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## Complete Summary

#### GUIDELINE TITLE

Screening for obstructive sleep apnea in the primary care setting.

#### BIBLIOGRAPHIC SOURCE(S)

University of Texas, School of Nursing, Family Nurse Practitioner
Program. Screening for obstructive sleep apnea in the primary care
setting. Austin (TX): University of Texas, School of Nursing; 2006 May.
13 p. \[24 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Obstructive sleep apnea

#### GUIDELINE CATEGORY

Prevention\
Risk Assessment\
Screening

#### CLINICAL SPECIALTY

Cardiology\
Family Practice\
Internal Medicine\
Neurology\
Nursing\
Otolaryngology\
Pulmonary Medicine\
Sleep Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Nurses\
Physician Assistants\
Physicians\
Respiratory Care Practitioners\
Students

#### GUIDELINE OBJECTIVE(S)

To provide evidence-based practice guidelines regarding screening for
obstructive sleep apnea in the primary care setting

#### TARGET POPULATION

Patients with obstructive sleep apnea (OSA) as well as:

-   Overweight patients with a body mass index (BMI) \>25

-   Patients with excess adipose tissue in the neck (Neck circumference
    \>16 \[women\], \>17 \[men\])

-   Patients with a history of snoring or excessive daytime sleepiness

-   Patients with erectile dysfunction of undetermined etiology

-   Patients with hypertension

-   Patients with congestive heart failure (CHF)

-   Patients with arrhythmias

-   Patients with cerebral vascular disorders (transient ischemic attack
    \[TIA\], Stroke, Dementia)

Other risk factors and comorbidities such as

-   Patients who currently smoke or have smoked heavily in the past, or
    consume alcohol

-   Patients with hypothyroidism

-   Patients with risk factors for cardiovascular disease

-   Patients with coronary artery disease, family history of obstructive
    sleep apnea (OSA), depression, diabetes

-   Patients who complain of fatigue

-   Post-menopausal women

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Risk Assessment/Screening**

1.  Subjective assessment including past medical and family history, and
    symptoms

2.  Objective assessment/physical examination including vital signs
    (blood pressure, pulse, respiration); height, weight, and body mass
    index (BMI); head, eye, ear, nose, and throat (HEENT); thyroid
    assessment; cardiovascular and pulmonary assessment, and
    psychological assessment for presence of depression

3.  Diagnostic tests if appropriate, including screening patients at
    risk of obstructive sleep apnea (OSA) using Epworth Sleepiness
    Scale; nocturnal polysomnographic diagnostic testing (NPSG Sleep
    Study); thyroid-stimulating hormone study; sleep diary

4.  Differential diagnosis

**Management**

1.  Referral to pulmonologist or sleep specialist

2.  Follow-up

#### MAJOR OUTCOMES CONSIDERED

-   Quality of life

-   Complications of obstructive sleep apnea and worsening of co-morbid
    conditions

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Online searches were performed for dates January 2000 to January 2006 of
the following databases: CINAHL, Medline, Pubmed, Cochrane, Academia
Search Premier (Major keywords used in searches: Obstructive Sleep
Apnea, Primary Care, Snoring, Apnea, Sleep Apnea Syndromes/prevention &
control, Hypertension, Sleep disorders, Daytime sleepiness). Position
statements from the American Academy of Sleep Medicine, American Heart
Association, and American Association of Sleep Apnea were also reviewed.
Additional resources were identified by review of bibliographies of
relevant articles and published guidelines.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Subjective Review\
Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Quality of Evidence** (Based on U.S. Preventive Services Task Force
Ratings)

**Good**: Evidence includes consistent results from well-designed,
well-conducted studies in representative populations that directly
assess effects on health outcomes

**Fair**: Evidence is sufficient to determine effects on health
outcomes, but the strength of the evidence is limited by the number,
quality, or consistency of the individual studies, generalizability to
routine practice, or indirect nature of the evidence on health outcomes.

**Poor**: Evidence is insufficient to assess the effects on health
outcomes because of limited number or power of studies, important flaws
in their design or conduct, gaps in the chain of evidence, or lack of
information on important health outcomes.

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Strength of Recommendations** (Based on U.S. Preventive Services Task
Force Ratings)

**A.** There is good evidence that the recommendation improves important
health outcomes. Benefits substantially outweigh harms.

**B.** There is at least fair evidence that the recommendation improves
important health outcomes. Benefits outweigh harms.

**C.** There is at least fair evidence that the recommendation can
improve health outcomes but the Balance of benefits and harms is too
close to justify a general recommendation.

**D.** There is at least fair evidence that the recommendation is
ineffective or that harms outweigh benefits.

**I.** Evidence that the recommendation is effective is lacking, of poor
quality, or conflicting, and the balance of benefits and harms cannot be
determined.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The guideline was developed by a group of family nurse practitioner
(FNP) students and submitted for review to FNP program faculty and
expert reviewers. Before submitting to the guideline committee,
revisions were made based on reviewer recommendations.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Strength of recommendations (A, B, C, D, I) and quality of evidence
(good, fair, poor) are defined at the end of \"Major Recommendations\"
field.

