Sleep-Related Breathing Disorders

Entitlement Eligibility Guideline (EEG)

Date reviewed: 29 July 2025

Date created: 22 January 2025

ICD-11 codes: 7A40, 7A41

VAC medical code:

78050

Obstructive sleep apnea syndrome, central sleep apnea syndrome, mixed sleep apnea syndrome

This publication is available upon request in alternate formats.
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Definition

Sleep-related breathing disorders are a spectrum of breathing disorders, with most falling into the categories of obstructive sleep apnea (OSA), central sleep apnea (CSA), or sleep-related hypoventilation. OSA is the most common sleep-related breathing disorder and is characterized by pauses of breathing during sleep.

In mixed sleep apnea, individuals experience characteristics of both OSA and CSA; the diagnosis can be challenging to make because symptoms overlap or shift between the two types.

For the purposes of this entitlement eligibility guideline (EEG), the following conditions are included:

  • obstructive sleep apnea (OSA)
  • central sleep apnea (CSA)
  • mixed sleep apnea.

Note:

  • For Veterans Affairs Canada (VAC) purposes, equivalent diagnoses for mixed sleep apnea include:
    • treatment-emergent CSA
    • complex sleep apnea.
  • Mixed sleep apnea may be entitled using OSA and/or CSA Section A factors.

Exclusions:

  • sleep-related hypoventilation
  • obesity hypoventilation.

Anatomy and physiology

Normal breathing during sleep involves a rhythmic and regular pattern of inhalation of oxygen and exhalation of carbon dioxide. The respiratory system works to maintain adequate oxygen levels in the body and remove carbon dioxide, promoting a restful and restorative sleep. Sleep-related breathing disorders are conditions that affect the normal pattern of breathing during sleep. These disorders can range from mild to severe and may lead to disruptions in sleep, drops in oxygen levels (called desaturations), and other health complications.

Breathing during sleep involves a complex interplay of respiratory, neurological, and muscular systems. The process is regulated by the brain to ensure proper oxygenation and carbon dioxide elimination. Air enters the mouth or nose during sleep with nasal passages filtering and humidifying the incoming air. The oropharynx (throat) connects the mouth and nose to the larynx, acting as a pathway for air to enter the lungs. The upper airway refers to the portion of the respiratory system that is located above the level of the trachea (windpipe). The diaphragm and intercostal muscles act as the primary muscles for breathing.

OSA results from repetitive closures of the upper airway during sleep, often resulting in snoring and lower oxygen levels. The muscles of the upper airway relax, causing the airway to close during inspiration which can lower the oxygen level in the blood and increase carbon dioxide levels. If vigorous inspiratory efforts continue against an obstructed airway, large swings in intrathoracic pressure occur. The swing in pressure stresses the cardiovascular system, causing brief periods of brain activation and wakening. This awakening is usually so brief that it is not remembered but causes fragmented sleep.

Obstruction of the upper airway can occur when the baseline cross-sectional area of the airway is reduced. Contributors can include enlarged tonsils or soft tissues, alterations in the craniofacial bony structures, and nasal obstruction. Muscles that maintain the upper airway can also be affected by certain drugs, medications, and medical and mental health conditions.

CSA is a less common form of sleep-related breathing disorder caused by intermittent pauses in the brain’s respiratory centres, rather than obstruction of the upper airway. The sensors in the brain controlling breathing during sleep are impacted and interfere with normal ventilation. CSA causes an alternation of hyper and hypoventilation.

Obstructive sleep apnea (OSA)

Diagnostic standard for obstructive sleep apnea

Diagnosis for obstructive sleep apnea

A diagnosis from a qualified physician, nurse practitioner, or physician assistant (within their scope of practice) is required.

Diagnostic considerations for obstructive sleep apnea

History and physical examination alone are insufficient to make a definitive diagnosis of OSA. Formal sleep testing by polysomnography or home sleep apnea device testing reported by a physician is required for diagnosis.

A definitive diagnosis requires objective evidence based on polysomnography reporting of the apnea-hypopnea index (AHI) or respiratory disturbance index (RDI). Alternatively, home sleep apnea devices reporting the respiratory event index (REI) may also be used.

Diagnostic criteria for obstructive sleep apnea

The International classification of sleep disorders provides diagnostic criteria for OSA.

Currently, in adults (> 18 years), OSA is diagnosed when the frequency of obstructive events (apneas, hypopneas or respiratory-event related arousals) is greater than 15 per hour.

