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Guideline Summary
Guideline Title
The treatment of central sleep apnea syndromes in adults: practice parameters with an evidence-based literature review and meta-analyses.
Bibliographic Source(s)
Aurora RN, Chowdhuri S, Ramar K, Bista SR, Casey KR, Lamm CI, Kristo DA, Mallea JM, Rowley JA, Zak RS, Tracy SL. The treatment of central sleep apnea syndromes in adults: practice parameters with an evidence-based literature review and meta-analyses. Sleep. 2012;35(1):17-40. [112 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Central sleep apnea syndromes (CSAS):

  • Primary central sleep apnea
  • Central sleep apnea due to Cheyne Stokes breathing pattern
  • Central sleep apnea due to medical condition not Cheyne Stokes
  • Central sleep apnea due to high-altitude periodic breathing
  • Central sleep apnea due to drug or substance

Note: Primary sleep apnea of infancy is not considered in this guideline.

Guideline Category
Assessment of Therapeutic Effectiveness
Evaluation
Management
Treatment
Clinical Specialty
Cardiology
Family Practice
Internal Medicine
Pulmonary Medicine
Sleep Medicine
Intended Users
Advanced Practice Nurses
Physician Assistants
Physicians
Respiratory Care Practitioners
Guideline Objective(s)

To review the available data for the treatment and management of central sleep apnea syndromes (CSAS) in adults

Target Population

Adults with central sleep apnea syndromes (CSAS)

Interventions and Practices Considered
  1. Continuous positive airway pressure (CPAP)
  2. Bilevel positive airway pressure (BPAP)
  3. Adaptive servo-ventilation (ASV)
  4. Oxygen therapy
  5. Acetazolamide
  6. Theophylline
  7. Zolpidem
  8. Triazolam
  9. Bicarbonate buffer use during dialysis and nocturnal dialysis for central sleep apnea syndromes related to end-stage renal disease

Note: The following interventions were considered, but no recommendation for use was made: carvedilol, captopril, erythropoietin, intravenous iron, carbon dioxide, cardiac interventions: cardiac resynchronization therapy (CRT), atrial overdrive pacing (AOP).

Major Outcomes Considered
  • Morbidity and mortality
  • Chance of congestive heart failure (CHF)
  • Left ventricular ejection fraction (LVEF)
  • Transplant-free survival in patients with CHF
  • Apnea-hypopnea index (AHI)
  • Severity of disease

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Literature Search

A search for articles on the medical treatment of central sleep apnea syndromes (CSAS) was conducted using the PubMed database from 1966 through June 2010. The key words for searches were: (central sleep apnea treatment), (Cheyne-Stokes treatment), [(central sleep apnea) and (heart failure) and treatment], [(sleep apnea) and narcotics and treatment], and [(sleep-related breathing disorders) and narcotics and treatment]. The limits on these searches were humans, English, adults (+19 years), clinical trials, meta-analyses, and randomized controlled trials. A second set of more specific searches was done with the limits of humans, English, and adults (+19 years) with (central sleep apnea) and the following terms: 1) high altitude, 2) opioid, 3) traumatic brain injury, 4) [(end stage renal disease) or (renal disease) or ESRD], and pharmacotherapy. The search was updated in June 2010 to include the latest research publications. Abstracts from these articles were reviewed to determine if they met inclusion criteria, which were a minimum of 5 patients plus clinical outcomes measures of mortality/transplant-free survival, left ventricular ejection fraction (LVEF), or apnea-hypopnea index (AHI). Complex sleep apnea was not included, as it is not currently listed as a disorder in the International Classification of Sleep Disorders, Second Edition (ICSD-2). Additionally, sleep disordered breathing had to be clearly differentiated between CSAS and obstructive sleep apnea (OSA). CSAS was defined as greater than 50% central events including periodic breathing if subjects presented with both CSAS and OSA. Additional articles were identified by pearling (i.e., checking the reference sections of search results for articles otherwise missed).

