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Obstructive sleep apnoea / hypopnoea syndrome -NICE guidance summary

OSAHS is a condition in which the upper airway is narrowed or closes during sleep when muscles relax, causing under breathing ( hypopnoea ) or stopping breathing 
( apnoea ) .

 

When to suspect OSAHS – if they have 2 or more of the following features snores witnessed apnoeas unrefreshing sleep waking headaches unexplained excessive sleepiness , tiredness or fatigue nocturia clocking during sleep sleep fragmentation or insomnia cognitive dysfunction or memory impairment

 

Risk of OSAHS increases in people with  obesity obesity or overweight in pregnancy treatment resistant hypertension type 2 diabetes cardiac arrhythmia – particularly AF stroke ot TIA chronic heart failure moderate or severe asthma polycystic ovary syndrome Down’s syndrome non- arterial anterior ischaemic optic neuropathy – sudden loss of vision in 1 eye due to decreased blood flow to the optic nerve hypothyroidism acromegaly

 

Assessment scales -Use Epworth Sleepiness Scale for initial assessment Consider using the SOP – Bang as well as the the ESS Do not use the Epworth Sleepiness Scale alone to determine if referral is needed as not all people with OSAHS have excessive sleepiness

 

Referral letter – result of assessment scores how does sleepiness affect the person comorbidities occupational risks oxygen saturation and blood gas if available

 

Guidance for rapid assessment by the sleep clinic -they have a vocational driving job job for which vigilance is critical for safety have unstable cardiovascular disease as poorly controlled arrhythmia , nocturnal angina or treatment resistant hypertension they are pregnant undergoing post-operative assessment for major surgery have non- arteritic anterior ischaemic optic neuropathy

 

Lifestyle interventions -Fo all severities of OSAHS
 smoking cessation preventing excessive weight gain address obesity alcohol use disorder

 

Mild OSAHS -if they have no symptoms or symptoms that do not affect usual day time activities
 treatment is usually not needed lifestyle changes and sleep habits can help

 

specialist led care involves offering fixed level continuous positive pressure airway pressure ( CPAP ) mandibular advancement splints positional modifiers – ie encouraging patients not to sleep on their backs surgical interventions as
○ tonsillectomy for people with OSAHS who have large obstructive tonsils and BMI of less than 35 oropharyngeal surgery

 

Rhinitis management -assess for underlying allergic or vasomotor rhinitis if they c/o nasal congestion if rhinitis diagnosed
○ offer topical nasal corticosteroids or antihistamines for allergic rhinitis OR topical nasal corticosteroid for vasomotor rhinitis refer for persistent rhinitis if
○ symptoms do not improve with initial treatment or
○ anatomical obstruction is suspected
 for those on CPAP rhinitis can affect tolerance to CPAP- in such cases
○ changing from a nasal to an orofacial mask and adding humidification can help
○ CPAP can worsen or cause rhinitis and nasal congestion.

 

Obesity hypoventilation syndrome -OHS- combination of obesity ( BMI of 30 or more ) , raised arterial or aterialised capillary
 carbon dioxide level when awake and breathing abnormalities during sleep which may consist of obstructive apnoeas and hypopnoeas or hypoventilation or a combinatio of both. OHS is a specific form of chronic ventilatory failure.

 

When to suspect OHS BMI 30 or more with
 features of OSAHS as described previously features of nocturnal hypoventilation as
○ waking headaches
○ peripheral oedema
○ arterial oxygen saturation less than 94 % on air
○ unexplained polycythemia

 

Assessment scales -use ESS not all people with OHS will have excessive sleepiness- do not use ESS alone to determine if a referral is needed

 

Information to be included in the referral letter -sleepiness score how does sleepiness affect the person BMI comorbidities occupational risk oxygen level and blood gas if available previous h/o emergency admissions and acute non invasive ventilation.

 

COPD –OSAHS overlap syndrome -Occurs in people who have both COPD and obstructive sleep apnoea / hypopnoea syndrome. Combined effect of these conditions on ventilatory load , gas exchange , comorbidities and QoL is greater than either condition alone.

 

In those with confirmed COPD &
 features of OSAHS features of nocturnal hypoventilation.

 

use ESS consider using the STOP- bang questionnaire as well as the EPS not all people with COPD- OSAHS will have excessive sleepiness- do not use EPS alone to determine if a referral is needed offer spirometry to assess the severity of COPD

 

Information in the letter -use ESS consider using the STOP- bang questionnaire as well as the EPS not all people with COPD- OSAHS will have excessive sleepiness- do not use EPS alone to determine if a referral is needed offer spirometry to assess the severity of COPD.

 

lifestyle advice CPAP Non invasive ventilation Supplemental oxygen therapy Rhinitis – as described for OSAHS

 

Patient must inform DVLA if they have
 confirmed moderate or severe obstructive sleep apnoea syndrome ( OSAS ) with excessive sleepiness either narcolepsy or cataplexy or both any other sleep condition that has caused excessive sleepiness for at least 3 months- including suspected or confirmed mild OSAS.

References

  1. obstructive sleep apnoea / hypopnoe syndrome and obesity hypoventilation syndrome in over 16s NICE Guideline 202 August 2021 Overview | Obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome in over 16s | Guidance | NICE
  2. Sleep Apnoea Trust NICE – The Sleep Apnoea Trust Association (sleep-apnoea-trust.org)

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