Diagnosis of Obstructive Sleep Apnea (OSA): A Comprehensive Guide

Introduction

Obstructive Sleep Apnea (OSA) is a prevalent sleep disorder characterized by recurrent episodes of interrupted breathing during sleep. These episodes, known as apneas and hypopneas, occur due to the collapse of the upper airway, leading to pauses or significant reductions in airflow. Typically, these respiratory events are accompanied by snoring, drops in blood oxygen levels (desaturations), and brief awakenings from sleep as the body struggles to resume normal breathing.

The severity of sleep apnea often fluctuates with body position, being worse when lying on the back (supine position), and during the Rapid Eye Movement (REM) sleep stage, when muscles are most relaxed. Factors like alcohol consumption or the use of sedatives can exacerbate snoring and OSA due to their muscle-relaxant effects, further compromising airway patency.

Epidemiology of OSA

Early epidemiological studies, such as the Wisconsin Sleep Cohort Study from 1993, indicated a significant prevalence of OSA (defined as an Apnea-Hypopnea Index or AHI ≥5 events per hour) in the general population. This study estimated that 24% of men and 9% of women met the criteria for OSA. However, when considering symptomatic OSA, or OSA syndrome, the prevalence was lower, at 4% in men and 2% in women.1 Given the global rise in obesity rates since then, current estimates suggest a substantial increase in OSA prevalence, particularly in North America, where it is now believed to affect 20–30% of men and 10–15% of women.2

A recent report from the American Academy of Sleep Medicine (AASM) highlights the significant public health impact of OSA, estimating that it affects 12% of the US adult population, equating to 29.4 million individuals. Alarmingly, it is estimated that 80% of these individuals remain undiagnosed. The economic consequences of undiagnosed OSA are considerable, with annual costs estimated at around $150 billion in 2015, primarily due to healthcare expenses, lost productivity, and accidents.3

Obesity stands out as a primary risk factor for OSA. Studies indicate that OSA is present in up to 70% of individuals with morbid obesity.4 Other significant risk factors include advancing age, craniofacial abnormalities that narrow the upper airway, smoking, and a family history of sleep apnea. Postmenopausal women also have an increased risk. Furthermore, OSA is more prevalent in individuals with certain coexisting medical conditions, such as pregnancy, atrial fibrillation, stroke, congestive heart failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), hypothyroidism, and Polycystic Ovary Syndrome (PCOS). These comorbidities often share pathophysiological links with OSA or exacerbate its symptoms.

Diagnostic Criteria for OSA

The diagnosis of obstructive sleep apnea is formally defined by the International Classification of Sleep Disorders – Third edition (ICSD-3)5 and requires meeting specific criteria. The diagnostic process involves assessing both clinical symptoms and objective measurements from sleep studies.

Diagnosis is established if either criteria (A and B) or criterion C is met:

A. Clinical Presentation: Presence of one or more of the following symptoms

1. Daytime Symptoms: The patient reports excessive daytime sleepiness, non-restorative sleep despite adequate sleep duration, persistent fatigue, or symptoms of insomnia. These daytime issues significantly impact daily functioning and quality of life.
2. Nocturnal Breathing Disturbances: The patient wakes up with sensations of breath-holding, gasping for air, or choking episodes. These are direct indications of disrupted breathing during sleep.
3. Witnessed Apneas and Snoring: A bed partner or another observer reports loud, habitual snoring and/or witnessed episodes of breathing pauses or interruptions during the patient’s sleep. This third-party information is crucial as patients may be unaware of their nocturnal breathing problems.
4. Comorbid Conditions: The patient has been diagnosed with hypertension, a mood disorder (like depression or anxiety), cognitive dysfunction (such as memory or concentration problems), coronary artery disease, stroke, congestive heart failure, atrial fibrillation, or type 2 diabetes mellitus. OSA is recognized as a significant comorbidity in these conditions, and its diagnosis is important for comprehensive management.

