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Vol. 58. Issue 1.
Pages T52-T68 (January 2022)
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Vol. 58. Issue 1.
Pages T52-T68 (January 2022)
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[Translated article] International consensus document on obstructive sleep apnea
Documento internacional de consenso sobre apnea obstructiva del sueño
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Olga Medianoa,b,c,
Corresponding author
olgamediano@hotmail.com

Corresponding author.
, Nicolás González Mangadoc,d, Josep M. Montserratc,e, M. Luz Alonso-Álvarezc,f, Isaac Almendrosc,g, Alberto Alonso-Fernándezc,h, Ferran Barbéc,i, Eduardo Borsinic,j, Candelaria Caballero-Erasoc,k, Irene Cano-Pumaregac,l, Felix de Carlos Villafrancam, Carmen Carmona-Bernaln, Jose Luis Carrillo Alduendao, Eusebi Chinerp, José Aurelio Cordero Guevaraq, Luis de Manuelr, Joaquín Durán-Cantollas, Ramón Farréc,g, Carlos Franceschinit, Carles Gaigu, Pedro Garcia Ramosv, Francisco García-Ríoc,w, Onintza Garmendiax, Teresa Gómez Garcíac,y, Silvia González Pondalc,y, M. Blanca Hoyo Rodrigoz, Albert Lecubeaa,ab, Juan Antonio Madridac,ad, Lourdes Maniegas Lozanoae,d, José Luis Martínez Carrascoaf, Juan Fernando Masaag,c, María José Masdeu Margalefc,ah, Mercè Mayos Pérezc,ai, Enrique Mirabet Lisaj, Carmen Monasterioc,ak, Nieves Navarro Sorianoal, Erika Olea de la Fuenteam, Guillermo Plazaan,ao, Francisco Javier Puertas Cuestaap, Claudio Rabecaq, Pilar Resanoa, David Rigauar, Alejandra Ronceroas, Concepción Ruizu, Neus Salordak, Adriana Saltijeralat, Gabriel Sampol Rubioc,au, M. Ángeles Sánchez Quirogaav,c, Óscar Sans Capdevilaaw, Carlos Teixeiraax, Francisco Tinahones Madueñoay,bf, Sônia Maria Togeiroaz, María Fernanda Troncoso Acevedoba, Leslie Katherine Vargas Ramírezbb, Joao Winckbc, Nerea Zabala Urionaguenabd, Carlos Egeac,be, el Spanish Sleep Network
a Unidad de Sueño, Departamento de Neumología, Hospital Universitario de Guadalajara, Guadalajara, Spain
b Departamento de Medicina, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
c Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
d Neumología, Unidad Multidisciplinar de Sueño (UMS), Instituto de Investigación Sanitaria de la Fundación Jiménez Díaz, Madrid, Spain
e Unidad Multidisciplinar de Patología del Sueño y VNID, Servei de Pneumologia, Institut Clínic Respiratori, Hospital Clínic, Universidad de Barcelona, Barcelona, Spain
f Unidad de Sueño, Dr. J. Terán Santos, Departamento de Neumología, Hospital Universitario de Burgos, Burgos, Spain
g Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Institut d'Investigacions Biomediques August Pi Sunyer, Barcelona, Spain
h Servicio de Neumología, Hospital Universitario Son Espases, Instituto de Investigación Sanitaria de las Islas Baleares (IdISBa), Palma, Baleares, Spain
i Group of Translational Research in Respiratory Medicine, IRBLleida, Hospital Universitari Arnau de Vilanova y Santa Maria, Lleida, Spain
j Unidad de Sueño y Ventilación, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
k Unidad de Trastornos Respiratorios del Sueño, Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío, Sevilla, Spain
l Unidad de Sueño, Departamento de Neumología, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
m Servicio de Estomatología, Facultad de Medicina y Ciencias de la Salud, Universidad de Oviedo, Oviedo, Asturias, Spain
n Unidad de Trastornos Respiratorios del Sueño, Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío, Sevilla, Spain
o Unidad de Medicina del Sueño, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Ciudad de México, Mexico
p Unidad Multidisciplinar del Sueño, Servicio de Neumología, Hospital Universitario San Juan de Alicante, San Juan de Alicante, Alicante, Spain
q Grupo de Investigación en Epidemiología y Salud Pública, Unidad de Metodología y Estadística, Instituto de Investigación Sanitaria Bioaraba, Vitoria-Gasteiz, Álava, Spain
r Corte del Ilustre Colegio de Abogados de Madrid, Madrid, Spain
s Servicio de Investigación, Instituto de Investigación, OSI Araba, Hospital Universitario de Araba, Vitoria-Gasteiz, Álava, Spain
t Unidad de Sueño y Ventilación Mecánica, Hospital Cosme Argerich, Buenos Aires, Argentina
u Servicio de Neurología, Unidad Multidisciplinar de Sueño, Hospital Clínic de Barcelona, Barcelona, Spain
v Centro de Salud Don Benito Oeste, Servicio Extremeño de Salud, Don Benito, Badajoz, Spain
w Unidad de Sueño, Servicio de Neumología, Hospital Universitario La Paz, IdiPAZ, Departamento de Medicina, Universidad Autónoma de Madrid, Madrid, Spain
x Unidad del Sueño, Servicio de Neumología, Hospital Clínic, Barcelona, Spain
y Servicio de Odontología y Unidad Multidisciplinar del Sueño del Hospital Universitario Fundación Jiménez Díaz, Sociedad Española de Medicina Dental del Sueño (SEMDeS), Madrid, Spain
z Sociedad Española de Neurofisiología Clínica (SENFC), Oviedo, Asturias, Spain
aa Grupo de investigación en Obesidad, Diabetes y Metabolismo (ODIM), Servicio de Endocrinología y Nutrición, Hospital Universitari Arnau de Vilanova, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
ab Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
ac Laboratorio de Cronobiología, Universidad de Murcia, IMIB-Arrixaca, Murcia, Spain
ad Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
ae Fundación Jiménez Díaz, Madrid, Spain
af Centro de Salud Fuencarral, Universidad Autónoma de Madrid, Madrid, Spain
ag Hospital San Pedro de Alcántara, Instituto Universitario de Investigación Biosanitaria en Extremadura (INUBE), San Pedro de Alcántara, Cáceres, Spain
ah Unidad Multidisciplinar del Sueño, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain
ai Unidad de Sueño, Servicio de Neumología, Hospital de la Santa Creu i Sant Pau, Departamento de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
aj Sociedad Española de Medicina del Tráfico (SEMT), Madrid, Spain
ak Unidad Multidisciplinar del Sueño, Hospital Universitario de Bellvitge, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Barcelona, Spain
al Unidad de Sueño, Servicio de Neumología, Hospital Clínico Universitario, Valencia, Spain
am Servicio de Anestesiología y Reanimación, Hospital Universitario Araba, Vitoria-Gasteiz, Álava, Spain
an Servicio de Otorrinolaringología, Hospital Universitario de Fuenlabrada, Universidad Rey Juan Carlos, Fuenlabrada, Madrid, Spain
ao Hospital Universitario La Zarzuela, Madrid, Spain
ap Unidad de Sueño, Servicio de Neurofisiología, Hospital Universitario de La Ribera, Facultad de Medicina y Ciencias de la Salud, Universidad Católica de Valencia, Alzira, Valencia, Spain
aq Service de Pneumologie et Réanimation Respiratoire, Centre Hospitalier et Universitaire de Dijon, Dijon, France
ar Centro Cochrane Iberoamericano, Barcelona, Spain
as Unidad Multidisciplinar del Sueño, Servicio de Neumología, Hospital San Pedro, Logroño, La Rioja, Spain
at Servicio de Cardiología, Hospital Universitario del Tajo, Universidad Alfonso X El Sabio, Aranjuez, Madrid, Spain
au Unidad Multidisciplinar del Sueño, Servicio de Neumología, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
av Hospital Virgen del Puerto, Instituto Universitario de Investigación Biosanitaria en Extremadura (INUBE), Plasencia, Cáceres, Spain
aw Unidad del Sueño, Servicio de Neurología Pediátrica, Hospital Sant Joan de Déu, Barcelona, Spain
ax European Society of Sleep Technologists (EEST), Porto, Portugal
ay Sociedad Española para el Estudio de la Obesidad (SEEDO), Madrid, Spain
az Disciplina de Pneumologia, Departamento de Medicina, Disciplina de Medicina y Biologia del Sueño - Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, Brazil
ba Servicio de Neumología, Unidad Multidisciplinar del Sueño, Fundación Jiménez Díaz, Madrid, Spain
bb Instituto Neumológico del Oriente, Bucaramanga, Santander, Colombia
bc Faculdade de Medicina, Universidade do Porto, Porto, Portugal
bd Unidad del Sueño, Hospital Universitario Cruces, Barakaldo, Bizkaia, Spain
be Unidad Funcional de Sueño, Hospital Universitario Araba, OSI Araba, Vitoria-Gasteiz, Álava, Spain
bf Servicio de Endocrinología, Hospital Virgen de la Victoria, (IBIMA), Centro de Investigación Biomédica en Red de Fisiopatología Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), 28029, Madrid, Spain
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Tables (5)
Table 1. Classification of the degree of consensus on topics included.
Table 2. Studies reporting country-specific OSA prevalence data.
Table 3. Consequences of obstructive sleep apnea: prevalence, incidence, consequences and effect of treatment.
Table 4. Summary of existing scientific evidence on the efficacy of mandibular advancement device in patients with obstructive sleep apnea.
Table 5. Summary of current evidence and indications for alternative therapies in the management of OSA.
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Abstract

