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
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Background
Ultrasound Shear Wave Elastography of the Tongue during Selective Hypoglossal Nerve Stimulation in Patients with Obstructive Sleep Apnea Syndrome
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“EEG, electrocardiography (ECG), EOG, and EMG signals emitted during sleep are also used for diagnosis (Gottlieb and Punjabi, 2020).”
Method
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MethodInfluential
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Background
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Background
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Background
Gut microbiota has important roles in the obstructive sleep apnea-induced inflammation and consequent neurocognitive impairment
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Background
Obstructive sleep apnea is a determinant of asthma control independent of smoking, reflux, and rhinitis
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“There is a wide range of treatment options for OSA, including surgical interventions, lifestyle modifications, drug control, continuous positive airway pressure (CPAP), oral appliances (OAs) and hypoglossal nerve stimulation (HGNS) [4].”
Background
Assessment of simulated snoring sounds with artificial intelligence for the diagnosis of obstructive sleep apnea
Fang, L., Cai, J., Huang, Z., Tuohuti, A., & Chen, X. (2024) · Sleep Medicine · doi:10.1016/j.sleep.2024.11.018 · Cited by 18
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Acetyl-CoA carboxylase activation disrupts iron homeostasis to drive ferroptosis
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“As already mentioned, IH, SF, enhanced sympathetic system activity, and disrupted homeostasis are associated with systemic low-grade inflammation (LGI) [61].”
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The effects of obstructive sleep apnea-hypopnea syndrome (OSAHS) on learn and memory function of 6–12 years old children
Li, H., Chen, L., Wu, X., Zhu, F., Bing, X., Shi, L., Li, X., Qi, W., Xia, M., Zhang, X., et al. (2022) · International Journal of Pediatric Otorhinolaryngology · doi:10.1016/j.ijporl.2022.111194 · Cited by 14
Independent Association Between Oxygen Desaturation Index and Cardiovascular Disease in Non-Sleepy Sleep-Disordered Breathing Subtype: A Chinese Community-Based Study
Wang, L., Ou, Q., Shan, G., Lao, M., Pei, G., Xu, Y., Jinhuan, H., Tan, J., Chen, W., & Lu, B. (2022) · Nature and Science of Sleep · doi:10.2147/nss.s370471 · Cited by 14
Lax eyelid condition (LEC) and floppy eyelid syndrome (FES) prevalence in obstructive sleep apnea syndrome (OSA) patients: a systematic review and meta-analysis
Aiello, F., Afflitto, G. G., Bonetti, M. A., Ceccarelli, F., Cesareo, M., & Nucci, C. (2022) · Graefe s Archive for Clinical and Experimental Ophthalmology · doi:10.1007/s00417-022-05890-5 · Cited by 14
Implications of sleep disorders for periodontitis
Chen, L., Wang, N., Jinmei, Z., & Yang, J. (2022) · Sleep And Breathing · doi:10.1007/s11325-022-02769-x · Cited by 14
A Review of Neurological Symptoms in Long COVID and Clinical Management
Navis, A. (2023) · Seminars in Neurology · doi:10.1055/s-0043-1767781 · Cited by 14
Oxygen resaturation rate is significantly associated with objectively assessed excessive daytime sleepiness in suspected obstructive sleep apnoea patients.
Howarth, T., Karhu, T., Kainulainen, S., Chen, X., Mahamid, A., Töyräs, J., & Leppänen, T. (2023) · Sleep Medicine · doi:10.1016/j.sleep.2023.04.027 · Cited by 10
TDP43/HDAC6/Prdx1 signaling pathway participated in the cognitive impairment of obstructive sleep apnea via regulating inflammation and oxidative stress
Ou, Y., Shen, C., Chen, Z., Liu, T., Peng, Y., Zong, D., & Ouyang, R. (2023) · International Immunopharmacology · doi:10.1016/j.intimp.2023.111350 · Cited by 14
Detection and severity assessment of obstructive sleep apnea according to deep learning of single‐lead electrocardiogram signals
Zhang, Y., Shi, Y., Su, Y., Cao, Z., Li, C., Xie, Y., Niu, X., Yuan, Y., Ma, L., Zhu, S., et al. (2024) · Journal of Sleep Research · doi:10.1111/jsr.14285 · Cited by 16
Chronic obstructive pulmonary disease and obstructive sleep apnea overlap: who to treat and how?
