Sleep Medicine

Obstructive sleep apnea: Epidemiology

Peppard PE, Young T, Barnet JH, et al. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013; 177:1006-14. This important study highlights the prevalence estimates of sleep-disordered breathing in the United States using data from the Wisconsin Sleep Cohort study, modeled by age and sex. The study demonstrated substantial increases in prevalence over 2 decades, with relative increases between 14% and 55% depending on the subgroup.

PMID: 23589584

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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; 7:687-698.  This is the first study to report the global prevalence of OSA, which exceeds 50% in some countries, affecting almost 1 billion people across the world. This underscores the need for effective diagnostic and treatment strategies to minimize the negative health impacts of sleep-disordered breathing.

PMID: 31300334

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Marin JM, Carrizo SJ, Vicente E, et al. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005; 365:1046-53. This landmark prospective observational study found that patients with severe untreated OSA had a higher incidence of fatal and non-fatal cardiovascular event in multivariate analysis, as compared to patients with mild disease, and those treated with CPAP.

PMID: 15781100.


Obstructive Sleep Apnea : Diagnosis

Iber C, O'Brien C, Schluter J, et al. Single night studies in obstructive sleep apnea. Sleep 1991;14:383-5. Contrary to the accompanying editorial, this study first documented the effectiveness of split-night studies for the evaluation of OSA and helped establish split-night studies as the standard of care.

PMID: 1759089.

Corral J, Sanchez-Quiroga MA, Carmona-Bernal C, et al. Conventional polysomnography is not necessary for the management of most patients with suspected obstructive sleep apnea. Noninferiority, randomized controlled trial. Am J Respir Crit Care Med 2017; 196:1181-90. This 6-month study of 430 patients with moderate to high suspicion for OSA found use of home sleep study for diagnosis was noninferior to use of laboratory polysomnography and was less expensive. All patients diagnosed with OSA underwent a separate single CPAP auto-titration home session.

PMID: 28636405

Obstructive Sleep Apnea: Treatment

Sullivan CE, Berthon-Jones M, Issa FQ et al. Reversal of obstructive sleep apnea by continuous positive airway pressure applied through the nares. Lancet 1981 April 18; 1(8225):862-5. First description of CPAP in the treatment of OSA.

PMID: 6112294

McEvoy RD, Antic NA, Heeley E, et al. CPAP for prevention of cardiovascular events in obstructive sleep apnea. N Engl J Med. 2016; 375: 919-31. 2717 adults between 45 and 75 years of age with moderate-to-severe OSA and established coronary or cerebrovascular disease were randomized to CPAP treatment plus usual care or usual care alone and followed for an average of 3.7 years. There was no difference in death from cardiovascular causes, myocardial infarction, stroke, hospitalization for unstable angina, heart failure, or transient ischemic attack, and no difference in a composite of these outcomes.  CPAP significantly reduced snoring and daytime sleepiness and improved health-related quality of life and mood.

PMID: 27571048

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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;186:677-83. This prospective blinded trial of sleepy patients with mild obstructive sleep apnea found improvement in functional outcome after 8 weeks with CPAP when compared with sham CPAP.

PMID: 22837377

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Barbe F, Duran-Cantolla J, Sanchez-de-le-Torre M, et al. Effect of continuous positive airway pressure on the incidence of hypertension and cardiovascular events in non-sleepy patients with obstructive sleep apnea: a randomized controlled trial. JAMA. 2012;307:2161-2168.The efficacy of CPAP in non-sleepy patients with OSA is unclear. This trial of 725 patients with low Epworth scores and AHI > 20 found no reduction in the incidence of hypertension or cardiovascular events over a median 4-year follow-up, although the authors note the study may have been underpowered.

PMID: 22618923

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Traaen GM, Aakeroy 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; 204:573-582. Trial included 108 patients with paroxysmal atrial fibrillation and moderate to severe sleep apnea plus tolerance of CPAP during a run-in period. After 5 months of therapy, there was no significant differences in time spent in atrial fibrillation during the final 3 months of treatment.