Number of Source Documents

A total of 252 articles were identified, but only 77 articles met the specific inclusion criteria for this guideline and were reviewed, graded, and extracted.

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Summary of Grading of Recommendations Assessment, Development and Evaluation (GRADE) Approach to Rating Quality of Evidence*

Study Design Initial Quality of a Body of Evidence Lower if Higher if Quality of a Body of Evidence
Randomized trials High → Risk of bias
−1 Serious
−2 Very serious
Large effect
+1 Large
+2 Very large
High (four plus:++++)
Inconsistency
−1 Serious
−2 Very serious
Dose response
+1 Evidence of a gradient
Moderate (three plus:+++O)
Observational studies Low → Indirectness
−1 Serious
−2 Very serious
All plausible residual confounding
+1 Would reduce a demonstrated effect
Low (two plus: ++OO)
Imprecision
−1 Serious
−2 Very serious
Publication bias
−1 Likely
−2 Very likely
+1 Would suggest a spurious effect if no effect was observed Very Low (one plus:+OOO)

Final Assessments of Level of Bodies of Evidence*

High: The guideline developers are very confident that the true effect lies close to that of the estimate of the effect.

Moderate: The guideline developers are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.

Low: The confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.

Very low: The guideline developers have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

*From Balshem H, Helfand M, Schunemann H, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol 2011;64:401-6.

Methods Used to Analyze the Evidence
Meta-Analysis
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Quality of Evidence

The assessment of evidence quality was performed according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process. The GRADE system differs from other grading systems as each study is not only evaluated for study design and risk of bias, but, additionally, an estimate of effect (see footnote A in the original guideline document) is generated for each outcome. Multiple aspects of quality are assessed including study limitations, imprecision, inconsistency of results, indirectness of evidence, and likeliness of publication bias. The quality of effects from observational studies can be adjusted by the presence of large magnitudes of effect, evidence of dose-response associations, and the presence of confounders. Quality refers to the confidence that the estimates of the effects are correct, and the quality rating is applied to a body of evidence and not to individual studies.

Briefly, risk of bias includes aspects of study design (randomized control trials [RCTs] versus non-randomized controlled trials or before-after trials) and conduct such as blinding, allocation concealment, large loss to follow up, or selective outcome reporting. Imprecision refers to wide confidence intervals around the estimate of effect when there are relatively few patients and few events. Indirectness occurs when the question being addressed is different than the available evidence regarding population, intervention, comparator, or outcome. There is inconsistency when there is unexplained heterogeneity of the results. Reporting bias can occur if there is selective reporting of studies or outcomes, which may occur if the published evidence is limited to a small number of trials funded by a for-profit organization.

As a first step, all individual studies were assessed by 2 task force members for study design and limitations to validity (bias) for each outcome of interest. RCTs were considered a higher level of evidence than observational, nonrandomized, or before-after interventional studies (see the "Rating Scheme for the Strength of the Evidence" field). Blinding for objective outcomes (mortality, apnea-hypopnea index [AHI], if scoring was blinded) was not considered a threat to internal validity. Subsequently, the body of evidence for each outcome was assessed and graded, taking into account the results of the meta-analysis (if applicable) and other factors as described above. The final assessment, as defined in the "Rating Scheme for the Strength of the Evidence" field, was determined for each treatment and outcome measure.

The results are reported in summary tables in each section of the original guideline document that include the number of studies, study design, limitations, inconsistency, indirectness, imprecision, and other considerations that went into the quality of evidence for each outcome of interest. Also reported are the number of patients that were studied, the overall effect that was calculated in the meta-analysis (reported as the mean difference [MD]), and a qualitative assessment of the relative importance of the outcome.

Meta-Analysis

All meta-analyses were performed using MIX software. The analyses were performed on the AHI and the left ventricular ejection fraction (LVEF) when available. All analyses are presented using the random effects model.

