/

Table of contents

Expand All Topics

Obstructive sleep apnea

What's new

The United States Department of Veterans Affairs (VA) and Department of Defense (DoD) have updated their guidelines for the management of obstructive sleep apnea (OSA). For mild-to-moderate OSA, recommended treatment options include mandibular advancement devices and positive airway pressure (PAP) therapy with an autotitrating approach. Eszopiclone is suggested for patients receiving PAP therapy to improve adherence. Evaluation for nasal surgery is suggested for patients with anatomical nasal obstruction that impairs PAP use. Positional therapy and weight loss are also suggested in appropriate patients. Wakefulness-promoting agents (armodafinil, modafinil, solriamfetol) are suggested for OSA-related residual excessive daytime sleepiness. Hypoglossal nerve stimulation is suggested for patients not responding to PAP therapy. .

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.
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.
2
3
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.
4
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.
4
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.
3
5

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 Diabetes Association (ADA 2025), the United States Department of Defense (DoD/VA 2025,2020), the American Academy of Family Physicians (AAFP 2024,2022,2013), the European Society of Cardiology (ESC/EACTS 2024), the British Thoracic Society (BTS 2023), the Heart ...
Show more

Screening and diagnosis

Indications for screening, general population: 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

  • Indications for screening (sleep complaints)

  • Indications for screening (CVDs)

  • Indications for screening (PCOS)

  • Indications for screening (surgical candidates)

  • 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.
B
Show 2 more
Create free account

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.
B
Recognize that tonsil size may be associated with disease severity, as measured by apnea-hypopnea indices, in adult patients with OSA.
B
Create free account

More topics in this section

  • Initial sleep study

  • Confirmatory sleep study

  • Actigraphy

  • Echocardiography

Respiratory support

Positive airway pressure therapy: as per DoD/VA 2025 guidelines, consider offering positive airway pressure as a first-line therapy option for the treatment of mild-to-moderate OSA (Event Index < 30 per hour).
C
Show 3 more
Create free account

More topics in this section

  • Supplemental oxygen

Medical management

Management of daytime sleepiness: as per DoD/VA 2025 guidelines, consider adding armodafinil, modafinil, or solriamfetol for the treatment of OSA-related residual excessive daytime sleepiness in patients who are optimally treated with sufficient therapy use.
C
Create free account

More topics in this section

  • Management of insomnia

  • Agents with no evidence for benefit

Nonpharmacologic interventions

Weight loss: as per DoD/VA 2025 guidelines, consider offering evidence-based weight management in combination with other treatments for OSA in patients with overweight or obesity.
C
Create free account

More topics in this section

  • Oral appliances

  • Myofunctional therapy

  • Positional therapy

Therapeutic procedures

Hypoglossal nerve stimulation: as per DoD/VA 2025 guidelines, consider referring patients with OSA, including those with an apnea-hypopnea index ≥ 15 per hour, who have not been successful with positive airway pressure therapy, for evaluation for hypoglossal nerve stimulation.
C
Create free account

More topics in this section

  • Therapies with no evidence for benefit

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
Create free account

More topics in this section

  • Postoperative supplemental oxygen

  • Postoperative monitoring

Surgical interventions

Upper airway surgery: as per DoD/VA 2025 guidelines, consider obtaining evaluation for nasal surgery in patients with anatomical nasal obstruction as a barrier to positive airway pressure use.
C
Create free account

More topics in this section

  • Bariatric surgery

Specific circumstances

Pediatric patients, screening: as per ADA 2025 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.
B
Create free account

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 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.
D
Show 6 more
Create free account