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"identificador" => "aff0050" ] 10 => array:3 [ "entidad" => "Unidad de Trastornos Respiratorios del Sueño, Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "k" "identificador" => "aff0055" ] 11 => array:3 [ "entidad" => "Unidad de Sueño, Departamento de Neumología, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain" "etiqueta" => "l" "identificador" => "aff0060" ] 12 => array:3 [ "entidad" => "Servicio de Estomatología, Facultad de Medicina y Ciencias de la Salud, Universidad de Oviedo, Oviedo, Asturias, Spain" "etiqueta" => "m" "identificador" => "aff0065" ] 13 => array:3 [ "entidad" => "Unidad de Trastornos Respiratorios del Sueño, Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "n" "identificador" => "aff0070" ] 14 => array:3 [ "entidad" => "Unidad de Medicina del Sueño, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Ciudad de México, Mexico" "etiqueta" => "o" "identificador" => "aff0075" ] 15 => array:3 [ "entidad" => "Unidad Multidisciplinar del Sueño, Servicio de Neumología, Hospital Universitario San Juan de Alicante, San Juan de Alicante, Alicante, Spain" "etiqueta" => "p" "identificador" => "aff0080" ] 16 => array:3 [ "entidad" => "Grupo de Investigación en Epidemiología y Salud Pública, Unidad de Metodología y Estadística, Instituto de Investigación Sanitaria Bioaraba, Vitoria-Gasteiz, Álava, Spain" "etiqueta" => "q" "identificador" => "aff0085" ] 17 => array:3 [ "entidad" => "Corte del Ilustre Colegio de Abogados de Madrid, Madrid, Spain" "etiqueta" => "r" "identificador" => "aff0090" ] 18 => array:3 [ "entidad" => "Servicio de Investigación, Instituto de Investigación, OSI Araba, Hospital Universitario de Araba, Vitoria-Gasteiz, Álava, Spain" "etiqueta" => "s" "identificador" => "aff0095" ] 19 => array:3 [ "entidad" => "Unidad de Sueño y Ventilación Mecánica, Hospital Cosme Argerich, Buenos Aires, Argentina" "etiqueta" => "t" "identificador" => "aff0100" ] 20 => array:3 [ "entidad" => "Servicio de Neurología, Unidad Multidisciplinar de Sueño, Hospital Clínic de Barcelona, Barcelona, Spain" "etiqueta" => "u" "identificador" => "aff0105" ] 21 => array:3 [ "entidad" => "Centro de Salud Don Benito Oeste, Servicio Extremeño de Salud, Don Benito, Badajoz, Spain" "etiqueta" => "v" "identificador" => "aff0110" ] 22 => array:3 [ "entidad" => "Unidad de Sueño, Servicio de Neumología, Hospital Universitario La Paz, IdiPAZ, Departamento de Medicina, Universidad Autónoma de Madrid, Madrid, Spain" "etiqueta" => "w" "identificador" => "aff0115" ] 23 => array:3 [ "entidad" => "Unidad del Sueño, Servicio de Neumología, Hospital Clínic, Barcelona, Spain" "etiqueta" => "x" "identificador" => "aff0120" ] 24 => array:3 [ "entidad" => "Servicio de Odontología y Unidad Multidisciplinar del Sueño del Hospital Universitario Fundación Jiménez Díaz, Sociedad Española de Medicina Dental del Sueño (SEMDeS), Madrid, Spain" "etiqueta" => "y" "identificador" => "aff0125" ] 25 => array:3 [ "entidad" => "Sociedad Española de Neurofisiología Clínica (SENFC), Oviedo, Asturias, Spain" "etiqueta" => "z" "identificador" => "aff0130" ] 26 => array:3 [ "entidad" => "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" "etiqueta" => "aa" "identificador" => "aff0135" ] 27 => array:3 [ "entidad" => "Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain" "etiqueta" => "ab" "identificador" => "aff0140" ] 28 => array:3 [ "entidad" => "Laboratorio de Cronobiología, Universidad de Murcia, IMIB-Arrixaca, Murcia, Spain" "etiqueta" => "ac" "identificador" => "aff0145" ] 29 => array:3 [ "entidad" => "Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain" "etiqueta" => "ad" "identificador" => "aff0150" ] 30 => array:3 [ "entidad" => "Fundación Jiménez Díaz, Madrid, Spain" "etiqueta" => "ae" "identificador" => "aff0155" ] 31 => array:3 [ "entidad" => "Centro de Salud Fuencarral, Universidad Autónoma de Madrid, Madrid, Spain" "etiqueta" => "af" "identificador" => "aff0160" ] 32 => array:3 [ "entidad" => "Hospital San Pedro de Alcántara, Instituto Universitario de Investigación Biosanitaria en Extremadura (INUBE), San Pedro de Alcántara, Cáceres, Spain" "etiqueta" => "ag" "identificador" => "aff0165" ] 33 => array:3 [ "entidad" => "Unidad Multidisciplinar del Sueño, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain" "etiqueta" => "ah" "identificador" => "aff0170" ] 34 => array:3 [ "entidad" => "Unidad de Sueño, Servicio de Neumología, Hospital de la Santa Creu i Sant Pau, Departamento de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain" "etiqueta" => "ai" "identificador" => "aff0175" ] 35 => array:3 [ "entidad" => "Sociedad Española de Medicina del Tráfico (SEMT), Madrid, Spain" "etiqueta" => "aj" "identificador" => "aff0180" ] 36 => array:3 [ "entidad" => "Unidad Multidisciplinar del Sueño, Hospital Universitario de Bellvitge, Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Barcelona, Spain" "etiqueta" => "ak" "identificador" => "aff0185" ] 37 => array:3 [ "entidad" => "Unidad de Sueño, Servicio de Neumología, Hospital Clínico Universitario, Valencia, Spain" "etiqueta" => "al" "identificador" => "aff0190" ] 38 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Universitario Araba, Vitoria-Gasteiz, Álava, Spain" "etiqueta" => "am" "identificador" => "aff0195" ] 39 => array:3 [ "entidad" => "Servicio de Otorrinolaringología, Hospital Universitario de Fuenlabrada, Universidad Rey Juan Carlos, Fuenlabrada, Madrid, Spain" "etiqueta" => "an" "identificador" => "aff0200" ] 40 => array:3 [ "entidad" => "Hospital Universitario La Zarzuela, Madrid, Spain" "etiqueta" => "ao" "identificador" => "aff0205" ] 41 => array:3 [ "entidad" => "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" "etiqueta" => "ap" "identificador" => "aff0210" ] 42 => array:3 [ "entidad" => "Service de Pneumologie et Réanimation Respiratoire, Centre Hospitalier et Universitaire de Dijon, Dijon, France" "etiqueta" => "aq" "identificador" => "aff0215" ] 43 => array:3 [ "entidad" => "Centro Cochrane Iberoamericano, Barcelona, Spain" "etiqueta" => "ar" "identificador" => "aff0220" ] 