B. Polysomnography (PSG) or Out-of-Center Sleep Testing (OCST) Confirmation

Objective sleep testing, either in a sleep laboratory (PSG) or at home (OCST), must demonstrate:

• Respiratory Event Frequency: Five or more predominantly obstructive respiratory events per hour of sleep during PSG, or per hour of monitoring during OCST. These events include obstructive apneas, hypopneas, or respiratory effort-related arousals (RERAs). This criterion is applicable when the patient also presents with one or more symptoms from criterion A.

C. Significant Respiratory Event Burden

Alternatively, diagnosis can be established based on sleep study findings alone, even without prominent symptoms from criterion A:

• Elevated Respiratory Event Index: PSG or OCST reveals fifteen or more predominantly obstructive respiratory events (apneas, hypopneas, or RERAs) per hour of sleep (PSG) or per hour of monitoring (OCST). This criterion acknowledges that some individuals may have a high frequency of respiratory events without experiencing or reporting typical daytime symptoms, yet still be at risk for the long-term health consequences of OSA.

Defining Respiratory Events in Polysomnography

The American Academy of Sleep Medicine (AASM) provides standardized criteria for scoring respiratory events during polysomnography (PSG).6 These definitions are essential for accurate diagnosis and consistent reporting of sleep study results.

• Obstructive Apnea: An obstructive apnea is scored when there is a significant drop in airflow, specifically a decrease of ≥90% from the pre-event baseline in the respiratory effort signal. This reduction must last for ≥10 seconds and be accompanied by continued or increased inspiratory effort, evident from chest and/or abdominal movement sensors. The presence of respiratory effort distinguishes obstructive apnea from central apnea, where respiratory effort is absent.

• Hypopnea: A hypopnea is defined as a reduction in airflow of ≥30% from the pre-event baseline for ≥10 seconds. Crucially, this airflow reduction must be associated with oxygen desaturation, indicated by either a ≥3% drop from baseline according to AASM criteria, or a ≥4% drop based on the Centers for Medicare & Medicaid Services (CMS) criteria. The desaturation criterion reflects the physiological impact of reduced airflow on blood oxygen levels.

• Respiratory Effort-Related Arousal (RERA): A RERA is scored when there is a sequence of breaths lasting ≥10 seconds characterized by increasing respiratory effort or flattening of the inspiratory nasal pressure waveform, leading to an arousal from sleep. These events do not meet the strict criteria for apneas or hypopneas in terms of airflow reduction, but they still disrupt sleep continuity due to increased respiratory effort and subsequent arousals.

The severity of OSA is quantified using indices derived from PSG or OCST data. The most commonly used indices are:

• Apnea-Hypopnea Index (AHI): Calculated as the total number of apneas and hypopneas per hour of sleep (AHI = [Number of Apneas + Hypopneas] / Total Sleep Time in hours). AHI is used when sleep time is accurately measured, typically during PSG.

• Respiratory Disturbance Index (RDI): Includes all respiratory events – apneas, hypopneas, and RERAs – per hour of sleep (RDI = [Number of Apneas + Hypopneas + RERAs] / Total Sleep Time in hours). RDI provides a broader measure of sleep disruption related to respiratory events.

• Respiratory Event Index (REI): Used primarily with OCST, as sleep time is not directly measured. REI is calculated as the number of apneas and hypopneas per hour of monitoring time (REI = [Number of Apneas + Hypopneas] / Total Monitoring Time in hours).

The AHI or REI is used to categorize the severity of OSA: mild, moderate, or severe, which guides treatment decisions.

Signs and Symptoms of OSA

The clinical presentation of obstructive sleep apnea is varied, but certain symptoms are commonly reported by patients and observed by their bed partners. Recognizing these signs and symptoms is the first step towards diagnosis and effective management.

