Amir Qaseem, MD, PhD, MHA; Paul Dallas, MD; Douglas K. Owens, MD, MS; Melissa Starkey, PhD; Jon-Erik C. Holty, MD, MS; Paul Shekelle, MD, PhD; for the Clinical Guidelines Committee of the American College of Physicians (*)
Note: Clinical practice guidelines are “guides” only and may not apply to all patients and clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.
Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an official position of the U.S. Department of Veterans Affairs.
Financial Support: Financial support for the development of this guideline comes exclusively from the ACP operating budget.
Disclosures: Dr. Shekelle reports a grant from the Agency for Healthcare Research and Quality during the conduct of the study; personal fees from ECRI Institute and the U.S. Department of Veterans Affairs outside the submitted work; grants from the Agency for Healthcare Research and Quality, U.S. Department of Veterans Affairs, Centers for Medicare & Medicaid Services, and Office of the National Coordinator outside the submitted work; and a patent with royalties paid to UpToDate. Authors not named here have disclosed no conflicts of interest. Authors followed the policy regarding conflicts of interest described at www.annals.org/article.aspx?articleid=745942. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-3187. A record of conflicts of interest is kept for each Clinical Guidelines Committee meeting and conference call and can be viewed at www.acponline.org/clinical_information/guidelines/guidelines/conflicts_cgc.htm.
Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, email@example.com.
Current Author Addresses: Drs. Qaseem and Starkey: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. Dallas: Virginia Tech Carilion School of Medicine, 1906 Belleview Avenue, Roanoke, VA 24014.
Drs. Owens and Holty: Stanford University, 117 Encina Commons, Stanford, CA 94305.
Dr. Shekelle: West Los Angeles Veterans Affairs Medical Center, 11301 Wilshire Boulevard, Los Angeles, CA 90073.
Author Contributions: Conception and design: A. Qaseem, D.K. Owens, J.E.C. Holty, P. Shekelle.
Analysis and interpretation of the data: A. Qaseem, P. Dallas, D.K. Owens, M. Starkey, J.E.C. Holty.
Drafting of the article: A. Qaseem, M. Starkey.
Critical revision of the article for important intellectual content: A. Qaseem, P. Dallas, D.K. Owens, M. Starkey, J.E.C. Holty, P. Shekelle.
Final approval of the article: A. Qaseem, P. Dallas, D.K. Owens, J.E.C. Holty, P. Shekelle.
Statistical expertise: A. Qaseem.
Administrative, technical, or logistic support: A. Qaseem, M. Starkey.
Collection and assembly of data: A. Qaseem, D.K. Owens, M. Starkey, J.E.C. Holty.
The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the diagnosis of obstructive sleep apnea in adults.
This guideline is based on published literature on this topic that was identified by using MEDLINE (1966 through May 2013), the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews. Searches were limited to English-language publications. The clinical outcomes evaluated for this guideline included all-cause mortality, cardiovascular mortality, nonfatal cardiovascular disease, stroke, hypertension, type 2 diabetes, postsurgical outcomes, and quality of life. Sensitivities, specificities, and likelihood ratios were also assessed as outcomes of diagnostic tests. This guideline grades the evidence and recommendations by using ACP's clinical practice guidelines grading system.
ACP recommends a sleep study for patients with unexplained daytime sleepiness. (Grade: weak recommendation, low-quality evidence)
ACP recommends polysomnography for diagnostic testing in patients suspected of obstructive sleep apnea. ACP recommends portable sleep monitors in patients without serious comorbidities as an alternative to polysomnography when polysomnography is not available for diagnostic testing. (Grade: weak recommendation, moderate-quality evidence)
Table 1. Types of Monitors for Diagnosis of Obstructive Sleep Apnea*
Table 2. The American College of Physicians' Guideline Grading System*
Table 3. Accuracy of Portable Monitors and Questionnaires for Diagnosis of Obstructive Sleep Apnea
Table 4. The AHI as a Predictor of Clinical Outcomes
Summary of the American College of Physicians guideline on diagnosis of OSA in adults.
AHI = apnea–hypopnea index; CHD = coronary heart disease; CPAP = continuous positive airway pressure; OSA = obstructive sleep apnea; PSG = polysomnography.
