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pulm.osa.core.v1

Obstructive sleep apnea (adult chronic — AASM dx + PAP-first therapy ladder)

pulmonologychronicadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Adult chronic OSA — outpatient sleep-clinic + primary-care shared care; scope = diagnosis + long-term therapy. Exclude pediatric OSA (sibling pointer) and pure CSA/OHS (route out). OSA = repetitive upper-airway collapse with preserved respiratory effort (vs CSA — absent effort) (AASM 2017)

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Adult chronic OSA in scope; pediatric / pure-CSA / OHS routed out

Patient inputs (19)

STOP-BANG age >50 item; OSA prevalence rises with age (Senaratna PMID 27568340)

STOP-BANG male item; male:female prevalence ~2:1 (Senaratna PMID 27568340)

STOP-BANG BMI >35 item; obesity is the dominant modifiable risk factor; gates weight-loss pharmacotherapy/bariatric branch (SURMOUNT-OSA PMID 38912654; Sleep AHEAD PMID 19786682)

STOP-BANG hypertension item; OSA is the commonest contributory cause of resistant HTN; CPAP lowers BP ~2–3 mmHg (Bratton PMID 26624827)

STOP-BANG snoring item + cardinal OSA symptom (AASM 2017)

STOP-BANG tiredness item; Epworth ≥11 quantifies sleepiness — driving-safety gate (Chiu PMID 27919588)

STOP-BANG observed-apnea item; bed-partner report (AASM 2017)

HF/COPD/CAD/AF/stroke/pulmonary HT — drives PSG-over-HSAT decision and CV-risk overlay (AASM 2017 — HSAT not validated with significant cardiopulmonary disease)

Commercial-driver / safety-sensitive occupation — DOT/CDL certification requires documented treatment + objective adherence (severity trigger)

Apnea-hypopnea / respiratory-disturbance index from HSAT or PSG — AASM/Berry scoring rules (PMID 23066376); severity band drives therapy intensity

Awake hypercapnia pivot — serum HCO3 ≥27 prompts ABG; PaCO2 ≥45 mmHg = OHS (NIV/BiPAP not plain CPAP) (AASM 2017; OHS branch)

ECG if AF suspected; echo for cor pulmonale / HFrEF (ASV-contraindication gate per SERVE-HF PMID 26323938)

STOP-BANG neck >40 cm item; upper-airway crowding surrogate (AASM 2017)

Opioid/sedative use raises CSA risk and perioperative hazard; alcohol worsens collapsibility (AASM 2017; perioperative branch)

Pregnancy branch — CPAP safe/preferred; screen if gestational HTN/pre-eclampsia/obesity

Sedatives/opioids worsen events; tirzepatide/GLP-1 overlap with weight-loss branch and endo.dm2.core.v1

Hypothyroidism is a reversible OSA contributor / sleepiness mimic (AASM 2017)

Chronic-hypoxemia secondary erythrocytosis screen (AASM 2017)

Oxygen-desaturation index + nadir SpO2 — hypoxic burden; very low nadir / OHS concern routes to ABG

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningasv_contraindicated_hfref_predominant_csa
    HFrEF (LVEF ≤45%) with predominant central sleep apnea / Cheyne-Stokes respiration — adaptive servo-ventilation (ASV) is CONTRAINDICATED (HARM signal)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_osa_with_cv_risk_or_driving_hazard
    AHI ≥30 (severe) with excessive sleepiness (Epworth ≥16) AND/OR established CV disease/AF/resistant-HTN AND/OR safety-sensitive occupation (commercial driver) — high-priority treat-and-document
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereohs_awake_hypercapnia
    Awake hypercapnia — serum HCO3 ≥27 prompting ABG, PaCO2 ≥45 mmHg with obesity (BMI ≥30) and sleep-disordered breathing = obesity-hypoventilation syndrome (OHS), NOT plain OSA
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecpap_intolerant_alternative_ladder
    CPAP-intolerant / non-adherent (<4 h/night or <70% nights) despite ≥3-month structured adherence programme
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatedifferential_osa_vs_csa_vs_ohs
    Sleep-disordered breathing — is it OSA, central sleep apnea, or OHS? Pivots: respiratory EFFORT during events (present → obstructive/OSA; absent → central/CSA); awake PaCO2 (≥45 with obesity → OHS, NOT plain OSA); substrate (HFrEF/opioid/altitude → CSA). Encoded for therapy selection + ASV-contraindication gating
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatedifferential_hypersomnia_osa_vs_narcolepsy_vs_insomnia_vs_plmd
    Daytime hypersomnia not explained by OSA — §5.5.2 pivots: OSA (AHI ≥5 + obstructive events); narcolepsy (REM-dissociation, cataplexy, MSLT mean sleep latency ≤8 min + ≥2 SOREMPs); chronic insomnia (sleep-onset/maintenance complaint, NO respiratory events); PLMD (periodic limb-movement index elevated, arousals); nocturnal GERD/asthma (reflux/bronchospasm mimicking arousal)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateoverlap_syndrome_osa_plus_copd
    OSA + COPD = "overlap syndrome" — higher nocturnal desaturation, hypercapnia and pulmonary-hypertension risk than either alone; fixed airflow obstruction on spirometry plus OSA on sleep study
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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Recommended regimen

