ATS Core Curriculum 2021. Adult Sleep Medicine: Sleep Apnea

Abstract

The American Thoracic Society Sleep Core Curriculum updates clinicians on important sleep topics, presented during the annual meeting, and appearing in summary here. This year's sleep core theme is sleep-disordered breathing and its management. Topics range from pathophysiological mechanisms for the association of obstructive sleep apnea (OSA) and metabolic syndrome, surgical modalities of OSA treatment, comorbid insomnia and OSA, central sleep apnea, and sleep practices during a pandemic. OSA has been associated with metabolic syndrome, independent of the role of obesity, and the pathophysiology suggests a role for sleep fragmentation and intermittent hypoxia in observed metabolic outcomes. In specific patient populations, surgical treatment modalities for OSA have demonstrated large reductions in objective disease severity compared with no treatment and may facilitate adherence to positive airway pressure treatment. Patient-centered approaches to comorbid insomnia and sleep apnea include evaluating for both OSA and insomnia simultaneously and using shared-decision making to determine the order and timing of positive airway pressure therapy and cognitive behavioral therapy for insomnia. The pathophysiology of central sleep apnea is complex and may be due to the loss of drive to breathe or instability in the regulatory pathways that control ventilation. Pandemic-era sleep practices have evolved rapidly to balance safety and sustainability of care for patients with sleep-disordered breathing.

Keywords: central sleep apnea; insomnia; metabolic syndrome; obstructive sleep apnea; upper airway surgery.

Figure 1.

Mechanisms underlying metabolic impacts of obstructive sleep apnea. ↑ = increase; ↓ = decrease; HPA = hypothalamus–pituitary–adrenal; SNS = sympathetic nervous system.

Figure 2.

The diagnostic dilemma of comorbid insomnia and sleep apnea. HSAT = home sleep apnea test; PSG = polysomnography.

Figure 3.

Process flow for coronavirus disease (COVID-19) screening and testing for sleep testing laboratories. APAP = auto–positive airway pressure device; CDC = Centers for Disease Control and Prevention; FFP2 = filtering face piece class 2; HSAT = home sleep apnea test; PPE = personal protective equipment.