The main aim of this international consensus document on obstructive sleep apnea is to provide guidelines based on a critical analysis of the latest literature to help health professionals make the best decisions in the care of adult patients with this disease. The expert working group was formed primarily of 17 scientific societies and 56 specialists from a wide geographical area (including the participation of 4 international societies), an expert in methodology, and a documentalist from the Iberoamerican Cochrane Center. The document consists of a main section containing the most significant innovations from the ICD and a series of online manuscripts that report the systematic literature searches performed for each section of the ICD. This document does not discuss pediatric patients or the management of patients receiving chronic non-invasive mechanical ventilation (these topics will be addressed in separate consensus documents).

Keywords:
Obstructive sleep apnea
Diagnosis
Treatment
Resumen

El objetivo principal de este documento internacional de consenso sobre apnea obstructiva del sueño es proporcionar unas directrices que permitan a los profesionales sanitarios tomar las mejores decisiones en la asistencia de los pacientes adultos con esta enfermedad según un resumen crítico de la literatura más actualizada. El grupo de trabajo de expertos se ha constituido principalmente por 17 sociedades científicas y 56 especialistas con amplia representación geográfica (con la participación de 4 sociedades internacionales), además de un metodólogo experto y un documentalista del Centro Cochrane Iberoamericano. El documento consta de un manuscrito principal, con las novedades más relevantes del DIC, y una serie de manuscritos online que recogen las búsquedas bibliográficas sistemáticas de cada uno de los apartados del DIC. Este documento no cubre la edad pediátrica ni el manejo del paciente en ventilación mecánica crónica no invasiva (que se publicarán en sendos documentos de consenso aparte).

Palabras clave:
Apnea obstructiva del sueño
Diagnóstico
Tratamiento
Full Text
Introduction and literature search

The main objective of this international consensus document (ICD) on obstructive sleep apnea (OSA) is to provide guidelines based on a critical analysis of the latest literature to help healthcare professionals make the best decisions in the care of adult patients with this disease. This document does not discuss pediatric patients or the management of patients receiving chronic non-invasive mechanical ventilation (these topics will be addressed in separate consensus documents).

The task force was formed primarily of 17 scientific societies and 56 specialists from a wide geographical area (including 4 international societies), an expert in methodology, and a documentalist from the Iberoamerican Cochrane Center, all of whom participated as consultants and conducted the systematic literature search.

The literature search strategy was primarily designed to identify systematic reviews published in the last 10 years in English or Spanish, followed by randomized clinical trials, observational studies, clinical practice guidelines, and economic studies according to the topic of each section. Validated methodological filters were used to identify the different types of study design.

The search was conducted on MEDLINE (via PubMed), EMBASE (via Ovid), The Cochrane Library, and CENTRAL (Appendix B available in online material).

Methodology

An adaptation of the RAND-UCLA method1,2 was used for the preparation of this document. The responsible organizations and the general coordinator of the project established the topics for consensus and selected the experts and task force leaders.

Topics requiring a systematic search of the scientific literature were identified. Structured searches were conducted by expert documentalists. The document was subsequently developed from a draft drawn up by the leaders of each task force. The experts in each group expressed their agreement on the areas for consensus (Table 1 and Fig. 1).

Table 1.

Classification of the degree of consensus on topics included.

  Median score  Degree of consensus 
Good  ≥7  No lack of consensus 
Poor  <3  No lack of consensus 
Uncleara  4–6 or lack of consensus
a

“Unclear” topics were reviewed in an in-person evaluation (second round).

Fig. 1.

Study methodology flow chart (adapted from RAND/UCLA).

(0.37MB).
Pathophysiology of obstructive sleep apnea

The upper airway of patients with obstructive apneas tends to collapse during sleep, resulting in total or partial airway occlusion. Breathing stops until a microarousal occurs, which reactivates the muscles and reopens the airway. Apnea occurs when the factors that tend to close the airway cannot be offset by the ability of the dilating muscles of the pharynx and/or respiratory centers to keep it open (Fig. 2).

Fig. 2.

Overview of the physiological and biological processes of obstructive sleep apnea. As shown in the top left section of the figure, upper airway obstruction is the result of an imbalance between forces that tend to keep it open (muscle activity) and forces that tend to close it (anatomical factors). This imbalance increases the collapsibility of the upper airway, resulting in the respiratory episode (apnea hypopnea). It is estimated that 19% of the general population has an apnea-hypopnea rate > 10/h3. These episodes involve a series of physiological changes (hypoxia, transient arousals, and intrathoracic pressure changes) and biological changes (inflammation, oxidative stress, etc.). Depending on individual adaptation phenomena, these episodes cause secondary disease in the form of symptoms and are risk factors for the development of various entities (HBP, among others). Several generic factors modulate predisposition to these consequences. AHI: apnea-hypopnea index; HBP: high blood pressure; OSA: obstructive sleep apnea.

(0.27MB).
Definition of obstructive sleep apnea

This ICD proposes updating the nomenclature of sleep apnea syndrome to reintroduce the term “obstructive” in the acronyms accepted in 2005, since it defines the nature of the disease and clearly differentiates it from central sleep apnea. We decided to simplify the nomenclature and to remove the word “hypopnea” and the word “syndrome”, which is an outdated term that fails to reflect the current reality of the disease. We therefore recommended the use of the term “obstructive sleep apnea” and the acronym “OSA”.

In this ICD, OSA is defined as the presence of one of the following criteria:

  • 1

    Presence of an apnea-hypopnea index (AHI) ≥ 15/h that is predominantly obstructive.

  • 2

    AHI ≥ 5/h accompanied by one or more of the following factors: excessive daytime sleepiness, non-restorative sleep, excessive tiredness, and/or impaired sleep-related quality of life, which cannot be explained by other causes.

For the assessment of OSA severity, the position of this ICD is that classifications based solely on AHI are limited and do not reflect the heterogeneity of the disease. In line with current thinking among the scientific community4,5, we have prioritized the search for new scores that reflect this heterogeneity and are predictors of the long-term effects of the disease. Since no validated score is currently available, and although the factors or cut-off points leading to a classification of severe are not clearly established, we recommend that the following be taken into account: AHI; time with oxygen saturation below 90%, reflecting hypoxemia; daytime sleepiness; degree of obesity measured by body mass index and comorbidities (risk factors and cardiovascular disease) associated with OSA (high blood pressure [HBP], especially if treatment-refractory or non-dipping; diabetes mellitus type 2 [DM2]; dyslipidemia; coronary disease; stroke; heart failure or atrial fibrillation) (Fig. 3).

Fig. 3.

Assessment of the severity of the patient with obstructive sleep apnea (OSA) based on various objective parameters recommended by this International Consensus Document. AHI: apnea-hypopnea index; HBP: high blood pressure; BMI: body mass index; CHF: congestive heart failure; CT 90%: accumulated time with oxygen saturation below 90%; CV: cardiovascular or cerebrovascular disease; CVD: cerebrovascular disease; CVRF: cardiovascular risk factors; DLP: dyslipidemia; DM2: diabetes mellitus type 2; EPWORTH: Epworth Sleepiness Scale; IHD: ischemic heart disease.

