An estimated 83 million American adults live with obstructive sleep apnea, and roughly 80 to 90 percent of them have never been diagnosed. The gap is not primarily a technology problem, and the newest effort to close it is aimed at the referral pathway rather than at a device.
The American Thoracic Society is working with four health-system teams on a quality improvement project called Optimizing Sleep Apnea Diagnosis in Primary Care, launched this year. The participating sites are West Virginia University, the VA Pittsburgh Healthcare System, the San Francisco Health Network with the University of California San Francisco, and the Mount Sinai Health System. Each will partner with primary care colleagues to increase identification and testing.
Disclosure: The society states that the project is funded by Eli Lilly and Company, which markets a medication approved for obstructive sleep apnea in adults with obesity. Readers should weigh that when assessing any diagnosis-expansion effort.
The Diagnosis Is Missed for Structural Reasons
Understanding why apnea goes undetected explains why a new gadget does not fix it.
The symptoms occur during sleep, so the person experiencing them cannot observe them. Loud snoring, gasping and witnessed pauses in breathing are usually reported by a bed partner, which means people who sleep alone lose the most reliable signal entirely.
The daytime symptoms are easy to attribute to something else. Fatigue, difficulty concentrating, irritability, morning headaches and falling asleep in front of a screen get blamed on work, age, stress or poor sleep habits.
The stereotype also misleads. Apnea is more common in men and in people with obesity, but it occurs in women, in people of normal weight, in older adults whose airway tissue has changed, and in people with anatomical features such as a narrow airway or large tonsils. Women more often report insomnia and fatigue rather than classic snoring, and are diagnosed later as a result.
ATS President Michelle Ng Gong framed the shortfall as systemic rather than individual, saying the number of patients who remain undiagnosed points to barriers in engaging patients at all. The project's stated aims are to increase primary care engagement with screening, streamline sleep testing processes, and improve access to sleep medicine specialists. With the health system partners confirmed, it now moves to testing, refining and evaluating interventions.
What Testing Actually Involves Now
The process is less burdensome than most people assume, which is worth saying because the imagined burden deters referrals.
In-laboratory polysomnography remains the most comprehensive test, requiring an overnight stay with sensors monitoring brain activity, breathing, oxygen, heart rhythm and movement. It is the reference standard and is necessary in complex cases.
For many adults with suspected moderate to severe obstructive sleep apnea and no significant heart or lung disease, a home sleep apnea test is appropriate. The patient sleeps at home wearing a small device that records airflow, respiratory effort, oxygen saturation and heart rate. It is cheaper, faster to schedule and generally covered when criteria are met.
Home tests can produce false negatives, because they measure less and cannot distinguish sleep from wakefulness. A normal home test in someone with strong symptoms often warrants in-lab testing rather than reassurance.
Wearables Screen, They Do Not Diagnose
This distinction is the single most important thing for consumers to understand, and marketing routinely blurs it.
A small number of consumer devices have received FDA clearance for sleep apnea notification features, and others track oxygen saturation and heart rate patterns without any clearance for this purpose. Cleared or not, none of them diagnoses sleep apnea.
The American Academy of Sleep Medicine's position is direct: consumer sleep technology must be FDA cleared and rigorously tested against current standards if it is intended to render a diagnosis, and these tools are not substitutes for medical evaluation.
The practical way to use a wearable is as a prompt. A flagged reading is a reason to see a clinician and request evaluation, not a diagnosis to act on. It is also not a reason for reassurance: a wearable that shows nothing does not rule out apnea, and symptoms outweigh a device reading.
Where wearables may genuinely help is earlier in the funnel, by surfacing people who would never have raised the issue with a clinician at all, and potentially in supporting adherence to treatment after diagnosis is confirmed. Whether they reduce the diagnostic delay at scale has not been established.
Why Untreated Apnea Matters and What to Do
The consequences justify pursuing an answer rather than living with fatigue.
Untreated obstructive sleep apnea is associated with hypertension that resists medication, atrial fibrillation and other arrhythmias, heart failure, stroke, type 2 diabetes and worsened glucose control, depression, and substantially elevated motor vehicle crash risk from daytime sleepiness.
The reasonable steps are ordinary. If you snore loudly, wake gasping, or have unexplained daytime sleepiness, tell a primary care clinician and ask specifically about sleep apnea evaluation. Ask a bed partner what they observe, since their account is often the most useful data available. If you have hypertension that is hard to control, atrial fibrillation or poorly controlled diabetes, raise apnea directly, because those conditions raise the pretest probability.
Treatment is not only CPAP. Options include oral appliances fitted by a dentist, positional therapy, weight management where relevant, surgical approaches in selected patients, and an implanted nerve stimulation device. Anyone who has abandoned CPAP should know that mask fit, pressure settings and humidification are adjustable, and that intolerance is frequently solvable rather than permanent.
Do not drive when severely sleepy, and tell a clinician directly if you have ever nodded off at the wheel. This article is general information and is not a diagnosis.
Frequently Asked Questions
How many cases go undiagnosed? An estimated 83 million American adults have obstructive sleep apnea, and roughly 80 to 90 percent are undiagnosed.
Why is it missed? Symptoms occur during sleep, daytime effects are attributed to stress or age, and the stereotype of who has apnea excludes many people who do.
Can a smartwatch diagnose it? No. A few consumer devices are FDA cleared to notify users of possible apnea, but none diagnoses it. A flagged reading means see a clinician.
What does testing involve? Either an overnight in-lab study or a home sleep apnea test using a small device you wear while sleeping at home.
Can a home test miss it? Yes. A normal home test with strong symptoms often warrants in-lab testing.
Why does treatment matter? Untreated apnea is linked to resistant hypertension, arrhythmias, stroke, diabetes and elevated crash risk.
Is CPAP the only option? No. Oral appliances, positional therapy, surgery and implanted nerve stimulation are alternatives worth discussing.