Sunwoo, B. Y., Raphelson, J. R., & Malhotra, A. (2024) · Expert Review of Respiratory Medicine · doi:10.1080/17476348.2024.2384036 · Cited by 15
International expert consensus statement: surgical failure in obstructive sleep apnea
Iannella, G., Pace, A., Magliulo, G., Vicini, C., Lugo, R., Vanderveken, O. M., de Vries, N., Pang, K. P., Thuler, E. R., Jacobowitz, O., et al. (2024) · Sleep And Breathing · doi:10.1007/s11325-024-03162-6 · Cited by 14
Dentoskeletal changes of long‐term oral appliance treatment in patients with obstructive sleep apnea: A systematic review and meta‐analysis
Chen, Y., Alhozgi, A., & Almeida, F. R. (2024) · Journal of Prosthodontics · doi:10.1111/jopr.13946 · Cited by 15
Impact of Obstructive Sleep Apnea and Continuous Positive Airway Pressure Treatment on Dry Eye Disease: A Systematic Review and Meta-Analysis
Lin, C., Su, Y.-C., Liu, J.-D., Su, H.-C., Chiang, T., Chiu, L., Lin, H., Chang, C., & Lin, P. (2024) · Nature and Science of Sleep · doi:10.2147/nss.s495883 · Cited by 15
Development and validation of a nomogram for predicting the risk of obstructive sleep apnea in patients with type 2 diabetes
Shi, H., Xiang, S., Huang, X., Wang, L., Hua, F., & Jiang, X. (2020) · Annals of Translational Medicine · doi:10.21037/atm-20-6890 · Cited by 15
“While in the United States, hypoglossal nerve stimulation is an effective treatment for some patients with a body mass index (BMI) less than 32 kg/m(2) (9).”
Background
Lumbar spine abnormalities in patients with obstructive sleep apnoea
Tárnoki, Á. D., Tárnoki, D. L., Oláh, C., Szily, M., Kovacs, D. T., Dienes, A., Piroska, M., Forgó, B., Pinheiro, M. B., Ferreira, P. H., et al. (2021) · Scientific Reports · doi:10.1038/s41598-021-95667-3 · Cited by 14
“Chronic intermittent hypoxia in OSA leads to oxidative stress and in ammation [8], both of which are associated with disc degeneration [23].”
BackgroundInfluential
Functional Connectivity Changes in the Insular Subregions of Patients with Obstructive Sleep Apnea after 6 Months of Continuous Positive Airway Pressure Treatment
Long, T., Li, H., Shu, Y., Li, K., Xie, W., Zeng, Y., Huang, L., Zeng, L., Liu, X., & Peng, D. (2023) · Neural Plasticity · doi:10.1155/2023/5598047 · Cited by 13
“Obstructive sleep apnea (OSA) is characterized by recurrent episodes of partial or complete collapse of the upper airway during sleep, resulting in hypoventilation or apnea [1].”
Background
Diabetes, Polycystic Ovarian Syndrome, Obstructive Sleep Apnea, and Obesity: A Systematic Review and Important Emerging Themes.
Bambhroliya, Z., Sandrugu, J., Lowe, M., Okunlola, O. I., Raza, S., Osasan, S. A., Sethia, S., Batool, T., & Hamid, P. (2022) · PubMed Central · doi:10.7759/cureus.26325 · Cited by 17
“Is obesity a cause or effect of PCOS and OSA? We assess current evidence from review articles, identify established cause-and-effect relationships, and summarize findings of interest to endocrinologists, OBGYNs, any healthcare provider concerned with BMI management, and even dentists, who play an increasing role in th…”
Background
Efficacy comparison of aerobic exercise, combined exercise, oropharyngeal exercise and respiratory muscle training for obstructive sleep apnea: A systematic review and network meta-analysis
Tang, R., Pan, J., Huang, Y., & Ren, X. (2024) · Sleep Medicine · doi:10.1016/j.sleep.2024.10.026 · Cited by 13
Machine Listening for OSA Diagnosis
Tan, B. K. J., Gao, E. Y., Tan, N. K. W., Yeo, B. S. Y., Tan, C. J., Ng, A. C. W., Leong, Z. H., Phua, C. Q., Uataya, M., Goh, L. C., et al. (2025) · CHEST Journal · doi:10.1016/j.chest.2025.04.006 · Cited by 17
“14 Although STOP-Bang is > 90% sensitive, it is only 30% speci ﬁ c, which results in numerous false-positive ﬁ ndings.”