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Doctors should assess the risk factors for and the symptoms of obstructive sleep apnea in patients with unexplained daytime sleepiness.
Timothy I. Morgenthaler
Mayo Clinic Center for Sleep Medicine, Mayo Clinic, Rochester, MN
September 4, 2014
Conflict of Interest:
I serve as President of the American Academy of Sleep Medicine (AASM). The opinion expressed here reflects the positions and policies of the AASM as well as my own.
Diagnostic Testing for Obstructive Sleep Apnea; Almost Right
The American College of Physicians' (ACP) clinical practice guideline regarding the diagnosis of obstructive sleep apnea (OSA) in adults addresses a prevalent and serious medical illness that deserves the attention of internists.(1) Although there is some similarity between the clinical guidelines published by the ACP and the American Academy of Sleep Medicine (AASM), significant differences are of concern to the AASM.The ACP’s recommendation to limit home sleep apnea testing to situations “when polysomnography is not available for diagnostic testing” is both overly restrictive and inconsistent with the AASM clinical guideline. Home sleep apnea testing interpreted by a sleep specialist, in conjunction with a comprehensive sleep evaluation, may be an equally viable diagnostic option in patients with a high pre-test probability for at least moderate to severe OSA who do not have comorbid cardiopulmonary or neuromuscular disorders, or in whom other sleep disorders are not a consideration.(2) Under these conditions a home sleep apnea test may be the most reasonable choice even when polysomnography is available. When these conditions are not met, yet sleep disordered breathing is a consideration, we agree that PSG is the test of choice at this time.Furthermore, the ACP guideline places an inordinate emphasis on sleepiness as the main reason for evaluation with sleep testing. In the Wisconsin Sleep Cohort Study, only 37% of patients with severe OSA (AHI>=30) reported daytime sleepiness, which is one among many symptoms that might suggest that OSA be included in the differential diagnosis.(3) Other symptoms include witnessed apneas, snoring, nocturnal gasping or choking, nonrefreshing sleep, disturbed sleep, nocturia, morning headaches, impaired concentration, memory loss, and decreased libido.(4) Concurrent risk factors, such as obesity, retrognathia on exam, hypertension, or type 2 diabetes, should prompt consideration for sleep apnea testing; however, some of the other causes of sleepiness do not require sleep apnea testing and respond to specific interventions. A complaint of excessive sleepiness should prompt a comprehensive review of the patients sleep schedule, questioning for auxiliary symptoms of narcolepsy, and consideration for sleep specialist referral if the cause is not apparent.(5)It is critical to advance high-value care of patients with a sleep illness such as OSA. Physicians should inquire for symptoms of sleep disturbances and specifically look for sleep apnea in patients belonging to high-risk populations, including those who do not complain of sleepiness. The AASM recognizes that internists have an important role to play in the management of patients with OSA, and we believe that collaborative relationships between sleep specialists and internists will undergird our efforts to improve public health by promoting healthy sleep.1. Qaseem A, Dallas P, Owens DK, et al. Diagnosis of obstructive sleep apnea in adults: a clinical practice guideline from the american college of physicians. Ann Intern Med 2014;161:210-20.2. Epstein LJ, Kristo D, Strollo Jr PJ, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. Journal of Clinical Sleep Medicine 2009;5:263-76.3. Young T, Finn L, Peppard PE, et al. Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort. Sleep 2008;31:1071-8.4. American Academy of Sleep Medicine. International Classification of Sleep Disorders. Diagnostic and Coding Manual. 3rd ed: American Academy of Sleep Medicine, 2014.5. Kushida CA, Littner MR, Morgenthaler T, et al. Practice parameters for the indications for polysomnography and related procedures: an update for 2005. Sleep 2005;28:499-521.
Jordanna Hostler MD, David Hostler MD/MPH, Aaron Holley MD/FACP/FCCP/AASM Diplomate
Walter Reed NAtional Military Medical Center
September 8, 2014
Conflict of Interest:
The views represented in this letter are those of the authors and not reflective of the policies of the DoD or the US Army. <br/><br/>There are no other conflicts of interest.
