Archivos de Bronconeumología 58 (2022) T52–T68 www.archbronconeumol.org SEPAR’s voice [Translated article] International consensus document on obstructive sleep apnea夽 Olga Mediano a,b,c,∗ , Nicolás González Mangado c,d , Josep M. Montserrat c,e , M. Luz Alonso-Álvarez c,f , Isaac Almendros c,g , Alberto Alonso-Fernández c,h , Ferran Barbé c,i , Eduardo Borsini c,j , Candelaria Caballero-Eraso c,k , Irene Cano-Pumarega c,l , Felix de Carlos Villafranca m , Carmen Carmona-Bernal n , Jose Luis Carrillo Alduenda o , Eusebi Chiner p , José Aurelio Cordero Guevara q , Luis de Manuel r , Joaquín Durán-Cantolla s , Ramón Farré c,g , Carlos Franceschini t , Carles Gaig u , Pedro Garcia Ramos v , Francisco García-Río c,w , Onintza Garmendia x , Teresa Gómez García c,y , Silvia González Pondal c,y , M. Blanca Hoyo Rodrigo z , Albert Lecube aa,ab , Juan Antonio Madrid ac,ad , Lourdes Maniegas Lozano ae,d , José Luis Martínez Carrasco af , Juan Fernando Masa ag,c , María José Masdeu Margalef c,ah , Mercè Mayos Pérez c,ai , Enrique Mirabet Lis aj , Carmen Monasterio c,ak , Nieves Navarro Soriano al , Erika Olea de la Fuente am , Guillermo Plaza an,ao , Francisco Javier Puertas Cuesta ap , Claudio Rabec aq , Pilar Resano a , David Rigau ar , Alejandra Roncero as , Concepción Ruiz u , Neus Salord ak , Adriana Saltijeral at , Gabriel Sampol Rubio c,au , M. Ángeles Sánchez Quiroga av,c , Óscar Sans Capdevila aw , Carlos Teixeira ax , Francisco Tinahones Madueño ay,bf , Sônia Maria Togeiro az , María Fernanda Troncoso Acevedo ba , Leslie Katherine Vargas Ramírez bb , Joao Winck bc , Nerea Zabala Urionaguena bd , Carlos Egea c,be , el Spanish Sleep Network a Unidad de Sueño, Departamento de Neumología, Hospital Universitario de Guadalajara, Guadalajara, Spain b Departamento de Medicina, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain c Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain d Neumología, Unidad Multidisciplinar de Sueño (UMS), Instituto de Investigación Sanitaria de la Fundación Jiménez Díaz, Madrid, Spain e Unidad Multidisciplinar de Patología del Sueño y VNID, Servei de Pneumologia, Institut Clínic Respiratori, Hospital Clínic, Universidad de Barcelona, Barcelona, Spain f Unidad de Sueño, Dr. J. Terán Santos, Departamento de Neumología, Hospital Universitario de Burgos, Burgos, Spain g Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Institut d’Investigacions Biomediques August Pi Sunyer, Barcelona, Spain h Servicio de Neumología, Hospital Universitario Son Espases, Instituto de Investigación Sanitaria de las Islas Baleares (IdISBa), Palma, Baleares, Spain i Group of Translational Research in Respiratory Medicine, IRBLleida, Hospital Universitari Arnau de Vilanova y Santa Maria, Lleida, Spain j Unidad de Sueño y Ventilación, Hospital Británico de Buenos Aires, Buenos Aires, Argentina k Unidad de Trastornos Respiratorios del Sueño, Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío, Sevilla, Spain l Unidad de Sueño, Departamento de Neumología, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain m Servicio de Estomatología, Facultad de Medicina y Ciencias de la Salud, Universidad de Oviedo, Oviedo, Asturias, Spain n Unidad de Trastornos Respiratorios del Sueño, Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío, Sevilla, Spain o Unidad de Medicina del Sueño, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Ciudad de México, Mexico p Unidad Multidisciplinar del Sueño, Servicio de Neumología, Hospital Universitario San Juan de Alicante, San Juan de Alicante, Alicante, Spain q Grupo de Investigación en Epidemiología y Salud Pública, Unidad de Metodología y Estadística, Instituto de Investigación Sanitaria Bioaraba, Vitoria-Gasteiz, Álava, Spain r Corte del Ilustre Colegio de Abogados de Madrid, Madrid, Spain s Servicio de Investigación, Instituto de Investigación, OSI Araba, Hospital Universitario de Araba, Vitoria-Gasteiz, Álava, Spain t Unidad de Sueño y Ventilación Mecánica, Hospital Cosme Argerich, Buenos Aires, Argentina u Servicio de Neurología, Unidad Multidisciplinar de Sueño, Hospital Clínic de Barcelona, Barcelona, Spain v Centro de Salud Don Benito Oeste, Servicio Extremeño de Salud, Don Benito, Badajoz, Spain w Unidad de Sueño, Servicio de Neumología, Hospital Universitario La Paz, IdiPAZ, Departamento de Medicina, Universidad Autónoma de Madrid, Madrid, Spain x Unidad del Sueño, Servicio de Neumología, Hospital Clínic, Barcelona, Spain y Servicio de Odontología y Unidad Multidisciplinar del Sueño del Hospital Universitario Fundación Jiménez Díaz, Sociedad Española de Medicina Dental del Sueño (SEMDeS), Madrid, Spain DOI of original article: https://doi.org/10.1016/j.arbres.2021.03.017 夽 Please cite this article as: Mediano O, González Mangado N, Montserrat JM, Alonso-Álvarez ML, Almendros I, Alonso-Fernández A, et al., Documento internacional de consenso sobre apnea obstructiva del sueño. Arch Bronconeumol. 2022;58:52–68. ∗ Corresponding author. E-mail address: olgamediano@hotmail.com (O. Mediano). https://doi.org/10.1016/j.arbres.2021.03.027 0300-2896/© 2021 The Author(s). Published by Elsevier España, S.L.U. on behalf of SEPAR. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/). O. Mediano, N. González Mangado, J.M. Montserrat et al. Archivos de Bronconeumología 58 (2022) T52–T68 z Sociedad Española de Neurofisiología Clínica (SENFC), Oviedo, Asturias, Spain aa Grupo de investigación en Obesidad, Diabetes y Metabolismo (ODIM), Servicio de Endocrinología y Nutrición, Hospital Universitari Arnau de Vilanova, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain ab Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain ac Laboratorio de Cronobiología, Universidad de Murcia, IMIB-Arrixaca, Murcia, Spain ad Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain ae Fundación Jiménez Díaz, Madrid, Spain af Centro de Salud Fuencarral, Universidad Autónoma de Madrid, Madrid, Spain ag Hospital San Pedro de Alcántara, Instituto Universitario de Investigación Biosanitaria en Extremadura (INUBE), San Pedro de Alcántara, Cáceres, Spain ah Unidad Multidisciplinar del Sueño, Hospital Universitari Parc Taulí, Institut d’Investigació i Innovació Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain ai Unidad de Sueño, Servicio de Neumología, Hospital de la Santa Creu i Sant Pau, Departamento de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain aj Sociedad Española de Medicina del Tráfico (SEMT), Madrid, Spain ak Unidad Multidisciplinar del Sueño, Hospital Universitario de Bellvitge, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Barcelona, Spain al Unidad de Sueño, Servicio de Neumología, Hospital Clínico Universitario, Valencia, Spain am Servicio de Anestesiología y Reanimación, Hospital Universitario Araba, Vitoria-Gasteiz, Álava, Spain