Management of Obstructive Sleep Apnea in Patients With Heart Failure
Wang, Y., Schöbel, C., & Penzel, T. (2022) · Frontiers in Medicine · doi:10.3389/fmed.2022.803388 · Cited by 13
Effect of obstructive sleep apnoea on coronary collateral vessel development in patients with ST ‐segment elevation myocardial infarction
Liu, T., Wang, X., Fan, J., Guo, R., Hao, W., Gong, W., Fan, Z., & Nie, S. (2022) · Respirology · doi:10.1111/resp.14277 · Cited by 13
Effect of Sleep Surgery on Inflammatory Cytokines in Adult Obstructive Sleep Apnea: A Systematic Review and Meta‐Analysis
Lee, C., Hsu, W., Yeh, T., Ko, J., Lin, M., & Kang, K. (2022) · The Laryngoscope · doi:10.1002/lary.30176 · Cited by 13
“This meta-analysis is the first to estimate the effect size (i.e., MD and SMD change) of sleep surgery on TNF-α and IL-6 concentrations in adults with OSA.”
BackgroundInfluential
Design and rationale for the treating Obstructive Sleep Apnea using Targeted Hypoglossal Nerve Stimulation (OSPREY) trial
Jacobowitz, O., Schwartz, A. R., Lovett, E. G., Ranuzzi, G., & Malhotra, A. (2022) · Contemporary Clinical Trials · doi:10.1016/j.cct.2022.106804 · Cited by 17
Diagnostic accuracy of home sleep apnea testing using peripheral arterial tonometry for sleep apnea: A systematic review and meta‐analysis
Ichikawa, M., Akiyama, T., Tsujimoto, Y., Anan, K., Yamakawa, T., & Terauchi, Y. (2022) · Journal of Sleep Research · doi:10.1111/jsr.13682 · Cited by 18
Impact of Unintentional Air Leaks on Automatic Positive Airway Pressure Device Performance in Simulated Sleep Apnea Events
Fasquel, L., Yazdani, P., Zaugg, C., Barras, A., Michotte, J.-B., Correvon, N., & Contal, O. (2022) · Respiratory Care · doi:10.4187/respcare.10065 · Cited by 13
Risk Factors of Nonalcoholic Fatty Liver Disease and Liver Fibrosis in Non-Obese Patients with Obstructive Sleep Apnea
Lian, N., Wu, J., Wang, B., Lin, S., Huang, J., Chen, J., & Lin, Q. (2022) · Nature and Science of Sleep · doi:10.2147/nss.s388203 · Cited by 13
Effects of the combination of novel eye mask sleep position therapy device and oral appliance on positional OSA: A multi-arm, parallel-group randomized controlled trial
Huang, W., Li, C., Zou, J., Wang, X., Zhang, J., Guan, J., Yi, H., & Yin, S. (2022) · Sleep Medicine · doi:10.1016/j.sleep.2022.12.017 · Cited by 14
Autoantibodies of inflammatory cytokines as serum biomarkers in OSA patients
Fang, Y., Su, J., Zhang, B., Zhao, C., Ji, L., Liang, F., Wang, Z., Hao, J., Meng, Y., Wei, B., et al. (2023) · Clinica Chimica Acta · doi:10.1016/j.cca.2023.117399 · Cited by 13
Differences in the effects of orthodontic treatment on airway-craniocervical functional environment in adult and adolescent patients with skeletal class II high-angle: a retrospective pilot study
Shen, Y., Li, X., Feng, X., Yu, L., Weng, L., Zhang, C., Shang, Y., & Lin, J. (2023) · BMC Oral Health · doi:10.1186/s12903-023-03328-w · Cited by 13
Obstructive sleep apnea heterogeneity and autonomic function: a role for heart rate variability in therapy selection and efficacy monitoring
Qin, H., Fietze, I., Mazzotti, D. R., Steenbergen, N., Kraemer, J. F., Glos, M., Wessel, N., Song, L.-J., Penzel, T., & Zhang, X. (2023) · Journal of Sleep Research · doi:10.1111/jsr.14020 · Cited by 15
“Currently, proposed criteria for the diagnosis of OSA that requires treatment are an AHI of ≥ 5 events/h with symptoms or an AHI of ≥ 15 events/h (Gottlieb & Punjabi, 2020).”
