By Reena Mehra, MD, MS, FAASM, and Dennis Auckley, MD, FAASM
The first American Academy of Sleep Medicine clinical practice guideline addressing the topic of inpatient sleep medicine examines obstructive sleep apnea (OSA) in medically hospitalized adults. To date, the existing clinical paradigm for the diagnosis, management and treatment of OSA has focused on the outpatient arena.
This clinical practice guideline was developed to provide guidance regarding the evaluation and management of OSA in medically hospitalized adults, a setting that is increasingly recognized as an opportunity to identify and manage OSA with the intent to improve clinical outcomes. A multidisciplinary task force of experts and methodologists was convened to conduct a systematic review of the literature utilizing the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology to develop, analyze and assign strengths to recommendations.
The prevalence of moderate-to-severe OSA in medically hospitalized adults is estimated to be 25-77%, depending upon the population studied, and the majority are undiagnosed. Furthermore, OSA is associated with a 17% increased length of stay per whole day increment and 67% increased costs even after accounting for potential confounding factors.
As such, the AASM board of directors determined a critical analysis of the literature was warranted, as 1) this topic represents an area of growing concern, 2) it involves an inherently diverse and complex patient population that may be at risk for worse clinical outcomes attributable to OSA, and 3) a systematic synthesis of the existing literature and knowledge to inform and guide clinical practice is lacking.
The recommendations are as outlined in the table below.
| # | Recommendation |
|---|---|
| 1 | 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 positive airway pressure rather than no in-hospital screening. (Conditional recommendation, low certainty of evidence)
Remarks: Screening may include validated questionnaires and/or screening with overnight high-resolution pulse oximetry. High risk for OSA is defined by signs and symptoms that suggest moderate-to-severe OSA (e.g., excessive daytime somnolence plus two of the following: diagnosed hypertension; habitual loud snoring; witnessed apnea, gasping, or choking and/or association of high-risk comorbidities). |
| 2 | 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 positive airway pressure. (Conditional recommendation, low certainty of evidence)
Remarks: A good practice statement was issued for medically hospitalized adults with an established diagnosis of sleep-disordered breathing and on active treatment, that existing treatment should be continued rather than withheld unless contraindicated. |
| 3 | 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. (Conditional recommendation, very low certainty of evidence)
Remarks: It is recognized that there will be variability in the availability of hospital-based expertise and resources specific to sleep medicine consultation; therefore, suggestions are provided in terms of the construct of the model of care which will need to be tailored according to the resources and personnel available. |
| 4 | 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. (Conditional recommendation, very low certainty of evidence) |
Certain caveats should be considered with these recommendations:
- The process was initially designed to address sleep-disordered breathing (SDB), i.e., inclusive of disorders such as central sleep apnea and sleep-related hypoventilation, in addition to OSA. As most of the evidence was focused on OSA, and the task force did not believe it was appropriate to extrapolate evidence to non-OSA sleep-related breathing disorders, the guideline is focused on OSA.
- The guideline is not intended to provide guidance on management of hospitalized patients with acute or chronic respiratory failure requiring noninvasive ventilatory support, nor are the recommendations crafted to address OSA considerations in the perioperative surgical or procedural inpatient population.
- It is recognized that the hospital environment can be disruptive to sleep in terms of interruptions of sleep, light exposures and noise; however, these aspects and the consideration of sleep disorders other than SDB (e.g., parasomnias, restless legs syndrome) are not addressed by this guideline.
In summary, the recommendations for medically hospitalized adults support screening for OSA as part of an overall inpatient management pathway. They also call for inpatient PAP therapy for those with newly diagnosed OSA, or with a prior established diagnosis of moderate-to-severe OSA who have not used therapy as outpatients, continued PAP therapy for those with an established diagnosis of moderate-to-severe OSA already on outpatient PAP therapy, inpatient sleep medicine consultative services when feasible, and an OSA-focused peri-discharge management plan. There was insufficient evidence to provide recommendations specific to the utility of inpatient physiological monitoring in the hospitalized medical patient with OSA.
There are many opportunities for future investigation to better inform the benefits and value of approaches to diagnosis and management of SDB in the inpatient setting. Rigorously conducted studies are needed to examine the effectiveness of optimal objective and subjective screening approaches, diagnostic testing approaches, and OSA interventions in the inpatient setting. High-priority areas for future studies include: the approaches to care for those with established or suspected OSA and other forms of SDB in those with highly complex cardiopulmonary pathophysiology (e.g., hypoventilation syndromes and central sleep apnea), utility of inpatient physiological monitoring to detect early warning signs of a deteriorating clinical state, cost benefit analyses, and models of consultative and peri-discharge care. Importantly, improved coverage of inpatient sleep testing and services will be a key driver of addressing inpatient gaps in sleep medicine care.
Acknowledgments: Martha E. Billings, MD; Gerard Carandang, MS; Yngve Falck-Ytter, MD; Karin G. Johnson, MD, FAAN, FAASM; Rami N. Khayat, MD, FAASM; Reem A. Mustafa, MD; Susheel P. Patil, MD, PhD, FAASM; Cinthya Pena-Orbea, MD; Ashima S. Sahni, MD, FAASM; Sunil Sharma, MD, FAASM