an Servicio de Otorrinolaringología, Hospital Universitario de Fuenlabrada, Universidad Rey Juan Carlos, Fuenlabrada, Madrid, Spain ao Hospital Universitario La Zarzuela, Madrid, Spain ap Unidad de Sueño, Servicio de Neurofisiología, Hospital Universitario de La Ribera, Facultad de Medicina y Ciencias de la Salud, Universidad Católica de Valencia, Alzira, Valencia, Spain aq Service de Pneumologie et Réanimation Respiratoire, Centre Hospitalier et Universitaire de Dijon, Dijon, France ar Centro Cochrane Iberoamericano, Barcelona, Spain as Unidad Multidisciplinar del Sueño, Servicio de Neumología, Hospital San Pedro, Logroño, La Rioja, Spain at Servicio de Cardiología, Hospital Universitario del Tajo, Universidad Alfonso X El Sabio, Aranjuez, Madrid, Spain au Unidad Multidisciplinar del Sueño, Servicio de Neumología, Hospital Universitario Vall d’Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain av Hospital Virgen del Puerto, Instituto Universitario de Investigación Biosanitaria en Extremadura (INUBE), Plasencia, Cáceres, Spain aw Unidad del Sueño, Servicio de Neurología Pediátrica, Hospital Sant Joan de Déu, Barcelona, Spain ax European Society of Sleep Technologists (EEST), Porto, Portugal ay Sociedad Española para el Estudio de la Obesidad (SEEDO), Madrid, Spain az Disciplina de Pneumologia, Departamento de Medicina, Disciplina de Medicina y Biologia del Sueño - Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, Brazil ba Servicio de Neumología, Unidad Multidisciplinar del Sueño, Fundación Jiménez Díaz, Madrid, Spain bb Instituto Neumológico del Oriente, Bucaramanga, Santander, Colombia bc Faculdade de Medicina, Universidade do Porto, Porto, Portugal bd Unidad del Sueño, Hospital Universitario Cruces, Barakaldo, Bizkaia, Spain be Unidad Funcional de Sueño, Hospital Universitario Araba, OSI Araba, Vitoria-Gasteiz, Álava, Spain bf Servicio de Endocrinología, Hospital Virgen de la Victoria, (IBIMA), Centro de Investigación Biomédica en Red de Fisiopatología Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), 28029, Madrid, Spain a r t i c l e i n f o a b s t r a c t Article history: The main aim of this international consensus document on obstructive sleep apnea is to provide guidelines Received 3 February 2021 based on a critical analysis of the latest literature to help health professionals make the best decisions in Accepted 15 March 2021 the care of adult patients with this disease. The expert working group was formed primarily of 17 scientific societies and 56 specialists from a wide geographical area (including the participation of 4 international Keywords: societies), an expert in methodology, and a documentalist from the Iberoamerican Cochrane Center. The Obstructive sleep apnea document consists of a main section containing the most significant innovations from the ICD and a series Diagnosis of online manuscripts that report the systematic literature searches performed for each section of the Treatment ICD. This document does not discuss pediatric patients or the management of patients receiving chronic non-invasive mechanical ventilation (these topics will be addressed in separate consensus documents). © 2021 The Author(s). Published by Elsevier España, S.L.U. on behalf of SEPAR. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Documento internacional de consenso sobre apnea obstructiva del sueño r e s u m e n Palabras clave: El objetivo principal de este documento internacional de consenso sobre apnea obstructiva del sueño es Apnea obstructiva del sueño proporcionar unas directrices que permitan a los profesionales sanitarios tomar las mejores decisiones Diagnóstico en la asistencia de los pacientes adultos con esta enfermedad según un resumen crítico de la literatura Tratamiento más actualizada. El grupo de trabajo de expertos se ha constituido principalmente por 17 sociedades científicas y 56 especialistas con amplia representación geográfica (con la participación de 4 sociedades internacionales), además de un metodólogo experto y un documentalista del Centro Cochrane Iberoamer- icano. El documento consta de un manuscrito principal, con las novedades más relevantes del DIC, y una serie de manuscritos online que recogen las búsquedas bibliográficas sistemáticas de cada uno de los apartados del DIC. Este documento no cubre la edad pediátrica ni el manejo del paciente en ventilación mecánica crónica no invasiva (que se publicarán en sendos documentos de consenso aparte). © 2021 El Autor(s). Publicado por Elsevier España, S.L.U. en nombre de SEPAR. Este es un artı́culo Open Access bajo la licencia CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/). T53 O. Mediano, N. González Mangado, J.M. Montserrat et al. Archivos de Bronconeumología 58 (2022) T52–T68 Introduction and literature search the current reality of the disease. We therefore recommended the use of the term “obstructive sleep apnea” and the acronym “OSA”. The main objective of this international consensus document In this ICD, OSA is defined as the presence of one of the following (ICD) on obstructive sleep apnea (OSA) is to provide guidelines criteria: based on a critical analysis of the latest literature to help health- care professionals make the best decisions in the care of adult 1 Presence of an apnea-hypopnea index (AHI) ≥ 15/h that is pre- patients with this disease. This document does not discuss pediatric dominantly obstructive. patients or the management of patients receiving chronic non- 2 AHI ≥ 5/h accompanied by one or more of the following factors: invasive mechanical ventilation (these topics will be addressed in excessive daytime sleepiness, non-restorative sleep, excessive separate consensus documents). tiredness, and/or impaired sleep-related quality of life, which The task force was formed primarily of 17 scientific societies and cannot be explained by other causes. 