Cited by 1,482Obstructive Sleep Apnea ResearchSleep and related disordersNeuroscience of respiration and sleep

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Diagnosis and Management of Obstructive Sleep Apnea: A Review

Gottlieb, Daniel J., Punjabi, Naresh M.·2020·JAMA

DOI 10.1001/jama.2020.3514

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Abstract

Importance: Obstructive sleep apnea (OSA) affects 17% of women and 34% of men in the US and has a similar prevalence in other countries. This review provides an update on the diagnosis and treatment of OSA. Observations: The most common presenting symptom of OSA is excessive sleepiness, although this symptom is reported by as few as 15% to 50% of people with OSA in the general population. OSA is associated with a 2- to 3-fold increased risk of cardiovascular and metabolic disease. In many patients, OSA can be diagnosed with home sleep apnea testing, which has a sensitivity of approximately 80%. Effective treatments include weight loss and exercise, positive airway pressure, oral appliances that hold the jaw forward during sleep, and surgical modification of the pharyngeal soft tissues or facial skeleton to enlarge the upper airway. Hypoglossal nerve stimulation is effective in select patients with a body mass index less than 32. There are currently no effective pharmacological therapies. Treatment with positive airway pressure lowers blood pressure, especially in patients with resistant hypertension; however, randomized clinical trials of OSA treatment have not demonstrated significant benefit on rates of cardiovascular or cerebrovascular events. Conclusions and Relevance: OSA is common and the prevalence is increasing with the increased prevalence of obesity. Daytime sleepiness is among the most common symptoms, but many patients with OSA are asymptomatic. Patients with OSA who are asymptomatic, or whose symptoms are minimally bothersome and pose no apparent risk to driving safety, can be treated with behavioral measures, such as weight loss and exercise. Interventions such as positive airway pressure are recommended for those with excessive sleepiness and resistant hypertension. Managing asymptomatic OSA to reduce cardiovascular and cerebrovascular events is not currently supported by high-quality evidence.

