Last reviewed: 1 Nov 2021
Last updated: 16 Mar 2018



History and exam

Key diagnostic factors

  • insomnia, especially sleep-maintenance insomnia
  • poor concentration and attention span
  • observed periodic breathing or cessation of breathing or snoring during sleep (by partner)
  • transient dyspnea that awakens from sleep or prevents sleep onset
  • headaches upon arising
  • complaints of poorly restorative sleep and/or daytime sleepiness
  • periodic breathing during wakefulness

Other diagnostic factors

  • abnormal heart rhythm or the presence of third or fourth heart sounds
  • focal abnormality on neurologic exam
  • neuromuscular weakness
  • hx of endocrine disorders

Risk factors

  • CHF
  • stroke
  • renal failure
  • male gender
  • atrial fibrillation
  • age ≥60 years
  • opioid use
  • brainstem lesions
  • neuromuscular weakness
  • acromegaly
  • hypothyroidism

Diagnostic investigations

Investigations to consider

  • serum TSH
  • serum creatinine
  • ECG
  • serum insulin-like growth factor 1 (acromegaly testing)
  • echocardiogram

Treatment algorithm



Bernardo J. Selim, MD

Assistant Professor of Medicine

Division of Pulmonary and Critical Care Medicine

Mayo Clinic




BJS declares that he has no competing interests.

Lauren A. Tobias, MD

Assistant Professor of Medicine

Yale University School of Medicine

Department of Internal Medicine

Section of Pulmonary, Critical Care and Sleep Medicine

New Haven



LAT declares that she has no competing interests.


Dr Bernardo J. Selim and Dr Lauren A. Tobias would like to gratefully acknowledge Dr J. Shirine Allam, Dr Timothy I. Morgenthaler, and Dr Christine H. Won, previous contributors to this monograph. JSA and TIM declare that they have no competing interests. CHW declares that she has been a speaker for Respironics CME.

Peer reviewers

Teofilo Lee-Chiong, MD

National Jewish Medical and Research Center




TLC has been reimbursed by the American College of Chest Physicians (ACCP), American Academy of Sleep Medicine, American Thoracic Society, and Cephalon, the manufacturer of modafinil, for attending several conferences. He has been paid by the ACCP for running educational programs and by Elsevier for serving as consultant of the Sleep Medicine Clinics. He has also received research funding from the National Institutes of Health, Respironics, Restore, and Schwarz Pharma, and has been a member of the speakers' bureau for GlaxoSmithKline.

John A. Fleetham, MD, FRCP


University of British Columbia




JAF declares that he has no competing interests.

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