Department of Medicine, University of North Carolina at Chapel Hill2RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center3Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.
RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center3Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.
JAMA. 2017 Jan 24;317(4):415-433. doi: 10.1001/jama.2016.19635.
Many adverse health outcomes are associated with obstructive sleep apnea (OSA).
To review primary care-relevant evidence on screening adults for OSA, test accuracy, and treatment of OSA, to inform the US Preventive Services Task Force.
MEDLINE, Cochrane Library, EMBASE, and trial registries through October 2015, references, and experts, with surveillance of the literature through October 5, 2016.
English-language randomized clinical trials (RCTs); studies evaluating accuracy of screening questionnaires or prediction tools, diagnostic accuracy of portable monitors, or association between apnea-hypopnea index (AHI) and health outcomes among community-based participants.
Two investigators independently reviewed abstracts and full-text articles. When multiple similar studies were available, random-effects meta-analyses were conducted.
Sensitivity, specificity, area under the curve (AUC), AHI, Epworth Sleepiness Scale (ESS) scores, blood pressure, mortality, cardiovascular events, motor vehicle crashes, quality of life, and harms.
A total of 110 studies were included (N = 46 188). No RCTs compared screening with no screening. In 2 studies (n = 702), the screening accuracy of the multivariable apnea prediction score followed by home portable monitor testing for detecting severe OSA syndrome (AHI ≥30 and ESS score >10) was AUC 0.80 (95% CI, 0.78 to 0.82) and 0.83 (95% CI, 0.77 to 0.90), respectively, but the studies oversampled high-risk participants and those with OSA and OSA syndrome. No studies prospectively evaluated screening tools to report calibration or clinical utility for improving health outcomes. Meta-analysis found that continuous positive airway pressure (CPAP) compared with sham was significantly associated with reduction of AHI (weighted mean difference [WMD], -33.8 [95% CI, -42.0 to -25.6]; 13 trials, 543 participants), excessive sleepiness assessed by ESS score (WMD, -2.0 [95% CI, -2.6 to -1.4]; 22 trials, 2721 participants), diurnal systolic blood pressure (WMD, -2.4 points [95% CI, -3.9 to -0.9]; 15 trials, 1190 participants), and diurnal diastolic blood pressure (WMD, -1.3 points [95% CI, -2.2 to -0.4]; 15 trials, 1190 participants). CPAP was associated with modest improvement in sleep-related quality of life (Cohen d, 0.28 [95% CI, 0.14 to 0.42]; 13 trials, 2325 participants). Mandibular advancement devices (MADs) and weight loss programs were also associated with reduced AHI and excessive sleepiness. Common adverse effects of CPAP and MADs included oral or nasal dryness, irritation, and pain, among others. In cohort studies, there was a consistent association between AHI and all-cause mortality.
There is uncertainty about the accuracy or clinical utility of all potential screening tools. Multiple treatments for OSA reduce AHI, ESS scores, and blood pressure. Trials of CPAP and other treatments have not established whether treatment reduces mortality or improves most other health outcomes, except for modest improvement in sleep-related quality of life.
许多不良健康后果与阻塞性睡眠呼吸暂停（OSA）有关。
综述与初级保健相关的成人 OSA 筛查、检测准确性和治疗的证据，为美国预防服务工作组提供信息。
通过 2015 年 10 月的 MEDLINE、Cochrane 图书馆、EMBASE 和试验登记处、参考文献和专家检索，以及 2016 年 10 月 5 日的文献监测。
英语随机临床试验（RCT）；评估筛查问卷或预测工具准确性、便携式监测仪诊断准确性或社区参与者中呼吸暂停低通气指数（AHI）与健康结果之间关系的研究。
两名研究人员独立审查了摘要和全文文章。当有多个类似的研究时，进行了随机效应荟萃分析。
敏感性、特异性、曲线下面积（AUC）、AHI、Epworth 睡眠量表（ESS）评分、血压、死亡率、心血管事件、机动车事故、生活质量和危害。
共纳入 110 项研究（N=46188）。没有 RCT 比较过筛查与不筛查。在 2 项研究（n=702）中，多变量呼吸暂停预测评分后进行家庭便携式监测测试以检测严重 OSA 综合征（AHI≥30 和 ESS 评分>10）的筛查准确性为 AUC 0.80（95% CI，0.78 至 0.82）和 0.83（95% CI，0.77 至 0.90），但这些研究对高风险参与者和 OSA 及 OSA 综合征患者进行了过采样。没有研究前瞻性评估筛查工具以报告改善健康结果的校准或临床实用性。荟萃分析发现，与假相比，持续气道正压通气（CPAP）显著降低 AHI（加权均数差 [WMD]，-33.8 [95% CI，-42.0 至-25.6]；13 项试验，543 名参与者）、ESS 评分评估的过度嗜睡（WMD，-2.0 [95% CI，-2.6 至-1.4]；22 项试验，2721 名参与者）、日间收缩压（WMD，-2.4 分 [95% CI，-3.9 至-0.9]；15 项试验，1190 名参与者）和日间舒张压（WMD，-1.3 分 [95% CI，-2.2 至-0.4]；15 项试验，1190 名参与者）。CPAP 与睡眠相关生活质量的适度改善相关（Cohen d，0.28 [95% CI，0.14 至 0.42]；13 项试验，2325 名参与者）。下颌前伸装置（MADs）和减肥计划也与降低 AHI 和过度嗜睡有关。CPAP 和 MADs 的常见不良反应包括口腔或鼻腔干燥、刺激和疼痛等。在队列研究中，AHI 与全因死亡率之间存在一致的关联。
所有潜在筛查工具的准确性或临床实用性都存在不确定性。多种 OSA 治疗方法可降低 AHI、ESS 评分和血压。CPAP 和其他治疗方法的试验尚未确定治疗是否降低死亡率或改善大多数其他健康结果，除了睡眠相关生活质量的适度改善。
