Advancing Sleep Medicine: Why Precision Diagnostics are Essential for Modern OSA Treatment

For decades, the diagnostic pathway for patients suspected of having obstructive sleep apnea (OSA) has followed a predictable sequence. Typically, a patient undergoes overnight testing in a sleep lab, a technician scores the data, and the patient receives an apnea-hypopnea index (AHI) score to quantify their breathing disruptions per hour of sleep. If the score is sufficiently high, the patient is prescribed continuous positive airway pressure (CPAP) therapy. This linear protocol was effective primarily because CPAP was the only major treatment option available.

However, recent years have introduced a variety of new sleep apnea treatments. In December 2024, Zepbound became the first FDA-approved pharmacologic therapy for OSA. Additionally, Apnimed recently published Phase 3 trial results for an oral candidate targeting the neuromuscular causes of OSA, with a potential PDUFA target action date expected early next year. Hypoglossal nerve stimulation has also matured into a standard surgical option, and oral appliances are becoming increasingly mainstream for suitable candidates. While CPAP remains a cornerstone of therapy for many, it is no longer the only solution—a significant development for the estimated 84 million Americans living with OSA.

This therapeutic shift presents both an opportunity and a challenge for clinicians. Matching the appropriate patient to the correct therapy now requires understanding the physiological drivers of apnea, rather than just the frequency of events. This places immense pressure on a diagnostic system that, for most, still relies on a single overnight lab test, a single AHI value, and a workforce of sleep technicians who are increasingly stretched thin. Addressing this gap requires a fundamental rethink of what sleep apnea testing identifies and where that testing occurs.

The Limitations of AHI

The constraints of current standards are evident in clinical practice. Consider two patients who both receive a diagnosis of moderate OSA with an AHI of 22. While their records appear identical, their underlying causes may be entirely different. One patient’s apnea may be driven by an anatomically collapsible upper airway, while the other’s condition may be related to obesity and excess tissue around the neck and airway.

This distinction was less critical when CPAP was the default for everyone, but it is now vital. The first patient might be an ideal candidate for an oral appliance or hypoglossal nerve stimulation, whereas the second might benefit more from a GLP-1 therapy like Zepbound. These nuanced treatment decisions cannot be made based on AHI alone.

Current diagnostic standards often lack information regarding the underlying physiology that produces the AHI. The necessary signals—including measurements of airflow, respiratory effort, and oxygenation—are available, yet diagnostic protocols have not been updated to require or interpret them as critical clinical inputs rather than mere technical details.

The Access Bottleneck

Beyond diagnostic depth, there is the issue of accessibility. Sleep labs evolved from research environments and maintain a traditional operating model: one patient per bed, per night, scored by a technologist and reviewed by a physician. This model limits the number of patients that can be evaluated at any given time.

The workforce is under similar strain. The ratio of Americans to board-certified sleep medicine specialists exceeds 43,000:1, and millions of Americans live in counties without a specialist. This leads to month-long wait times for appointments and testing, which can be dangerous for a condition linked to stroke, cardiovascular disease, and metabolic dysfunction.

This capacity gap is expected to widen as public awareness of OSA grows, driven by consumer wearables and a new array of therapy options. The system cannot scale by simply building more labs; it must embrace home-based diagnostic work that preserves the essential respiratory signals needed for clinical accuracy.

The Need for a Diagnostic Upgrade

Personalized sleep medicine requires personalized diagnostics. This principle is already standard in fields like oncology and rheumatology. In sleep medicine, the most necessary upgrade is “endotyping”—the characterization of the specific physiological mechanism driving a patient’s apnea.

While AHI measures how often breathing is disrupted, endotyping explains *why*. Some patients have a breathing control system that overcorrects to blood gas changes; others have a low arousal threshold that causes them to wake from minor disturbances; others have an anatomically collapsible airway. Because many patients exhibit a combination of these traits, detailed measurement is essential for effective treatment.

Endotyping requires data that current standard processes often fail to surface. Physiological measurements of airflow, respiratory effort, and oxygenation must be captured across multiple nights, rather than averaged into a single number. Because apnea severity can fluctuate night to night, a single overnight test can misclassify a patient or miss the underlying mechanism.

Furthermore, this diagnostic capability supports longitudinal care. Historically, OSA has been managed as a one-time diagnosis followed by a long-term prescription, with little feedback on treatment efficacy. With a diverse range of therapies now available, clinicians and patients need ways to assess progress, adjust dosages, and switch approaches when results fall short. The tools that enable endotyping at the start of care are the same tools needed to monitor therapy throughout a patient’s life.

The Path Forward

The gap between innovative treatments and diagnostic capability is narrowing. The physiological signals required for endotyping are well-understood, and technology is improving our ability to capture them outside of a lab. The remaining challenge is operational: we must update diagnostic standards to include data beyond AHI, expand access through home-based testing, and reframe OSA as a chronic condition requiring continuous management.

For patients, this shift promises faster diagnoses, more accurate treatments, and the ability to course-correct when a therapy isn’t working. For clinicians, it provides the comprehensive data needed to manage sleep apnea with the same precision used for other chronic conditions.

Sleep medicine is finally moving toward personalized care. While new therapies are highly visible, the diagnostic system is what will ultimately determine the success of these medical advancements.

Photo: Roos Koole, Getty Images

Amir Reuveny is the CEO and co-founder of Wesper, a leading provider of advanced home sleep apnea testing (HSAT). Before founding Wesper, Dr. Reuveny was a postdoctoral fellow at Cornell Tech University, investigating commercial applications for flexible electronics. Amir received his Ph.D. in Electrical Engineering and Information Systems from the University of Tokyo and holds a double major degree with honors from Technion, Israel.

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