[Guidelines for the diagnosis and treatment of obstructive sleep apnea in adults (2025)].

Obstructive sleep apnea (OSA) is a highly prevalent sleep-related breathing disorder with a considerable healthcare burden. Previously, the 2011 guideline for adult obstructive sleep apnea was largely formulated on the basis of expert opinion and consensus, which played an important role in guiding clinical practice. With the growing body of evidence from high-quality clinical studies, however, guideline development models that rely primarily on expert consensus are no longer adequate to support contemporary clinical decision-making. To further standardize the screening, diagnosis, treatment, and long-term management of OSA in adults, the Sleep Disordered Breathing Assembly of the Chinese Thoracic Society has developed evidence-based clinical practice guidelines. The recommendations were formulated according to the best currently available evidence, following the. Based on an extensive preliminary investigation, the guideline addresses 18 key clinical questions and provides detailed, evidence-based recommendations, aiming to support clinical decision-making and to promote standardized diagnosis, treatment, and management of adults with OSA in China.The clinical questions and recommendations are listed below.Which populations should be screened for OSA?Routine screening for OSA is not recommended in the general population without high-risk features (1, A). Screening is recommended for individuals at high risk for OSA who exhibit typical symptoms or physical signs, or who have relevant comorbidities. Screening is also recommended for perioperative patients (e.g., candidates for bariatric surgery or other high-risk procedures) (1, A). Screening may be considered for high-risk individuals without typical symptoms (2, B). Screening is also recommended for individuals whose OSA may increase the risk of driving or occupational accidents (1, A).High-risk populations for OSA include: (1) Individuals with typical OSA symptoms, such as habitual snoring, excessive daytime sleepiness, witnessed apneas, nocturnal gasping or choking, morning headaches, morning dry mouth, non-restorative sleep, nocturia, impaired attention, memory decline, and reduced sexual function; (2) Individuals with typical physical signs of OSA, including obesity, increased neck circumference, retrognathia or micrognathia, macroglossia, enlarged uvula and soft palate, and tonsillar hypertrophy; (3) Individuals with OSA-related complications or comorbidities, such as obesity, hypertension, type 2 diabetes mellitus, cardiovascular disease, metabolic syndrome, hypothyroidism, polycystic ovary syndrome, acromegaly, neuromuscular diseases, depression, and anxiety; (4) Specific populations, including middle-aged and older men, pregnant women, and postmenopausal women; (5) Individuals with a family history of OSA, particularly those with first-degree relatives affected by OSA (1, A).What is the role of questionnaires, craniofacial assessment, and other predictive tools in screening and evaluating individuals at high risk for OSA?The STOP-Bang questionnaire is recommended for OSA screening (1, A). The Berlin questionnaire and STOP questionnaire may also be considered (1, B). The Epworth Sleepiness Scale (ESS) is recommended to assess daytime sleepiness severity but should not be used to diagnose OSA (1, A). Subjective questionnaires alone, without objective sleep monitoring, are not recommended for OSA diagnosis (1, A).A structured physical examination of the upper airway and craniofacial features is recommended, including the modified Mallampati score and Friedman tongue position classification. Further evaluation (e.g., cephalometric radiography, CT or MRI of the upper airway) may be performed when indicated (1, A).Clinically validated consumer-grade sleep monitors and wearable AI devices may be considered to assist self-screening in high-risk individuals and encourage timely medical consultation. However, these are non-medical screening tools and should not replace medical-grade sleep monitoring for diagnosis (1, A).How should polysomnography (PSG) and home sleep apnea testing (HSAT) be used in the diagnosis of OSA in adults?PSG is the gold standard for diagnosing OSA in adults (1, A). It is recommended as the first choice for complex cases (especially those with comorbid sleep disorders) and individuals in high-risk occupations (1, A). PSG is also preferred for precise assessment of treatment efficacy and follow-up (1, A).HSAT is recommended for diagnosing clinically suspected moderate-to-severe uncomplicated OSA, but should not be used to rule out OSA (1, A). It may also be used for hospitalized patients