Obstructive Sleep Apnea Screening Demonstrates Uncertainty
The USPSTF showed uncertainty about the accuracy and clinical utility of potential screening tools for obstructive sleep apnea in adults.
An evidence report from the US Preventive Services Task Force (USPSTF) showed uncertainty about the accuracy and clinical utility of potential screening tools for obstructive sleep apnea in adults, as published in JAMA. The task force concluded that there is insufficient evidence to assess the benefits and harms of screenings in asymptomatic adults.
The USPSTF noted that there are multiple treatments for obstructive sleep apnea that reduce apnea-hypopnea index, Epworth Sleepiness Scale (ESS) scores, and blood pressure. Trials of continuous positive airway pressure (CPAP) and other treatments have not determined whether treatment reduces mortality or improves other health outcomes, with the exception of an improvement in sleep-related quality of life.
The task force conducted random-effects meta analyses that included 110 studies (n=46,188). The analyses found that, compared with sham, CPAP was associated with a reduction of apnea-hypopnea index (weighted mean difference [WMD], -33.8; 13 trials; 543 participants), excessive sleepiness assessed by the ESS score (WMD, -2.0; 22 trials; 2,721 participants), diurnal systolic blood pressure (WMD, -2.4 points; 15 trials; 1,190 participants), and diurnal diastolic blood pressure (WMD, -1.3 points; 15 trials; 1,190 participants).
Treatment with CPAP was associated with improvement in sleep-related quality of life (standardized mean difference [Cohen d], 0.28; 13 trials; 2,325 participants). Mandibular advancement devices and weight loss programs were also associated with reduced apnea-hypopnea index and excessive sleepiness.
The USPSTF noted that common adverse effects of CPAP and mandibular advancement devices include oral or nasal dryness, irritation, and pain. In cohort studies, the task force found that there was a consistent association between apnea-hypopnea index and all-cause mortality.
In its corresponding recommendation statement, the USPSTF concluded that, “the current evidence is insufficient to assess the balance of benefits and harms of screening for obstructive sleep apnea in asymptomatic adults.
“It is sensible that the USPSTF did not recommend screening of asymptomatic individuals for OSA [obstructive sleep apnea],” wrote Kathleen Yaremchuk, MD, MSA, from the Department of Otolaryngology-Head and Neck Surgery, Henry Ford Hospital, Detroit, stated in an accompanying editorial. “While observational studies demonstrate that patients with severe OSA have a 2-fold increased risk of all-cause and cardiovascular mortality, the most commonly accepted treatment with CPAP has not demonstrated an improvement in health outcomes.”
In an additional editorial, Susan Redline, MD, MPH, noted that additional studies should generate evidence that will improve the recognition and treatment of obstructive sleep apnea in the population. “However, the current recommendations, if misinterpreted, could negatively influence public health if they are used to discourage direct questioning or deployment of short screening questionnaires for identifying patients at high risk for OSA [obstructive sleep apnea],” she wrote.
“Encouraging patient and clinician discussion of relevant symptoms and signs of OSA is one way to help address early recognition,” Dr Redline continued. “Although increasing the likelihood of early recognition is not without its challenges, primary care clinicians have an important role in mitigating the adverse health consequences of OSA that can ensue from years of unrecognized disease.”
- Jonas DE, Amick HR, Feltner C, et al. Screening for obstructive sleep apnea in adults: Evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2017;317(4):415-433. doi:10.1001/jama.2016.19635
- Redline S. Screening for Obstructive Sleep Apnea: Implications for the sleep health of the population. JAMA. 2017;317(4):368-370. doi:10.1001/jama.2016.18630
- 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.2016.20325
- Yaremchuk K. USPSTF recommendation for obstructive sleep apnea screening in adults. JAMA Otolaryngol Head Neck Surg. 2017. doi:10.1001/jamaoto.2016.4720