(0.21MB).
Prevalence of obstructive sleep apnea

OSA is one of the most prevalent sleep disorders, but epidemiological studies in the literature vary widely in terms of methodology, the inclusion of clinical series or population series, diagnostic criteria, and the assessment of severity. A recently published study that analyzed the global burden of this entity6 reported rates ranging between 4% and 30%. Results are summarized in Table 2.

Table 2.

Studies reporting country-specific OSA prevalence data.

Country  Author  Age range  Men (%)  Analysis criteria  AHI > 5  AHI > 15 
          Male; female  Male; female 
Australia  Marshall NS, 2008  40–65  73  AASM 2012  25.5%; 23.5%  4.7%; 4.9% 
Brazil  Tufik S, 2010  20–80  45  AASM 2007  46.5%; 30.6%  24.8%; 9.6% 
Germany  Fietze I, 2018  20–81  54  AASM 2007  59.4%; 33.2%  29.7%; 13.2% 
Hong Kong  Ip MS, 2001  30–60  100  AASM 2007  8.8%  5.3% 
Hong Kong  Ip MS, 2004  30–60  AASM 2007  3.7%  1.9% 
Iceland  Arnardottir ES, 2016  40–65  –  AASM 2007  13.3%; 10.8%  10.6%; 4.8% 
Japan  Nakayama-Ashida Y, 2008  23–59  –  AASM 2012  59.7%  22.3% 
New Zealand  Mihaere KM, 2009  30–59  –  AASM 2007  12.5%; 3.4%  3.9%; 0.2% 
Norway  Hrubos-Strom H, 2011  30–65  55  AASM 2007  21%; 13%  11.0%; 6.0% 
Poland  Plywaczewski R, 2008  41–72  54  AASM 2007  36.2%; 18.4%  15.8%; 7.6% 
South Korea  Kim J, 2004  40–69  69  AASM 2007  27.1%; 16.8%  10.1%; 4.7% 
Singapore  Tan A, 2016  21–79  50  AASM 2007  62.3%; 62.3%  26.1%; 26.1% 
Singapore  Tan A, 2016  21–79  50  AASM 2012  70.8%; 70.8%  30.5%; 30.5% 
Switzerland  Heinzer R, 2015  40–85  48  AASM 2012  83.8%; 60.8%  49.7%; 23.4% 
U.S.  Peppard PE, 2013  30–70  55  AASM 2007  33.9%; 17.4%  13.0%; 6.0% 
Spain  Duran J, 2001  30–70  49  AASM 2007  26.2%; 28.0%  14.2%; 7.0% 

AASM: American Academy of Sleep Medicine; AHI: apnea-hypopnea index.

Consequences of obstructive sleep apnea

The main pathophysiological mechanisms that underlie the association between OSA and its consequences are intermittent hypoxia, sleep fragmentation, intrathoracic pressure changes, and a number of intermediate elements (Fig. 4).

Fig. 4.

Consequences of obstructive sleep apnea (OSA) and associated pathophysiological mechanisms.

Adapted and reproduced with permission from the SEPAR Manual of Pulmonology and Thoracic Surgery.

(0.22MB).

Table 3 summarizes the scientific evidence available on the association between OSA and its different consequences. OSA increases the risk of workplace and road traffic accidents. In the cardiovascular field, one of the manifestations for which the most evidence is available is arterial hypertension. The prevalence of OSA in DM2 is very high and OSA is an independent risk factor for developing DM2. OSA is also very common in coronary disease, but data on its clinical consequences and the effect of treatment are conflicting. OSA also increases the risk of stroke and may be associated with greater functional/cognitive impairment and higher mortality. Sleep-disordered breathing in heart failure is very prevalent, increases the risk of new episodes, and may increase mortality. Arrthythmias, pulmonary thromboembolism, and pulmonary arterial hypertension are also associated with a very high rate of OSA. Severe OSA is also associated with an increased risk of cancer, mortality, and tumor aggressiveness (melanoma), although current evidence is not yet strong. In neurocognitive terms, OSA causes major cognitive impairment (mainly in executive function, attention, and memory) and has a bidirectional association with depression.

Table 3.

Consequences of obstructive sleep apnea: prevalence, incidence, consequences and effect of treatment.

  References  Prevalence and association  Consequences  Effect of treatment 
Traffic and occupational accidents  Terán-Santos, 2017Tregear, 2010  OSA increases the risk of a traffic accident by 3–6-fold. 7% of traffic accidents in men are due to OSAOccupational accident risk doubles in OSA (especially in professional drivers)  OSA is included among the physical and mental fitness criteria for obtaining/extending driving licenses (European Union Directive 2014/85/EU)  CPAP reduces the risk of traffic accidents and derived costs 
HBP  Javaheri, 2020Martínez-García, 2013Martínez-García, 2019Mazzotti, 2019  50% of moderate-severe OSA patients have HBP. 30% of HBP patients have OSA (70% have resistant HTA). Independent association between OSA and HBP. Dose-response ratio. Higher frequency of non-dipping patterns  OSA has been positioned as the leading cause of secondary HBPData on whether OSA increases the risk of HBP incidence are conflicting  CPAP discreetly reduces blood pressure (systolic BP by 2–2.5 mmHg and diastolic BP by 1–1.5 mmHg). Probably has a greater effect on patients with a non-dipping BP pattern and on resistant and refractory HBP 
Cerebrovascular disease  Boulos, 2021Dong, 2018Javaheri, 2020Kang, 2020  OSA is very common (60%) in ischemic and thromboembolic cerebrovascular disease. OSA increases the risk of stroke by 2–3-fold  OSA may lead to increased functional and cognitive impairment and higher mortality after strokeData on whether OSA increases the risk of stroke incidence are conflicting  CPAP may improve recovery after an episode of stroke. No data available on mortality 
Arrhythmias  Qureshi, 2015Mehra, 2006Kwon, 2017  50% prevalence of arrhythmias in OSA; the most common are atrioventricular block, sinus pauses, and premature atrial and ventricular complexes. Frequency increases with the severity of OSA and associated hypoxia. 20%–80% of patients with AF have OSA and 3%–5% of OSA patients have AF  OSA increases the risk of AF incidence (dose-response ratio) and recurrence  Observational studies show that CPAP reduces the rate of AF recurrence after sinus rhythm recovery after ablation. There are no clinical trials 
Ischemic heart disease  Javaheri, 2017Sánchez de la Torre, 2020McEvoy, 2016  The prevalence of OSA in coronary heart disease is 38%–65%  OSA can worsen the prognosis of patients with previous coronary disease, increasing the risk of new cardiovascular events and restenosis after revascularization. However, recent data show no differences in the number of new cardiovascular events in untreated moderate-severe OSA, but without drowsiness  Observational studies show that CPAP decreases cardiovascular events, but clinical trials in patients without drowsiness do not show any beneficial effects in secondary prevention 
Pulmonary embolism  Alonso-Fernández, 2013Alonso-Fernández, 2016  OSA is an age-independent risk factor for PE  It could increase the risk of recurrence and confer greater severity, but there is little evidence  Unknown 
Pulmonary hypertension  Arias, 2006Sajkov, 2009  PHT is a prevalent but mild disease in OSA (20%–30%)  Uncertain clinical significance. Evidence is currently insufficient to recommend investigating PHT in OSA patients, but OSA should be ruled out in the study of PTH patients  CPAP improves right heart function and reduces pulmonary pressures 
Heart failure  Javaheri, 2020  The prevalence of OSA and CSA in CHF is high (50%–75%). The prevalence of CHF in OSA is double that of healthy controls and is similar in both stable heart failure with preserved ejection fraction and reduced heart failure  OSA increases the risk of emerging CHFPrognosis of CHF is worse and mortality is higher if it coexists with OSA or ACS  CPAP improves BP, sympathetic tone, left ventricular ejection fraction, and quality of life in these patients, but not mortality 
Diabetes mellitus, metabolic syndrome  Anothaisintawee, 2016Martínez-Cerón, 2016Shang, 2021  Prevalence of OSA in DM2 is very high (60%–85%)The prevalence of MS in OSA patients is 6–9 times more frequent than in the general population  OSA is an independent risk factor for developing DM2, which is increased in case of excessive daytime sleepiness or a higher grade of nocturnal hypoxemiaMetabolic control is worse if DM2 and OSA co-exist, although it is not known whether there is an increased risk for medium-long-term complications  CPAP with good adherence improves insulin resistance and may contribute to better glycemic control, but results are divergent 
Cancer  Nieto, 2012Campos-Rodriguez, 2013Martínez-García, 2016Martínez-García, 2018  Several studies show an association between OSA and cancer incidence that is higher in young patients  OSA severity and nocturnal hypoxia are associated with higher cancer mortality, higher incidence in some types of cancer (melanoma, lung), tumor aggressiveness (melanoma), and metastatic ability (animals)  There are no clinical trials 
Neurodegeneration  Emamian, 2016Bubu, 2020  Prevalence of cognitive impairment 2.5%–50%. AD confers a 5-fold higher risk of OSA and 50% of AD patients have OSA  OSA can lead to increased and earlier onset of cognitive impairment (affecting mainly executive function, attention, and memory)  Results on the effect of CPAP are conflicting 
Depression  Patil, 2019Edwards, 2020  There is a two-way relationship between OSA and depression. The risk of developing depression in OSA is 2-fold, especially in women (35 vs. 12–25% in men) and the elderly. The risk of OSA in patients with depression is 5-fold    Results are discordant, although CPAP appears to improve depressive symptoms in the elderly and in women 