BackgroundInfluential
Association of sleep quality and mitochondrial DNA copy number in healthy middle-aged adults
Han, S., Kim, D.-K., Jun, S., & Kim, N. (2023) · Sleep Medicine · doi:10.1016/j.sleep.2023.11.011 · Cited by 15
Association of residential greenness with obstructive sleep apnea among Chinese old adults and the mediation role of PM2.5 and leisure-time physical activity
Duan, X., Zhao, W., Yang, B., Lao, L., Mei, Y., Wu, C., Liao, Y., Wang, Y., Feng, Z., Chen, W., et al. (2024) · The Science of The Total Environment · doi:10.1016/j.scitotenv.2024.170120 · Cited by 12
The Integration of Sleep Research Into Eating Disorders Research: Recommendations and Best Practices
Irish, L. A., Bottera, A. R., Manasse, S. M., Christensen, K. A., & Schaefer, L. M. (2024) · International Journal of Eating Disorders · doi:10.1002/eat.24241 · Cited by 14
Identifying and validating immunological biomarkers in obstructive sleep apnea through bioinformatics analysis
Zhou, E., Zhou, T., Wang, X., Zhang, J., Guan, J., Yin, S., Huang, W., Yi, H., & Zou, J. (2025) · Scientific Reports · doi:10.1038/s41598-025-93915-4 · Cited by 13
Obstructive Sleep Apnea Is Associated With Low Testosterone Levels in Severely Obese Men
Tančić‐Gajić, M., Vukčević, M., Ivović, M., Marina, L., Arizanović, Z., Soldatović, I., Stojanovic, M. M., Đogo, A., Kendereški, A., & Vujović, S. (2021) · Frontiers in Endocrinology · doi:10.3389/fendo.2021.622496 · Cited by 13
A new design of mandibular advancement device (IMYS) in the treatment of obstructive sleep apnea
Ciavarella, D., Campobasso, A., Suriano, C., Muzio, E. L., Guida, L., Salcuni, F., Laurenziello, M., Illuzzi, G., & Tepedino, M. (2022) · CRANIO® · doi:10.1080/08869634.2022.2041271 · Cited by 13
Clinical Characteristics of Rapid Eye Movement-Related Obstructive Sleep Apnea: An Experience in a Tertiary Medical Center of Taiwan
Chiu, H., Liu, Y.-Y., Shiao, T., Su, K., Chou, K., & Chen, Y. (2022) · Nature and Science of Sleep · doi:10.2147/nss.s368659 · Cited by 13
“OSA is common and occurs in approximately 25% of adults in the US, affecting 34% of men and 17% of women.(1) In Taiwan, the prevalence of snoring is 51.”
Background
30-Day Postoperative Outcomes in Adults with Obstructive Sleep Apnea Undergoing Upper Airway Surgery
Knoedler, S. A., Knoedler, L., Baecher, H., Kauke‐Navarro, M., Obed, D., Hoch, C. C., Diehm, Y. F., Vosler, P. S., Harréus, U., Kneser, U., et al. (2022) · Journal of Clinical Medicine · doi:10.3390/jcm11247371 · Cited by 13
“A wide array of surgical treatment options exist, including (i) uvulopalatopharyngoplasty (UPPP); (ii) other soft tissue reduction procedures, such as tonsillectomy, glossectomy, and epiglottidectomy; (iii) skeletal surgeries, such as maxillomandibular advancement (MMA), genioglossus advancement (GA), and hyoid myotom…”
Continuous Positive Airway Pressure Reduces Plasma Neurochemical Levels in Patients with OSA: A Pilot Study
Liu, W., Huang, H.-T., Hung, H.-Y., Lin, S., Hsu, W.-H., Lee, F.-Y., Kuan, Y., Lin, Y.-T., Hsu, C.-R., Stettler, M. E. J., et al. (2023) · Life · doi:10.3390/life13030613 · Cited by 13
“Although most patients with OSA experience mild symptoms, OSA is a risk factor for various comorbidities, such as cardiovascular disease, metabolic disorder, and neurocognitive impairment [2,3].”
Airline Point-of-Care System on Seat Belt for Hybrid Physiological Signal Monitoring
Ji, X., Rao, Z., Zhang, W., Liu, C., Wang, Z., Zhang, S., Zhang, B., Hu, M.-L. M., Servati, P., & Xiao, X. (2022) · Micromachines · doi:10.3390/mi13111880 · Cited by 13
“In addition, the standard diagnostic test of SAHS is done by polysomnography (PSG) [33].”
Method
CAISR: achieving human-level performance in automated sleep analysis across all clinical sleep metrics
Nasiri, S., Ganglberger, W., Nassi, T. E., Meulenbrugge, E., Junior, V. F. M., Ghanta, M., Gupta, A., Stone, K. L., Kjær, M. R., Sum‐Ping, O., et al. (2025) · SLEEP · doi:10.1093/sleep/zsaf134 · 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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