Obstructive Sleep Apnoea

 

The term obstructive sleep apnoea/hypopnoea (OSAH) is used to describe people with irregular breathing at night, but without daytime sleepiness.  The British Thoracic Society (BTS) use the term 'obstructive sleep apnoea syndrome' (OSAS) in people with repetitive apnoeas and symptoms of sleep fragmentation with excessive daytime sleepiness. Obstructive sleep apnoea syndrome affects all age groups. Reports suggest that up to 4% of middle-aged men and 2% of middle-aged women are affected in the UK.  International studies suggest that the prevalence of OSAS in children is around 1–2%, and this may be increasing due to increasing obesity

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Risk factors

Risk factors for developing obstructive sleep apnoea syndrome (OSAS) in adults include:

  • Male sex (the male to female ratio is 2–3:1)
  • Obesity
  • Neck circumference greater than 43 cm
  • Family history of OSAS
  • Smoking
  • Alcohol intake before bed
  • Sleeping supine
  • Hypothyroidism
  • Craniofacial abnormalities
  • Acromegaly

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Risk factors for OSAS in children include:

  • Adenotonsillar hypertrophy
  • Obesity
  • Congenital conditions (such as Down's syndrome, neuromuscular disease, craniofacial abnormalities, achondroplasia, and Prader–Willi syndrome)

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When to suspect obstructive sleep apnoea syndrome

Suspect obstructive sleep apnoea syndrome (OSAS) in a person with any of the following symptoms:

  • Excessive daytime sleepiness and snoring and/or impaired concentration.
  • Witnessed apnoeas or choking noises while sleeping
  • Feeling unrefreshed on waking
  • Mood swings, personality changes, or depression
  • Nocturia
  • Rarely, nocturnal sweating, reduced libido, and gastro–oesophageal reflux disease (GORD)

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Suspect OSAS in children with:

  • Snoring and pauses in breathing, which may be followed by a gasp or snort
  • Restlessness and sudden arousals from sleep, laboured breathing, unusual sleep posture (for example head bent backwards), and bedwetting
  • Daytime symptoms such as changes in behaviour (for example irritability), poor concentration, decreased performance at school, tiredness and sleepiness, failure to gain weight or grow, and mouth breathing

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Assessment

  1. Consider if there are features of an alternative diagnosis (e.g. sleep disturbance, sleep deprivation, narcolepsy, restless leg syndrome)
  2. Ask about associated symptoms which may suggest an underlying head or neck cancer, including:
    1. Unilateral nasal bleeding and/or severe nasal obstruction
    2. Change in voice character and/or unexplained hoarseness
    3. Dysphagia
    4. Unusually rapid onset of symptoms in the absence of marked weight gain
  3. Ask about any risk factors for obstructive sleep apnoea syndrome (OSAS)
  4. Ask about the effects of daytime sleepiness on driving and work performance, relationships, mood, sleeping, and social life. In children, ask about school performance, concentration, behaviour, and growth
  5. Take a collateral history from a partner, if possible, regarding snoring habits, apnoeas, and choking episodes
  6. Examine for:
    1. Enlarged tonsils
    2. Small jaw
    3. Nasal blockage (for example due to polyps or a deviated nasal septum)
    4. Signs of chronic obstructive pulmonary disease, respiratory failure, or cor pulmonale (which may influence the urgency of referral)
  7. Check the person's blood pressure, body mass index (BMI), and neck circumference (collar size)
  8. Ask the person to complete an Epworth sleepiness questionnaire, to assess the extent and severity of symptoms
  9. Consider arranging investigations if an underlying cause is suspected (for example thyroid function tests if hypothyroidism is suspected)

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Referral

  1. Refer urgently (2-week wait) to ENT if there are features suggestive of a head and neck cancer
  2. Refer to the sleep clinic for confirmation of the diagnosis using sleep studies and for secondary care treatments (for example continuous positive airway pressure)
  3. For adults, refer urgently those:
    1. Who are sleepy whilst driving or working with machinery, or are employed in hazardous occupations (for example pilot or bus or lorry driver). Advise the person not to drive until they have been assessed by a specialist
    2. With signs of respiratory failure or heart failure
    3. With symptoms suggestive of severe obstructive sleep apnoea syndrome (OSAS) and coexistent chronic obstructive pulmonary disease
  4. For adults, refer routinely those with symptoms suggestive of OSAS and/or an accompanying Epworth sleepiness questionnaire score of more than 10
  5. For adults where there are concerns about job security, ensure through personal communication with the sleep unit that diagnosis and treatment can be completed within four weeks of referral
  6. Refer children to a paediatric ENT specialist if they have clinical features of adenotonsillar hypertrophy, symptoms of persistent snoring, and features of OSAS

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Management in primary care

  1. Give lifestyle advice (if appropriate) on weight loss, exercise, reducing alcohol intake and sedative use, and smoking cessation - see CVD Prevention
  2. Advise on sleeping position:  if the person sleeps supine, advise them to try sleeping on their side
  3. Assess the person's risk of cardiovascular disease and diabetes
  4. Monitor the person's blood pressure regularly
  5. Encourage adherence to treatment, such as continuous positive airway pressure (CPAP) or intra-oral devices. Explain that both CPAP and intra-oral devices help manage symptoms and reduce the risk of long–term complications
  6. Give advice on driving and entitlement to drive. Advise the person to check with their insurer that they are still insured to drive under their current policy
  7. Give information on support groups that provide self-management advice (e.g. the British Snoring and Sleep Apnoea Association)

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Blood tests / Phlebotomy

If your practice does not have a practice nurse who is trained to take bloods, you can refer a patient to the Pathology Department at East Kent Hospitals for a blood test (find details here)

Alternatively, Buckland Hospital (Dover) and the Royal Victoria Hospital (Folkestone) both operate a walk-in service where no appointment is necessary, except for if the patient requires a Glucose Tolerance Test (GTT).  In the event that a GTT is required, please call 01304 222552 (for Buckland) and 01303 854484 (for Royal Victoria) to arrange a suitable appointment

Please ensure that the patient remembers to take with them their blood test form to the walk-in centres

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Sleep Studies Clinics

If a patient has sleep apnoea or obesity-related respiratory failure, enquiries for the sleep studies clinics may be made here

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Epworth Sleepiness Scale

Use the Epworth sleepiness questionnaire, to assess the extent and severity of sleep apnoea symptoms

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

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