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  • – Adults.


American Academy of Sleep Medicine 2012

  • Primary CSAS

    • Use positive airway pressure therapy.

    • Limited evidence to support the use of acetazolamide for CSAS.

    • Consider zolpidem or triazolam if patients are not at high risk for respiratory depression.

  • CSAS related to CHF

    • Nocturnal oxygen therapy.

    • CPAP therapy targeted to normalize the apnea-hypopnea index.

  • CSAS related to ESRD

    • Options for therapy include CPAP, nocturnal oxygen, and bicarbonate buffer use during dialysis.




  • – Adults.


AASM 2017, 2019

  • Diagnosis

    • Test for OSA in conjunction with a comprehensive sleep evaluation.

    • Diagnose OSA when apnea-hypopnea index (AHI) is ≥5 events/h. Severe OSA is AHI ≥ 30 events/h.

    • Use a polysomnogram or home sleep apnea testing with a technically adequate device to diagnose OSA in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate-to-severe OSA.

    • Use a polysomnogram, rather than home sleep apnea testing, to diagnose 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, and history of stroke or severe insomnia.

    • If a single home sleep apnea testing is negative, inconclusive, or technically inadequate, a polysomnogram be performed for the diagnosis or exclusion of OSA.

  • Treatment with Positive Airway Pressure (PAP)

    • Treat OSA with PAP, either Continuous PAP (CPAP) or auto-adjusting PAP (APAP).

    • Choose CPAP and APAP rather than Bi-level PAP (BPAP) because BPAP is more costly and does not prevent obstructive breathing events at low expiratory pressure levels. Patients with a PAP requirement over 20 cm H2O will require BPAP because of the limitation of settings on CPAP.

    • Alternatives to PAP include weight loss, positional therapy, oral appliance therapy, surgical management of anatomical nasal obstruction, or maxillomandibular advancement.

    • To improve adherence, choose nasal or intranasal mask interface rather than oronasal or oral, use heated humidification (reduces sleepiness, dry mouth/throat/nose, nasal congestion, hoarseness, headache, epistaxis), and offer educational, behavioral, and other troubleshooting interventions particularly in the setting of PTSD/anxiety.


  1. Excessive daytime sleepiness: PAP, when compared to no treatment, shows significant improvement in sleepiness.

  2. Impaired sleep: mixed data that PAP will alleviate this symptom.

  3. HTN: BP reduction is clinically significant on PAP therapy, but patients without sleep symptoms may benefit enough from standard anti-HTN treatment to not need PAP if PAP is burdensome to their sleep cycle.

  4. CV events/mortality: insufficient evidence to recommend PAP as a means to reduce CV events or CV mortality.


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