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Chapter 7
Is Screening of Obstructive Sleep Apnea
Necessary? Current Perspectives
on Screening/Diagnosis
Barry Krakow and Mahadevappa Hunasikatti
Abstract It is well known that the associations between untreated moderate or
severe OSA with significant medical consequences are much clearer when compared
to patients with mild sleep apnea. In a prospective, population-based cohort study of
middle-aged women and men, followed up to 24 years, SDB was associated with
incident CHD or heart failure after adjusting for age, sex, BMI, and smoking. The
association was strongest in the most severe SDB category and remained significant
after further controlling for sleep duration, total cholesterol, and HDL cholesterol.
We are not sure if the screening of obstructive sleep apnea is associated with any
significant medical benefit to the population. In 2017, U.S. Preventive Services Task
Force (USPTF) concluded that “The USPSTF concludes that the current evidence is
insufficient to assess the balance of benefits and harms of screening for obstructive
sleep apnea (OSA) in asymptomatic adults.”
The position of USPTF was not well received by the sleep community. USPTF is
revising its recommendations in 2021. The truth is somewhere in the middle. Both
overdiagnosis and underdiagnosis are possible in some segment of the population if
we screen all asymptomatic adults. It is in the best interest of the public that
screening for obstructive sleep apnea is done in targeted, selective population:
1. Asymptomatic adults with congestive heart failure, COPD, Down syndrome, or
patients with stroke.
2. Asymptomatic adults who work in sensitive occupations, which involve the
safety of public like: bus drivers, pilots, air traffic controllers, heavy machi ne
operators, etc.
3. Asymptomatic adults who are morbidly obese with BMI > 35/m
2
or who have
neck circumference of >40 cm.
B. Krakow
Maimonides Sleep Arts and Sciences, Savannah, GA, USA
M. Hunasikatti (
✉)
Division of Respiratory, Sleep and Anesthesiology (DSRA), OHT1, Food and Drug
Administration (FDA), Silver Spring, MD, USA
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
A. S. BaHammam, M. Hunasikatti (eds.), Sleep Apnea Frontiers, Progress in Sleep
Research,
https://doi.org/10.1007/978-981-99-7901-1_7
101
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102 B. Krakow and M. Hunasikatti
Keywords Obstructive sleep apnea (OSA) · US preventive services task force
(USPSTF) · Screening strategies · Asymptomat ic adults · Medical consequences
7.1 Introduction
7.1.1 Why Is Diagnosis of Obstructive Sleep Apnea (OSA)
Important?
7.1.1.1 Mild OSA
There is some evidence that mild OSA may have some adverse consequences on the
health of patients eventually. It is a highly prevalent disorder in adults. However,
whether mild OSA has significant neurocognitive and cardiovascular complications is
uncertain (Laratta et al.
2017). Mild OSA is diagnosed with OSA severity (apnea–
hypopnea index, respiratory disturbance index, or oxygen desaturation index) in the
sleep study was at least 5/h and less than 15/h. Most randomized controlled trials with
continuous positive airway pressure (CPAP) demonstrate that treatment of mild OSA
improves subjective assessments of daytime sleepiness by a small amount and that this
effect may only be present in patients with an elevated level of sleepiness at baseline.
However, limited existing data show no impact of treatment on objective measures of
sleepiness. We may need to evaluate and manage the patients with this limita-
tion (Jonas DE, Amick HR, Feltner C et al. (2017). Nonetheless, mild OSA and its
variant upper airway resistance syndrome (UARS) may be common among insomnia
patients in the syndrome described as complex insomnia. Recent research suggests
treatment of mild to moderate OSA will enhance sleep quality and decrease insomnia
symptoms, more so with advanced PAP machines compared to standard CPAP.
7.1.1.2 Moderate and Severe OSA
Associations between untreated moderate or severe OSA with significant medical
consequences are much clearer. In a prospective, population-based cohort study of
middle-aged women and men, followed up to 24 years, SDB was associated with
incident CHD or heart failure after adjusting for age, sex, BMI, and smoking. The
association was strongest in the most severe SDB category and remained significant
after further controlling for sleep duration, total cholesterol, and HDL cholesterol
(Hla et al. 2015).
In another study, a total of 5422 participants without a history of stroke at the
baseline examination and untreated for sleep apnea were followed for a median of
8.7 years. One hundred ninety-three ischemic strokes were observed. A significant
positive association between ischemic stroke and OAHI was observed in men. Men
in the highest OAHI quartile (>19) had an adjusted hazard ratio of 2.86. In the mild
to moderate range (OAHI, 5–25), each one-unit increase in OAHI in men was
estimated to increase stroke risk by 6%. In women, stroke was not significantly
associated with OAHI quartiles, but increased risk was observed at an OAHI greater
than 25 (Redline et al.
