What is the recommended approach for screening and diagnosing sleep apnea?

Screening and Diagnosis of Sleep Apnea

All adults should be routinely screened for snoring during health maintenance visits, and those with habitual snoring require comprehensive sleep evaluation followed by objective testing with polysomnography (PSG) or home sleep apnea testing (HSAT) to diagnose obstructive sleep apnea—clinical tools and questionnaires alone cannot diagnose OSA. 1

Screening Approach

Routine Screening Questions

• Ask about snoring at every routine health visit, as this is the most sensitive screening measure for OSA 1
• Inquire specifically about: witnessed apneas, nocturnal choking or gasping, restlessness during sleep, and excessive daytime sleepiness 1
• Screen for associated medical conditions: obesity, hypertension, stroke, congestive heart failure, and diabetes 1

High-Risk Features Requiring Evaluation

Patients presenting with excessive daytime sleepiness plus at least two of the following warrant comprehensive sleep evaluation 1:

• Habitual loud snoring
• Witnessed apneas, gasping, or choking
• Diagnosed hypertension

Comprehensive Sleep Evaluation

Before any diagnostic testing, perform a thorough sleep-oriented history and physical examination focusing on 1:

History Components

• Complete sleep history including sleep duration, quality, and timing 1
• Snoring patterns, witnessed breathing interruptions, nocturnal choking 1
• Daytime symptoms: sleepiness, fatigue, morning headaches, cognitive impairment 1
• Screen for other sleep disorders (insomnia, restless legs syndrome, narcolepsy) 1

Physical Examination

• Respiratory system: upper airway anatomy, nasal patency, oropharyngeal crowding 1
• Cardiovascular system: blood pressure, signs of heart failure, arrhythmias 1
• Neurologic system: cranial nerve function, signs of stroke or neuromuscular disease 1
• Body mass index and neck circumference 1

Diagnostic Testing Algorithm

Clinical Tools and Questionnaires

Do NOT use clinical tools, questionnaires, or prediction algorithms (such as STOP-BANG, Epworth Sleepiness Scale, or Berlin Questionnaire) to diagnose OSA—they have low diagnostic accuracy and cannot substitute for objective testing. 1 These tools may help identify high-risk patients requiring evaluation but are insufficient for diagnosis 1.

Objective Testing Selection

For uncomplicated patients with suspected moderate-to-severe OSA:

• Use either PSG or HSAT with a technically adequate device 1
• HSAT is appropriate for patients without significant comorbidities 1

PSG is mandatory (not HSAT) for patients with: 1

• Significant cardiorespiratory disease (heart failure, COPD, pulmonary hypertension)
• Potential respiratory muscle weakness from neuromuscular conditions
• Awake hypoventilation or suspected sleep-related hypoventilation
• Chronic opioid medication use
• History of stroke
• Severe insomnia
• Symptoms suggesting other sleep disorders

Follow-Up Testing

If HSAT is negative, inconclusive, or technically inadequate, proceed immediately to PSG 1 rather than repeating HSAT, as false negatives are common with home testing 1.

If initial PSG is negative but clinical suspicion remains high, consider a second PSG 1 as night-to-night variability can occur 1.

Critical Pitfalls to Avoid

Common Diagnostic Errors

• Never rely on absence of daytime sleepiness to rule out OSA—many patients with severe OSA (AHI >30) do not report sleepiness 1, 2
• Do not trust self-reported symptoms alone—studies show 78% of drivers with confirmed OSA denied snoring and sleepiness 1
• History and physical examination alone cannot differentiate primary snoring from OSA—objective testing is always required 1

Testing Supervision Requirements

• All diagnostic testing must be performed by an accredited sleep center under supervision of a board-certified sleep medicine physician 1
• Comprehensive follow-up after testing is mandatory to ensure appropriate interpretation and treatment initiation 1

Special Populations

• Children: Screen for snoring at all health maintenance visits; if present, perform detailed evaluation as history/exam alone are inadequate 1
• Commercial drivers and safety-sensitive workers: Objective measures (BMI, comorbidities) are more reliable than symptom reporting for screening 1

Diagnostic Criteria

OSA is diagnosed when either 1, 2:

• ≥5 obstructive respiratory events per hour (apneas, hypopneas, or respiratory effort-related arousals) plus symptoms (daytime sleepiness, snoring, witnessed apneas, or awakenings with gasping/choking)
• ≥15 obstructive respiratory events per hour even without symptoms, due to increased cardiovascular disease risk 1, 2