OSA PAP-first therapy ladder (AASM 2019 PAP CPG) — chronic outpatient
axis: osa_therapy_ladderstep 1 - Step 1 — CPAP / APAP (gold standard) + adherence sub-loop
Selected step "Step 1 — CPAP / APAP (gold standard) + adherence sub-loop" — Confirmed OSA (AHI ≥5 with symptoms, or AHI ≥15 regardless) — all severities; first-line for all unless awake hypercapnia (OHS → Step OHS) or predominant CSA in HFrEF
  • CPAP (fixed) or auto-titrating APAP + behavioural/educational/telemonitoring adherence interventions
    first line
    positive_airway_pressure
    CPAP 4–20 cmH2O titrated (in-lab or APAP auto-set); humidified; mask-fit + desensitisation; compliance target ≥4 h/night on ≥70% of nights • nasal/oronasal mask • every sleep period
    triggers: confirmed_OSA_any_severity, symptomatic_AHI_ge_5, AHI_ge_15
    AASM 2019 PAP CPG (PMID 30736887) STRONG recommendation — CPAP/APAP first-line; reduces AHI, sleepiness (Epworth), improves QoL and lowers BP (SBP −2.5 / DBP −2.0 mmHg, +1 h/night → additional −1.5/−0.9 mmHg; Bratton JAMA 2015 PMID 26624827). HONESTY: SAVE (PMID 27571048) showed NO reduction in CV events in established CVD with non-sleepy OSA — value is symptom/QoL/BP, not CV mortality

outpatient playbook — drug actions (6)

  1. 1. CPAP or APAP (gold standard) + adherence sub-loop
    CPAP 4–20 cmH2O titrated / APAP auto-set; humidified; mask-fit + desensitisation; target ≥4 h/night ≥70% nights • nasal/oronasal mask • every sleep period
    trigger: Confirmed OSA (symptomatic AHI ≥5 or AHI ≥15)
    AASM 2019 PAP CPG (PMID 30736887) STRONG; symptom/QoL/BP benefit (Bratton PMID 26624827); SAVE honesty caveat (PMID 27571048)
  2. 2. BiPAP
    IPAP/EPAP titrated; ST + backup rate if hypoventilation • nasal/oronasal mask • every sleep period
    trigger: CPAP pressure-intolerant or coexisting hypoventilation
    AASM 2019 PAP CPG option for CPAP-intolerant; NIV for OHS
  3. 3. Oral appliance (MAD)
    Custom titratable MAD; verify with repeat sleep study • intraoral • every sleep period
    trigger: Mild–moderate OR CPAP-intolerant/refusing
    Comparable BP outcome to CPAP via higher adherence (Bratton PMID 26624827)
  4. 4. Hypoglossal-nerve stimulation (Inspire)
    Implant + titration; activation ~1 mo post-op • implanted • nightly (patient-activated)
    trigger: CPAP-intolerant, AHI 15–65, BMI <35, no concentric collapse on DISE
    STAR — AHI −68% (PMID 24401051)
  5. 5. Tirzepatide (obese OSA)
    2.5 mg SC weekly → titrate to max 15 mg/week • SC • once weekly
    trigger: Obese OSA (BMI ≥30) adjunct/substitute
    SURMOUNT-OSA — AHI −20 to −30/h (PMID 38912654); rxcui 2601723 verified RxNav
  6. 6. Wake-promoting adjunct (modafinil/solriamfetol/pitolisant)
    Modafinil 200 mg AM (max 400); solriamfetol 37.5–75 mg AM renally dosed • PO • once daily (AM)
    trigger: Residual sleepiness ONLY after PAP optimised + adherent
    Adjunct, NOT a PAP substitute (AASM)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Loud habitual snoring + witnessed apnea + daytime sleepiness (AASM 2017 dx CPG); Non-restorative sleep, nocturia, morning headache, choking/gasping arousals (AASM 2017); Resistant hypertension / atrial fibrillation / stroke — OSA contributory cause; reciprocal screen (cardio.htn.resistant.v1, cardio.afib.core.v1).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Obstructive sleep apnea (adult chronic — AASM dx + PAP-first therapy ladder)** (pulm.osa.core.v1).
Phenotype framing: §5.5.2 differential as data — OSA vs CSA (absent effort; HF/opioid/altitude substrate) vs OHS (awake PaCO2 ≥45) vs narcolepsy (REM-dissociation, cataplexy, MSLT MSL ≤8 min + ≥2 SOREMPs) vs chronic insomnia (sleep-onset/maintenance complaint, no respiratory events) vs PLMD (periodic limb movements, PLMI) vs nocturnal GERD/asthma (reflux/bronchospasm mimicking arousal). Pivots + test characteristics encoded in severity_triggers + sibling_differentiation
Scope: Adult chronic OSA — outpatient sleep-clinic + primary-care shared care; scope = diagnosis + long-term therapy. Exclude pediatric OSA (sibling pointer) and pure CSA/OHS (route out). OSA = repetitive upper-airway collapse with preserved respiratory effort (vs CSA — absent effort) (AASM 2017)