The result of each meta-analysis is shown in a figure with several components in the original guideline document. Each study of the meta-analysis is identified along the left-hand column, and adjacent to it is the year of the study, treatment (exposed, "e") results, and control ("c") results. The results are expressed as "n/M/SD" corresponding to "number/mean/standard deviation." A graphical representation of the data is shown in the center of the figure. The vertical red line indicates the average response of all studies. The zero line represents no effect. The width of the red diamond at the bottom of the plot represents the standard deviation of the meta-analysis. If the red diamond does not touch the zero line, the meta-analysis results indicate that the treatment is different from zero (i.e., it has an effect). The magnitude of the effect across all studies is given by the value of the association measure along with the 95% confidence intervals.

Tables of the data used in the meta-analyses are presented at the end of the manuscript in the appendix in the original guideline document.

Methods Used to Formulate the Recommendations
Other
Description of Methods Used to Formulate the Recommendations

The assessment of evidence quality was performed according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process. All individual studies were evaluated for study design, risk of bias, and an estimate of effect for each outcome measure. Multiple aspects of quality are assessed for bodies of evidence, including study limitations, imprecision, inconsistency of results, indirectness of evidence, and likeliness of publication bias. Bodies of evidence were assessed to be high, moderate, low, or very low (see Box 2 in the original guideline document).

Definitions of levels of recommendations used by the American Academy of Sleep Medicine (AASM) appear in the table in the "Rating Scheme for the Strength of the Recommendations" field. Particularly noteworthy on this table is that when harm/burden clearly outweighs benefit, a STANDARD level of recommendation against the proposed therapy is given regardless of the overall quality of evidence. Sections titled "Values and Trade-offs" appear under each individual practice parameter. The Values and Trade-offs discussion elucidates the rationale leading to each recommendation. These sections are an integral part of the GRADE system and offer transparency to the process.

Rating Scheme for the Strength of the Recommendations

American Academy of Sleep Medicine (AASM) Levels of Recommendations

Final Standards of Practice Recommendations Overall Quality of Evidence
High Moderate Low Very Low
Assessment of benefit/harm/burden Benefits clearly outweigh harm/burden Standard Standard Guideline Option
Benefits closely balanced with harm/burden
OR
uncertainty in the estimates of benefit/harm/burden
Guideline Guideline Option Option
Harm/burden clearly outweighs benefits Standard Standard Standard Standard
Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

The Standards of Practice Committee (SPC) of the American Academy of Sleep Medicine (AASM) developed and the Board of Directors of the AASM approved these practice parameters. The recommendations were also critically reviewed by 2 outside experts, and the concerns that were raised were addressed by the SPC prior to approval by the Board.

Recommendations

Major Recommendations

The levels of evidence (high, moderate, low, very low) and levels of recommendation (standard, guideline, option) are defined at the end of the "Major Recommendations" field.

Treatment of Central Sleep Apnea Syndrome (CSAS)

Primary CSAS

Positive airway pressure therapy may be considered for the treatment of primary CSAS. (OPTION)

Values and Trade-offs: The literature on the use of positive airway pressure (PAP) therapy (continuous positive airway pressure [CPAP], bilevel positive airway pressure in a spontaneous-timed mode [BPAP-ST], adaptive servo-ventilation [ASV]) for the treatment of primary CSAS is very limited. However, PAP therapy offers the following benefits: (1) it has the potential to ameliorate central respiratory events; (2) it typically does not confer significant risks; and (3) it is readily available in most centers. Therefore, PAP therapy can be considered for the treatment of primary CSAS. The overall very low level of quality of evidence rendered an OPTION level recommendation.

Acetazolamide has limited supporting evidence but may be considered for the treatment of primary CSAS. (OPTION)

Values and Trade-offs: Given the low overall quality of evidence and the potential for side effects including paresthesias, tinnitus, gastrointestinal symptoms, metabolic acidosis, electrolyte imbalance, and drowsiness, the use of acetazolamide for the treatment of primary CSAS received an OPTION level recommendation.

