[Skip to Navigation]
Sign In
Figure 1.  Analytic Framework and Key Questions: Screening for Obstructive Sleep Apnea in Adults
Analytic Framework and Key Questions: Screening for Obstructive Sleep Apnea in Adults

Evidence reviews for the US Preventive Services Task Force (USPSTF) use an analytic framework to visually display the key questions that the review will address to allow the USPSTF to evaluate the effectiveness and safety of a preventive service. The questions are depicted by linkages that relate interventions and outcomes. A dashed line depicts a health outcome that follows an intermediate outcome. For additional information, see the USPSTF Procedure Manual.12 AHI indicates apnea/hypopnea index; MAD, mandibular advancement device; OSA, obstructive sleep apnea; PAP, positive airway pressure.

Figure 2.  Literature Search Flow Diagram: Screening for Obstructive Sleep Apnea in Adults
Literature Search Flow Diagram: Screening for Obstructive Sleep Apnea in Adults

The sum of the number of studies per key question (KQ) exceeds the total number of studies because some studies were applicable to multiple KQs. USPSTF indicates US Preventive Services Task Force.

Figure 3.  Comparison of Positive Airway Pressure vs Inactive Control for Change in ESS
Comparison of Positive Airway Pressure vs Inactive Control for Change in ESS

ESS indicates Epworth Sleepiness Scale; OSA, obstructive sleep apnea; PAP, positive airway pressure.