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Background
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Background
Relevance of cortical arousals for risk stratification in sleep apnea: a 3 cohort analysis
Azarbarzin, A., Sands, S. A., Han, S., Sofer, T., Gonzalo Labarca, T., Stone, K. L., Gottlieb, D. J., Javaheri, S., Wellman, A., White, D. P., et al. (2023) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.10598 · Cited by 23
Self-citation
Sleep disorders in Lewy body dementia: Mechanisms, clinical relevance, and unanswered questions
Townsend, L., Anderson, K. N., Boeve, B. F., McKeith, I. G., & Taylor, J. (2023) · Alzheimer s & Dementia · doi:10.1002/alz.13350 · Cited by 24
Sleep apnoea syndrome prevalence in chronic kidney disease and end-stage kidney disease patients: a systematic review and meta-analysis
Pisano, A., Zoccali, C., Bolignano, D., D'Arrigo, G., & Mallamaci, F. (2023) · Clinical Kidney Journal · doi:10.1093/ckj/sfad179 · Cited by 18
“…], by a reduced glomerular filtration rate ( GFR 90 mL/min/1.73 m 2 ) and/or pathological evidence of kidney damage ( persistence of urinary abnormalities, such as albuminuria, proteinuria or haematuria) with a preserved GFR ( ≥ 90 mL/min [26 ], recently reviewed by Gottlieb and Punjabi [27 ].”
BackgroundInfluential
Cardiovascular Risks in People With Narcolepsy: Expert Panel Consensus Recommendations
Kwon, Y., Gami, A. S., Javaheri, S., Pressman, G. S., Scammell, T. E., Surkin, L. A., & Zee, P. C. (2024) · Journal of the American Heart Association · doi:10.1161/jaha.124.035168 · Cited by 24
Mitigating Increased Cardiovascular Risk in Patients with Obstructive Sleep Apnea Using GLP-1 Receptor Agonists and SGLT2 Inhibitors: Hype or Hope?
Karakasis, P., Sagris, Μ., Patoulias, D., Koufakis, T., Theofilis, P., Klisic, A. N., Fragakis, N., El‐Tanani, M., & Rizzo, M. (2024) · Biomedicines · doi:10.3390/biomedicines12112503 · Cited by 24
“However, upon reentering sleep, upper airway obstruction recurs, perpetuating this cycle throughout the night [47].”
Prevalence and Predictors of Sleep-Disordered Breathing in Men Participating in the Multicenter AIDS Cohort Study
Punjabi, N. M., Brown, T. T., Aurora, R. N., Patel, S. R., Stosor, V., Cho, H. J., DʼSouza, G., & Margolick, J. B. (2022) · CHEST Journal · doi:10.1016/j.chest.2022.10.030 · Cited by 22
Self-citation
Evaluation of HIF-1 Involvement in the BDNF and ProBDNF Signaling Pathways among Obstructive Sleep Apnea Patients
Gabryelska, A., & Sochal, M. (2022) · International Journal of Molecular Sciences · doi:10.3390/ijms232314876 · Cited by 22
“This results in sleep fragmentation due to the presence of frequent arousals, nocturnal desaturations, and excessive daytime sleepiness [1].”
Background
Pharmacological treatment for obstructive sleep apnea: A systematic review and meta-analysis
Nobre, M. L., Sarmento, A. C. A., de Oliveira, P. F., Wanderley, F. F., Júnior, J. D., & Gonçalves, A. K. (2024) · Clinics · doi:10.1016/j.clinsp.2024.100330 · Cited by 22
Application Value of Cardiometabolic Index for the Screening of Obstructive Sleep Apnea with or Without Metabolic Syndrome
Wang, D., Chen, Y., Ding, Y., Tang, Y., Su, X., Li, S., Zhang, H., Zhou, Y., Zhuang, Z., Gan, Q., et al. (2024) · Nature and Science of Sleep · doi:10.2147/nss.s449862 · Cited by 23
Development and application of a machine learning-based predictive model for obstructive sleep apnea screening
Liu, K., Geng, S., Shen, P., Zhao, L., Zhou, P., & Liu, W. (2024) · Frontiers in Big Data · doi:10.3389/fdata.2024.1353469 · Cited by 22
Higher ambient temperatures may worsen obstructive sleep apnea: A nationwide smartwatch-based analysis of 6.2 million person-days
Li, A., Zhang, Q., Yao, Y., Zhu, X., Liu, C., Guo, Y., Kan, H., & Chen, R. (2024) · 中国科学通报：英文版 · doi:10.1016/j.scib.2024.05.016 · Cited by 21
Continuous Positive Airway Pressure Treatment and Hypertensive Adverse Outcomes in Pregnancy
Lee, Y., Chang, Y., Tseng, L.-W., Lin, W., Lu, C., Lee, L., Fang, T., Cheng, W., & Li, H. (2024) · JAMA Network Open · doi:10.1001/jamanetworkopen.2024.27557 · Cited by 21
Evaluation of a non-contact ultra-wideband bio-radar sleep monitoring device for screening of sleep breathing disease
Wei, Z., Xu, J., Li, W., Wang, X., Qin, Z., Zhou, J., & Wang, W. (2021) · Sleep And Breathing · doi:10.1007/s11325-021-02424-x · Cited by 21
Performance of a commercial smart watch compared to polysomnography reference for overnight continuous oximetry measurement and sleep apnea evaluation
Browne, S. H., Vaida, F., Umlauf, A., Kim, J. J., DeYoung, P. N., & Owens, R. L. (2024) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.11178 · Cited by 21