The use of zolpidem and triazolam may be considered for the treatment of primary CSAS only if the patient does not have underlying risk factors for respiratory depression. (OPTION)

Values and Trade-offs: Due to the limited available evidence and the significant potential for adverse side effects especially respiratory depression, the use of zolpidem and triazolam in the setting of primary CSAS is not a preferable option and remains the last therapeutic option, to be considered only if the other therapeutic options listed above fail. Very close clinical follow-up must be provided to consider the use of these hypnotic agents.

CSAS Due to Congestive Heart Failure (CHF) Including Cheyne Stokes Breathing Pattern (CSBP) and Not Cheyne Stokes Breathing

CPAP therapy targeted to normalize the apnea hypopnea index (AHI) is indicated for the initial treatment of CSAS related to congestive heart failure (CHF). (STANDARD)

Values and Trade-offs: The overall quality of evidence for the use of CPAP in the setting of CSAS related to CHF is moderate, but with a large effect size and consistent findings for reduction of AHI and improvement in left ventricular ejection fraction (LVEF). Post hoc analysis of the Canadian continuous positive airway pressure (CANPAP) data indicates that CPAP treatment targeted to an AHI <15 has a positive effect on transplant-free survival in patients with CSAS and CHF. Given the relative ease of availability of this therapeutic intervention and overall familiarity with its use, a STANDARD level of recommendation was given. An alternate treatment option should be considered in the absence of adequate control of CSAS related to CHF with CPAP.

BPAP therapy in a spontaneous timed (ST) mode targeted to normalize the apnea hypopnea index (AHI) may be considered for the treatment of CSAS related to CHF only if there is no response to adequate trials of CPAP, ASV, and oxygen therapies. (OPTION)

Values and Trade-offs: There were a limited number of studies that examined the effectiveness of BPAP in the treatment of CSAS/CSR. ST mode was used more frequently compared with spontaneous mode in the available studies. The level of evidence for BPAP with spontaneous mode is comprised only of 1 trial that met inclusion criteria. Therefore, no recommendation can be made for this mode of BPAP until further evidence is available. BPAP-ST therapy offers many of the same advantages as CPAP therapy, such as low risk and easy availability. BPAP-ST may be considered only in those who fail CPAP, ASV, and oxygen therapy, as these latter options have substantially more evidence supporting their use. BPAP-ST is a form of noninvasive ventilation that requires specialized expertise. The cost is approximately $1900 compared with $400-$1000 for CPAP. The paucity of data allows only an OPTION level of recommendation at this time.

Adaptive servo-ventilation (ASV) targeted to normalize the apnea-hypopnea index (AHI) is indicated for the treatment of CSAS related to CHF. (STANDARD)

Values and Tradeoff: The overall quality of evidence for ASV is moderate. While there is no survival or long-term data available for ASV at this time, there is a sufficient amount of data consistently demonstrating improvement in both the AHI and LVEF. Additionally, there was a study suggesting overall better compliance with ASV compared with CPAP. It is worth noting that most of the available studies are industry sponsored, and different manufacturers utilize different algorithms to detect respiratory events and determine characteristics of pressure delivery. Therefore, generalizability is not possible or appropriate. There is also some uncertainty as to what are the optimum settings, reflecting an overall lack of experience with using these devices. It should be mentioned that the cost of these devices is several-fold greater than the cost of CPAP, and availability is not universal. Nonetheless, the data for ASV is consistent and is at least comparable if not better than the data supporting CPAP use.

Nocturnal oxygen therapy is indicated for the treatment of CSAS related to CHF. (STANDARD)

Values and Trade-offs: Based on data presented in the original guideline document, the benefits of oxygen supplementation for the treatment of CSAS are abundant and outweigh any potential disadvantages. While the variable duration of treatment in each study limits recommendations in regard to duration of oxygen therapy, the overall positive direction of results with respect to reducing AHI and improving LVEF confirms the recommendation. Although 1 paper reported that the cumulative incidence rate of cardiac events was no different between oxygen therapy and control groups, its effect on transplant free survival has not been assessed. The universal availability of oxygen therapy coupled with the overall quality of evidence discussed above influenced the level of recommendation. It should be noted that while oxygen therapy does not confer outcome advantages over CPAP therapy in the available evidence, supplemental oxygen can be easily administered and can be given for those individuals with CSAS related to CHF who are unable to comply with CPAP therapy. Consideration should be given to a repeat sleep study with oxygen to ensure adequate resolution of central sleep apnea events. In the US, the current cost of supplemental oxygen therapy is approximately $200 per month.

