Scope of this summary
Adults evaluated for obstructive sleep apnea (OSA), adults with confirmed OSA receiving positive-airway-pressure treatment, and adults in whom obesity hypoventilation syndrome (OHS) is suspected. Pediatric sleep-disordered breathing, central sleep apnea, dental-device selection and perioperative protocols require separate guidance.
The Bottom Line
- Diagnostic testing must follow a comprehensive sleep evaluation and be paired with clinical follow-up; questionnaires can estimate risk but cannot diagnose OSA without polysomnography or technically adequate home sleep apnea testing.
- Use polysomnography or home testing in an uncomplicated adult at increased risk of moderate to severe OSA; proceed to polysomnography after a negative, inconclusive or technically inadequate home test when suspicion remains.
- Prefer polysomnography rather than home testing when significant cardiorespiratory disease, neuromuscular respiratory weakness, suspected hypoventilation, chronic opioid use, prior stroke or severe insomnia is present.
- Treat symptomatic confirmed OSA with positive airway pressure when indicated; AASM supports home auto-adjusting PAP initiation or laboratory titration only in adults without significant comorbidity and supports CPAP or auto-adjusting PAP for ongoing therapy.
- In OHS, establish awake hypercapnia appropriately, provide PAP during sleep, and use CPAP first-line for stable ambulatory patients who also have severe OSA, while individualizing treatment and follow-up.
Practical clinical workflow
1
Ask about snoring, witnessed apnea, sleepiness, driving and work risk, insomnia, sleep duration, cardiometabolic disease, opioids and prior airway or sleep treatment; examine upper airway and cardiopulmonary status.
2
Choose polysomnography or home testing from pretest risk and comorbidity rather than convenience alone; arrange interpretation and a plan for inconclusive results.
3
When OHS risk is high, measure arterial carbon dioxide; when suspicion is low to moderate, use the ATS serum-bicarbonate strategy to decide who needs an arterial measurement rather than treating oximetry as diagnostic.
4
After diagnosis, discuss PAP options, supply mask and device education, troubleshoot leak and comfort, and review objective adherence and therapeutic data early in treatment.
5
Address sustained weight management, alcohol or sedative risk, nasal symptoms and cardiometabolic disease, and reassess persistent sleepiness or hypoventilation despite apparently adequate PAP.
Safety boundaries and escalation
- Acute hypercapnic respiratory failure, severe resting hypoxemia, altered consciousness or decompensated right-heart failure requires emergency care, not routine home sleep testing.
- ATS suggests that hospitalized patients with respiratory failure and suspected OHS leave hospital with temporary noninvasive ventilation until prompt outpatient diagnostic testing and PAP titration; discharge equipment does not replace that work-up.
- Advise patients with uncontrolled sleepiness about driving and safety-sensitive work under applicable state law and employer rules; treatment response must be documented rather than assumed.
- Do not prescribe oxygen alone as a substitute for treating obstructive events or hypoventilation, and do not infer ventilator settings from this summary.
Localization
US testing and PAP access is shaped by AASM standards, state driving rules, durable-medical-equipment suppliers and payer adherence requirements. Medicare or insurer coverage criteria are administrative rules, not diagnostic definitions.
Source documents
Use the linked source documents for complete recommendations, evidence grading, exclusions and implementation detail.
- American Academy of Sleep MedicineClinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep ApneaDOI 10.5664/jcsm.6506 路 published 2017-03-15 路 accessed 2026-08-20view source
- American Academy of Sleep MedicineTreatment of Adult Obstructive Sleep Apnea with Positive Airway Pressure: An American Academy of Sleep Medicine Clinical Practice GuidelineDOI 10.5664/jcsm.7640 路 published 2019-02-15 路 accessed 2026-08-20view source
- American Thoracic SocietyEvaluation and Management of Obesity Hypoventilation Syndrome: An Official ATS Clinical Practice GuidelineDOI 10.1164/rccm.201905-1071ST 路 published 2019-08-01 路 accessed 2026-08-20view source
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