Common Nighttime Symptoms:

• Snoring: Loud and habitual snoring is one of the hallmark symptoms of OSA. The snoring associated with OSA is often characterized by pauses and gasps, as opposed to simple, continuous snoring.
• Witnessed Apneas: Bed partners frequently report witnessing the patient stop breathing during sleep, followed by gasping or choking sounds as breathing resumes. These witnessed apneas are a significant indicator of OSA.
• Waking Up Gasping or Choking: Patients may awaken suddenly with a sensation of gasping for air or choking. This is a direct consequence of upper airway obstruction and the body’s attempt to restore breathing.
• Restless Sleep: Fragmented and restless sleep is common, even if the patient is not fully aware of frequent awakenings. This restlessness is due to repeated arousals from sleep associated with respiratory events.
• Frequent Arousals: Although often subtle, frequent awakenings from sleep are a core feature of OSA. These arousals are usually brief and may not be consciously remembered, but they disrupt sleep architecture.
• Nocturia: An increased need to urinate during the night (nocturia) can be associated with OSA. This is thought to be related to hormonal changes and increased atrial natriuretic peptide release due to sleep apnea.
• Erectile Dysfunction: Men with OSA have a higher prevalence of erectile dysfunction. The underlying mechanisms are complex and may involve endothelial dysfunction, hypoxemia, and hormonal imbalances.

Common Daytime Symptoms:

• Excessive Daytime Sleepiness: Despite seemingly adequate time in bed, patients often experience excessive daytime sleepiness. This is a cardinal symptom of OSA and can significantly impair daily activities.
• Non-refreshing Sleep: Sleep is not restorative, and patients wake up feeling unrefreshed and fatigued, even after many hours of sleep.
• Early Morning Headaches: Headaches, particularly in the morning, are a common complaint. These are thought to be related to nocturnal hypoxemia and hypercapnia.
• Lack of Energy and Fatigue: Persistent fatigue and low energy levels are frequent consequences of disrupted sleep and hypoxemia in OSA.
• Poor Concentration and Cognitive Dysfunction: OSA can impair cognitive functions, including attention, concentration, memory, and executive functions. This can affect work performance and daily tasks.
• Mood Disturbances: Irritability, mood swings, anxiety, and depression are more common in individuals with OSA. Sleep fragmentation and hypoxemia can contribute to these mood changes.

Untreated OSA has significant implications beyond just sleepiness. It is associated with impaired attention, reduced productivity at work, and an increased risk of accidents, particularly motor vehicle crashes. Studies have shown that OSA increases the risk of motor vehicle accidents by two to three times.7 Importantly, effective treatment of OSA, such as with Continuous Positive Airway Pressure (CPAP) therapy, can significantly reduce this risk, highlighting the importance of diagnosis and intervention.

Physical Examination for OSA

A thorough physical examination is an important component of the diagnostic process for obstructive sleep apnea. While physical findings alone cannot definitively diagnose OSA, they can raise clinical suspicion and guide further evaluation.

• Body Mass Index (BMI) Measurement: Given the strong association between obesity and OSA, measuring Body Mass Index (BMI) is crucial. Elevated BMI is a significant risk factor, and the degree of obesity often correlates with OSA severity.

• Neck Circumference: Increased neck circumference is another easily measurable physical characteristic associated with OSA. A neck circumference of ≥17 inches in men and ≥16 inches in women is linked to a higher risk. Larger neck circumference may indicate increased fat deposition around the upper airway, contributing to airway narrowing.

• Upper Airway Examination: A detailed examination of the upper airway can reveal anatomical factors that predispose to OSA. This includes:

  • Macroglossia: Enlarged tongue (macroglossia) can encroach on the airway space.
  • Tonsillar Hypertrophy: Enlarged tonsils can obstruct the oropharynx, especially in children and some adults.
  • Large Uvula: An elongated or enlarged uvula can contribute to airway obstruction.
  • Retrognathia and Micrognathia: Recessed mandible (retrognathia) or small mandible (micrognathia) can reduce the space for the tongue and soft tissues, narrowing the airway.
  • Nasal Septal Deviation and Turbinate Hypertrophy: Nasal obstruction due to septal deviation or enlarged turbinates can worsen OSA, although it is not a primary cause.