“Predictive models of PSG AHI demonstrated the WD alone identified severe OSA with a performance comparable to that of at-home diagnostic tests, 9,30,31 with discrimination for mild and moderate-to-severe OSA just within a range considered excellent.”
Influential
Obstructive Sleep Apnea and Its Cardiac Implications in the United States: An Age‐Stratified Analysis Between Young and Older Adults
Strenth, C. R., Wani, A., Alla, R., Khan, S. S., Schneider, D., & Thakur, B. (2024) · Journal of the American Heart Association · doi:10.1161/jaha.123.033810 · Cited by 21
Obstructive sleep apnea and memory impairments: Clinical characterization, treatment strategies, and mechanisms
Zhang, X., Xu, H., Yin, S., Gozal, D., & Khalyfa, A. (2025) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2025.102092 · Cited by 24
Empagliflozin therapy and insulin resistance-associated disorders: effects and promises beyond a diabetic state
Papaetis, G. S. (2021) · Archives of Medical Science - Atherosclerotic Diseases · doi:10.5114/amsad.2021.105314 · Cited by 24
“Current therapeutic approaches include body weight reduction and exercise, continue positive airway pressure (CPAP), surgical treatment of the pharyngeal soft tissues or facial skeleton to enlarge the upper airway, and oral appliances that hold the jaw forward during sleep [129].”
Background
A single-arm, open-label, multicenter, and comparative study of the ANNE sleep system vs polysomnography to diagnose obstructive sleep apnea
Davies, C., Lee, J. Y., Walter, J., Kim, D., Yu, L., Park, J., Blake, S., Kalluri, L., Cziraky, M., Stanek, E., et al. (2022) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.10194 · Cited by 23
A Bidirectional Association Between Obstructive Sleep Apnea and Metabolic-Associated Fatty Liver Disease
Preshy, A., & Brown, J. (2023) · Endocrinology and Metabolism Clinics of North America · doi:10.1016/j.ecl.2023.01.006 · Cited by 23
Deep Learning Models for Automatic Upper Airway Segmentation and Minimum Cross-Sectional Area Localisation in Two-Dimensional Images
Chu, G., Zhang, R., He, Y., Ng, C. H., Gu, M., Leung, Y. Y., He, H., & Yang, Y. (2023) · Bioengineering · doi:10.3390/bioengineering10080915 · Cited by 23
“OSA caused by upper airway obstruction is common in the modern global population and has been associated with increased incidences of hypertension, atrial fibrillation, coronary heart disease and stroke [3,4].”
Background
Oxygen saturation as a predictor of inflammation in obstructive sleep apnea
Fernandes, E. R., Pires, G. N., Andersen, M. L., Tufik, S. B., & Rosa, D. S. (2021) · Sleep And Breathing · doi:10.1007/s11325-021-02521-x · Cited by 20
New diagnostic tools to screen and assess a still too underestimated disease: the role of the wrist-worn peripheral arterial tonometry device—a systematic review
Moffa, A., Giorgi, L., Carnuccio, L., Mangino, C., Lugo, R., Baptista, P., & Casale, M. (2022) · Sleep And Breathing · doi:10.1007/s11325-022-02700-4 · Cited by 20
Temporomandibular Disorders Within the Context of Sleep Disorders
Manfredini, D., Thomas, D. C., & Lobbezoo, F. (2023) · Dental Clinics of North America · doi:10.1016/j.cden.2022.10.004 · Cited by 20
Diagnosis of obstructive sleep apnea using a bio-radar contact-free system compared with an established HST device in older adults
Li, C. X., Zhang, Y. F., Zhu, Z., Lu, F. Y., Wang, Y., Zhang, L. Y., Li, N., Sun, X. W., & Li, Q. Y. (2023) · Sleep Health · doi:10.1016/j.sleh.2023.01.001 · Cited by 21
Endotyping, phenotyping and personalised therapy in obstructive sleep apnoea: are we there yet?
Turnbull, C. D., & Stradling, J. R. (2023) · Thorax · doi:10.1136/thorax-2023-220037 · Cited by 22
Can the ketogenic diet improve our dreams? Effect of very low-calorie ketogenic diet (VLCKD) on sleep quality
Barrea, L., Verde, L., Lorenzo, C. D., Savastano, S., Colao, A., & Muscogiuri, G. (2023) · Journal of Translational Medicine · doi:10.1186/s12967-023-04280-7 · Cited by 22
All Obstructive Sleep Apnea Events Are Not Created Equal: The Relationship Between Event-Related Hypoxemia and Physiologic Response
Hajipour, M., Allen, A. J. H., Beaudin, A. E., Raneri, J. K., Jen, R., Foster, G. E., Fogel, S. M., Kendzerska, T., Sériès, F., Skomro, R. P., et al. (2024) · Annals of the American Thoracic Society · doi:10.1513/annalsats.202309-777oc · Cited by 20
The association of weight loss from anti‐obesity medications or bariatric surgery and apnea‐hypopnea index in obstructive sleep apnea
Locke, B. W., Gómez-Lumbreras, A., Tan, C. J., Nonthasawadsri, T., Veettil, S. K., Patikorn, C., & Chaiyakunapruk, N. (2024) · Obesity Reviews · doi:10.1111/obr.13697 · Cited by 20
Effects of aerobic exercise and resistance training on obstructive sleep apnea: a systematic review and meta-analysis
