Clinicians should recommend a sleep study using polysomnography for adults who have unexplained daytime sleepiness, according to a clinical practice guideline on diagnosing obstructive sleep apnea.
The guideline was published online Aug. 4 in Annals of Internal Medicine.
There is still "considerable" controversy concerning the type and level of respiratory abnormality that defines obstructive sleep apnea (OSA), as well as the presence and type of signs or symptoms that are diagnostic of the disorder, said Dr. Amir Qaseem, director of clinical policy at the American College of Physicians, Philadelphia.
To formulate a clinical practice guideline, Dr. Qaseem and his associates performed a comprehensive review of the literature through May 2013, which included a comparative effectiveness technology review of portable sleep monitors sponsored by the Agency for Healthcare Research and Quality.
The guideline recommends that internists, family physicians, and other clinicians focus assessment of OSA on their adult patients who have unexplained daytime sleepiness. To do so, they must rule out other potential causes such as thyroid disease or gastroesophageal reflux disease.
Then, clinicians should evaluate patients for risk factors and common presenting symptoms of the disorder. Chief among risk factors is obesity, and frequent symptoms include unintentionally falling asleep during waking hours, unrefreshing sleep, fatigue, insomnia, and snoring (Ann. Intern. Med. 2014;161:210-20).
Once OSA is suspected, the guideline recommends full-night, in-laboratory polysomnography to establish the diagnosis. This requires specialized facilities, is expensive, and demands that patients "spend the night under observation in a foreign environment," but yields the most accurate diagnostic information.
Portable sleep monitors for home use are an alternative if a sleep laboratory is not available, but these can yield substantially different scores on the apnea-hypopnea index, usually because of data loss that limits interpretation of the results.
In addition, the ability of portable sleep monitors to diagnose OSA is questionable in the subset of patients who have comorbid conditions such as chronic lung disease, heart failure, or neurologic disorders.
Development of this clinical practice guideline was supported solely by the American College of Physicians. Dr. Qaseem and his associates reported no relevant financial conflicts of interest.