International Consensus Statement on Obstructive Sleep Apnea

doi:10.1002/alr.23079

Review

. 2023 Jul;13(7):1061-1482.

doi: 10.1002/alr.23079. Epub 2023 Mar 30.

International Consensus Statement on Obstructive Sleep Apnea

Jolie L Chang¹, Andrew N Goldberg¹, Jeremiah A Alt², Alzoubaidi Mohammed³, Liza Ashbrook¹, Dennis Auckley⁴, Indu Ayappa⁵, Hira Bakhtiar⁶, José E Barrera⁷, Bethany L Bartley⁸, Martha E Billings⁹, Maurits S Boon¹⁰, Pien Bosschieter¹¹, Itzhak Braverman¹², Kara Brodie¹, Cristina Cabrera-Muffly¹³, Ray Caesar¹⁴, Michel B Cahali¹⁵, Yi Cai¹, Michelle Cao¹⁶, Robson Capasso¹⁶, Sean M Caples¹⁷, Lana M Chahine¹⁸, Corissa P Chang¹⁹, Katherine W Chang²⁰, Nilika Chaudhary²¹, Crystal S J Cheong²², Susmita Chowdhuri²³, Peter A Cistulli²⁴, David Claman¹, Jacob Collen²⁵, Kevin C Coughlin²⁶, Jennifer Creamer²⁵, Eric M Davis²⁷, Kara L Dupuy-McCauley¹⁷, Megan L Durr²⁸, Mohan Dutt²⁹, Mazen El Ali¹⁸, Nabil M Elkassabany²⁷, Lawrence J Epstein⁸, Justin A Fiala³, Neil Freedman³⁰, Kirat Gill¹⁶, M Boyd Gillespie²⁶, Lea Golisch³¹, Nalaka Gooneratne¹⁹, Daniel J Gottlieb⁸, Katherine K Green³², Arushi Gulati¹, Indira Gurubhagavatula¹⁹, Nathan Hayward³³, Paul T Hoff²⁹, Oliver M G Hoffmann³¹, Steven J Holfinger³⁴, Jennifer Hsia³⁵, Colin Huntley¹⁰, Kevin C Huoh³⁶, Phillip Huyett⁸, Sanjana Inala⁵, Stacey L Ishman³⁷, Tarun K Jella⁴, Aesha M Jobanputra³⁸, Andrew P Johnson¹³, Mithri R Junna¹⁷, Jenna T Kado³⁹, Thomas M Kaffenberger¹⁸, Vishesh K Kapur⁹, Eric J Kezirian⁴⁰, Meena Khan³⁴, Douglas B Kirsch⁴¹, Alan Kominsky⁴², Meir Kryger⁴³, Andrew D Krystal¹, Clete A Kushida¹⁶, Thomas J Kuzniar³⁰, Derek J Lam⁴⁴, Christopher J Lettieri²⁵, Diane C Lim⁴⁵, Hsin-Ching Lin⁴⁶, Stanley Y C Liu¹⁶, Stuart G MacKay⁴⁷, Ulysses J Magalang³⁴, Atul Malhotra⁴⁸, Meghna P Mansukhani¹⁷, Joachim T Maurer³¹, Anna M May⁴, Ron B Mitchell⁴⁹, Babak Mokhlesi⁵⁰, Anna E Mullins³⁰, Eman M Nada⁵¹, Sreelatha Naik⁵², Brandon Nokes⁴⁸, Michael D Olson¹⁷, Allan I Pack¹⁹, Edward B Pang⁵³, Kenny P Pang⁵⁴, Susheel P Patil⁴, Eli Van de Perck⁵⁵, Jay F Piccirillo²⁰, Grace W Pien⁵⁶, Amanda J Piper⁵⁷, Andrea Plawecki⁵⁸, Mark Quigg²⁷, Madeline J L Ravesloot⁵⁹, Susan Redline⁶⁰, Brian W Rotenberg⁶¹, Armand Ryden⁶², Kathleen F Sarmiento¹, Firas Sbeih⁴², Amy E Schell³², Christopher N Schmickl⁴⁸, Helena M Schotland⁵, Richard J Schwab¹⁹, Jiyeon Seo⁶³, Neomi Shah⁵, Anita Valanju Shelgikar²⁹, Isaac Shochat⁶⁴, Ryan J Soose¹⁸, Toby O Steele⁶⁵, Erika Stephens¹, Carl Stepnowsky⁴⁸, Kingman P Strohl⁴, Kate Sutherland⁵⁷, Maria V Suurna⁶⁶, Erica Thaler¹⁹, Sritika Thapa⁴³, Olivier M Vanderveken⁵⁵, Nico de Vries¹¹, Edward M Weaver⁹, Ian D Weir⁴³, Lisa F Wolfe³, B Tucker Woodson⁶⁷, Christine H J Won⁴³, Josie Xu⁶⁸, Pratyusha Yalamanchi²⁹, Kathleen Yaremchuk⁵⁸, Yerem Yeghiazarians¹, Jason L Yu⁶⁹, Michelle Zeidler⁶³, Ilene M Rosen¹⁹