• Mallampati Score: The Mallampati score is a clinical tool used to assess the degree of oropharyngeal airway narrowing. It is determined by visualizing the structures visible in the oropharynx with the patient sitting, mouth open, and tongue protruded maximally. A higher Mallampati score (Class 3 or 4) indicates greater airway narrowing and is associated with increased OSA risk.

While these physical examination findings are helpful, it’s important to remember that their absence does not rule out OSA, and their presence does not confirm it. Objective sleep testing is always necessary to establish a definitive diagnosis.

Screening Tools for OSA

Given the high prevalence of undiagnosed OSA, especially in primary care and pre-operative settings, several screening questionnaires have been developed to identify individuals at higher risk who warrant further diagnostic testing. These tools are not diagnostic themselves but help in risk stratification.

• Berlin Questionnaire: One of the earlier validated questionnaires, the Berlin Questionnaire categorizes patients into high and low risk for OSA based on symptoms related to snoring, daytime sleepiness/fatigue, and hypertension/obesity.

• STOP-BANG Questionnaire: The STOP-BANG questionnaire is a widely used and easily administered tool, particularly effective in surgical populations. It has high sensitivity for detecting moderate to severe OSA. The acronym STOP-BANG stands for:

  • Snoring: Do you snore loudly?
  • Tired: Do you feel tired or sleepy during the daytime?
  • Observed: Has anyone observed you stop breathing or gasp during your sleep?
  • Pressure: Do you have or are you being treated for high blood pressure?
  • BMI: Is your BMI > 35 kg/m²?
  • Age: Are you older than 50 years?
  • Neck circumference: Is your neck circumference large? (≥17 inches for men, ≥16 inches for women)
  • Gender: Are you male?

Each “yes” answer scores one point. A total score of 0-2 indicates low risk of OSA, while a score of 5-8 indicates a high risk of moderate to severe OSA (AHI >15).8

• Epworth Sleepiness Scale (ESS): The ESS is a subjective measure of daytime sleepiness. It asks patients to rate their likelihood of falling asleep in eight different situations. While ESS is commonly used in sleep clinics, it is less specific for OSA screening compared to tools like STOP-BANG, as daytime sleepiness can be caused by various factors.

• Preoperative OSA Screening Questionnaires: Several questionnaires are specifically designed for preoperative risk assessment of OSA, aiming to identify patients at risk of perioperative complications related to undiagnosed OSA.

Table 1. STOP-BANG Questionnaire for OSA Risk Assessment

Question	Yes/No
Snore: Do you Snore loudly (louder than talking or loud enough to be heard through closed doors)?	Yes
Tired: Do you often feel Tired, fatigued, or sleepy during the daytime?	Yes
Observed: Has anyone Observed you stop breathing or choking/gasping during your sleep?	Yes
Pressure: Do you have or are you being treated for high blood Pressure?	Yes
BMI: Is your Body Mass Index (BMI) greater than 35 kg/m²?	Yes
Age: Are you age 50 years or older?	Yes
Neck circumference: Large Neck circumference (≥ 43 cm or 17 inches in men; ≥ 41 cm or 16 inches in women)?	Yes
Gender: Are you Gender male?	Yes

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Adapted from Chung F, Abdullah HR, Liao P. STOP-Bang Questionnaire: A practical approach to screen for obstructive sleep apnea. CHEST Journal. 2016;149(3):631–8.(8)

These screening tools are valuable for identifying individuals who should undergo more definitive diagnostic testing for OSA, particularly polysomnography or home sleep apnea testing.

Diagnostic Tests for OSA

Definitive diagnosis of obstructive sleep apnea relies on objective sleep testing. These tests are categorized based on the complexity and number of physiological parameters monitored.