The following therapies have limited supporting evidence but may be considered for the treatment of CSAS related to CHF, after optimization of standard medical therapy, if PAP therapy is not tolerated, and if accompanied by close clinical follow-up: acetazolamide and theophylline. (OPTION)

Values and Trade-offs: There is only 1 study for acetazolamide and 2 studies for theophylline. Therefore the data for each agent are very low. Furthermore, the benefits vs. harms are unclear. Side effects of acetazolamide have been previously outlined. Theophylline is also associated with a number of potential adverse effects such as cardiac arrhythmias, central nervous system (CNS) excitability, and gastrointestinal symptoms. Additionally, it has a narrow therapeutic index, and therefore close monitoring of levels is important. These pharmacological therapies require further research to generate more confidence in their effectiveness and to justify more than an OPTION level of recommendation.

CSAS Due to Medical Condition Not Cheyne Stokes: End-Stage Renal Disease (ESRD)

The following possible treatment options for CSAS related to end stage renal disease may be considered: CPAP, supplemental oxygen, bicarbonate buffer use during dialysis, and nocturnal dialysis. (OPTION)

Values and Trade-offs: At this time, the level of evidence is very low and the estimate of benefits vs. harms is unclear regarding any specific mode of therapy in end-stage renal disease (ESRD) patients with CSAS; therefore, an OPTION level of recommendation has been accorded. However, despite the very low level of evidence, it is clear that bicarbonate buffer is preferable during hemodialysis in these patients. Further studies are needed to elucidate the role of oxygen, CPAP, bicarbonate buffer use during dialysis, and nocturnal hemodialysis in patients with ESRD.

Definitions:

Summary of Grading of Recommendations Assessment, Development and Evaluation (GRADE) Approach to Rating Quality of Evidence*

Study Design Initial Quality of a Body of Evidence Lower if Higher if Quality of a Body of Evidence
Randomized trials High → Risk of bias
−1 Serious
−2 Very serious
Large effect
+1 Large
+2 Very large
High (four plus:++++)
Inconsistency
−1 Serious
−2 Very serious
Dose response
+1 Evidence of a gradient
Moderate (three plus:+++O)
Observational studies Low → Indirectness
−1 Serious
−2 Very serious
All plausible residual confounding
+1 Would reduce a demonstrated effect
Low (two plus: ++OO)
Imprecision
−1 Serious
−2 Very serious
Publication bias
−1 Likely
−2 Very likely
+1 Would suggest a spurious effect if no effect was observed Very Low (one plus:+OOO)

Final Assessments of Level of Bodies of Evidence*

High: The guideline developers are very confident that the true effect lies close to that of the estimate of the effect.

Moderate: The guideline developers are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.

Low: The confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.

Very low: The guideline developers have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

*From Balshem H, Helfand M, Schunemann H, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol 2011;64:401-6.