Affiliations

¹ University of California, San Francisco, California, USA.
² University of Utah, Salt Lake City, Utah, USA.
³ Northwestern University, Chicago, Illinois, USA.
⁴ Case Western Reserve University, Cleveland, Ohio, USA.
⁵ Icahn School of Medicine at Mount Sinai, New York, New York, USA.
⁶ Norwalk Hospital, Norwalk, Connecticut, USA.
⁷ Uniformed Services University, Washington D.C., USA.
⁸ Harvard Medical School, Boston, Massachusetts, USA.
⁹ University of Washington, Seattle, Washington, USA.
¹⁰ Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
¹¹ Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands.
¹² Hillel Yaffe Medical Center, Hadera Technion, Faculty of Medicine, Hadera, Israel.
¹³ University of Colorado School of Medicine, Aurora, Colorado, USA.
¹⁴ Stone Oak Orthodontics, San Antonio, Texas, USA.
¹⁵ University of Sao Paulo, São Paulo, Brazil.
¹⁶ Stanford University, Palo Alto, California, USA.
¹⁷ Mayo Clinic, Rochester, Minnesota, USA.
¹⁸ University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
¹⁹ University of Pennsylvania, Philadelphia, Pennsylvania, USA.
²⁰ Washington University, St. Louis, Missouri, USA.
²¹ Brigham and Women's Hospital, Boston, MA, USA.
²² National University Hospital, Singapore.
²³ Wayne State University and John D. Dingell VA Medical Center, Detroit, Michigan, USA.
²⁴ Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
²⁵ Uniformed Services University, Bethesda, Maryland, USA.
²⁶ University of Tennessee, Memphis, Tennessee, USA.
²⁷ University of Virginia, Charlottesville, Virginia, USA.
²⁸ Kaiser Permanente, Oakland, California, USA.
²⁹ University of Michigan, Ann Arbor, Michigan, USA.
³⁰ University of Chicago, Chicago, Illinois, USA.
³¹ University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany.
³² University of Colorado, Aurora, Colorado, USA.
³³ Monash Health, Victoria, Australia.
³⁴ Ohio State University, Columbus, Ohio, USA.
³⁵ University of Minnesota, Minneapolis, Minnesota, USA.
³⁶ University of California, Irvine, California, USA.
³⁷ University of Cincinnati, Cincinnati, Ohio, USA.
³⁸ Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.
³⁹ University of Toledo, Toledo, Ohio, USA.
⁴⁰ University of Southern California, Los Angeles, California, USA.
⁴¹ University of North Carolina School of Medicine, Charlotte.
⁴² Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA.
⁴³ Yale School of Medicine, New Haven, Connecticut, USA.
⁴⁴ Oregon Health and Science University, Portland, Oregon, USA.
⁴⁵ University of Miami, Miami, Florida, USA.
⁴⁶ Chang Gung University, Kaohsiung, Taiwan.
⁴⁷ University of Wollongong, Wollongong, Australia.
⁴⁸ University of California, San Diego, California, USA.
⁴⁹ University of Texas, Southwestern and Children's Medical Center Dallas, Texas, USA.
⁵⁰ Rush University Medical Center, Chicago, IL, USA.
⁵¹ Stony Brook University, New York, New York, USA.
⁵² Geisinger Health System, Danville, California, USA.
⁵³ University of Glasgow, Glasgow, UK.
⁵⁴ Paragon Medical Centre, Singapore.
⁵⁵ University of Antwerp, Belgium.
⁵⁶ Johns Hopkins University, Baltimore, Maryland, USA.
⁵⁷ University of Sydney, Sydney, Australia.
⁵⁸ Henry Ford Health, Detroit, Michigan, USA.
⁵⁹ OLVG, Amsterdam, The Netherlands.
⁶⁰ Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
⁶¹ Western University, Ontario, Canada.
⁶² Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA.
⁶³ University of California, Los Angeles, California, USA.
⁶⁴ Hillel Yaffe Medical Center, Hadera, Israel.
⁶⁵ University of California, Davis, California, USA.
⁶⁶ Weill Cornell Medicine, New York, New York, USA.
⁶⁷ Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
⁶⁸ University of Toronto, Ontario, Canada.
⁶⁹ Emory University, Georgia, USA.