AD: Alzheimer's disease; AF: atrial fibrillation; HBP: high blood pressure; BMI: body mass index; BP: blood pressure; CHF: congestive heart failure; CPAP: continuous positive upper airway pressure; CSA: central sleep apnea; DM2: diabetes mellitus type 2; MS: metabolic syndrome; OSA: obstructive sleep apnea; PE: pulmonary embolism; PHT: pulmonary arterial hypertension.

Diagnostic algorithm

Please refer to the online material for a detailed description of clinical presentation, physical examination, and complementary tests. In this section, we will only describe the diagnostic algorithm proposed in this ICD for indicating sleep studies.

As OSA is a highly prevalent disease, it should be managed at different healthcare levels in order to satisfy the demand for care7. Two diagnostic algorithms are proposed. In specialized centers (Fig. 5), patients with moderate-to-severe chronic respiratory disease, unstable cardiovascular disease, other suspected sleep disorders that can cause symptoms or coexist with OSA and some patients with anxiety-depression or insomnia may be candidates for polysomnography (PSG) studies. Patients with a low probability of disease, according to an expert evaluation, may be candidates for follow-up and correction of other influencing factors, or a decision may be taken to perform PSG or respiratory polygraphy. Patients with an intermediate to high probability of OSA can be evaluated by respiratory polygraphy.

Fig. 5.

Proposed algorithm for the diagnosis of patients with suspected obstructive sleep apnea (OSA) at a specialized level. AHI: apnea-hypopnea index; CPD: cardiopulmonary disease; EDS: excessive daytime sleepiness; PSG: polysomnography; RP: respiratory polygraphy; TD: therapeutic decision.

*Intermediate-high probability is defined as the presence of EDS (Epworth > 10) and 2 of the following 3 criteria: usual intense snoring, observed choking arousals or apneas, and/or arterial hypertension.

(0.31MB).

A second algorithm is proposed for primary care (Fig. 6), in which patients with a high probability of disease due to excessive daytime symptoms (Epworth ≥ 12) could be evaluated by simplified studies with single- or double-channel devices based on oximetry and/or nasal pressure8. It should be emphasized that this management must always be conducted in coordination with a reference sleep laboratory that can offer the necessary support, using protocols adjusted to specific needs. A therapeutic decision could be made in primary care and coordinated by specialists, but these models may be less generalizable, and they would have to be used in specific, previously validated areas9.

Fig. 6.

Proposed diagnostic algorithm in patients with suspected obstructive sleep apnea (OSA) seen in primary care and coordinated with the reference sleep laboratory. AHI: apnea-hypopnea index; BMI: body mass index; CPD: cardiopulmonary disease; EDS: excessive daytime sleepiness; SS: simplified study (one or 2 channels corresponding to nasal pressure and oximetry); TD: therapeutic decision.

*High probability is defined as the presence of EDS (Epworth ≥ 12) and 2 of the following 3 criteria: habitual intense snoring, observed choking arousals or apneas, and/or arterial hypertension.

**In these cases, a manual analysis of the recording by the coordinating sleep laboratory may offer a more accurate diagnosis.

(0.28MB).
Medical treatment of obstructive sleep apnea: a therapeutic algorithm

The goals of OSA treatment are to resolve the signs and symptoms of the disease, restore sleep quality, normalize AHI, improve oxygen saturation as far as possible, reduce the risk of complications, and lower the costs of the disease. This ICD emphasizes that the various alternatives are combinable and recommends a multidisciplinary therapeutic approach.

All medical, surgical, and physical options for the treatment of OSA should be complementary, not exclusive. Each patient should be offered the widest range of possibilities, and all strategies should be applied rationally, either alone or in combination, and individually adapted after an in-depth study. The patient's role in therapeutic decision-making must be emphasized. This should be the standard approach in multidisciplinary teamwork1–3,6,8 (Fig. 7).

Fig. 7.

Multidisciplinary approach to obstructive sleep apnea (OSA): all interventions are combinable. CPAP: continuous positive airway pressure; DISE: drug-induced sleep endoscopy; UA: upper airway.

(0.23MB).

It is important to note that before starting any of the therapeutic alternatives, the clinical diagnosis of OSA must be confirmed by a sleep study validated according to the previously recommended diagnostic algorithm. The therapeutic algorithm (Fig. 8) is as follows:

  • 1

    Hygienic-dietary measures should be implemented (Fig. 9) in all patients with OSA, regardless of whether continuous positive airway pressure (CPAP) therapy is indicated.

    Fig. 9.

    Recommended hygienic-dietary measures for all patients with obstructive sleep apnea, irrespective of an indication of continuous positive airway pressure.

    (0.71MB).
  • 2

    The patient must be evaluated to identify conditions associated with OSA and potentially reversible causes. Accordingly, this ICD recommends:

    • Treatment of obesity: excess weight or obesity should be treated in all patients with OSA. Initial treatment should be part of a comprehensive, high-intensity program that includes behavioral strategies10. Severe obesity requires more durable strategies that should be evaluated in specialized units, where the use of anti-obesity drugs10 or surgery (for patients > 35 kg/m2) will be evaluated when conservative treatment fails11–14.

    • Treatment of reversible causes: thyroid hormone replacement therapy is recommended in patients with OSA and hypothyroidism, so levels should be determined in case of clinical suspicion of hypothyroidism15. In case of gastroesophageal reflux, positional and dietary measures should be indicated, and treatment with proton pump inhibitors should be offered on an individual basis. If the patient presents tonsillar hypertrophy grade III/IV or severe dental or facial alterations, surgery to treat OSA should be considered.

Fig. 8.

Proposed therapeutic algorithm for obstructive sleep apnea (OSA). A more detailed description of the scientific evidence that supports this algorithm can be found in the online material. AHI: apnea-hypopnea index; BMI: body mass index; CPAP: continuous positive airway pressure; ENT: ear, nose, and throat; MAD: mandibular advancement devices.

(0.65MB).

In any of these situations, the need for CPAP until treatment of the reversible cause becomes effective can be assessed.

  • 3

    Indications for CPAP: CPAP is an effective treatment to reduce OSA severity, assessed according to AHI, and remains the treatment of choice in many of these patients16–29. Once the steps described above have been completed, the following recommendations for indicating CPAP, based on quality evidence evaluated according to currently available information in line with American Academy of Sleep Medicine guidelines30,31, should be followed.

A detailed explanation of the scientific evidence supporting selected cut-off points, symptoms and/or comorbidities used to determine the indication of CPAP can be found in the online material. This ICD recommends CPAP in:

  • Patients with a targeted diagnosis of moderate-severe OSA (AHI ≥ 15/h) with excessive daytime sleepiness (Epworth > 10), altered sleep-related quality of life (intense snoring, episodes of night choking, insomnia, morning headache, nocturia, impaired work or academic performance, social impact, and/or tiredness during the day) and/or HBP (especially if resistant or refractory).

  • In patients with no indication for CPAP due to AHI ≥ 15/h who do not present the above criteria, AHI between 5 and 15/h, or in whom CPAP is indicated but rejected (refusal to accept treatment or treatment unsuccessfully attempted for less than 4 weeks), alternative treatments should be assessed individually (mandibular advancement devices [MAD], positional treatment, surgery, etc.). These treatments and their indications are described in detail in the online material of this ICD.

