The American Academy of Sleep Medicine (AASM) has released its first clinical practice guideline for the evaluation and management of OSA in medically hospitalized adults, signaling a shift of sleep medicine further into the inpatient arena.1 The document outlines a structured pathway for hospital-based screening, diagnosis, treatment with PAP, sleep consultation, and peri-discharge planning.
The authors of the new guideline note that despite growing data linking sleep-disordered breathing to longer lengths of stay, higher costs, and worse outcomes for acutely ill patients who are hospitalized, previous guidelines were not designed for this population. In-hospital patients represent a diverse and clinically complex population, and the setting provides a unique opportunity to identify and manage OSA in those with high acuity of illness, they wrote.
Task force member Dennis H. Auckley, MD, FCCP, explained that the guideline was prompted by the acknowledgment of a high prevalence of unrecognized OSA in patients who are hospitalized, the rapid expansion of out-of-center testing technologies that now make inpatient or early postdischarge evaluation feasible, and concern for adverse outcomes associated with unrecognized or undiagnosed OSA in the inpatient setting.
Dr. Auckley, Professor of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, noted several challenges with developing guidelines that are unique to the inpatient setting:
- Staying focused on OSA in this population when patients may also have complicated sleep-disordered breathing, including hypoventilation or central sleep apnea;
- Working with a literature base lacking in large studies using well-controlled designs that consider no intervention comparisons; and
- Deciding whether testing and treatment initiated shortly following discharge should be considered part of an inpatient-initiated process.
The guideline includes one Good Practice Statement and four conditional recommendations for patients who are hospitalized with acute illness.
Good Practice Statement: For adults with an established diagnosis of sleep-disordered breathing and on active treatment, existing therapy should be continued rather than withheld, unless contraindicated.
Recommendation 1: For adults at increased risk for OSA, the AASM suggests in-hospital screening as part of a pathway that incorporates diagnosis and PAP treatment rather than no in-hospital screening (conditional, low certainty). Screening can use validated questionnaires and/or overnight high-resolution pulse oximetry.
Recommendation 2: For adults with newly diagnosed OSA, or with prior moderate to severe OSA not currently treated, the AASM suggests inpatient PAP therapy rather than no PAP (conditional, low certainty).
Recommendation 3: For adults at increased risk for or with established OSA, the AASM suggests that sleep medicine consultation be available within an evaluation and management pathway (conditional, very low certainty).
Recommendation 4: For adults at increased risk for or with established OSA, the AASM suggests a discharge management plan to ensure timely diagnosis and effective management, rather than no plan (conditional, very low certainty).
“The conditional nature of the recommendations resulted from a low to very low degree of certainty about the evidence as related to imprecision and potential for bias based on the randomized studies included being small in nature, use of different methodologies, and reported variable outcomes,” Dr. Auckley said. “There were also several studies that were observational in nature. These were generally consistent in terms of direction of the outcomes, but the lack of adequate controls contributed to the weak strengths of the conclusions.”
The guideline similarly stresses that conditional recommendations require clinicians to weigh patient values, competing priorities of the hospitalization, and institutional resources when deciding whether and how to implement screening, diagnostic testing, and PAP therapy.
Dr. Auckley said he would advise clinicians to lean on institution-specific decision-making in areas of uncertainty. He also said that local infrastructure, staffing, and technology “need to be weighed to determine the feasibility of an overarching evaluation and management protocol.”
The guideline offers flexible implementation pathways with teleconsults, e-consults, and telehealth follow-up explicitly endorsed, Dr. Auckley said, recognizing variability in hospital resources and sleep medicine expertise.
“Resource limitations will impact many institutions in terms of what services they can offer regarding inpatient evaluation and management for OSA,” he said. “The guideline discuss[es] a wide range of options that institutions can consider.”
Dr. Auckley said he hopes the document will put inpatient OSA evaluation and management on the radars of hospitals, inpatient providers, and sleep providers and help to move the field into the inpatient arena. He pointed out that about 80% of patients with OSA are undiagnosed and said that the inpatient setting offers “a great opportunity to begin to capture some of the many patients with undiagnosed OSA with the goal of improving long-term mortality and, in the nearer term, reducing readmissions in specific groups.”
References
1. Mehra R, Auckley DH, Johnson KG, et al. Evaluation and management of obstructive sleep apnea in adults hospitalized for medical care: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2025;21(12):2193-2203. doi:10.5664/jcsm.11864
