Sleep and Breathing

, Volume 19, Issue 2, pp 473–480 | Cite as

Positional OSA part 1: towards a clinical classification system for position-dependent obstructive sleep apnoea

  • M. H. Frank
  • M. J. L. Ravesloot
  • J. P. van Maanen
  • E. Verhagen
  • J. de Lange
  • N. de Vries
Original Article



In 1984, Cartwright suggested that physicians should differentiate between patients with either positional obstructive sleep apnoea (POSA) or non-positional OSA. Treatment of POSA has advanced dramatically recently with the introduction of a new generation of positional therapy (PT), a small device attached to either the neck or chest which corrects the patient from adopting the supine position through a vibrating stimulus. Encouraging data have been published suggesting that this simple therapy successfully prevents patients with POSA from adopting the supine position without negatively influencing sleep efficiency, as well as allowing for good adherence. Unfortunately, evaluating the efficacy of PT and comparing results are hindered by the fact that there are no universally used POSA criteria. In 1984, Cartwright introduced the arbitrary cut-off point of a difference of 50 % or more in apnoea index between supine and non-supine positions.


The aim of this project was to introduce a new classification system, which ideally should identify suitable candidates for PT: patients that will benefit from a clinically significant improvement of their OSA with PT. The shared use of this classification can facilitate collection of data across multiple centres and comparison of results across studies. We report on the development and process that resulted in the Amsterdam Positional OSA Classification (APOC).


A panel of three field experts were instructed to independently assign the diagnosis POSA to 100 randomly selected patients they considered likely to benefit from a clinically significant improvement of their OSA with PT. In a group setting, the completed lists were compared. Discrepancies were discussed until consensus was met. This resulted in the consensus standard used to calibrate the new classification. Using the nominal group technique, the APOC was developed.


The APOC criteria evolve around the percentage of total sleep time spent in either the worst sleeping position (WSP) or the best sleeping position (BSP) and the apnoea–hypopnoea index (AHI) in BSP. On applying APOC, one discriminates between the true positional patient, the non-positional patient and the multifactorial patient, whose OSA severity is influenced in part by sleep position. APOC has an increased sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) compared to previously applied POSA criteria in identifying patients that will benefit from positional therapy.


Sleep apnoea Obstructive Sleeping position Positional therapy 

List of abbreviations


Apnoea–hypopnoea index


Amsterdam Positional OSA Classification


Body mass index


Best sleeping position


Continuous positive airway pressure


Desaturation index


Intercorrelation coefficient


Negative predictive value


Obstructive sleep apnoea


Position-dependent obstructive sleep apnoea


Positive predictive value




Positional therapy


Saturation oxygen


Tennis ball technique


Total sleep time


Worst sleeping position


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Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • M. H. Frank
    • 1
  • M. J. L. Ravesloot
    • 2
  • J. P. van Maanen
    • 2
  • E. Verhagen
    • 3
  • J. de Lange
    • 1
  • N. de Vries
    • 2
  1. 1.Department of Oral and Maxillofacial Surgery, Academic Medical CentreUniversity of AmsterdamAmsterdamThe Netherlands
  2. 2.Department of Otolaryngology/Head and Neck SurgerySint Lucas Andreas ZiekenhuisAmsterdamThe Netherlands
  3. 3.Department of Public and Occupational Health, EMGO Institute for Health and Care ResearchVU Medical CenterAmsterdamThe Netherlands

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