Table 1.  Characteristics of Included Studies Assessing the Accuracy of Clinical Prediction Tools or Screening Questionnaires (KQ2)
Characteristics of Included Studies Assessing the Accuracy of Clinical Prediction Tools or Screening Questionnaires (KQ2)
Table 2.  Results of Included Studies Assessing the Accuracy of Clinical Prediction Tools or Screening Questionnaires (KQ2)
Results of Included Studies Assessing the Accuracy of Clinical Prediction Tools or Screening Questionnaires (KQ2)
Table 3.  Summary of Pooled Findings from Positive Airway Pressure Treatment Studies
Summary of Pooled Findings from Positive Airway Pressure Treatment Studies
Table 4.  Summary of Evidence for Screening and Treatment of Obstructive Sleep Apnea
Summary of Evidence for Screening and Treatment of Obstructive Sleep Apnea
1.
Osman  AM, Carter  SG, Carberry  JC, Eckert  DJ.  Obstructive sleep apnea: current perspectives.   Nat Sci Sleep. 2018;10:21-34. doi:10.2147/NSS.S124657PubMedGoogle ScholarCrossref
2.
Faber  J, Faber  C, Faber  AP.  Obstructive sleep apnea in adults.   Dental Press J Orthod. 2019;24(3):99-109. doi:10.1590/2177-6709.24.3.099-109.sarPubMedGoogle ScholarCrossref
3.
Veasey  SC, Rosen  IM.  Obstructive sleep apnea in adults.   N Engl J Med. 2019;380(15):1442-1449. doi:10.1056/NEJMcp1816152PubMedGoogle ScholarCrossref
4.
Benjafield  AV, Ayas  NT, Eastwood  PR,  et al.  Estimation of the global prevalence and burden of obstructive sleep apnoea: a literature-based analysis.   Lancet Respir Med. 2019;7(8):687-698. doi:10.1016/S2213-2600(19)30198-5PubMedGoogle ScholarCrossref
5.
Peppard  PE, Young  T, Barnet  JH, Palta  M, Hagen  EW, Hla  KM.  Increased prevalence of sleep-disordered breathing in adults.   Am J Epidemiol. 2013;177(9):1006-1014. doi:10.1093/aje/kws342PubMedGoogle ScholarCrossref
6.
Bixler  EO, Vgontzas  AN, Lin  HM,  et al.  Prevalence of sleep-disordered breathing in women: effects of gender.   Am J Respir Crit Care Med. 2001;163(3 Pt 1):608-613. doi:10.1164/ajrccm.163.3.9911064PubMedGoogle ScholarCrossref
7.
Bixler  EO, Vgontzas  AN, Ten Have  T, Tyson  K, Kales  A.  Effects of age on sleep apnea in men, I: prevalence and severity.   Am J Respir Crit Care Med. 1998;157(1):144-148. doi:10.1164/ajrccm.157.1.9706079PubMedGoogle ScholarCrossref
8.
Young  T, Shahar  E, Nieto  FJ,  et al; Sleep Heart Health Study Research Group.  Predictors of sleep-disordered breathing in community-dwelling adults: the Sleep Heart Health Study.   Arch Intern Med. 2002;162(8):893-900. doi:10.1001/archinte.162.8.893PubMedGoogle ScholarCrossref
9.
Balk  EM, Moorthy  D, Obadan  NO,  et al.  Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Agency for Healthcare Research and Quality; 2011.
10.
Knauert  M, Naik  S, Gillespie  MB, Kryger  M.  Clinical consequences and economic costs of untreated obstructive sleep apnea syndrome.   World J Otorhinolaryngol Head Neck Surg. 2015;1(1):17-27. doi:10.1016/j.wjorl.2015.08.001PubMedGoogle ScholarCrossref
11.
Bibbins-Domingo  K, Grossman  DC, Curry  SJ,  et al; US Preventive Services Task Force.  Screening for obstructive sleep apnea in adults: US Preventive Services Task Force recommendation statement.   JAMA. 2017;317(4):407-414. doi:10.1001/jama.2016.20325PubMedGoogle ScholarCrossref
12.
US Preventive Services Task Force. US Preventive Services Task Force Procedure Manual. Updated May 2021. Accessed October 11, 2022. https://www.uspreventiveservicestaskforce.org/uspstf/procedure-manual
13.
Feltner  C, Jonas  DE, Wallace  I, Aymes  S, Hicks  K, Cook Middleton  J.  Screening for Obstructive Sleep Apnea in Adults: an Evidence Review for the US Preventive Services Task Force. Evidence Synthesis No. 220. Agency for Healthcare Research and Quality; 2022. AHRQ publication 22-05292-EF-1.
14.
 Human Development Report 2020: The Next Frontier: Human Development and the Anthropocene. United Nations Development Program; 2020.
15.
Whiting  PF, Rutjes  AW, Westwood  ME,  et al; QUADAS-2 Group.  QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies.   Ann Intern Med. 2011;155(8):529-536. doi:10.7326/0003-4819-155-8-201110180-00009PubMedGoogle ScholarCrossref
16.
Shea  BJ, Grimshaw  JM, Wells  GA,  et al.  Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews.   BMC Med Res Methodol. 2007;7:10. doi:10.1186/1471-2288-7-10PubMedGoogle ScholarCrossref
17.
West  SL, Gartlehner  G, Mansfield  AJ,  et al. Comparative Effectiveness Review Methods: Clinical Heterogeneity. Report 10-EHC070-EF. Agency for Healthcare Research and Quality. Published 2010. Accessed October 11, 2022. https://pubmed.ncbi.nlm.nih.gov/21433337/
18.
StataCorp. StataCorp LP; 2019.
19.
Higgins  JP, Thompson  SG.  Quantifying heterogeneity in a meta-analysis.   Stat Med. 2002;21(11):1539-1558. doi:10.1002/sim.1186PubMedGoogle ScholarCrossref
20.
Higgins  JP, Thompson  SG, Deeks  JJ, Altman  DG.  Measuring inconsistency in meta-analyses.   BMJ. 2003;327(7414):557-560. doi:10.1136/bmj.327.7414.557PubMedGoogle ScholarCrossref
21.
Higgins  J, Thomas  J, Chandler  J,  et al. Cochrane Handbook for Systematic Reviews of Interventions. Version 6.3. Cochrane. Published 2022. Accessed October 11, 2022. https://training.cochrane.org/handbook
22.
Hrubos-Strøm  H, Randby  A, Namtvedt  SK,  et al.  A Norwegian population-based study on the risk and prevalence of obstructive sleep apnea: the Akershus Sleep Apnea Project (ASAP).   J Sleep Res. 2011;20(1, pt 2):162-170. doi:10.1111/j.1365-2869.2010.00861.xPubMedGoogle ScholarCrossref
23.
Morales  CR, Hurley  S, Wick  LC,  et al.  In-home, self-assembled sleep studies are useful in diagnosing sleep apnea in the elderly.   Sleep. 2012;35(11):1491-1501. doi:10.5665/sleep.2196PubMedGoogle ScholarCrossref
24.
Gurubhagavatula  I, Fields  BG, Morales  CR,  et al.  Screening for severe obstructive sleep apnea syndrome in hypertensive outpatients.   J Clin Hypertens (Greenwich). 2013;15(4):279-288. doi:10.1111/jch.12073PubMedGoogle ScholarCrossref
25.
Edmonds  PJ, Gunasekaran  K, Edmonds  LC.  Neck grasp predicts obstructive sleep apnea in type 2 diabetes mellitus.   Sleep Disord. 2019;2019:3184382. doi:10.1155/2019/3184382PubMedGoogle ScholarCrossref
26.
Jorge  C, Benítez  I, Torres  G,  et al.  The STOP-Bang and Berlin questionnaires to identify obstructive sleep apnoea in Alzheimer’s disease patients.   Sleep Med. 2019;57:15-20. doi:10.1016/j.sleep.2019.01.033PubMedGoogle ScholarCrossref
27.
Shin  C, Baik  I.  Evaluation of a modified STOP-BANG questionnaire for sleep apnea in adults from the Korean general population.   Sleep Med Res. 2021;12(1):28-35. doi:10.17241/smr.2020.00808Google ScholarCrossref
28.
Selvanathan  J, Waseem  R, Peng  P, Wong  J, Ryan  CM, Chung  F.  Simple screening model for identifying the risk of sleep apnea in patients on opioids for chronic pain.   Reg Anesth Pain Med. 2021;46(10):886-891. doi:10.1136/rapm-2020-102388PubMedGoogle ScholarCrossref
29.
Netzer  NC, Stoohs  RA, Netzer  CM, Clark  K, Strohl  KP.  Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome.   Ann Intern Med. 1999;131(7):485-491. doi:10.7326/0003-4819-131-7-199910050-00002PubMedGoogle ScholarCrossref
30.
Chung  F, Yegneswaran  B, Liao  P,  et al.  STOP questionnaire: a tool to screen patients for obstructive sleep apnea.   Anesthesiology. 2008;108(5):812-821. doi:10.1097/ALN.0b013e31816d83e4PubMedGoogle ScholarCrossref
31.
Farney  RJ, Walker  BS, Farney  RM, Snow  GL, Walker  JM.  The STOP-Bang equivalent model and prediction of severity of obstructive sleep apnea: relation to polysomnographic measurements of the apnea/hypopnea index.   J Clin Sleep Med. 2011;7(5):459-65B. doi:10.5664/JCSM.1306PubMedGoogle ScholarCrossref
32.
Maislin  G, Pack  AI, Kribbs  NB,  et al.  A survey screen for prediction of apnea.   Sleep. 1995;18(3):158-166. doi:10.1093/sleep/18.3.158PubMedGoogle ScholarCrossref
33.
Lloyd-Jones  DM.  Cardiovascular risk prediction: basic concepts, current status, and future directions.   Circulation. 2010;121(15):1768-1777. doi:10.1161/CIRCULATIONAHA.109.849166PubMedGoogle ScholarCrossref
34.
Hosmer  DW, Lemeshow  S.  Applied Logistic Regression. John Wiley & Sons; 2000. doi:10.1002/0471722146
35.
de Vries  GE, Wijkstra  PJ, Houwerzijl  EJ, Kerstjens  HAM, Hoekema  A.  Cardiovascular effects of oral appliance therapy in obstructive sleep apnea: a systematic review and meta-analysis.   Sleep Med Rev. 2018;40:55-68. doi:10.1016/j.smrv.2017.10.004PubMedGoogle ScholarCrossref
36.
Labarca  G, Schmidt  A, Dreyse  J,  et al.  Efficacy of continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea (OSA) and resistant hypertension (RH): systematic review and meta-analysis.   Sleep Med Rev. 2021;58:101446. doi:10.1016/j.smrv.2021.101446PubMedGoogle ScholarCrossref
37.
Patil  SP, Ayappa  IA, Caples  SM, Kimoff  RJ, Patel  SR, Harrod  CG.  Treatment of adult obstructive sleep apnea with positive airway pressure: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment.   J Clin Sleep Med. 2019;15(2):301-334. doi:10.5664/jcsm.7638PubMedGoogle ScholarCrossref
38.
Zhang  D, Luo  J, Qiao  Y, Xiao  Y.  Continuous positive airway pressure therapy in non-sleepy patients with obstructive sleep apnea: results of a meta-analysis.   J Thorac Dis. 2016;8(10):2738-2747. doi:10.21037/jtd.2016.09.40PubMedGoogle ScholarCrossref
39.
Arias  MA, García-Río  F, Alonso-Fernández  A, Mediano  O, Martínez  I, Villamor  J.  Obstructive sleep apnea syndrome affects left ventricular diastolic function: effects of nasal continuous positive airway pressure in men.   Circulation. 2005;112(3):375-383. doi:10.1161/CIRCULATIONAHA.104.501841PubMedGoogle ScholarCrossref
40.
Barbé  F, Mayoralas  LR, Duran  J,  et al.  Treatment with continuous positive airway pressure is not effective in patients with sleep apnea but no daytime sleepiness: a randomized, controlled trial.   Ann Intern Med. 2001;134(11):1015-1023. doi:10.7326/0003-4819-134-11-200106050-00007PubMedGoogle ScholarCrossref
41.
Campos-Rodriguez  F, Grilo-Reina  A, Perez-Ronchel  J,  et al.  Effect of continuous positive airway pressure on ambulatory BP in patients with sleep apnea and hypertension: a placebo-controlled trial.   Chest. 2006;129(6):1459-1467. doi:10.1378/chest.129.6.1459PubMedGoogle ScholarCrossref
42.
Chasens  ER, Korytkowski  M, Sereika  SM, Burke  LE, Drumheller  OJ, Strollo  PJ  Jr.  Improving activity in adults with diabetes and coexisting obstructive sleep apnea.   West J Nurs Res. 2014;36(3):294-311. doi:10.1177/0193945913500567PubMedGoogle ScholarCrossref
43.
Chong  MS, Ayalon  L, Marler  M,  et al.  Continuous positive airway pressure reduces subjective daytime sleepiness in patients with mild to moderate Alzheimer’s disease with sleep disordered breathing.   J Am Geriatr Soc. 2006;54(5):777-781. doi:10.1111/j.1532-5415.2006.00694.xPubMedGoogle ScholarCrossref
44.
Coughlin  SR, Mawdsley  L, Mugarza  JA, Wilding  JP, Calverley  PM.  Cardiovascular and metabolic effects of CPAP in obese males with OSA.   Eur Respir J. 2007;29(4):720-727. doi:10.1183/09031936.00043306PubMedGoogle ScholarCrossref
45.
Durán-Cantolla  J, Aizpuru  F, Montserrat  JM,  et al; Spanish Sleep and Breathing Group.  Continuous positive airway pressure as treatment for systemic hypertension in people with obstructive sleep apnoea: randomised controlled trial.   BMJ. 2010;341:c5991. doi:10.1136/bmj.c5991PubMedGoogle ScholarCrossref
46.
Egea  CJ, Aizpuru  F, Pinto  JA,  et al; Spanish Group of Sleep Breathing Disorders.  Cardiac function after CPAP therapy in patients with chronic heart failure and sleep apnea: a multicenter study.   Sleep Med. 2008;9(6):660-666. doi:10.1016/j.sleep.2007.06.018PubMedGoogle ScholarCrossref
47.
Haensel  A, Norman  D, Natarajan  L, Bardwell  WA, Ancoli-Israel  S, Dimsdale  JE.  Effect of a 2 week CPAP treatment on mood states in patients with obstructive sleep apnea: a double-blind trial.   Sleep Breath. 2007;11(4):239-244. doi:10.1007/s11325-007-0115-0PubMedGoogle ScholarCrossref
48.
Hoyos  CM, Killick  R, Yee  BJ, Phillips  CL, Grunstein  RR, Liu  PY.  Cardiometabolic changes after continuous positive airway pressure for obstructive sleep apnoea: a randomised sham-controlled study.   Thorax. 2012;67(12):1081-1089. doi:10.1136/thoraxjnl-2011-201420PubMedGoogle ScholarCrossref
49.
Hui  DS, To  KW, Ko  FW,  et al.  Nasal CPAP reduces systemic blood pressure in patients with obstructive sleep apnoea and mild sleepiness.   Thorax. 2006;61(12):1083-1090. doi:10.1136/thx.2006.064063PubMedGoogle ScholarCrossref
50.
Jenkinson  C, Davies  RJ, Mullins  R, Stradling  JR.  Comparison of therapeutic and subtherapeutic nasal continuous positive airway pressure for obstructive sleep apnoea: a randomised prospective parallel trial.   Lancet. 1999;353(9170):2100-2105. doi:10.1016/S0140-6736(98)10532-9PubMedGoogle ScholarCrossref
51.
Hack  M, Davies  RJ, Mullins  R,  et al.  Randomised prospective parallel trial of therapeutic versus subtherapeutic nasal continuous positive airway pressure on simulated steering performance in patients with obstructive sleep apnoea.   Thorax. 2000;55(3):224-231. doi:10.1136/thorax.55.3.224PubMedGoogle ScholarCrossref
52.
Jones  A, Vennelle  M, Connell  M,  et al.  The effect of continuous positive airway pressure therapy on arterial stiffness and endothelial function in obstructive sleep apnea: a randomized controlled trial in patients without cardiovascular disease.   Sleep Med. 2013;14(12):1260-1265. doi:10.1016/j.sleep.2013.08.786PubMedGoogle ScholarCrossref
53.
Kushida  CA, Nichols  DA, Holmes  TH,  et al.  Effects of continuous positive airway pressure on neurocognitive function in obstructive sleep apnea patients: the Apnea Positive Pressure Long-term Efficacy Study (APPLES).   Sleep. 2012;35(12):1593-1602. doi:10.5665/sleep.2226PubMedGoogle ScholarCrossref
54.
Batool-Anwar  S, Goodwin  JL, Kushida  CA,  et al.  Impact of continuous positive airway pressure (CPAP) on quality of life in patients with obstructive sleep apnea (OSA).   J Sleep Res. 2016;25(6):731-738. doi:10.1111/jsr.12430PubMedGoogle ScholarCrossref
55.
Lam  JC, Lam  B, Yao  TJ,  et al.  A randomised controlled trial of nasal continuous positive airway pressure on insulin sensitivity in obstructive sleep apnoea.   Eur Respir J. 2010;35(1):138-145. doi:10.1183/09031936.00047709PubMedGoogle ScholarCrossref
56.
Lee  IS, Bardwell  WA, Kamat  R,  et al.  A model for studying neuropsychological effects of sleep intervention: the effect of 3-week continuous positive airway pressure treatment.   Drug Discov Today Dis Models. 2011;8(4):147-154. doi:10.1016/j.ddmod.2011.10.001PubMedGoogle ScholarCrossref
57.
Loredo  JS, Ancoli-Israel  S, Kim  EJ, Lim  WJ, Dimsdale  JE.  Effect of continuous positive airway pressure versus supplemental oxygen on sleep quality in obstructive sleep apnea: a placebo-CPAP-controlled study.   Sleep. 2006;29(4):564-571. doi:10.1093/sleep/29.4.564PubMedGoogle ScholarCrossref
58.
Marshall  NS, Neill  AM, Campbell  AJ, Sheppard  DS.  Randomised controlled crossover trial of humidified continuous positive airway pressure in mild obstructive sleep apnoea.   Thorax. 2005;60(5):427-432. doi:10.1136/thx.2004.032078PubMedGoogle ScholarCrossref
59.
Melehan  KL, Hoyos  CM, Hamilton  GS,  et al.  Randomized trial of CPAP and vardenafil on erectile and arterial function in men with obstructive sleep apnea and erectile dysfunction.   J Clin Endocrinol Metab. 2018;103(4):1601-1611. doi:10.1210/jc.2017-02389PubMedGoogle ScholarCrossref
60.
Montserrat  JM, Ferrer  M, Hernandez  L,  et al.  Effectiveness of CPAP treatment in daytime function in sleep apnea syndrome: a randomized controlled study with an optimized placebo.   Am J Respir Crit Care Med. 2001;164(4):608-613. doi:10.1164/ajrccm.164.4.2006034PubMedGoogle ScholarCrossref
61.
Neikrug  AB, Liu  L, Avanzino  JA,  et al.  Continuous positive airway pressure improves sleep and daytime sleepiness in patients with Parkinson disease and sleep apnea.   Sleep. 2014;37(1):177-185. doi:10.5665/sleep.3332PubMedGoogle ScholarCrossref
62.
Nguyen  PK, Katikireddy  CK, McConnell  MV, Kushida  C, Yang  PC.  Nasal continuous positive airway pressure improves myocardial perfusion reserve and endothelial-dependent vasodilation in patients with obstructive sleep apnea.   J Cardiovasc Magn Reson. 2010;12:50. doi:10.1186/1532-429X-12-50PubMedGoogle ScholarCrossref
63.
Pepperell  JC, Ramdassingh-Dow  S, Crosthwaite  N,  et al.  Ambulatory blood pressure after therapeutic and subtherapeutic nasal continuous positive airway pressure for obstructive sleep apnoea: a randomised parallel trial.   Lancet. 2002;359(9302):204-210. doi:10.1016/S0140-6736(02)07445-7PubMedGoogle ScholarCrossref
64.
Kohler  M, Pepperell  JC, Casadei  B,  et al.  CPAP and measures of cardiovascular risk in males with OSAS.   Eur Respir J. 2008;32(6):1488-1496. doi:10.1183/09031936.00026608PubMedGoogle ScholarCrossref
65.
Phillips  CL, Yee  BJ, Marshall  NS, Liu  PY, Sullivan  DR, Grunstein  RR.  Continuous positive airway pressure reduces postprandial lipidemia in obstructive sleep apnea: a randomized, placebo-controlled crossover trial.   Am J Respir Crit Care Med. 2011;184(3):355-361. doi:10.1164/rccm.201102-0316OCPubMedGoogle ScholarCrossref
66.
Robinson  GV, Smith  DM, Langford  BA, Davies  RJ, Stradling  JR.  Continuous positive airway pressure does not reduce blood pressure in nonsleepy hypertensive OSA patients.   Eur Respir J. 2006;27(6):1229-1235. doi:10.1183/09031936.06.00062805PubMedGoogle ScholarCrossref
67.
Siccoli  MM, Pepperell  JC, Kohler  M, Craig  SE, Davies  RJ, Stradling  JR.  Effects of continuous positive airway pressure on quality of life in patients with moderate to severe obstructive sleep apnea: data from a randomized controlled trial.   Sleep. 2008;31(11):1551-1558. doi:10.1093/sleep/31.11.1551PubMedGoogle ScholarCrossref
68.
Smith  LA, Vennelle  M, Gardner  RS,  et al.  Auto-titrating continuous positive airway pressure therapy in patients with chronic heart failure and obstructive sleep apnoea: a randomized placebo-controlled trial.   Eur Heart J. 2007;28(10):1221-1227. doi:10.1093/eurheartj/ehm131PubMedGoogle ScholarCrossref
69.
Weaver  TE, Mancini  C, Maislin  G,  et al.  Continuous positive airway pressure treatment of sleepy patients with milder obstructive sleep apnea: results of the CPAP Apnea Trial North American Program (CATNAP) randomized clinical trial.   Am J Respir Crit Care Med. 2012;186(7):677-683. doi:10.1164/rccm.201202-0200OCPubMedGoogle ScholarCrossref
70.
West  SD, Nicoll  DJ, Wallace  TM, Matthews  DR, Stradling  JR.  Effect of CPAP on insulin resistance and HbA1c in men with obstructive sleep apnoea and type 2 diabetes.   Thorax. 2007;62(11):969-974. doi:10.1136/thx.2006.074351PubMedGoogle ScholarCrossref
71.
West  SD, Kohler  M, Nicoll  DJ, Stradling  JR.  The effect of continuous positive airway pressure treatment on physical activity in patients with obstructive sleep apnoea: a randomised controlled trial.   Sleep Med. 2009;10(9):1056-1058. doi:10.1016/j.sleep.2008.11.007PubMedGoogle ScholarCrossref
72.
Ballester  E, Badia  JR, Hernández  L,  et al.  Evidence of the effectiveness of continuous positive airway pressure in the treatment of sleep apnea/hypopnea syndrome.   Am J Respir Crit Care Med. 1999;159(2):495-501. doi:10.1164/ajrccm.159.2.9804061PubMedGoogle ScholarCrossref
73.
Banghøj  AM, Krogager  C, Kristensen  PL,  et al.  Effect of 12-week continuous positive airway pressure therapy on glucose levels assessed by continuous glucose monitoring in people with type 2 diabetes and obstructive sleep apnoea: a randomized controlled trial.   Endocrinol Diabetes Metab. 2020;4(2):e00148. doi:10.1002/edm2.148PubMedGoogle ScholarCrossref
74.
Barbé  F, Durán-Cantolla  J, Capote  F,  et al; Spanish Sleep and Breathing Group.  Long-term effect of continuous positive airway pressure in hypertensive patients with sleep apnea.   Am J Respir Crit Care Med. 2010;181(7):718-726. doi:10.1164/rccm.200901-0050OCPubMedGoogle ScholarCrossref
75.
Barbé  F, Durán-Cantolla  J, Sánchez-de-la-Torre  M,  et al; Spanish Sleep and Breathing Network.  Effect of continuous positive airway pressure on the incidence of hypertension and cardiovascular events in nonsleepy patients with obstructive sleep apnea: a randomized controlled trial.   JAMA. 2012;307(20):2161-2168. doi:10.1001/jama.2012.4366PubMedGoogle ScholarCrossref
76.
Barnes  M, McEvoy  RD, Banks  S,  et al.  Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea.   Am J Respir Crit Care Med. 2004;170(6):656-664. doi:10.1164/rccm.200311-1571OCPubMedGoogle ScholarCrossref
77.
Campos-Rodriguez  F, Queipo-Corona  C, Carmona-Bernal  C,  et al; Spanish Sleep Network.  Continuous positive airway pressure improves quality of life in women with obstructive sleep apnea: a randomized controlled trial.   Am J Respir Crit Care Med. 2016;194(10):1286-1294. doi:10.1164/rccm.201602-0265OCPubMedGoogle ScholarCrossref
78.