  • Insufficient evidence is available to consistently recommend the use of CPAP to reduce the risk of death or cardiovascular or cerebrovascular events in adults who do not meet the 3 criteria listed above. These patients should be offered conservative treatment with monitoring of symptoms or an individualized assessment including a CPAP trial (with short-term reassessment of treatment continuity depending on efficacy and tolerance).

  • Similarly, in patients with OSA who have AHI < 15/h but are highly symptomatic or have a high burden of cardiovascular, cerebrovascular, or metabolic disease, a CPAP trial may be considered if the patient agrees. Current evidence suggests that CPAP may play a greater role in preventing cerebrovascular events than cardiovascular events32.

  • Alternative treatments should be considered individually if the therapeutic trial fails.

The scientific evidence supporting these recommendations and a more detailed description can be found in the online material.

Adequate pressure titration and monitoring of CPAP compliance are essential to achieve the treatment objectives described. Please refer to the online material for a detailed description of these factors. In short, this ICD recommends considering PSG pressure titration for patients with significant (severe COPD) or unstable cardiopulmonary disease (heart failure), complex sleep-disordered breathing (central sleep apnea, suspected incipient central sleep apnea, or obesity-hypoventilation syndrome), or when titration with simplified methods has not been possible. For all other patients, pressure titration with auto-CPAP provides a level of OSA control similar to PSG titration. It is essential that the patient be trained before titration is attempted. This document recommends visual analysis of the graph and selection of the minimum pressure that, regardless of leakage peaks, covers about 90% of the entire pressure graph. It is also recommended that at least 5 valid hours of recording be examined. Finally, empirical formula calculation should only be considered between the start of treatment and until the definitive titration study (auto-CPAP, CPAP with memory card, or manual titration) is performed.

Compliance during the first 3 months can predict long-term use of the device33, so careful attention in this period will be key to achieving adequate long-term compliance34. This ICD defines good adherence as the use of the device for at least 4 h/night on 70% of nights. The current evidence points to a dose-response relationship between hours of use and therapeutic response35,36, and the neurocognitive and cardiovascular effects of CPAP and the perceived benefits in quality of life depend on this compliance37. For this reason, we propose the concept of optimal compliance with a minimum of 6 h/night, an approach which has shown benefits in symptom control and morbidity. As for the type of device, the use of auto-CPAP has not been shown to increase the percentage of nights with more than 4 h use38,39. Therefore, its use is only recommended for patients with high or highly variable effective pressure throughout the night.

Interventions for improving adherence are described in detail in the online material. Since the evidence suggests that telemonitoring improves CPAP adherence40,41, this strategy should be considered during the initial period of CPAP treatment. If it is used, remote recording of CPAP parameters30,31 should include hours of use, residual AHI, unintentional leaks, and machine configuration30,31,42.

Multidisciplinary management with the participation of a sleep specialist, the nursing team, and the suppliers will be important in the follow-up of patients receiving CPAP. Primary care should be included in long-term monitoring.

All patients receiving CPAP should be monitored after the first month of treatment and a brief in-person review should be performed at 6 months. Adherence at 3 months can be determined from telemonitoring. If the treatment is well established, with good clinical response and no side effects, the patient may be referred to primary care for follow-up after the first year.

If the patient has frank and proven intolerance to CPAP (the patient has tried to use it for more than 4 weeks, but has not been able to adapt), withdrawal should be considered. If either rejection or intolerance cannot be rectified, other therapeutic alternatives should be considered. In the event of clear lack of adherence with an average use of less than 3 h/night, the patient should be included in a compliance program, preferably with a telemonitoring system, and re-evaluated after at least 3 months, before assessing the possible withdrawal of CPAP and an alternative therapeutic proposal. Occasionally, patients who use CPAP for less than 3 h/night report symptomatic improvements, so the decision to discontinue treatment should be individualized.

Surgical treatment

The surgical algorithm recommended in this ICD for use by ENT specialists and oral or maxillofacial surgeons is an update of the standard Stanford 2-tiered protocol (Fig. 10)43,44. In this era of personalized medicine, a precise indication for palatal and oropharyngeal surgeries may initially be made based on clinical findings and drug-induced sedation endoscopy (DISE)45–47, but skeletal surgery, especially bimaxillary advancement, may also be indicated as initial surgical treatment of OSA in patients with severe disease (AHI > 65 and/or concentric collapse on DISE and/or severe dental and facial alterations). An indication for surgery never definitively excludes other treatments, or vice versa. Refer to the online material for a more detailed description of the systematic review and indications for surgery in OSA patients.

Fig. 10.

Algorithm for indicating surgical treatment in obstructive sleep apnea (OSA) using personalized precision medicine. CAPSO: cautery-assisted palatal stiffening operation; CELL: coblator endoscopic lingual lightening; CPAP: continuous positive airway pressure; DISE: drug-induced sleep endoscopy; DOME: distraction osteogenesis maxillary expansion; ENT/MXF; ear, nose and throat/maxillofacial; MAD: mandibular advancement device; PSG: polysomnography; RP: respiratory polygraph; RX/CT: radiological studies; TORS: transoral robotic surgery; UA: upper airway; UPPP: uvulopalatopharyngoplasty. (1) In case of severe dental or facial alterations, bimaxillary advancement may be indicated directly, although CPAP will be prescribed until surgery is conducted. (2) In case of tonsillar hypertrophy grade ≥ 3, tonsillectomy may be indicated directly, although CPAP will be prescribed until surgery. (3) In case of CPAP intolerance after ORL evaluation, nasal surgery is recommended as soon as possible to improve intolerance and retitrate CPAP. (4) In case of CPAP intolerance after dental/maxillofacial evaluation, adaptation of MAD or assessment for orthognathic surgery is recommended. (5) In case of CPAP intolerance after ENT evaluation, DISE is recommended to determine the most appropriate upper airway treatment. (6) After intolerance to CPAP and failure of other surgeries, a repeat DISE is recommended. If collapse is non-concentric, hypoglossal neurostimulation may be indicated.

(0.36MB).

The proposed algorithm moves on from the classic concept of soft tissue removal or skeletal modification44. It divides the surgical procedures to be performed according to the affected organ, and the choice of procedure is based primarily on the exploratory and diagnostic findings and on the final decision of the patient after all the options have been explained, none of which is either exclusive or prevailing. It is common for patients to have airway obstructions at different levels, so the current tendency is to perform multilevel surgery, in which, once the different sites of upper airway obstruction have been determined, a decision is made on the different procedures to be performed, alone or in combination, aiming to achieve optimal results48–51.

Treatment with mandibular advancement devices

Recent randomized controlled trials have demonstrated the efficacy of MADs on various aspects of OSA as summarized in Table 4 (see also online material):

Table 4.

Summary of existing scientific evidence on the efficacy of mandibular advancement device in patients with obstructive sleep apnea.

  Effect  Comments 
AHI  Significant reduction in 60% of patients  Disparate success criteria: final AHI < 5/h, <10/h, or 50% decrease in baseline AHINotable heterogeneity among the different studiesThe degree of mandibular advancement should be individualized in each patient 
Other sleep variables  Improved oximeter parameters and sleep fragmentation  Improvement associated with reduction in AHI 
Sleepiness  Reduced  Improvement associated with reduction in AHIEvaluated almost exclusively by the Epworth scale 
Quality of life and cognitive aspects  Improved quality of lifeScant exploration of cognitive improvement  Improvement associated with reduction in AHI 
Cardiovascular aspects  Improved night BP controlLittle evidence on other cardiovascular aspects  Improvement associated with reduction in AHI 
Snoring  Usually improves frequency and/or intensity   

AHI: apnea-hypopnea index.

This ICD therefore recommends that52,53:

  • The diagnosis of OSA and the efficacy of MAD should always be determined by respiratory polygraphy or PSG.

  • The indications for MAD are:

    • 1

      Patients with OSA of any severity who are candidates for CPAP therapy but unable to adapt to it. MAD is principally indicated as an alternative to CPAP and should be available in sleep units in the public health system, or

    • 2

      Patients with mild to moderate OSA, minor symptoms, or troublesome snoring and no indication for CPAP or any other treatment.

  • Before prescribing an MAD, the dentist must perform an oral examination to rule out patients who do not meet dental inclusion criteria.