Lin, C.-F. J., Ho, N., Hsu, W.-L., Lin, C.-H., Wang, Y., & Wang, Y. (2024) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.11310 · Cited by 22
Is REM sleep behavior disorder a friend or foe of obstructive sleep apnea? Clinical and etiological implications for neurodegeneration
Jung, Y. J., & Oh, E. (2021) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.9144 · Cited by 19
Symptomatic response to CPAP in obstructive sleep apnea versus COPD- obstructive sleep apnea overlap syndrome: Insights from a large national registry
Adler, D., Bailly, S., Soccal, P. M., Janssens, J.-P., Sapène, M., Grillet, Y., Stach, B., Tamisier, R., & Pépin, J. (2021) · PLoS ONE · doi:10.1371/journal.pone.0256230 · Cited by 19
BASH-GN: a new machine learning–derived questionnaire for screening obstructive sleep apnea
Huo, J., Quan, S. F., Roveda, J. M., & Li, A. (2022) · Sleep And Breathing · doi:10.1007/s11325-022-02629-8 · Cited by 19
“It is estimated that 25% of American adults are affected by OSA [2].”
Background
Combined noradrenergic plus antimuscarinic agents for obstructive sleep apnea - A systematic review and meta-analysis of randomized controlled trials
Zha, S., Yang, H., Fang, Y., Zhang, Q., & Hu, K. (2022) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2022.101649 · Cited by 19
Effectiveness of Tonsillectomy vs Modified Uvulopalatopharyngoplasty in Patients With Tonsillar Hypertrophy and Obstructive Sleep Apnea
Sundman, J., Nerfeldt, P., Fehrm, J., Bring, J., Browaldh, N., & Friberg, D. (2022) · JAMA Otolaryngology–Head & Neck Surgery · doi:10.1001/jamaoto.2022.3432 · Cited by 21
A Scientometric Review of Obstructive Sleep Apnea and Obesity
Neoh, M. J. Y., Carollo, A., Lim, M., Dimitriou, D., & Esposito, G. (2023) · Applied Sciences · doi:10.3390/app13020753 · Cited by 20
“This attention on tackling the embedded shortcomings of traditional instruments can be observed from how the cited references of this cluster examined diagnostic tools for OSA [63,228,229].”
Background
Implication of a novel measure of obstructive sleep apnea severity for cardiovascular morbidity
Cao, W., Luo, J., Huang, R., & Xiao, Y. (2023) · Sleep Medicine · doi:10.1016/j.sleep.2023.02.001 · Cited by 20
Influence of apnea vs hypopnea predominance in predicting mean therapeutic positive airway pressures among patients with obstructive sleep apnea
Yu, J. L., Liu, Y., Tangutur, A., Arnold, M., Seay, E. G., Schwartz, A. R., & Dedhia, R. C. (2021) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.9342 · Cited by 21
The Causal Relationships Between Sleep-related Phenotypes and Body Composition: A Mendelian Randomized Study
Chen, Y., Li, C., Cheng, S., Pan, C., Zhang, H., Zhang, J., Zhang, Z., Yao, Y., Cheng, B., Liu, L., et al. (2022) · The Journal of Clinical Endocrinology & Metabolism · doi:10.1210/clinem/dgac234 · Cited by 19
Intermittent hypoxia aggravates asthma inflammation via NLRP3/IL-1β-dependent pyroptosis mediated by HIF-1α signalling pathway
Zhou, L., Zhang, H., Liu, L., Zhang, F., Wang, L., Zheng, P., Mao, Z., Zhu, X., Zi, G., Chen, L., et al. (2025) · Chinese Medical Journal · doi:10.1097/cm9.0000000000003608 · Cited by 18
“[4] Research has suggested a close mutual relationship between these two diseases.”
High-Fat Diet-Induced Mitochondrial Dysfunction Promotes Genioglossus Injury – A Potential Mechanism for Obstructive Sleep Apnea with Obesity
Chen, Q., Han, X., Chen, M., Zhao, B., Sun, B., Sun, L., Zhang, W., Yu, L., & Liu, Y. (2021) · Nature and Science of Sleep · doi:10.2147/nss.s343721 · Cited by 19
“Obstructive sleep apnea (OSA) is one of the most common respiratory diseases and is characterized by intermittent and recurrent collapse of the upper airway during sleep, inducing hypoxia or apnea and causing a significant threat to the health and quality of life of the affected individuals.(6,7) Obesity is highly cor…”
Background
Obstructive Sleep Apnea is Associated with an Increased Prevalence of Polycythemia in Patients with Chronic Obstructive Pulmonary Disease
Zeng, Z., Song, Y., He, X., Yang, H., Yue, F., Xiong, M., & Hu, K. (2022) · International Journal of COPD · doi:10.2147/copd.s338824 · Cited by 18
“Obstructive sleep apnea (OSA) is characterized by recurrent episodes of partial or complete collapse of the upper airway during sleep, and it can lead to chronic intermittent hypoxia related to red blood cell (RBC) proliferation.(7,8) OSA severity is significantly associated with hemoglobin (Hb) and RBC counts,(7) and…”
Background
Clinical Predictors of Mixed Apneas in Patients with Obstructive Sleep Apnea (OSA)
Liu, P., Chen, Q., Yuan, F., Zhang, Q., Zhang, X., Xue, C., Wei, Y., Wang, Y., & Wang, H. (2022) · Nature and Science of Sleep · doi:10.2147/nss.s351946 · Cited by 18