2010).
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7 Is Screening of Obstructive Sleep Apnea Necessary? Current Perspectives... 103
With changing times, the diagnosis of OSA has changed. Due to a large economic
burden, the expensive polysomnogram may not be justified despite its greater
accuracy and validity through its actual measurements of sleep staging and, thus,
sleep fragm entation. AASM recommendations regarding diagnostic testing for indi-
cations for PSG and HST are the current practice of medicine. Due to the high
prevalence of OSA, there is a significant cost associated with evaluating all patients
suspected of having OSA with PSG (currently considered the gold standard diag-
nostic test). Further, there also may be limited access to laboratory testing in some
areas. HSAT is an alternative to in-lab sleep studies for diagnosing OSA in adults.
While it may be less costly and more efficient for some populations, it has notable
limitations, including the absence of sleep scoring and inconsistencies in determin-
ing the severity of OSA/UARS. The AASM guidelines have adopted an evidence-
based approach to address some of these issues. However, they have not fully
addressed the challenges associated with UAR S diagnosis.
7.1.1.3 AASM Recommendations
1. We recommend that clinical tools, questionnaires, and prediction algorithms not
be used to diagnose OSA in adults, in the absence of polysomnography or home
sleep apnea testing. (STRONG)
2. We recommend that polysomnography, or home sleep apnea testing with a
technically adequate device, be used for the diagnosis of OSA in uncomplicated
adult patients presenting with signs and symptoms that indicate an increased risk
of moderate to severe OSA. (STRONG)
3. We recommend that if a single home sleep apnea test is negative, inconclusive, or
technically inadequate, polysomnography be performed for the diagnosis of
OSA. (STRONG)
4. We recommend that polysomnography, rather than home sleep apnea testing, be
used for the diagnosis of OSA in patients with significant cardiorespiratory
disease, potential respiratory muscle weakness due to neuromuscular condition,
awake hypoventilation or suspicion of sleep related hypoventilation, chronic
opioid medication use, history of stroke, or severe insomnia. Moreover, emerging
research suggests mental health patients with sleep disorders may receive more
reliable assessments with PSG. (STRONG)
5. We suggest that, if clinically appropriate, a split-night diagnostic protocol, rather
than a full-night diagnostic protocol for polysomnography, be used to diagnose
OSA. (WEAK)
6. We suggest that when the initial polysomnogram is negative and clinical suspi-
cion for OSA remains, a second polysomnogram be considered for the diagnosis
of OSA. (WEAK) Keywords: obstructive sleep apnea, diagnosis,
polysomnography, home sleep testing (Kapur et al.
2017).
Diagnostic testing for OSA should be performed in conjunction with a compre-
hensive sleep evaluation and adequate follow-up.
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104 B. Krakow and M. Hunasikatti
Table 7.1 Indications for evaluation by a sleep medicine physician
Primary criteria Secondary criteria
1. BMI > 40 kg/mm
2
1. Symptoms of OSA:
2. BMI > 33 kg/mm
2
– Loud, habitual snoring
With either – Witnessed apnea
(a) Hypertension requiring two medications or more – Sleepiness during the major wake
period
(b) Type II diabetes – Chronic insomnia
3. Sleepiness-related crash or accident, off-road deviation/
near miss
– Nocturia
4. Fatigue or sleepiness during duty period – Morning headache
5. Reports of unexplained poor-quality sleep – Chronic allergic or nonallergic
rhinitis
Polysomnography is the standard diagnostic test for the diagnosis of OSA in
adult patients in whom there is a concern for OSA based on a comprehensive
sleep evaluation.
While PSG remains the gold standard for the diagnosis of OSA, it involves
cumbersome sensors and devices that, if minimized and less obtrusive, could make
PSG more tolerable for patients. So AASM has published the guidelines regarding
HST (Kapur et al.
2017). Neve rtheless, the deficits in HSAT, such as the absence of
sleep scoring and the inconsist encies in scoring AHI or RDI for OSA and UARS,
have not yet been addressed (Table 7.1).
7.1.2 Is Screening of Sleep Apnea Necessary?
The US Preventive Services Task Force (USPSTF) makes recommendations about
the effectiveness of specific preventive care services for patients without obvious
related signs or symptoms. It bases its recommendations on the evidence of both the
benefits and harms of the service and an assessment of the balance. The USPSTF
does not consider the costs of providing a service in this assessment.
“The USPSTF concludes that the current evidence is insufficient to assess the
balance of benefits and harms of screening for OSA in asymptomatic adults” (Kapur
et al. 2017).
The American Academy of Family Physicians’ recom mendation is consistent
with that of the USPSTF and concludes that the current evidence is insufficient to
assess the balance of benefits and harms of screening for OSA in asymptomatic
adults.