Craig  SE, Kohler  M, Nicoll  D,  et al.  Continuous positive airway pressure improves sleepiness but not calculated vascular risk in patients with minimally symptomatic obstructive sleep apnoea: the MOSAIC randomised controlled trial.   Thorax. 2012;67(12):1090-1096. doi:10.1136/thoraxjnl-2012-202178PubMedGoogle ScholarCrossref
79.
Dalmases  M, Solé-Padullés  C, Torres  M,  et al.  Effect of CPAP on cognition, brain function, and structure among elderly patients with OSA: a randomized pilot study.   Chest. 2015;148(5):1214-1223. doi:10.1378/chest.15-0171PubMedGoogle ScholarCrossref
80.
Engleman  HM, Martin  SE, Deary  IJ, Douglas  NJ.  Effect of continuous positive airway pressure treatment on daytime function in sleep apnoea/hypopnoea syndrome.   Lancet. 1994;343(8897):572-575. doi:10.1016/S0140-6736(94)91522-9PubMedGoogle ScholarCrossref
81.
Engleman  HM, Martin  SE, Deary  IJ, Douglas  NJ.  Effect of CPAP therapy on daytime function in patients with mild sleep apnoea/hypopnoea syndrome.   Thorax. 1997;52(2):114-119. doi:10.1136/thx.52.2.114PubMedGoogle ScholarCrossref
82.
Engleman  HM, Martin  SE, Kingshott  RN, Mackay  TW, Deary  IJ, Douglas  NJ.  Randomised placebo controlled trial of daytime function after continuous positive airway pressure (CPAP) therapy for the sleep apnoea/hypopnoea syndrome.   Thorax. 1998;53(5):341-345. doi:10.1136/thx.53.5.341PubMedGoogle ScholarCrossref
83.
Engleman  HM, Kingshott  RN, Wraith  PK, Mackay  TW, Deary  IJ, Douglas  NJ.  Randomized placebo-controlled crossover trial of continuous positive airway pressure for mild sleep apnea/hypopnea syndrome.   Am J Respir Crit Care Med. 1999;159(2):461-467. doi:10.1164/ajrccm.159.2.9803121PubMedGoogle ScholarCrossref
84.
Faccenda  JF, Mackay  TW, Boon  NA, Douglas  NJ.  Randomized placebo-controlled trial of continuous positive airway pressure on blood pressure in the sleep apnea-hypopnea syndrome.   Am J Respir Crit Care Med. 2001;163(2):344-348. doi:10.1164/ajrccm.163.2.2005037PubMedGoogle ScholarCrossref
85.
Gottlieb  DJ, Punjabi  NM, Mehra  R,  et al.  CPAP versus oxygen in obstructive sleep apnea.   N Engl J Med. 2014;370(24):2276-2285. doi:10.1056/NEJMoa1306766PubMedGoogle ScholarCrossref
86.
Lewis  EF, Wang  R, Punjabi  N,  et al.  Impact of continuous positive airway pressure and oxygen on health status in patients with coronary heart disease, cardiovascular risk factors, and obstructive sleep apnea: a Heart Biomarker Evaluation in Apnea Treatment (HEARTBEAT) analysis.   Am Heart J. 2017;189:59-67. doi:10.1016/j.ahj.2017.03.001PubMedGoogle ScholarCrossref
87.
Jackson  ML, Tolson  J, Schembri  R,  et al.  Does continuous positive airways pressure treatment improve clinical depression in obstructive sleep apnea? a randomized wait-list controlled study.   Depress Anxiety. 2021;38(5):498-507. doi:10.1002/da.23131PubMedGoogle ScholarCrossref
88.
Jackson  ML, Tolson  J, Bartlett  D, Berlowitz  DJ, Varma  P, Barnes  M.  Clinical depression in untreated obstructive sleep apnea: examining predictors and a meta-analysis of prevalence rates.   Sleep Med. 2019;62:22-28. doi:10.1016/j.sleep.2019.03.011PubMedGoogle ScholarCrossref
89.
Lam  B, Sam  K, Mok  WY,  et al.  Randomised study of three non-surgical treatments in mild to moderate obstructive sleep apnoea.   Thorax. 2007;62(4):354-359. doi:10.1136/thx.2006.063644PubMedGoogle ScholarCrossref
90.
Lim  W, Bardwell  WA, Loredo  JS,  et al.  Neuropsychological effects of 2-week continuous positive airway pressure treatment and supplemental oxygen in patients with obstructive sleep apnea: a randomized placebo-controlled study.   J Clin Sleep Med. 2007;3(4):380-386. doi:10.5664/jcsm.26860PubMedGoogle ScholarCrossref
91.
Lui  MMS, Mak  JCW, Chong  PWC, Lam  DCL, Ip  MSM.  Circulating adipocyte fatty acid-binding protein is reduced by continuous positive airway pressure treatment for obstructive sleep apnea—a randomized controlled study.   Sleep Breath. 2020;24(3):817-824. doi:10.1007/s11325-019-01893-5PubMedGoogle ScholarCrossref
92.
Martínez-García  MA, Capote  F, Campos-Rodríguez  F,  et al; Spanish Sleep Network.  Effect of CPAP on blood pressure in patients with obstructive sleep apnea and resistant hypertension: the HIPARCO randomized clinical trial.   JAMA. 2013;310(22):2407-2415. doi:10.1001/jama.2013.281250PubMedGoogle ScholarCrossref
93.
Martínez-García  MÁ, Chiner  E, Hernández  L,  et al; Spanish Sleep Network.  Obstructive sleep apnoea in the elderly: role of continuous positive airway pressure treatment.   Eur Respir J. 2015;46(1):142-151. doi:10.1183/09031936.00064214PubMedGoogle ScholarCrossref
94.
Masa  JF, Corral  J, Alonso  ML,  et al; Spanish Sleep Network.  Efficacy of different treatment alternatives for obesity hypoventilation syndrome: Pickwick Study.   Am J Respir Crit Care Med. 2015;192(1):86-95. doi:10.1164/rccm.201410-1900OCPubMedGoogle ScholarCrossref
95.
McArdle  N, Douglas  NJ.  Effect of continuous positive airway pressure on sleep architecture in the sleep apnea-hypopnea syndrome: a randomized controlled trial.   Am J Respir Crit Care Med. 2001;164(8 Pt 1):1459-1463. doi:10.1164/ajrccm.164.8.2008146PubMedGoogle ScholarCrossref
96.
McMillan  A, Bratton  DJ, Faria  R,  et al; PREDICT Investigators.  Continuous positive airway pressure in older people with obstructive sleep apnoea syndrome (PREDICT): a 12-month, multicentre, randomised trial.   Lancet Respir Med. 2014;2(10):804-812. doi:10.1016/S2213-2600(14)70172-9PubMedGoogle ScholarCrossref
97.
Peker  Y, Glantz  H, Eulenburg  C, Wegscheider  K, Herlitz  J, Thunström  E.  Effect of positive airway pressure on cardiovascular outcomes in coronary artery disease patients with nonsleepy obstructive sleep apnea: the RICCADSA randomized controlled trial.   Am J Respir Crit Care Med. 2016;194(5):613-620. doi:10.1164/rccm.201601-0088OCPubMedGoogle ScholarCrossref
98.
Balcan  B, Thunström  E, Strollo  PJ  Jr, Peker  Y.  Continuous positive airway pressure treatment and depression in adults with coronary artery disease and nonsleepy obstructive sleep apnea: a secondary analysis of the RICCADSA Trial.   Ann Am Thorac Soc. 2019;16(1):62-70. doi:10.1513/AnnalsATS.201803-174OCPubMedGoogle ScholarCrossref
99.
Celik  Y, Thunström  E, Strollo  PJ  Jr, Peker  Y.  Continuous positive airway pressure treatment and anxiety in adults with coronary artery disease and nonsleepy obstructive sleep apnea in the RICCADSA trial.   Sleep Med. 2021;77:96-103. doi:10.1016/j.sleep.2020.11.034PubMedGoogle ScholarCrossref
100.
Ponce  S, Pastor  E, Orosa  B,  et al; Sleep Respiratory Disorders Group of the Sociedad Valenciana de Neumología.  The role of CPAP treatment in elderly patients with moderate obstructive sleep apnoea: a multicentre randomised controlled trial.   Eur Respir J. 2019;54(2):1900518. doi:10.1183/13993003.00518-2019PubMedGoogle ScholarCrossref
101.
Redline  S, Adams  N, Strauss  ME, Roebuck  T, Winters  M, Rosenberg  C.  Improvement of mild sleep-disordered breathing with CPAP compared with conservative therapy.   Am J Respir Crit Care Med. 1998;157(3, pt 1):858-865. doi:10.1164/ajrccm.157.3.9709042PubMedGoogle ScholarCrossref
102.
Ruttanaumpawan  P, Gilman  MP, Usui  K, Floras  JS, Bradley  TD.  Sustained effect of continuous positive airway pressure on baroreflex sensitivity in congestive heart failure patients with obstructive sleep apnea.   J Hypertens. 2008;26(6):1163-1168. doi:10.1097/HJH.0b013e3282fb81edPubMedGoogle ScholarCrossref
103.
Kaneko  Y, Floras  JS, Usui  K,  et al.  Cardiovascular effects of continuous positive airway pressure in patients with heart failure and obstructive sleep apnea.   N Engl J Med. 2003;348(13):1233-1241. doi:10.1056/NEJMoa022479PubMedGoogle ScholarCrossref
104.
Salord  N, Fortuna  AM, Monasterio  C,  et al.  A randomized controlled trial of continuous positive airway pressure on glucose tolerance in obese patients with obstructive sleep apnea.   Sleep. 2016;39(1):35-41. doi:10.5665/sleep.5312PubMedGoogle ScholarCrossref
105.
Shaw  JE, Punjabi  NM, Naughton  MT,  et al.  The effect of treatment of obstructive sleep apnea on glycemic control in type 2 diabetes.   Am J Respir Crit Care Med. 2016;194(4):486-492. doi:10.1164/rccm.201511-2260OCPubMedGoogle ScholarCrossref
106.
Tomfohr  LM, Ancoli-Israel  S, Loredo  JS, Dimsdale  JE.  Effects of continuous positive airway pressure on fatigue and sleepiness in patients with obstructive sleep apnea: data from a randomized controlled trial.   Sleep. 2011;34(1):121-126. doi:10.1093/sleep/34.1.121PubMedGoogle ScholarCrossref
107.
Wimms  AJ, Kelly  JL, Turnbull  CD,  et al; MERGE Trial Investigators.  Continuous positive airway pressure versus standard care for the treatment of people with mild obstructive sleep apnoea (MERGE): a multicentre, randomised controlled trial.   Lancet Respir Med. 2020;8(4):349-358. doi:10.1016/S2213-2600(19)30402-3PubMedGoogle ScholarCrossref
108.
Zhao  YY, Wang  R, Gleason  KJ,  et al; BestAIR Investigators.  Effect of continuous positive airway pressure treatment on health-related quality of life and sleepiness in high cardiovascular risk individuals with sleep apnea: Best Apnea Interventions for Research (BestAIR) trial.   Sleep. 2017;40(4):zsx040. doi:10.1093/sleep/zsx040PubMedGoogle ScholarCrossref
109.
Ng  SSS, Chan  TO, To  KW,  et al.  Continuous positive airway pressure for obstructive sleep apnoea does not improve asthma control.   Respirology. 2018;23(11):1055-1062. doi:10.1111/resp.13363PubMedGoogle ScholarCrossref
110.
Celik  Y, Yapici-Eser  H, Balcan  B, Peker  Y.  Association of excessive daytime sleepiness with the Zung self-rated depression subscales in adults with coronary artery disease and obstructive sleep apnea.   Diagnostics (Basel). 2021;11(7):1176. doi:10.3390/diagnostics11071176PubMedGoogle ScholarCrossref
111.
Traaen  GM, Aakerøy  L, Hunt  TE,  et al.  Effect of continuous positive airway pressure on arrhythmia in atrial fibrillation and sleep apnea: a randomized controlled trial.   Am J Respir Crit Care Med. 2021;204(5):573-582. doi:10.1164/rccm.202011-4133OCPubMedGoogle ScholarCrossref
112.
Wallström  S, Balcan  B, Thunström  E, Wolf  A, Peker  Y.  CPAP and health-related quality of life in adults with coronary artery disease and nonsleepy obstructive sleep apnea in the RICCADSA trial.   J Clin Sleep Med. 2019;15(9):1311-1320. doi:10.5664/jcsm.7926PubMedGoogle ScholarCrossref
113.
Weinstock  TG, Wang  X, Rueschman  M,  et al.  A controlled trial of CPAP therapy on metabolic control in individuals with impaired glucose tolerance and sleep apnea.   Sleep. 2012;35(5):617-625B. doi:10.5665/sleep.1816PubMedGoogle ScholarCrossref
114.
Patel  S, Kon  SSC, Nolan  CM,  et al.  The Epworth Sleepiness Scale: minimum clinically important difference in obstructive sleep apnea.   Am J Respir Crit Care Med. 2018;197(7):961-963. doi:10.1164/rccm.201704-0672LEPubMedGoogle ScholarCrossref
115.
Crook  S, Sievi  NA, Bloch  KE,  et al.  Minimum important difference of the Epworth Sleepiness Scale in obstructive sleep apnoea: estimation from three randomised controlled trials.   Thorax. 2019;74(4):390-396. doi:10.1136/thoraxjnl-2018-211959PubMedGoogle ScholarCrossref
116.
Ware  JE  Jr, Sherbourne  CD.  The MOS 36-item short-form health survey (SF-36), I: conceptual framework and item selection.   Med Care. 1992;30(6):473-483. doi:10.1097/00005650-199206000-00002PubMedGoogle ScholarCrossref
117.
Wyrwich  KW, Tierney  WM, Babu  AN, Kroenke  K, Wolinsky  FD.  A comparison of clinically important differences in health-related quality of life for patients with chronic lung disease, asthma, or heart disease.   Health Serv Res. 2005;40(2):577-591. doi:10.1111/j.1475-6773.2005.0l374.xPubMedGoogle ScholarCrossref
118.
Weaver  TE, Crosby  RD, Bron  M, Menno  D, Mathias  SD.  Using multiple anchor-based and distribution-based estimates to determine the Minimal Important Difference (MID) for the FOSQ-10.   Sleep. 2018;41(suppl 1):A227. doi:10.1093/sleep/zsy061.611Google ScholarCrossref
119.
Flemons  WW, Reimer  MA.  Development of a disease-specific health-related quality of life questionnaire for sleep apnea.   Am J Respir Crit Care Med. 1998;158(2):494-503. doi:10.1164/ajrccm.158.2.9712036PubMedGoogle ScholarCrossref
120.
Aarab  G, Lobbezoo  F, Hamburger  HL, Naeije  M.  Oral appliance therapy versus nasal continuous positive airway pressure in obstructive sleep apnea: a randomized, placebo-controlled trial.   Respiration. 2011;81(5):411-419. doi:10.1159/000319595PubMedGoogle ScholarCrossref
121.
Nikolopoulou  M, Aarab  G, Ahlberg  J, Hamburger  HL, de Lange  J, Lobbezoo  F.  Oral appliance therapy versus nasal continuous positive airway pressure in obstructive sleep apnea: a randomized, placebo-controlled trial on temporomandibular side-effects.   Clin Exp Dent Res. 2020;6(4):400-406. doi:10.1002/cre2.288PubMedGoogle ScholarCrossref
122.
Andrén  A, Hedberg  P, Walker-Engström  ML, Wahlén  P, Tegelberg  A.  Effects of treatment with oral appliance on 24-h blood pressure in patients with obstructive sleep apnea and hypertension: a randomized clinical trial.   Sleep Breath. 2013;17(2):705-712. doi:10.1007/s11325-012-0746-7PubMedGoogle ScholarCrossref
123.
Bloch  KE, Iseli  A, Zhang  JN,  et al.  A randomized, controlled crossover trial of two oral appliances for sleep apnea treatment.   Am J Respir Crit Care Med. 2000;162(1):246-251. doi:10.1164/ajrccm.162.1.9908112PubMedGoogle ScholarCrossref
124.
Durán-Cantolla  J, Crovetto-Martínez  R, Alkhraisat  MH,  et al.  Efficacy of mandibular advancement device in the treatment of obstructive sleep apnea syndrome: a randomized controlled crossover clinical trial.   Med Oral Patol Oral Cir Bucal. 2015;20(5):e605-e615. doi:10.4317/medoral.20649PubMedGoogle ScholarCrossref
125.
Naismith  SL, Winter  VR, Hickie  IB, Cistulli  PA.  Effect of oral appliance therapy on neurobehavioral functioning in obstructive sleep apnea: a randomized controlled trial.   J Clin Sleep Med. 2005;1(4):374-380. doi:10.5664/jcsm.26365PubMedGoogle ScholarCrossref
126.
Gotsopoulos  H, Chen  C, Qian  J, Cistulli  PA.  Oral appliance therapy improves symptoms in obstructive sleep apnea: a randomized, controlled trial.   Am J Respir Crit Care Med. 2002;166(5):743-748. doi:10.1164/rccm.200203-208OCPubMedGoogle ScholarCrossref
127.
Gotsopoulos  H, Kelly  JJ, Cistulli  PA.  Oral appliance therapy reduces blood pressure in obstructive sleep apnea: a randomized, controlled trial.   Sleep. 2004;27(5):934-941. doi:10.1093/sleep/27.5.934PubMedGoogle ScholarCrossref
128.
Johnston  CD, Gleadhill  IC, Cinnamond  MJ, Gabbey  J, Burden  DJ.  Mandibular advancement appliances and obstructive sleep apnoea: a randomized clinical trial.   Eur J Orthod. 2002;24(3):251-262. doi:10.1093/ejo/24.3.251PubMedGoogle ScholarCrossref
129.
Quinnell  TG, Bennett  M, Jordan  J,  et al.  A crossover randomised controlled trial of oral mandibular advancement devices for obstructive sleep apnoea-hypopnoea (TOMADO).   Thorax. 2014;69(10):938-945. doi:10.1136/thoraxjnl-2014-205464PubMedGoogle ScholarCrossref
130.
Gagnadoux  F, Pépin  JL, Vielle  B,  et al.  Impact of mandibular advancement therapy on endothelial function in severe obstructive sleep apnea.   Am J Respir Crit Care Med. 2017;195(9):1244-1252. doi:10.1164/rccm.201609-1817OCPubMedGoogle ScholarCrossref
131.
Marklund  M, Carlberg  B, Forsgren  L, Olsson  T, Stenlund  H, Franklin  KA.  Oral appliance therapy in patients with daytime sleepiness and snoring or mild to moderate sleep apnea: a randomized clinical trial.   JAMA Intern Med. 2015;175(8):1278-1285. doi:10.1001/jamainternmed.2015.2051PubMedGoogle ScholarCrossref
132.
Petri  N, Svanholt  P, Solow  B, Wildschiødtz  G, Winkel  P.  Mandibular advancement appliance for obstructive sleep apnoea: results of a randomised placebo controlled trial using parallel group design.   J Sleep Res. 2008;17(2):221-229. doi:10.1111/j.1365-2869.2008.00645.xPubMedGoogle ScholarCrossref
133.
Malow  BA, Foldvary-Schaefer  N, Vaughn  BV,  et al.  Treating obstructive sleep apnea in adults with epilepsy: a randomized pilot trial.   Neurology. 2008;71(8):572-577. doi:10.1212/01.wnl.0000323927.13250.54PubMedGoogle ScholarCrossref
134.
Redline  S. Effects of treatment of sleep apnea on metabolic syndrome. [NCT01385995]. 2014. Accessed October 11, 2022. https://www.clinicaltrials.gov/show/NCT01385995
135.
Goehring  C, Perrier  A, Morabia  A.  Spectrum bias: a quantitative and graphical analysis of the variability of medical diagnostic test performance.   Stat Med. 2004;23(1):125-135. doi:10.1002/sim.1591PubMedGoogle ScholarCrossref
136.
Mulherin  SA, Miller  WC.  Spectrum bias or spectrum effect? subgroup variation in diagnostic test evaluation.   Ann Intern Med. 2002;137(7):598-602. doi:10.7326/0003-4819-137-7-200210010-00011PubMedGoogle ScholarCrossref
137.
Jelinek  M.  Spectrum bias: why generalists and specialists do not connect.   Evid Based Med. 2008;13(5):132-133. doi:10.1136/ebm.13.5.132PubMedGoogle ScholarCrossref
138.
Lachs  MS, Nachamkin  I, Edelstein  PH, Goldman  J, Feinstein  AR, Schwartz  JS.  Spectrum bias in the evaluation of diagnostic tests: lessons from the rapid dipstick test for urinary tract infection.   Ann Intern Med. 1992;117(2):135-140. doi:10.7326/0003-4819-117-2-135PubMedGoogle ScholarCrossref
139.
Willis  BH.  Spectrum bias—why clinicians need to be cautious when applying diagnostic test studies.   Fam Pract. 2008;25(5):390-396. doi:10.1093/fampra/cmn051PubMedGoogle ScholarCrossref
140.
Myers  KA, Mrkobrada  M, Simel  DL.  Does this patient have obstructive sleep apnea?: the Rational Clinical Examination systematic review.   JAMA. 2013;310(7):731-741. doi:10.1001/jama.2013.276185PubMedGoogle ScholarCrossref
141.
Qaseem  A, Dallas  P, Owens  DK, Starkey  M, Holty  JE, Shekelle  P; Clinical Guidelines Committee of the American College of Physicians.  Diagnosis of obstructive sleep apnea in adults: a clinical practice guideline from theAmerican College of Physicians.   Ann Intern Med. 2014;161(3):210-220. doi:10.7326/M12-3187PubMedGoogle ScholarCrossref
142.
Johns  M, Hocking  B.  Daytime sleepiness and sleep habits of Australian workers.   Sleep. 1997;20(10):844-849. doi:10.1093/sleep/20.10.844PubMedGoogle ScholarCrossref
143.
Johns  MW.  Sensitivity and specificity of the multiple sleep latency test (MSLT), the maintenance of wakefulness test and the Epworth Sleepiness Scale: failure of the MSLT as a gold standard.   J Sleep Res. 2000;9(1):5-11. doi:10.1046/j.1365-2869.2000.00177.xPubMedGoogle ScholarCrossref
144.
US Modafinil in Narcolepsy Multicenter Study Group.  Randomized trial of modafinil for the treatment of pathological somnolence in narcolepsy.   Ann Neurol. 1998;43(1):88-97. doi:10.1002/ana.410430115PubMedGoogle ScholarCrossref
145.
Kingshott  RN, Vennelle  M, Coleman  EL, Engleman  HM, Mackay  TW, Douglas  NJ.  Randomized, double-blind, placebo-controlled crossover trial of modafinil in the treatment of residual excessive daytime sleepiness in the sleep apnea/hypopnea syndrome.   Am J Respir Crit Care Med. 2001;163(4):918-923. doi:10.1164/ajrccm.163.4.2005036PubMedGoogle ScholarCrossref
146.
Puhan  MA, Suarez  A, Lo Cascio  C, Zahn  A, Heitz  M, Braendli  O.  Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome: randomised controlled trial.   BMJ. 2006;332(7536):266-270. doi:10.1136/bmj.38705.470590.55PubMedGoogle ScholarCrossref
147.
Medical Advisory Secretariat.  Oral appliances for obstructive sleep apnea: an evidence-based analysis.   Ont Health Technol Assess Ser. 2009;9(5):1-51.PubMedGoogle Scholar
148.
Miletin  MS, Hanly  PJ.  Measurement properties of the Epworth Sleepiness Scale.   Sleep Med. 2003;4(3):195-199. doi:10.1016/S1389-9457(03)00031-5PubMedGoogle ScholarCrossref
149.
Smith  SS, Oei  TP, Douglas  JA, Brown  I, Jorgensen  G, Andrews  J.  Confirmatory factor analysis of the Epworth Sleepiness Scale (ESS) in patients with obstructive sleep apnoea.   Sleep Med. 2008;9(7):739-744. doi:10.1016/j.sleep.2007.08.004PubMedGoogle ScholarCrossref
150.
Vongpatanasin  W.  Resistant hypertension: a review of diagnosis and management.  []  JAMA. 2014;311(21):2216-2224. doi:10.1001/jama.2014.5180PubMedGoogle ScholarCrossref
151.
Bisognano  JD, Bakris  G, Nadim  MK,  et al.  Baroreflex activation therapy lowers blood pressure in patients with resistant hypertension: results from the double-blind, randomized, placebo-controlled rheos pivotal trial.   J Am Coll Cardiol. 2011;58(7):765-773. doi:10.1016/j.jacc.2011.06.008PubMedGoogle ScholarCrossref
152.
Esler  MD, Krum  H, Sobotka  PA, Schlaich  MP, Schmieder  RE, Böhm  M; Symplicity HTN-2 Investigators.  Renal sympathetic denervation in patients with treatment-resistant hypertension (the Symplicity HTN-2 trial): a randomised controlled trial.   Lancet. 2010;376(9756):1903-1909. doi:10.1016/S0140-6736(10)62039-9PubMedGoogle ScholarCrossref
153.
Chobanian  AV, Bakris  GL, Black  HR,  et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee.  The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.   JAMA. 2003;289(19):2560-2572. doi:10.1001/jama.289.19.2560PubMedGoogle ScholarCrossref
Views 3,670
Citations 0
US Preventive Services Task Force
Evidence Report
November 15, 2022