Authors: Gottlieb, D. J., & Punjabi, N. M.
Affiliations: Brigham and Women's Hospital (US)
Johns Hopkins University (US)
ORCID: Gottlieb, Daniel J.
Punjabi, Naresh M.
Venue: JAMA
Publisher: American Medical Association (AMA)
Published: 2020-04-14
Volume: 323
Issue: 14
Pages: 1389
ISSN: 0002-9955 (ISSN-L)
0098-7484
DOI: 10.1001/jama.2020.3514
OpenAlex: W3015537361
Semantic Scholar: 0172e9c7f7ea58bd5623bd24ef5636cfe5f6c7df
Cited by: 1,482
References: 112
Citations by year: 2026: 266 · 2025: 330 · 2024: 287 · 2023: 230 · 2022: 225 · 2021: 109 · 2020: 32
FWCI: 19.00
Type: journal article
Language: en
Open access: closed
Locations: JAMA (publishedVersion)
PubMed (publishedVersion)
Funders: National Heart, Lung, and Blood Institute (R01HL146709, R01HL137234)
National Institute of Nursing Research (R01NR018335)
National Institute of Diabetes and Digestive and Kidney Diseases (U34DK120051)
Topics: Health Sciences › Medicine › Physiology (medical) › Obstructive Sleep Apnea Research
Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
Life Sciences › Neuroscience › Endocrine and Autonomic Systems › Neuroscience of respiration and sleep
Keywords: obstructive sleep apnea, sleep apnea diagnosis, home sleep apnea testing, positive airway pressure, oral appliances, hypoglossal nerve stimulation, weight loss, physical activity, obesity, daytime sleepiness, resistant hypertension, cardiovascular risk, cerebrovascular risk, pharyngeal surgery, pharmacotherapy
MeSH terms: Female, Humans, Male, Prognosis, Risk Factors, Weight Loss, Health Behavior, Exercise, Mandibular Advancement, Sleep Apnea, Obstructive, Continuous Positive Airway Pressure

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Diagnosis and Management of Obstructive Sleep Apnea: A Review

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