Treatment of Adult Obstructive Sleep Apnea with Positive Airway Pressure: An American Academy of Sleep Medicine Clinical Practice Guideline

Abstract

Introduction: This guideline establishes clinical practice recommendations for positive airway pressure (PAP) treatment of obstructive sleep apnea (OSA) in adults and is intended for use in conjunction with other American Academy of Sleep Medicine (AASM) guidelines in the evaluation and treatment of sleep-disordered breathing in adults.

Methods: The AASM commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process was used to assess the evidence. The task force developed recommendations and assigned strengths based on the quality of evidence, the balance of clinically significant benefits and harms, patient values and preferences, and resource use. In addition, the task force adopted recommendations from prior guidelines as "good practice statements" that establish the basis for appropriate and effective treatment of OSA. The AASM Board of Directors approved the final recommendations.

Good practice statements: The following good practice statements are based on expert consensus, and their implementation is necessary for appropriate and effective management of patients with OSA treated with positive airway pressure: (1) Treatment of OSA with PAP therapy should be based on a diagnosis of OSA established using objective sleep apnea testing. (2) Adequate follow-up, including troubleshooting and monitoring of objective efficacy and usage data to ensure adequate treatment and adherence, should occur following PAP therapy initiation and during treatment of OSA.

Recommendations: The following recommendations are intended as a guide for clinicians using PAP to treat OSA in adults. A STRONG (ie, "We recommend…") recommendation is one that clinicians should follow under most circumstances. A CONDITIONAL recommendation (ie, "We suggest…") reflects a lower degree of certainty regarding the outcome and appropriateness of the patient-care strategy for all patients. The ultimate judgment regarding any specific care must be made by the treating clinician and the patient, taking into consideration the individual circumstances of the patient, available treatment options, and resources. (1) We recommend that clinicians use PAP, compared to no therapy, to treat OSA in adults with excessive sleepiness. (STRONG) (2) We suggest that clinicians use PAP, compared to no therapy, to treat OSA in adults with impaired sleep-related quality of life. (CONDITIONAL) (3) We suggest that clinicians use PAP, compared to no therapy, to treat OSA in adults with comorbid hypertension. (CONDITIONAL) (4) We recommend that PAP therapy be initiated using either APAP at home or in-laboratory PAP titration in adults with OSA and no significant comorbidities. (STRONG) (5) We recommend that clinicians use either CPAP or APAP for ongoing treatment of OSA in adults. (STRONG) (6) We suggest that clinicians use CPAP or APAP over BPAP in the routine treatment of OSA in adults. (CONDITIONAL) (7) We recommend that educational interventions be given with initiation of PAP therapy in adults with OSA. (STRONG) (8) We suggest that behavioral and/or troubleshooting interventions be given during the initial period of PAP therapy in adults with OSA. (CONDITIONAL) (9) We suggest that clinicians use telemonitoring-guided interventions during the initial period of PAP therapy in adults with OSA. (CONDITIONAL).

Keywords: OSA; PAP; obstructive sleep apnea; positive airway pressure.

Copyright © 2019 American Academy of Sleep Medicine. All rights reserved.

Figures

Figure 1. Flow chart for implementation of clinical practice guideline.

a = Kapur et al., 2017. b = symptoms that can impair sleep-related QOL include but are not limited to snoring, sleep-related choking, insomnia, disruption of bedpartner's sleep, morning headaches, nocturia, impairments in productivity or social functioning, and daytime fatigue. c = comorbidities may include: congestive heart failure, chronic opiate use, significant lung disease such as chronic obstructive pulmonary disease, neuromuscular disease, history of uvulopalatopharyngoplasty, those with known sleep-related oxygen requirements or expected to have nocturnal arterial oxyhemoglobin desaturation due to conditions other than OSA including hypoventilation syndromes and central sleep apnea syndromes. d = alternative therapies may include, but are not limited to, weight loss, positional therapy, oral appliance therapy or surgical interventions. e = BPAP is defined as a respiratory assist device that delivers inspiratory and expiratory positive airway pressure. f = BPAP devices may need to be used for patients with therapeutic pressure requirements greater than can be provided with CPAP or APAP; the decision to use BPAP should be based on the clinician's clinical judgement and needs of the individual patient. g = PAP therapy should be performed in conjunction with adequate follow-up to ensure adequate treatment and adherence. h = recommendations included within these boxes should be considered concurrently. i = educational interventions include those focused primarily on providing information about what OSA is, downstream consequences of untreated OSA, what PAP therapy is, how to use it, and the potential benefits of PAP therapy. j = behavioral interventions include those focused on behavior change related to use of PAP therapy using strategies such as cognitive behavioral therapy or motivational enhancement. Troubleshooting interventions include those focused on close patient communication to identify PAP-related problems and to initiate potential solutions. k = telemonitoring interventions include those that remotely monitor data obtained from a PAP device to identify PAP-related problems and to initiate potential solutions. l = when implementing the above recommendations, providers should consider additional strategies that will maximize the individual patient's comfort and adherence. APAP = auto-adjusting positive airway pressure, BPAP = bilevel positive airway pressure, CPAP = continuous positive airway pressure, OSA = obstructive sleep apnea, PAP = positive airway pressure, QOL = quality of life.