  • Current evidence supports the use of custom-made, adjustable devices.

  • Following assessment of the patient's suitability from the point of view of oral health, treatment should be implemented and followed up by a certified dentist or OSA sleep-disordered breathing expert working in coordination with a sleep unit. Respiratory polygraphy may be used by an experienced sleep dentist as a tool for MAD titration.

Alternative treatments

OSA is a heterogeneous disease in terms of both its pathophysiology and its polysomnographic expression and clinical presentation. In recent years, various OSA phenotypes have been described that are explained in depth in the online material of this document. This phenotype approach has helped improve our knowledge of the mechanisms involved in the disease and the development of different therapeutic strategies, and has contributed to the development of a more personalized medicine. Table 5 summarizes current evidence and indications for other alternative therapies (see also online material).

Table 5.

Summary of current evidence and indications for alternative therapies in the management of OSA.

Treatment  Evidence  Indications 
Positional therapy54  Significant reduction in AHI in some cases to below 5/h, but in very small samples with inconsistent results on daytime sleepiness and quality of life  As a single treatment in patients with respiratory episodes exclusively in supine position or with an AHI < 15/h in other positions, always with confirmation of disease controlAs an adjuvant therapy to decrease CPAP pressure in patients with predominantly supine episodesIn patients with predominantly supine episodes who reject first-line therapies 
Pharmacological treatment55  In 20 patients with OSA, combined single-dose atomoxetine (norepinephrine reuptake inhibitor) and oxybutynin (muscarinic blocker) reduced AHI (63%; from 28.5 to 7.5 episodes/h) and improved minimal saturation by increasing the response of the genioglossus muscle during sleepLong-term effect and safety remain to be determined  Although in the future drug therapy may be useful in some patient phenotypes, this ICD considers that it is currently premature to use this combination or any other drug for the treatment of OSA 
Myofunctional therapy56  Randomized studies in patients with OSA have shown that it can decrease AHI (50%; from 24.5 to 12.3 episodes/h), improve minimal saturation, daytime sleepiness, and quality of life  Therapeutic alternative in non-obese patients with mild-moderate OSAConcomitant treatment to improve the efficacy and tolerance of CPAP, reducing required pressure levelsComplementary treatment in patients with MAD 
BiPAP57  BiPAP has not shown superior efficacy to CPAP in reducing AHI or improving sleepiness, quality of life, side effects, or therapeutic adherence, except in patients who have difficulty in complying with CPAP therapy  Patients who have not been able to tolerate CPAP because they require very high pressuresConsider switching to BiPAP in patients who require CPAP pressures greater than 15 for the control of respiratory episodes, and whenever CPAP pressures greater than 20 are requiredPatients with concomitant disease who require BiPAP 
Nasal EPAP58  A systematic review showed a mean 53% relative reduction in AHI, although there are no predictors to determine who might benefit from this therapy  Given the lack of response predictors and the lack of more extensive studies, this approach could only be considered as an alternative in selected patients with mild-moderate OSA 
Oral pressure therapy59  In a multicenter study of 63 patients, 32% had an AHI < 10 on the first night, with a 50% reduction from baseline  There is currently insufficient evidence to recommend its use as an alternative treatment in patients with OSA 

AHI: apnea-hypopnea index; BiPAP: bilevel positive airway pressure; CPAP: continuous positive airway pressure; EPAP: expiratory positive airway pressure; ICD: international consensus document; MAD: mandibular advancement devices; OSA: obstructive sleep apnea.

Role of primary care medicine in the management of obstructive sleep apnea

In light of the current evidence, the recommendations of this ICD on the role of primary care in the management of OSA patients are as follows:

  • 1

    The involvement of primary care physicians is essential to improve the current situation of OSA underdiagnosis.

  • 2

    The implementation of training plans in primary care improves the suspicion and diagnostic process of OSA.

  • 3

    The criterion for clinical suspicion should be the presence of 2 of the 3 main symptoms: snoring, observed apneas, and/or excessive daytime sleepiness or unexplained intense tiredness.

  • 4

    The situations that require urgent referral are summarized in Fig. 11:

    • a)

      Primary care diagnostic procedures should be performed in consensus with the reference sleep unit, working in a network.

    • b)

      At the moment, evidence on how to start CPAP treatment exclusively in a primary care setting is insufficient.

    • c)

      Most treatment follow-up requirements can be met in primary care.

    Fig. 11.

    Proposed algorithm for the referral of patients with suspected obstructive sleep apnea (OSA) from primary care. HBP: high blood pressure; BMI: body mass index; EDS: excessive daytime sleepiness.

    (0.3MB).

These activities should be conducted as indicated in Fig. 12. A more detailed explanation can be found in the online material.

Fig. 12.

Proposal for the main areas of primary care intervention in the care of patients with obstructive sleep apnea (OSA). HBP: high blood pressure; CPAP: continuous positive airway pressure; CVRF: cardiovascular risk factors; EDS: excessive daytime sleepiness.

(0.29MB).
Conclusions

OSA is a highly prevalent disease with significant consequences. Its diagnostic and therapeutic management requires multidisciplinary treatment and involves all levels of care. Identification of possible reversible causes and assessment of all treatment options, all of which are combinable, will contribute to comprehensive patient management.

Authorship

All the authors have participated in the study and read and approved the manuscript.

Conflict of interests

Pedro García Ramos states that he has collaborated with GSK, Laboratorios Ferrer, Angelini, Novartis, Almirall, Gebro Pharma, Rovi, Esteve, Recordati, MSD, and Teva. Carlos Teixeira states that he is an employee of Philips (Sleep and Respiratory Care Division). Francisco Javier Puertas Cuesta states that he has received fees for consultancy and speaking in courses and seminars from Jazz Pharmaceuticals, UCB Pharma, GSK, Esteve Teijin, and ResMed, and has received research grants from Philips. The other authors state that they have no conflict of interests with the manuscript.

Acknowledgements

Esteve Teijin organized the first national in-person meeting. Philips (Sleep and Respiratory Care Division) organized the final in-person document review meeting. None of these companies was involved in the scientific discussion or the drafting of the document. Ivan Solà participated in the research work as an expert documentalist. This ICD is especially dedicated to our companion Mari Luz Alonso-Álvarez, who always set an example of best practices in the quest for scientific evidence.

Appendix A
Supplementary data

The following are Supplementary data to this article:

Sueño en general

Prevalencia

Definicion y exploracion fisica

Metodos diagnosticos

Consecuencias

A Tratamiento medico

B Dispositivos del avance

C.Tratamiento quirurgico

D. Tratamientos alternativos

Papel de la AP

Otras apneas

Proceso anestesico

Aspectos legales

Patologia sueño

Cronobiologia

Enfermedad integral

Medicina de precision

Coste-effectividad

Niveles aistenciales

Rol de los pacientes

Control de calidad

Tecnico enfermeria

Metodologia

Anexos

Appendix C
Spanish scientific societies

Spanish Society of Pulmonology and Thoracic Surgery (SEPAR), Spanish Society of Neurology (SEN), Spanish Society of General and Family Physicians (SEMG), Spanish Society of Dental Sleep Medicine (SEMDeS), Spanish Society of Clinical Neurophysiology (SENFC), Spanish Society of Endocrinology and Nutrition (SEEN), Spanish Society of Oral and Maxillofacial and Head and Neck Surgery (SECOM CYC), Spanish Society of Family and Community Medicine (semFYC), Spanish Society of Traffic Medicine (SEMT), Spanish Society of Otorhinolaryngology and Cervical Surgery (SEORL-CCC), Spanish Society of Cardiology (SEC), Spanish Society of Sleep (SES), Spanish Society for the Study of Obesity (SEEDO).

Appendix D
International scientific societies

Latin American Thoracic Association (ALAT), Brazilian Society of Pulmonology and Phthisiology (SBPT), Portuguese Society of Pulmonology (SPP), SomnoNIV Group of the French Language Pulmonology Society (SPLF).