56 specialists from a wide geographical area (including 4 interna- tional societies), an expert in methodology, and a documentalist from the Iberoamerican Cochrane Center, all of whom participated For the assessment of OSA severity, the position of this ICD is that as consultants and conducted the systematic literature search. classifications based solely on AHI are limited and do not reflect the The literature search strategy was primarily designed to iden- heterogeneity of the disease. In line with current thinking among tify systematic reviews published in the last 10 years in English the scientific community4,5 , we have prioritized the search for new or Spanish, followed by randomized clinical trials, observational scores that reflect this heterogeneity and are predictors of the long- studies, clinical practice guidelines, and economic studies accord- term effects of the disease. Since no validated score is currently ing to the topic of each section. Validated methodological filters available, and although the factors or cut-off points leading to a were used to identify the different types of study design. classification of severe are not clearly established, we recommend The search was conducted on MEDLINE (via PubMed), EMBASE that the following be taken into account: AHI; time with oxygen (via Ovid), The Cochrane Library, and CENTRAL (Appendix B avail- saturation below 90%, reflecting hypoxemia; daytime sleepiness; able in online material). degree of obesity measured by body mass index and comorbidities (risk factors and cardiovascular disease) associated with OSA (high blood pressure [HBP], especially if treatment-refractory or non- Methodology dipping; diabetes mellitus type 2 [DM2]; dyslipidemia; coronary disease; stroke; heart failure or atrial fibrillation) (Fig. 3). An adaptation of the RAND-UCLA method1,2 was used for the preparation of this document. The responsible organizations and the general coordinator of the project established the topics for Prevalence of obstructive sleep apnea consensus and selected the experts and task force leaders. Topics requiring a systematic search of the scientific literature OSA is one of the most prevalent sleep disorders, but epi- were identified. Structured searches were conducted by expert doc- demiological studies in the literature vary widely in terms of umentalists. The document was subsequently developed from a methodology, the inclusion of clinical series or population series, draft drawn up by the leaders of each task force. The experts in diagnostic criteria, and the assessment of severity. A recently pub- each group expressed their agreement on the areas for consensus lished study that analyzed the global burden of this entity6 reported (Table 1 and Fig. 1). rates ranging between 4% and 30%. Results are summarized in Table 2. Pathophysiology of obstructive sleep apnea Consequences of obstructive sleep apnea The upper airway of patients with obstructive apneas tends to collapse during sleep, resulting in total or partial airway occlusion. The main pathophysiological mechanisms that underlie the Breathing stops until a microarousal occurs, which reactivates the association between OSA and its consequences are intermittent muscles and reopens the airway. Apnea occurs when the factors hypoxia, sleep fragmentation, intrathoracic pressure changes, and that tend to close the airway cannot be offset by the ability of the a number of intermediate elements (Fig. 4). dilating muscles of the pharynx and/or respiratory centers to keep Table 3 summarizes the scientific evidence available on the asso- it open (Fig. 2). ciation between OSA and its different consequences. OSA increases the risk of workplace and road traffic accidents. In the cardiovas- Definition of obstructive sleep apnea cular field, one of the manifestations for which the most evidence is available is arterial hypertension. The prevalence of OSA in DM2 This ICD proposes updating the nomenclature of sleep apnea is very high and OSA is an independent risk factor for developing syndrome to reintroduce the term “obstructive” in the acronyms DM2. OSA is also very common in coronary disease, but data on accepted in 2005, since it defines the nature of the disease and its clinical consequences and the effect of treatment are conflict- clearly differentiates it from central sleep apnea. We decided to ing. OSA also increases the risk of stroke and may be associated simplify the nomenclature and to remove the word “hypopnea” and with greater functional/cognitive impairment and higher mortal- the word “syndrome”, which is an outdated term that fails to reflect ity. Sleep-disordered breathing in heart failure is very prevalent, increases the risk of new episodes, and may increase mortality. Arrthythmias, pulmonary thromboembolism, and pulmonary arte- Table 1 rial hypertension are also associated with a very high rate of Classification of the degree of consensus on topics included. OSA. Severe OSA is also associated with an increased risk of can- Median score Degree of consensus cer, mortality, and tumor aggressiveness (melanoma), although Good ≥7 No lack of consensus current evidence is not yet strong. In neurocognitive terms, OSA Poor <3 No lack of consensus causes major cognitive impairment (mainly in executive function, Uncleara 4–6 or lack of consensus attention, and memory) and has a bidirectional association with a “Unclear” topics were reviewed in an in-person evaluation (second round). depression. T54 O. Mediano, N. González Mangado, J.M. Montserrat et al. Archivos de Bronconeumología 58 (2022) T52–T68 Fig. 1. Study methodology flow chart (adapted from RAND/UCLA). Diagnostic algorithm follow-up and correction of other influencing factors, or a decision may be taken to perform PSG or respiratory polygraphy. Patients Please refer to the online material for a detailed description with an intermediate to high probability of OSA can be evaluated of clinical presentation, physical examination, and complementary by respiratory polygraphy. tests. In this section, we will only describe the diagnostic algorithm A second algorithm is proposed for primary care (Fig. 6), in proposed in this ICD for indicating sleep studies. which patients with a high probability of disease due to excessive As OSA is a highly prevalent disease, it should be managed daytime symptoms (Epworth ≥ 12) could be evaluated by sim- at different healthcare levels in order to satisfy the demand for plified studies with single- or double-channel devices based on care7 . Two diagnostic algorithms are proposed. In specialized cen- oximetry and/or nasal pressure8 . It should be emphasized that this ters (Fig. 5), patients with moderate-to-severe chronic respiratory management must always be conducted in coordination with a ref- disease, unstable cardiovascular disease, other suspected sleep dis- erence sleep laboratory that can offer the necessary support, using orders that can cause symptoms or coexist with OSA and some protocols adjusted to specific needs. A therapeutic decision could patients with anxiety-depression or insomnia may be candidates be made in primary care and coordinated by specialists, but these for polysomnography (PSG) studies. Patients with a low probability of disease, according to an expert evaluation, may be candidates for T55 O. Mediano, N. González Mangado, J.M. Montserrat et al. Archivos de Bronconeumología 58 (2022) T52–T68 Fig. 2. Overview of the physiological and biological processes of obstructive sleep apnea. As shown in the top left section of the figure, upper airway obstruction is the result of an imbalance between forces that tend to