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

Clinical Highlights and Recommendations:

• The following signs and symptoms may suggest significant risk for obstructive sleep apnea hypopnea syndrome (OSAHS):
  - Reported apneas by sleep partner
  - Awakening with choking
  - Intense snoring
  - Severe daytime sleepiness, especially with impairment of driving
  - Male gender and postmenopausal females
  - Obesity (BMI greater than or equal to 30)
  - Large neck circumference
  - Hypertension
  
• OSAHS 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.
  
• 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 OSAHS is polysomnography, which is indicated for the diagnosis of all patients suspected of having this disorder.
  
• All patients with a diagnosis of OSAHS 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 OSAHS may include one or more of the following treatment modalities: oral appliances, positive airway pressure devices, surgery.
  
• Management of moderate to severe OSAHS 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 OSAHS through a sleep study evaluation.
   
2. Increase the percentage of patients with OSAHS who have received appropriate treatment according to guideline.
   
3. Improve PAP treatment adherence rate for those who are diagnosed with OSAHS.
   
4. Increase patient understanding of the health risk factors related to OSAHS.

Introduction
Sleep apnea is under-diagnosed. Studies indicate that 2%-4% of adult Americans have the disease and obstructive sleep apnea hypopnea syndrome (OSAHS) 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 OSAHS and 10 million remain undiagnosed. Patients with severe OSAHS 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 OSAHS patients may be sleep deprived because of the severe nocturnal snoring. OSAHS is increasingly being recognized as a 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 who present to the physician's office at risk for OSAHS. 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 OSAHS. The diagnosis and treatment of OSAHS 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.