Updated Recommendations for Obstructive Sleep Apnea in General Population

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US Prevention Services Task Force (USPSTF) announces that after reviewing the clinical utility of obstructive sleep apnea screening tools in a primary care setting, there's insufficient evidence to determine the balance between benefit and harm.

The US Preventive Services Task Force (USPSTF) aimed to update the screening recommendations for obstructive sleep apnea (OSA) in a primary care setting from its last recommendation in 2017. The task force initiated the evaluation with a systematic review to determine the potential benefits and harms of screening for OSA in the general adult population.

Ultimately, USPSTF concluded that the current available evidence failed to provide enough clarity in order to properly assess if implementing screening in this population would be worth it based on the potential benefits and harms involved.

While the prevalence of obstructive sleep apnea (OSA) in the US is not well understood, cohort and survey data from 2007-2010 estimated that 14% of men and 5% of women between the ages of 30-70 years were at least affected by mild OSA with the presence of daytime sleepiness.

Adults with severe OSA are at an increased risk of all-cause mortality in addition to adverse health outcomes such as cardiovascular disease and erebrovascular events, type 2 diabetes, cognitive impairment, decreased quality of life, and motor vehicle crashes.

Patients and Practices

Adults aged 18 years or older who were asymptomatic or had unrecognized symptoms present were the focus of this recommendation review and does not apply to patients who exhibit symptoms and concerns of the condition, those who have been referred for evaluation of suspected OSA, or patients with acute conditions that would initiate the onset of OSA.

Various screening questionnaires and clinical prediction tools are available to aid in the identification of obstructive sleep apnea in individuals who are at an elevated risk for the condition, though none were adequately validated in a primary care setting for the general population.

These prediction tools include the Epworth Sleepiness Scale (ESS), STOP questionnaire (snoring, tiredness, observed apnea, high blood pressure), STOP- BANG questionnaire (STOP questionnaire plus BMI, age, neck cir- cumference, and gender), Berlin Questionnaire, Wisconsin Sleep Questionnaire, and the Multivariable Apnea Prediction tool.

When an individual is suspected to have obstructive sleep apnea, a diagnosis comes as a result of polysomnography. With data gathered from several measurements of an electroencephalogram, electrooculogram, chin electromyelogram, airflow monitor, oxygen saturation, respiratory effort, and electrocardiogram or heart rate, polysomnography can confirm a diagnosis and the severity of the condition.

Current Treatment and Adverse Events

Routine screening for obstructive sleep apnea doesn't typical occur in primary care settings. According to data noted in the statement, only 20% of patients with sleep-related symptoms addressed them with their primary care physician (PCP) without prompting.

Currently, most PCPs refer to a specialist for thorough diagnostic testing and treatment when presented with an adult who has unrecognized symptoms and concerns of the possibility of OSA.

There are a number of harms associated with positive airway pressure, the primary device used to treat OSA. Common reports consist of oral or nasal dryness, eye or skin irritation, rash, and pain.

An alternative approach is a mandibular advancement device (MAD) which patients can opt for if they experience, or want to avoid, adverse events associated with positive airway pressure. However, this treatment also has reported harms to consider: oral mucosal, dental, or jaw symptoms, such as mucosal or dental pain, discomfort or tenderness, mucosal erosions, and jaw or temporomandibular joint pain or discomfort.

Oftentimes, adverse events experienced as a result of either treatment resolve after therapy is discontinued.

USPSTF was unable to identify any studies that directly evaluated harms associated with screening for OSA, though 19 were identified as evaluating those associated with treatment. Overall, the reporting on harms related to treatment was lacking and no investigations included screen-detected adults from a primary care setting, which led the task force to forgo making any recommendation changes without the presence of sufficient evidence.

Screening for Obstructive Sleep Apnea in Adults US Preventive Services Task Force Recommendation Statement:

This recommendation replaces the 2017 USPSTF recommendation on screening for OSA. In 2017, the USPSTF found insufficient evidence to assess the balance of benefits and harms of screening for OSA in asymptomatic adults (I statement). This recommendation statement is consistent with the I statement from 2017.