Guideline issued on diagnostic testing for obstructive sleep apnea

The American Academy of Sleep Medicine issued a clinical practice guideline last week on diagnostic testing for obstructive sleep apnea (OSA) in adults.

The guideline, which was based on a systematic review of the literature, was developed by a task force of experts in sleep medicine. Recommendations were developed and rated on the basis of quality of evidence, balance of benefits and harms, patient values and preferences, and resource use.

The task force defined strong recommendations as those that should be followed under most circumstances and weak recommendations as those with a lower degree of certainty for outcome and appropriateness in all patients. The task force also adopted two foundational recommendations from previous guidelines as “good practice statements” that established a basis for appropriate, effective OSA diagnosis. These stated that diagnostic testing for OSA should be done along with a comprehensive sleep evaluation and adequate follow-up and that polysomnography is the standard diagnostic test for OSA in adults whose sleep evaluation raises OSA concerns.

“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,” the task force wrote.

Strong recommendations from the task force are as follows:

• Clinical tools, questionnaires, and prediction algorithms are not recommended for OSA diagnosis in adults in the absence of polysomnography or home sleep apnea testing.
• Polysomnography, or home sleep apnea testing with a technically adequate device, is recommended for OSA diagnosis in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA.
• If a single home sleep apnea test is negative, inconclusive, or technically inadequate, polysomnography is recommended for OSA diagnosis, because home sleep apnea testing is less sensitive than polysomnography; because of the higher likelihood that a second home test will also be negative, inconclusive, or technically inadequate; and because of an increased risk that patients will not complete the diagnostic process before a definitive diagnosis is made, the task force authors wrote.
• Polysomnography, rather than home sleep apnea testing, is recommended 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.

Weak recommendations are as follows:

• If clinically appropriate, a split-night diagnostic polysomnography protocol rather than a full-night diagnostic protocol is suggested for OSA diagnosis.
• When the initial polysomnogram is negative and clinical suspicion for OSA remains, it is suggested that a second polysomnogram be considered for OSA diagnosis.

The guideline was published online by the Journal of Clinical Sleep Medicine.

ACP's guidelines for diagnosis of OSA were published in Annals of Internal Medicine in 2014 and are available free of charge online.