Obstructive sleep apnea (OSA) is a common sleep disorder affecting up to 38% of adults. The disorder occurs when the upper airway collapses during sleep causing partial or full obstruction of airflow. OSA is more common with increasing age and body mass index (BMI). Patients may complain of loud snoring, gasping or choking during sleep, excessive daytime sleepiness, headaches, and irritability. Prompt diagnosis and appropriate management are important to avoid potential long-term sequelae like cardiovascular disease and metabolic syndrome.
In this side-by-side comparison, we look at the latest clinical practice guidelines from the American Academy of Sleep Medicine (AASM) and the Veterans Health Administration/Department of Defense (VA/DoD) on obstructive sleep apnea.
Guidelines for Comparison
| Item | Evaluation and Management of Obstructive Sleep Apnea in Adults Hospitalized for Medical Care: an American Academy of Sleep Medicine Clinical Practice Guideline | Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea |
|---|---|---|
| Authoring Organization | American Academy of Sleep Medicine | Veterans Health Administration/Department of Defense |
| Date Published | August 2025 | February 2025 |
| Graded Recommendations | Yes | Yes |
| Uses GRADE | Yes | Yes |
| Links | Summary / Full Text | Summary / Full Text |
Key Takeaways
Patient Population:
- The AASM recommendations are intended for medically hospitalized adults.
- The VA/DoD recommendations are intended for the evaluation and management of OSA in all adults.
Screening:
- Both guidelines recommend screening for OSA.
- AASM suggests in-patient screening for OSA.
- VA/DoD suggests screening be done using a validated tool like the STOP questionnaire.
Diagnosis:
- AASM does not address diagnostic testing for OSA, but does recommend a sleep medicine consultation and a discharge plan that ensure timely diagnosis and management of OSA.
- The VA/DoD recommends polysomnography or home sleep apnea testing for the diagnosis of OSA.
Treatment:
- The only treatment recommendation from the AASM in this guideline is that medically hospitalized adults with OSA be treated with positive airway pressure (PAP).
- The VA/DoD makes 13 treatment recommendations for OSA.
- Mandibular advancement devices:
- First-line option for mild to moderate OSA.
- Positive airway pressure (PAP):
- First-line option for mild to moderate OSA.
- Suggest starting with auto-titrating over fixed continuous positive airway pressure to facilitate usage by making treatment more comfortable for patients.
- For certain patients, up to a two-week course of eszopiclone is suggested to improve positive airway pressure usage.
- Referral for surgical evaluation:
- For patients with anatomical nasal obstruction.
- Weight management:
- In combination with other therapies for patients with overweight or obesity.
- Positional therapy:
- For adults with positional OSA.
- Hypoglossal nerve stimulation therapy:
- For certain patients who were not successfully treated with PAP.
- Medication for day-time sleepiness:
- For those with successfully treated OSA who still have residual day-time sleepiness the following may be offered:
- Armodafinil
- Modafinil
- Solriamfetol
- For those with successfully treated OSA who still have residual day-time sleepiness the following may be offered:
- The VA/DoD also made several recommendations against therapies and found insufficient evidence to make a recommendation for or against several other therapies. These can be found in the table below, but are not reviewed in detail here.
Comparison of Recommendations
| Type | AASM | VA/DoD |
|---|---|---|
| Screening | For medically hospitalized adults at increased risk for OSA, the AASM suggests in-hospital screening for OSA as part of an evaluation and management pathway that incorporates diagnosis and treatment with PAP rather than no in-hospital screening. | For screening of patients with sleep complaints, we suggest using validated screening instruments for both insomnia (e.g., Insomnia Severity Index or Athens Insomnia Scale) and obstructive sleep apnea (e.g., STOP) to identify patients who need further evaluation. |
| Diagnosis | For medically hospitalized adults at increased risk for or with an established diagnosis of OSA, the AASM suggests that sleep medicine consultation be available as part of an evaluation and management pathway, rather than no sleep medicine consultation. For medically hospitalized adults at increased risk for or with an established diagnosis of OSA, the AASM suggests a discharge management plan to ensure timely diagnosis and effective management of OSA, rather than no plan. | For diagnosis of clinically suspected obstructive sleep apnea, we recommend diagnosis with polysomnography or home sleep apnea testing. For diagnosis of obstructive sleep apnea in appropriate patients, we suggest home sleep apnea testing as an alternative to in-laboratory polysomnography. For diagnosis of patients with a non-diagnostic home sleep apnea test, we recommend further sleep testing for obstructive sleep apnea with in-lab polysomnography or HSAT. |
| Treatment | For medically hospitalized adults with newly diagnosed OSA, or with a prior established diagnosis of moderate-to-severe OSA but not currently on treatment, the AASM suggests the use of inpatient treatment with PAP rather than no PAP. | For treatment of obstructive sleep apnea, we recommend one or more of the following evidence-based therapies, depending on patient values and characteristics: Mandibular advancement devices, positive airway pressure (PAP), and referral for surgical evaluation. For treatment of mild to moderate obstructive sleep apnea (Event Index <30 per hour), we suggest either mandibular advancement devices or positive airway pressure as first line therapy options. For treatment of newly diagnosed obstructive sleep apnea, we suggest initiating auto-titrating over fixed continuous positive airway pressure to facilitate usage. For treatment of obstructive sleep apnea in patients with overweight or obesity, we suggest evidence-based weight management in combination with other treatments for obstructive sleep apnea. (See VA/DOD CPG on Management of Overweight and Obesity). For treatment of positional obstructive sleep apnea, we suggest positional therapy. For treatment of obstructive sleep apnea in appropriate patients (including with an apnea hypopnea index of 15 or greater per hour) who have not been successful with positive airway pressure therapy, we suggest referral for evaluation for hypoglossal nerve stimulation therapy. For treatment of obstructive sleep apnea in patients who cannot tolerate other recommended therapies, we suggest against oxygen therapy as a standalone treatment. For treatment of obstructive sleep apnea, we suggest against atomoxetine or a combination of atomoxetine and oxybutynin. For treatment of obstructive sleep apnea there is insufficient evidence to suggest for or against these interventions: Expiratory positive airway pressure (EPAP), inspiratory muscle therapy, intra-oral negative airway pressure, myofunctional exercise, neuromuscular electrical stimulation, transcutaneous electrical nerve stimulation (TENS). For treatment of obstructive sleep apnea in patients who are prescribed positive airway pressure therapy, we suggest the use of in-person or telehealth educational, behavioral, and supportive interventions to improve PAP usage. For treatment of obstructive sleep apnea in appropriate patients, we suggest up to a two-week course of eszopiclone to improve positive airway pressure usage. For treatment of obstructive sleep apnea in patients with anatomical nasal obstruction as a barrier to positive airway pressure use, we suggest evaluation for nasal surgery. For treatment of obstructive sleep apnea-related residual excessive daytime sleepiness in patients who are optimally treated with sufficient therapy use, we suggest adding: Armodafinil, Modafinil, Solriamfetol. |
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