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Treatment of Adult Obstructive Sleep Apnea with Positive Airway Pressure: An American Academy of Sleep Medicine Clinical Practice Guideline
Open accessAbstract
Introduction This guideline establishes clinical practice recommendations for positive airway pressure (PAP) treatment of obstructive sleep apnea (OSA) in adults and is intended for use in conjunction with other American Academy of Sleep Medicine (AASM) guidelines in the evaluation and treatment of sleep-disordered breathing in adults.Methods The AASM commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process was used to assess the evidence. The task force developed recommendations and assigned strengths based on the quality of evidence, the balance of clinically significant benefits and harms, patient values and preferences, and resource use. In addition, the task force adopted recommendations from prior guidelines as "good practice statements" that establish the basis for appropriate and effective treatment of OSA. The AASM Board of Directors approved the final recommendations.Good practice statements The following good practice statements are based on expert consensus, and their implementation is necessary for appropriate and effective management of patients with OSA treated with positive airway pressure: (1) Treatment of OSA with PAP therapy should be based on a diagnosis of OSA established using objective sleep apnea testing. (2) Adequate follow-up, including troubleshooting and monitoring of objective efficacy and usage data to ensure adequate treatment and adherence, should occur following PAP therapy initiation and during treatment of OSA.Recommendations The following recommendations are intended as a guide for clinicians using PAP to treat OSA in adults. A STRONG (ie, "We recommend…") recommendation is one that clinicians should follow under most circumstances. A CONDITIONAL recommendation (ie, "We suggest…") reflects a lower degree of certainty regarding the outcome and appropriateness of the patient-care strategy for all patients. The ultimate judgment regarding any specific care must be made by the treating clinician and the patient, taking into consideration the individual circumstances of the patient, available treatment options, and resources. (1) We recommend that clinicians use PAP, compared to no therapy, to treat OSA in adults with excessive sleepiness. (STRONG) (2) We suggest that clinicians use PAP, compared to no therapy, to treat OSA in adults with impaired sleep-related quality of life. (CONDITIONAL) (3) We suggest that clinicians use PAP, compared to no therapy, to treat OSA in adults with comorbid hypertension. (CONDITIONAL) (4) We recommend that PAP therapy be initiated using either APAP at home or in-laboratory PAP titration in adults with OSA and no significant comorbidities. (STRONG) (5) We recommend that clinicians use either CPAP or APAP for ongoing treatment of OSA in adults. (STRONG) (6) We suggest that clinicians use CPAP or APAP over BPAP in the routine treatment of OSA in adults. (CONDITIONAL) (7) We recommend that educational interventions be given with initiation of PAP therapy in adults with OSA. (STRONG) (8) We suggest that behavioral and/or troubleshooting interventions be given during the initial period of PAP therapy in adults with OSA. (CONDITIONAL) (9) We suggest that clinicians use telemonitoring-guided interventions during the initial period of PAP therapy in adults with OSA. (CONDITIONAL).
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“Data were insufficient to perform analyses examining differences in QOL or interface-associated side effects.”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
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Experimental — accuracy not yet measuredThe cited source doesn’t support the claim as written.