44 => array:3 [ "entidad" => "Unidad Multidisciplinar del Sueño, Servicio de Neumología, Hospital San Pedro, Logroño, La Rioja, Spain" "etiqueta" => "as" "identificador" => "aff0225" ] 45 => array:3 [ "entidad" => "Servicio de Cardiología, Hospital Universitario del Tajo, Universidad Alfonso X El Sabio, Aranjuez, Madrid, Spain" "etiqueta" => "at" "identificador" => "aff0230" ] 46 => array:3 [ "entidad" => "Unidad Multidisciplinar del Sueño, Servicio de Neumología, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain" "etiqueta" => "au" "identificador" => "aff0235" ] 47 => array:3 [ "entidad" => "Hospital Virgen del Puerto, Instituto Universitario de Investigación Biosanitaria en Extremadura (INUBE), Plasencia, Cáceres, Spain" "etiqueta" => "av" "identificador" => "aff0240" ] 48 => array:3 [ "entidad" => "Unidad del Sueño, Servicio de Neurología Pediátrica, Hospital Sant Joan de Déu, Barcelona, Spain" "etiqueta" => "aw" "identificador" => "aff0245" ] 49 => array:3 [ "entidad" => "European Society of Sleep Technologists (EEST), Porto, Portugal" "etiqueta" => "ax" "identificador" => "aff0250" ] 50 => array:3 [ "entidad" => "Sociedad Española para el Estudio de la Obesidad (SEEDO), Madrid, Spain" "etiqueta" => "ay" "identificador" => "aff0255" ] 51 => array:3 [ "entidad" => "Disciplina de Pneumologia, Departamento de Medicina, Disciplina de Medicina y Biologia del Sueño - Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, Brazil" "etiqueta" => "az" "identificador" => "aff0260" ] 52 => array:3 [ "entidad" => "Servicio de Neumología, Unidad Multidisciplinar del Sueño, Fundación Jiménez Díaz, Madrid, Spain" "etiqueta" => "ba" "identificador" => "aff0265" ] 53 => array:3 [ "entidad" => "Instituto Neumológico del Oriente, Bucaramanga, Santander, Colombia" "etiqueta" => "bb" "identificador" => "aff0270" ] 54 => array:3 [ "entidad" => "Faculdade de Medicina, Universidade do Porto, Porto, Portugal" "etiqueta" => "bc" "identificador" => "aff0275" ] 55 => array:3 [ "entidad" => "Unidad del Sueño, Hospital Universitario Cruces, Barakaldo, Bizkaia, Spain" "etiqueta" => "bd" "identificador" => "aff0280" ] 56 => array:3 [ "entidad" => "Unidad Funcional de Sueño, Hospital Universitario Araba, OSI Araba, Vitoria-Gasteiz, Álava, Spain" "etiqueta" => "be" "identificador" => "aff0285" ] 57 => array:3 [ "entidad" => "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" "etiqueta" => "bf" "identificador" => "aff0290" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Documento internacional de consenso sobre apnea obstructiva del sueño" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1888 "Ancho" => 2508 "Tamanyo" => 219895 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">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.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction and literature search</span><p id="par0005" class="elsevierStylePara elsevierViewall">The main objective of this international consensus document (ICD) on obstructive sleep apnea (OSA) is to provide guidelines based on a critical analysis of the latest literature to help healthcare professionals make the best decisions in the care of adult patients with this disease. 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).</p><p id="par0010" class="elsevierStylePara elsevierViewall">The task force was formed primarily of 17 scientific societies and 56 specialists from a wide geographical area (including 4 international societies), an expert in methodology, and a documentalist from the Iberoamerican Cochrane Center, all of whom participated as consultants and conducted the systematic literature search.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The literature search strategy was primarily designed to identify systematic reviews published in the last 10 years in English or Spanish, followed by randomized clinical trials, observational studies, clinical practice guidelines, and economic studies according to the topic of each section. Validated methodological filters were used to identify the different types of study design.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The search was conducted on MEDLINE (via PubMed), EMBASE (via Ovid), The Cochrane Library, and CENTRAL (Appendix B available in online material).</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methodology</span><p id="par0025" class="elsevierStylePara elsevierViewall">An adaptation of the RAND-UCLA method<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> was used for the preparation of this document. The responsible organizations and the general coordinator of the project established the topics for consensus and selected the experts and task force leaders.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Topics requiring a systematic search of the scientific literature were identified. Structured searches were conducted by expert documentalists. The document was subsequently developed from a draft drawn up by the leaders of each task force. The experts in each group expressed their agreement on the areas for consensus (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Pathophysiology of obstructive sleep apnea</span><p id="par0035" class="elsevierStylePara elsevierViewall">The upper airway of patients with obstructive apneas tends to collapse during sleep, resulting in total or partial airway occlusion. Breathing stops until a microarousal occurs, which reactivates the muscles and reopens the airway. Apnea occurs when the factors that tend to close the airway cannot be offset by the ability of the dilating muscles of the pharynx and/or respiratory centers to keep it open (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Definition of obstructive sleep apnea</span><p id="par0040" class="elsevierStylePara elsevierViewall">This ICD proposes updating the nomenclature of sleep apnea syndrome to reintroduce the term “obstructive” in the acronyms accepted in 2005, since it defines the nature of the disease and clearly differentiates it from central sleep apnea. We decided to simplify the nomenclature and to remove the word “hypopnea” and the word “syndrome”, which is an outdated term that fails to reflect the current reality of the disease. We therefore recommended the use of the term “obstructive sleep apnea” and the acronym “OSA”.