American Academy of Sleep Medicine (AASM) Levels of Recommendations

Final Standards of Practice Recommendations Overall Quality of Evidence
High Moderate Low Very Low
Assessment of benefit/harm/burden Benefits clearly outweigh harm/burden Standard Standard Guideline Option
Benefits closely balanced with harm/burden
OR
uncertainty in the estimates of benefit/harm/burden
Guideline Guideline Option Option
Harm/burden clearly outweighs benefits Standard Standard Standard Standard
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Positive airway pressure (PAP) therapy offers the following benefits: (1) it has the potential to ameliorate central respiratory events; (2) it typically does not confer significant risks; (3) it is readily available in most centers; (4) it reduces apnea-hypopnea index (AHI) and improves left ventricular ejection fraction (LVEF) in the setting of central sleep apnea syndromes (CSAS) related to congestive heart failure (CHF); and (5) it has a positive effect on transplant-free survival in patients with CSAS and CHF.
  • Adaptive servo-ventilation (ASV) consistently showed improvement in both the AHI and LVEF when treating CSAS related to CHF. There is also overall better compliance with ASV than continuous positive airway pressure (CPAP).
  • The benefits of oxygen supplementation for the treatment of central sleep apnea syndromes (CSAS) are abundant and outweigh any potential disadvantages. While the variable duration of treatment in each study limits recommendations in regard to duration of oxygen therapy, the overall positive direction of results with respect to reducing AHI and improving LVEF confirms the developers' recommendation.

Refer to the "Values and Trade-offs" sections under each parameter in the "Major Recommendations" section for specific information on potential benefits of individual treatments.

Potential Harms
  • Acetazolamide has the potential for side effects including paresthesias, tinnitus, gastrointestinal symptoms, metabolic acidosis, electrolyte imbalance, and drowsiness.
  • Theophylline is associated with a number of potential adverse effects such as cardiac arrhythmias, central nervous system (CNS) excitability, and gastrointestinal symptoms. Additionally, it has a narrow therapeutic index, and therefore close monitoring of levels is important.
  • Due to the limited available evidence and the significant potential for adverse side effects especially respiratory depression, the use of zolpidem and triazolam in the setting of primary central sleep apnea syndromes (CSAS) is not a preferable option and remains the last therapeutic option, to be considered only if the other therapeutic options listed in the guideline fail. Very close clinical follow-up must be provided to consider the use of these hypnotic agents.

Qualifying Statements

Qualifying Statements

These practice parameters define principles of practice that should meet the needs of most patients in most situations. These guidelines should not, however, be considered inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding propriety of any specific care must be made by the physician, in light of the individual circumstances presented by the patient, available diagnostic tools, accessible treatment options, and resources.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Aurora RN, Chowdhuri S, Ramar K, Bista SR, Casey KR, Lamm CI, Kristo DA, Mallea JM, Rowley JA, Zak RS, Tracy SL. The treatment of central sleep apnea syndromes in adults: practice parameters with an evidence-based literature review and meta-analyses. Sleep. 2012;35(1):17-40. [112 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2012 Jan
Guideline Developer(s)
American Academy of Sleep Medicine - Professional Association
Source(s) of Funding

American Academy of Sleep Medicine

This is not an industry supported study.

Guideline Committee

Standards of Practice Committee

Composition of Group That Authored the Guideline

Committee Members: R. Nisha Aurora, MD; Susmita Chowdhuri, MD; Kannan Ramar, MD; Sabin R. Bista, MD; Kenneth R. Casey, MD, MPH; Carin I. Lamm, MD; David A. Kristo, MD; Jorge M. Mallea, MD; James A. Rowley, MD; Rochelle S. Zak, MD; Sharon L. Tracy, PhD

Financial Disclosures/Conflicts of Interest

All members of the American Academy of Sleep Medicine (AASM) Standards of Practice Committee (SPC) and Board of Directors completed detailed conflict-of-interest statements and were found to have no conflicts of interest with regard to this subject.

The authors have indicated no financial conflicts of interest.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the American Academy of Sleep Medicine (AASM) Web site External Web Site Policy.

Print copies: Available from the Department of Science & Research, American Academy of Sleep Medicine, 2510 North Frontage Road, Darien, IL 60561. Web site: www.aasmnet.org External Web Site Policy.
Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on April 20, 2012. The information was verified by the guideline developer on May 17, 2012. This summary was updated by ECRI Institute on January 23, 2013 following the U.S. Food and Drug Administration advisory on Zolpidem containing products.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please contact the American Academy of Sleep Medicine (AASM) for information regarding reproduction of AASM guidelines.

Disclaimer

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