Guidance

1 Obstructive sleep apnoea/hypopnoea syndrome

1 Obstructive sleep apnoea/hypopnoea syndrome

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

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Please note that the following guidance from the Driver and Vehicle Licensing Agency (DVLA) and the UK government is relevant to these recommendations:

Obstructive sleep apnoea/hypopnoea syndrome (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). The person wakes or lightens sleep to stop these episodes, which can lead to disrupted sleep and potentially excessive sleepiness.

1.1 Initial assessment for OSAHS

When to suspect OSAHS

1.1.1

Take a sleep history and assess people for OSAHS if they have 2 or more of the following features:

  • snoring

  • witnessed apnoeas

  • unrefreshing sleep

  • waking headaches

  • unexplained excessive sleepiness, tiredness or fatigue

  • nocturia (waking from sleep to urinate)

  • choking during sleep

  • sleep fragmentation or insomnia

  • cognitive dysfunction or memory impairment.

1.1.2

Be aware that there is a higher prevalence of OSAHS in people with any of the following conditions:

  • obesity or overweight

  • obesity or overweight in pregnancy

  • treatment-resistant hypertension

  • type 2 diabetes

  • cardiac arrythmia, particularly atrial fibrillation

  • stroke or transient ischaemic attack

  • chronic heart failure

  • moderate or severe asthma

  • polycystic ovary syndrome

  • Down's syndrome

  • non-arteritic anterior ischaemic optic neuropathy (sudden loss of vision in 1 eye due to decreased blood flow to the optic nerve)

  • hypothyroidism

  • acromegaly.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on when to suspect OSAHS.

Full details of the evidence and the committee's discussion are in evidence review A: when to suspect OSAHS, OHS and COPD–OSAHS overlap syndrome.

Assessment scales for suspected OSAHS

1.1.4

Do not use the Epworth Sleepiness Scale alone to determine if referral is needed, because not all people with OSAHS have excessive sleepiness.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on assessment scales for suspected OSAHS.

Full details of the evidence and the committee's discussion are in evidence review B: assessment tools for people with suspected OSAHS, OHS or COPD–OSAHS overlap syndrome.

1.2 Prioritising people for rapid assessment by a sleep service

See also recommendation 4.1.1 on providing information for people with suspected OSAHS who are being referred to a sleep service.

1.2.1

When referring people with suspected OSAHS to a sleep service, include the following information in the referral letter to facilitate rapid assessment:

  • results of the person's assessment scores

  • how sleepiness affects the person

  • comorbidities

  • occupational risk

  • oxygen saturation and blood gas values, if available.

1.2.2

Within the sleep service, prioritise people with suspected OSAHS for rapid assessment if any of the following apply:

  • they have a vocational driving job

  • they have a job for which vigilance is critical for safety

  • they have unstable cardiovascular disease, for example, poorly controlled arrhythmia, nocturnal angina or treatment-resistant hypertension

  • they are pregnant

  • they are undergoing preoperative assessment for major surgery

  • they have non-arteritic anterior ischaemic optic neuropathy.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on prioritising people for rapid assessment by a sleep service.

Full details of the evidence and the committee's discussion are in evidence review C: prioritisation for rapid assessment at a sleep centre of people with suspected OSAHS, OHS or COPD–OSAHS overlap syndrome.

1.3 Diagnostic tests for OSAHS

See also section 4 on providing information for people who have been diagnosed with OSAHS.

1.3.1

Offer home respiratory polygraphy to people with suspected OSAHS.

1.3.2

If access to home respiratory polygraphy is limited, consider home oximetry for people with suspected OSAHS. Take into account that oximetry alone may be inaccurate for differentiating between OSAHS and other causes of hypoxaemia in people with heart failure or chronic lung diseases.

1.3.3

Consider respiratory polygraphy or polysomnography if oximetry results are negative but the person has significant symptoms.

1.3.4

Consider hospital respiratory polygraphy for people with suspected OSAHS if home respiratory polygraphy and home oximetry are impractical or additional monitoring is needed.

1.3.5

Consider polysomnography if respiratory polygraphy results are negative but symptoms continue.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on diagnostic tests for OSAHS.

Full details of the evidence and the committee's discussion are in evidence review D: diagnostic tests for OSAHS, OHS and COPD–OSAHS overlap syndrome.

1.4 Lifestyle advice for all severities of OSAHS

1.4.1

Discuss appropriate lifestyle changes with all people with OSAHS. Provide support and information on losing weight, stopping smoking, reducing alcohol intake and improving sleep hygiene, tailored to the person's needs and in line with the NICE guidelines on:

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on lifestyle advice for all severities of OSAHS.

1.5 Treatments for mild OSAHS

See also section 4 on providing information for people starting treatment for OSAHS.

Lifestyle advice alone for mild OSAHS

1.5.1

Explain to people with mild OSAHS who have no symptoms or with symptoms that do not affect usual daytime activities that:

  • treatment is not usually needed and

  • changes to lifestyle and sleep habits (see recommendation 1.4.1 on lifestyle advice) can help to prevent OSAHS from worsening.

Continuous positive airway pressure for mild OSAHS

Recommendation 1.5.2 updates recommendation 1.2 in NICE's technology appraisal guidance on continuous positive airway pressure for the treatment of obstructive sleep apnoea/hypopnoea syndrome.

1.5.2

For people with mild OSAHS who have symptoms that affect their quality of life and usual daytime activities, offer fixed-level continuous positive airway pressure (CPAP):

1.5.3

For people with mild OSAHS having CPAP:

  • Offer telemonitoring with CPAP for up to 12 months.