keep it open (muscle activity) and forces that tend to close it (anatomical factors). This imbalance increases the collapsibility of the upper airway, resulting in the respiratory episode (apnea hypopnea). It is estimated that 19% of the general population has an apnea-hypopnea rate > 10/h3 . These episodes involve a series of physiological changes (hypoxia, transient arousals, and intrathoracic pressure changes) and biological changes (inflammation, oxidative stress, etc.). Depending on individual adaptation phenomena, these episodes cause secondary disease in the form of symptoms and are risk factors for the development of various entities (HBP, among others). Several generic factors modulate predisposition to these consequences. AHI: apnea-hypopnea index; HBP: high blood pressure; OSA: obstructive sleep apnea. Fig. 3. Assessment of the severity of the patient with obstructive sleep apnea (OSA) based on various objective parameters recommended by this International Consensus Document. AHI: apnea-hypopnea index; HBP: high blood pressure; BMI: body mass index; CHF: congestive heart failure; CT 90%: accumulated time with oxygen saturation below 90%; CV: cardiovascular or cerebrovascular disease; CVD: cerebrovascular disease; CVRF: cardiovascular risk factors; DLP: dyslipidemia; DM2: diabetes mellitus type 2; EPWORTH: Epworth Sleepiness Scale; IHD: ischemic heart disease. T56 O. Mediano, N. González Mangado, J.M. Montserrat et al. Archivos de Bronconeumología 58 (2022) T52–T68 Table 2 Studies reporting country-specific OSA prevalence data. Country Author Age range Men (%) Analysis criteria AHI > 5 AHI > 15 Male; female Male; female Australia Marshall NS, 2008 40–65 73 AASM 2012 25.5%; 23.5% 4.7%; 4.9% Brazil Tufik S, 2010 20–80 45 AASM 2007 46.5%; 30.6% 24.8%; 9.6% Germany Fietze I, 2018 20–81 54 AASM 2007 59.4%; 33.2% 29.7%; 13.2% Hong Kong Ip MS, 2001 30–60 100 AASM 2007 8.8% 5.3% Hong Kong Ip MS, 2004 30–60 0 AASM 2007 3.7% 1.9% Iceland Arnardottir ES, 2016 40–65 – AASM 2007 13.3%; 10.8% 10.6%; 4.8% Japan Nakayama-Ashida Y, 2008 23–59 – AASM 2012 59.7% 22.3% New Zealand Mihaere KM, 2009 30–59 – AASM 2007 12.5%; 3.4% 3.9%; 0.2% Norway Hrubos-Strom H, 2011 30–65 55 AASM 2007 21%; 13% 11.0%; 6.0% Poland Plywaczewski R, 2008 41–72 54 AASM 2007 36.2%; 18.4% 15.8%; 7.6% South Korea Kim J, 2004 40–69 69 AASM 2007 27.1%; 16.8% 10.1%; 4.7% Singapore Tan A, 2016 21–79 50 AASM 2007 62.3%; 62.3% 26.1%; 26.1% Singapore Tan A, 2016 21–79 50 AASM 2012 70.8%; 70.8% 30.5%; 30.5% Switzerland Heinzer R, 2015 40–85 48 AASM 2012 83.8%; 60.8% 49.7%; 23.4% U.S. Peppard PE, 2013 30–70 55 AASM 2007 33.9%; 17.4% 13.0%; 6.0% Spain Duran J, 2001 30–70 49 AASM 2007 26.2%; 28.0% 14.2%; 7.0% AASM: American Academy of Sleep Medicine; AHI: apnea-hypopnea index. Fig. 4. Consequences of obstructive sleep apnea (OSA) and associated pathophysiological mechanisms. Adapted and reproduced with permission from the SEPAR Manual of Pulmonology and Thoracic Surgery. models may be less generalizable, and they would have to be used vidually adapted after an in-depth study. The patient’s role in in specific, previously validated areas9 . therapeutic decision-making must be emphasized. This should be the standard approach in multidisciplinary teamwork1–3,6,8 (Fig. 7). Medical treatment of obstructive sleep apnea: a therapeutic It is important to note that before starting any of the therapeu- algorithm tic alternatives, the clinical diagnosis of OSA must be confirmed by a sleep study validated according to the previously recommended The goals of OSA treatment are to resolve the signs and symp- diagnostic algorithm. The therapeutic algorithm (Fig. 8) is as fol- toms of the disease, restore sleep quality, normalize AHI, improve lows: oxygen saturation as far as possible, reduce the risk of compli- cations, and lower the costs of the disease. This ICD emphasizes 1 Hygienic-dietary measures should be implemented (Fig. 9) in that the various alternatives are combinable and recommends a all patients with OSA, regardless of whether continuous positive multidisciplinary therapeutic approach. airway pressure (CPAP) therapy is indicated. All medical, surgical, and physical options for the treatment of 2 The patient must be evaluated to identify conditions associated OSA should be complementary, not exclusive. Each patient should with OSA and potentially reversible causes. Accordingly, this ICD be offered the widest range of possibilities, and all strategies should recommends: be applied rationally, either alone or in combination, and indi- T57 O. Mediano, N. González Mangado, J.M. Montserrat et al. Archivos de Bronconeumología 58 (2022) T52–T68 Table 3 Consequences of obstructive sleep apnea: prevalence, incidence, consequences and effect of treatment. References Prevalence and association Consequences Effect of treatment Traffic and Terán-Santos, 2017 OSA increases the risk of a traffic OSA is included among the physical CPAP reduces the risk of traffic occupational Tregear, 2010 accident by 3–6-fold. 7% of traffic and mental fitness criteria for accidents and derived costs accidents accidents in men are due to OSA obtaining/extending driving licenses Occupational accident risk doubles in (European Union Directive OSA (especially in professional drivers) 2014/85/EU) HBP Javaheri, 2020 50% of moderate-severe OSA patients OSA has been positioned as the leading CPAP discreetly reduces blood Martínez-García, 2013 have HBP. 30% of HBP patients have OSA cause of secondary HBP pressure (systolic BP by Martínez-García, 2019 (70% have resistant HTA). Independent Data on whether OSA increases the risk 2–2.5 mmHg and diastolic BP Mazzotti, 2019 association between OSA and HBP. of HBP incidence are conflicting by 1–1.5 mmHg). Probably has Dose-response ratio. Higher frequency of a greater effect on patients non-dipping patterns with a non-dipping BP pattern and on resistant and refractory HBP Cerebrovascular Boulos, 2021 OSA is very common (60%) in ischemic OSA may lead to increased functional CPAP may improve recovery disease Dong, 2018 and thromboembolic cerebrovascular and cognitive impairment and higher after an episode of stroke. No Javaheri, 2020 disease. OSA increases the risk of stroke mortality after stroke data available on mortality Kang, 2020 by 2–3-fold Data on whether OSA increases the risk of stroke incidence are conflicting Arrhythmias Qureshi, 2015 50% prevalence of arrhythmias in OSA; OSA increases the risk of AF incidence Observational studies show Mehra, 2006 the most common are atrioventricular (dose-response ratio) and recurrence that CPAP reduces the rate of Kwon, 2017 block, sinus pauses, and premature atrial AF recurrence after sinus and ventricular complexes. Frequency rhythm recovery after ablation. increases with the severity of OSA and There are no clinical trials associated hypoxia. 