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Diagnosis and Treatment of Obstructive Sleep Apnea in Adults
Comparative Effectiveness Reviews, No. 32
Investigators: Ethan M Balk, MD, MPH, Denish Moorthy, MBBS, MS, Ndidiamaka O Obadan, MD, MS, Kamal Patel, MPH, MBA, Stanley Ip, MD, Mei Chung, PhD, MPH, Raveendhara R Bannuru, MD, Georgios D Kitsios, MD, PhD, Srila Sen, MA, Ramon C Iovin, PhD, James M Gaylor, BA, Carolyn D’Ambrosio, MD, MS, and Joseph Lau, MD.
Author Information and AffiliationsStructured Abstract
Background:
Methods for diagnosing and treating obstructive sleep apnea (OSA) are cumbersome, resource-intensive, and often inconvenient for the patient.
Purpose:
Systematically review the evidence on OSA diagnosis and treatment in adults. The Key Questions focus on OSA screening and diagnosis, treatments, associations between apnea-hypopnea index (AHI) and clinical outcomes, and predictors of treatment compliance.
Data Sources:
MEDLINE®, Cochrane Central Register of Controlled Trials, and existing systematic and narrative reviews.
Study selection:
Primarily prospective comparative studies of different tests, randomized controlled trials of treatments, and multivariable association studies. Only published, peer-reviewed, English-language articles were selected and manually screened based on predetermined eligibility criteria.
Data extraction:
A standardized protocol was used to extract details on design, diagnoses, interventions, outcomes, and quality.
Data synthesis:
In total, 234 studies met eligibility criteria (46 on diagnostic tests, 17 predictor studies, 190 on treatments). We found moderate evidence that portable monitors are accurate in diagnosing OSA (as defined by polysomnography), but retain a variable bias in estimating AHI; low strength of evidence that the Berlin Questionnaire is able to prescreen patients with OSA with moderate accuracy; and insufficient evidence to evaluate other questionnaires or clinical prediction rules. No study adequately addressed phased testing for OSA. There was insufficient evidence on routine preoperative testing for OSA. High strength of evidence indicates an AHI >30 events/hr is an independent predictor of death; lesser evidence for other outcomes. We found moderate evidence that continuous positive airway pressure (CPAP) is an effective treatment for OSA; moderate evidence that autotitrating and fixed CPAP have similar effects; insufficient evidence regarding comparisons of other CPAP devices; moderate evidence that oral devices are effective treatment for OSA; moderate evidence that CPAP is superior to oral devices; and insufficient trial evidence regarding the relative value of most other OSA interventions, including surgery. We found high and moderate evidence, respectively, that AHI and Epworth Sleepiness Scale are independent predictors of CPAP compliance, and low evidence that some treatments improve CPAP compliance.
Limitations:
Very few trials evaluated objective clinical outcomes. Data were meager for many specific questions. Studies were generally of moderate to poor quality, and often had short followups, high dropout rates, and poor analyses and reporting.
Conclusions:
Portable monitors and questionnaires may be effective screening tools, but assessments with clinical outcomes are necessary to prove their value over polysomnography. CPAP is highly effective in minimizing AHI and improving sleepiness. Oral devices are also effective, although not as effective as CPAP. Other interventions, including those to improve compliance, have not been adequately tested.
Contents
- Preface
- Technical Expert Panel
- Additional Key Informants
- Invited Peer Reviewers
- Executive Summary
- Introduction
- Methods
- AHRQ Task Order Officer
- External Expert Input
- Key Questions
- Analytic Framework
- Literature Search
- Study Selection and Eligibility Criteria
- Data Extraction and Summaries
- Quality Assessment
- Data Synthesis
- Summary Tables
- Grading a Body of Evidence for Each Key Question
- Overall Summary Table
- Peer Review and Public Commentary
- Results
- Key Question 1. How do different available tests compare in their ability to diagnose sleep apnea in adults with symptoms suggestive of disordered sleep? How do these tests compare in different subgroups of patients, based on: race, sex, body mass index, existing non-insulin-dependent diabetes mellitus, existing cardiovascular disease, existing hypertension, clinical symptoms, previous stroke, or airway characteristics?
- Key Question 2. How does phased testing (screening tests or battery followed by full test) compare to full testing alone?
- Key Question 3. What is the effect of preoperative screening for sleep apnea on surgical outcomes?
- Key Question 4. In adults being screened for obstructive sleep apnea, what are the relationships between apnea-hypopnea index or oxygen desaturation index and other patient characteristics with respect to long-term clinical and functional outcomes?
- Key Question 5. What is the comparative effect of different treatments for obstructive sleep apnea in adults?
- Key Question 6. In OSA patients prescribed nonsurgical treatments, what are the associations of pretreatment patient-level characteristics with treatment compliance?
- Key Question 7. What is the effect of interventions to improve compliance with device (positive airway pressure, oral appliances, positional therapy) use on clinical and intermediate outcomes?
- Summary and Discussion
- Future Research
- References
- Acronyms and Abbreviations
- Appendixes
Suggested citation:
Balk EM, Moorthy D, Obadan NO, Patel K, Ip S, Chung M, Bannuru RR, Kitsios GD, Sen S, Iovin RC, Gaylor JM, D’Ambrosio C, Lau J. Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Comparative Effectiveness Review No. 32. (Prepared by Tufts Evidence-based Practice Center under Contract No. 290-2007-10055-1). AHRQ Publication No. 11-EHC052-EF. Rockville, MD: Agency for Healthcare Research and Quality. July 2011. Available at: www.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the Tufts Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10055-1). The findings and conclusions in this document are those of the authors, who are responsible for its content, and do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.
None of the investigators has any affiliations or financial involvement that conflicts with the material presented in this report.
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