• Type 1 Polysomnography (PSG): PSG, also known as an in-laboratory sleep study, is considered the gold standard for OSA diagnosis. It is a comprehensive, attended study conducted overnight in a sleep laboratory. PSG involves monitoring multiple physiological parameters simultaneously, including:
  • Electroencephalography (EEG): To stage sleep (wake, N1, N2, N3, REM).
  • Electrooculography (EOG): To detect eye movements and identify REM sleep.
  • Electromyography (EMG): To monitor muscle tone, typically submental EMG.
  • Electrocardiography (ECG): To monitor heart rate and rhythm.
  • Airflow: Using nasal pressure cannula and/or thermistor to measure airflow at the nose and mouth.
  • Respiratory Effort: Using chest and abdominal belts to measure respiratory effort.
  • Oxygen Saturation (SpO2): Pulse oximetry to continuously monitor blood oxygen levels.
  • Body Position: To correlate respiratory events with body position.
  • Snoring: Microphone to record snoring sounds.
  • Leg EMG (optional): To detect periodic limb movements in sleep (PLMS).

PSG provides detailed information about sleep architecture, respiratory events, oxygen desaturation, and other sleep-related parameters. It allows for accurate calculation of AHI and RDI, and is essential for diagnosing complex sleep disorders and titrating PAP therapy.

• Type 3 Out-of-Center Sleep Testing (OCST) or Home Sleep Apnea Test (HSAT): HSAT is a simplified sleep study that can be performed at home. It is a type 3 test, monitoring fewer channels than PSG. Typically, HSAT includes:
  • Airflow: Nasal pressure cannula.
  • Respiratory Effort: Chest or abdominal belt.
  • Oxygen Saturation (SpO2): Pulse oximetry.
  • Heart Rate: Derived from pulse oximetry or ECG.

Crucially, HSAT does not include EEG, EOG, or chin EMG, so it does not directly measure sleep and cannot stage sleep or detect arousals reliably. Therefore, respiratory events are scored per hour of recording time, not sleep time, and the Respiratory Event Index (REI) is calculated.

The AASM recommends HSAT as an acceptable alternative to PSG for diagnosing OSA in patients with a high pretest probability of moderate to severe OSA after a comprehensive sleep evaluation.9 HSAT is more convenient and less expensive than PSG, but it has limitations. It should not be used as a general screening tool and is not appropriate for patients with significant comorbidities such as severe pulmonary disease, congestive heart failure, neuromuscular disease, or other suspected sleep disorders like periodic limb movement disorder (PLMD), narcolepsy, or parasomnias. In these complex cases, PSG is necessary. A negative or technically inadequate HSAT in a symptomatic patient with a high clinical suspicion for OSA should be followed by an in-laboratory PSG to rule out OSA or other sleep disorders.

Management and Treatment of Obstructive Sleep Apnea

Managing obstructive sleep apnea is crucial due to its significant health risks. Untreated moderate to severe OSA is associated with increased cardiovascular morbidity, mortality, and all-cause mortality.10–12 Treatment decisions are guided by OSA severity, symptoms, and comorbidities.

Treatment is generally recommended for all patients with moderate to severe OSA. For mild OSA, treatment is considered for symptomatic patients (those with daytime sleepiness, fatigue, insomnia) or those with comorbid conditions such as heart failure, ischemic heart disease, atrial fibrillation, hypertension, stroke, pulmonary hypertension, metabolic syndrome, diabetes mellitus, cognitive impairment, and mood disorders.

The American Academy of Sleep Medicine (AASM) guidelines recommend Positive Airway Pressure (PAP) therapy as the first-line treatment for OSA of all severities.13 However, alternative therapies are available, particularly for patients who cannot tolerate or adhere to PAP therapy.