Screening for Obstructive Sleep Apnea in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Author Affiliations
  • 1RTI International–University of North Carolina at Chapel Hill Evidence-based Practice Center
  • 2Department of Medicine, University of North Carolina at Chapel Hill
  • 3Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
  • 4RTI International, Research Triangle Park, North Carolina
  • 5Department of Otolaryngology–Head and Neck Surgery, University of North Carolina at Chapel Hill
  • 6Department of Internal Medicine, The Ohio State University, Columbus
  • 7Center for Rural Health Research, Department of Health Services Management and Policy, College of Public Health, East Tennessee State University, Johnson City
JAMA. 2022;328(19):1951-1971. doi:10.1001/jama.2022.18357
Abstract

Importance  Obstructive sleep apnea (OSA) is associated with adverse health outcomes.

Objective  To review the evidence on screening for OSA in asymptomatic adults or those with unrecognized OSA symptoms to inform the US Preventive Services Task Force.

Data Sources  PubMed/MEDLINE, Cochrane Library, Embase, and trial registries through August 23, 2021; surveillance through September 23, 2022.

Study Selection  English-language studies of screening test accuracy, randomized clinical trials (RCTs) of screening or treatment of OSA reporting health outcomes or harms, and systematic reviews of treatment reporting changes in blood pressure and apnea-hypopnea index (AHI) scores.

Data Extraction and Synthesis  Dual review of abstracts, full-text articles, and study quality. Meta-analysis of intervention trials.

Main Outcomes and Measures  Test accuracy, excessive daytime sleepiness, sleep-related and general health–related quality of life (QOL), and harms.