The American College of Physicians recommends conducting a sleep study for
patients with unexplained daytime sleepiness (grade: weak recommendation,
low-quality evidence). It also recommends polysomnography for diagnostic testing
in patients with suspected OSA. For patients without serious comorbid conditions,
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portable sleep monitors are recommended when polysomnography is not available
(grade: weak recommendation, moderate-quality evidence).
7 Is Screening of Obstructive Sleep Apnea Necessary? Current Perspectives... 105
The American Academy of Sleep Medicine recommends that routine health
maintenance evaluations include questions about OSA and evaluation for risk
factors (obesity,
retrognathia, and treatment-refractory hypertension). Positive find-
ings should trigger a comprehensive sleep evaluation.
7.1.3 Should the Screening Be Individualized?
In view of contradictory recommendations regarding screening of OSA, it may be
prudent to consider Screening of asymptomatic people (Jonas DE, Amick HR,
Feltner C et al. (
2017), National Academies of Sciences, Engineering, and Medicine
(2013).
1. Asymptomatic patients with patients with congestive heart failure, and cardiac
arrythmias (atrial fibrillation)
2. Asymptomatic patients with pulmonary conditions like COPD (chronic obstruc-
tive pulmonary disease)
3. Obese patients (BMI > 30 kg
2
/m)
4. Refractory hypertension
5. Craniofacial deformities: micrognathia, retrognathia
6. Commercial drivers: truck drivers, taxi drivers, train drivers, airline pilots, air
traffic controllers
7. Mental health patients, particularly those with posttraumatic stress disorder
(PTSD) or depressive disorders
Even if all patients who screened positive were tested with a home-based portable
monitoring device at a cost of $162 each, the increase in health care costs would be
an estimated $4.4 billion. When we consider the cost of diagnosing patients with
mild OSA, with no known long-term medical consequences without (compared to
with) treatment, the balance tips heavily against screening in the general popula-
tion (Frost and Sullivan 2016).
However, the overall cost to society can be reduced, need to be considered in
terms of the following:
– Treatment of OSA can reduce the risk of crashes.
– Although commercial truck drivers are safer per vehicle-mile traveled compared
to passenger car drivers.
– Large vehicle crashes are particularly deadly, disabling, and expensive.
– Commercial truck crashes are estimated to cost between $304,500 and $7 million,
depending on the size of the truck and the severity of the incident (Federal Motor
Carrier Safety Administration
2015).
–
These costs are generated by property and vehicular damage, lost wages from
absenteeism, and insurance and related medical expenses. Rail safety incidents
can cost much more.
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106 B. Krakow and M. Hunasikatti
“Management of Obstructive Sleep Apnea in Commercia l Motor Vehicle Oper-
ators: Recommendations of the AASM Sleep and Transportation Safety Awareness
Task Force” by Gurubhagavathula et al. are important for the safety of the public.
(Gurubhagavatula et al.
2017) Routine screening should be conducted as part of the
preexisting required fitness-for-duty medical evaluation. If this screening suggests
substantial risk for OSA, we believe a comprehensive sleep evaluation should be
performed by a board-certified sleep medicine physician.
7.2 How Can We Control the Total Cost Related to OSA?
If OSA-related health costs remain unchecked, the United States will continue to
incur billion s of dollars in unnecessary expenses. Reducing these costs requires a
multidisciplinary approach that involves many constituency groups, including
patients, families, physicians, payors, employers, and government agencies
(Gurubhagavatula et al. 2017).
References
Federal Motor Carrier Safety Administration (2015) 2015 Pocket guide to large truck and bus
statistics. U.S. Department of Transportation, Washington, DC
Frost and Sullivan (2016) Hidden health crisis costing America Billions. https://aasm.org/resources/
pdf/sleep-apnea-economic-crisis.pdf
Gurubhagavatula I, Sullivan S, Meoli A et al (2017) Management of obstructive sleep apnea in
commercial motor vehicle operators: recommendations of the AASM sleep and transportation
safety awareness task force. J Clin Sleep Med 13(5):745–758. https://doi.org/10.5664/jcsm.
6598
Hla KM, Young T, Hagen EW, Stein JH, Finn LA, Nieto FJ, Peppard PE (2015) Coronary heart
disease incidence in sleep disordered breathing: the Wisconsin Sleep Cohort Study. Sleep 38(5):
677–684. https://doi.org/10.5665/sleep.4654
Jonas DE, Amick HR, Feltner C et al (2017) Screening for obstructive sleep apnea in adults: an
evidence review for the U.S. Preventive Services Task orce. Evidence synthesis no. 146. AHRQ
publication no. 14-05216-EF-1. Rockville, Agency for Healthcare Research and Quality
Kapur VK, Auckley DH, Chowdhuri S, Kuhlmann DC, Mehra R, Ramar K, Harrod CG (2017)
Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American
Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med 13(3):479–504
Laratta CR, Ayas NT, Povitz M, Pendharkar SR (2017) Diagnosis and treatment of obstructive
sleep apnea in adults. CMAJ 189(48):E1481–E1488. https://doi.org/10.1503/cmaj.170296
National Academies of Sciences, Engineering, and Medicine (2013) National Cooperative Highway
Research Program report 755: comprehensive costs of highway-rail grade crossing crashes.