Table 2. Treatment Strategies for OSA Based on Severity

Severity of OSA	Primary Treatment	Secondary Treatment	Adjunctive Therapies
Mild OSA (AHI/RDI 5–14.9)	Observe (if asymptomatic), Positional Therapy, Oral Appliance, Surgery (UPPP)	PAP therapy	Weight loss, Positional Therapy, Avoidance of Alcohol/Sedatives
Moderate OSA (AHI/RDI 15–29.9)	PAP therapy	Oral Appliance, Surgery (UPPP)	Weight loss, Positional Therapy, Avoidance of Alcohol/Sedatives
Severe OSA (AHI/RDI ≥30)	PAP therapy	Surgery (MMA), Oral Appliance	Weight loss, Positional Therapy, Avoidance of Alcohol/Sedatives

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AHI – Apnea Hypopnea Index; RDI – Respiratory Disturbance Index; PAP – Positive Airway Pressure; UPPP – Uvulopalatopharyngoplasty; MMA – Maxillomandibular Advancement

Adapted from Epstein LJ, Kristo D, Strollo Jr PJ, Friedman N, Malhotra A, Patil SP, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009;5(3):263–76.(13)

Continuous Positive Airway Pressure (CPAP) Therapy

CPAP is the most effective and commonly prescribed treatment for moderate to severe OSA. CPAP delivers a continuous stream of pressurized air through a mask worn over the nose and/or mouth. This positive pressure acts as a pneumatic splint, keeping the upper airway open during inspiration and preventing collapse. Nasal CPAP was introduced in 198114 and has become the cornerstone of OSA therapy.

Medicare and Medicaid Services (CMS) criteria for CPAP coverage include patients with moderate or severe OSA (AHI ≥ 15) and patients with mild OSA (AHI ≥ 5 – 14.9) who have documented symptoms such as excessive daytime sleepiness, hypertension, ischemic heart disease, history of stroke, cognitive impairment, mood disorder, or insomnia.15

While CPAP is highly effective, adherence can be a challenge for some patients due to mask discomfort, nasal congestion, claustrophobia, or other issues. Alternative PAP modes, such as autotitrating PAP (APAP) and bilevel PAP (BPAP), are available to improve comfort and adherence in select patients.

Behavioral Treatments for OSA

Behavioral modifications play an important role in the comprehensive management of OSA. These are often used as adjunctive therapies but can be primary treatments for mild OSA, particularly positional therapy and weight loss.

• Weight Loss: Obesity is a major risk factor for OSA, and weight loss can significantly improve OSA severity. Even a modest weight reduction of 5-10% can reduce AHI. Weight loss to achieve a BMI of ≤25 kg/m² is often recommended.

• Positional Therapy: OSA is frequently worse in the supine position. Positional therapy aims to avoid sleeping on the back. Simple methods include sewing tennis balls into the back of a pajama top or using commercially available positional devices or alarms that provide feedback when the patient rolls onto their back during sleep.

• Avoidance of Alcohol and Sedatives: Alcohol and sedative medications relax upper airway muscles, which can worsen OSA. Avoiding these substances, especially close to bedtime, is advisable for patients with OSA.

Oral Appliances for OSA

Oral appliances (OAs), also known as mandibular repositioning appliances (MRAs), are custom-fitted dental devices that are worn during sleep to treat snoring and OSA. OAs work by advancing the mandible forward, which increases the space in the upper airway, reducing collapsibility.

OAT is considered an effective alternative to CPAP for mild to moderate OSA and for patients who cannot tolerate CPAP. However, OAs are generally less effective than CPAP for severe OSA. For severe OSA, OAT may be considered as a second-line therapy after CPAP failure or intolerance.

Several types of OAs are available, and custom-fitted appliances prescribed and fitted by a dentist with expertise in sleep-disordered breathing are generally recommended. Potential side effects of OAT include temporomandibular joint (TMJ) pain, dental discomfort, dry mouth, and changes in bite. Regular dental follow-up is necessary for patients using OAs.

Surgical Treatments for OSA

Surgical options for OSA aim to either bypass the obstruction (tracheostomy) or modify the upper airway anatomy to reduce collapsibility.

• Tracheostomy: Tracheostomy, creating a surgical opening in the trachea, bypasses the upper airway obstruction entirely and is highly effective for OSA. However, it is an invasive procedure with significant social and lifestyle implications and is generally reserved for very severe, life-threatening OSA when other treatments have failed.