Results  Eighty-six studies were included (N = 11 051). No study directly compared screening with no screening. Screening accuracy of the Multivariable Apnea Prediction score followed by unattended home sleep testing for detecting severe OSA syndrome (AHI ≥30 and Epworth Sleepiness Scale [ESS] score >10) measured as the area under the curve in 2 studies (n = 702) was 0.80 (95% CI, 0.78 to 0.82) and 0.83 (95% CI, 0.77 to 0.90). Five studies assessing the accuracy of other screening tools were heterogeneous and results were inconsistent. Compared with inactive control, positive airway pressure was associated with a significant improvement in ESS score from baseline (pooled mean difference, −2.33 [95% CI, −2.75 to −1.90]; 47 trials; n = 7024), sleep-related QOL (standardized mean difference, 0.30 [95% CI, 0.19 to 0.42]; 17 trials; n = 3083), and general health–related QOL measured by the 36-Item Short Form Health Survey (SF-36) mental health component summary score change (pooled mean difference, 2.20 [95% CI, 0.95 to 3.44]; 15 trials; n = 2345) and SF-36 physical health component summary score change (pooled mean difference, 1.53 [95% CI, 0.29 to 2.77]; 13 trials; n = 2031). Use of mandibular advancement devices was also associated with a significantly larger ESS score change compared with controls (pooled mean difference, −1.67 [95% CI, 2.09 to −1.25]; 10 trials; n = 1540). Reporting of other health outcomes was sparse; no included trial found significant benefit associated with treatment on mortality, cardiovascular events, or motor vehicle crashes. In 3 systematic reviews, positive airway pressure was significantly associated with reduced blood pressure; however, the difference was relatively small (2-3 mm Hg).

Conclusions and Relevance  The accuracy and clinical utility of OSA screening tools that could be used in primary care settings were uncertain. Positive airway pressure and mandibular advancement devices reduced ESS score. Trials of positive airway pressure found modest improvement in sleep-related and general health–related QOL but have not established whether treatment reduces mortality or improves most other health outcomes.

Introduction

Obstructive sleep apnea (OSA) is a sleep disorder marked by episodes of narrowing and obstruction of the upper airway during sleep, resulting in reduction or cessation in breathing.1 OSA is defined as more than 5 events per hour of partial (hypopnea) or total (apnea) upper airway obstruction despite efforts to breathe.2 Apnea is defined as total airway obstruction (>90%) for more than 10 seconds, and hypopnea as a partial airway obstruction (>30%) sufficient to cause at least a 3% reduction in blood oxygen saturation or sleep arousals.3 The apnea-hypopnea index (AHI) is used to define the severity of OSA: mild (5-15 events per hour), moderate (16-30 events per hour), and severe (>30 events per hour). Standardized prevalence estimates using the 2012 American Academy of Sleep Medicine (AASM) scoring criteria were 33.2% for any OSA (AHI ≥5) and 14.5% for moderate to severe OSA (AHI ≥15).4 Risk factors for OSA include male sex,5 postmenopausal status,6 increasing age (40-70 years),7,8 and higher body mass index (BMI).5 A variety of adverse health outcomes are associated with untreated OSA, including cardiovascular disease events, coronary heart disease, heart failure, atrial fibrillation, and stroke. Severe OSA (AHI ≥30) is associated with increased all-cause mortality.9,10

In 2017, the US Preventive Services Task Force (USPSTF) concluded that the evidence was insufficient to assess the balance of benefits and harms of screening for OSA in asymptomatic adults (I statement).11 This updated review assessed the current evidence on OSA screening in individuals and settings relevant to US primary care and was used to update the USPSTF recommendation.

Methods
Scope of Review

Figure 1 shows the analytic framework and key questions (KQs) that guided the review. Detailed methods are available in the full evidence review.13 In addition to the KQs, this review looked for evidence related to 2 contextual questions that focused on barriers to undergoing diagnostic testing for OSA and the association between AHI and health outcomes (eContextual Questions in the Supplement).

Data Sources and Searches

PubMed/MEDLINE, the Cochrane Library, and Embase were searched for English-language articles published through August 23, 2021 (eMethods in the Supplement). ClinicalTrials.gov was searched for unpublished studies. The searches were supplemented by reviewing reference lists of pertinent articles, studies suggested by peer reviewers, and comments received during public commenting periods. From August 23, 2021, through September 23, 2022, ongoing surveillance was conducted through article alerts and targeted searches of journals to identify major studies published in the interim that may affect the conclusions or understanding of the evidence and the related USPSTF recommendation.

Study Selection

Two investigators independently reviewed titles, abstracts, and full-text articles using prespecified eligibility criteria (eTable 1 in the Supplement). Disagreements were resolved by consensus. For all KQs, English-language studies of adults 18 years or older conducted in countries categorized as “very high” on the Human Development Index14 and rated as fair or good quality were included.

For KQ1 and KQ3 (direct evidence of benefits and harms of screening) and KQ2 (accuracy of screening tools), studies of asymptomatic adults with OSA or persons with unrecognized OSA symptoms were included. For KQ1 and KQ3, randomized clinical trials (RCTs) comparing screened groups with nonscreened groups and reporting on health outcomes were eligible. For KQ2, prospective cohort studies and cross-sectional studies assessing the accuracy of screening questionnaires or clinical prediction tools (alone or followed by an unattended home sleep test) compared with polysomnography conducted in a sleep laboratory were eligible. For KQ2, studies limited to persons referred to sleep laboratories for suspected OSA were excluded. For KQ3 (harms of screening), studies eligible for KQ1 or KQ2 that reported harms of screening or diagnostic tests (eg, false-positive results leading to unnecessary treatment, anxiety, distress, or stigma) were eligible.

For KQs 4 through 6 (benefits and harms of treatment), studies were limited to those of interventions considered first-line treatment for persons diagnosed with OSA (positive airway pressure or mandibular advancement devices [MADs]) compared with inactive control; other interventions (eg, weight loss interventions, oral surgical procedures) were excluded. For KQ4 (benefit of treatment for improving intermediate outcomes), good-quality, recent (within 5 years) systematic reviews comparing positive airway pressure or MADs with an inactive control and reporting on changes in blood pressure or AHI were included. For KQs on the benefits of treatment for improving health outcomes (KQ5) and on the harms of treatment (KQ6), RCTs of adults with a confirmed diagnosis of OSA were eligible.

Data Extraction and Quality Assessment

For each study, 1 investigator extracted information about populations, tests or interventions, comparators, outcomes, settings, and designs, and a second investigator reviewed the information for completeness and accuracy. Two investigators independently assessed the quality of included studies using criteria defined by the USPSTF adapted for this topic supplemented with criteria from the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2)15 and from A Measurement Tool to Assess Systematic Reviews (AMSTAR)16 (eTables 2-8 in the Supplement). Each study was assigned a final quality rating of good, fair, or poor; disagreements were resolved by discussion and consensus.

Data Synthesis and Analysis

Findings for each KQ were summarized in tables, figures, and narrative format. To determine whether meta-analyses were appropriate, the clinical and methodological heterogeneity of the studies were assessed following established guidance.17 For KQ5, random-effects restricted maximum likelihood models were conducted on continuous measures of sleepiness, general health–related quality of life (QOL), and sleep-related QOL associated with positive airway pressure and MAD use when at least 3 similar studies were available, analyzing the mean difference in change from the baseline score or the standardized mean difference (SMD). The meta command in Stata version 16 was used to conduct all quantitative analyses.18 The I2 statistic was used to assess the statistical heterogeneity in effects between studies.19-21 Statistical significance was assumed when 95% CIs of pooled results did not cross the null. All testing was 2-sided.

Results

A total of 86 studies (reported in 101 articles; N = 11 051) were included (Figure 2) in the review. Individual study quality ratings are reported in eTables 2 through 8 in the Supplement.

Benefits of Screening

Key Question 1. Does screening for OSA in adults improve health outcomes, including for specific subgroups of interest?

No eligible studies addressed this question.

Accuracy of Screening

Key Question 2. What is the accuracy of screening questionnaires, clinical prediction tools, and multistep screening approaches (eg, using a questionnaire followed by home-based oximetry/testing) in identifying persons in the general population who are more or less likely to have OSA, including for specific subgroups of interest?

Seven fair-quality studies (n = 2589)22-28 assessing clinical prediction tools or screening questionnaires compared with facility-based polysomnography were included, 4 of which were new to this review (Table 1).25-28 Two evaluated the Berlin Questionnaire,22,25 4 evaluated the STOP-BANG (snoring, tiredness, observed apnea, high blood pressure, BMI, age, neck circumference, gender) questionnaire,25-28 and 2 evaluated the Multivariable Apnea Prediction (MVAP) score—alone and when followed by an unattended home sleep test.23,24

Berlin Questionnaire

The Berlin Questionnaire includes 10 questions about snoring, tiredness, and blood pressure and gathers information on age, sex, height, and weight to classify OSA risk.29 Two included studies of the Berlin Questionnaire enrolled different populations. One sampled Norwegians from the National Population Register.22 Of those who responded, 24% were classified as high risk on the Berlin Questionnaire. The final sample enrolled a population with a mean age of 48 years, 45% were women, the mean BMI was 28 (calculated as weight in kilograms divided by height in meters squared), and the median AHI was 6.4. Although the group receiving polysomnography oversampled high-risk participants (70% were high risk), the authors’ analyses adjusted for bias in the sampling procedure to report estimated screening properties for the general population. In contrast, the second study assessing the Berlin Questionnaire25 included a small (n = 43) but unselected sample of adults with type 2 diabetes recruited from a US general internal medicine clinic. A majority (53%) were female, the mean BMI was 38.3, and the mean AHI was 31.2.

The study enrolling Norwegian participants22 found suboptimal screening accuracy for AHI 5 or greater (sensitivity, 37%; specificity, 84%) and for AHI 15 or greater (sensitivity, 43%; specificity, 80%) (Table 2). The study enrolling US participants with type 2 diabetes from a general internal medicine clinic assessed accuracy for mild (AHI 5-14), moderate (AHI 15-29), and severe (AHI ≥30) OSA.25 Specificity of the Berlin Questionnaire was suboptimal for all categories of OSA severity (mild, 0%; moderate, 31%; severe, 26%). Sensitivity was higher for moderate OSA (89%) and for severe OSA (93%) but was lower for mild OSA (80%).

STOP-BANG Questionnaire

The STOP-BANG questionnaire includes 8 dichotomous items (snoring, tiredness, observed apnea, blood pressure, BMI, age, neck circumference, and gender).30,31 The 4 studies assessing the accuracy of the STOP-BANG questionnaire enrolled diverse populations and used different scoring criteria and additional variables to determine a positive screen result.25-28 Detailed characteristics of each study are reported in Table 1.

The heterogeneity of studies and scoring approaches limits the ability to assess consistency of results. Overall, estimates varied, and no study found both high sensitivity and high specificity (Table 2). One study enrolling US adults with type 2 diabetes found good sensitivity for detecting mild (87%), moderate (93%), and severe (94%) OSA but very low specificity for the same subgroups (mild, 0%; moderate, 19%; severe, 15%).25 In contrast, the study enrolling Spanish adults with Alzheimer disease found modest sensitivity (61%) and somewhat better specificity (76%) for severe OSA.26 The study of Korean adults found moderate sensitivity (62%) and specificity (64%) for detecting mild through severe OSA.27The study of adults receiving opioids for chronic pain provided accuracy data for the STOP-BANG questionnaire alone as well as for the STOP-BANG questionnaire plus resting daytime Spo2 (first stage). Results for various cutoffs are reported in Table 2; across all screening approaches, sensitivity for the STOP-BANG to detect moderate to severe OSA was very good, but specificity was limited.

MVAP Score

The MVAP score combines symptoms of snoring, choking, and witnessed apnea events with BMI, age, and sex.32 It rates apnea risk between 0 and 1, with 0 representing the lowest risk and 1 representing the highest risk. The 2 included studies assessing the MVAP were conducted by the same research group from Philadelphia.23,24 One study evaluated Medicare recipients (n = 452) from the city’s greater metropolitan area, most of whom (74%) had daytime sleepiness.23 The percentage with OSA was not reported, but 27% had OSA syndrome (OSAS) defined as AHI 5 or greater and Epworth Sleepiness Scale [ESS] score greater than 10. The second study evaluated patients with hypertension from internal medicine practices at a Veterans Affairs medical center and a university-based hypertension clinic (n = 250).24 Eighty percent of participants had OSA (AHI ≥5); of those, 22% had moderate OSA and 25% had severe OSA. Twenty-five percent of all participants had OSAS. The mean ages of participants were 71 years23 and 53 years,24 60% to 64% were non-White, and the mean BMIs were 30 to 32. The study of Medicare recipients included 70% women23; the other study included 20% women.24 Key quality limitations included concern for attrition bias24 and moderate concern for selection bias or spectrum bias (with high prevalence of OSA, OSAS, and/or sleepiness among those receiving polysomnography) (eTables 2 and 3 in the Supplement).23,24

Both studies reported operating characteristics of MVAP to predict severe OSAS (AHI ≥30 and ESS score >10) using MVAP cutoff scores of 0.48 to 0.49 (Table 2). Sensitivity was 90%23 and 92%,24 with specificity of 64% and 44%, respectively (95% CIs not reported). The study of Medicare recipients reported reasonable discrimination (area under the curve [AUC], 0.78 [95% CI, 0.71-0.85]), whereas the other study found inadequate discrimination (AUC, 0.68 [95% CI, 0.67-0.70]). An AUC less than 0.70 is thought to indicate inadequate discrimination.33,34 Calibration, which is often assessed by plotting the predicted risk vs the observed rate,33 was not reported.

The study of patients with hypertension24 also reported operating characteristics of MVAP to predict any OSAS (AHI ≥5 and ESS score >10) using an MVAP cutoff score of 0.559. That study reported a sensitivity of 69.4%, a specificity of 56.5%, and an AUC of 0.61.

MVAP Score Followed by Home Sleep Test

The same 2 studies described in the previous section also reported measures of discrimination for the MVAP score followed by an unattended home sleep test compared with in-laboratory polysomnography (Table 1).23,24 Both reported characteristics to predict severe OSAS (AHI ≥30 and ESS score >10) using different home sleep test AHI cutoffs: 1 used 15,23 and the other used 18.24 Both studies found better operating characteristics with MVAP followed by a home sleep test than with MVAP alone (sensitivity, 88%-91%; specificity, 72%-76%; AUC, 0.80-0.83).

The study of patients with hypertension also reported operating characteristics of MVAP to predict any OSAS (AHI ≥5 and ESS score >10) using a home sleep test AHI cutoff of 13.5. It reported a sensitivity of 81%, a specificity of 54%, and an AUC of 0.67.

Harms of Screening

Key Question 3. What are the harms associated with screening or subsequent diagnostic testing for OSA, including for specific subgroups of interest?

No eligible study addressed this question.

Benefits of Treatment

Key Question 4. How effective is treatment with positive airway pressure or MADs for improving intermediate outcomes (ie, the AHI or blood pressure) in persons with OSA, including for specific subgroups of interest?

Four systematic reviews comparing positive airway pressure or MADs with inactive control for reducing AHI or blood pressure were included (eTable 9 in the Supplement).35-38 For blood pressure outcomes, 1 review of MADs found benefit associated with treatment compared with inactive control (by 1-2 mm Hg); however, differences between groups were imprecise and not statistically significant (eTable 9 in the Supplement).35 For positive airway pressure, pooled estimates from 1 review found benefit associated with positive airway pressure compared with control for reducing mean 24-hour blood pressure (−2.63 mm Hg [95% CI, −3.86 to −1.39]; 8 trials; n = 994); pooled results for measures of daytime systolic blood pressure and diastolic blood pressure were also significantly lower with positive airway pressure vs control, ranging from −2.76 to −1.98 mm Hg, respectively (eTable 9 in the Supplement). Results from 2 additional reviews focused on specific populations, including participants with treatment-resistant hypertension, are reported in eTable 9 in the Supplement.

Two reviews of positive airway pressure reported on the difference between groups in change from baseline AHI.37,38 One found a greater reduction in AHI associated with positive airway pressure than with controls (pooled mean difference, −23.41 events per hour [95% CI, −28.51 to −18.30]; 11 trials; n = 832).37 The second review—which limited inclusion to studies of asymptomatic adults with OSA or studies of minimally symptomatic, nonsleepy adults—found consistent but imprecise pooled estimates (eTable 9 in the Supplement).38

Effectiveness of Treatment

Key Question 5. How effective is treatment with positive airway pressure or MADs for improving health outcomes in persons with OSA, including for specific subgroups of interest?

This review included 73 good- or fair-quality RCTs (reported in 87 articles) that reported at least 1 eligible health outcome among groups treated with positive airway pressure or a MADs compared with inactive control.

Positive Airway Pressure

Sixty-three RCTs (74 articles) comparing positive airway pressure with sham positive airway pressure (29 RCTs, 33 articles)39-71 or another inactive control (34 RCTs, 41 articles)72-112 reported at least 1 eligible health outcome. Most trials identified participants from sleep clinics or referrals, and none focused on persons who were screen detected in primary care settings. Detailed characteristics are reported in eTables 10 and 11 in the Supplement.

Most trials (53) followed up participants for 12 weeks or less; 10 trials followed up participants over a longer duration (16 to 24 weeks [5 trials],53,78,87,105,111 52 weeks [3 trials],74,96,108 a median of 4 years [1 trial],75 and a median of 4.7 years [1 trial]).97 The mean age of enrolled populations ranged from 44 to 78 years, and most trials enrolled populations with a mean age of 40 to 59 years; 7 enrolled populations with a mean age of 65 years or older.43,61,79,93,96,97,100 The majority of participants in most trials were men; 1 trial limited enrollment to women,77 and 3 enrolled a majority of women.104,109,113 Most trials did not describe the race and ethnicity of enrolled populations, and those that did (14 trials) used heterogeneous categories and varying levels of detail (eTables 10 and 11 in the Supplement). The mean BMI in most trials was 30 to 36 (range, 25-47). The mean or median baseline AHI (or similar measure) for most trials was in the severe OSA range (AHI ≥30); 13 trials reported mean baseline AHI in the moderate OSA range (AHI 16-30),43,58,61,66,76,80,89,96,97,105,108,109,111 and 6 reported a mean baseline AHI in the mild OSA range (AHI 5-15).69,78,81,83,101,107 The severity of OSA for participants enrolled in trials most frequently ranged from moderate to severe (29 trials) or from mild to severe (16 trials). Seventeen trials limited participants to more narrow ranges: mild only,83,107 mild to moderate or moderate only,58,69,76,97,100,101,105 or severe only.40,59,79,91-94,104 One trial did not report sufficient data to determine the range of OSA severity of participants.78 The mean or median baseline ESS score was 10 or greater in most trials, indicating excessive daytime sleepiness (EDS). Eighteen trials reported a mean baseline ESS score of less than 10,40,43,46,66,73-75,78,79,85,87,92,97,100,104,108,109,111 and 6 trials did not report a baseline ESS score.

