Inside the AASM Sleep Guidelines on Sleep Apnea and Insomnia Therapy, With Susheel Patil, MD, PhD

Undertreated sleep disorders show up across a multitude of clinical settings, and a session at SLEEP 2026 led by Susheel Patil, MD, PhD, system director and system chief for sleep medicine at the University Hospitals of Cleveland, addressed 3 of them directly.

Reviewing new AASM clinical practice guidelines on central sleep apnea, inpatient OSA, and chronic insomnia combination therapy, Patil outlined the key practice changes each guideline introduces and the clinical scenarios where they are most likely to matter.¹

The 3 guidelines share a common thread: each identifies a point where current practice falls short and offers updated, evidence-based direction for course correction. Only 5% of hospitalized patients with known OSA continue their treatment during admission, CBT-I remains underused relative to pharmacotherapy in chronic insomnia despite its superior evidence base, and CSA continues to be managed by AHI targets alone, without adequate attention to whether symptoms are actually resolving.

Central Sleep Apnea: Symptom-Based Treatment Targets and Updated Device Guidance

The updated AASM CSA guideline introduces several changes Patil highlighted as particularly relevant for clinical practice. The guideline formalizes a good practice statement emphasizing symptom resolution as the benchmark for treatment adequacy, not AHI normalization alone.

"Don't just treat the number," Patil said. "Make sure with any intervention you implement, you're reversing not just the numbers, but also reversing the symptoms. Otherwise, you should reassess what you're doing."¹

The guideline also adds a conditional recommendation for transvenous phrenic nerve stimulation (TPNS), a neurostimulation implant, in patients with primary CSA and heart failure-associated CSA. Patil noted TPNS should not be considered before conventional therapies given its invasive nature and limited accessibility. A new recommendation against BiPAP without a backup rate in CSA patients is also included, as it may worsen the condition. CPAP, BiPAP with a backup rate, and adaptive servo ventilation (ASV) remain supported options.¹

A notable update concerns ASV in patients with heart failure and CSA. Prior guidelines discouraged its use due to mortality concerns, but updated systematic review data no longer support a safety signal. ASV is now a reasonable option in this population, though Patil noted it should be managed by centers with substantial experience. For primary care physicians, CSA risk factors worth flagging include older age in men, atrial fibrillation, congestive heart failure, volume-overloaded states, and chronic opioid therapy. Symptomatically, CSA is difficult to distinguish from OSA, making risk factor awareness the key diagnostic trigger.

Inpatient OSA and Chronic Insomnia: a First-Ever Guideline and a Treatment Hierarchy

The inpatient OSA guideline is the first AASM document specifically addressing OSA management in medically hospitalized adults, and Patil identified a stark practice gap it targets directly. Only 5% of patients with known OSA continue their treatment during hospitalization, despite evidence associating untreated inpatient OSA with higher resource utilization, greater likelihood of escalation to a higher level of care, and elevated 30-day readmission risk.¹

"It's very natural for us to think about continuing medications for diabetes or hypertension when patients are in the hospital," Patil said. "Ask patients if they have sleep apnea, ask if they're on treatment, and ask if someone can bring in their device, or see if you have hospital resources to continue the treatment."¹

The guideline recommends developing inpatient sleep screening programs, offering treatment during admission where feasible, and ensuring a structured discharge management plan with timely sleep medicine follow-up for high-risk patients identified during hospitalization.

The chronic insomnia combination therapy guideline addresses a question prior AASM guidelines did not: how does concurrent CBT-I plus pharmacotherapy compare with either approach used alone? The guideline establishes a clear hierarchy:

• CBT-I alone is preferred.
• Combination therapy is conditionally recommended over pharmacotherapy alone, as it produces modest improvements in insomnia severity and sleep continuity.
• Adding medication to CBT-I does not produce clinically meaningful improvements over CBT-I alone and carries slightly higher rates of adverse effects including morning sleepiness.
• Pharmacotherapy alone is the least preferred strategy.

Patil distilled the message: "If you're going to do any one thing, think about CBT-I. If you're going to think about combination therapy, that's the second thing. The last thing you should think about is pharmacotherapy alone."¹

References

1. Patil S. Session: Highlights from the New AASM Clinical Practice Guidelines. Presented at: SLEEP 2026; June 2026.

2. Combination treatment for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2026. doi:10.1007/s44470-025-00038-8

3. Badr MS, Khayat RN, Allam JS, et al. Treatment of central sleep apnea in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2025;21(12):2181-2191. doi:10.5664/jcsm.11858

4. Mehra R, Auckley DH, Johnson KG, et al. Evaluation and management of obstructive sleep apnea in adults hospitalized for medical care: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2025;21(12):2193-2203. doi:10.5664/jcsm.11864