PMID: 36068685
PMCID: PMC10359192
DOI: 10.1002/alr.23079

Review

International Consensus Statement on Obstructive Sleep Apnea

Jolie L Chang et al. Int Forum Allergy Rhinol. 2023 Jul.

. 2023 Jul;13(7):1061-1482.

doi: 10.1002/alr.23079. Epub 2023 Mar 30.

Authors

Affiliations

¹ University of California, San Francisco, California, USA.
² University of Utah, Salt Lake City, Utah, USA.
³ Northwestern University, Chicago, Illinois, USA.
⁴ Case Western Reserve University, Cleveland, Ohio, USA.
⁵ Icahn School of Medicine at Mount Sinai, New York, New York, USA.
⁶ Norwalk Hospital, Norwalk, Connecticut, USA.
⁷ Uniformed Services University, Washington D.C., USA.
⁸ Harvard Medical School, Boston, Massachusetts, USA.
⁹ University of Washington, Seattle, Washington, USA.
¹⁰ Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
¹¹ Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands.
¹² Hillel Yaffe Medical Center, Hadera Technion, Faculty of Medicine, Hadera, Israel.
¹³ University of Colorado School of Medicine, Aurora, Colorado, USA.
¹⁴ Stone Oak Orthodontics, San Antonio, Texas, USA.
¹⁵ University of Sao Paulo, São Paulo, Brazil.
¹⁶ Stanford University, Palo Alto, California, USA.
¹⁷ Mayo Clinic, Rochester, Minnesota, USA.
¹⁸ University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
¹⁹ University of Pennsylvania, Philadelphia, Pennsylvania, USA.
²⁰ Washington University, St. Louis, Missouri, USA.
²¹ Brigham and Women's Hospital, Boston, MA, USA.
²² National University Hospital, Singapore.
²³ Wayne State University and John D. Dingell VA Medical Center, Detroit, Michigan, USA.
²⁴ Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
²⁵ Uniformed Services University, Bethesda, Maryland, USA.
²⁶ University of Tennessee, Memphis, Tennessee, USA.
²⁷ University of Virginia, Charlottesville, Virginia, USA.
²⁸ Kaiser Permanente, Oakland, California, USA.
²⁹ University of Michigan, Ann Arbor, Michigan, USA.
³⁰ University of Chicago, Chicago, Illinois, USA.
³¹ University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany.
³² University of Colorado, Aurora, Colorado, USA.
³³ Monash Health, Victoria, Australia.
³⁴ Ohio State University, Columbus, Ohio, USA.
³⁵ University of Minnesota, Minneapolis, Minnesota, USA.
³⁶ University of California, Irvine, California, USA.
³⁷ University of Cincinnati, Cincinnati, Ohio, USA.
³⁸ Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.
³⁹ University of Toledo, Toledo, Ohio, USA.
⁴⁰ University of Southern California, Los Angeles, California, USA.
⁴¹ University of North Carolina School of Medicine, Charlotte.
⁴² Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA.
⁴³ Yale School of Medicine, New Haven, Connecticut, USA.
⁴⁴ Oregon Health and Science University, Portland, Oregon, USA.
⁴⁵ University of Miami, Miami, Florida, USA.
⁴⁶ Chang Gung University, Kaohsiung, Taiwan.
⁴⁷ University of Wollongong, Wollongong, Australia.
⁴⁸ University of California, San Diego, California, USA.
⁴⁹ University of Texas, Southwestern and Children's Medical Center Dallas, Texas, USA.
⁵⁰ Rush University Medical Center, Chicago, IL, USA.
⁵¹ Stony Brook University, New York, New York, USA.
⁵² Geisinger Health System, Danville, California, USA.
⁵³ University of Glasgow, Glasgow, UK.
⁵⁴ Paragon Medical Centre, Singapore.
⁵⁵ University of Antwerp, Belgium.
⁵⁶ Johns Hopkins University, Baltimore, Maryland, USA.
⁵⁷ University of Sydney, Sydney, Australia.
⁵⁸ Henry Ford Health, Detroit, Michigan, USA.
⁵⁹ OLVG, Amsterdam, The Netherlands.
⁶⁰ Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
⁶¹ Western University, Ontario, Canada.
⁶² Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA.
⁶³ University of California, Los Angeles, California, USA.
⁶⁴ Hillel Yaffe Medical Center, Hadera, Israel.
⁶⁵ University of California, Davis, California, USA.
⁶⁶ Weill Cornell Medicine, New York, New York, USA.
⁶⁷ Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
⁶⁸ University of Toronto, Ontario, Canada.
⁶⁹ Emory University, Georgia, USA.