Mortality

Thirty-one RCTs reported on the number of deaths during the study period (eTable 12 in the Supplement). The majority (28 RCTs) reported mortality rates at 24 weeks or less, and most of these (25 RCTs) reported no deaths in any study group (eTable 12 in the Supplement). Two reported on mortality over a median duration of 4 to 5 years; 1 (n = 723) reported 8 deaths in the positive airway pressure group and 3 in the control group (incidence density ratio, 2.6 [95% CI, 0.70-11.8]; P = .16),75 and the second (n = 364) found a similar number of deaths among the positive airway pressure and control groups (8% vs 7%, respectively).97

General Health–Related QOL

Twenty RCTs reported on QOL using the 36-Item Short Form Health Survey (SF-36)40,46,50,59,60,67-69,76,78,83,86,89,94,96,105,107,108,111,112; most trials reported changes on the SF-36 physical component summary score and the mental component summary score. Pooled estimates in change from baseline SF-36 mental component summary score found a significantly greater improvement associated with positive airway pressure compared with inactive control (2.20 [95% CI, 0.95-3.44]; 15 trials; n = 2345).40,46,50,60,67-69,78,86,94,105,107,108,111,112 Similarly, pooled estimates for change in SF-36 physical component summary score from baseline found significantly greater improvement associated with positive airway pressure than with control (1.53 [95% CI, 0.29-2.77]; 13 trials; n = 2031 participants) (Table 3; eFigure 1 in the Supplement).40,46,50,60,67-69,86,94,107,108,111,112 The pooled estimates for change from baseline SF-36 mental component summary score and SF-36 physical component summary score associated with positive airway pressure were smaller than the range considered a minimal clinically important difference (MCID), which is 4 to 7 for both SF-36 component summary scores.116,117 Few RCTs reported on other measures of QOL. Few studies reported on other QOL measures; overall, results were mixed (eTable 12 in the Supplement).

Sleep-Related QOL

Seventeen RCTs assessed sleep-related QOL: 6 using the Sleep Apnea Quality of Life Index (SAQLI),54,67,70,78,89,96 10 using the Functional Outcomes of Sleep Questionnaire (FOSQ),40,58-60,65,69,76,84,94,107,111 and 1 using the Quebec Sleep Questionnaire.79 The meta-analysis (combining all measures) found that positive airway pressure was associated with a small but statistically significant improvement in sleep-related QOL compared with controls (SMD, 0.30 [95% CI, 0.19-0.42]; 17 trials; n = 3083) (eFigure 2 in the Supplement). The subgroup analysis by mean baseline ESS score found a similar but slightly larger effect size in trials with a mean ESS score of 10 or greater (SMD, 0.35 [95% CI, 0.22-0.49]; 11 trials, n = 2228). In studies with a mean baseline ESS score of less than 10, the effect size was smaller and the pooled estimate was not statistically significant (eFigure 4 in the Supplement). Results shown as a mean difference in scores for each sleep-related QOL measure are provided in eFigure 3 in the Supplement and summarized in Table 3. For both the SAQLI and FOSQ, the pooled mean difference falls below the range considered an MCID.

ESS Score

Forty-seven trials reported sufficient ESS data to include in meta-analyses. Most were 12 weeks or less in duration; 7 followed up participants for 24 weeks,53,105,111 48 to 52 weeks,74,96,108 or longer.75 The meta-analyses found that positive airway pressure reduced mean ESS scores more than controls (pooled mean difference, −2.33 [95% CI, −2.75 to −1.90]; 47 trials; n = 7024) (Figure 3). The pooled mean difference is within the range considered an MCID for the ESS (−2 to −3).114,115 These analyses found substantial statistical heterogeneity that may be due to variation in positive airway pressure devices, participant characteristics (eg, baseline ESS score), treatment adherence, study duration, or chance; however, no clear explanation was found. As shown in Figure 3, heterogeneity is lower in subgroups defined by narrow ranges of OSA severity (severe only and mild only or mild to moderate vs mild to severe) (Figure 3). However, the meta-analyses by OSA severity subgroup (4 categories: mild to severe, mild only and mild to moderate, moderate only and moderate to severe, and severe only) did not find a clear difference by OSA severity. Differences in mean score change were −2.61 for mild to severe, −1.91 for mild only and mild to moderate, −2.21 for moderate only and moderate to severe, and −3.08 for severe only, and CIs overlapped; the analysis still found considerable statistical heterogeneity within the mild to severe group and the moderate only or moderate to severe group (Figure 3).

Other Health Outcomes

Fewer studies reported on other health outcomes (eTable 12 in the Supplement). Three RCTs reported on the incidence of motor vehicle crashes over 12 to 52 weeks, and none found a statistically significant difference between groups.53,85,96 Ten reported on the incidence of 1 or more heterogeneous cardiovascular outcomes.46,53,58,70,75,78,85,96,97,111 Six RCTs (1773 total participants) reported on the incidence of myocardial infarction; in 4 of these, a total of 1 myocardial infarction occurred (combined) in either group over 3 weeks to 1 year.58,78,85,96 Two RCTs reported on outcomes over a median of 4 to 5 years; 1 (n = 723) reported 2 myocardial infarctions in the positive airway pressure group and 8 in the control group,75 and the second (n = 244) found a similar number of myocardial infarctions in the positive airway pressure and control groups (9% vs 7%, respectively).97

RCTs reporting on other health outcomes (eg, angina, transient ischemic attacks, measures of cognitive impairment) are shown in eTable 12 in the Supplement. Overall, too few events occurred to draw conclusions.

Mandibular Advancement Devices

Twelve RCTs (15 articles) evaluated the benefit of MADs for improving health outcomes (eTable 13 in the Supplement).76,89,120-132 Four studies compared MADs with sham devices that did not advance the mandible,120,121,130-132 1 compared a MAD with a placebo tablet,76 2 compared MADs with no treatment,123,129 and 1 compared a MAD with conservative management of OSA with weight loss.89 All studies recruited participants with known or suspected OSA from specialty clinics, such as sleep medicine or otolaryngology. Treatment durations ranged from 4 to 12 weeks for most studies; however, 1 lasted for only 1 week123 and 1 for 24 weeks.120,121 The mean age of enrolled participants ranged from 46 to 58 years. In 11 trials reporting on sex, the majority of participants were men. No study reported the percentage of minority participants. Almost all studies included participants with mild to moderate OSA, and 6 also included participants with severe OSA.89,122,123,125,128,132

Mortality

Four trials reported on deaths in each group over 1 to 12 weeks of follow-up,76,123,129,132 3 reported no participant deaths, and 1 reported a single death in the control group.132

General Health–Related and Sleep-Related QOL

Six RCTs reported on at least 1 QOL measure.76,89,120,121,129,131,132 Overall, results were mixed, with some studies finding no significant improvement in QOL from using MADs,89,120,121,131 some reporting possible benefits for some measures or subscales but not for others,76,132 and some reporting benefits for some overall QOL scores.129 Further details and specific data are provided in eTable 14 in the Supplement. Because of inconsistency, imprecision, and heterogeneity of reporting, findings are insufficient to make conclusions about the potential benefits of using MADs for improving QOL.

ESS Score

Ten RCTs of MADs provided sufficient data on change from ESS scores from baseline to be included in pooled estimates76,89,122-125,128-130,132; MADs were associated with significantly greater reduction from baseline ESS scores than controls (−1.67 [95% CI, −2.09 to −1.25]; 10 trials; n = 1540 participants) (eFigure 5 in the Supplement). The pooled mean difference, however, falls below the range considered an MCID for the ESS.114,115

Other Health Outcomes

This review included 1 trial assessing each of the following outcomes for participants using MADs over 6 to 12 weeks: cognitive impairment,76 motor vehicle crashes,129 cardiovascular events,129 and headaches.131 Specific data are provided in eTable 14 in the Supplement. Because of unknown consistency, imprecision, and very small numbers of events, findings were insufficient to make conclusions about the potential benefits of MADs for these outcomes.

Harms of Treatment

Key Question 6. What are the harms associated with treatment of OSA using positive airway pressure or MADs, including for specific subgroups of interest?

Reporting of harms in the included RCTs was sparse, and most did not report information on harms. Nineteen RCTs (reported in 24 articles) reported on harms associated with treatment of OSA, including 9 trials of positive airway pressure,49,53,54,68,69,83,89,101,105,113,133,134 9 of MADs,89,120,121,123-132 and 1 of positive airway pressure and MADs.89 Characteristics and detailed results of all 19 studies reporting harms are provided in eTables 10, 11, 13, 15, and 16 in the Supplement.

Positive Airway Pressure

Of the 10 included RCTs of positive airway pressure, 6 compared positive airway pressure with a sham device,49,53,54,68,69,113,133,134 and 4 compared positive airway pressure with another control (eg, oral placebo, usual care).83,89,101,105 Most enrolled fewer than 100 persons; 1 trial, the Apnea Positive Pressure Long-term Efficacy Study,53,54 enrolled more than 1000 participants. The majority of participants were men, the mean age ranged from 42 to 62 years, and most participants were overweight or obese (mean BMI, 27-39). Most of the studies followed up patients for 8 to 12 weeks, and 2 lasted 24 weeks.53,54,105

Outcomes reported were heterogeneous, and detailed results are reported in eTable 15 in the Supplement. In general, harms related to positive airway pressure treatment were likely short-lived and could have been alleviated by discontinuing treatment with positive airway pressure or by supplementing positive airway pressure with additional interventions. Overall, 1% to 47% of participants in trials of positive airway pressure reporting any harms had specific adverse events while using positive airway pressure, including claustrophobia, oral or nasal dryness, eye or skin irritation, rash, nosebleeds, and pain.

Mandibular Advancement Devices

Ten RCTs reported harms related to MAD use.89,120,121,123-132 Most RCTs (6) lasted 4 to 8 weeks, 1 lasted a single week,123 1 lasted 10 weeks,89 1 lasted 12 weeks,124 and 1 lasted 24 weeks.120,121 Across 3 studies that reported any discontinuation of treatment because of adverse events, 7% of patients in the active MAD group discontinued MAD use because of harms compared with 1% of patients in the control group.89,129,132 In 4 RCTs, rates of oral dryness ranged from 5% to 33% in the active MAD group compared with 0% to 3% in the control group.89,120,121,124,129 Six studies reported rates of excess salivation.89,120,121,124-127,129,131 Four trials reported significantly higher rates of excessive salivation associated with MAD use than with sham MAD or no treatment,89,120,121,129 In 7 studies, adverse oral mucosal, dental, or jaw symptoms ranged from 17% to 74% in MAD groups compared with 0% to 17% in the sham group, no-treatment group, or conservative management group. Two studies reported that there was a statistically significant difference only in the percentage who experienced jaw discomfort and tooth tenderness in the MAD group compared with that in the sham group.125-127,131

Discussion

This systematic review synthesized evidence relevant to screening for OSA in adults. Table 4 summarizes findings, including an assessment of the strength of evidence for each KQ. To date, there is no direct evidence from trials on the benefits and harms of screening for OSA vs no screening. Potential harms of routine screening include overdiagnosis and overtreatment for asymptomatic persons with OSA (AHI ≥5) who never had symptoms of OSA or adverse health outcomes from OSA. Other potential harms include costs associated with referrals and additional testing (eg, future polysomnography for follow-up care).

This review identified few eligible studies evaluating the accuracy of questionnaires or prediction tools for distinguishing persons in the general population who are more or less likely to have OSA. No included screening approach was assessed by more than 2 included studies, which limits the ability to draw conclusions about the accuracy of screening tools in primary care. The screening approach evaluated by 2 studies, the MVAP score followed by an unattended home sleep test for detecting severe OSAS (AHI ≥30 and ESS score >10), may have promise for screening, but the evidence was limited by potential spectrum bias135-139 due to oversampling of high-risk participants and of those with OSA and OSAS, which may substantially overestimate the accuracy of using the MVAP score to screen for OSA in the general population. The included studies evaluating MVAP enrolled populations with a high prevalence of OSAS (≥25%),23,24 OSA (AHI ≥5 for 80% of participants),24 and sleepiness (74%).23

This review included fewer studies evaluating questionnaires or clinical prediction tools than some previously published reviews and guidelines,9,140,141 primarily because of the requirement to include studies that enrolled asymptomatic adults or adults with unrecognized symptoms of OSA; referral populations (eg, to sleep clinics) were not eligible. Previous reviews and guidelines focused generally on diagnostic testing (of adults with symptoms suggestive of disordered sleep) rather than on screening (of asymptomatic persons with OSA or those with unrecognized symptoms of OSA). Nevertheless, these reviews and guidelines generally reported low overall quality and strength of evidence for questionnaires and prediction tools.

This review found consistent evidence from good- and fair-quality RCTs that positive airway pressure reduces excessive daytime sleepiness and may improve general health–related and sleep-related QOL. However, benefit associated with positive airway pressure for both general health–related and sleep-related QOL measures falls short of the range considered an MCID (Table 3), and the clinical significance of the 2-point mean reduction on the ESS is somewhat uncertain. For excessive sleepiness, the data suggest a clinically significant reduction in most included trials because 85% of the trials in the meta-analysis for ESS with mean baseline ESS scores of 10 or greater (indicating excessive daytime sleepiness) reported mean end point ESS scores in the normal range of less than 10142,143 for the positive airway pressure groups (mean end point ESS score <8). However, the threshold for a clinically significant change in ESS score is somewhat uncertain. Although recent systematic reviews noted that experts consider a 1-point change in ESS score clinically significant,9 other sources suggest that a 2- to 3-point change114,115 or a 3- to 4-point change should be the clinically significant threshold for its sample size calculations or interpretation of findings.144-146 Also, the American College of Chest Physicians’ outcome experts evaluating the ESS informally stated that a clinically significant change in the ESS score probably is at least 3 points and cited a specific example that a reduction of 1 point (eg, from 3 [high] to 2 [moderate]) on 2 of 7 ESS domains was unlikely to be clinically relevant (Jon-Erik C. Holty, MD, MS, Stanford University, email, October 2015). Regardless of the clinically significant threshold level, the subjective nature of the ESS creates potential bias in trials of treatment (eg, overreporting of improvements in sleepiness after receiving treatment), and some authors have raised concerns about its construct validity (ie, authors have expressed uncertainty regarding whether it is an accurate measure of sleepiness).147-149

For blood pressure reduction (KQ4), recent systematic reviews found that MAD and positive airway pressure are associated with a reduction in blood pressure of 2 to 3 mm Hg, and 1 review limited to populations with resistant hypertension found a slightly higher mean reduction (5 mm Hg). Some experts suggest that a difference of more than 9 mm Hg systolic/10 mm Hg diastolic is clinically meaningful for patients.150-152 However, guidelines have suggested that across a population, a smaller reduction in systolic blood pressure (2-3 mm Hg) could result in a clinically significant reduction in cardiovascular mortality (4%-5% for coronary heart disease and 6%-8% for stroke).153 Even though MADs and positive airway pressure have been shown to reduce mean blood pressure, no trial to date has shown a significant reduction in mortality or cardiovascular disease.

Evidence on most health outcomes was limited (ie, too few RCTs reported on outcomes or too few events occurred to evaluate the effectiveness of positive airway pressure for reducing mortality or motor vehicle crashes). As summarized in the eContextual Questions in the Supplement, a relatively large body of observational evidence supports an association between severe OSA and increased risk of many adverse health outcomes, including cardiovascular events, mortality, and cognitive impairment. Some observational studies suggest that the risk of such outcomes increases with each level of OSA severity, which may indicate a dose-response effect; however, this finding is not consistent across all studies or outcomes. In addition, findings of increased risk associated with severe OSA are the strongest among male populations; however, it is difficult to assess whether these relationships do not hold for female populations or reflect sparse evidence on female populations compared with male populations. Observational studies focused on this association are limited, however, primarily owing to potential confounding.

Reporting of harms from treatment in the included studies was sparse. In general, the adverse events related to positive airway pressure treatment were likely short-lived and could have been alleviated by discontinuing treatment with positive airway pressure or by supplementing positive airway pressure with additional interventions. Common adverse events included oral or nasal dryness, eye or skin irritation, and rash. Common adverse effects from MADs included oral or nasal dryness, excessive salivation, and jaw discomfort.

Evidence included in the current review suggests several important research needs. To better understand the potential effectiveness of screening for OSA, RCTs of asymptomatic persons (or those with unrecognized symptoms of OSA) that directly compare screening with no screening and assess health outcomes are needed. To better determine the accuracy of screening questionnaires and clinical prediction tools when used in the general population (related to KQ2), additional studies are needed; such studies should aim to include a representative community population, to avoid spectrum bias, and to further evaluate promising screening approaches (eg, MVAP followed by an unattended home sleep test) as well as other approaches assessed in similar populations for which there were few studies, such as the Berlin Questionnaire and STOP-BANG questionnaire. Trials of treatment (positive airway pressure and MAD) that enroll participants who are screen-detected in primary care settings are needed; results of trials that enroll participants referred for OSA symptoms and other sleep issues may not be applicable to populations who are screen-detected.

Limitations

This review has several limitations. First, studies of screening accuracy were required to have used in-laboratory polysomnography as the reference standard. This is similar to the approach used in previous systematic reviews. Second, studies that focused on the benefits and harms of treatment were limited to studies of interventions considered first-line treatment for persons with newly detected OSA (positive airway pressure and MAD); studies of interventions primarily offered to persons who do not benefit from or tolerate positive airway pressure or MAD were excluded. Third, some of the meta-analyses of RCTs evaluating the benefits of positive airway pressure (KQ5) found substantial statistical heterogeneity. Although a clear explanation for all statistical heterogeneity was not found, possible explanations include variation in enrolled populations, positive airway pressure devices (eg, machines, masks, humidifiers, filters, cushions), apnea and hypopnea definitions, adherence, study duration, study methods, or chance.

