Purpose: To systematically review the evidence on screening and treating asymptomatic adults with obstructive sleep apnea (OSA) or those with unrecognized symptoms for OSA.
Data Sources: PubMed/MEDLINE, the Cochrane Library, Embase, and trial registries through August 23, 2021; reference lists of retrieved articles; outside experts; and reviewers, with surveillance of the literature through September 23, 2022.
Study Selection: Two investigators independently selected English-language studies using a priori criteria. Eligible studies included randomized, controlled trials (RCTs) of screening for or treatment of OSA reporting on health outcomes, studies evaluating accuracy of screening questionnaires or clinical prediction tools in asymptomatic adults with OSA or persons with unrecognized symptoms of OSA, and systematic reviews of treatment reporting on changes in blood pressure (BP) and apnea-hypopnea index (AHI) scores.
Data Extraction: One investigator extracted data and a second checked accuracy. Two reviewers independently rated data quality for all included studies using predefined criteria.
Data Synthesis: No reviewed RCT directly compared screening with no screening. In two studies (702 total participants), the screening accuracy measured as AUC of the Multivariable Apnea Prediction (MVAP) score followed by unattended home sleep testing for detecting severe OSA syndrome (AHI ≥30 and Epworth Sleepiness Scale [ESS] score >10) was 0.80 (95% confidence interval [CI], 0.78 to 0.82) and 0.83 (95% CI, 0.77 to 0.90), respectively. Studies evaluating the Snoring, Tiredness, Observed apnea, blood Pressure, Body mass index, Age, Neck circumference, Gender (STOP-BANG) Questionnaire (k=4) and the Berlin Questionnaire (BQ) (k=2) enrolled different populations and used different criteria for a positive screening test. Recent systematic reviews of positive airway pressure (PAP) and mandibular advancement devices (MADs) show an association between PAP and MAD and reduction in BP and AHI, however reduction in BP outcomes versus inactive control is relatively small (2 to 3 mm Hg). Meta-analysis found that PAP compared with any control was associated with a significantly larger reduction in ESS score change (pooled mean difference, −2.33 [95% CI, −2.75 to −1.90]; 47 trials, 7,024 participants), modest improvement in sleep-related quality of life (QOL) (standardized mean difference, 0.30 [95% CI, 0.19 to 0.42]; 18 trials, 3,083 participants), and improved general health-related QOL measured by the SF-36 mental health component summary score change (2.20 [95% CI, 0.95 to 3.44]; 15 trials, 2,345 participants) and SF-36 physical health component summary score change (pooled mean difference, 1.53 [95% CI, 0.29 to 2.77]; 13 trials, 2,031 participants). Meta-analysis also found that use of MADs was associated with a significantly larger ESS score change than controls (pooled mean difference, −1.67 [95% CI, −2.09 to −1.25]; 10 trials, 1,540 participants). Reporting of other health outcomes was sparse; no included trial found significant benefit associated with PAP or MAD on mortality, cardiovascular outcomes, stroke, or motor vehicle accidents. Common adverse effects of PAP and MADs included oral or nasal dryness, irritation, and pain, among others.
Limitations: Two studies assessing the accuracy of the MVAP score oversampled participants at high risk of OSA and those with OSA syndrome. No study prospectively evaluated screening tools to report calibration or clinical utility for improving health outcomes. Three studies assessing the accuracy of the STOP-BANG and two assessing the BQ enrolled different populations and used different criteria for positive screening tests. Most included trials assessing the benefit of PAP and MADs reported outcomes over a relatively short duration (12 weeks or less), and most pooled estimates showing improvement in excessive sleepiness or QOL (except benefit of PAP for improving ESS scores) fell short of the range considered to be a minimal clinically important difference. Populations enrolled in trials of treatment were referred for treatment; no trial enrolled populations who were identified by screening in primary care.
Conclusions: The accuracy and clinical utility of potential screening tools for OSA that could be used in primary care settings are uncertain. PAP and MADs reduce AHI, BP and ESS score. Trials of PAP have not established whether treatment reduces mortality or improves most other health outcomes, except for its modest improvement in sleep-related QOL and general health–related QOL.