PMID: 36068685
PMCID: PMC10359192
DOI: 10.1002/alr.23079

Abstract

Background: Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

Methods: Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

Results: The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

Conclusion: This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Keywords: PAP adherence; atrial fibrillation; cardiovascular event; cerebrovascular disease; consensus; dementia; evidence-based medicine; home sleep apnea testing; hypertension; hypoglossal nerve stimulation; mortality; motor vehicle accidents; neurocognitive function; obstructive sleep apnea; outcomes; perioperative management; polysomnography; positive airway pressure; screening; sleep; sleep disordered breathing; sleep surgery; sleepiness; surgical outcomes; systematic review; treatment outcomes; uvulopalatopharyngoplasty.

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Figures

**FIGURE IX.C.2**
The VOTE classification

**FIGURE IV.C.3**
Common sagittal cephalometric findings associated with obstructive sleep apnea (OSA): (A) decreased cranial base length, (B) decreased maxillary length, (C) decreased mandibular length, (D) decreased posterior facial height, (E, F) increased anterior lower facial height and total facial height, (G) decreased cranial base angle, (H) decreased gonial angle (posterior rotation of mandible), (I) inferior and posterior displacement of the hyoid bone.

See this image and copyright information in PMC

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References

1. Gastaut H, Tassinari CA, Duron B. Polygraphic study of diurnal and nocturnal (hypnic and respiratory) episodal manifestations of Pickwick syndrome. Rev Neurol (Paris) 1965;112(6):568–579. - PubMed
1. Jung R, Kuhlo W. Neurophysiological studies of abnormal night sleep and the Pickwickian syndrome. Prog Brain Res 1965;18:140–159. - PubMed
1. Sullivan CE, Issa FG, Berthon-Jones M, Eves L. Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares. Lancet 1981;1(8225):862–865. - PubMed
1. Orlandi RR, Kingdom TT, Hwang PH, et al. International consensus statement on allergy and rhinology: rhinosinusitis. Int Forum Allergy Rhinol 2016;6(1):S22–S209. - PubMed
1. Rudmik L, Smith TL. Development of an evidence-based review with recommendations using an online iterative process. Int Forum Allergy Rhinol 2011;1(6):431–437. - PubMed

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[1] Gastaut H, Tassinari CA, Duron B. Polygraphic study of diurnal and nocturnal (hypnic and respiratory) episodal manifestations of Pickwick syndrome. Rev Neurol (Paris) 1965;112(6):568–579. - PubMed

[2] Gastaut H, Tassinari CA, Duron B. Polygraphic study of diurnal and nocturnal (hypnic and respiratory) episodal manifestations of Pickwick syndrome. Rev Neurol (Paris) 1965;112(6):568–579. - PubMed

[3] Jung R, Kuhlo W. Neurophysiological studies of abnormal night sleep and the Pickwickian syndrome. Prog Brain Res 1965;18:140–159. - PubMed

[4] Jung R, Kuhlo W. Neurophysiological studies of abnormal night sleep and the Pickwickian syndrome. Prog Brain Res 1965;18:140–159. - PubMed

[5] Sullivan CE, Issa FG, Berthon-Jones M, Eves L. Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares. Lancet 1981;1(8225):862–865. - PubMed

[6] Sullivan CE, Issa FG, Berthon-Jones M, Eves L. Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares. Lancet 1981;1(8225):862–865. - PubMed

[7] Orlandi RR, Kingdom TT, Hwang PH, et al. International consensus statement on allergy and rhinology: rhinosinusitis. Int Forum Allergy Rhinol 2016;6(1):S22–S209. - PubMed

[8] Orlandi RR, Kingdom TT, Hwang PH, et al. International consensus statement on allergy and rhinology: rhinosinusitis. Int Forum Allergy Rhinol 2016;6(1):S22–S209. - PubMed

[9] Rudmik L, Smith TL. Development of an evidence-based review with recommendations using an online iterative process. Int Forum Allergy Rhinol 2011;1(6):431–437. - PubMed

[10] Rudmik L, Smith TL. Development of an evidence-based review with recommendations using an online iterative process. Int Forum Allergy Rhinol 2011;1(6):431–437. - PubMed

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International Consensus Statement on Obstructive Sleep Apnea

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International Consensus Statement on Obstructive Sleep Apnea

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