AASM Releases First Guideline for Inpatient OSA Management

The American Academy of Sleep Medicine (AASM) has introduced its first clinical practice guideline specifically for managing obstructive sleep apnea (OSA) in hospitalized adults. This is significant because many patients with OSA go unrecognized during hospital stays, leading to longer recovery times and higher costs. The new guideline aims to improve patient care by outlining a clear approach to evaluating and managing OSA in the inpatient hospital setting.

Why it matters

This guideline change is important because it addresses a gap in the care of hospitalized patients who may suffer from OSA, a condition that affects breathing during sleep. With the right tools and screening methods in place, healthcare providers can identify these patients earlier. Improved recognition and management could lead to better health outcomes and shorter hospital stays, ultimately benefiting both patients and healthcare systems. As awareness grows, addressing sleep issues in hospitals could transform patient care by focusing on holistic recovery.

Led by a Task Force of Experts

The AASM commissioned a task force of experts in sleep medicine to develop recommendations and assign strengths based on a systematic review of the literature and an assessment of the evidence using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The assembled task force provided a summary of the relevant literature and the certainty of evidence, the balance between benefits and harms, patient values and preferences, and resource considerations that support the recommendations.

The final resulting Good Practice Statement was based on expert consensus. Its implementation is necessary for the appropriate and effective management of hospitalized adults with sleep-disordered breathing. For medically hospitalized adults with an established diagnosis of sleep-disordered breathing and on active treatment, existing treatment should be continued rather than withheld, unless contraindicated.

Recommendations

The agreed-upon recommendations are intended as a guide for clinicians in managing medically hospitalized adults with OSA. Each recommendation statement is assigned a strength – either Strong or Conditional. A “Strong” recommendation is one that clinicians should follow under most circumstances. A “Conditional” recommendation requires that the clinician use clinical knowledge and experience and strongly consider the patient’s values and preferences to determine the best course of action.

In addition to the one Good Practice Statement, there were four conditional recommendations for patients who are hospitalized with an acute illness:

• Recommendation 1: For adults at increased risk of OSA, in-hospital screening is recommended as part of a pathway that incorporates diagnosis and positive airway pressure (PAP) treatment, rather than no screening (conditional, low certainty). Screening can use validated questionnaires and/or overnight high-resolution pulse oximetry.
• Remarks: Screening may include validated questionnaires and/or screening with overnight high-resolution pulse oximetry. When considering in-hospital screening as part of a management pathway, (1) patients who place a lower value on the potential reduction of clinically meaningful outcomes (eg, cardiovascular events) and place a higher value on the possible downsides associated with the use of PAP (eg, sleep disruption, discomfort), or (2) clinicians who perceive that the diagnosis or management of OSA may interfere with medical care, would reasonably decline OSA screening or PAP during the hospitalization. High risk for OSA is defined by signs and symptoms that suggest moderate-to-severe OSA (eg, excessive daytime somnolence plus 2 of the following: diagnosed hypertension; habitual loud snoring; witnessed apnea, gasping, or choking; and/or association of high-risk comorbidities
• Recommendation 2: For adults with newly diagnosed OSA or with prior moderate to severe OSA not currently treated, inpatient PAP therapy is suggested over no PAP (conditional, low certainty).
• Remarks: When considering in-hospital OSA treatment, (1) patients who place a lower value on the potential reduction of clinically meaningful outcomes (eg, cardiovascular events) and place a higher value on the possible downsides associated with the use of PAP (eg, sleep disruption, discomfort), or (2) clinicians who perceive that the diagnosis or management of OSA may interfere with medical care, would reasonably decline OSA screening or PAP during the hospitalization.
• Recommendation 3: For adults at increased risk for or with established OSA, the AASM suggests that sleep medicine consultation be available within an evaluation and management pathway (conditional, very low certainty).
• Remarks: It is recognized that there will be variability in the availability of hospital-based expertise and resources specific to sleep medicine consultation; therefore, we provide specific guidance as follows. Oversight by a board-certified sleep medicine clinician and/or an AASM-accredited sleep center is preferable. However, elements of this consultation, including education and follow-up plan, can be provided by those with requisite expertise, including advanced practitioners, nurses, sleep technologists, respiratory therapists, care coordinators, case managers, health educators, or other available resource personnel. Given the variability of expertise and resources available, creative consultation models of care such as teleconsult/telehealth, E-consult, and/or nursing or respiratory therapist care can be considered. Availability of inpatient diagnostics and treatment as part of the consultation should be taken into consideration in terms of the feasibility of implementation of this recommendation.
• Recommendation 4: For adults at increased risk for or with established OSA, the AASM suggests a discharge management plan to ensure timely diagnosis and effective management, rather than no plan (conditional, very low certainty).
• Remarks: Consider ordering post-discharge testing or sleep medicine evaluation prior to discharge. Inpatient sleep testing prior to discharge and/or telehealth medicine may be an option to reduce barriers to care. Consider care coordination to ensure appropriate follow-up and postdischarge care.