No severity triggers fired against current inputs.

Plan

Regimen axis: **OSA PAP-first therapy ladder (AASM 2019 PAP CPG) — chronic outpatient** — step "Step 1 — CPAP / APAP (gold standard) + adherence sub-loop".
1. CPAP (fixed) or auto-titrating APAP + behavioural/educational/telemonitoring adherence interventions CPAP 4–20 cmH2O titrated (in-lab or APAP auto-set); humidified; mask-fit + desensitisation; compliance target ≥4 h/night on ≥70% of nights nasal/oronasal mask every sleep period (positive_airway_pressure, first line) — AASM 2019 PAP CPG (PMID 30736887) STRONG recommendation — CPAP/APAP first-line; reduces AHI, sleepiness (Epworth), improves QoL and lowers BP (SBP −2.5 / DBP −2.0 mmHg, +1 h/night → additional −1.5/−0.9 mmHg; Bratton JAMA 2015 PMID 26624827). HONESTY: SAVE (PMID 27571048) showed NO reduction in CV events in established CVD with non-sleepy OSA — value is symptom/QoL/BP, not CV mortality

Setting playbook (outpatient) — Confirm OSA + severity, start CPAP-first with a structured adherence sub-loop, escalate the alternative ladder for CPAP-intolerant patients, co-manage CV/metabolic comorbidity, and gate driving safety — all in sleep-clinic + primary-care shared care
2. CPAP or APAP (gold standard) + adherence sub-loop CPAP 4–20 cmH2O titrated / APAP auto-set; humidified; mask-fit + desensitisation; target ≥4 h/night ≥70% nights nasal/oronasal mask every sleep period — Confirmed OSA (symptomatic AHI ≥5 or AHI ≥15) (AASM 2019 PAP CPG (PMID 30736887) STRONG; symptom/QoL/BP benefit (Bratton PMID 26624827); SAVE honesty caveat (PMID 27571048))
3. BiPAP IPAP/EPAP titrated; ST + backup rate if hypoventilation nasal/oronasal mask every sleep period — CPAP pressure-intolerant or coexisting hypoventilation (AASM 2019 PAP CPG option for CPAP-intolerant; NIV for OHS)
4. Oral appliance (MAD) Custom titratable MAD; verify with repeat sleep study intraoral every sleep period — Mild–moderate OR CPAP-intolerant/refusing (Comparable BP outcome to CPAP via higher adherence (Bratton PMID 26624827))
5. Hypoglossal-nerve stimulation (Inspire) Implant + titration; activation ~1 mo post-op implanted nightly (patient-activated) — CPAP-intolerant, AHI 15–65, BMI <35, no concentric collapse on DISE (STAR — AHI −68% (PMID 24401051))
6. Tirzepatide (obese OSA) 2.5 mg SC weekly → titrate to max 15 mg/week SC once weekly — Obese OSA (BMI ≥30) adjunct/substitute (SURMOUNT-OSA — AHI −20 to −30/h (PMID 38912654); rxcui 2601723 verified RxNav)
7. Wake-promoting adjunct (modafinil/solriamfetol/pitolisant) Modafinil 200 mg AM (max 400); solriamfetol 37.5–75 mg AM renally dosed PO once daily (AM) — Residual sleepiness ONLY after PAP optimised + adherent (Adjunct, NOT a PAP substitute (AASM))