20%–80% of patients with AF have OSA and 3%–5% of OSA patients have AF Ischemic heart Javaheri, 2017 The prevalence of OSA in coronary heart OSA can worsen the prognosis of Observational studies show disease Sánchez de la Torre, disease is 38%–65% patients with previous coronary that CPAP decreases 2020 disease, increasing the risk of new cardiovascular events, but McEvoy, 2016 cardiovascular events and restenosis clinical trials in patients after revascularization. However, without drowsiness do not recent data show no differences in the show any beneficial effects in number of new cardiovascular events secondary prevention in untreated moderate-severe OSA, but without drowsiness Pulmonary Alonso-Fernández, OSA is an age-independent risk factor for It could increase the risk of recurrence Unknown embolism 2013 PE and confer greater severity, but there is Alonso-Fernández, little evidence 2016 Pulmonary Arias, 2006 PHT is a prevalent but mild disease in Uncertain clinical significance. CPAP improves right heart hypertension Sajkov, 2009 OSA (20%–30%) Evidence is currently insufficient to function and reduces recommend investigating PHT in OSA pulmonary pressures patients, but OSA should be ruled out in the study of PTH patients Heart failure Javaheri, 2020 The prevalence of OSA and CSA in CHF is OSA increases the risk of emerging CHF CPAP improves BP, high (50%–75%). The prevalence of CHF Prognosis of CHF is worse and sympathetic tone, left in OSA is double that of healthy controls mortality is higher if it coexists with ventricular ejection fraction, and is similar in both stable heart failure OSA or ACS and quality of life in these with preserved ejection fraction and patients, but not mortality reduced heart failure Diabetes Anothaisintawee, 2016 Prevalence of OSA in DM2 is very high OSA is an independent risk factor for CPAP with good adherence mellitus, Martínez-Cerón, 2016 (60%–85%) developing DM2, which is increased in improves insulin resistance metabolic Shang, 2021 The prevalence of MS in OSA patients is case of excessive daytime sleepiness or and may contribute to better syndrome 6–9 times more frequent than in the a higher grade of nocturnal hypoxemia glycemic control, but results general population Metabolic control is worse if DM2 and are divergent OSA co-exist, although it is not known whether there is an increased risk for medium-long-term complications Cancer Nieto, 2012 Several studies show an association OSA severity and nocturnal hypoxia There are no clinical trials Campos-Rodriguez, between OSA and cancer incidence that are associated with higher cancer 2013 is higher in young patients mortality, higher incidence in some Martínez-García, 2016 types of cancer (melanoma, lung), Martínez-García, 2018 tumor aggressiveness (melanoma), and metastatic ability (animals) Neurodegeneration Emamian, 2016 Prevalence of cognitive impairment OSA can lead to increased and earlier Results on the effect of CPAP Bubu, 2020 2.5%–50%. AD confers a 5-fold higher risk onset of cognitive impairment are conflicting of OSA and 50% of AD patients have OSA (affecting mainly executive function, attention, and memory) Depression Patil, 2019 There is a two-way relationship between Results are discordant, Edwards, 2020 OSA and depression. The risk of although CPAP appears to developing depression in OSA is 2-fold, improve depressive symptoms especially in women (35 vs. 12–25% in in the elderly and in women men) and the elderly. The risk of OSA in patients with depression is 5-fold AD: Alzheimer’s disease; AF: atrial fibrillation; HBP: high blood pressure; BMI: body mass index; BP: blood pressure; CHF: congestive heart failure; CPAP: continuous positive upper airway pressure; CSA: central sleep apnea; DM2: diabetes mellitus type 2; MS: metabolic syndrome; OSA: obstructive sleep apnea; PE: pulmonary embolism; PHT: pulmonary arterial hypertension. T58 O. Mediano, N. González Mangado, J.M. Montserrat et al. Archivos de Bronconeumología 58 (2022) T52–T68 Fig. 5. Proposed algorithm for the diagnosis of patients with suspected obstructive sleep apnea (OSA) at a specialized level. AHI: apnea-hypopnea index; CPD: cardiopulmonary disease; EDS: excessive daytime sleepiness; PSG: polysomnography; RP: respiratory polygraphy; TD: therapeutic decision. *Intermediate-high probability is defined as the presence of EDS (Epworth > 10) and 2 of the following 3 criteria: usual intense snoring, observed choking arousals or apneas, and/or arterial hypertension. Fig. 6. Proposed diagnostic algorithm in patients with suspected obstructive sleep apnea (OSA) seen in primary care and coordinated with the reference sleep laboratory. AHI: apnea-hypopnea index; BMI: body mass index; CPD: cardiopulmonary disease; EDS: excessive daytime sleepiness; SS: simplified study (one or 2 channels corresponding to nasal pressure and oximetry); TD: therapeutic decision. *High probability is defined as the presence of EDS (Epworth ≥ 12) and 2 of the following 3 criteria: habitual intense snoring, observed choking arousals or apneas, and/or arterial hypertension. **In these cases, a manual analysis of the recording by the coordinating sleep laboratory may offer a more accurate diagnosis. T59 O. Mediano, N. González Mangado, J.M. Montserrat et al. Archivos de Bronconeumología 58 (2022) T52–T68 Fig. 7. Multidisciplinary approach to obstructive sleep apnea (OSA): all interventions are combinable. CPAP: continuous positive airway pressure; DISE: drug-induced sleep endoscopy; UA: upper airway. – Patients with a targeted diagnosis of moderate-severe OSA – Treatment of obesity: excess weight or obesity should be treated (AHI ≥ 15/h) with excessive daytime sleepiness (Epworth > 10), in all patients with OSA. Initial treatment should be part of altered sleep-related quality of life (intense snoring, episodes of a comprehensive, high-intensity program that includes behav- night choking, insomnia, morning headache, nocturia, impaired ioral strategies10 . Severe obesity requires more durable strategies work or academic performance, social impact, and/or tiredness that should be evaluated in specialized units, where the use of during the day) and/or HBP (especially if resistant or refractory). anti-obesity drugs10 or surgery (for patients > 35 kg/m2 ) will be – In patients with no indication for CPAP due to AHI ≥ 15/h evaluated when conservative treatment fails11–14 . who do not present the above criteria, AHI between 5 and – Treatment of reversible causes: thyroid hormone replacement 15/h, or in whom CPAP is indicated but rejected (refusal to therapy is recommended in patients with OSA and hypothy- accept treatment or treatment unsuccessfully