In the citing paper
“The effect on BP appears to be sustained over time with continued use of CPAP and some evidence suggests that fixed CPAP devices may be better at decreasing BP than auto-titrating devices (APAP), although better tolerated APAP may be used for longer durations.39”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Current guidelines for the treatment of OSA typically take into account several factors including the AHI, presence or absence of symptoms, and associated comorbidities.39”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“An SR by Patil et al.39 demonstrated a clinically significant reduction in disease severity as evidenced by complete resolution or near resolution of the AHI”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“improvement in subjective sleepiness (reduction in ESS score of 2.4 points based on metanalysis of 38 RCTs, and ability to maintain wakefulness based on the Maintenance of Wakefulness Test [MWT])”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
Experimental — accuracy not yet measured
The source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“BPAP also confers no significant advantage over CPAP or APAP in improved adherence, except as a potential therapy option for patients nonadherent to CPAP.39”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Two SRs39,1035 evaluated the differences between APAP and CPAP devices. Both modalities resulted in a clinically significant reduction of the AHI, sleepiness as measured by the ESS, and QOL. There was no significant difference between the two treatment modalities.”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Residual AHI was higher using oronasal masks compared to nasal interfaces, though the difference was not clinically significant.”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“The SR by Patil et al.39 did not demonstrate any difference in PAP adherence as measured by hours used, nights used, or nights used with greater than 4 h of usage per night.”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Patil et al.39 examined the comparison between in-lab titration of CPAP and home APAP (without lab titration) for initiation of PAP therapy. Analysis showed similar effects on OSA severity, sleepiness, and adherence with APAP initiated at home.”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Review of studies showed no significant difference between BPAP, CPAP, and APAP for the improvement in OSA severity, sleepiness, and QOL.”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“An SR and MA of 10 RCTs comparing APAP at-home and in-lab PAP titration for initiation of PAP demonstrates high grade evidence that both approaches are effective in reducing OSA severity (AHI), daytime sleepiness, and for PAP adherence and QOL measures.39”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Additionally, the SR by Patil et al. showed moderate quality evidence that PAP adherence increased by 0.6 h/night with an educational intervention and is the basis for the AASM guidelines that strongly recommends the use of education with PAP therapy.39”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“However, it did show a significant reduction in incidence of side effects based on three RCTs, two of which were included in the 2018 review.39”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“An MA of seven RCTs showed a reduction in MWT or Oxford Sleep Resistance Test (OSLER) sleep latency by 0.5 min in subjects treated with PAP (95% CI: 0.2, 0.8) compared to control subjects.”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“The MA of four RCTs demonstrated that CPAP therapy did not reduce all-cause mortality; however, there was variability in CPAP adherence among the four trials. An MA of nine non-RCTs did demonstrate a clinically significant reduction in all-cause mortality with CPAP with a risk ratio of 0.4 (95% CI 0.24–0.69).”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Multiple SRs have consistently demonstrated that CPAP is effective at reducing the AHI.39,1201,1202”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“The MA of 38 RCTs demonstrated a clinically significant decrease in ESS score by 2.4 points in subjects using PAP compared with controls (95% CI: −2.8, −1.9).”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Despite the importance of long-term PAP therapy for chronic OSA, the current emphasis is on the initial 3 months of PAP,39 and there are limited data on long-term PAP after 3 months; therefore, long-term guidelines are based on expert opinion.”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Although several SRs and meta-analyses have noted reductions in BP with CPAP treatment of OSA, particularly moderate to severe OSA, caution is warranted because of heterogeneity in the pooled studies.39,654,1207–1211”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“The magnitude of reduction of 24-h mean BP with CPAP treatment of OSA is modest, in the range of 2–4 mmHg, may be related to the severity of OSA1213 and to the number of hours of nightly usage of the device.39,1207–1209”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“These meta-analyses have shown a significant decrease in nighttime BP as well as a long-term (12 weeks) reduction in mean and diastolic BP with CPAP device usage of 4 or more hours a night.39,1210,1211”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Individuals with OSA who report daytime sleepiness appear to demonstrate greater decline in BP compared to those who are not sleepy.39,1211”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
Experimental — accuracy not yet measuredThe cited source says what the claim attributes to it.
In the citing paper
“PAP therapy is considered first-line for the hypersomnic OSA patient [55].”
From Overview of sleep management during COVID-19. (2022) · cites this paper as [55]
The cited source says what the claim attributes to it.
In the citing paper
“sleep related QOL; and BP.”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
The cited source says what the claim attributes to it.
In the citing paper
“An SR of PAP treatments for OSA found no benefit for BPAP over CPAP.39”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
The cited source says what the claim attributes to it.
