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Sleep Med. 2018 Oct;50:145-151. doi: 10.1016/j.sleep.2018.05.012. Epub 2018 May 30.

A systematic comparison of factors that could impact treatment recommendations for patients with Positional Obstructive Sleep Apnea (POSA).

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Advanced Brain Monitoring, Carlsbad, CA, USA. Electronic address:
Sleep Disorders Unit, Loewenstein Hospital - Rehabilitation Center, Raanana, Israel.
Ear-Nose-Throat Unit, Head and Neck Department, Morgagni-Pierantoni Hospital, Forlì, Italy.
Sleep Medicine Center, Charité Universitätsmedizin Berlin, Berlin, Germany.
Levi's Sleep Clinic, West Gosford, Australia.
Advanced Brain Monitoring, Carlsbad, CA, USA.



Systematically compare four criteria for Positional Obstructive Sleep Apnea (POSA) based on AASM 2007 and 2012 hypopnea scoring definitions.


142 records acquired by in-home polysomnography (Sleep Profiler PSG2™) were retrospectively analyzed using AHI based on the American Academy Sleep Medicine 2007 and 2012 criteria (AHI2007 and AHI2012). Positional obstructive sleep apnea (POSA) was characterized using four criteria: Amsterdam Positional OSA Classification (APOC), supine AHI twice the non-supine AHI (Cartwright), Cartwright plus the non-supine AHI < 5 (Mador), and the overall AHI severity at least 1.4 times the non-supine severity (Overall/NS-AHI).


Correlations between the Cartwright and Overall/NS-AHI criteria increased with the inclusion of a more relaxed definition of hypopneas (AHI2007 = 0.79 and AHI2012 = 0.86, P < 0.00001). The prevalence of POSA based on the Cartwright and Overall/NS-AHI criteria was approximately 60% in those with at least mild OSA by AHI2007and AHI2012. A 16% reduction in POSA prevalence for AHI2012 vs. AHI2007 was attributed to the increased incident of mild OSA. For identification of those expected to have 25% or 35% reductions in SDB severity with positional therapy, Cartwright and Overall/NS-AHI exhibited the strongest sensitivity and Overall/NS-AHI and Mador the best specificity.


The four criteria used to identify POSA have similarities and differences. While there were similarities between the Cartwright and Overall/NS-AHI criteria in the detection of POSA prevalence across both scoring criteria, the Overall/NS-AHI provided the most consistent detection of those most likely to demonstrate important reductions in sleep disordered breathing severity if supine sleep is avoided.


Obstructive sleep apnea; Positional therapy; Prevalence; Sleep disordered breathing; Sleep position; Supine

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