French medical authorities are poised to revise diagnostic guidelines for obstructive sleep apnea, a condition affecting millions and linked to increased risks of cardiovascular disease and other health complications. The proposed updates, presented at the French-Language Pulmonology congress in lille, move away from a strict reliance on the Apnea-Hypopnea Index (AHI) and emphasize a more holistic evaluation of patient symptoms and their impact on daily life. These recommendations,more than a decade in the making,reflect evolving research into the complexities of sleep-disordered breathing and aim to improve both diagnosis and treatment efficacy.
French medical guidelines for adult sleep apnea are set to be updated with a new diagnostic approach, including revised criteria for determining the severity of the condition.
The proposed changes, discussed at the French-Language Pulmonology Congress (CPLF) in Lille last weekend, come over a decade after the previous recommendations were established in 2010 by several professional societies, including the French Society of Pulmonology (SPLF) and the French Society for Research and Medicine of Sleep (SFRMS). Sleep apnea is a common disorder in which breathing repeatedly stops and starts during sleep, and accurate diagnosis is crucial for effective treatment and management.
The upcoming guidelines address definitions, diagnosis, and screening for sleep apnea, explained Dr. Sandrine Launois of the Sleep Medical Institute in Neuilly-sur-Seine, who co-chaired a special session on January 30 where the proposals were presented.
Dr. Nicole Meslier of the University Hospital of Angers presented data from the medical literature and evolving understandings of respiratory events – including apneas, hypopneas, and respiratory effort-related arousals – which are used to diagnose sleep-related breathing disorders and sleep apnea specifically.
A key measurement in diagnosing sleep apnea is the Apnea-Hypopnea Index (AHI), which represents the number of obstructive respiratory events per hour of sleep. “The AHI remains the most widely accepted measure today,” with a threshold of 5 events per hour, although this threshold is adjusted to 15 events per hour for individuals aged 65 and older.
However, diagnosis requires more than just a measurement. “A syndrome doesn’t exist in the absence of symptoms,” noted Dr. Meslier. “There must be a clinical criterion of associated symptoms causing distress or disability.” Patients must exhibit symptoms from at least two of three categories, and those symptoms must be causing clinically significant distress or impairment.
Researchers acknowledged that symptoms of sleep apnea can be non-specific and subjective, as there are limited tools to objectively measure them, and experiences vary between patients. Dr. Cécile L’Hédéver of the University Hospital of Brest explained that the working group categorized the most common symptoms based on their causal link to sleep apnea.
The first category includes indicators of upper airway obstruction – direct signs of airway collapse, such as snoring, witnessed apneas reported by others, and nighttime choking sensations. The second category encompasses indicators of sleep disruption, including unrefreshing sleep, excessive daytime sleepiness, and insomnia.
A third category includes mixed indicators, related to both obstruction and sleep disruption, such as morning headaches, nocturia (frequent nighttime urination), and night sweats. The final category contains indirect indicators, where the causal link to sleep apnea is less clear, or studies are inconsistent – including fatigue, mood changes, cognitive impairment, and decreased libido.
For all symptoms, clinicians should systematically investigate other potential causes, such as sleep habits, medications, substance use, and other underlying medical or psychiatric conditions.
Evaluating Severity Based on Clinical Criteria
New data published since 2010 suggest that the AHI doesn’t reliably correlate with daytime sleepiness, treatment response to continuous positive airway pressure (CPAP), or cardiovascular outcomes. As a result, the updated guidelines recommend against using AHI thresholds as a marker of severity.
Previously, sleep apnea was categorized as mild (AHI between 5 and 15 events per hour), moderate (15 to 30 events per hour), and severe (30 or more events per hour). The working group now proposes evaluating severity based on clinical criteria, rather than solely on daytime sleepiness.
This involves assessing the impact of symptoms on the patient’s overall well-being, family relationships, social life, professional life, and specific context. Clinicians should determine if symptoms cause significant distress or disability, or if there is a particular risk of accidents, especially in certain professions. Identifying co-existing conditions that increase risk, such as resistant or non-dipping hypertension, chronic obstructive pulmonary disease (COPD), or high-risk pregnancies, is also important.
The new recommendations are not expected to significantly change diagnostic tests, as there have been no major technological advancements in polysomnography or ventilatory polygraphy.
Introducing AROS
The International Classification of Sleep Disorders, 3rd edition (ICSD-3) defines sleep apnea as an AHI of at least 15 respiratory events per hour, even in the absence of causal symptoms or significant distress. However, the working group proposes not adopting this criterion and instead adding a chapter to the guidelines to define a new entity: Obstructive Respiratory Events during Sleep (AROS). This is intended to address preventative care in certain asymptomatic populations.
AROS shares the same criteria for respiratory events during sleep as sleep apnea, but also includes either resistant or poorly controlled hypertension, or another clinical situation with a high suspicion of a causal link to AROS and a co-existing condition. However, AROS is common; with an AHI of 5 or more, it’s found in 84% of men and 61% of women, and with an AHI of 15 or more, in 50% of men and 23% of women. “It seems unreasonable to look for it in the general population,” emphasized Professor Wojciech Trzepizur of the University Hospital of Angers.
Research suggests that screening for AROS using validated questionnaires could improve care and outcomes in specific situations, such as patients with resistant hypertension or a “non-dipping” blood pressure pattern, COPD, high-risk pregnancies, or pre-operative evaluations. Routine screening in the general population, or in individuals with obesity, diabetes, coronary artery disease, heart failure, cerebrovascular disease, or atrial fibrillation, is not recommended.
Based on a dispatch published in APMnews on February 3, 2026.
