Scope and Target Population:
To identify and appropriately treat adult patients age 18 and older at risk for obstructive sleep apnea syndrome (OSA).

Clinical Highlights and Recommendations:

• The following signs and symptoms may suggest significant risk for obstructive sleep apnea syndrome (OSA). The more of these symptoms a patient has and the more severe these symptoms are, the greater the pretest probability that a patient will have moderate or severe OSA):
  - Awakening with choking
  - Hypertension
  - Intense snoring
  - Large neck circumference
  - Male gender or postmenopausal females
  - Obesity
  - Reported apneas or choking by sleep partner
  - Resistant hypertension and/or atrial fibrillation
  - Daytime sleepiness, especially with impairment of driving
  
• OSA is a significant risk factor for the development of hypertension and has been associated with type 2 diabetes, coronary artery disease and cerebrovascular disease, and may lead to significant impairment in quality of life.
  
• Untreated sleep apnea may mimic or exacerbate depression, ADHD and other chronic disorders.
  
• It is important to rule out sleep deprivation (i.e., insomnia or poor sleep hygiene) when evaluating daytime sleepiness.
  
• The accepted standard test for diagnosis of OSA is polysomnography, which is indicated for the diagnosis of all patients suspected of having this disorder.
  
• All patients with a diagnosis of OSA should receive education guidance in lifestyle modification, especially weight loss as a treatment for sleep apnea and referral to the A.W.A.K.E. program.
  
• All patients who have a weight loss or gain of 10%-15% should be assessed for symptoms of OSA and the need to adjust PAP settings.
  
• Management of mild OSA may include one or more of the following treatment modalities: oral appliances, positive airway pressure devices, surgery.
  
• Management of moderate to severe OSA includes the use of positive airway pressure devices. Patients who are intolerant of positive airway pressure devices, or those who are not adequately managed with positive airway pressure alone, may be considered for surgery.
  

Priority Aims:

1. Increase the percentage of patients 18 and older who are diagnosed with OSA through a sleep study evaluation.
   
2. Increase the percentage of patients with OSA who have received appropriate treatment according to guideline.
   
3. Improve PAP treatment adherence rate for those who are diagnosed with OSA.
   
4. Increase patient understanding of the health risk factors related to OSA.
   

Introduction
Sleep apnea is underdiagnosed. Studies indicate that 2%-4% of adult Americans have the disease and that obstructive sleep apnea syndrome (OSA) is as common as asthma. Theta Reports, based in New York, estimates that 40 million Americans may have some type of sleep disorder, 30 million likely have sleep apnea and 28.5 million are still undiagnosed. American Sleep Apnea Association research indicates that up to 12 million Americans may have OSA and 10 million remain undiagnosed. Patients with severe OSA and daytime sleepiness may have an increased risk for motor vehicle accidents. The risk may be reduced by a positive airway pressure device (PAP). The spouses of OSA patients may be sleep deprived because of the severe nocturnal snoring. OSA is an independent potential risk factor for cardiovascular disease and may be especially important in cardiovascular conditions that are resistant to standard therapy. This guideline was developed to identify those patients at risk for OSA who present to the physician's office. Realizing that patients present for well-person exams or for evaluation/follow-up of specific problems, we have identified three entry points for these patients in order to identify them.

Primary care providers should coordinate the diagnosis and management of OSA. The diagnosis and treatment of OSA should be managed by a physician with proper knowledge in this area. Such physicians may include primary care providers, or specialists such as pulmonologists, neurologists, otolaryngologists, psychiatrists or cardiologists.