with limited mobility or critical illness requiring prompt intervention (1, A). HSAT can serve as an adjunct tool for treatment response assessment and follow-up (1, A). It is not recommended for general screening of asymptomatic individuals or for diagnosing mild OSA (1, A).What are the diagnostic criteria and severity classification for OSA in adults?The ICSD-3-TR diagnostic criteria are recommended for diagnosing OSA in adults (1, A). In resource-limited primary care settings, simplified criteria incorporating history, physical examination, and pulse oximetry may be used (1, A).OSA severity should be classified primarily based on the apnea-hypopnea index (AHI), with nocturnal minimum pulse oxygen saturation as a supplementary measure of hypoxemia burden (1, A). Emerging indices such as HB and SBII may be considered when assessing cardiovascular and comorbidity risks (2, B).How should OSA phenotypes and endotypes be assessed?There is no universally accepted phenotyping standard. In clinical practice, symptom-based categories are commonly used: excessive daytime sleepiness predominant, sleep disturbance/fragmentation predominant, and asymptomatic/minimally symptomatic phenotypes (1, B). Phenotype assessment should integrate demographics, symptoms, history, PSG data, and validated questionnaires (1, B).Endotyping may be considered using four physiological traits: critical closing pressure, arousal threshold, loop gain, and upper airway muscle responsiveness (1, B). Techniques such as CPAP pressure titration and esophageal pressure monitoring may be used to assess OSA endotypes (1, B). Alternatively, OSA endotypes may be estimated through advanced analysis of PSG signals (2, B).Individualized assessment of patients with OSA may also incorporate potentially treatable traits, including daytime functional impairment (e.g., excessive daytime sleepiness), co-existing sleep disorders (e.g., insomnia), specific high-risk factors (e.g., obesity), and underlying pathophysiological mechanisms, such as those described in the PALM framework (2, B).Which health complications and safety risks should be prioritized in adults with OSA?Adults with OSA should be specifically monitored for cardiovascular disease, cerebrovascular disease, metabolic disorders, cognitive impairment, and traffic-or occupation-related safety risks (1, A). Evaluation for other potential risks, including malignancy, depression, chronic cough, asthma, and chronic obstructive pulmonary disease (COPD), is also recommended (1, B).How should comprehensive management of adults with OSA be implemented?Comprehensive management of adult OSA should be multidisciplinary, individualized, and long-term, based on disease severity, etiology, lifestyle, and patient preferences (1, A).Lifestyle interventions are recommended for all patients, including dietary control, alcohol avoidance, smoking cessation, cautious use or avoidance of sedative-hypnotic agents and other medications that may induce or exacerbate OSA, sleep hygiene, and regular physical activity (1, A). Positional therapy is recommended for position-dependent OSA (1, A). Active weight management with a body mass index (BMI)-based stepwise strategy is recommended (1, A).What are the indications for positive airway pressure (PAP) therapy in adults with OSA?PAP therapy is recommended as first-line treatment for adults with moderate-to-severe OSA (AHI≥15 events/h) (1, A). It may also be considered for patients with mild OSA who have cardiovascular or cerebrovascular disease, hypertension, diabetes, COPD, or prominent symptoms such as EDS, cognitive impairment, insomnia, or depression, as well as for perioperative patients (1, B).How should PAP modalities be selected for adults with OSA?CPAP, APAP and BPAP are comparable in efficacy, safety, and adherence. CPAP is recommended as the default modality due to lower cost (1, A). APAP is recommended for patients intolerant to CPAP, or with positional, sleep-stage dependent, or alcohol-related OSA, or significant weight fluctuations (1, A). For asymptomatic patients, CPAP or APAP is recommended (1, A). BPAP is indicated if obstructive events persist at CPAP pressures≥15 cmHO (1 cmHO=0.098 kPa), for intolerance to high CPAP pressures, or for OSA with chronic hypoventilation disorders such as COPD, neuromuscular diseases, or obesity hypoventilation syndrome (1, A).What are the principles and procedures for PAP titration?PAP pressure titration is recommended before initiating therapy (1, A). In-laboratory, full-night manual titration during PSG is the gold standard (1, A). For moderate-to-severe OSA, split-night in-laboratory titration or home auto-titration are acceptable alternatives (1, A). Manual titration is