Research Priorities for Translating Endophenotyping of Adult Obstructive Sleep Apnea to the Clinic. An Official American Thoracic Society Research Statement

Obstructive sleep apnea (OSA) pathogenesis, clinical manifestations, and consequences vary markedly among patients. Yet, OSA heterogeneity goes largely unaddressed in current management pathways, which are characterized by high treatment failure rates of ~50%. Growing knowledge of OSA pathogenesis has stimulated new lines of investigation for therapies targeted to specific underlying mechanisms or "endotypes". OSA endotypes include the primary anatomical predisposition to pharyngeal collapse, as well as "non-anatomic" mechanisms of low arousal threshold, unstable control of breathing (high loop gain), and impaired pharyngeal dilator muscle function. Identification of inter-individual differences in OSA endotypes and disease expression, or "OSA phenotypes," offer promise for a more targeted approach to OSA management in which appropriate treatments are tailored to individual needs. However, these concepts have largely been limited to the research setting and more evidence is needed to support clinical translation. To outline the rationale for clinical use, challenges, and key research priorities required to translate OSA endophenotyping for delivery of a more tailored approach to improve patient care and outcomes. An international multidisciplinary Working Group with expertise in OSA epidemiology, pathophysiology, diagnostics, and treatments was convened. The Group met at the ATS 2024 International Conference to discuss the current state of OSA endophenotyping and required research objectives. This Research Statement, authored with input from all members, summarizes the group discussion, identified Key Areas and Research Priorities. The Working Group identified research priorities that cover the spectrum from discovery to translation/implementation including technical standards, validation, establishment of clinical cutoffs/minimal clinically important differences, generalizability across diverse populations, stability and reproducibility of measurement, prospective study design/conduct, clinical utility, and impact analysis. This Research Statement provides a road map of the opportunities and key steps required to generate the evidence necessary to translate OSA endophenotyping concepts into clinical care at scale.