The disorder may also be diagnosed when the frequency is greater than five per hour and:

  1. symptoms attributable to the disorder (e.g., sleepiness or sleep disruption) are present
  2. nocturnal respiratory distress or observed apnea/habitual snoring are reported
  3. when hypertension, a mood disorder, cognitive dysfunction, coronary artery disease, stroke, congestive heart failure, atrial fibrillation, or type two diabetes mellitus are present.

Clinical features for obstructive sleep apnea

OSA involves the repetitive narrowing and collapse of the upper airway during sleep. This results in decreased airflow (hypopnea) or cessation of airflow (apnea) with subsequent sleep disruption and disturbances in the normal breathing gas exchange. Impaired gas exchange results in lower blood oxygen levels (hypoxemia) and higher blood carbon dioxide levels (hypercapnia).

Individuals with untreated OSA often feel symptoms of being unrested, fatigued, and sleepy during the daytime. Most people with OSA complain of daytime sleepiness, or their bed partner reports loud snoring, gasping, choking, snorting, or interruptions in breathing while sleeping. Up to one third of people with untreated OSA will also report morning headaches, commonly bifrontal and squeezing in quality. While no single symptom or sign can sufficiently predict the diagnosis of OSA, symptoms of OSA tend to increase as OSA severity increases.

People with untreated OSA may suffer from impairments in vigilance, concentration, cognitive function, social interactions, and quality of life. Diminished daytime function can translate into higher rates of job-related and motor vehicle accidents.

Untreated OSA is associated with an increased risk of developing cardiovascular disease, including difficult-to-control (also called refractory) blood pressure, coronary artery disease, congestive heart failure, arrhythmias, stroke, and metabolic dysregulation which affects glucose control and risk for diabetes. These risks are mitigated with accurate diagnosis and treatment.

OSA is more common in males than females with an approximately two to threefold higher risk for males. OSA tends to be less severe in premenopausal females or females receiving hormone replacement treatment compared to untreated postmenopausal females. While snoring and excessive daytime sleepiness are considered hallmarks of OSA, females are more likely to report non-specific symptoms of sleep apnea including headache, fatigue, depression, anxiety, and sleep disruption which contributes to an underdiagnosis of OSA in females. The prevalence of OSA also varies by ethnicity and with increasing rates of obesity.

Increased OSA risk has been observed in senior officers, army personnel, and those with a history of deployment.

Entitlement Considerations for obstructive sleep apnea

In this section

Section A: Causes and/or aggravation for obstructive sleep apnea

Section B: Medical conditions which are to be included in entitlement/assessment of obstructive sleep apnea

Section C: Common medical conditions which may result, in whole or in part, from obstructive sleep apnea and/or its treatment

Section A: Causes and/or aggravation for obstructive sleep apnea

For VAC entitlement purposes, the following factors are accepted to cause or aggravate OSA and mixed sleep apnea, and may be considered along with the evidence to assist in establishing a relationship to service. The factors have been determined based on a review of up-to-date scientific and medical literature, as well as evidence-based medical best practices. Factors other than those listed may be considered, however consultation with a disability consultant or medical advisor is recommended.

The timelines cited below are for guidance purposes. Each case should be adjudicated on the evidence provided and its own merits.

Factors for obstructive sleep apnea

  1. Having trauma or injury resulting in chronic craniofacial or upper airway abnormalities at the time of the clinical onset or aggravation of OSA and mixed sleep apnea. The upper airway includes the nasal cavity, nasopharynx, oropharynx, hypopharynx, or larynx. Examples of anatomical abnormalities of the upper airway include alterations to the mandibular and maxillary size and position, narrowed nasal cavities, and tonsillar and adenoid hypertrophy.
  2. Having chronic nasal congestion, obstruction, or chronic narrowing of the upper airway at the time of clinical onset or aggravation of OSA and mixed sleep apnea.
  3. Having a neuromuscular disease affecting the diaphragm, other respiratory muscles, or upper airway muscles at the time of the clinical onset or aggravation of OSA and mixed sleep apnea. Examples include but are not limited to myasthenia gravis and motor neuron disease.
  4. Having end stage chronic kidney disease at the time of the clinical onset or aggravation of OSA and mixed sleep apnea. End stage chronic kidney disease means having a glomerular filtration rate (GFR) of less than 15 ml/min/1.73m2 for at least three months or in need of ongoing dialysis or renal transplantation.
  5. Having congestive heart failure at the time of clinical onset or aggravation of OSA and mixed sleep apnea.

