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

Abstract

Introduction: This guideline establishes clinical practice recommendations for the diagnosis of obstructive sleep apnea (OSA) in adults and is intended for use in conjunction with other American Academy of Sleep Medicine (AASM) guidelines on the evaluation and treatment of sleep-disordered breathing in adults.

Methods: The AASM commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence. The task force developed recommendations and assigned strengths based on the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use. In addition, the task force adopted foundational recommendations from prior guidelines as "good practice statements", that establish the basis for appropriate and effective diagnosis of OSA. The AASM Board of Directors approved the final recommendations.

Recommendations: The following recommendations are intended as a guide for clinicians diagnosing OSA in adults. Under GRADE, a STRONG recommendation is one that clinicians should follow under most circumstances. A WEAK recommendation reflects a lower degree of certainty regarding the outcome and appropriateness of the patient-care strategy for all patients. The ultimate judgment regarding propriety of any specific care must be made by the clinician in light of the individual circumstances presented by the patient, available diagnostic tools, accessible treatment options, and resources. Good Practice Statements: Diagnostic testing for OSA should be performed in conjunction with a comprehensive sleep evaluation and adequate follow-up. Polysomnography is the standard diagnostic test for the diagnosis of OSA in adult patients in whom there is a concern for OSA based on a comprehensive sleep evaluation.Recommendations: We recommend that clinical tools, questionnaires and prediction algorithms not be used to diagnose OSA in adults, in the absence of polysomnography or home sleep apnea testing. (STRONG). We recommend that polysomnography, or home sleep apnea testing with a technically adequate device, be used for the diagnosis of OSA in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA. (STRONG). We recommend that if a single home sleep apnea test is negative, inconclusive, or technically inadequate, polysomnography be performed for the diagnosis of OSA. (STRONG). We recommend that polysomnography, rather than home sleep apnea testing, be used for the diagnosis of OSA in patients with significant cardiorespiratory disease, potential respiratory muscle weakness due to neuromuscular condition, awake hypoventilation or suspicion of sleep related hypoventilation, chronic opioid medication use, history of stroke or severe insomnia. (STRONG). We suggest that, if clinically appropriate, a split-night diagnostic protocol, rather than a full-night diagnostic protocol for polysomnography be used for the diagnosis of OSA. (WEAK). We suggest that when the initial polysomnogram is negative and clinical suspicion for OSA remains, a second polysomnogram be considered for the diagnosis of OSA. (WEAK).

Keywords: diagnosis; home sleep testing; obstructive sleep apnea; polysomnography.

Figure 1. Evidence base flow diagram.

Figure 2. Clinical algorithm for implementation of clinical practice guidelines.

a = Clinical suspicion based on a comprehensive sleep evaluation. b = Clinical tools, questionnaires and prediction algorithms should not be used to diagnose OSA in adults, in the absence of PSG or HSAT. c = Increased risk of moderate to severe OSA is indicated by the presence of excessive daytime sleepiness and at least two of the following three criteria: habitual loud snoring; witnessed apnea or gasping or choking; or diagnosed hypertension. d = This recommendation is based on conducting a single HSAT recording over at least one night. e = This recommendation is based on HSAT devices that incorporate a minimum of the following sensors: nasal pressure, chest and abdominal respiratory inductance plethysmography (RIP) and oximetry; or peripheral arterial tonometry (PAT) with oximetry and actigraphy. For additional information, refer to The AASM Manual for the Scoring of Sleep and Associated Events. f = A split-night protocol should only be conducted when the following criteria are met: (1) A moderate to severe degree of OSA is observed during a minimum of 2 hours of recording time on the diagnostic PSG; AND (2) At least 3 hours are available to complete CPAP titration. If these criteria are not met, a full-night diagnostic protocol should be followed. g = Clinically appropriate is defined as the absence of conditions identified by the clinician that are likely to interfere with successful diagnosis and treatment using a split-night protocol. h = A technically adequate HSAT includes a minimum of 4 hours of technically adequate oximetry and flow data, obtained during a recording attempt that encompasses the habitual sleep period. For additional information, refer to The AASM Manual for the Scoring of Sleep and Associated Events. i = Treatment of OSA should be initiated based on technically adequate PSG or HSAT study. j = Consider repeat in-laboratory PSG if clinical suspicion of OSA remains. k = There should be early follow-up after initiation of therapy.