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In this ICD, OSA is defined as the presence of one of the following criteria:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0050" class="elsevierStylePara elsevierViewall">Presence of an apnea-hypopnea index (AHI) ≥ 15/h that is predominantly obstructive.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0055" class="elsevierStylePara elsevierViewall">AHI ≥ 5/h accompanied by one or more of the following factors: excessive daytime sleepiness, non-restorative sleep, excessive tiredness, and/or impaired sleep-related quality of life, which cannot be explained by other causes.</p></li></ul></p><p id="par0060" class="elsevierStylePara elsevierViewall">For the assessment of OSA severity, the position of this ICD is that classifications based solely on AHI are limited and do not reflect the heterogeneity of the disease. In line with current thinking among the scientific community<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a>, we have prioritized the search for new scores that reflect this heterogeneity and are predictors of the long-term effects of the disease. Since no validated score is currently available, and although the factors or cut-off points leading to a classification of <span class="elsevierStyleItalic">severe</span> are not clearly established, we recommend that the following be taken into account: AHI; time with oxygen saturation below 90%, reflecting hypoxemia; daytime sleepiness; 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-dipping; diabetes mellitus type 2 [DM2]; dyslipidemia; coronary disease; stroke; heart failure or atrial fibrillation) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Prevalence of obstructive sleep apnea</span><p id="par0065" class="elsevierStylePara elsevierViewall">OSA is one of the most prevalent sleep disorders, but epidemiological studies in the literature vary widely in terms of methodology, the inclusion of clinical series or population series, diagnostic criteria, and the assessment of severity. A recently published study that analyzed the global burden of this entity<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> reported rates ranging between 4% and 30%. Results are summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Consequences of obstructive sleep apnea</span><p id="par0070" class="elsevierStylePara elsevierViewall">The main pathophysiological mechanisms that underlie the association between OSA and its consequences are intermittent hypoxia, sleep fragmentation, intrathoracic pressure changes, and a number of intermediate elements (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> summarizes the scientific evidence available on the association between OSA and its different consequences. OSA increases the risk of workplace and road traffic accidents. In the cardiovascular field, one of the manifestations for which the most evidence is available is arterial hypertension. The prevalence of OSA in DM2 is very high and OSA is an independent risk factor for developing DM2. OSA is also very common in coronary disease, but data on its clinical consequences and the effect of treatment are conflicting. OSA also increases the risk of stroke and may be associated with greater functional/cognitive impairment and higher mortality. Sleep-disordered breathing in heart failure is very prevalent, increases the risk of new episodes, and may increase mortality. Arrthythmias, pulmonary thromboembolism, and pulmonary arterial hypertension are also associated with a very high rate of OSA. Severe OSA is also associated with an increased risk of cancer, mortality, and tumor aggressiveness (melanoma), although current evidence is not yet strong. In neurocognitive terms, OSA causes major cognitive impairment (mainly in executive function, attention, and memory) and has a bidirectional association with depression.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Diagnostic algorithm</span><p id="par0080" class="elsevierStylePara elsevierViewall">Please refer to the online material for a detailed description of clinical presentation, physical examination, and complementary tests. In this section, we will only describe the diagnostic algorithm proposed in this ICD for indicating sleep studies.</p><p id="par0085" class="elsevierStylePara elsevierViewall">As OSA is a highly prevalent disease, it should be managed at different healthcare levels in order to satisfy the demand for care<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>. Two diagnostic algorithms are proposed. In specialized centers (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>), patients with moderate-to-severe chronic respiratory disease, unstable cardiovascular disease, other suspected sleep disorders that can cause symptoms or coexist with OSA and some patients with anxiety-depression or insomnia may be candidates for polysomnography (PSG) studies. Patients with a low probability of disease, according to an expert evaluation, may be candidates for follow-up and correction of other influencing factors, or a decision may be taken to perform PSG or respiratory polygraphy. Patients with an intermediate to high probability of OSA can be evaluated by respiratory polygraphy.</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">A second algorithm is proposed for primary care (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>), in which patients with a high probability of disease due to excessive daytime symptoms (Epworth ≥ 12) could be evaluated by simplified studies with single- or double-channel devices based on oximetry and/or nasal pressure<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>. It should be emphasized that this management must always be conducted in coordination with a reference sleep laboratory that can offer the necessary support, using protocols adjusted to specific needs. A therapeutic decision could be made in primary care and coordinated by specialists, but these models may be less generalizable, and they would have to be used in specific, previously validated areas<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>.