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Table 1 Canadian thoracic society guidelines for the treatment and diagnosis of obstructive sleep apnea-hypopnea syndrome

From: Exploring policy driven systemic inequities leading to differential access to care among Indigenous populations with obstructive sleep apnea in Canada

Diagnostic Criteria Referral Testing Recommendation
Individual must fulfill criterion A or B, plus C (level of evidence D). A. All patients who have suspected sleep-disordered breathing (SDB) should complete an assessment of daytime sleepiness such as the Epworth sleepiness scale (ESS) questionnaire to subjectively assess the degree of pre-treatment sleepiness. Level I (complete laboratory polysomnography) remains the accepted standard for evaluation of SDB and is the test of choice (level of evidence C). However, a 2010 joint position paper from the Canadian Sleep Society and the Canadian Thoracic Society recommends the use of portable monitoring testing in three generalized settings for suspected sleep apnea in uncomplicated patients (i.e. without comorbidities) [37].
A. Excessive daytime sleepiness that is not better explained by other factors.
B. Patient referrals for assessment of SDB should be physician generated and should provide sufficient information to be able to determine the urgency of assessment.
B. Two or more of the following that are not better explained by other factors: C. Patients referred for medical specialist assessment and/or polysomnography should be triaged by the categories and criteria listed below.
Priority 1 (Urgent): Patients with suspected SDB and major daytime sleepiness (ESS of 15 or greater) and a safety critical occupationa or patients with suspected SDB and a comorbid diseaseb or overnight home oximetry that reveals greater than 30 oxygen desaturations (4 % or greater) per hour.
1. Areas with acceptable wait times for a sleep medicine consultation and Level 1 sleep study.
1. Choking or gasping during sleep;
2. Areas where the prevalence of Level 1 laboratory and sleep specialists are limited and the waiting times are excessive.
2. Recurrent awakenings from sleep;
3. Primarily rural areas, where sleep medicine specialists and Level 1 testing are not available, and where general practitioners (including nurse practitioners under the signing name of a physician) are the primary caregivers.
Priority 2: Patients with suspected SDB and major daytime sleepiness (ESS of 15 or greater) but without a safety critical occupation.
3. Unrefreshing sleep; Priority 3: Patients with suspected SDB but without: major daytime sleepiness (i.e., ESS of 15 or greater), comorbid diseases, or a safety critical occupation.
4. Daytime fatigue; and
Further recommendations and principles regarding the use of portable monitoring testing, including the accreditation of portable monitoring programs and technical and interpretation considerations are detailed in the joint position paper.
5. Impaired concentration. Waiting times: Medical specialist assessment and/or polysomnography should be arranged and completed by the following times after referral (level of evidence D):
C. Sleep monitoring demonstrates five or more obstructive apneas/hypopneas per hour during sleep.
• Priority 1 (urgent) cases – within two to four weeks;
• Priority 2 cases – within two months; and
• Priority 3 cases – within six months.
  1. aSafety critical occupations or at high risk for a motor vehicle collision
  2. bIschemic heart disease, cerebrovascular disease, congestive heart failure, refractory systemic hypertension, obstructive/restrictive lung disease, pulmonary hypertension or hypercapnic respiratory failure, or pregnancy
  3. Sources: [30, 50]