attempted for less roidism, so levels should be determined in case of clinical than 4 weeks), alternative treatments should be assessed indi- suspicion of hypothyroidism15 . In case of gastroesophageal vidually (mandibular advancement devices [MAD], positional reflux, positional and dietary measures should be indicated, and treatment, surgery, etc.). These treatments and their indications treatment with proton pump inhibitors should be offered on are described in detail in the online material of this ICD. an individual basis. If the patient presents tonsillar hypertrophy – Insufficient evidence is available to consistently recommend the grade III/IV or severe dental or facial alterations, surgery to treat use of CPAP to reduce the risk of death or cardiovascular or cere- OSA should be considered. brovascular events in adults who do not meet the 3 criteria listed above. These patients should be offered conservative treatment In any of these situations, the need for CPAP until treatment of with monitoring of symptoms or an individualized assessment the reversible cause becomes effective can be assessed. including a CPAP trial (with short-term reassessment of treat- ment continuity depending on efficacy and tolerance). – Similarly, in patients with OSA who have AHI < 15/h but are 3 Indications for CPAP: CPAP is an effective treatment to reduce highly symptomatic or have a high burden of cardiovascular, OSA severity, assessed according to AHI, and remains the treat- cerebrovascular, or metabolic disease, a CPAP trial may be con- ment of choice in many of these patients16–29 . Once the steps sidered if the patient agrees. Current evidence suggests that CPAP described above have been completed, the following recommen- may play a greater role in preventing cerebrovascular events than dations for indicating CPAP, based on quality evidence evaluated cardiovascular events32 . according to currently available information in line with Amer- – Alternative treatments should be considered individually if the ican Academy of Sleep Medicine guidelines30,31 , should be therapeutic trial fails. followed. The scientific evidence supporting these recommendations and A detailed explanation of the scientific evidence supporting a more detailed description can be found in the online material. selected cut-off points, symptoms and/or comorbidities used to Adequate pressure titration and monitoring of CPAP compli- determine the indication of CPAP can be found in the online mate- ance are essential to achieve the treatment objectives described. rial. This ICD recommends CPAP in: Please refer to the online material for a detailed description of these T60 O. Mediano, N. González Mangado, J.M. Montserrat et al. Archivos de Bronconeumología 58 (2022) T52–T68 Fig. 8. Proposed therapeutic algorithm for obstructive sleep apnea (OSA). A more detailed description of the scientific evidence that supports this algorithm can be found in the online material. AHI: apnea-hypopnea index; BMI: body mass index; CPAP: continuous positive airway pressure; ENT: ear, nose, and throat; MAD: mandibular advancement devices. factors. In short, this ICD recommends considering PSG pressure should only be considered between the start of treatment and until titration for patients with significant (severe COPD) or unstable the definitive titration study (auto-CPAP, CPAP with memory card, cardiopulmonary disease (heart failure), complex sleep-disordered or manual titration) is performed. breathing (central sleep apnea, suspected incipient central sleep Compliance during the first 3 months can predict long-term apnea, or obesity-hypoventilation syndrome), or when titration use of the device33 , so careful attention in this period will be key with simplified methods has not been possible. For all other to achieving adequate long-term compliance34 . This ICD defines patients, pressure titration with auto-CPAP provides a level of OSA good adherence as the use of the device for at least 4 h/night on control similar to PSG titration. It is essential that the patient be 70% of nights. The current evidence points to a dose-response rela- trained before titration is attempted. This document recommends tionship between hours of use and therapeutic response35,36 , and visual analysis of the graph and selection of the minimum pressure the neurocognitive and cardiovascular effects of CPAP and the per- that, regardless of leakage peaks, covers about 90% of the entire ceived benefits in quality of life depend on this compliance37 . For pressure graph. It is also recommended that at least 5 valid hours this reason, we propose the concept of optimal compliance with of recording be examined. Finally, empirical formula calculation a minimum of 6 h/night, an approach which has shown benefits T61 O. Mediano, N. González Mangado, J.M. Montserrat et al. Archivos de Bronconeumología 58 (2022) T52–T68 Fig. 9. Recommended hygienic-dietary measures for all patients with obstructive sleep apnea, irrespective of an indication of continuous positive airway pressure. in symptom control and morbidity. As for the type of device, the the follow-up of patients receiving CPAP. Primary care should be use of auto-CPAP has not been shown to increase the percentage of included in long-term monitoring. nights with more than 4 h use38,39 . Therefore, its use is only recom- All patients receiving CPAP should be monitored after the first mended for patients with high or highly variable effective pressure month of treatment and a brief in-person review should be per- throughout the night. formed at 6 months. Adherence at 3 months can be determined Interventions for improving adherence are described in detail from telemonitoring. If the treatment is well established, with good in the online material. Since the evidence suggests that tele- clinical response and no side effects, the patient may be referred to monitoring improves CPAP adherence40,41 , this strategy should primary care for follow-up after the first year. be considered during the initial period of CPAP treatment. If it is If the patient has frank and proven intolerance to CPAP (the used, remote recording of CPAP parameters30,31 should include patient has tried to use it for more than 4 weeks, but has not been hours of use, residual AHI, unintentional leaks, and machine able to adapt), withdrawal should be considered. If either rejection configuration30,31,42 . or intolerance cannot be rectified, other therapeutic alternatives Multidisciplinary management with the participation of a sleep should be considered. In the event of clear lack of adherence with specialist, the nursing team, and the suppliers will be important in an average use of less than 3 h/night, the patient should be included T62 O. Mediano, N. González