</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Medical treatment of obstructive sleep apnea: a therapeutic algorithm</span><p id="par0095" class="elsevierStylePara elsevierViewall">The goals of OSA treatment are to resolve the signs and symptoms of the disease, restore sleep quality, normalize AHI, improve oxygen saturation as far as possible, reduce the risk of complications, and lower the costs of the disease. This ICD emphasizes that the various alternatives are combinable and recommends a multidisciplinary therapeutic approach.</p><p id="par0100" class="elsevierStylePara elsevierViewall">All medical, surgical, and physical options for the treatment of OSA should be complementary, not exclusive. Each patient should be offered the widest range of possibilities, and all strategies should be applied rationally, either alone or in combination, and individually adapted after an in-depth study. The patient's role in therapeutic decision-making must be emphasized. This should be the standard approach in multidisciplinary teamwork<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3,6,8</span></a> (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>).</p><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">It is important to note that before starting any of the therapeutic alternatives, the clinical diagnosis of OSA must be confirmed by a sleep study validated according to the previously recommended diagnostic algorithm. The therapeutic algorithm (<a class="elsevierStyleCrossRef" href="#fig0040">Fig. 8</a>) is as follows:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">1</span><p id="par0110" class="elsevierStylePara elsevierViewall">Hygienic-dietary measures should be implemented (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>) in all patients with OSA, regardless of whether continuous positive airway pressure (CPAP) therapy is indicated.</p><elsevierMultimedia ident="fig0045"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">2</span><p id="par0115" class="elsevierStylePara elsevierViewall">The patient must be evaluated to identify conditions associated with OSA and potentially reversible causes. Accordingly, this ICD recommends:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0120" class="elsevierStylePara elsevierViewall">Treatment of obesity: excess weight or obesity should be treated in all patients with OSA. Initial treatment should be part of a comprehensive, high-intensity program that includes behavioral strategies<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>. Severe obesity requires more durable strategies that should be evaluated in specialized units, where the use of anti-obesity drugs<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> or surgery (for patients > 35 kg/m<span class="elsevierStyleSup">2</span>) will be evaluated when conservative treatment fails<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11–14</span></a>.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0125" class="elsevierStylePara elsevierViewall">Treatment of reversible causes: thyroid hormone replacement therapy is recommended in patients with OSA and hypothyroidism, so levels should be determined in case of clinical suspicion of hypothyroidism<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>. In case of gastroesophageal reflux, positional and dietary measures should be indicated, and treatment with proton pump inhibitors should be offered on an individual basis. If the patient presents tonsillar hypertrophy grade <span class="elsevierStyleSmallCaps">III/IV</span> or severe dental or facial alterations, surgery to treat OSA should be considered.</p></li></ul></p></li></ul></p><elsevierMultimedia ident="fig0040"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">In any of these situations, the need for CPAP until treatment of the reversible cause becomes effective can be assessed.<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">3</span><p id="par0135" class="elsevierStylePara elsevierViewall">Indications for CPAP: CPAP is an effective treatment to reduce OSA severity, assessed according to AHI, and remains the treatment of choice in many of these patients<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16–29</span></a>. Once the steps described above have been completed, the following recommendations for indicating CPAP, based on quality evidence evaluated according to currently available information in line with American Academy of Sleep Medicine guidelines<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30,31</span></a>, should be followed.</p></li></ul></p><p id="par0140" class="elsevierStylePara elsevierViewall">A detailed explanation of the scientific evidence supporting selected cut-off points, symptoms and/or comorbidities used to determine the indication of CPAP can be found in the online material. This ICD recommends CPAP in:<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">•</span><p id="par0145" class="elsevierStylePara elsevierViewall">Patients with a targeted diagnosis of moderate-severe OSA (AHI ≥ 15/h) with excessive daytime sleepiness (Epworth > 10), altered sleep-related quality of life (intense snoring, episodes of night choking, insomnia, morning headache, nocturia, impaired work or academic performance, social impact, and/or tiredness during the day) and/or HBP (especially if resistant or refractory).</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">•</span><p id="par0150" class="elsevierStylePara elsevierViewall">In patients with no indication for CPAP due to AHI ≥ 15/h who do not present the above criteria, AHI between 5 and 15/h, or in whom CPAP is indicated but rejected (refusal to accept treatment or treatment unsuccessfully attempted for less than 4 weeks), alternative treatments should be assessed individually (mandibular advancement devices [MAD], positional treatment, surgery, etc.). These treatments and their indications are described in detail in the online material of this ICD.