“Weak recommendation, low-quality evidence: dangerous guideline”
”My candle burns at both ends, it will not last the night. But oh my friends and oh my foes it gives a lovely light.” – Edna St. Vincent MillayWe read with concern the recent ACP clinical guideline regarding the diagnosis of obstructive sleep apnea (OSA).(1) This guideline offers polysomnography (PSG) as a solitary tool for sleep-related symptoms; the guideline’s broad application could result in unnecessary testing and treatment. A PSG performed with current technologies and scored with current criteria will yield an AHI almost 3-fold higher than a study in an identical patient using the technologies and scoring criteria available at the time of the majority of the works cited by this guideline. Flow changes are currently graded using a pressure-transduced air flow monitor, which is far more sensitive than the thermistor utilized in prior studies.(2) In fact, a recent trial showed the prevalence of an AHI ≥5 utilizing the current criteria was 94.6% in a population with a “mild-moderate” pre-test probability of disease.(3) OSA exists on a spectrum and AHI cutoffs are largely arbitrary. Given the changes in diagnosis, are we measuring clinically meaningful disease? What are the costs of overdiagnosis?Furthermore, the term “unexplained sleepiness” (which is pivotal in the guideline’s first recommendation) is only meaningful when clinicians have a thorough understanding of the causes of sleepiness. The average physician receives approximately 2 hours of formal medical education on the evaluation of sleep disorders.(4) This guideline fails to acknowledge that behaviorally-induced insufficient sleep, insomnia, mood disorders, restless legs syndrome and many other problems cannot be measured by PSG or treated with CPAP. We know from survey data that the average American effectively “burns the candle at both ends”, obtaining 6 hours and 40 minutes of sleep on the average workday.(5) Recommending PSG for every patient whose sleepiness is “unexplained” – without also recommending qualitative and quantitative assessment of sleep duration – is ill-advised. We suggest ACP develop a comprehensive sleep-symptom guideline encouraging a more holistic evaluation of the patient presenting with sleepiness and focusing more attention on the limitations of PSG.References1. Diagnosis of Obstructive Sleep Apnea in Adults: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med. 2014;161:210-220.2. Ruehland W, Rochford R, O’Donoghue F, et al. The New AASM Criteria for Scoring Hypopneas: Impact on the Apena Hypopnea Index. Sleep Vol. 32, No. 2, 20093. Guerrero A, Embid C, Isetta V et al. Management of Sleep Apnea without High Pretest Probability or without Comorbidities by Three Nights of Portable Sleep Monitoring. Sleep. 2014;37(8):1363-73. 4. Rosen R, Mahowald M, Chesson A, et al. The Taskforce 2000 survey on medical education in sleep and sleep disorders. Sleep. 1998;21(3):235-254.5. National Sleep Foundation. Sleep in America Poll 2008. http://sleepfoundation.org/sites/default/files/2008%20POLL%20SOF.PDF accessed 8 September 2014.