**Subjective Assessment**

1.  Chief complaint(s) and/or clinical manifestations

    -   Complaints of frequent nocturnal awakenings

    -   Complaints of difficulty concentrating

    -   Complaints of problems with memory

    -   Complaints of snoring and/or apnea by patient or significant
        other

    -   Complaints of daytime sleepiness or fatigue

    -   Complaints of depression

    -   Sleep Assessment

2.  Review of Systems

    -   General

    -   Head, eyes, ears, nose, and throat (HEENT)

    -   Endocrine

    -   Heart

    -   Lungs

    -   Genitourinary (GU)

    -   Gastrointestinal (GI)

    -   Musculoskeletal (MS)

    -   Neurological

    -   Psychiatric

3.  History of present illness

    -   Onset and duration of symptom complaints

    -   Body weight changes

    -   Lifestyle habits, such as diet, exercise, smoking, alcohol or
        drug use

    -   Quantity and quality of sleep

4.  Past medical history

    -   Note hospitalizations, surgeries, and any/or procedures

    -   History of any trauma

    -   Co-morbid conditions such as: diabetes, hypertension, congestive
        heart failure (CHF), arrhythmias, cardiovascular disease,
        hypothyroid, depression, gastroesophageal reflux disease,
        nocturnal cardiac ischemia, asthma

5.  Medications

    -   Current prescription medications

    -   Any or all over the counter medications, including alternative
        medicines or herbal treatments

    -   Note previous sleep treatments, including use of sedatives or
        sleeping aids and response

6.  Family history

    -   Obstructive sleep apnea (OSA)

    -   Diabetes

    -   Hypertension

    -   Hypothyroid

    -   Coronary artery disease

    -   Cerebrovascular accident (CVA)

    -   Depression

7.  Psychosocial history

    -   Assess for depression, suicidal ideations, irritability,
        personality changes, and cognitive impairment

    -   Mental illness

    -   Support systems, coping strategies

(If OSA is suspected, important to inquire on type of job, if operating
heavy machinery, counseling regarding potential dangers, i.e., increased
risk of motor vehicle crashes secondary to sleep deprivation) (Netzer et
al., 2003; Schroder, 2005; Elliot, 2001; Mansfield & Naughton, 2005)

**Objective Assessment/Physical Examination**

-   Vital signs, including blood pressure, pulse, respirations: OSA is a
    leading cause of hypertension (The Seventh Report of the Joint
    National Committee on Prevention, Detection, Evaluation and
    Treatment of High Blood Pressure \[JNC-7\], 2003) **(Strength of
    Recommendation: B; Quality of Evidence: Fair)**

-   Height, weight, body mass index (BMI) calculation; BMI 25-30
    indicates overweight, BMI \>30 indicates obesity **(Strength of
    Recommendation: B; Quality of Evidence: Fair)**

-   HEENT: assess upper airway airflow obstruction, nasal polyps, septal
    deviation, mucosal congestion, turbinate hypertrophy, enlarged
    tonsils, large tongue volume, small jaw (micrognathia)

-   Measurement of neck circumference: \>16 (women), \>17 (men)

-   Neck exam: assess for thyroid enlargement **(Strength of
    Recommendation: B; Quality of Evidence: Fair)**

-   Cardiovascular exam: assess for rhythm regularity, bruits, murmurs
    (high prevalence with cardiovascular disease \[CVD\], CHF,
    arrhythmias, and hypertension (Hamilton, Solin, & Naughton, 2004;
    American Heart Association, 2005; JNC-7, 2003; Shahar et al., 2001
    **(Strength of Recommendation: B; Quality of Evidence: Fair)**

-   Pulmonary exam: assess breath sounds and quality of respirations

-   Abdominal exam: waist-hip ratio to determine body fat distribution:
    \>0.72 = abnormal

-   Musculoskeletal: deformities, swelling, or pain with movement

-   Neurological exam: sensory function, balance, deep tendon reflexes

-   Psychiatric exam: administration of depression screening form
    (Netzer et al., 2003; Schroder, 2005; Elliot, 2001; Mansfield &
    Naughton, 2005; Hamilton, Solin, & Naughton, 2004; Stevenson, 2003)

> **(Strength of Recommendation: B; Quality of Evidence: Fair)**

**Diagnostic Procedures**

1.  Laboratory studies

    -   Sleep questionnaire (e.g., Epworth Sleepiness Scale), screen for
        sleep abnormalities (Elliott, 2001) **(Strength of
        Recommendation: A; Quality of Evidence: Good)**

