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Obstructive Sleep Apnea in Adults: Common Questions and Answers

Breanna Gawrys, DO
Taran W. Silva, DO
Joel Herness, MD

American Family Physician. 2024;110(1):27-36.

Author disclosure: No relevant financial relationships.

Patient information: A handout on sleep apnea testing for patients with cardiovascular disease is available.

Obstructive sleep apnea (OSA) is a common disorder that affects quality of life and is associated with comorbidities such as hypertension, atrial fibrillation, heart failure, coronary heart disease, type 2 diabetes mellitus, and stroke. OSA is characterized by a reduction or cessation of breathing during sleep, resulting in intermittent hypoxemia, autonomic fluctuation, and sleep fragmentation. The U.S. Preventive Services Task Force states that there is insufficient evidence to recommend routine screening for OSA in the absence of symptoms. OSA should be considered in patients with excessive daytime fatigue, unrestful sleep, persistent snoring, and nocturnal awakenings with gasping or choking. The STOP-BANG questionnaire is the most sensitive screening tool for OSA, and the diagnostic standard is polysomnography with an observed apnea-hypopnea index greater than 5 in the presence of symptoms or greater than 15 without symptoms. Home sleep apnea testing is a useful diagnostic option in patients who have symptoms consistent with moderate to severe OSA without significant cardiopulmonary comorbidities. Positive airway pressure, with a humidified nasal or facial mask, is the first-line treatment for adults with OSA. Weight loss is a beneficial adjunct to treatment through intensive lifestyle modification, medications, or bariatric surgery. Alternatives for patients intolerant of or nonadherent to positive airway pressure include changing the type of mask used, mandibular advancement devices, hypoglossal nerve stimulation, and other surgical interventions. Although many OSA therapies effectively improve daytime sleepiness and blood pressure, none have demonstrated a mortality benefit in randomized controlled trials.

Obstructive sleep apnea (OSA) is a common disorder that causes functional impairment and decreased quality of life. As many as 17% of women and 34% of men in the United States have OSA, with rates increasing.1,2 OSA is characterized by a reduction or cessation of breathing during sleep that results in intermittent hypoxemia, autonomic fluctuation, and sleep fragmentation despite persistent respiratory effort, distinguishing OSA from central sleep apnea.1 OSA is clinically defined by the International Classification of Sleep Disorders, 3rd ed. (Table 1).3 Severity is determined by the apnea-hypopnea index (mild = 5 to 14 events per hour; moderate = 15 to 29 events per hour; severe = 30 or more events per hour).1,3,4 This article focuses on adults; a recent American Family Physician article details the evaluation and management of OSA in children.5

WHAT'S NEW ON THIS TOPIC

Obstructive Sleep Apnea
Patients with severe obstructive sleep apnea have a two-fold greater risk of major adverse cardiovascular events and stroke, a nearly threefold greater risk of cardiac death, and a twofold increase in all-cause mortality.
A 2020 systematic review evaluated interventions to improve positive airway pressure usage in adults with obstructive sleep apnea. In positive airway pressure–naive patients, behavioral strategies yielded an increase in device use of 1.3 hours per night.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comment
Home sleep apnea testing is a reasonable alternative to polysomnography in patients with a high pretest probability of moderate to severe OSA.1,4 C Consensus recommendation from the U.S. Department of Veterans Affairs/U.S. Department of Defense and the American Academy of Sleep Medicine
Evidence is insufficient to recommend routinely screening patients for OSA in the absence of symptoms.8 C U.S. Preventive Services Task Force recommendation
PAP therapy can improve sleep-related quality of life, decrease daytime sleepiness, and improve blood pressure. It is recommended as first-line treatment for patients with symptomatic OSA or with asymptomatic OSA and an apnea-hypopnea index greater than 15.1,24 C Recommendation from the U.S. Department of Veterans Affairs/U.S. Department of Defense and the American Academy of Sleep Medicine based on primarily disease-oriented outcomes
For patients intolerant of or otherwise nonadherent to PAP therapy, physicians can offer educational or behavioral resources, a nasal mask, humidified air, mandibular advancement devices, or a referral for upper airway surgery.1,24,27–31,37–42 B Meta-analysis of randomized controlled trials and observational studies
Mandibular advancement devices should be offered as an alternative to PAP for patients with mild to moderate OSA (i.e., apnea-hypopnea index less than 30 events per hour).1,29 B Meta-analysis of randomized controlled trials and observational studies
In patients with moderate to severe OSA and a body mass index less than 32 kg per m2 who are nonadherent to PAP therapy, referral for hypoglossal nerve stimulation surgery should be considered.1,37,38 B Meta-analysis of observational studies

OSA = obstructive sleep apnea; PAP = positive airway pressure.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

BREANNA GAWRYS, DO, FAAFP, DipABLM, is associate program director of the David Grant USAF Medical Center Family Medicine Residency Program, Travis Air Force Base, Calif.; an associate professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md.; and an associate professor of family medicine at the University of California Davis School of Medicine.

TARAN W. SILVA, DO, is faculty at the David Grant USAF Medical Center Family Medicine Residency Program, and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

JOEL HERNESS, MD, FAAFP, is faculty at the David Grant USAF Medical Center Family Medicine Residency Program, and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

Address correspondence to Breanna Gawrys, DO, at Breanna.L.gawrys.mil@health.mil.

Author disclosure: No relevant financial relationships.

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