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Prevalence and characteristics of positional obstructive sleep apnea (POSA) in patients with severe OSA



We assessed the prevalence of positional patients (PPs) and the main predictors of positional dependency in severe obstructive sleep apnea (OSA). A simulated effect of positional therapy (PT) vs. continuous positive airway pressure (CPAP) was also assessed.


Polysomnographic recordings of 292 consecutive patients with severe OSA (Apnea-Hypopnea Index (AHI) ≥ 30) who slept > 4 h and had ≥ 30 min sleep in both supine and lateral positions were assessed. PPs were defined to have a supine AHI/lateral AHI ratio ≥ two and non-positional patients (NPPs) a supine AHI/lateral AHI ratio < two.


A total of 35.3% of the severe OSA patients were PPs. They were less obese and had less severe OSA (p < 0.001) compared with NPPs. The percentage of total apnea-hypopnea time from total sleep time (AHT%) was the most significant predictor for positional dependency. By sleeping in the lateral posture (i.e. after simulated PT), 78 (75.7%) PPs obtained significant improvement of their OSA severity and 9 (8.7%) of them became “non-OSA”. Moreover, if CPAP was used only for 50% of total sleep time, 53 patients (18.2%) gained more benefit from avoiding the supine posture than from CPAP therapy.


More than a third of the studied severe OSA patients were PPs. These patients could achieve a significant decrease in the number and severity of apneas and hypopneas by adopting the lateral posture, suggesting that PT may be a valuable therapy for a significant portion of these severe OSA patients who for whatever reason are not being treated by CPAP.

Trial Registry Identifier: NCT03232658

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Fig. 1
Fig. 2
Fig. 3



apnea hypopnea index


apnea + hypopnea time as percentage of total sleep time


area under a ROC curve


a partial regression coefficient


body mass index


confidence interval


continuous positive airway pressure


ear, nose, and throat


epworth sleepiness scale


degree of freedom


non-positional patient


non-rapid eye movement sleep


odds ratio


obstructive sleep apnea


positional obstructive sleep apnea




positional patient


positional therapy


rapid eye movement sleep


receiver operating characteristic


a variation of a partial regression coefficient


total apnea time


total hypopnea time


total sleep time


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This research was supported by the Academy of Finland (decision number 313697), Finnish-Norwegian Medical Foundation, the Research Committee of the Kuopio University Hospital Catchment Area for the State Research Funding (projects 5041767 and 5041768), Tampere Tuberculosis Foundation, and the Respiratory Foundation of Kuopio Region.

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Authors and Affiliations



AO and NG conceived the research. TL carried out the analyses and prepared the Figures. JT proposed the simulation analysis. All authors assisted with writing and interpretation of the findings. All authors approved this manuscript in its final form.

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Correspondence to Arie Oksenberg.

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The authors declare that they have no conflicts of interest.

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This study was approved by the Helsinki ethical committee of the Loewenstein Hospital Rehabilitation Center (protocol 0006–17-LOE). For retrospective chart reviews, formal consent is not required.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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Oksenberg, A., Gadoth, N., Töyräs, J. et al. Prevalence and characteristics of positional obstructive sleep apnea (POSA) in patients with severe OSA. Sleep Breath 24, 551–559 (2020).

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  • Obstructive sleep apnea (OSA)
  • Severe OSA patients
  • Positional patients
  • Positional therapy
  • Supine posture
  • Lateral position
  • OSA treatment