated 20-30% of adults having at least mild OSA. Unfortunately, OSA is often undiagnosed, leading to long term health consequences such as hypertension, metabolic syndrome, and cardiovascular disease. The USPSTF has issued guidance on screening for obstructive sleep apnea in adults.  

CLINICAL SIGNS AND SYMPTOMS 

• OSA is a sleep-related breathing disorder in which the pharyngeal airway narrows and becomes obstructed during sleep, causing cessation in airflow that results in periods of apnea despite respiratory effort 
• Patients may have unrecognized signs and symptoms of OSA, especially if they sleep alone 
• Signs and symptoms include: Daytime somnolence | Snoring | Gasping or choking during sleep | Morning headaches | Mood changes | Witnessed apnea  
• On exam patient may be: Obese | Have a large neck circumference (> 40 cm) | High Mallampati score (inability to see back of oropharynx on exam)  
• Risk factors include: Male sex (2 to 3 times more common in men than women) | Postmenopausal | Craniofacial abnormalities | Obesity | Older age | Black patients | Latinx patients | Native American/Alaska Native patients 
• Patient may have evidence of complications of untreated OSA such as right sided heart failure and atrial fibrillation   

COMPLICATIONS 

•  OSA can lead to serious health consequences including 
  • Stroke 
  • Cardiovascular disease: Angina | Atrial fibrillation  
  • Daytime somnolence: Workplace accidents | Motor vehicle collisions | Lost productivity | Decreased quality of life 
  • Type 2 diabetes mellitus | Insulin resistance  
  • Cognitive impairment | Inattention | Mood changes  
  • Group III pulmonary hypertension | Right heart failure 
• Severe OSA increases all-cause mortality  

SCREENING  

USPSTF recommendation 

“The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for OSA in the general adult population” 

• For adults > 18 years, there is insufficient evidence to recommend screening for OSA in the absence of symptoms  
  • This recommendation applies to: Patients who are unaware of their symptoms (e.g., patients with apneic episodes at night that go unwitnessed) | Patients who are not concerned enough to report their symptoms 
  • Does not apply to: Pregnant patients | Patients undergoing occupation eval | Acute conditions that may trigger onset of OSA (e.g., stroke) 

AASM recommendation  

• The American Academy of Sleep Medicine recommends screening certain high-risk groups for sleep apnea, regardless of presence of symptoms 

• Workers who perform safety-sensitive functions in the transportation industry should be screened for OSA using both self-reported symptoms and objectively measurable criteria (e.g., comorbid conditions such as hypertension and obesity)  

ACP recommendation 

• The American College of Physicians recommends obtaining polysomnography in all adults with unexplained daytime sleepiness (weak recommendation)  

Screening tests 

• Screening tests include: Epworth Sleepiness Scale (ESS) | Berlin Questionnaire | Wisconsin Sleep 
  Questionnaire | Multivariable Apnea Prediction tool | STOP Questionnaire | STOP-BANG questionnaire  
• None of these screening tests have been properly validated, but are used nonetheless  
• The above screening tests should NOT be used to diagnosis OSA 
  • Diagnosis must be made with further testing (e.g., polysomnography)  

DIAGNOSIS  

• Polysomnography (PSG) 
  • Split-night diagnostic protocol preferred over full-night diagnostic protocol  
  • If initial PSG is negative and clinical suspicion for OSA remains, repeat PSG should be considered  
• Home sleep apnea testing  
  • Can be used for uncomplicated patients with signs and symptoms of moderate to severe OSA 
  • Should not be used in: Patients with significant cardiorespiratory disease | Respiratory muscle weakness |Awake hypoventilation | Obesity hypoventilations syndrome | Chronic opioid use | History of stroke | History of severe insomnia  
  • AASM recommends that if a single home sleep apnea test is negative, inconclusive, or technically inadequate, polysomnography be performed to diagnosis OSA 
• Diagnosis made based on number of apnea (airflow cessation during sleep) and hypopnea (reduced airflow during sleep) events  
  • 15 events/hr (with or without OSA symptoms) or 5 events/hr with OSA symptoms is sufficient for OSA diagnosis 
  • Severity of OSA classified according to apnea hypopnea index (AHI): Mild (5 to 14 events/hr) | Moderate (15 to 30 events/hr) | Severe (> 30 events/hr) 

KEY POINTS 

• Screening for OSA is not recommended in the absences of symptoms for most adults  
• The most common presenting complaint of OSA is increased daytime somnolence, which a patient may report as fatigue or tiredness  
• Screening tools and calculators can be helpful, but diagnosis of OSA can only be made with polysomnography or home sleep apnea testing  

Learn More – Primary Sources 

USPSTF Obstructive Sleep Apnea in Adults: Screening 

Enhancing public health and safety by diagnosing and treating obstructive sleep apnea in the transportation industry: an American Academy of Sleep Medicine position statement 

Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline 

American College of Physicians releases new recommendations for diagnosing obstructive sleep apnea in adults