Professional Statements and Societal Positions Guidelines
American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) 2016
The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be an effective second-line treatment of moderate to severe obstructive sleep apnea in individuals who are intolerant or unable to achieve benefit with positive pressure therapy (PAP). Not all adult individuals are candidates for UAS therapy and appropriate polysomnographic, age, BMI and objective upper airway evaluation measures are required for proper individual selection.
American Academy of Sleep Medicine (AASM)
Oral Appliance Therapy – 2015
The AASM along with the American Academy of Dental Sleep Medicine (AADSM) engaged a seven member task force for the treatment of OSA and snoring with oral appliance therapy developed recommendations and assigned strengths based on the quality of the evidence counterbalanced by an assessment of the relative benefit of the treatment versus the potential harms.
The AASM and AADSM Board of Directors approved the final guideline recommendations:
- That sleep physicians prescribe oral appliances, rather than no therapy, for adult individuals who request treatment of primary snoring (without obstructive sleep apnea).
- When oral appliance therapy is prescribed by a sleep physician for an adult individual with obstructive sleep apnea, we suggest that a qualified dentist use a custom, titratable appliance over non-custom oral devices.
- Sleep physicians consider prescription of oral appliances, rather than no treatment, for adult individuals with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy.
- Qualified dentists provide oversight— rather than no follow-up—of oral appliance therapy in adult individuals with obstructive sleep apnea, to survey for dental-related side effects or occlusal changes and reduce their incidence.
- Sleep physicians conduct follow-up sleep testing to improve or confirm treatment efficacy, rather than conduct follow-up without sleep testing, for individuals fitted with oral appliances.
- Sleep physicians and qualified dentists instruct adult individuals treated with oral appliances for obstructive sleep apnea to return for periodic office visits— as opposed to no follow-up—with a qualified dentist and a sleep physician.
Diagnosing OSA in Adults – 2017
AASMs recommendations are intended as a guide for clinicians diagnosing OSA in adults. The ultimate judgment regarding propriety of any specific care must be made by the clinician in light of the individual circumstances presented by the individual, available diagnostic tools, accessible treatment options, and resources:
Regarding diagnostic testing:
Diagnostic testing for OSA should be performed in conjunction with a comprehensive sleep evaluation and adequate follow-up. Polysomnography is the standard diagnostic test for the diagnosis of OSA in adult individuals in whom there is a concern for OSA based on a comprehensive sleep evaluation:
- Clinical tools, questionnaires and prediction algorithms not be used to diagnose OSA in adults, in the absence of polysomnography or home sleep apnea testing.
- Polysomnography, or home sleep apnea testing with a technically adequate device, be used for the diagnosis of OSA in uncomplicated adult individuals presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA.
- If a single home sleep apnea test is negative, inconclusive, or technically inadequate, polysomnography be performed for the diagnosis of OSA.
- Polysomnography, rather than home sleep apnea testing, be used for the diagnosis of OSA in individuals with significant cardiorespiratory disease, potential respiratory muscle weakness due to neuromuscular condition, awake hypoventilation or suspicion of sleep related hypoventilation, chronic opioid medication use, history of stroke or severe insomnia.
- If clinically appropriate, a split-night diagnostic protocol, rather than a full-night diagnostic protocol for polysomnography be used for the diagnosis of OSA.
- When the initial polysomnogram is negative and clinical suspicion for OSA remains, a second polysomnogram be considered for the diagnosis of OSA.
Clinical Use of a Home Sleep Apnea Test – 2017
American Academy of Sleep Medicine (AASM):
- Only a physician can diagnose medical conditions such as OSA and primary snoring. Throughout this statement, the term “physician” refers to a medical provider who is licensed to practice medicine. A home sleep apnea test (HSAT) is an alternative to polysomnography for the diagnosis of OSA in uncomplicated adults presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA.