PMID: 33938787


Phillips CL, Grunstein RR, Darendeliler MA, et al. Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial. Am J Respir Crit Care Med. 2013; 187:879-87. Crossover study of predominantly moderate OSA patients found better subjectively-reported adherence with use of a mandibular advancement device and no overall difference in daytime sleepiness and quality of life despite greater reduction in AHI with CPAP. Blood pressure was unchanged in both groups but patients were normotensive at baseline. Patients with severe OSA still had moderate OSA while using an oral appliance.


Strollo PJ Jr, Soose RJ, Maurer JT et al. Upper-airway stimulation for obstructive sleep apnea. N Engl J Med 2014; 370: 139-49. This uncontrolled cohort study assessed the efficacy of  hypoglossal nerve stimulation in a highly selected group of patients with difficulty accepting or adhering to CPAP. Subjects had moderate-to-severe sleep apnea, and those with a BMI > 32 were excluded. In addition to PSG, bronchoscopy during propofol-induced sleep was part of the evaluation. They found a decrease in mean AHI from 29 to 9 and improvement in QoL measures. Although these results suggest treatment efficacy, randomized comparative trials are needed to clarify the role of hypoglossal nerve stimulator in OSA management.

PMID: 24401051

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Central sleep apnea

Bradley TD, Logan AG, Kimoff RJ, et al. Continuous positive airway pressure for central sleep apnea and heart failure. N Engl J Med 2005; 353:2025-33. The oft-cited, randomized CANPAP study of 258 patients found use of CPAP in patients with CHF and Cheyne-Stokes Respirations did not improve mortality. Some believe the lack of benefit compared to previous studies is due to advances in CHF treatment with beta blockers.

PMID: 16282177

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Cowie MR, Woehrle H, Wegscheider K, et al. Adaptive servo-ventilation for central sleep apnea in systolic heart failure. New Engl J Med 2015; 373:1095-1105. A randomized trial of guideline based medical care with and without ASV in patients with depressed EF, AHI> 15 and predominance of central apneas. There was no significant difference in composite of death from any cause, lifesaving cardiovascular intervention or unplanned hospitalization for worsening heart failure. There was, however, a significant increase in both all cause and cardiovascular mortality in the ASV group. This unexpected finding has been cause for reassessing the previously rapid growth of ASV for treatment of this population.

PMID: 26323938

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Obesity hypoventilation syndrome

Mokhlesi B, Masa JF, Brozek JL, et al. Evaluation and management of obesity hypoventilation syndrome. An official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2019; 200:e6-e24. This article reviews the current evidence supporting different modes of positive airway pressure therapy used in managing individuals with OHS and includes a recommendation for CPAP as firs-tline treatment rather than noninvasive ventilation in stable OHS patients with concomitant severe OSA.

PMID: 31368798

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Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021;17:255-262. This guideline summarizes the basis of the panels’ strong recommendation for multicomponent cognitive behavioral therapy for chronic insomnia in patients with, and without, comorbidities. The panel did not make recommendations for specific delivery methods, including digital CBT.

PMID: 33164742

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Anguizola E SS, Botta P LM, Castro-Villacañas A, et al The clinical evaluation of sleep-related movement disorders. Sleep Med Clin. 2021; 16:223-231. Provides a nice overview of the presentation, diagnosis, and classification of restless legs syndrome, periodic limb movement disorder, REM sleep behavior disorder, and others.

PMID: 33985649



Bassetti CLA, Adamantidis A, Burdakov D, et al. Narcolepsy - clinical spectrum, aetiopathophysiology, diagnosis and treatment. Nat Rev Neurol. 2019; 15:519-539. This is an excellent overview of narcolepsy pathophysiology, clinical spectrum of the disorder, as well as current diagnostic and treatment approaches.

PMID: 31324898.



Circadian rhythm disorders

Auger RR, Burgess HJ, Emens JS, et al. Clinical practice guideline for the treatment of intrinsic circadian rhythm sleep-wake disorders: advanced sleep-wake phase disorder (ASWPD), delayed sleep-wake phase disorder (DSWPD), non-24-hour sleep-wake rhythm disorder (N24SWD), and irregular sleep-wake rhythm disorder (ISWRD). an update for 2015: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2015; 11:1199-236. This is an update to the previous American Academy of Sleep Medicine guidelines on intrinsic circadian rhythm sleep-wake disorders.

PMID: 26414986