References
[1]
K. Fitch, S.J. Bernstein, M.D. Aguilar, B. Burnand, J.R. Lacalle, P. Lazaro, et al.
The RAND/UCLA appropriateness method user's manual.
[2]
K. Fitch, P. Lázaro.
Using appropriateness criteria to improve health care.
Eurohealth, 5 (1999), pp. 19-21
[3]
J. Duran, S. Esnaola, R. Rubio, A. Iztueta.
Obstructive sleep apnea-hypopnea and related clinical features in a population-based sample of subjects aged 30 to 70 yr.
Am J Respir Crit Care Med, 163 (2001), pp. 685-689
[4]
M.A. Martínez-García, F. Campos-Rodríguez, F. Barbé, D. Gozal, A. Agustí.
Precision medicine in obstructive sleep apnoea.
Lancet Respir Med, 7 (2019), pp. 456-464
[5]
W.J. Randerath, S. Herkenrath, M. Treml, L. Grote, J. Hedner, M.R. Bonsignore, et al.
Evaluation of a multicomponent grading system (Baveno classification) for obstructive sleep apnoea.
[6]
A.V. Benjafield, N.T. Ayas, P.R. Eastwood, R. Heinzer, M. Ip, M.J. Morrell, et al.
Estimation of the global prevalence and burden of obstructive sleep apnoea: a literature-based analysis.
Lancet Respir Med, 7 (2019), pp. 687-698
[7]
R.B. Berry, S.F. Quan, A.R. Abreu, M.L. Bibbs, L. DelRosso, S.M. Harding, et al.
The AASM Manual of the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications.
American Academy of Sleep Medicine, (2020),
[8]
M.A. Sánchez Quiroga, J. Corral, F.J. Gómez de Terreros, C. Carmona Bernal, M.I. Asensio Cruz, M. Cabello, et al.
Primary care physicians can comprehensively manage patients with sleep apnea.
Am J Respir Crit Care Med, 198 (2018), pp. 648-656
[9]
N. Tarraubella, M. Sánchez-de-la-Torre, N. Nadal, J. De Batlle, I. Benítez, A. Cortijo, et al.
Management of obstructive sleep apnoea in a primary care vs sleep unit setting: a randomised controlled trial.
Thorax, 73 (2018), pp. 1152-1160
[10]
D.W. Hudgel, S.R. Patel, A.M. Ahasic, S.J. Bartlett, D.H. Bessesen, M.A. Coaker, et al.
The role of weight management in the treatment of adult obstructive sleep apnea. An Official American Thoracic Society Clinical Practice Guideline.
Am J Respir Crit Care Med, 198 (2018), pp. e70-e87
[11]
S.A. Guardiano, J.A. Scott, J.C. Ware, S.A. Schechner.
The long-term results of gastric bypass on indexes of sleep apnea.
Chest, 124 (2003), pp. 1615-1619
[12]
J.B. Dixon, L.M. Schachter, P.E. O'Brien, K. Jones, M. Grima, G. Lambert, et al.
Surgical vs conventional therapy for weight loss treatment of obstructive sleep apnea: a randomized controlled trial.
JAMA, 308 (2012), pp. 1142-1149
[13]
B. Feigel-Guiller, D. Drui, J. Dimet, Y. Zair, M. Le Bras, N. Fuertes-Zamorano, B. Cariou, et al.
Laparoscopic gastric banding in obese with sleep apnea: a 3 year controlled study and follow-up after 10 years.
Obes Surg, 25 (2015), pp. 1886-1892
[14]
P. Peromaa-Haavisto, H. Tuomilehto, J. Kössi, J. Virtanen, M. Luostarinen, J. Pihlajamäki, et al.
Obstructive sleep apnea: the effect of bariatric surgery after 12 months. A prospective multicenter trial.
Sleep Med, 35 (2017), pp. 85-90
[15]
W. Kuczyński, A. Gabryelska, Ł. Mokros, P. Białasiewicz.
Obstructive sleep apnea syndrome and hypothyroidism-merely concurrence or causal association.
Pneumonol Alergol Pol, 84 (2016), pp. 302-306
[16]
T.E. Weaver, C. Mancini, G. Maislin, J. Cater, B. Staley, J.R. Landis, et al.
Continuous positive airway pressure treatment of sleepy patients with milder obstructive sleep apnea: results of the CPAP Apnea Trial North American Program (CATNAP) randomized clinical trial.
Am J Respir Crit Care Med, 186 (2012), pp. 677-683
[17]
A.C. Amaro, F.H. Duarte, R.S. Jallad, M.D. Bronstein, S. Redline, G. Lorenzi-Filho.
The use of nasal dilator strips as a placebo for trials evaluating continuous positive airway pressure.
Clinics (Sao Paulo), 67 (2012), pp. 469-474
[18]
M. Barnes, R.D. McEvoy, S. Banks, N. Tarquinio, C.G. Murray, N. Vowles, et al.
Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea.
Am J respir Crit Care Med, 170 (2004), pp. 656-664
[19]
H.F. Becker, A. Jerrentrup, T. Ploch, L. Grote, T. Penzel, C.E. Sullivan, et al.
Effect of nasal continuous positive airway pressure treatment on blood pressure in patients with obstructive sleep apnea.
[20]
C.M. Hoyos, R. Killick, B.J. Yee, C.L. Phillips, R.R. Grunstein, P.Y. Liu.
Cardiometabolic changes after continuous positive airway pressure for obstructive sleep apnoea: a randomized sham-controlled study.
Thorax, 67 (2012), pp. 1081-1089
[21]
B. Lam, K. Sam, W.Y. Mok, M.T. Cheung, D.Y. Fong, J.C. Lam, et al.
Randomised study of three non-surgical treatments in mild to moderate obstructive sleep apnoea.
Thorax, 62 (2007), pp. 354-359
[22]
C. Monasterio, S. Vidal, J. Duran, M. Ferrer, C. Carmona, F. Barbé, et al.
Effectiveness of continuous positive airway pressure in mild sleep apnea-hypopnea syndrome.
Am J Respir Crit Care Med, 164 (2001), pp. 939-943
[23]
C.L. Phillips, B.J. Yee, N.S. Marshall, P.Y. Liu, D.R. Sullivan, R.R. Grunstein.
Continuous positive airway pressure reduces postprandial lipidemia in obstructive sleep apnea: a randomized, placebo-controlled crossover trial.
Am J Respir Crit Care Med, 184 (2011), pp. 355-361
[24]
B.T. Woodson, D.L. Steward, E.M. Weaver, S. Javaheri.
A randomized trial of temperature-controlled radiofrequency, continuous positive airway pressure, and placebo for obstructive sleep apnea syndrome.
Otolaryngol Head Neck Surg, 128 (2003), pp. 848-861
[25]
M.S. Ip, H.F. Tse, B. Lam, K.W. Tsang, W.K. Lam.
Endothelial function in obstructive sleep apnea and response to treatment.
Am J Respir Crit Care Med, 169 (2004), pp. 348-353
[26]
P.K. Nguyen, C.K. Katikireddy, M.V. McConnell, C. Kushida, P.C. Yang.
Nasal continuous positive airway pressure improves myocardial perfusion reserve and endothelial-dependent vasodilation in patients with obstructive sleep apnea.
J Cardiovasc Magn Reson, 12 (2010), pp. 50
[27]
C. Navarro-Soriano, M.A. Martínez-García, G. Torres, F. Barbé, C. Caballero-Eraso, P. Lloberes, et al.
Effect of continuous positive airway pressure in patients with true refractory hypertension and sleep apnea: a post-hoc intention-to-treat analysis of the HIPARCO randomized clinical trial.
J Hypertens, 37 (2019), pp. 1269-1275
[28]
C. Navarro-Soriano, M.A. Martínez-García, G. Torres, F. Barbé, M. Sánchez-de-la-Torre, C. Caballero-Eraso, et al.
Long-term effect of CPAP treatment on cardiovascular events in patients with resistant hypertension and sleep apnea. Data from the HIPARCO-2 study.
Arch Bronconeumol, 57 (2020), pp. 165-171
[29]
C. Navarro-Soriano, G. Torres, F. Barbé, M. Sánchez-de-la-Torre, P. Mañas, P. Lloberes, et al.
The HIPARCO-2 study: long-term effect of continuous positive airway pressure on blood pressure in patients with resistant hypertension: a multicenter prospective study.
J Hypertens, 39 (2021), pp. 302-309
[30]
S.P. Patil, I.A. Ayappa, S.M. Caples, R.J. Kimoff, S.R. Patel, C.G. Harrod.
Treatment of adult obstructive sleep apnea with positive airway pressure: an American Academy of Sleep Medicine Systematic review, a meta-analysis, and GRADE assessment.