Non-pharmacologic actions:
- Structured CPAP adherence sub-loop — mask change, pressure-relief, desensitisation, telemonitoring, motivational support (early adherence predicts long-term; ~50% adherent at 1 yr)
- Weight management — intensive lifestyle (≥7–10% loss), tirzepatide, or bariatric referral if BMI ≥40 (or ≥35 + comorbidity) (Sleep AHEAD PMID 19786682; SURMOUNT-OSA PMID 38912654)
- Positional therapy for supine-predominant OSA (AASM 2017)
- Alcohol/sedative reduction + sleep-hygiene + treat nasal obstruction
- OHS pathway — NIV/BiPAP (not plain CPAP) if awake PaCO2 ≥45 (AASM 2017)
- Driving-safety counselling + documentation for commercial drivers (DOT/CDL)
- CV/metabolic co-management referral — cardio.htn.resistant.v1, cardio.afib.core.v1, endo.dm2.core.v1

AVOID / contraindication checks:
- ASV_CONTRAINDICATED_in_HFrEF_LVEF_le_45_with_predominant_central_sleep_apnea (SERVE HF Cowie NEJM 2015 PMID 26323938 — all cause mortality HR 1.28, CV mortality HR 1.34)
- OHS_awake_hypercapnia_PaCO2_ge_45_use_NIV_BiPAP_not_plain_CPAP_first (AASM 2017 — OHS ≠ OSA; plain CPAP inadequate for awake hypoventilation)
- Supplemental_O2_alone_can_worsen_hypercapnia_in_OHS_optimise_ventilation_first (AASM 2017)
- Wake_promoting_agents_NOT_a_substitute_for_PAP_use_only_for_residual_sleepiness_on_adherent_PAP (AASM)
- No_overstated_CV_benefit_CPAP_is_CV_event_neutral_value_is_symptom_QoL_BP (SAVE McEvoy NEJM 2016 PMID 27571048)
- Avoid_weight_loss_pharmacotherapy_tirzepatide_in_pregnancy (pregnancy branch)
- Severe_OSA_plus_sleepiness_in_commercial_driver_document_treatment_and_objective_adherence_before_certification (DOT/CDL)
- Hypoglossal_stim_label_BMI_lt_35_AHI_15_to_65_no_complete_concentric_collapse_on_DISE (STAR Strollo NEJM 2014 PMID 24401051)
- Opioid_sedative_caution_perioperatively_and_in_baseline_OSA (AASM 2017 perioperative)
- Solriamfetol_renal_dose_adjust_per_eGFR (calc.ckd_epi_2021)

Monitoring

Regimen monitoring:
- cpap compliance download q3 6 months objective hours residual AHI leak (AASM 2019 PAP CPG PMID 30736887; ≥4 h/night ≥70% nights)
- epworth sleepiness trend each visit (Chiu PMID 27919588 — symptom burden + driving-safety)
- blood pressure each visit (Bratton PMID 26624827 — +1 h/night CPAP → additional SBP −1.5 / DBP −0.9 mmHg)
- weight BMI each visit re titrate if ge 10pct change (re-titration trigger; SURMOUNT-OSA PMID 38912654 weight-AHI link)
- partner reported snoring and nocturia trend (AASM 2017)
- driving safety re attestation for commercial drivers (DOT/CDL severity trigger)
- tirzepatide GI tolerance and weight response if on weight loss branch (SURMOUNT-OSA PMID 38912654)
- venous bicarb or ABG if OHS suspected or persistent hypoxemia (AASM 2017 OHS pivot)

Setting (outpatient) monitoring:
- CPAP compliance download q3–6 mo — objective hours, residual AHI, mask leak (AASM 2019 PMID 30736887)
- Epworth trend each visit (Chiu PMID 27919588)
- BP each visit (Bratton PMID 26624827)
- Weight/BMI each visit — re-titrate if ≥10% change or pregnancy
- Partner-reported snoring + nocturia trend
- Driving-safety re-attestation for commercial drivers