  6. Having a clinically significant psychiatric condition prior to clinical onset or aggravation of OSA and mixed sleep apnea.

    Note: For VAC purposes, clinically significant means requiring ongoing treatment and clinical management.

  7. Having a history of moderate to severe traumatic brain injury at time of clinical onset or aggravation of OSA and mixed sleep apnea.
  8. Having class 3/severe obesity (defined as body mass index [BMI] of 40 or greater) at the time of clinical onset or aggravation of OSA and mixed sleep apnea.
  9. Using medication from the specified list below before the clinical onset or aggravation of OSA and mixed sleep apnea. The medications include, but are not limited to, the following:
    • benzodiazepines
    • hypnotics
    • opiates.

    Note:

    • Individual medications may belong to a class of medications. The effects of a specific medication may vary from the class. The effects of the specific medication should be considered.
    • If it is claimed a medication resulted in the clinical onset or aggravation of OSA or mixed sleep apnea, the following must be established:
      • the medication was prescribed to treat an entitled condition
      • the individual was receiving the medication at the time of the clinical onset or aggravation of the OSA
      • the current medical literature supports this medication can result in the clinical onset or aggravation of OSA
      • the medication use is long-term, ongoing, and cannot reasonably be replaced with another medication or the medication is known to have enduring effects after discontinuation.
  10. Inability to obtain appropriate clinical management of OSA and mixed sleep apnea.

Section B: Medical conditions which are to be included in entitlement/assessment of obstructive sleep apnea

Section B provides a list of diagnosed medical conditions which are considered for VAC purposes to be included in the entitlement and assessment of OSA and mixed sleep apnea.

  • Central sleep apnea (CSA)
  • Mixed sleep apnea/treatment-emergent CSA/complex sleep apnea

Section C: Common medical conditions which may result, in whole or in part, from obstructive sleep apnea and/or its treatment

Section C is a list of conditions which can be caused or aggravated by OSA and mixed sleep apnea and/or their treatment. Conditions listed in Section C are not included in the entitlement and assessment of OSA and mixed sleep apnea. A consequential entitlement decision may be considered where the individual merits and the medical evidence of the case support a consequential relationship.

Conditions other than those listed in Section C may be considered; consultation with a disability consultant or medical advisor is recommended.

Central sleep apnea (CSA)

Diagnostic standard for central sleep apnea

Diagnosis for central sleep apnea

A diagnosis from a qualified physician, nurse practitioner, or physician assistant (within their scope of practice) is required.

Diagnosis consideration for central sleep apnea

History and physical examination alone are insufficient to make a definitive diagnosis. Formal sleep testing by polysomnography or home sleep apnea device testing reported by a physician is required for diagnosis.

A definitive diagnosis requires objective evidence based on polysomnography reporting of the apnea-hypopnea index (AHI) or respiratory disturbance index (RDI). Alternatively, home sleep apnea devices capable of differentiating OSA from CSA may also be used. Respiratory event index (REI) may be used.

Diagnostic criteria for central sleep apnea

The International Classification of Sleep Disorders lists the diagnostic criteria for all subtypes of CSA. The symptoms and polysomnographic features are nearly identical for the various CSA subtypes. Subtypes include primary CSA, CSA with Cheyne- Stokes breathing, CSA due to high-altitude periodic breathing, CSA due to a medication or substance.

The existing diagnostic criteria address CSA as a sole condition. A significant proportion of individuals with CSA, however, have mixed sleep apnea or complex sleep apnea. In mixed sleep apnea, individuals experience characteristics of both OSA and CSA; diagnosis can be challenging to make because symptoms overlap or shift between the two types.

Clinical features for central sleep apnea

CSAs are characterized by a reduction or cessation of airflow due to absent or reduced respiratory effort. Central apnea (cessation of airflow) or hypopnea (reduction in airflow) may occur in a cyclical or intermittent fashion. The key feature of CSA is a lack of drive to breathe while asleep which results in repeated periods of absent airflow. Although common, CSA is less common than OSA and is often associated with other medical conditions, especially congestive heart failure, stroke, and opioid medications.

CSA encompasses various subtypes with different etiologies, pathophysiology, and treatments. The subtypes of CSA disorders diagnosed in adults are:

  • primary central sleep apnea
  • central sleep apnea with Cheyne-Stokes breathing
  • central sleep apnea due to high altitude breathing
  • central sleep apnea due to a medication or substance
  • central sleep apnea due to a medical disorder without Cheyne-Stokes breathing
  • treatment-emergent central sleep apnea.

