Sleep apnea syndrome

This guideline offers evidence-based recommendations on the targets of Sleep apnea syndrome. The recommendations are intended to provide healthcare professionals with practical guidance on diagnosis and treatment guidelines of adult obstructive sleep apnea and improving health outcomes for people living with Sleep apnea syndrome. 

Recommendations

Diagnosis

•  We recommend either polysomnography or home sleep apnea test be performed to establish diagnosis of obstructive sleep apnea when diagnosis is suspected based on results of comprehensive sleep evaluation which encompasses clinical tools, questionnaires and/or prediction algorithms. (Strong recommendation)

•  We recommend either polysomnography or home sleep apnea testing be used to establish diagnosis of obstructive sleep apnea for adult uncomplicated patients who present with signs and symptoms suggesting moderate to severe OSA.  (Strong recommendation)

•  We recommend that polysomnography be performed to confirm diagnosis of obstructive sleep apnea if home sleep apnea test is negative, inconclusive, or technically inadequate. (Strong recommendation)

•  We recommend that polysomnography, rather than home sleep apnea testing, be used for the diagnosis of obstructive sleep apnea 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 recommendation)

•  We suggest that a second polysomnogram be performed to exclude obstructive sleep apnea when the initial test is negative in patients with clinical suspicion of obstructive sleep apnea. (Conditional recommendation)

•  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. (Conditional recommendation)

Treatment

· CPAP treatment is effective for OSA, with CPAP treatment recommended as the first choice for patients with strong clinical symptoms such as daytime sleepiness due to OSA, and for moderate to severe cases. (Strong recommendation)

· We suggest that oral appliances to be performed in mild to moderate cases for which CPAP treatment is not indicated, or for cases in which CPAP cannot be used. (Conditional recommendation)

· Weight loss therapy is recommended for obese OSA patients. (Strong recommendation)

· Some OSA patients have apnea alleviated by sleeping in a non-supine position (mainly in a lateral position). We propose that patients with mild cases, along with those who have difficulty with standard treatment such as CPAP treatment, should be instructed regarding their sleeping position, upon confirming that apnea can be reduced in the lateral position. (Conditional recommendation)

· If CPAP or oral appliances cannot be used and there is an indication for otolaryngological surgery, we suggest that it be performed after fully explaining the side effects of the surgery. (Conditional recommendation)

· Oxygen therapy may be performed on patients who cannot use CPAP or oral appliances. (Good Practice Statement)

· If CPAP or oral appliances cannot be used and maxillofacial plastic and reconstructive surgery is indicated, we suggest that it be performed after fully explaining the side effects of the surgery. (Conditional recommendation)

· On the basis of health care professional judgment and patient preference, therapeutic effects are determined by prognosis, reduction of cardiovascular risk factors, effect on complications such as hypertension, quality of life (QOL), effect on subjective symptoms such as drowsiness, and improvement of various indicators in sleep tests. OSA sleepiness improves with proper treatment. (Strong recommendation)

· For OSA patients with insomnia, prioritize treatment of OSA without using hypnotics first. Side effects of hypnotics include an increase in the number of respiratory events and an extension of event time in severe cases. (Conditional recommendation)

· Follow-up PSG or HSAT for routine reassessment of asymptomatic patients with obstructive sleep apnea on PAP therapy, however, follow-up PSG or HSAT can be used to reassess patients with recurrent or persistent symptoms, despite good PAP adherence. (Conditional recommendation)

· Follow-up PSG or HSAT to assess response to treatment with non-PAP interventions. (Strong recommendation)

· Follow-up PSG or HSAT may be used if clinically significant weight gain or loss has occurred since diagnosis of OSA or initiation of treatment. (Conditional recommendation)

· Follow-up PSG may be used for reassessment of sleep-related hypoxemia and/or sleep-related hypoventilation following initiation of treatment for OSA. (Conditional recommendation)

· Follow-up PSG or HSAT may be used in patients being treated for OSA who develop or have a change in cardiovascular disease. (Conditional recommendation)

· Follow-up PSG may be used in patients with unexplained PAP device-generated data. (Conditional recommendation)