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">•</span><p id="par0155" class="elsevierStylePara elsevierViewall">Insufficient evidence is available to consistently recommend the use of CPAP to reduce the risk of death or cardiovascular or cerebrovascular events in adults who do not meet the 3 criteria listed above. These patients should be offered conservative treatment with monitoring of symptoms or an individualized assessment including a CPAP trial (with short-term reassessment of treatment continuity depending on efficacy and tolerance).</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">•</span><p id="par0160" class="elsevierStylePara elsevierViewall">Similarly, in patients with OSA who have AHI < 15/h but are highly symptomatic or have a high burden of cardiovascular, cerebrovascular, or metabolic disease, a CPAP trial may be considered if the patient agrees. Current evidence suggests that CPAP may play a greater role in preventing cerebrovascular events than cardiovascular events<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a>.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">•</span><p id="par0165" class="elsevierStylePara elsevierViewall">Alternative treatments should be considered individually if the therapeutic trial fails.</p></li></ul></p><p id="par0170" class="elsevierStylePara elsevierViewall">The scientific evidence supporting these recommendations and a more detailed description can be found in the online material.</p><p id="par0175" class="elsevierStylePara elsevierViewall">Adequate pressure titration and monitoring of CPAP compliance are essential to achieve the treatment objectives described. Please refer to the online material for a detailed description of these factors. In short, this ICD recommends considering PSG pressure titration for patients with significant (severe COPD) or unstable cardiopulmonary disease (heart failure), complex sleep-disordered breathing (central sleep apnea, suspected incipient central sleep apnea, or obesity-hypoventilation syndrome), or when titration with simplified methods has not been possible. For all other patients, pressure titration with auto-CPAP provides a level of OSA control similar to PSG titration. It is essential that the patient be trained before titration is attempted. This document recommends visual analysis of the graph and selection of the minimum pressure that, regardless of leakage peaks, covers about 90% of the entire pressure graph. It is also recommended that at least 5 valid hours of recording be examined. Finally, empirical formula calculation should only be considered between the start of treatment and until the definitive titration study (auto-CPAP, CPAP with memory card, or manual titration) is performed.</p><p id="par0180" class="elsevierStylePara elsevierViewall">Compliance during the first 3 months can predict long-term use of the device<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>, so careful attention in this period will be key to achieving adequate long-term compliance<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a>. This ICD defines good adherence as the use of the device for at least 4 h/night on 70% of nights. The current evidence points to a dose-response relationship between hours of use and therapeutic response<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">35,36</span></a>, and the neurocognitive and cardiovascular effects of CPAP and the perceived benefits in quality of life depend on this compliance<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a>. For this reason, we propose the concept of optimal compliance with a minimum of 6 h/night, an approach which has shown benefits in symptom control and morbidity. As for the type of device, the use of auto-CPAP has not been shown to increase the percentage of nights with more than 4 h use<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38,39</span></a>. Therefore, its use is only recommended for patients with high or highly variable effective pressure throughout the night.</p><p id="par0185" class="elsevierStylePara elsevierViewall">Interventions for improving adherence are described in detail in the online material. Since the evidence suggests that telemonitoring improves CPAP adherence<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40,41</span></a>, this strategy should be considered during the initial period of CPAP treatment. If it is used, remote recording of CPAP parameters<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30,31</span></a> should include hours of use, residual AHI, unintentional leaks, and machine configuration<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30,31,42</span></a>.</p><p id="par0190" class="elsevierStylePara elsevierViewall">Multidisciplinary management with the participation of a sleep specialist, the nursing team, and the suppliers will be important in the follow-up of patients receiving CPAP. Primary care should be included in long-term monitoring.</p><p id="par0195" class="elsevierStylePara elsevierViewall">All patients receiving CPAP should be monitored after the first month of treatment and a brief in-person review should be performed at 6 months. Adherence at 3 months can be determined from telemonitoring. If the treatment is well established, with good clinical response and no side effects, the patient may be referred to primary care for follow-up after the first year.</p><p id="par0200" class="elsevierStylePara elsevierViewall">If the patient has frank and proven intolerance to CPAP (the patient has tried to use it for more than 4 weeks, but has not been able to adapt), withdrawal should be considered. If either rejection or intolerance cannot be rectified, other therapeutic alternatives should be considered. In the event of clear lack of adherence with an average use of less than 3 h/night, the patient should be included in a compliance program, preferably with a telemonitoring system, and re-evaluated after at least 3 months, before assessing the possible withdrawal of CPAP and an alternative therapeutic proposal. Occasionally, patients who use CPAP for less than 3 h/night report symptomatic improvements, so the decision to discontinue treatment should be individualized.