What are the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) vs ISCD (International Sleep Disorders Classification) diagnostic criteria for supine Obstructive Sleep Apnea (OSA)?

From the Guidelines

The DSM-5 does not specifically define supine obstructive sleep apnea as a distinct condition, but rather includes OSA under Sleep-Related Breathing Disorders, while the International Classification of Sleep Disorders (ICSD-3) provides specific criteria for OSA diagnosis, including positional or supine OSA when the supine AHI is at least twice the non-supine AHI, with a supine AHI ≥5, as stated in the American Academy of Sleep Medicine position statement 1.

Diagnostic Criteria

The diagnostic criteria for OSA in the DSM-5 require evidence of respiratory disturbance during sleep (apneas, hypopneas, or respiratory effort-related arousals) plus either daytime sleepiness, fatigue, or unrefreshing sleep; or two or more symptoms such as gasping during sleep, loud snoring, or observed apneas.

• The ICSD-3, on the other hand, requires either an AHI (Apnea-Hypopnea Index) ≥5 events/hour with associated symptoms or an AHI ≥15 regardless of symptoms, as outlined in the clinical practice guideline for diagnostic testing for adult obstructive sleep apnea 1.
• For positional or supine OSA specifically, the ICSD-3 recognizes it when the supine AHI is at least twice the non-supine AHI, with a supine AHI ≥5, which is a crucial distinction for treatment planning, including the potential use of positional therapy in addition to standard OSA treatments like CPAP, as emphasized in the clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients 1.

Clinical Importance

The distinction between supine and non-supine OSA is clinically important because patients with primarily supine OSA may benefit from positional therapy alone or as an adjunct to other treatments, potentially improving compliance and outcomes.

• This approach is supported by the American Academy of Sleep Medicine's position on polysomnography for obstructive sleep apnea, which highlights the importance of comprehensive sleep evaluation and accurate diagnostic testing 1.
• Furthermore, the use of portable monitoring for OSA diagnosis should be performed in conjunction with a comprehensive sleep evaluation, ensuring that patients receive appropriate and effective care, as recommended in the clinical practice guideline for diagnostic testing for adult obstructive sleep apnea 1.

From the Research

Diagnostic Criteria for Supine OSA

The diagnostic criteria for supine Obstructive Sleep Apnea (OSA) are not explicitly stated in the provided studies as being different from the general diagnostic criteria for OSA. However, the following points can be noted:

• The DSM-5 does not provide specific diagnostic criteria for supine OSA, but it does provide criteria for OSA in general, which includes symptoms such as snoring, breathing pauses, and daytime sleepiness 2.
• The ISCD also does not provide specific diagnostic criteria for supine OSA, but it does provide criteria for OSA, which includes an apnea-hypopnea index (AHI) of 5 or more per hour 3.
• The diagnosis of OSA, including supine OSA, typically involves overnight polysomnography, which can detect apneic and hypopneic events, as well as other sleep-related parameters 2, 4.
• Home sleep apnea testing can also be used to diagnose OSA, but it may not be as accurate as polysomnography 4, 5.

Key Factors in Diagnosing Supine OSA

Some key factors to consider when diagnosing supine OSA include:

• Symptoms such as snoring, breathing pauses, and daytime sleepiness 2, 4
• Risk factors such as obesity, male sex, age, and specific craniofacial features 4, 5
• The presence of apneic and hypopneic events during sleep, which can be detected using polysomnography or home sleep apnea testing 2, 4, 3, 5
• The impact of supine position on sleep quality and OSA severity, which can be assessed using positional therapy or other treatments 6, 5

Treatment Options for Supine OSA

Treatment options for supine OSA include:

• Positive airway pressure (PAP) therapy, which is the most common treatment for OSA 2, 4, 5
• Positional therapy, which involves avoiding the supine position during sleep 2, 6
• Oral appliances, such as mandibular advancement devices, which can help keep the airway open during sleep 4, 5
• Surgical options, such as upper airway stimulation or maxillomandibular advancement, which can help enlarge the upper airway and reduce OSA severity 6, 5