Transportation Research Board.
http://www.trb.org/Main/Blurbs/169061.aspx
Redline S, Yenokyan G, Gottlieb DJ, Shahar E, O’Connor GT, Resnick HE, Diener-West M,
Sanders MH, Wolf PA, Geraghty EM, Ali T, Lebowitz M, Punjabi NM (2010) Obstructive sleep
apnea-hypopnea and incident stroke: the sleep heart health study. Am J Respir Crit Care Med
182(2):269–277.
https://doi.org/10.1164/rccm.200911-1746OC
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Chapter 8
Diagnosis and Management of OSA
Comorbid with Insomnia (COMISA)
Ravi Gupta and Lokesh Kumar Saini
Abstract Research addressing comorbid insomnia with obstructive sleep apnea
(OSA) (COMISA) has been conducted in two different ways—firstly, looking for
the insomnia among subjects with OSA and secondly, assessment of OSA among
subjects with chronic insomnia. This research has shown that prevalence of insomnia
among subjects with OSA is higher than the prevalence of OSA among subjects with
insomnia. While investigated through polysomnography, subjects with pure insom-
nia and COMISA show shorter total sleep time, greater percentage of wake after
sleep onset and, poorer sleep efficiency compared to subjects having OSA and
normal controls. Patients with COMISA suffer from two disorders and this combi-
nation is likely to produce greater disability and poorer quality of life among them
compared to patients with either disorders alone. Pathophysiological models based
on the scientific evidences favor that (i) OSA may lead to insomnia, (ii) insomnia
may also lead to OSA and both can work in feed forward manner to develop
COMISA. Insomnia is difficult to be diagnosed in the presence of other sleep
disorders including OSA. It needs to be remembered that overlap of symptoms
between OSA and insomnia may have a positive influence the diagnosis of either
disorders before and, even after the treatment of both the disorders making the
diagnosis difficult. A number of other challenges also make diagnosis of COMISA
difficult that include physician’s knowledge of all versus selected sleep disor-
ders and, methods of assessment of sleep disorders. In view of limited literature,
no consensus exists on the management of cases having COMISA. However,
available evidences suggest that concurrent therapy (CBTi with PAP) could be
better than sequential therapies where management of one disorder is followed by
other.
R. Gupta (✉)
Department of Psychiatry and Division of Sleep Medicine, All India Institute of Medical
Sciences, Rishikesh, Uttarakhand, India
L. K. Saini
Department of Pulmonary Medicine and Division of Sleep Medicine, All India Institute of
Medical Sciences, Rishikesh, Uttarakhand, India
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
A. S. BaHammam, M. Hunasikatti (eds.), Sleep Apnea Frontiers, Progress in Sleep
Research,
https://doi.org/10.1007/978-981-99-7901-1_8
107
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108 R. Gupta and L. K. Saini
Keywords Sleep-apnea · Insomnia · COMISA · Sleep · PAP · Cognitive behavior
therapy for insomnia
8.1 History of Insomnia and OSA Comorbidity Research
Comorbidity of obstructive sleep apnea (OSA) and insomnia (COMISA) was first
recognized by Guilleminault et al. (1973) in tw o cases and later in a study of
56 patients with chronic insomnia (Sweetman et al. 2019a). However, it took another
three decades before the research picked up in this area, perhaps due to the fact that
two disorders were earlier considered to be affecting two different populations and,
which rarely co-occur (Fig. 8.1) (Sweetman et al. 2019a). While OSA was consid-
ered to be disorders affecting primarily middle-aged obese males and characterized
by daytime sleepiness, insomnia was thought to affect middle-aged females
presenting with worries, anxiety, and depression (Sweetman et al.
2019a). However,
researchers at that time failed to recognize that disorders have a number of symptoms
that overlap with each other (Fig.
8.2).
Patients with COMISA differ across a numbe r of demographic and clinical
variables from the patients having either of the disorders alone. Moreover, presence
of these two disorders together influence the outcome of the therapy for either of the
disorders, as discussed in this chapter.
Fig. 8.1 Evolution of research on coexisting insomnia and sleep apnea, beginning with the 1973
article by Guilleminault and colleagues, with notable gaps in extensive research until the emergence
of pivotal articles by Lichstein et al. (1999) and Krakov et al. (2001)
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