[Expert consensus on the diagnosis and treatment of excessive daytime sleepiness in obstructive sleep apnea].

Obstructive sleep apnea (OSA) is a common sleep-disordered breathing condition. Excessive daytime sleepiness (EDS) is one of the most common clinical manifestations in patients with OSA. Some OSA patients continue to experience residual EDS despite receiving standard treatment. EDS significantly impairs patients' occupational performance and quality of life, increases the risk of traffic accidents, and is an economic burden for both society and individuals. Currently, there are no specific diagnostic or treatment guidelines for EDS in patients with OSA in China. Therefore, the Sleep Disorder Group of Chinese Thoracic Society has developed this expert consensus based on the latest domestic and international research. The consensus provides a detailed discussion on the definition, epidemiology, clinical manifestations, diagnostic approach, and treatment of EDS in OSA, with the aim of providing standardized recommendations for the diagnosis and treatment of EDS in patients with OSA and improving clinical awareness of this condition. The key recommendations are as follows.<b>Recommendation 1:</b> The Epworth sleepiness scale (ESS) is considered as a subjective tool for assessing EDS in patients with OSA. It can be used for diagnosis, severity assessment, and monitoring of treatment effects. A clinical threshold of 10 points is recommended, with a minimum clinically important difference (MCID) of 2-3 points (2, B).<b>Recommendation 2:</b> The maintenance of wakefulness test (MWT) and the multiple sleep latency test (MSLT) are considered to be objective tools for ruling out comorbid sleep disorders. They should not be used independently for diagnosis (2, B).<b>Recommendation 3:</b> The Karolinska sleepiness scale (KSS) and the Stanford sleepiness scale (SSS) can be used as supplementary assessment tools for EDS, but should not be used independently for diagnosis (4, C).<b>Recommendation 4:</b> CPAP is recommended as the first-line therapy for patients with OSA to improve EDS (1, A).<b>Recommendation 5:</b> Patients who refuse, cannot tolerate, or do not adhere to CPAP may benefit from oral appliances or surgical interventions. Customized oral appliances should be preferable. Upper airway surgery should be chosen based on patterns of anatomical obstruction. Surgical interventions can also be used as an adjunctive therapy to CPAP (2, B).<b>Recommendation 6:</b> OSA patients with EDS should make lifestyle changes, including correcting poor lifestyle habits and improving sleep hygiene, to improve nocturnal sleep quality and daytime alertness (3, B).<b>Recommendation 7:</b> Pharmacological wake-promoting agents may be considered, after careful clinical evaluation, in OSA patients who meet the following criteria: ① Residual EDS persists despite adequate and adherent conventional OSA therapy (including CPAP, oral appliances, and surgery) with exclusion of other EDS etiologies; ② Patients with EDS who refuse, are intolerant of, or are not compliant with conventional therapy; ③ Patients with EDS that severely impairs quality of life, interferes with work/study performance, or increases the risk of accidents (including those with actual or near-miss accidents) (expert consensus, ungraded).<b>Recommendation 8:</b> For patients with residual EDS despite adequate and adherent conventional OSA therapy, solriamfetol, pitolisant, or modafinil are recommended to improve hypersomnolence (1, A).<b>Recommendation 9:</b> For EDS patients refusing, intolerant or non-adherent to conventional OSA therapy, individualized treatment with solriamfetol or pitolisant is recommended (1, A), with consideration of modafinil (2, B). Regular encouragement to continue conventional OSA therapy should be provided throughout the treatment period.<b>Recommendation 10:</b> Methylphenidate or dextroamphetamine is not currently recommended for OSA-related EDS due to insufficient evidence (no evidence, D).<b>Recommendation 11:</b> Regular monitoring of the efficacy and safety of wake-promoting agents is recommended. The frequency of monitoring should be determined clinically, using subjective EDS scales, and supplemented by objective assessments when available. Strict monitoring for adverse effects is required during treatment, including the risk of drug dependence, addiction, and cardiovascular events. Caution should be exercised when prescribing these agents to patients with cardiovascular risk factors (3, B).