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Surgical treatment</span><p id="par0205" class="elsevierStylePara elsevierViewall">The surgical algorithm recommended in this ICD for use by ENT specialists and oral or maxillofacial surgeons is an update of the standard Stanford 2-tiered protocol (<a class="elsevierStyleCrossRef" href="#fig0050">Fig. 10</a>)<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43,44</span></a>. In this era of personalized medicine, a precise indication for palatal and oropharyngeal surgeries may initially be made based on clinical findings and drug-induced sedation endoscopy (DISE)<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45–47</span></a>, but 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 dental and facial alterations). An indication for surgery never definitively excludes other treatments, or vice versa. Refer to the online material for a more detailed description of the systematic review and indications for surgery in OSA patients.</p><elsevierMultimedia ident="fig0050"></elsevierMultimedia><p id="par0210" class="elsevierStylePara elsevierViewall">The proposed algorithm moves on from the classic concept of soft tissue removal or skeletal modification<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a>. It divides the surgical procedures to be performed according to the affected organ, and the choice of procedure is based primarily on the exploratory and diagnostic findings and on the final decision of the patient after all the options have been explained, none of which is either exclusive or prevailing. It is common for patients to have airway obstructions at different levels, so the current tendency is to perform multilevel surgery, in which, once the different sites of upper airway obstruction have been determined, a decision is made on the different procedures to be performed, alone or in combination, aiming to achieve optimal results<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">48–51</span></a>.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Treatment with mandibular advancement devices</span><p id="par0215" class="elsevierStylePara elsevierViewall">Recent randomized controlled trials have demonstrated the efficacy of MADs on various aspects of OSA as summarized in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> (see also online material):</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0220" class="elsevierStylePara elsevierViewall">This ICD therefore recommends that<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">52,53</span></a>:<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">•</span><p id="par0225" class="elsevierStylePara elsevierViewall">The diagnosis of OSA and the efficacy of MAD should always be determined by respiratory polygraphy or PSG.</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">•</span><p id="par0230" class="elsevierStylePara elsevierViewall">The indications for MAD are:<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">1</span><p id="par0235" class="elsevierStylePara elsevierViewall">Patients with OSA of any severity who are candidates for CPAP therapy but unable to adapt to it. MAD is principally indicated as an alternative to CPAP and should be available in sleep units in the public health system, or</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">2</span><p id="par0240" class="elsevierStylePara elsevierViewall">Patients with mild to moderate OSA, minor symptoms, or troublesome snoring and no indication for CPAP or any other treatment.</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">•</span><p id="par0245" class="elsevierStylePara elsevierViewall">Before prescribing an MAD, the dentist must perform an oral examination to rule out patients who do not meet dental inclusion criteria.</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">•</span><p id="par0250" class="elsevierStylePara elsevierViewall">Current evidence supports the use of custom-made, adjustable devices.</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">•</span><p id="par0255" class="elsevierStylePara elsevierViewall">Following assessment of the patient's suitability from the point of view of oral health, treatment should be implemented and followed up by a certified dentist or OSA sleep-disordered breathing expert working in coordination with a sleep unit. Respiratory polygraphy may be used by an experienced sleep dentist as a tool for MAD titration.</p></li></ul></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Alternative treatments</span><p id="par0260" class="elsevierStylePara elsevierViewall">OSA is a heterogeneous disease in terms of both its pathophysiology and its polysomnographic expression and clinical presentation. In recent years, various OSA phenotypes have been described that are explained in depth in the online material of this document. This phenotype approach has helped improve our knowledge of the mechanisms involved in the disease and the development of different therapeutic strategies, and has contributed to the development of a more personalized medicine. <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> summarizes current evidence and indications for other alternative therapies (see also online material).</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Role of primary care medicine in the management of obstructive sleep apnea</span><p id="par0265" class="elsevierStylePara elsevierViewall">In light of the current evidence, the recommendations of this ICD on the role of primary care in the management of OSA patients are as follows:<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">1</span><p id="par0270" class="elsevierStylePara elsevierViewall">The involvement of primary care physicians is essential to improve the current situation of OSA underdiagnosis.