Excessive daytime sleepiness is a common feature of CSA and can often go unnoticed or underestimated because of its insidious onset and chronicity. In addition to daytime sleepiness, other symptoms of disrupted sleep may be present, including symptoms of poor sleep quality, fatigue, inattention, poor concentration, moodiness, and decreased libido. Morning headaches may be present and bed partners may report periods of apnea.

CSA should be suspected in people with unexplained daytime sleepiness and risk factors for CSA such as heart failure or chronic use of opioids. CSA may occur in a cyclical or intermittent pattern. Individuals with CSA of various etiologies may also exhibit obstructive events, in which case diagnoses of mixed sleep apnea may be given.

The prevalence of symptomatic CSA appears to be higher in older adults, males, and those individuals with certain comorbid medical conditions such as heart failure, and patients who chronically use opioids.

Entitlement considerations for central sleep apnea

In this section

Section A: Causes and/or aggravation for central sleep apnea

Section : Medical conditions which are to be included in entitlement/assessment of central sleep apnea

Section C: Common medical conditions which may result, in whole or in part, from central sleep apnea and/or its treatment

Section A: Causes and/or aggravation for central sleep apnea

For VAC entitlement purposes, the following factors are accepted to cause or aggravate CSA and mixed sleep apnea, and may be considered along with the evidence to assist in establishing a relationship to service. The factors have been determined based on a review of up-to-date scientific and medical literature, as well as evidence-based medical best practices. Factors other than those listed may be considered, however consultation with a disability consultant or medical advisor is recommended.

The timelines cited below are for guidance purposes. Each case should be adjudicated on the evidence provided and its own merits.

Factors for central sleep apnea

  1. Having a central nervous system lesion or disorder at the time of onset or clinical aggravation of CSA and mixed sleep apnea. Central nervous system lesions or disorders can include moderate to severe traumatic brain injuries, spinal cord injuries involving the cervical spine, or tumours/lesions of the cervical spine.
  2. Having congestive heart failure at the time of clinical onset or aggravation of CSA and mixed sleep apnea.
  3. Having a cerebrovascular accident, also known as a stroke, at the time of clinical onset or aggravation of CSA and mixed sleep apnea.
  4. Having end stage chronic kidney disease at the time of the clinical onset or aggravation of CSA and mixed sleep apnea. End stage chronic kidney disease means having a glomerular filtration rate (GFR) of less than 15 mL/min/1.73m2 for at least three months or in need of ongoing dialysis or renal transplantation.
  5. Using medication from the specified list below before the clinical onset or aggravation of CSA and mixed sleep apnea. The medications include, but are not limited to, the following:
    • benzodiazepines
    • hypnotics
    • opiates.

      Note:

      • Individual medications may belong to a class of medications. The effects of a specific medication may vary from the class. The effects of the specific medication should be considered.
      • If it is claimed a medication resulted in the clinical onset or aggravation of CSA or mixed sleep apnea, the following must be established:
        • the medication was prescribed to treat an entitled condition
        • the individual was receiving the medication at the time of the clinical onset or aggravation of the CSA
        • the current medical literature supports the medication can result in the clinical onset or aggravation of CSA
        • the medication use is long-term, ongoing, and cannot reasonably be replaced with another medication or the medication is known to have enduring effects after discontinuation.
  6. Inability to obtain appropriate clinical management of CSA and mixed sleep apnea.

Section B: Medical conditions which are to be included in entitlement/assessment of central sleep apnea

Section B provides a list of diagnosed medical conditions which are considered for VAC purposes to be included in the entitlement and assessment of CSA and mixed sleep apnea.

  • Obstructive sleep apnea (OSA)
  • Mixed sleep apnea/treatment-emergent CSA/complex sleep apnea

Section C: Common medical conditions which may result, in whole or in part, from central sleep apnea and/or its treatment

Section C is a list of conditions which can be caused or aggravated by CSA and mixed sleep apnea and/or their treatment. Conditions listed in Section C are not included in the entitlement and assessment of CSA and mixed sleep apnea. A consequential entitlement decision may be considered where the individual merits and the medical evidence of the case support a consequential relationship.

Conditions other than those listed in Section C may be considered; consultation with a disability consultant or medical advisor is recommended.

Related VAC guidance and policy:

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