Diagnosing Obstructive Sleep Apnea

Guideline Watch |
August 14, 2014

Diagnosing Obstructive Sleep Apnea

  1. Jamaluddin Moloo, MD, MPH

The American College of Physicians recommends polysomnography over portable monitors.

  1. Jamaluddin Moloo, MD, MPH

Sponsoring Organization: American College of Physicians (ACP)

Target Audience: Internists, family physicians, and other primary care clinicians

Background and Objective

Despite the relatively high prevalence of obstructive sleep apnea (OSA), experts still disagree on the optimal approach to its diagnosis. The ACP has issued a new guideline on diagnosing OSA.

Key Points

  • For diagnosing OSA, polysomnography (PSG) is the gold standard; however, it must be performed in a sleep lab and is costly. An alternative is a portable monitor, but available portable monitors do not measure all relevant parameters: Some are unable to distinguish between central and obstructive apneas. Evidence was insufficient to determine whether questionnaires are an effective screening tool.

  • Medicare and Medicaid reimburse for OSA treatment if a patient's apnea-hypopnea index (AHI) is ≥15 events per hour or is ≥5 events per hour in patients with daytime somnolence, fatigue, or cardiovascular comorbid conditions such as ischemic heart disease, stroke, or hypertension.

  • High-quality evidence shows an association between AHI scores of >30 events per hour and excess all-cause mortality. Low-quality evidence suggests an association between higher AHI scores and incident diabetes.

  • Several trials showed that continuous positive airway pressure (CPAP) lowers blood pressure in OSA patients who have daytime sleepiness. A randomized trial showed that CPAP failed to prevent excess mortality or adverse coronary events in patients with OSA who did not have daytime sleepiness.

The ACP makes the following recommendations:

  • A sleep study is recommended for patients with unexplained daytime sleepiness (weak recommendation, low-quality evidence).

  • Polysomnography is recommended for diagnostic testing. A portable sleep monitor can be used if polysomnography is not available (weak recommendation, moderate-quality evidence).


Given the limited quality of available evidence, this guideline provides us with “weak recommendations” only. However, the ACP does suggest that we focus our attention on patients with suspected OSA who also have daytime sleepiness, and it recommends formal polysomnography instead of portable monitors for diagnostic testing.

Editor Disclosures at Time of Publication

  • Disclosures for Jamaluddin Moloo, MD, MPH at time of publication Grant / Research support Colorado Health Foundation


Reader Comments (2)

E. Licari Other Healthcare Professional, Other, consultant

Some time ago, one of the diagnostic departments over which I had responsibility was a polysomnography laboratory. I was awed with some of the results, showing a very grave danger of a patient having a cardiac or pulmonary event while operating machinery, trains or busses. The interventions that were done saved untold numbers of lives (who will never know that they were in danger).

fred nachtwey Physician, Pulmonary Medicine, office

too brief a summary

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