Conference Coverage

Recognizing and Managing Obstructive Sleep Apnea in Primary Care

Anthony Calabro, MA

Key Highlights 

  • OSA is underdiagnosed in up to 80% of moderate-to-severe cases.
  • Women often present atypically, with insomnia instead of snoring.
  • Polysomnography is the gold standard for diagnosing OSA, but home testing is suitable in many cases.
  • Continuous positive airway pressure is effective, but alternatives exist for those who cannot tolerate it.

In her presentation at the 2025 Practical Updates in Primary Care virtual conference, Julianne Blythe, MPA, PA-C, RPSGT, a physician assistant at the University of California at San Francisco, noted that obstructive sleep apnea (OSA) remains significantly underdiagnosed, with an estimated 80% of moderate-to-severe cases unrecognized in the general population.

OSA affects approximately 33.9% of men and 17% of women in the United States and is frequently associated with comorbid conditions such as hypertension, atrial fibrillation, type 2 diabetes, and congestive heart failure. Ms Blythe emphasized that even individuals with a normal BMI may have OSA depending on craniofacial anatomy, stating, “We all stop breathing in our sleep. People don’t realize that all adults do this—less than five times an hour is normal.”

OSA is characterized by repeated episodes of upper airway obstruction during sleep, leading to intermittent hypoxia, electroencephalogram arousals, and sympathetic activation. Ms Blythe reviewed the definitions of apneas, hypopneas, and respiratory effort-related arousals (RERAs), noting that the Apnea-Hypopnea Index (AHI) is used to classify severity. AHI values of 5–15 are considered mild, 15–29 moderate, and ≥30 severe. She presented polysomnogram tracings to illustrate how airflow cessation, effort patterns, and oxygen desaturation define apneic events.

Ms Blythe also detailed the presentation of OSA in women, who frequently report insomnia and fragmented sleep rather than daytime sleepiness or snoring.

“[Women] typically say they have insomnia, and the main type of insomnia is difficulty with maintenance of sleep,” she noted.

For women, OSA risk factors include pregnancy, menopause, polycystic ovary syndrome, and lack of hormone replacement therapy. Comorbid conditions such as atrial fibrillation, resistant hypertension, stroke, and gastroesophageal reflux disease further elevate clinical suspicion. Morning headaches, nocturia, weight loss resistance, and cognitive impairment are also commonly reported symptoms.

Diagnostic pathways were reviewed during the presentation, with polysomnography (PSG) positioned as the diagnostic gold standard, particularly in complex presentations such as parasomnias or suspected central apnea. However, home sleep apnea testing (HSAT), particularly Type 3 devices, is suitable for many patients with high pretest probability. Ms Blythe acknowledged the impact of payer policies on test selection and the limitations of HSAT, particularly in detecting borderline or positional apnea.

Following an OSA diagnosis, continuous positive airway pressure (CPAP) is the first-line option for moderate-to-severe cases, with compliance rates varying from 50% to 90%. Ms Blythe emphasized practical guidance on Medicare requirements and noted that auto-adjusting CPAP offers flexibility for changing conditions such as pregnancy or weight loss. Alternatives such as mandibular advancement devices, positional therapy, and upper airway stimulation were also discussed, as was the emerging role of GLP-1 agonists, and ultimately tailoring treatment based on individual tolerance and comorbidity.

Finally, Ms Blythe presented three patient cases, including the case of a 78-year-old man with a history of paroxysmal atrial fibrillation, hypertension, high cholesterol, and gout.

Despite his high AHI of 72 and oxygen desaturation that fell as low as 80%, the patient denied sleepiness or any sense of impaired sleep. Importantly, CPAP treatment reduced his AHI to 3.3 and improved oxygenation.

This case highlighted the challenge of managing patients who do not feel tired and are thus reluctant to initiate or continue treatment. Indeed, Ms Blythe noted that patients often do not recognize their baseline fatigue until it is improved with treatment.

“Everyone is different on how sleep apnea affects them,” she explained. “I've had people with an AHI of 90 and not been tired, and an AHI of 5.2 and have been exhausted. So, you know, once again, let’s treat the patient, not the numbers.”

Reference:
Blythe J. Obstructive sleep apnea: Testing and referring guidelines. Practical Updates in Primary Care. July 16-18, 2025. https://www.hmpglobalevents.com/pupc