Who it affects

Patients who are already hospitalized for other illnesses may be most impacted by this new guideline, as many of them might have undiagnosed OSA. Healthcare providers, including doctors and nurses, will play a critical role in adopting these recommendations. Additionally, hospitals and healthcare systems will need to consider how to implement these guidelines effectively, incorporating new technologies and staffing needs.

What is OSA?

OSA is a serious chronic medical condition, although it is very common, and perhaps one of the most fatal sleep disorders because of repeated cycles of typically above-airway collapse during sleep that result in intermittent hypoxia, sleep fragmentation, and excessive sleepiness during the daytime. It has been estimated to affect nearly 936 million adults aged between 30 and 69 worldwide. As of 2024, an estimated 83.7 million (32.4%) adults in the United States have OSA. Prevalence also increases with age; individuals 50 years or older, and many women, develop the disorder as men do. The increasing prevalence of OSA is also related to the rising rates of obesity.

OSA significantly affects cardiovascular health, behavioral conditions, quality of life, and driving safety. Complications from OSA include:

• Hypertension
• Myocardial infarction
• Atrial fibrillation
• Congestive heart failure
• Cerebrovascular accident
• Depression
• Sleeplessness-related accidents

Managing OSA requires a multi-factorial approach that should be tailored to each patient. Continuous positive airway pressure (CPAP) is the most effective treatment for adults with OSA. Bilevel PAP is also better tolerated by patients who require higher pressure settings (>15 cm H2O). However, despite the high efficacy of CPAP in eliminating respiratory events, its effectiveness is limited by decreased usage during sleep and poor adherence.

In the inpatient hospital setting, the presence of OSA can influence the outcomes of the patient’s acute illness, length of hospital stay, and discharge planning. While there is a paucity of data on sleep disorders in patients who are hospitalized, understanding the management of OSA in the inpatient setting is important for inpatient management.

Research shows that certain patient populations in the inpatient setting require additional considerations, like patients with chronic heart failure (CHF), patients with pulmonary disorders and infections, as well as patients diagnosed with a cerebrovascular accident (CVA) or a transient ischemic attack (TIA). In particular, patients with both OSA and chronic obstructive pulmonary disorder (COPD) are termed to have overlap syndrome. This unique patient population has more profound nocturnal hypoxemia than patients with either individual condition. Managing overlap syndrome requires the concurrent treatment of both conditions. CPAP continues to be an accepted treatment for overlap syndrome and has been shown to improve respiratory lab values (eg, PaO2, PCO2, pulmonary artery pressures, etc.). This specific patient population will most likely benefit greatly from the updated guidelines regarding inpatient screening questions and treatment of OSA during hospital stays.

What changes

• The authors indicated several notable challenges with developing the guidelines that are unique to the inpatient setting:
• Staying focused on OSA in this population when patients may also have complicated sleep-disordered breathing, including hypoventilation or central sleep apnea
• Working with a literature base lacking in large studies using well-controlled designs that consider no intervention comparisons
• Deciding whether testing and treatment initiated shortly following discharge should be considered part of an inpatient-initiated process
• Hospitals are encouraged to routinely screen patients for OSA, improving early detection and treatment options during hospital stays.
• Patients diagnosed with OSA will be offered effective management strategies, such as continuous positive airway pressure (CPAP) therapy, while still hospitalized.
• Clear discharge plans will be developed for patients with OSA to ensure that they receive timely follow-up care, patient education, and appropriate resources to reduce the risk of readmission.
• Managing OSA is most effectively achieved through an interprofessional team that includes a sleep specialist, primary care provider, cardiologist, otolaryngologist, dietitian, pulmonologist, neurologist, and nurses.

References

1. https://pmc.ncbi.nlm.nih.gov/articles/PMC12071658/
2. https://pubmed.ncbi.nlm.nih.gov/40957495/
3. https://www.mdpi.com/2076-3417/13/4/2108
4. https://pubmed.ncbi.nlm.nih.gov/40838698/