- The need for, and appropriateness of, an HSAT must be based on the individual's medical history and a face-to-face examination by a physician, either in person or via telemedicine;
- An HSAT is a medical assessment that must be ordered by a physician to diagnose OSA or evaluate treatment efficacy;
- An HSAT should not be used for general screening of asymptomatic populations; diagnosis, assessment of treatment efficacy, and treatment decisions must not be based solely on automatically scored HSAT data, which could lead to sub-optimal care that jeopardizes individual health and safety;
- The raw data from the HSAT device must be reviewed and interpreted by a physician who is either board-certified in sleep medicine or overseen by a board-certified sleep medicine physician.
Use of Actigraphy in Adult and Pediatric [Individuals] – 2018
AASM recommendations are intended as a guide for clinicians using actigraphy in evaluating individuals with sleep disorders and circadian rhythm sleep-wake disorders, and only apply to the use of FDA-approved devices.
Each recommendation statement is assigned a strength (“Strong” or “Conditional”).
- A “Strong” recommendation (i.e., “We recommend…”) 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 individual-care strategy for all individuals. The ultimate judgment regarding any specific care must be made by the treating clinician and the individual, taking into consideration the individual circumstances of the individual, available treatment options, and resources.
- Suggest clinicians use actigraphy to estimate sleep parameters in adult individuals with insomnia disorder.
- Suggest clinicians use actigraphy in the assessment of pediatric individuals with insomnia disorder.
- Suggest clinicians use actigraphy in the assessment of adult individuals with circadian rhythm sleep-wake disorder. (Conditional) 4. We suggest that clinicians use actigraphy in the assessment of pediatric individuals with circadian rhythm sleep-wake disorder.
- Suggest clinicians use actigraphy integrated with home sleep apnea test devices to estimate total sleep time during recording (in the absence of alternative objective measurements of total sleep time) in adult individuals suspected of sleep-disordered breathing.
- Suggest clinicians use actigraphy to monitor total sleep time prior to testing with the Multiple Sleep Latency Test in adult and pediatric individuals with suspected central disorders of hypersomnolence.
- Suggest clinicians use actigraphy to estimate total sleep time in adult individuals with suspected insufficient sleep syndrome.
- Recommend clinicians not use actigraphy in place of electromyography for the diagnosis of periodic limb movement disorder in adult and pediatric individuals.
Treatment of OSA with PAP Therapy – 2019
Based on expert consensus from the AASM, the following good practice statements and their implementation is necessary for appropriate and effective management of individuals with OSA treated with positive airway pressure:
- Treatment of OSA with PAP therapy should be based on a diagnosis of OSA established using objective sleep apnea testing.
- 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.
The following recommendations are intended as a guide for clinicians using PAP to treat OSA in adults. A STRONG (i.e., “We recommend…”) recommendation is one that clinicians should follow under most circumstances. A CONDITIONAL recommendation (i.e., “We suggest…”) reflects a lower degree of certainty regarding the outcome and appropriateness of the individual-care strategy for all individuals. The ultimate judgment regarding any specific care must be made by the treating clinician and the individual, taking into consideration the individual circumstances of the individual, available treatment options, and resources.
- We recommend that clinicians use PAP, compared to no therapy, to treat OSA in adults with excessive sleepiness.
- We suggest that clinicians use PAP, compared to no therapy, to treat OSA in adults with impaired sleep-related quality of life.
- We suggest that clinicians use PAP, compared to no therapy, to treat OSA in adults with comorbid hypertension.
- 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.
- We recommend that clinicians use either CPAP or APAP for ongoing treatment of OSA in adults.
- We suggest that clinicians use CPAP or APAP over BPAP in the routine treatment of OSA in adults.
- We recommend that educational interventions be given with initiation of PAP therapy in adults with OSA.
- We suggest that behavioral and/or troubleshooting interventions be given during the initial period of PAP therapy in adults with OSA.
- We suggest that clinicians use telemonitoring-guided interventions during the initial period of PAP therapy in adults with OSA.