Conclusions

The accuracy and clinical utility of OSA screening tools that could be used in primary care settings were uncertain. Positive airway pressure and mandibular advancement devices reduced ESS score. Trials of positive airway pressure found modest improvement in sleep-related and general health–related QOL but have not established whether treatment reduces mortality or improves most other health outcomes.

Back to top
Article Information

Corresponding Author: Cynthia Feltner, MD, MPH, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Martin Luther King Jr Blvd, CB#7295, Chapel Hill, NC 27599 (cindy_feltner@med.unc.edu).

Accepted for Publication: September 19, 2022.

Author Contributions: Dr Feltner had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Feltner, Wallace, Hicks, Voisin, Jonas.

Acquisition, analysis, or interpretation of data: Feltner, Wallace, Aymes, Cook Middleton, Hicks, Schwimmer, Baker, Balio, Moore, Jonas.

Drafting of the manuscript: Feltner, Wallace, Aymes, Cook Middleton, Hicks, Schwimmer, Baker, Moore, Voisin, Jonas.

Critical revision of the manuscript for important intellectual content: Feltner, Wallace, Hicks, Balio, Jonas.

Statistical analysis: Feltner, Wallace, Aymes, Hicks.

Obtained funding: Feltner, Jonas.

Administrative, technical, or material support: Feltner, Cook Middleton, Schwimmer, Baker, Moore, Voisin, Jonas.

Supervision: Feltner, Jonas.

Conflict of Interest Disclosures: Dr Aymes reported receiving a Health Resources and Services Administration Preventive Medicine Training Grant. No other disclosures were reported.

Funding/Support: This research was funded under contract HHSA-75Q80120D00007, Task Order 01, from the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services, under a contract to support the US Preventive Services Task Force (USPSTF).

Role of the Funder/Sponsor: Investigators worked with USPSTF members and AHRQ staff to develop the scope, analytic framework, and key questions for this review. AHRQ had no role in study selection, quality assessment, or synthesis. AHRQ staff provided project oversight, reviewed the evidence review to ensure that the analysis met methodological standards, and distributed the draft for public comment and review by federal partners. Otherwise, AHRQ had no role in the conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript findings. The opinions expressed in this document are those of the authors and do not reflect the official position of AHRQ or the US Department of Health and Human Services.

Additional Contributions: We gratefully acknowledge the following individuals for their contributions to this project, including AHRQ staff (Justin Mills, MD, MPH, and Tracy Wolff, MD, MPH) and RTI International–University of North Carolina–Chapel Hill Evidence-based Practice Center (EPC) staff (Carol Woodell, BSPH, Roberta Wines, MPH, Staci Rachman, BA, Sharon Barrell, MA, Loraine Monroe, and Teyonna Downing). The USPSTF members, expert reviewers, and federal partner reviewers did not receive financial compensation for their contributions. Ms Woodell, Ms Wines, Ms Rachman, Ms Barrell, Ms Monroe, and Ms Downing received compensation for their role in this project.

Additional Information: A draft version of the full evidence review underwent external peer review from 3 content experts (Sean M. Caples, DO, MS, Mayo Clinic; Jon-Erik C. Holty, MD, MS, Stanford University; Paul E. Peppard, PhD, MS, University of Wisconsin-Madison) and 5 federal partner reviewers (Centers for Disease Control and Prevention; National Institute of Dental and Craniofacial Research; National Heart, Lung, and Blood Institute; National Institute on Minority Health and Health Disparities; and National Institutes of Health Office of Research on Women’s Health). Comments from reviewers were presented to the USPSTF during its deliberation of the evidence and were considered in preparing the final evidence review. USPSTF members and peer reviewers did not receive financial compensation for their contributions.

Editorial Disclaimer: This evidence review is presented as a document in support of the accompanying USPSTF recommendation statement. It did not undergo additional peer review after submission to JAMA.