Mangado, J.M. Montserrat et al. Archivos de Bronconeumología 58 (2022) T52–T68 Fig. 10. Algorithm for indicating surgical treatment in obstructive sleep apnea (OSA) using personalized precision medicine. CAPSO: cautery-assisted palatal stiffening operation; CELL: coblator endoscopic lingual lightening; CPAP: continuous positive airway pressure; DISE: drug-induced sleep endoscopy; DOME: distraction osteogenesis maxillary expansion; ENT/MXF; ear, nose and throat/maxillofacial; MAD: mandibular advancement device; PSG: polysomnography; RP: respiratory polygraph; RX/CT: radiological studies; TORS: transoral robotic surgery; UA: upper airway; UPPP: uvulopalatopharyngoplasty. (1) In case of severe dental or facial alterations, bimaxillary advancement may be indicated directly, although CPAP will be prescribed until surgery is conducted. (2) In case of tonsillar hypertrophy grade ≥ 3, tonsillectomy may be indicated directly, although CPAP will be prescribed until surgery. (3) In case of CPAP intolerance after ORL evaluation, nasal surgery is recommended as soon as possible to improve intolerance and retitrate CPAP. (4) In case of CPAP intolerance after dental/maxillofacial evaluation, adaptation of MAD or assessment for orthognathic surgery is recommended. (5) In case of CPAP intolerance after ENT evaluation, DISE is recommended to determine the most appropriate upper airway treatment. (6) After intolerance to CPAP and failure of other surgeries, a repeat DISE is recommended. If collapse is non-concentric, hypoglossal neurostimulation may be indicated. in a compliance program, preferably with a telemonitoring sys- the options have been explained, none of which is either exclusive tem, and re-evaluated after at least 3 months, before assessing the or prevailing. It is common for patients to have airway obstructions possible withdrawal of CPAP and an alternative therapeutic pro- at different levels, so the current tendency is to perform multilevel posal. Occasionally, patients who use CPAP for less than 3 h/night surgery, in which, once the different sites of upper airway obstruc- report symptomatic improvements, so the decision to discontinue tion have been determined, a decision is made on the different treatment should be individualized. procedures to be performed, alone or in combination, aiming to achieve optimal results48–51 . Surgical treatment The surgical algorithm recommended in this ICD for use by Treatment with mandibular advancement devices ENT specialists and oral or maxillofacial surgeons is an update of the standard Stanford 2-tiered protocol (Fig. 10)43,44 . In this Recent randomized controlled trials have demonstrated the effi- era of personalized medicine, a precise indication for palatal and cacy of MADs on various aspects of OSA as summarized in Table 4 oropharyngeal surgeries may initially be made based on clinical (see also online material): findings and drug-induced sedation endoscopy (DISE)45–47 , but This ICD therefore recommends that52,53 : skeletal surgery, especially bimaxillary advancement, may also be indicated as initial surgical treatment of OSA in patients with severe disease (AHI > 65 and/or concentric collapse on DISE and/or severe • The diagnosis of OSA and the efficacy of MAD should always be dental and facial alterations). An indication for surgery never defini- determined by respiratory polygraphy or PSG. tively excludes other treatments, or vice versa. Refer to the online • The indications for MAD are: material for a more detailed description of the systematic review 1 Patients with OSA of any severity who are candidates for CPAP and indications for surgery in OSA patients. therapy but unable to adapt to it. MAD is principally indicated The proposed algorithm moves on from the classic concept of as an alternative to CPAP and should be available in sleep units soft tissue removal or skeletal modification44 . It divides the surgi- in the public health system, or cal procedures to be performed according to the affected organ, and 2 Patients with mild to moderate OSA, minor symptoms, or the choice of procedure is based primarily on the exploratory and troublesome snoring and no indication for CPAP or any other diagnostic findings and on the final decision of the patient after all treatment. T63 O. Mediano, N. González Mangado, J.M. Montserrat et al. Archivos de Bronconeumología 58 (2022) T52–T68 Table 4 Summary of existing scientific evidence on the efficacy of mandibular advancement device in patients with obstructive sleep apnea. Effect Comments AHI Significant reduction in 60% of patients Disparate success criteria: final AHI < 5/h, <10/h, or 50% decrease in baseline AHI Notable heterogeneity among the different studies The degree of mandibular advancement should be individualized in each patient Other sleep variables Improved oximeter parameters and Improvement associated with reduction in AHI sleep fragmentation Sleepiness Reduced Improvement associated with reduction in AHI Evaluated almost exclusively by the Epworth scale Quality of life and cognitive Improved quality of life Improvement associated with reduction in AHI aspects Scant exploration of cognitive improvement Cardiovascular aspects Improved night BP control Improvement associated with reduction in AHI Little evidence on other cardiovascular aspects Snoring Usually improves frequency and/or intensity AHI: apnea-hypopnea index. Table 5 Summary of current evidence and indications for alternative therapies in the management of OSA. Treatment Evidence Indications Positional therapy54 Significant reduction in AHI in some cases to below 5/h, As a single treatment in patients with respiratory episodes but in very small samples with inconsistent results on exclusively in supine position or with an AHI < 15/h in other daytime sleepiness and quality of life positions, always with confirmation of disease control As an adjuvant therapy to decrease CPAP pressure in patients with predominantly supine episodes In patients with predominantly supine episodes who reject first-line therapies Pharmacological In 20 patients with OSA, combined single-dose Although in the future drug therapy may be useful in some patient treatment55 atomoxetine (norepinephrine reuptake inhibitor) and phenotypes, this ICD considers that it is currently premature to use oxybutynin (muscarinic blocker) reduced AHI (63%; from this combination or any other drug for the treatment of OSA 28.5 to 7.5 episodes/h) and improved minimal saturation by increasing the response of the genioglossus muscle during sleep Long-term effect and safety remain to be determined Myofunctional Randomized studies in patients with OSA have shown that Therapeutic alternative in non-obese patients with mild-moderate therapy56 it