Follow-up plan: Annual review; re-titration if ≥10% weight change or pregnancy; reinforce adherence (early adherence predicts long-term — adherence ~50% at 1 yr); driving-safety re-attestation for CDL; comorbidity (HTN/AF/T2DM/stroke) co-management; pregnancy re-evaluation post-partum
- Close-out criterion: Annual review + re-titration triggers + driving re-attestation scheduled

Monitoring phase: CPAP compliance download q3–6 mo (objective hours, residual AHI, mask leak; ≥4 h/night ≥70% nights threshold); Epworth trend; BP; weight; partner-reported snoring; nocturia. Each +1 h/night CPAP use = additional SBP −1.5 / DBP −0.9 mmHg (Bratton PMID 26624827)

Disposition

Current setting: outpatient — Confirm OSA + severity, start CPAP-first with a structured adherence sub-loop, escalate the alternative ladder for CPAP-intolerant patients, co-manage CV/metabolic comorbidity, and gate driving safety — all in sleep-clinic + primary-care shared care

Disposition criteria:
- Continue shared care if adherent (≥4 h/night ≥70% nights) + symptoms/BP controlled
- Refer sleep medicine if refractory, diagnostic uncertainty, suspected CSA/OHS, or CPAP-intolerant
- Refer ENT/oral-medicine for MAD or upper-airway surgery; Inspire/bariatric referral if eligible
- Co-manage CV/metabolic comorbidity (resistant HTN, AF, T2DM, stroke)

Escalation triggers (move to higher acuity):
- Severe sleepiness + driving/occupational hazard (Epworth ≥16 or near-miss MVA) → expedite testing + treatment + driving counselling
- Suspected OHS (awake hypercapnia, HCO3 ≥27 → ABG PaCO2 ≥45) → NIV/BiPAP pathway + sleep medicine
- Suspected predominant CSA in HFrEF (LVEF ≤45%) → cardiology + sleep medicine; do NOT prescribe ASV (SERVE-HF PMID 26323938)
- Decompensated cor pulmonale / refractory hypoxemia → escalate care
- CPAP-intolerant despite ≥3-month structured adherence programme → sleep-medicine referral for alternative ladder

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] HFrEF (LVEF ≤45%) with predominant central sleep apnea / Cheyne-Stokes respiration — adaptive servo-ventilation (ASV) is CONTRAINDICATED (HARM signal)
- [SEVERE] AHI ≥30 (severe) with excessive sleepiness (Epworth ≥16) AND/OR established CV disease/AF/resistant-HTN AND/OR safety-sensitive occupation (commercial driver) — high-priority treat-and-document
- [SEVERE] Awake hypercapnia — serum HCO3 ≥27 prompting ABG, PaCO2 ≥45 mmHg with obesity (BMI ≥30) and sleep-disordered breathing = obesity-hypoventilation syndrome (OHS), NOT plain OSA

Citations

- AASM 2017 Diagnostic Testing for Adult OSA CPG (Kapur) + AASM 2019 PAP Treatment of Adult OSA CPG (Patil) + AASM 2021 surgical-referral CPG (Kent) + AASM 2025 hospitalized-OSA CPG (Mehra) + AASM Manual respiratory-event scoring (Berry); ICSD-3-TR (AASM 2023) diagnostic classification [PMID:28162150](https://pubmed.ncbi.nlm.nih.gov/28162150/)
- Cited evidence (PMID 30736887) [PMID:30736887](https://pubmed.ncbi.nlm.nih.gov/30736887/)
- Cited evidence (PMID 30736888) [PMID:30736888](https://pubmed.ncbi.nlm.nih.gov/30736888/)
- Cited evidence (PMID 34351848) [PMID:34351848](https://pubmed.ncbi.nlm.nih.gov/34351848/)
- Cited evidence (PMID 40838698) [PMID:40838698](https://pubmed.ncbi.nlm.nih.gov/40838698/)

Last reconciled with current guidelines: 2026-05-26.
References
  • AASM 2017 Diagnostic Testing for Adult OSA CPG (Kapur) + AASM 2019 PAP Treatment of Adult OSA CPG (Patil) + AASM 2021 surgical-referral CPG (Kent) + AASM 2025 hospitalized-OSA CPG (Mehra) + AASM Manual respiratory-event scoring (Berry); ICSD-3-TR (AASM 2023) diagnostic classification — PMID:28162150
  • Cited evidence (PMID 30736887) — PMID:30736887
  • Cited evidence (PMID 30736888) — PMID:30736888
  • Cited evidence (PMID 34351848) — PMID:34351848
  • Cited evidence (PMID 40838698) — PMID:40838698