preferred over auto-titration in patients with congestive heart failure, severe pulmonary disease, neuromuscular disease, prior uvulopalatopharyngoplasty, need for nocturnal oxygen, or expected desaturation from non-OSA causes (e.g., hypoventilation or central sleep apnea syndromes) (1, A).How can adherence to PAP therapy be improved?A structured, regular follow-up system is recommended, including telemedicine (remote monitoring, phone/video consultations, AI/smartphone apps) and behavioral or psychosocial interventions (e.g., motivational enhancement therapy, motivational interviewing) (1, A).What are the indications for oral appliance therapy?Oral appliance therapy is recommended for primary snoring and mild-to-moderate OSA (1, A). It is also recommended as an alternative or adjunct for patients with poor PAP tolerance or adherence (1, A). Custom-made oral appliances are preferred over non-custom devices to improve adherence and effectiveness (1, A).What are the indications for oropharyngeal myofunctional therapy?Oropharyngeal myofunctional therapy is recommended as an adjunct or combined therapy in patients with OSA (1, A).What are the indications for upper airway surgery?Upper airway surgery may be considered for adults with significant anatomical abnormalities who are intolerant or nonadherent to PAP therapy, after a careful evaluation of the potential benefits and risks (1, A).What are the indications for pharmacological therapy?Pharmacological therapy is not recommended as routine treatment for all adults with OSA (1, A). It may be considered as adjunctive treatment for specific phenotypes or treatable traits such as EDS, insomnia, or obesity, with appropriate patient selection (1, B).For OSA-related EDS: After careful clinical evaluation, wake-promoting agents may be considered for patients with OSA-related EDS who meet one or more of the following criteria: 1. Residual EDS despite adequate and adherent standard OSA therapy (including CPAP, oral appliance therapy, or surgery), with other causes of EDS excluded; 2. Presence of EDS in patients who refuse, are intolerant of, or are nonadherent to standard OSA therapy; 3. EDS that substantially impairs quality of life, interferes with work or study, or significantly increases the risk of traffic or occupational accidents (e.g., documented accidents or near-miss events)(Expert consensus; no grading). For patients with residual EDS despite adequate and adherent OSA therapy, treatment with solriamfetol or modafinil is recommended to improve daytime sleepiness (1, A). For patients with EDS who refuse or cannot tolerate standard OSA therapy, individualized treatment with solriamfetol is recommended (1, A), while modafinil may be considered (2, B). During pharmacologic treatment, continued counseling and encouragement to initiate or resume standard OSA therapy are recommended.For COMISA: With attention to interindividual variability in treatment response, short-term use of non-benzodiazepine hypnotic agents may be considered to improve insomnia symptoms (1, B). When non-benzodiazepine hypnotics are deemed necessary, they should be used under close monitoring or in combination with CPAP therapy (1, B). Benzodiazepines are not recommended for the treatment of COMISA (1, A).For OSA with obesity: For patients with moderate-to-severe OSA complicated by obesity, who have not achieved adequate control despite structured weight-management interventions (including dietary modifications and exercise), treatment with dual GIP/GLP-1 receptor agonists (e.g., tirzepatide) may be considered as an adjunctive therapy (1, A).How can phenotype-and endotype-based evaluation guide individualized treatment?An individualized treatment strategy based on OSA phenotypes and endotypes may be considered in adults with OSA (1, B).How should long-term follow-up of adults with OSA be planned?Follow-up should assess symptoms, sleep-related quality of life, patient-reported sleep quality, treatment adherence, adverse events, and patient/family satisfaction (1, A). Tools may include questionnaires (ESS, PSQI, SF) and objective tests (PSG, HSAT, pulse oximetry, MSLT, MWT) (1, A). Follow-up intervals should be tailored to the treatment; for PAP therapy, visits at 1 week, 1 month, and 3 months are recommended, and then every 6-12 months if stable (1, A).What are the major applications of telemedicine in comprehensive OSA management?Telemedicine is valuable for remote diagnosis, treatment, and follow-up. It is recommended to improve PAP adherence (1, A). Remote diagnostic pathways combining HSAT with electronic questionnaires may be considered (2, B). Quality control measures should be implemented to ensure safety and effectiveness (1, A).