can decrease AHI (50%; from 24.5 to 12.3 episodes/h), OSA improve minimal saturation, daytime sleepiness, and Concomitant treatment to improve the efficacy and tolerance of quality of life CPAP, reducing required pressure levels Complementary treatment in patients with MAD BiPAP57 BiPAP has not shown superior efficacy to CPAP in reducing Patients who have not been able to tolerate CPAP because they AHI or improving sleepiness, quality of life, side effects, or require very high pressures therapeutic adherence, except in patients who have Consider switching to BiPAP in patients who require CPAP difficulty in complying with CPAP therapy pressures greater than 15 for the control of respiratory episodes, and whenever CPAP pressures greater than 20 are required Patients with concomitant disease who require BiPAP Nasal EPAP58 A systematic review showed a mean 53% relative reduction Given the lack of response predictors and the lack of more in AHI, although there are no predictors to determine who extensive studies, this approach could only be considered as an might benefit from this therapy alternative in selected patients with mild-moderate OSA Oral pressure therapy59 In a multicenter study of 63 patients, 32% had an AHI < 10 There is currently insufficient evidence to recommend its use as an on the first night, with a 50% reduction from baseline alternative treatment in patients with OSA AHI: apnea-hypopnea index; BiPAP: bilevel positive airway pressure; CPAP: continuous positive airway pressure; EPAP: expiratory positive airway pressure; ICD: international consensus document; MAD: mandibular advancement devices; OSA: obstructive sleep apnea. • Before prescribing an MAD, the dentist must perform an oral polygraphy may be used by an experienced sleep dentist as a tool examination to rule out patients who do not meet dental inclu- for MAD titration. sion criteria. • Current evidence supports the use of custom-made, adjustable Alternative treatments devices. • Following assessment of the patient’s suitability from the point OSA is a heterogeneous disease in terms of both its patho- of view of oral health, treatment should be implemented and physiology and its polysomnographic expression and clinical followed up by a certified dentist or OSA sleep-disordered breath- presentation. In recent years, various OSA phenotypes have been ing expert working in coordination with a sleep unit. Respiratory T64 O. Mediano, N. González Mangado, J.M. Montserrat et al. Archivos de Bronconeumología 58 (2022) T52–T68 Fig. 11. Proposed algorithm for the referral of patients with suspected obstructive sleep apnea (OSA) from primary care. HBP: high blood pressure; BMI: body mass index; EDS: excessive daytime sleepiness. described that are explained in depth in the online material of c) Most treatment follow-up requirements can be met in primary this document. This phenotype approach has helped improve care. our knowledge of the mechanisms involved in the disease and the development of different therapeutic strategies, and has con- These activities should be conducted as indicated in Fig. 12. A tributed to the development of a more personalized medicine. more detailed explanation can be found in the online material. Table 5 summarizes current evidence and indications for other alternative therapies (see also online material). Conclusions OSA is a highly prevalent disease with significant consequences. Role of primary care medicine in the management of Its diagnostic and therapeutic management requires multidisci- obstructive sleep apnea plinary treatment and involves all levels of care. Identification of possible reversible causes and assessment of all treatment options, In light of the current evidence, the recommendations of this all of which are combinable, will contribute to comprehensive ICD on the role of primary care in the management of OSA patients patient management. are as follows: Authorship 1 The involvement of primary care physicians is essential to improve the current situation of OSA underdiagnosis. All the authors have participated in the study and read and 2 The implementation of training plans in primary care improves approved the manuscript. the suspicion and diagnostic process of OSA. 3 The criterion for clinical suspicion should be the presence of 2 of Conflict of interests the 3 main symptoms: snoring, observed apneas, and/or exces- sive daytime sleepiness or unexplained intense tiredness. Pedro García Ramos states that he has collaborated with GSK, 4 The situations that require urgent referral are summarized in Laboratorios Ferrer, Angelini, Novartis, Almirall, Gebro Pharma, Fig. 11: Rovi, Esteve, Recordati, MSD, and Teva. Carlos Teixeira states that a) Primary care diagnostic procedures should be performed in he is an employee of Philips (Sleep and Respiratory Care Division). consensus with the reference sleep unit, working in a network. Francisco Javier Puertas Cuesta states that he has received fees for b) At the moment, evidence on how to start CPAP treatment consultancy and speaking in courses and seminars from Jazz Phar- exclusively in a primary care setting is insufficient. maceuticals, UCB Pharma, GSK, Esteve Teijin, and ResMed, and has T65 O. Mediano, N. González Mangado, J.M. Montserrat et al. Archivos de Bronconeumología 58 (2022) T52–T68 Fig. 12. Proposal for the main areas of primary care intervention in the care of patients with obstructive sleep apnea (OSA). HBP: high blood pressure; CPAP: continuous positive airway pressure; CVRF: cardiovascular risk factors; EDS: excessive daytime sleepiness. received research grants from Philips. The other authors state that Appendix D. International scientific societies they have no conflict of interests with the manuscript. Latin American Thoracic Association (ALAT), Brazilian Society Acknowledgements of Pulmonology and Phthisiology (SBPT), Portuguese Society of Pulmonology (SPP), SomnoNIV Group of the French Language Pul- Esteve Teijin organized the first national in-person meeting. monology Society (SPLF). Philips (Sleep and Respiratory Care Division) organized the final in-person document review meeting. None of these companies was References involved in the scientific discussion or the drafting of the document. Ivan Solà participated in the research work as an expert documen- 1. Fitch K, Bernstein SJ, Aguilar MD, Burnand B, Lacalle JR, Lazaro P, et al, Available from: https://www.rand.org/ talist. This ICD is especially dedicated to our companion Mari Luz content/dam/rand/pubs/monograph reports/2011/MR1269.pdf, 2001. Alonso-Álvarez, who always set an example of best practices in the 2. Fitch K, Lázaro P. Using appropriateness criteria to improve health care. 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