• Uvulopalatopharyngoplasty (UPPP): UPPP is the most commonly performed surgical procedure for OSA. It involves removing the tonsils (if present), uvula, and a portion of the soft palate to enlarge the retropalatal airway. UPPP is most effective for retropalatal obstruction but does not address obstruction at the tongue base (retrolingual). Success rates for UPPP vary, generally reported around 40-50%.16, 17

• Maxillomandibular Advancement (MMA): MMA surgery is a more complex and invasive procedure but has higher success rates than UPPP, with reported cure rates of 80-90%.17 MMA involves surgically moving both the upper (maxilla) and lower (mandible) jaws forward, which significantly increases both the retrolingual and retropalatal airway space. MMA is considered an alternative treatment for severe OSA, particularly in patients with craniofacial abnormalities contributing to airway obstruction.13

• Bariatric Surgery: For obese patients with OSA, bariatric surgery (weight loss surgery) can lead to significant improvement or resolution of OSA by promoting substantial weight loss.

New and Novel Therapies for OSA

Despite the effectiveness of CPAP, adherence remains a significant challenge for many patients. This has driven the development of newer, alternative therapies for OSA.

• Oral Pressure Therapy (OPT) – Winx®: The Winx® Sleep Therapy System utilizes oral pressure therapy. It delivers a mild negative pressure to the oral cavity through a mouthpiece connected to a quiet vacuum. This negative pressure gently pulls the soft palate and tongue forward, increasing the dimensions of both the retropalatal and retrolingual airways.21

• Nasal Expiratory Positive Airway Pressure (EPAP) – Provent®: Provent® is a nasal EPAP device. It consists of disposable, single-use valves that are adhered to the nostrils. These valves create resistance during exhalation, generating positive pressure in the upper airway throughout the expiratory cycle. This positive pressure helps to stent the airway open and reduce collapse during subsequent inspiration.22 Studies have shown efficacy across all severities of OSA.23

• Upper Airway Stimulation (UAS) – Inspire®: The Inspire® system is an implantable neurostimulator for upper airway stimulation. It involves surgical implantation of a device that stimulates the hypoglossal nerve, which controls the genioglossus muscle (tongue muscle). The device is programmed to deliver stimulation synchronously with each breath, causing the tongue to protrude forward and open the airway. Inspire® is FDA-approved for carefully selected patients with moderate to severe OSA who are CPAP-intolerant and have a BMI below 32.24, 25 It is currently available at specialized centers.

Conclusion

Obstructive sleep apnea is a common and serious medical condition with significant health and economic implications. A substantial portion of affected individuals remain undiagnosed, highlighting the need for increased awareness and effective screening strategies. The STOP-BANG questionnaire serves as a reliable tool for identifying individuals at risk. Definitive diagnosis relies on objective sleep testing, either in-laboratory polysomnography (PSG) or home sleep apnea testing (HSAT).

Continuous Positive Airway Pressure (CPAP) remains the gold standard treatment for moderate to severe OSA. However, a range of alternative therapies, including oral appliances, surgical procedures, behavioral modifications, and novel therapies, are available for patients who cannot tolerate CPAP or for specific clinical situations. Ongoing research continues to explore new and improved treatment options to enhance efficacy and patient adherence in the management of OSA. Early diagnosis and appropriate treatment are essential to mitigate the adverse health consequences of OSA and improve patient quality of life.

Biography

Munish Goyal, MD, MCh, is Assistant Professor of Neurology & Sleep Medicine and Associate Program Director of Sleep Medicine Fellowship Program at University of Missouri – Columbia.

Jeremy C. Johnson, DO, is Chief of Pulmonary, Critical Care & Sleep Medicine and Medical Director of Sleep Disorders Center at Harry S. Truman Veterans’ Hospital. He is also Assistant Professor of Clinical Medicine, Division of Pulmonary, Critical Care, and Environmental Medicine, Department of Internal Medicine at University of Missouri-Columbia.

Contact: [email protected]

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Footnotes

Disclosure

None reported.