Paul Shekelle, MD, PhD, Jon-Erik C. Holty, MD, Thomas Denberg, MD, PhD, Amir Qaseem MD, PhD
Clinical Practice Guideline from the American College of Physicians
December 2, 2014
Dr. Morgenthaler objects to the focus on unexplained daytime sleepiness as the symptom prompting investigation, and suggests that other symptoms, including snoring, non-refreshing sleep, morning headaches, impaired concentration, memory loss, and decreased libido should prompt an OSA evaluation. We disagree with Dr. Morgenthaler because many patients who come in to a primary care practice have at least one of these symptoms and they all do not need sleep studies. Unexplained daytime sleepiness is the only OSA symptom that has evidence from randomized controlled trials showing that it is responsive to treatment. Population studies suggest that high rates of subjective sleepiness in the general population are not associated with sleep apnea and likely attributable to factors other than primary sleep disorders (1). Another study of the general population has shown the prevalence of sleep complaints or disturbance to be 75% of current US adults reporting at least one sleep-related symptom (2). Furthermore, there is no evidence showing that treatment specifically improves the particular outcomes mentioned above, thus knowledge of a diagnosis neither provides any useful information to patients about their prognosis nor improves clinical outcomes. Although home monitors may be appropriate for some patients, the current evidence shows that PSG is still the gold standard diagnostic test and should be the diagnostic test of choice, when available. Hence, we disagree with Dr. Morgenthaler’s comments that ACP’s recommendation to use PSG as a first option for sleep testing is too restrictive. Although AASM recommends using portable sleep monitors for patients with a high-pre-test probability for moderate-severe OSA, there is currently no accurate way to predict who is at high risk for OSA prior to conducting a sleep study. The AHRQ evidence report (3) as well as the evidence review update both showed poor diagnostic accuracy for screening questionnaires. Also, there is no current evidence showing that untreated mild OSA has any impact on mortality or morbidity. We agree with Dr. Hostler that generally, medical students receive inadequate training regarding sleep disorders. We suggest that physicians take a history to understand more about the patient’s sleepiness, rather than recommending sleep studies for all tired patients. We also suggest that patients who report inadequate hours of sleep be instructed to get more sleep before further investigation. Dr. Hostler also points out that newer sensors are more sensitive than older forms of PSG, and we agree that as technology changes, so do the implications for disease diagnoses. However, this is true for many different fields of medicine. The update of the AHRQ evidence report included studies published since 2010 that includes the newer technologies. However, similar to the pre-2010 data, there was substantial heterogeneity between studies on definitions and measurements of apneas or hypopneas. Additionally, the study that Dr. Hostler cites, (6) which suggested a higher prevalence of OSA and potential overdiagnosis, was conducted in a patient population with mild-moderate clinical suspicion of OSA, and their hypopnea definition was liberal, possibly accounting for a larger prevalence. Paul Shekelle, MD, PhDGreater Los Angeles Veterans Affairs Health Center and RAND Corporation, Los Angeles, CaliforniaJon-Erik C. Holty, MD, MSStanford University, Stanford, CaliforniaThomas D. Denberg, MD, PhDCarilion Clinic, Roanoke, VirginiaAmir Qaseem, MD, PhD, MHAAmerican College of Physicians, Philadelphia, Pennsylvania References1. Kapur VK, Baldwin CM, Resnick HE, Gottlieb DJ, Nieto FJ. Sleepiness in patients with moderate to severe sleep-disordered breathing. Sleep. 2005;28(4):472-7.2. National Sleep Foundation. 2005 Sleep in America Poll - Summary of Findings. Washington, DC. http://sleepfoundation.org/sites/default/files/2005_summary_of_findings.pdf. Last accessed 10/16/14.3. Balk EM, Moorthy D, Obadan NO, Patel K, Ip S, Chung M, et al. Diagnosis and treatment of obstructive sleep apnea in adults. Comparative effectiveness review no. 32. AHRQ publication no. 11-EHC052-EF. (Prepared by Tufts Evidence-based Practice Center under contract 290-2007-100551.). Rockville, MD: Agency for Healthcare Research and Quality; 2011.http://www.effectivehealthcare.ahrq.gov/ehc/products/117/683/CER32_SleepApnea_FinalReview_201108.pdf. Last accessed 10/16/14.4. Montesi SB, Edwards BA, Malhotra A, Bakker JP. The effect of continuous positive airway pressure treatment on blood pressure: a systematic review and meta-analysis of randomized controlled trials. J Clin Sleep Med. 2012;8(5):587-96.5. Fava C, Dorigoni S, Dalle Vedove F, Danese E, Montagnana M, Guidi GC, et al. Effect of cpap on blood pressure in patients with osa/hypopnea: A systematic review and meta-analysis. Chest. 2014;145(4):762-71.6. Guerrero A, Embid C, Isetta V, Farre R, Duran-Cantolla J, Parra O, et al. Management of sleep apnea without high pretest probability or with comorbidities by three nights of portable sleep monitoring. Sleep. 2014;37(8):1363-73.
Qaseem A, Dallas P, Owens DK, Starkey M, Holty JC, Shekelle P, et al. Diagnosis of Obstructive Sleep Apnea in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2014;161:210–220. doi: 10.7326/M12-3187
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Published: Ann Intern Med. 2014;161(3):210-220.
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