</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">2</span><p id="par0275" class="elsevierStylePara elsevierViewall">The implementation of training plans in primary care improves the suspicion and diagnostic process of OSA.</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">3</span><p id="par0280" class="elsevierStylePara elsevierViewall">The criterion for clinical suspicion should be the presence of 2 of the 3 main symptoms: snoring, observed apneas, and/or excessive daytime sleepiness or unexplained intense tiredness.</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">4</span><p id="par0285" class="elsevierStylePara elsevierViewall">The situations that require urgent referral are summarized in <a class="elsevierStyleCrossRef" href="#fig0055">Fig. 11</a>:<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">a)</span><p id="par0290" class="elsevierStylePara elsevierViewall">Primary care diagnostic procedures should be performed in consensus with the reference sleep unit, working in a network.</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">b)</span><p id="par0295" class="elsevierStylePara elsevierViewall">At the moment, evidence on how to start CPAP treatment exclusively in a primary care setting is insufficient.</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">c)</span><p id="par0300" class="elsevierStylePara elsevierViewall">Most treatment follow-up requirements can be met in primary care.</p></li></ul></p><elsevierMultimedia ident="fig0055"></elsevierMultimedia></li></ul></p><p id="par0305" class="elsevierStylePara elsevierViewall">These activities should be conducted as indicated in <a class="elsevierStyleCrossRef" href="#fig0060">Fig. 12</a>. A more detailed explanation can be found in the online material.</p><elsevierMultimedia ident="fig0060"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0310" class="elsevierStylePara elsevierViewall">OSA is a highly prevalent disease with significant consequences. Its diagnostic and therapeutic management requires multidisciplinary treatment and involves all levels of care. Identification of possible reversible causes and assessment of all treatment options, all of which are combinable, will contribute to comprehensive patient management.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Authorship</span><p id="par0315" class="elsevierStylePara elsevierViewall">All the authors have participated in the study and read and approved the manuscript.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interests</span><p id="par0320" class="elsevierStylePara elsevierViewall">Pedro García Ramos states that he has collaborated with GSK, Laboratorios Ferrer, Angelini, Novartis, Almirall, Gebro Pharma, Rovi, Esteve, Recordati, MSD, and Teva. Carlos Teixeira states that he is an employee of Philips (Sleep and Respiratory Care Division). Francisco Javier Puertas Cuesta states that he has received fees for consultancy and speaking in courses and seminars from Jazz Pharmaceuticals, UCB Pharma, GSK, Esteve Teijin, and ResMed, and has received research grants from Philips. The other authors state that they have no conflict of interests with the manuscript.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:21 [ 0 => array:3 [ "identificador" => "xres1645425" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1466105" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1645426" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1466104" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction and literature search" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methodology" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Pathophysiology of obstructive sleep apnea" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Definition of obstructive sleep apnea" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Prevalence of obstructive sleep apnea" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Consequences of obstructive sleep apnea" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Diagnostic algorithm" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Medical treatment of obstructive sleep apnea: a therapeutic algorithm" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Surgical treatment" ] 13 => array:2 [ "identificador" => "sec0050" "titulo" => "Treatment with mandibular advancement devices" ] 14 => array:2 [ "identificador" => "sec0055" "titulo" => "Alternative treatments" ] 15 => array:2 [ "identificador" => "sec0060" "titulo" => "Role of primary care medicine in the management of obstructive sleep apnea" ] 16 => array:2 [ "identificador" => "sec0065" "titulo" => "Conclusions" ] 17 => array:2 [ "identificador" => "sec0070" "titulo" => "Authorship" ] 18 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflict of interests" ] 19 => array:2 [ "identificador" => "xack581125" "titulo" => "Acknowledgements" ] 20 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-02-03" "fechaAceptado" => "2021-03-15" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1466105" "palabras" => array:3 [ 0 => "Obstructive sleep apnea" 1 => "Diagnosis" 2 => "Treatment" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1466104" "palabras" => array:3 [ 0 => "Apnea obstructiva del sueño" 1 => "Diagnóstico" 2 => "Tratamiento" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">The main aim of this international consensus document on obstructive sleep apnea is to provide guidelines based on a critical analysis of the latest literature to help health professionals make the best decisions in 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 societies), an expert in methodology, and a documentalist from the Iberoamerican Cochrane Center. The document consists of a main section containing the most significant innovations from the ICD and a series of online manuscripts that report the systematic literature searches performed for each section of the 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).