J Clin Sleep Med, 15 (2019), pp. 301-334
[31]
S.P. Patil, L.P. Shirsath, B.L. Chaudhari.
Treatment of adult obstructive sleep apnea with positive airway pressure: an American Academy Sleep Medicine Clinical Practice Guideline.
J Clin Sleep Med, 15 (2019), pp. 335-343
[32]
S. Javaheri, M.A. Martinez-Garcia, F. Campos-Rodriguez, A. Muriel, Y. Peker.
Continuous positive airway pressure adherence for prevention of major adverse cerebrovascular and cardiovascular events in obstructive sleep apnea.
Am J Respir Crit Care Med, 201 (2020), pp. 607-610
[33]
J. Krieger, D. Kurtz, C. Petiau, E. Sforza, D. Trautmann.
Long-term compliance with CPAP therapy in obstructive sleep apnea patients and in snores.
Sleep, 19 9 Suppl (1996), pp. S136-S143
[34]
R. Budhiraja, S. Parthasarathy, C.L. Drake, T. Roth, I. Sharief, P. Budhiraja, et al.
Early CPAP use identifies subsequent adherence to CPAP therapy.
Sleep, 30 (2007), pp. 320-324
[35]
N.A. Antic, P. Catcheside, C. Buchan, M. Hensley, M.T. Naughton, S. Rowland, et al.
The effect of CPAP in normalizing daytime sleepiness, quality of life, and neurocognitive function in patients with moderate to severe OSA.
Sleep, 34 (2011), pp. 111-119
[36]
T.E. Weaver, G. Maislin, D.F. Dinges, T. Bloxham, C.F. George, H. Greenberg, et al.
Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning.
Sleep, 30 (2007), pp. 711-719
[37]
T.E. Weaver.
Don't start celebrating–CPAP adherence remains a problem.
J Clin Sleep Med, 9 (2013), pp. 551-552
[38]
D.W. Hudgel, C. Fung.
A long-term randomized, cross-over comparison of auto-titrating and standard nasal continuous airway pressure.
Sleep, 23 (2000), pp. 645-648
[39]
Y. Nussbaumer, K.E. Bloch, T. Genser, R. Thurnheer.
Equivalence of autoadjusted and constant continuous positive airway pressure in home treatment of sleep apnea.
Chest, 129 (2006), pp. 638-643
[40]
C. Chen, J. Wang, L. Pang, Y. Wang, G. Ma, W. Liao.
Telemonitor care helps CPAP compliance in patients with obstructive sleep apnea: a systemic review and meta-analysis of randomized controlled trials.
Ther Adv Chronic Dis, 11 (2020),
[41]
K. Murase, K. Tanizawa, T. Minami, T. Matsumoto, R. Tachikawa, N. Takahashi, et al.
A randomized controlled trial of telemedicine for long-term sleep apnea continuous positive airway pressure management.
Ann Am Thorac Soc, 17 (2020), pp. 329-337
[42]
J.M. Montserrat Canal, M. Suárez-Girón, C. Egea, C. Embid, M. Matute-Villacís, L. de Manuel Martínez, et al.
Spanish Society of Pulmonology and Thoracic Surgery positioning on the use of telemedine in sleep-disordered breathing and mechanical ventilation.
Arch Bronconeumol, 57 (2020), pp. 281-290
[43]
S.Y. Liu, R. Wayne Riley, A. Pogrel, C. Guilleminault.
Sleep surgery in the era of precision medicine.
Atlas Oral Maxillofac Surg Clin North Am, 27 (2019), pp. 1-5
[44]
S.Y. Liu, M. Awad, R. Riley, R. Capasso.
The role of the revised Stanford protocol in today's precision medicine.
Sleep Med Clin, 14 (2019), pp. 99-107
[45]
E. Esteller, M. Carrasco, M.Á Díaz-Herrera, J. Vila, G. Sampol, J. Juvanteny, et al.
Recomendaciones de la Guía de Práctica Clínica de la exploración de la vía aérea superior para pacientes adultos con sospecha de síndrome de apnea-hipoapnea obstructiva del sueño (versión reducida).
Acta Otorrinolaringol Esp, 70 (2019), pp. 364-372
[46]
M. Carrasco Llatas, P. Martínez Ruiz de Apodaca, P. Baptista Jardín, C. O'Connor Reina, G. Plaza Mayor, I. Méndez-Benegassi Silva, et al.
Endoscopia inducida por sueño.
Acta Otorrinolaringol Esp, 71 (2020), pp. 316-320
[47]
A. De Vito, M. Carrasco Llatas, M.J. Ravesloot, B. Kotecha, N. De Vries, E. Hamans, et al.
European position paper on drug-induced sleep endoscopy: 2017 update.
Clin Otolaryngol, 43 (2018), pp. 1541-1552
[48]
M. He, G. Yin, S. Zhan, J. Xu, X. Cao, J. Li, et al.
Long-term efficacy of uvulopalatopharyngoplasty among adult patients with obstructive sleep apnea: a systematic review and meta-analysis.
Otolaryngol Head Neck Surg, 161 (2019), pp. 401-411
[49]
P. Martínez Ruiz de Apodaca, M. Carrasco Llatas, M. Valenzuela Gras, J. Dalmau Galofre.
Improving surgical results in velopharyngeal surgery: our experience in the last decade.
Acta Otorrinolaringol Esp, 71 (2020), pp. 197-203
[50]
S. MacKay, A.S. Carney, P.G. Catcheside, C.L. Chai-Coetzer, M. Chia, P.A. Cistulli, et al.
Effect of multilevel upper airway surgery vs medical management on the apnea-hypopnea index and patient-reported daytime sleepiness among patients with moderate or severe obstructive sleep apnea: the SAMS randomized clinical trial.
JAMA, 324 (2020), pp. 1168-1179
[51]
A. Costantino, V. Rinaldi, A. Moffa, V. Luccarelli, F. Bressi, M. Cassano, et al.
Hypoglossal nerve stimulation long-term clinical outcomes: a systematic review and meta-analysis.
Sleep Breath, 24 (2020), pp. 399-411
[52]
guiasalud.es. Biblioteca de Guías de Práctica Clínica del Sistema Nacional de Salud.
Guía de práctica clínica sobre la utilización de los dispositivos de avance mandibular (DAM) en el tratamiento de pacientes adultos con síndrome de apneas-hipoapneas del sueño.
[53]
H. Chan, D.J. Eckert, P.F. van der Stelt, J. Guo, S. Ge, E. Ememi, et al.
Phenotypes of responders to mandibular advancement device therapy in obstructive sleep apnea patients: a systematic review and metaanalysis.
[54]
O. Omobomi, S.F. Quan.
Positional therapy in the management of positional obstructive sleep apnea. A review of the current literature.
Sleep Breath, 22 (2018), pp. 297-304
[55]
L. Taranto-Montemurro, L. Messineo, A. Wellman.
Targeting endotypic traits with medications for the pharmacological treatment of obstructive sleep apnea. A re-view of the current literature.
J Clin Med, 8 (2019), pp. 1846
[56]
C.M. De Felício, F.V. da Silva Dias, L.V.V. Trawitzki.
Obstructive sleep apnea: focus on myofunctional therapy.
Nat Sci Sleep, 10 (2018), pp. 271-286
[57]
S.P. Patil, I.A. Ayappa, S.M. Caples, R.J. Kimoff, S.R. Patel, C.G. Harrod.
Treatment of adult obstructive sleep apnea with positive airway pressure: an American Academy of Sleep Medicine clinical practice guideline.
J Clin Sleep Med, 15 (2019), pp. 335-343
[58]
M. Riaz, V. Certal, G. Nigam, J. Abdullatif, S. Zaghi, C.A. Kushida, et al.
Nasal expiratory positive airway pressure devices (Provent) for OSA: a systematic review and meta-analysis.
Sleep Disord, 2015 (2015),
[59]
I.M. Colrain, J. Black, L.C. Siegel, R.K. Bogan, P.M. Becker, M. Farid-Moayer, et al.
A multicenter evaluation of oral pressure therapy for the treatment of obstructive sleep apnea.
Sleep Med, 14 (2013), pp. 830-837

Please cite this article as: Mediano O, González Mangado N, Montserrat JM, Alonso-Álvarez ML, Almendros I, Alonso-Fernández A, et al., Documento internacional de consenso sobre apnea obstructiva del sueño. Arch Bronconeumol. 2022;58:52–68.

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