2.  Diagnostic tests

    -   NPSG Sleep Study: Nocturnal polysomnographic diagnostic testing
        (Netzer et al., 2003; Schroder, 2005; Elliot, 2001; Mansfield &
        Naughton, 2005; Hamilton, Solin, & Naughton, 2004; Rodsutti et
        al., 2004) **(Strength of Recommendation: A; Quality of
        Evidence: Good)**

**Differential Diagnoses**

1.  Narcolepsy

2.  Idiopathic daytime hypersomnolence

3.  Inadequate sleep time

4.  Depressive episodes

5.  Asthma

6.  Chronic obstructive pulmonary disease (COPD)

7.  CHF

8.  Panic attacks

9.  Gastroesophageal reflux disease (GERD)

10. Sleep associated seizures

11. Anemia

12. Fibromyalgia

13. Restless leg syndrome

> (Netzer et al., 2003; Schroder, 2005; Elliot, 2001; Mansfield &
> Naughton, 2005; Hamilton, Solin, & Naughton, 2004; Rodsutti et al.,
> 2004)
>
> **(Strength of Recommendation: C; Quality of Evidence: Fair)**

**Management/Treatment**

Referral to pulmonologist, sleep specialist **(Strength of
Recommendation: B; Quality of Evidence: Fair)**

Patients should be referred for abnormal polysomnogram results and/or
sleep complaints consistent for 3 to 6 months with restless leg
syndrome, periodic limb movements, narcolepsy, or complex motor
activity. (Elliott, 2001) **(Strength of Recommendation: B; Quality of
Evidence: Fair)**

**Follow Up**

Obtain records from referral physician, and assess patient\'s adherence
to recommendations of management/treatment. **(Strength of
Recommendation: I; Quality of Evidence: Poor)**

**Definitions**:

**Quality of Evidence** (Based on U.S. Preventive Services Task Force
Ratings)

**Good**: Evidence includes consistent results from well-designed,
well-conducted studies in representative populations that directly
assess effects on health outcomes

**Fair**: Evidence is sufficient to determine effects on health
outcomes, but the strength of the evidence is limited by the number,
quality, or consistency of the individual studies, generalizability to
routine practice, or indirect nature of the evidence on health outcomes.

**Poor**: Evidence is insufficient to assess the effects on health
outcomes because of limited number or power of studies, important flaws
in their design or conduct, gaps in the chain of evidence, or lack of
information on important health outcomes.

**Strength of Recommendations** (Based on U.S. Preventive Services Task
Force Ratings)

**A.** There is good evidence that the recommendation improves important
health outcomes.  Benefits substantially outweigh harms.

**B.** There is at least fair evidence that the recommendation improves
important health outcomes. Benefits outweigh harms.

**C.** There is at least fair evidence that the recommendation can
improve health outcomes but the balance of benefits and harms is too
close to justify general recommendation.

**D.** There is at least fair evidence that the recommendation is
ineffective or that harms outweigh benefits.

**I.** Evidence that the recommendation is effective is lacking, of poor
quality, or conflicting, and the balance of benefits and harms cannot be
determined.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=9436)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for selected
recommendations (see the \"Major Recommendations\" field).

These guidelines are based on sources such as research studies
(randomized controlled trials), meta-analysis, literature reviews,
practice guidelines and statements from the American Academy of Sleep
Medicine and the American Association of Sleep Apnea.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Improved screening and identification of patients with obstructive
    sleep apnea

-   Improved diagnosis and referral for management and treatment of
    obstructive sleep apnea

-   Improved quality of life for patients with obstructive sleep apnea:

    -   Return of normal sleep patterns

    -   Decreased daytime sleepiness or fatigue

    -   Prevention of co-morbidities associated with untreated sleep
        apnea: (hypertension, cardiovascular disease, congestive heart
        failure, strokes, heart attacks)

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

This guideline provides a general screening and assessment for patients
who are at risk for obstructive sleep apnea.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Chart Documentation/Checklists/Forms

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

University of Texas, School of Nursing, Family Nurse Practitioner
Program. Screening for obstructive sleep apnea in the primary care
setting. Austin (TX): University of Texas, School of Nursing; 2006 May.
13 p. \[24 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2006 May

#### GUIDELINE DEVELOPER(S)

University of Texas at Austin School of Nursing, Family Nurse
Practitioner Program - Academic Institution

#### SOURCE(S) OF FUNDING

University of Texas at Austin, School of Nursing, Family Nurse
Practitioner Program

#### GUIDELINE COMMITTEE

Practice Guidelines Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Authors*: Gina Bates, RN, MSN, FNP; Marsha Koebcke, RN, MSN, FNP; Patty
Kypke, RN, MSN, FNP

*Internal Reviewer*: Barbara Jones, MSN, FNP

*External Reviewer*: Robert J. Morrison, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: None available.

Print copies: Available from the University of Texas at Austin, School
of Nursing. 1700 Red River, Austin, Texas, 78701-1499

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on August 25, 2006. The
information was verified by the guideline developer on November 14,
2006.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which may be
subject to the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/3/2008