</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">El objetivo principal de este documento internacional de consenso sobre apnea obstructiva del sueño es proporcionar unas directrices que permitan a los profesionales sanitarios tomar las mejores decisiones en la asistencia de los pacientes adultos con esta enfermedad según un resumen crítico de la literatura 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 Iberoamericano. El documento consta de un manuscrito principal, con las novedades más relevantes del DIC, y una serie de manuscritos <span class="elsevierStyleItalic">online</span> 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).</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">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.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:3 [ 0 => array:4 [ "apendice" => "<p id="par0335" class="elsevierStylePara elsevierViewall">The following are Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia><elsevierMultimedia ident="upi0015"></elsevierMultimedia><elsevierMultimedia ident="upi0020"></elsevierMultimedia><elsevierMultimedia ident="upi0025"></elsevierMultimedia><elsevierMultimedia ident="upi0030"></elsevierMultimedia><elsevierMultimedia ident="upi0035"></elsevierMultimedia><elsevierMultimedia ident="upi0040"></elsevierMultimedia><elsevierMultimedia ident="upi0045"></elsevierMultimedia><elsevierMultimedia ident="upi0050"></elsevierMultimedia><elsevierMultimedia ident="upi0055"></elsevierMultimedia><elsevierMultimedia ident="upi0060"></elsevierMultimedia><elsevierMultimedia ident="upi0065"></elsevierMultimedia><elsevierMultimedia ident="upi0070"></elsevierMultimedia><elsevierMultimedia ident="upi0075"></elsevierMultimedia><elsevierMultimedia ident="upi0080"></elsevierMultimedia><elsevierMultimedia ident="upi0085"></elsevierMultimedia><elsevierMultimedia ident="upi0090"></elsevierMultimedia><elsevierMultimedia ident="upi1095"></elsevierMultimedia><elsevierMultimedia ident="upi0095"></elsevierMultimedia><elsevierMultimedia ident="upi0100"></elsevierMultimedia><elsevierMultimedia ident="upi0105"></elsevierMultimedia><elsevierMultimedia ident="upi0110"></elsevierMultimedia><elsevierMultimedia ident="upi0115"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0085" ] 1 => array:4 [ "apendice" => "<p id="par0340" class="elsevierStylePara elsevierViewall">Spanish Society of Pulmonology and Thoracic Surgery (SEPAR), Spanish Society of Neurology (SEN), Spanish Society of General and Family Physicians (SEMG), Spanish Society of Dental Sleep Medicine (SEMDeS), Spanish Society of Clinical Neurophysiology (SENFC), Spanish Society of Endocrinology and Nutrition (SEEN), Spanish Society of Oral and Maxillofacial and Head and Neck Surgery (SECOM CYC), Spanish Society of Family and Community Medicine (semFYC), Spanish Society of Traffic Medicine (SEMT), Spanish Society of Otorhinolaryngology and Cervical Surgery (SEORL-CCC), Spanish Society of Cardiology (SEC), Spanish Society of Sleep (SES), Spanish Society for the Study of Obesity (SEEDO).</p>" "etiqueta" => "Appendix C" "titulo" => "Spanish scientific societies" "identificador" => "sec0090" ] 2 => array:4 [ "apendice" => "<p id="par0345" class="elsevierStylePara elsevierViewall">Latin American Thoracic Association (ALAT), Brazilian Society of Pulmonology and Phthisiology (SBPT), Portuguese Society of Pulmonology (SPP), SomnoNIV Group of the French Language Pulmonology Society (SPLF).</p>" "etiqueta" => "Appendix D" "titulo" => "International scientific societies" "identificador" => "sec0095" ] ] ] ] "multimedia" => array:41 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3463 "Ancho" => 2508 "Tamanyo" => 383320 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Study methodology flow chart (adapted from RAND/UCLA).</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2115 "Ancho" => 2508 "Tamanyo" => 281197 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">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/h<span class="elsevierStyleSup">3</span>. 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.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1888 "Ancho" => 2508 "Tamanyo" => 219895 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">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.</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1620 "Ancho" => 2508 "Tamanyo" => 232862 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Consequences of obstructive sleep apnea (OSA) and associated pathophysiological mechanisms.</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Adapted and reproduced with permission from the SEPAR Manual of Pulmonology and Thoracic Surgery.</p>" ] ] 4 => array:8 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 2581 "Ancho" => 2508 "Tamanyo" => 327039 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">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.</p> <p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">*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.</p>" ] ] 5 => array:8 [ "identificador" => "fig0030" "etiqueta" => "Fig. 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 2428 "Ancho" => 2508 "Tamanyo" => 290174 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">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.</p> <p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">*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.</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">**In these cases, a manual analysis of the recording by the coordinating sleep laboratory may offer a more accurate diagnosis.</p>" ] ] 6 => array:8 [ "identificador" => "fig0035" "etiqueta" => "Fig. 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1916 "Ancho" => 2508 "Tamanyo" => 240288 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Multidisciplinary approach to obstructive sleep apnea (OSA): all interventions are combinable. CPAP: continuous positive airway pressure; DISE: drug-induced sleep endoscopy; UA: upper airway.</p>" ] ] 7 => array:8 [ "identificador" => "fig0040" "etiqueta" => "Fig. 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1