In the citing paper
“there is “insufficient and inconclusive evidence to either recommend or withhold PAP to treat non-sleepy adults with OSA as a means to reduce CV events or mortality.””
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
The cited source says what the claim attributes to it.
In the citing paper
“No significant differences in sleepiness were observed in comparisons of oronasal and nasal masks, nor in comparisons between nasal pillows and nasal masks.”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
The cited source says what the claim attributes to it.
In the citing paper
“however, adherence was significantly higher with nasal interfaces compared to oronasal interfaces.”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
The cited source says what the claim attributes to it.
In the citing paper
“Adherence to CPAP was similar when intranasal (nasal pillows) and nasal interfaces were compared”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
The cited source says what the claim attributes to it.
In the citing paper
“Another SR by Patil et al. in 2019 reviewed nine RCTs, also showed no clinically significant difference in adherence with or without humidification.”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
The check wasn’t confident either way, so it gives no verdict — never disputed.
In the citing paper
“Patil et al. performed an MA of five RCTs measuring LVEF by echocardiography or radionuclide ventriculography to compare the efficacy of CPAP against control conditions in patients with hFrEF. While some studies showed modest improvements in the absolute value of LVEF associated with CPAP, most reported changes (typically less than 5%) that would not be considered clinically significant.39”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
Experimental — accuracy not yet measuredThe check wasn’t confident either way, so it gives no verdict — never disputed.
In the citing paper
“Nevertheless, there is no evidence that treatment-emergence central sleep apnea poses any harm to the patient.39”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
Experimental — accuracy not yet measuredThe check wasn’t confident either way, so it gives no verdict — never disputed.
In the citing paper
“An MA of seven RCTs found no significant difference in mean sleep latency in subjects treated with PAP compared to controls (mean difference 0.25 min, 95% CI: −0.89, 1.38).”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
Experimental — accuracy not yet measuredThe check wasn’t confident either way, so it gives no verdict — never disputed.
In the citing paper
“One MA demonstrated a mean decrease in AHI of 23 events/h with CPAP therapy compared to control interventions. The other MA showed a mean decrease in AHI of 29 events/h comparing subjects pre- and post-treatment. The mean difference in AHI was most pronounced in study groups where the mean pre-treatment AHI was greater than 30 events/h.”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [39]
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Metadata
- Authors
- Patil, S. P., Ayappa, I. A., Caples, S. M., Kimoff, R. J., Patel, S. R., & Harrod, C. G.
- Affiliations
- Johns Hopkins University (US)
- Icahn School of Medicine at Mount Sinai (US)
- Mayo Clinic (US)
- McGill University Health Centre (CA)
- University of Pittsburgh (US)
- American Academy of Sleep Medicine (US)
- Corresponding author
- Patil, Susheel P.
- Venue
- Journal of Clinical Sleep Medicine
- Published
- 2019-02-15
- Volume
- 15
- Issue
- 2
- Pages
- 335-343
- ISSN
- 1550-9389 (ISSN-L)
- 1550-9397
- PMC
- PMC6374094
- OpenAlex
- W2912654414
- Cited by
- 881
- References
- 18
- Citations by year
- 2026: 142 · 2025: 153 · 2024: 146 · 2023: 122 · 2022: 112 · 2021: 113 · 2020: 69 · 2019: 23
- FWCI
- 54.33
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of Clinical Sleep Medicine (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Physiology (medical) › Obstructive Sleep Apnea Research
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Respiratory Support and Mechanisms
- Keywords
- obstructive sleep apnea, positive airway pressure, continuous positive airway pressure, paracetamol, medication adherence, excessive daytime sleepiness, sleep-related quality of life, hypertension, treatment follow-up, sleep apnea diagnosis, adults, clinical guidelines, sleep-disordered breathing, treatment response monitoring, patient values and preferences, resource utilization (health care), cost-effectiveness
- MeSH terms
- GRADE Approach, Adult, Humans, Positive-Pressure Respiration, United States, Treatment Outcome, Sleep Apnea, Obstructive
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