References
1.
Osman  AM, Carter  SG, Carberry  JC, Eckert  DJ.  Obstructive sleep apnea: current perspectives.   Nat Sci Sleep. 2018;10:21-34. doi:10.2147/NSS.S124657PubMedGoogle ScholarCrossref
2.
Faber  J, Faber  C, Faber  AP.  Obstructive sleep apnea in adults.   Dental Press J Orthod. 2019;24(3):99-109. doi:10.1590/2177-6709.24.3.099-109.sarPubMedGoogle ScholarCrossref
3.
Veasey  SC, Rosen  IM.  Obstructive sleep apnea in adults.   N Engl J Med. 2019;380(15):1442-1449. doi:10.1056/NEJMcp1816152PubMedGoogle ScholarCrossref
4.
Benjafield  AV, Ayas  NT, Eastwood  PR,  et al.  Estimation of the global prevalence and burden of obstructive sleep apnoea: a literature-based analysis.   Lancet Respir Med. 2019;7(8):687-698. doi:10.1016/S2213-2600(19)30198-5PubMedGoogle ScholarCrossref
5.
Peppard  PE, Young  T, Barnet  JH, Palta  M, Hagen  EW, Hla  KM.  Increased prevalence of sleep-disordered breathing in adults.   Am J Epidemiol. 2013;177(9):1006-1014. doi:10.1093/aje/kws342PubMedGoogle ScholarCrossref
6.
Bixler  EO, Vgontzas  AN, Lin  HM,  et al.  Prevalence of sleep-disordered breathing in women: effects of gender.   Am J Respir Crit Care Med. 2001;163(3 Pt 1):608-613. doi:10.1164/ajrccm.163.3.9911064PubMedGoogle ScholarCrossref
7.
Bixler  EO, Vgontzas  AN, Ten Have  T, Tyson  K, Kales  A.  Effects of age on sleep apnea in men, I: prevalence and severity.   Am J Respir Crit Care Med. 1998;157(1):144-148. doi:10.1164/ajrccm.157.1.9706079PubMedGoogle ScholarCrossref
8.
Young  T, Shahar  E, Nieto  FJ,  et al; Sleep Heart Health Study Research Group.  Predictors of sleep-disordered breathing in community-dwelling adults: the Sleep Heart Health Study.   Arch Intern Med. 2002;162(8):893-900. doi:10.1001/archinte.162.8.893PubMedGoogle ScholarCrossref
9.
Balk  EM, Moorthy  D, Obadan  NO,  et al.  Diagnosis and Treatment of Obstructive Sleep Apnea in Adults. Agency for Healthcare Research and Quality; 2011.
10.
Knauert  M, Naik  S, Gillespie  MB, Kryger  M.  Clinical consequences and economic costs of untreated obstructive sleep apnea syndrome.   World J Otorhinolaryngol Head Neck Surg. 2015;1(1):17-27. doi:10.1016/j.wjorl.2015.08.001PubMedGoogle ScholarCrossref
11.
Bibbins-Domingo  K, Grossman  DC, Curry  SJ,  et al; US Preventive Services Task Force.  Screening for obstructive sleep apnea in adults: US Preventive Services Task Force recommendation statement.   JAMA. 2017;317(4):407-414. doi:10.1001/jama.2016.20325PubMedGoogle ScholarCrossref
12.
US Preventive Services Task Force. US Preventive Services Task Force Procedure Manual. Updated May 2021. Accessed October 11, 2022. https://www.uspreventiveservicestaskforce.org/uspstf/procedure-manual
13.
Feltner  C, Jonas  DE, Wallace  I, Aymes  S, Hicks  K, Cook Middleton  J.  Screening for Obstructive Sleep Apnea in Adults: an Evidence Review for the US Preventive Services Task Force. Evidence Synthesis No. 220. Agency for Healthcare Research and Quality; 2022. AHRQ publication 22-05292-EF-1.
14.
 Human Development Report 2020: The Next Frontier: Human Development and the Anthropocene. United Nations Development Program; 2020.
15.
Whiting  PF, Rutjes  AW, Westwood  ME,  et al; QUADAS-2 Group.  QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies.   Ann Intern Med. 2011;155(8):529-536. doi:10.7326/0003-4819-155-8-201110180-00009PubMedGoogle ScholarCrossref
16.
Shea  BJ, Grimshaw  JM, Wells  GA,  et al.  Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews.   BMC Med Res Methodol. 2007;7:10. doi:10.1186/1471-2288-7-10PubMedGoogle ScholarCrossref
17.
West  SL, Gartlehner  G, Mansfield  AJ,  et al. Comparative Effectiveness Review Methods: Clinical Heterogeneity. Report 10-EHC070-EF. Agency for Healthcare Research and Quality. Published 2010. Accessed October 11, 2022. https://pubmed.ncbi.nlm.nih.gov/21433337/
18.
StataCorp. StataCorp LP; 2019.
19.
Higgins  JP, Thompson  SG.  Quantifying heterogeneity in a meta-analysis.   Stat Med. 2002;21(11):1539-1558. doi:10.1002/sim.1186PubMedGoogle ScholarCrossref
20.
Higgins  JP, Thompson  SG, Deeks  JJ, Altman  DG.  Measuring inconsistency in meta-analyses.   BMJ. 2003;327(7414):557-560. doi:10.1136/bmj.327.7414.557PubMedGoogle ScholarCrossref
21.
Higgins  J, Thomas  J, Chandler  J,  et al. Cochrane Handbook for Systematic Reviews of Interventions. Version 6.3. Cochrane. Published 2022. Accessed October 11, 2022. https://training.cochrane.org/handbook
22.
Hrubos-Strøm  H, Randby  A, Namtvedt  SK,  et al.  A Norwegian population-based study on the risk and prevalence of obstructive sleep apnea: the Akershus Sleep Apnea Project (ASAP).   J Sleep Res. 2011;20(1, pt 2):162-170. doi:10.1111/j.1365-2869.2010.00861.xPubMedGoogle ScholarCrossref
23.
Morales  CR, Hurley  S, Wick  LC,  et al.  In-home, self-assembled sleep studies are useful in diagnosing sleep apnea in the elderly.   Sleep. 2012;35(11):1491-1501. doi:10.5665/sleep.2196PubMedGoogle ScholarCrossref
24.
Gurubhagavatula  I, Fields  BG, Morales  CR,  et al.  Screening for severe obstructive sleep apnea syndrome in hypertensive outpatients.   J Clin Hypertens (Greenwich). 2013;15(4):279-288. doi:10.1111/jch.12073PubMedGoogle ScholarCrossref
25.
Edmonds  PJ, Gunasekaran  K, Edmonds  LC.  Neck grasp predicts obstructive sleep apnea in type 2 diabetes mellitus.   Sleep Disord. 2019;2019:3184382. doi:10.1155/2019/3184382PubMedGoogle ScholarCrossref
26.
Jorge  C, Benítez  I, Torres  G,  et al.  The STOP-Bang and Berlin questionnaires to identify obstructive sleep apnoea in Alzheimer’s disease patients.   Sleep Med. 2019;57:15-20. doi:10.1016/j.sleep.2019.01.033PubMedGoogle ScholarCrossref
27.
Shin  C, Baik  I.  Evaluation of a modified STOP-BANG questionnaire for sleep apnea in adults from the Korean general population.   Sleep Med Res. 2021;12(1):28-35. doi:10.17241/smr.2020.00808Google ScholarCrossref
28.
Selvanathan  J, Waseem  R, Peng  P, Wong  J, Ryan  CM, Chung  F.  Simple screening model for identifying the risk of sleep apnea in patients on opioids for chronic pain.   Reg Anesth Pain Med. 2021;46(10):886-891. doi:10.1136/rapm-2020-102388PubMedGoogle ScholarCrossref
29.
Netzer  NC, Stoohs  RA, Netzer  CM, Clark  K, Strohl  KP.  Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome.   Ann Intern Med. 1999;131(7):485-491. doi:10.7326/0003-4819-131-7-199910050-00002PubMedGoogle ScholarCrossref
30.
Chung  F, Yegneswaran  B, Liao  P,  et al.  STOP questionnaire: a tool to screen patients for obstructive sleep apnea.   Anesthesiology. 2008;108(5):812-821. doi:10.1097/ALN.0b013e31816d83e4PubMedGoogle ScholarCrossref
31.
Farney  RJ, Walker  BS, Farney  RM, Snow  GL, Walker  JM.  The STOP-Bang equivalent model and prediction of severity of obstructive sleep apnea: relation to polysomnographic measurements of the apnea/hypopnea index.   J Clin Sleep Med. 2011;7(5):459-65B. doi:10.5664/JCSM.1306PubMedGoogle ScholarCrossref
32.
Maislin  G, Pack  AI, Kribbs  NB,  et al.  A survey screen for prediction of apnea.   Sleep. 1995;18(3):158-166. doi:10.1093/sleep/18.3.158PubMedGoogle ScholarCrossref
33.
Lloyd-Jones  DM.  Cardiovascular risk prediction: basic concepts, current status, and future directions.   Circulation. 2010;121(15):1768-1777. doi:10.1161/CIRCULATIONAHA.109.849166PubMedGoogle ScholarCrossref
34.
Hosmer  DW, Lemeshow  S.  Applied Logistic Regression. John Wiley & Sons; 2000. doi:10.1002/0471722146
35.
de Vries  GE, Wijkstra  PJ, Houwerzijl  EJ, Kerstjens  HAM, Hoekema  A.  Cardiovascular effects of oral appliance therapy in obstructive sleep apnea: a systematic review and meta-analysis.   Sleep Med Rev. 2018;40:55-68. doi:10.1016/j.smrv.2017.10.004PubMedGoogle ScholarCrossref
36.
Labarca  G, Schmidt  A, Dreyse  J,  et al.  Efficacy of continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea (OSA) and resistant hypertension (RH): systematic review and meta-analysis.   Sleep Med Rev. 2021;58:101446. doi:10.1016/j.smrv.2021.101446PubMedGoogle ScholarCrossref
37.
Patil  SP, Ayappa  IA, Caples  SM, Kimoff  RJ, Patel  SR, Harrod  CG.  Treatment of adult obstructive sleep apnea with positive airway pressure: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment.   J Clin Sleep Med. 2019;15(2):301-334. doi:10.5664/jcsm.7638PubMedGoogle ScholarCrossref
38.
Zhang  D, Luo  J, Qiao  Y, Xiao  Y.  Continuous positive airway pressure therapy in non-sleepy patients with obstructive sleep apnea: results of a meta-analysis.   J Thorac Dis. 2016;8(10):2738-2747. doi:10.21037/jtd.2016.09.40PubMedGoogle ScholarCrossref
39.
Arias  MA, García-Río  F, Alonso-Fernández  A, Mediano  O, Martínez  I, Villamor  J.  Obstructive sleep apnea syndrome affects left ventricular diastolic function: effects of nasal continuous positive airway pressure in men.   Circulation. 2005;112(3):375-383. doi:10.1161/CIRCULATIONAHA.104.501841PubMedGoogle ScholarCrossref
40.
Barbé  F, Mayoralas  LR, Duran  J,  et al.  Treatment with continuous positive airway pressure is not effective in patients with sleep apnea but no daytime sleepiness: a randomized, controlled trial.   Ann Intern Med. 2001;134(11):1015-1023. doi:10.7326/0003-4819-134-11-200106050-00007PubMedGoogle ScholarCrossref
41.
Campos-Rodriguez  F, Grilo-Reina  A, Perez-Ronchel  J,  et al.  Effect of continuous positive airway pressure on ambulatory BP in patients with sleep apnea and hypertension: a placebo-controlled trial.   Chest. 2006;129(6):1459-1467. doi:10.1378/chest.129.6.1459PubMedGoogle ScholarCrossref
42.
Chasens  ER, Korytkowski  M, Sereika  SM, Burke  LE, Drumheller  OJ, Strollo  PJ  Jr.  Improving activity in adults with diabetes and coexisting obstructive sleep apnea.   West J Nurs Res. 2014;36(3):294-311. doi:10.1177/0193945913500567PubMedGoogle ScholarCrossref
43.
Chong  MS, Ayalon  L, Marler  M,  et al.  Continuous positive airway pressure reduces subjective daytime sleepiness in patients with mild to moderate Alzheimer’s disease with sleep disordered breathing.   J Am Geriatr Soc. 2006;54(5):777-781. doi:10.1111/j.1532-5415.2006.00694.xPubMedGoogle ScholarCrossref
44.
Coughlin  SR, Mawdsley  L, Mugarza  JA, Wilding  JP, Calverley  PM.  Cardiovascular and metabolic effects of CPAP in obese males with OSA.   Eur Respir J. 2007;29(4):720-727. doi:10.1183/09031936.00043306PubMedGoogle ScholarCrossref
45.
Durán-Cantolla  J, Aizpuru  F, Montserrat  JM,  et al; Spanish Sleep and Breathing Group.  Continuous positive airway pressure as treatment for systemic hypertension in people with obstructive sleep apnoea: randomised controlled trial.   BMJ. 2010;341:c5991. doi:10.1136/bmj.c5991PubMedGoogle ScholarCrossref
46.
Egea  CJ, Aizpuru  F, Pinto  JA,  et al; Spanish Group of Sleep Breathing Disorders.  Cardiac function after CPAP therapy in patients with chronic heart failure and sleep apnea: a multicenter study.   Sleep Med. 2008;9(6):660-666. doi:10.1016/j.sleep.2007.06.018PubMedGoogle ScholarCrossref
47.
Haensel  A, Norman  D, Natarajan  L, Bardwell  WA, Ancoli-Israel  S, Dimsdale  JE.  Effect of a 2 week CPAP treatment on mood states in patients with obstructive sleep apnea: a double-blind trial.   Sleep Breath. 2007;11(4):239-244. doi:10.1007/s11325-007-0115-0PubMedGoogle ScholarCrossref
48.
Hoyos  CM, Killick  R, Yee  BJ, Phillips  CL, Grunstein  RR, Liu  PY.  Cardiometabolic changes after continuous positive airway pressure for obstructive sleep apnoea: a randomised sham-controlled study.   Thorax. 2012;67(12):1081-1089. doi:10.1136/thoraxjnl-2011-201420PubMedGoogle ScholarCrossref
49.
Hui  DS, To  KW, Ko  FW,  et al.  Nasal CPAP reduces systemic blood pressure in patients with obstructive sleep apnoea and mild sleepiness.   Thorax. 2006;61(12):1083-1090. doi:10.1136/thx.2006.064063PubMedGoogle ScholarCrossref
50.
Jenkinson  C, Davies  RJ, Mullins  R, Stradling  JR.  Comparison of therapeutic and subtherapeutic nasal continuous positive airway pressure for obstructive sleep apnoea: a randomised prospective parallel trial.   Lancet. 1999;353(9170):2100-2105. doi:10.1016/S0140-6736(98)10532-9PubMedGoogle ScholarCrossref
51.
Hack  M, Davies  RJ, Mullins  R,  et al.  Randomised prospective parallel trial of therapeutic versus subtherapeutic nasal continuous positive airway pressure on simulated steering performance in patients with obstructive sleep apnoea.   Thorax. 2000;55(3):224-231. doi:10.1136/thorax.55.3.224PubMedGoogle ScholarCrossref
52.
Jones  A, Vennelle  M, Connell  M,  et al.  The effect of continuous positive airway pressure therapy on arterial stiffness and endothelial function in obstructive sleep apnea: a randomized controlled trial in patients without cardiovascular disease.   Sleep Med. 2013;14(12):1260-1265. doi:10.1016/j.sleep.2013.08.786PubMedGoogle ScholarCrossref
53.
Kushida  CA, Nichols  DA, Holmes  TH,  et al.  Effects of continuous positive airway pressure on neurocognitive function in obstructive sleep apnea patients: the Apnea Positive Pressure Long-term Efficacy Study (APPLES).   Sleep. 2012;35(12):1593-1602. doi:10.5665/sleep.2226PubMedGoogle ScholarCrossref
54.
Batool-Anwar  S, Goodwin  JL, Kushida  CA,  et al.  Impact of continuous positive airway pressure (CPAP) on quality of life in patients with obstructive sleep apnea (OSA).   J Sleep Res. 2016;25(6):731-738. doi:10.1111/jsr.12430PubMedGoogle ScholarCrossref
55.
Lam  JC, Lam  B, Yao  TJ,  et al.  A randomised controlled trial of nasal continuous positive airway pressure on insulin sensitivity in obstructive sleep apnoea.   Eur Respir J. 2010;35(1):138-145. doi:10.1183/09031936.00047709PubMedGoogle ScholarCrossref
56.
Lee  IS, Bardwell  WA, Kamat  R,  et al.  A model for studying neuropsychological effects of sleep intervention: the effect of 3-week continuous positive airway pressure treatment.   Drug Discov Today Dis Models. 2011;8(4):147-154. doi:10.1016/j.ddmod.2011.10.001PubMedGoogle ScholarCrossref
57.
Loredo  JS, Ancoli-Israel  S, Kim  EJ, Lim  WJ, Dimsdale  JE.  Effect of continuous positive airway pressure versus supplemental oxygen on sleep quality in obstructive sleep apnea: a placebo-CPAP-controlled study.   Sleep. 2006;29(4):564-571. doi:10.1093/sleep/29.4.564PubMedGoogle ScholarCrossref
58.
Marshall  NS, Neill  AM, Campbell  AJ, Sheppard  DS.  Randomised controlled crossover trial of humidified continuous positive airway pressure in mild obstructive sleep apnoea.   Thorax. 2005;60(5):427-432. doi:10.1136/thx.2004.032078PubMedGoogle ScholarCrossref
59.
Melehan  KL, Hoyos  CM, Hamilton  GS,  et al.  Randomized trial of CPAP and vardenafil on erectile and arterial function in men with obstructive sleep apnea and erectile dysfunction.   J Clin Endocrinol Metab. 2018;103(4):1601-1611. doi:10.1210/jc.2017-02389PubMedGoogle ScholarCrossref
60.
Montserrat  JM, Ferrer  M, Hernandez  L,  et al.  Effectiveness of CPAP treatment in daytime function in sleep apnea syndrome: a randomized controlled study with an optimized placebo.   Am J Respir Crit Care Med. 2001;164(4):608-613. doi:10.1164/ajrccm.164.4.2006034PubMedGoogle ScholarCrossref
61.
Neikrug  AB, Liu  L, Avanzino  JA,  et al.  Continuous positive airway pressure improves sleep and daytime sleepiness in patients with Parkinson disease and sleep apnea.   Sleep. 2014;37(1):177-185. doi:10.5665/sleep.3332PubMedGoogle ScholarCrossref
62.
Nguyen  PK, Katikireddy  CK, McConnell  MV, Kushida  C, Yang  PC.  Nasal continuous positive airway pressure improves myocardial perfusion reserve and endothelial-dependent vasodilation in patients with obstructive sleep apnea.   J Cardiovasc Magn Reson. 2010;12:50. doi:10.1186/1532-429X-12-50PubMedGoogle ScholarCrossref
63.
Pepperell  JC, Ramdassingh-Dow  S, Crosthwaite  N,  et al.  Ambulatory blood pressure after therapeutic and subtherapeutic nasal continuous positive airway pressure for obstructive sleep apnoea: a randomised parallel trial.   Lancet. 2002;359(9302):204-210. doi:10.1016/S0140-6736(02)07445-7PubMedGoogle ScholarCrossref
64.
Kohler  M, Pepperell  JC, Casadei  B,  et al.  CPAP and measures of cardiovascular risk in males with OSAS.   Eur Respir J. 2008;32(6):1488-1496. doi:10.1183/09031936.00026608PubMedGoogle ScholarCrossref
65.
Phillips  CL, Yee  BJ, Marshall  NS, Liu  PY, Sullivan  DR, Grunstein  RR.  Continuous positive airway pressure reduces postprandial lipidemia in obstructive sleep apnea: a randomized, placebo-controlled crossover trial.   Am J Respir Crit Care Med. 2011;184(3):355-361. doi:10.1164/rccm.201102-0316OCPubMedGoogle ScholarCrossref
66.
Robinson  GV, Smith  DM, Langford  BA, Davies  RJ, Stradling  JR.  Continuous positive airway pressure does not reduce blood pressure in nonsleepy hypertensive OSA patients.   Eur Respir J. 2006;27(6):1229-1235. doi:10.1183/09031936.06.00062805PubMedGoogle ScholarCrossref
67.
Siccoli  MM, Pepperell  JC, Kohler  M, Craig  SE, Davies  RJ, Stradling  JR.  Effects of continuous positive airway pressure on quality of life in patients with moderate to severe obstructive sleep apnea: data from a randomized controlled trial.   Sleep. 2008;31(11):1551-1558. doi:10.1093/sleep/31.11.1551PubMedGoogle ScholarCrossref
68.
Smith  LA, Vennelle  M, Gardner  RS,  et al.  Auto-titrating continuous positive airway pressure therapy in patients with chronic heart failure and obstructive sleep apnoea: a randomized placebo-controlled trial.   Eur Heart J. 2007;28(10):1221-1227. doi:10.1093/eurheartj/ehm131PubMedGoogle ScholarCrossref
69.
Weaver  TE, Mancini  C, Maislin  G,  et al.  Continuous positive airway pressure treatment of sleepy patients with milder obstructive sleep apnea: results of the CPAP Apnea Trial North American Program (CATNAP) randomized clinical trial.   Am J Respir Crit Care Med. 2012;186(7):677-683. doi:10.1164/rccm.201202-0200OCPubMedGoogle ScholarCrossref
70.
West  SD, Nicoll  DJ, Wallace  TM, Matthews  DR, Stradling  JR.  Effect of CPAP on insulin resistance and HbA1c in men with obstructive sleep apnoea and type 2 diabetes.   Thorax. 2007;62(11):969-974. doi:10.1136/thx.2006.074351PubMedGoogle ScholarCrossref
71.
West  SD, Kohler  M, Nicoll  DJ, Stradling  JR.  The effect of continuous positive airway pressure treatment on physical activity in patients with obstructive sleep apnoea: a randomised controlled trial.   Sleep Med. 2009;10(9):1056-1058. doi:10.1016/j.sleep.2008.11.007PubMedGoogle ScholarCrossref
72.
Ballester  E, Badia  JR, Hernández  L,  et al.  Evidence of the effectiveness of continuous positive airway pressure in the treatment of sleep apnea/hypopnea syndrome.   Am J Respir Crit Care Med. 1999;159(2):495-501. doi:10.1164/ajrccm.159.2.9804061PubMedGoogle ScholarCrossref
73.
Banghøj  AM, Krogager  C, Kristensen  PL,  et al.  Effect of 12-week continuous positive airway pressure therapy on glucose levels assessed by continuous glucose monitoring in people with type 2 diabetes and obstructive sleep apnoea: a randomized controlled trial.   Endocrinol Diabetes Metab. 2020;4(2):e00148. doi:10.1002/edm2.148PubMedGoogle ScholarCrossref
74.
Barbé  F, Durán-Cantolla  J, Capote  F,  et al; Spanish Sleep and Breathing Group.  Long-term effect of continuous positive airway pressure in hypertensive patients with sleep apnea.   Am J Respir Crit Care Med. 2010;181(7):718-726. doi:10.1164/rccm.200901-0050OCPubMedGoogle ScholarCrossref
75.
Barbé  F, Durán-Cantolla  J, Sánchez-de-la-Torre  M,  et al; Spanish Sleep and Breathing Network.  Effect of continuous positive airway pressure on the incidence of hypertension and cardiovascular events in nonsleepy patients with obstructive sleep apnea: a randomized controlled trial.   JAMA. 2012;307(20):2161-2168. doi:10.1001/jama.2012.4366PubMedGoogle ScholarCrossref
76.
Barnes  M, McEvoy  RD, Banks  S,  et al.  Efficacy of positive airway pressure and oral appliance in mild to moderate obstructive sleep apnea.   Am J Respir Crit Care Med. 2004;170(6):656-664. doi:10.1164/rccm.200311-1571OCPubMedGoogle ScholarCrossref
77.
Campos-Rodriguez  F, Queipo-Corona  C, Carmona-Bernal  C,  et al; Spanish Sleep Network.  Continuous positive airway pressure improves quality of life in women with obstructive sleep apnea: a randomized controlled trial.   Am J Respir Crit Care Med. 2016;194(10):1286-1294. doi:10.1164/rccm.201602-0265OCPubMedGoogle ScholarCrossref
78.
Craig  SE, Kohler  M, Nicoll  D,  et al.  Continuous positive airway pressure improves sleepiness but not calculated vascular risk in patients with minimally symptomatic obstructive sleep apnoea: the MOSAIC randomised controlled trial.   Thorax. 2012;67(12):1090-1096. doi:10.1136/thoraxjnl-2012-202178PubMedGoogle ScholarCrossref
79.
Dalmases  M, Solé-Padullés  C, Torres  M,  et al.  Effect of CPAP on cognition, brain function, and structure among elderly patients with OSA: a randomized pilot study.   Chest. 2015;148(5):1214-1223. doi:10.1378/chest.15-0171PubMedGoogle ScholarCrossref
80.
Engleman  HM, Martin  SE, Deary  IJ, Douglas  NJ.  Effect of continuous positive airway pressure treatment on daytime function in sleep apnoea/hypopnoea syndrome.   Lancet. 1994;343(8897):572-575. doi:10.1016/S0140-6736(94)91522-9PubMedGoogle ScholarCrossref
81.
Engleman  HM, Martin  SE, Deary  IJ, Douglas  NJ.  Effect of CPAP therapy on daytime function in patients with mild sleep apnoea/hypopnoea syndrome.   Thorax. 1997;52(2):114-119. doi:10.1136/thx.52.2.114PubMedGoogle ScholarCrossref
82.
Engleman  HM, Martin  SE, Kingshott  RN, Mackay  TW, Deary  IJ, Douglas  NJ.  Randomised placebo controlled trial of daytime function after continuous positive airway pressure (CPAP) therapy for the sleep apnoea/hypopnoea syndrome.   Thorax. 1998;53(5):341-345. doi:10.1136/thx.53.5.341PubMedGoogle ScholarCrossref
83.
Engleman  HM, Kingshott  RN, Wraith  PK, Mackay  TW, Deary  IJ, Douglas  NJ.  Randomized placebo-controlled crossover trial of continuous positive airway pressure for mild sleep apnea/hypopnea syndrome.   Am J Respir Crit Care Med. 1999;159(2):461-467. doi:10.1164/ajrccm.159.2.9803121PubMedGoogle ScholarCrossref
84.
Faccenda  JF, Mackay  TW, Boon  NA, Douglas  NJ.  Randomized placebo-controlled trial of continuous positive airway pressure on blood pressure in the sleep apnea-hypopnea syndrome.   Am J Respir Crit Care Med. 2001;163(2):344-348. doi:10.1164/ajrccm.163.2.2005037PubMedGoogle ScholarCrossref
85.
Gottlieb  DJ, Punjabi  NM, Mehra  R,  et al.  CPAP versus oxygen in obstructive sleep apnea.   N Engl J Med. 2014;370(24):2276-2285. doi:10.1056/NEJMoa1306766PubMedGoogle ScholarCrossref
86.
Lewis  EF, Wang  R, Punjabi  N,  et al.  Impact of continuous positive airway pressure and oxygen on health status in patients with coronary heart disease, cardiovascular risk factors, and obstructive sleep apnea: a Heart Biomarker Evaluation in Apnea Treatment (HEARTBEAT) analysis.   Am Heart J. 2017;189:59-67. doi:10.1016/j.ahj.2017.03.001PubMedGoogle ScholarCrossref
87.
Jackson  ML, Tolson  J, Schembri  R,  et al.  Does continuous positive airways pressure treatment improve clinical depression in obstructive sleep apnea? a randomized wait-list controlled study.   Depress Anxiety. 2021;38(5):498-507. doi:10.1002/da.23131PubMedGoogle ScholarCrossref
88.
Jackson  ML, Tolson  J, Bartlett  D, Berlowitz  DJ, Varma  P, Barnes  M.  Clinical depression in untreated obstructive sleep apnea: examining predictors and a meta-analysis of prevalence rates.   Sleep Med. 2019;62:22-28. doi:10.1016/j.sleep.2019.03.011PubMedGoogle ScholarCrossref
89.
Lam  B, Sam  K, Mok  WY,  et al.  Randomised study of three non-surgical treatments in mild to moderate obstructive sleep apnoea.   Thorax. 2007;62(4):354-359. doi:10.1136/thx.2006.063644PubMedGoogle ScholarCrossref
90.
Lim  W, Bardwell  WA, Loredo  JS,  et al.  Neuropsychological effects of 2-week continuous positive airway pressure treatment and supplemental oxygen in patients with obstructive sleep apnea: a randomized placebo-controlled study.   J Clin Sleep Med. 2007;3(4):380-386. doi:10.5664/jcsm.26860PubMedGoogle ScholarCrossref
91.
Lui  MMS, Mak  JCW, Chong  PWC, Lam  DCL, Ip  MSM.  Circulating adipocyte fatty acid-binding protein is reduced by continuous positive airway pressure treatment for obstructive sleep apnea—a randomized controlled study.   Sleep Breath. 2020;24(3):817-824. doi:10.1007/s11325-019-01893-5PubMedGoogle ScholarCrossref
92.
Martínez-García  MA, Capote  F, Campos-Rodríguez  F,  et al; Spanish Sleep Network.  Effect of CPAP on blood pressure in patients with obstructive sleep apnea and resistant hypertension: the HIPARCO randomized clinical trial.   JAMA. 2013;310(22):2407-2415. doi:10.1001/jama.2013.281250PubMedGoogle ScholarCrossref
93.
Martínez-García  MÁ, Chiner  E, Hernández  L,  et al; Spanish Sleep Network.  Obstructive sleep apnoea in the elderly: role of continuous positive airway pressure treatment.   Eur Respir J. 2015;46(1):142-151. doi:10.1183/09031936.00064214PubMedGoogle ScholarCrossref
94.
Masa  JF, Corral  J, Alonso  ML,  et al; Spanish Sleep Network.  Efficacy of different treatment alternatives for obesity hypoventilation syndrome: Pickwick Study.   Am J Respir Crit Care Med. 2015;192(1):86-95. doi:10.1164/rccm.201410-1900OCPubMedGoogle ScholarCrossref
95.
McArdle  N, Douglas  NJ.  Effect of continuous positive airway pressure on sleep architecture in the sleep apnea-hypopnea syndrome: a randomized controlled trial.   Am J Respir Crit Care Med. 2001;164(8 Pt 1):1459-1463. doi:10.1164/ajrccm.164.8.2008146PubMedGoogle ScholarCrossref
96.
McMillan  A, Bratton  DJ, Faria  R,  et al; PREDICT Investigators.  Continuous positive airway pressure in older people with obstructive sleep apnoea syndrome (PREDICT): a 12-month, multicentre, randomised trial.   Lancet Respir Med. 2014;2(10):804-812. doi:10.1016/S2213-2600(14)70172-9PubMedGoogle ScholarCrossref
97.
Peker  Y, Glantz  H, Eulenburg  C, Wegscheider  K, Herlitz  J, Thunström  E.  Effect of positive airway pressure on cardiovascular outcomes in coronary artery disease patients with nonsleepy obstructive sleep apnea: the RICCADSA randomized controlled trial.   Am J Respir Crit Care Med. 2016;194(5):613-620. doi:10.1164/rccm.201601-0088OCPubMedGoogle ScholarCrossref
98.
Balcan  B, Thunström  E, Strollo  PJ  Jr, Peker  Y.  Continuous positive airway pressure treatment and depression in adults with coronary artery disease and nonsleepy obstructive sleep apnea: a secondary analysis of the RICCADSA Trial.   Ann Am Thorac Soc. 2019;16(1):62-70. doi:10.1513/AnnalsATS.201803-174OCPubMedGoogle ScholarCrossref
99.
Celik  Y, Thunström  E, Strollo  PJ  Jr, Peker  Y.  Continuous positive airway pressure treatment and anxiety in adults with coronary artery disease and nonsleepy obstructive sleep apnea in the RICCADSA trial.   Sleep Med. 2021;77:96-103. doi:10.1016/j.sleep.2020.11.034PubMedGoogle ScholarCrossref
100.
Ponce  S, Pastor  E, Orosa  B,  et al; Sleep Respiratory Disorders Group of the Sociedad Valenciana de Neumología.  The role of CPAP treatment in elderly patients with moderate obstructive sleep apnoea: a multicentre randomised controlled trial.   Eur Respir J. 2019;54(2):1900518. doi:10.1183/13993003.00518-2019PubMedGoogle ScholarCrossref
101.
Redline  S, Adams  N, Strauss  ME, Roebuck  T, Winters  M, Rosenberg  C.  Improvement of mild sleep-disordered breathing with CPAP compared with conservative therapy.   Am J Respir Crit Care Med. 1998;157(3, pt 1):858-865. doi:10.1164/ajrccm.157.3.9709042PubMedGoogle ScholarCrossref
102.
Ruttanaumpawan  P, Gilman  MP, Usui  K, Floras  JS, Bradley  TD.  Sustained effect of continuous positive airway pressure on baroreflex sensitivity in congestive heart failure patients with obstructive sleep apnea.   J Hypertens. 2008;26(6):1163-1168. doi:10.1097/HJH.0b013e3282fb81edPubMedGoogle ScholarCrossref
103.
Kaneko  Y, Floras  JS, Usui  K,  et al.  Cardiovascular effects of continuous positive airway pressure in patients with heart failure and obstructive sleep apnea.   N Engl J Med. 2003;348(13):1233-1241. doi:10.1056/NEJMoa022479PubMedGoogle ScholarCrossref
104.
Salord  N, Fortuna  AM, Monasterio  C,  et al.  A randomized controlled trial of continuous positive airway pressure on glucose tolerance in obese patients with obstructive sleep apnea.   Sleep. 2016;39(1):35-41. doi:10.5665/sleep.5312PubMedGoogle ScholarCrossref
105.
Shaw  JE, Punjabi  NM, Naughton  MT,  et al.  The effect of treatment of obstructive sleep apnea on glycemic control in type 2 diabetes.   Am J Respir Crit Care Med. 2016;194(4):486-492. doi:10.1164/rccm.201511-2260OCPubMedGoogle ScholarCrossref
106.
Tomfohr  LM, Ancoli-Israel  S, Loredo  JS, Dimsdale  JE.  Effects of continuous positive airway pressure on fatigue and sleepiness in patients with obstructive sleep apnea: data from a randomized controlled trial.   Sleep. 2011;34(1):121-126. doi:10.1093/sleep/34.1.121PubMedGoogle ScholarCrossref
107.
Wimms  AJ, Kelly  JL, Turnbull  CD,  et al; MERGE Trial Investigators.  Continuous positive airway pressure versus standard care for the treatment of people with mild obstructive sleep apnoea (MERGE): a multicentre, randomised controlled trial.   Lancet Respir Med. 2020;8(4):349-358. doi:10.1016/S2213-2600(19)30402-3PubMedGoogle ScholarCrossref
108.
Zhao  YY, Wang  R, Gleason  KJ,  et al; BestAIR Investigators.  Effect of continuous positive airway pressure treatment on health-related quality of life and sleepiness in high cardiovascular risk individuals with sleep apnea: Best Apnea Interventions for Research (BestAIR) trial.   Sleep. 2017;40(4):zsx040. doi:10.1093/sleep/zsx040PubMedGoogle ScholarCrossref
109.
Ng  SSS, Chan  TO, To  KW,  et al.  Continuous positive airway pressure for obstructive sleep apnoea does not improve asthma control.   Respirology. 2018;23(11):1055-1062. doi:10.1111/resp.13363PubMedGoogle ScholarCrossref
110.
Celik  Y, Yapici-Eser  H, Balcan  B, Peker  Y.  Association of excessive daytime sleepiness with the Zung self-rated depression subscales in adults with coronary artery disease and obstructive sleep apnea.   Diagnostics (Basel). 2021;11(7):1176. doi:10.3390/diagnostics11071176PubMedGoogle ScholarCrossref
111.
Traaen  GM, Aakerøy  L, Hunt  TE,  et al.  Effect of continuous positive airway pressure on arrhythmia in atrial fibrillation and sleep apnea: a randomized controlled trial.   Am J Respir Crit Care Med. 2021;204(5):573-582. doi:10.1164/rccm.202011-4133OCPubMedGoogle ScholarCrossref
112.
Wallström  S, Balcan  B, Thunström  E, Wolf  A, Peker  Y.  CPAP and health-related quality of life in adults with coronary artery disease and nonsleepy obstructive sleep apnea in the RICCADSA trial.   J Clin Sleep Med. 2019;15(9):1311-1320. doi:10.5664/jcsm.7926PubMedGoogle ScholarCrossref
113.
Weinstock  TG, Wang  X, Rueschman  M,  et al.  A controlled trial of CPAP therapy on metabolic control in individuals with impaired glucose tolerance and sleep apnea.   Sleep. 2012;35(5):617-625B. doi:10.5665/sleep.1816PubMedGoogle ScholarCrossref
114.
Patel  S, Kon  SSC, Nolan  CM,  et al.  The Epworth Sleepiness Scale: minimum clinically important difference in obstructive sleep apnea.   Am J Respir Crit Care Med. 2018;197(7):961-963. doi:10.1164/rccm.201704-0672LEPubMedGoogle ScholarCrossref
115.
Crook  S, Sievi  NA, Bloch  KE,  et al.  Minimum important difference of the Epworth Sleepiness Scale in obstructive sleep apnoea: estimation from three randomised controlled trials.   Thorax. 2019;74(4):390-396. doi:10.1136/thoraxjnl-2018-211959PubMedGoogle ScholarCrossref
116.
Ware  JE  Jr, Sherbourne  CD.  The MOS 36-item short-form health survey (SF-36), I: conceptual framework and item selection.   Med Care. 1992;30(6):473-483. doi:10.1097/00005650-199206000-00002PubMedGoogle ScholarCrossref
117.
Wyrwich  KW, Tierney  WM, Babu  AN, Kroenke  K, Wolinsky  FD.  A comparison of clinically important differences in health-related quality of life for patients with chronic lung disease, asthma, or heart disease.   Health Serv Res. 2005;40(2):577-591. doi:10.1111/j.1475-6773.2005.0l374.xPubMedGoogle ScholarCrossref
118.
Weaver  TE, Crosby  RD, Bron  M, Menno  D, Mathias  SD.  Using multiple anchor-based and distribution-based estimates to determine the Minimal Important Difference (MID) for the FOSQ-10.   Sleep. 2018;41(suppl 1):A227. doi:10.1093/sleep/zsy061.611Google ScholarCrossref
119.
Flemons  WW, Reimer  MA.  Development of a disease-specific health-related quality of life questionnaire for sleep apnea.   Am J Respir Crit Care Med. 1998;158(2):494-503. doi:10.1164/ajrccm.158.2.9712036PubMedGoogle ScholarCrossref
120.
Aarab  G, Lobbezoo  F, Hamburger  HL, Naeije  M.  Oral appliance therapy versus nasal continuous positive airway pressure in obstructive sleep apnea: a randomized, placebo-controlled trial.   Respiration. 2011;81(5):411-419. doi:10.1159/000319595PubMedGoogle ScholarCrossref
121.
Nikolopoulou  M, Aarab  G, Ahlberg  J, Hamburger  HL, de Lange  J, Lobbezoo  F.  Oral appliance therapy versus nasal continuous positive airway pressure in obstructive sleep apnea: a randomized, placebo-controlled trial on temporomandibular side-effects.   Clin Exp Dent Res. 2020;6(4):400-406. doi:10.1002/cre2.288PubMedGoogle ScholarCrossref
122.
Andrén  A, Hedberg  P, Walker-Engström  ML, Wahlén  P, Tegelberg  A.  Effects of treatment with oral appliance on 24-h blood pressure in patients with obstructive sleep apnea and hypertension: a randomized clinical trial.   Sleep Breath. 2013;17(2):705-712. doi:10.1007/s11325-012-0746-7PubMedGoogle ScholarCrossref
123.
Bloch  KE, Iseli  A, Zhang  JN,  et al.  A randomized, controlled crossover trial of two oral appliances for sleep apnea treatment.   Am J Respir Crit Care Med. 2000;162(1):246-251. doi:10.1164/ajrccm.162.1.9908112PubMedGoogle ScholarCrossref
124.
Durán-Cantolla  J, Crovetto-Martínez  R, Alkhraisat  MH,  et al.  Efficacy of mandibular advancement device in the treatment of obstructive sleep apnea syndrome: a randomized controlled crossover clinical trial.   Med Oral Patol Oral Cir Bucal. 2015;20(5):e605-e615. doi:10.4317/medoral.20649PubMedGoogle ScholarCrossref
125.
Naismith  SL, Winter  VR, Hickie  IB, Cistulli  PA.  Effect of oral appliance therapy on neurobehavioral functioning in obstructive sleep apnea: a randomized controlled trial.   J Clin Sleep Med. 2005;1(4):374-380. doi:10.5664/jcsm.26365PubMedGoogle ScholarCrossref
126.
Gotsopoulos  H, Chen  C, Qian  J, Cistulli  PA.  Oral appliance therapy improves symptoms in obstructive sleep apnea: a randomized, controlled trial.   Am J Respir Crit Care Med. 2002;166(5):743-748. doi:10.1164/rccm.200203-208OCPubMedGoogle ScholarCrossref
127.
Gotsopoulos  H, Kelly  JJ, Cistulli  PA.  Oral appliance therapy reduces blood pressure in obstructive sleep apnea: a randomized, controlled trial.   Sleep. 2004;27(5):934-941. doi:10.1093/sleep/27.5.934PubMedGoogle ScholarCrossref
128.
Johnston  CD, Gleadhill  IC, Cinnamond  MJ, Gabbey  J, Burden  DJ.  Mandibular advancement appliances and obstructive sleep apnoea: a randomized clinical trial.   Eur J Orthod. 2002;24(3):251-262. doi:10.1093/ejo/24.3.251PubMedGoogle ScholarCrossref
129.
Quinnell  TG, Bennett  M, Jordan  J,  et al.  A crossover randomised controlled trial of oral mandibular advancement devices for obstructive sleep apnoea-hypopnoea (TOMADO).   Thorax. 2014;69(10):938-945. doi:10.1136/thoraxjnl-2014-205464PubMedGoogle ScholarCrossref
130.
Gagnadoux  F, Pépin  JL, Vielle  B,  et al.  Impact of mandibular advancement therapy on endothelial function in severe obstructive sleep apnea.   Am J Respir Crit Care Med. 2017;195(9):1244-1252. doi:10.1164/rccm.201609-1817OCPubMedGoogle ScholarCrossref
131.
Marklund  M, Carlberg  B, Forsgren  L, Olsson  T, Stenlund  H, Franklin  KA.  Oral appliance therapy in patients with daytime sleepiness and snoring or mild to moderate sleep apnea: a randomized clinical trial.   JAMA Intern Med. 2015;175(8):1278-1285. doi:10.1001/jamainternmed.2015.2051PubMedGoogle ScholarCrossref
132.
Petri  N, Svanholt  P, Solow  B, Wildschiødtz  G, Winkel  P.  Mandibular advancement appliance for obstructive sleep apnoea: results of a randomised placebo controlled trial using parallel group design.   J Sleep Res. 2008;17(2):221-229. doi:10.1111/j.1365-2869.2008.00645.xPubMedGoogle ScholarCrossref
133.
Malow  BA, Foldvary-Schaefer  N, Vaughn  BV,  et al.  Treating obstructive sleep apnea in adults with epilepsy: a randomized pilot trial.   Neurology. 2008;71(8):572-577. doi:10.1212/01.wnl.0000323927.13250.54PubMedGoogle ScholarCrossref
134.
Redline  S. Effects of treatment of sleep apnea on metabolic syndrome. [NCT01385995]. 2014. Accessed October 11, 2022. https://www.clinicaltrials.gov/show/NCT01385995
135.
Goehring  C, Perrier  A, Morabia  A.  Spectrum bias: a quantitative and graphical analysis of the variability of medical diagnostic test performance.   Stat Med. 2004;23(1):125-135. doi:10.1002/sim.1591PubMedGoogle ScholarCrossref
136.
Mulherin  SA, Miller  WC.  Spectrum bias or spectrum effect? subgroup variation in diagnostic test evaluation.   Ann Intern Med. 2002;137(7):598-602. doi:10.7326/0003-4819-137-7-200210010-00011PubMedGoogle ScholarCrossref
137.
Jelinek  M.  Spectrum bias: why generalists and specialists do not connect.   Evid Based Med. 2008;13(5):132-133. doi:10.1136/ebm.13.5.132PubMedGoogle ScholarCrossref
138.
Lachs  MS, Nachamkin  I, Edelstein  PH, Goldman  J, Feinstein  AR, Schwartz  JS.  Spectrum bias in the evaluation of diagnostic tests: lessons from the rapid dipstick test for urinary tract infection.   Ann Intern Med. 1992;117(2):135-140. doi:10.7326/0003-4819-117-2-135PubMedGoogle ScholarCrossref
139.
Willis  BH.  Spectrum bias—why clinicians need to be cautious when applying diagnostic test studies.   Fam Pract. 2008;25(5):390-396. doi:10.1093/fampra/cmn051PubMedGoogle ScholarCrossref
140.
Myers  KA, Mrkobrada  M, Simel  DL.  Does this patient have obstructive sleep apnea?: the Rational Clinical Examination systematic review.   JAMA. 2013;310(7):731-741. doi:10.1001/jama.2013.276185PubMedGoogle ScholarCrossref
141.
Qaseem  A, Dallas  P, Owens  DK, Starkey  M, Holty  JE, Shekelle  P; Clinical Guidelines Committee of the American College of Physicians.  Diagnosis of obstructive sleep apnea in adults: a clinical practice guideline from theAmerican College of Physicians.   Ann Intern Med. 2014;161(3):210-220. doi:10.7326/M12-3187PubMedGoogle ScholarCrossref
142.
Johns  M, Hocking  B.  Daytime sleepiness and sleep habits of Australian workers.   Sleep. 1997;20(10):844-849. doi:10.1093/sleep/20.10.844PubMedGoogle ScholarCrossref
143.
Johns  MW.  Sensitivity and specificity of the multiple sleep latency test (MSLT), the maintenance of wakefulness test and the Epworth Sleepiness Scale: failure of the MSLT as a gold standard.   J Sleep Res. 2000;9(1):5-11. doi:10.1046/j.1365-2869.2000.00177.xPubMedGoogle ScholarCrossref
144.
US Modafinil in Narcolepsy Multicenter Study Group.  Randomized trial of modafinil for the treatment of pathological somnolence in narcolepsy.   Ann Neurol. 1998;43(1):88-97. doi:10.1002/ana.410430115PubMedGoogle ScholarCrossref
145.
Kingshott  RN, Vennelle  M, Coleman  EL, Engleman  HM, Mackay  TW, Douglas  NJ.  Randomized, double-blind, placebo-controlled crossover trial of modafinil in the treatment of residual excessive daytime sleepiness in the sleep apnea/hypopnea syndrome.   Am J Respir Crit Care Med. 2001;163(4):918-923. doi:10.1164/ajrccm.163.4.2005036PubMedGoogle ScholarCrossref
146.
Puhan  MA, Suarez  A, Lo Cascio  C, Zahn  A, Heitz  M, Braendli  O.  Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome: randomised controlled trial.   BMJ. 2006;332(7536):266-270. doi:10.1136/bmj.38705.470590.55PubMedGoogle ScholarCrossref
147.
Medical Advisory Secretariat.  Oral appliances for obstructive sleep apnea: an evidence-based analysis.   Ont Health Technol Assess Ser. 2009;9(5):1-51.PubMedGoogle Scholar
148.
Miletin  MS, Hanly  PJ.  Measurement properties of the Epworth Sleepiness Scale.   Sleep Med. 2003;4(3):195-199. doi:10.1016/S1389-9457(03)00031-5PubMedGoogle ScholarCrossref
149.
Smith  SS, Oei  TP, Douglas  JA, Brown  I, Jorgensen  G, Andrews  J.  Confirmatory factor analysis of the Epworth Sleepiness Scale (ESS) in patients with obstructive sleep apnoea.   Sleep Med. 2008;9(7):739-744. doi:10.1016/j.sleep.2007.08.004PubMedGoogle ScholarCrossref
150.
Vongpatanasin  W.  Resistant hypertension: a review of diagnosis and management.  []  JAMA. 2014;311(21):2216-2224. doi:10.1001/jama.2014.5180PubMedGoogle ScholarCrossref
151.
Bisognano  JD, Bakris  G, Nadim  MK,  et al.  Baroreflex activation therapy lowers blood pressure in patients with resistant hypertension: results from the double-blind, randomized, placebo-controlled rheos pivotal trial.   J Am Coll Cardiol. 2011;58(7):765-773. doi:10.1016/j.jacc.2011.06.008PubMedGoogle ScholarCrossref
152.
Esler  MD, Krum  H, Sobotka  PA, Schlaich  MP, Schmieder  RE, Böhm  M; Symplicity HTN-2 Investigators.  Renal sympathetic denervation in patients with treatment-resistant hypertension (the Symplicity HTN-2 trial): a randomised controlled trial.   Lancet. 2010;376(9756):1903-1909. doi:10.1016/S0140-6736(10)62039-9PubMedGoogle ScholarCrossref
153.
Chobanian  AV, Bakris  GL, Black  HR,  et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee.  The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.   JAMA. 2003;289(19):2560-2572. doi:10.1001/jama.289.19.2560PubMedGoogle ScholarCrossref
×