  • Consider using telemonitoring beyond 12 months.

1.5.4

Consider auto‑CPAP as an alternative to fixed-level CPAP in people with mild OSAHS if:

  • high pressure is needed only for certain times during sleep or

  • they are unable to tolerate fixed-level CPAP or

  • telemonitoring cannot be used for technological reasons or

  • auto‑CPAP is available at the same or lower cost than fixed-level CPAP, and this price is guaranteed for an extended period of time.

1.5.5

Consider heated humidification for people with mild OSAHS having CPAP who have upper airway side effects, such as nasal and mouth dryness, and CPAP-induced rhinitis.

Reducing the risk of transmission of infection when using CPAP
1.5.6

Be aware that CPAP is an aerosol-generating procedure and, if there is a risk of airborne infection, such as COVID‑19, appropriate infection control precautions should be taken. These may include setting up the device at home by video consultation or with precautions in hospital.

For more information, see the UK government guidance on COVID-19: infection prevention and control and local guidance.

Mandibular advancement splints for mild OSAHS

1.5.7

If a person with mild OSAHS and symptoms that affect their usual daytime activities is unable to tolerate or declines to try CPAP, consider a customised or semi-customised mandibular advancement splint as an alternative to CPAP if they:

  • are aged 18 and over and

  • have optimal dental and periodontal health.

1.5.8

Be aware that semi-customised mandibular advancement splints may be inappropriate for people with:

  • active periodontal disease or untreated dental decay

  • few or no teeth

  • generalised tonic-clonic seizures.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on treatments for mild OSAHS.

Full details of the evidence and the committee's discussion are in:

1.6 Treatments for moderate and severe OSAHS

See also section 4 on providing information for people starting treatment for OSAHS.

CPAP for moderate and severe OSAHS

CPAP is recommended as a treatment option for adults with moderate or severe symptomatic OSAHS in NICE's technology appraisal guidance on continuous positive airway pressure for the treatment of obstructive sleep apnoea/hypopnoea syndrome.

1.6.1

Offer fixed-level CPAP, in addition to lifestyle advice, to people with moderate or severe OSAHS.

1.6.2

For people with moderate or severe OSAHS having CPAP:

  • Offer telemonitoring with CPAP for up to 12 months.

  • Consider using telemonitoring beyond 12 months.

1.6.3

Consider auto‑CPAP as an alternative to fixed-level CPAP in people with moderate or severe OSAHS if:

  • high pressure is needed only for certain times during sleep or

  • they are unable to tolerate fixed-level CPAP or

  • telemonitoring cannot be used for technological reasons or

  • auto‑CPAP is available at the same or lower cost than fixed-level CPAP, and this price is guaranteed for an extended period of time.

1.6.4

Consider heated humidification for people with moderate or severe OSAHS having CPAP who have upper airway side effects such as nasal and mouth dryness, and CPAP-induced rhinitis.

Reducing the risk of transmission of infection when using CPAP
1.6.5

Be aware that CPAP is an aerosol-generating procedure and, if there is a risk of airborne infection, such as COVID‑19, appropriate infection control precautions should be taken. These may include setting up the device at home by video consultation or with precautions in hospital.

For more information, see the UK government guidance on COVID-19: infection prevention and control and local guidance.

Mandibular advancement splints for moderate and severe OSAHS

1.6.6

If a person with moderate or severe OSAHS is unable to tolerate or declines to try CPAP, consider a customised or semi-customised mandibular advancement splint as an alternative to CPAP if they:

  • are aged 18 and over and

  • have optimal dental and periodontal health.

1.6.7

Be aware that semi-customised mandibular advancement splints may be inappropriate for people with:

  • active periodontal disease or untreated dental decay

  • few or no teeth

  • generalised tonic-clonic seizures.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on treatments for moderate and severe OSAHS.

Full details of the evidence and the committee's discussion are in evidence review F: positive airway pressure therapy variants for OSAHS, OHS and COPD–OSAHS overlap syndrome and evidence review G: oral devices.

1.7 Further treatment options for OSAHS

Positional modifiers for OSAHS

1.7.2

Be aware that positional modifiers are unlikely to be effective in severe OSAHS.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on positional modifiers for OSAHS.

Full details of the evidence and the committee's discussion are in evidence review H: positional modifiers.

Surgery for OSAHS

1.7.3

Consider tonsillectomy for people with OSAHS who have large obstructive tonsils and a body mass index (BMI) of less than 35 kg/m2.

1.7.4

Consider referral for assessment for oropharyngeal surgery in people with severe OSAHS who have been unable to tolerate CPAP and a customised mandibular advancement splint despite medically supervised attempts.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on surgery for OSAHS.

Full details of the evidence and the committee's discussion are in evidence review J: surgery.

1.8 Managing rhinitis in people with OSAHS

1.8.1

Assess people with nasal congestion and OSAHS for underlying allergic or vasomotor rhinitis.

1.8.2

If rhinitis is diagnosed in people with OSAHS, offer initial treatment with:

  • topical nasal corticosteroids or antihistamines for allergic rhinitis or

  • topical nasal corticosteroids for vasomotor rhinitis.

1.8.3

For people with OSAHS and persistent rhinitis, consider referral to an ear, nose and throat specialist if:

  • symptoms do not improve with initial treatment or

  • anatomical obstruction is suspected.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on managing rhinitis in people with OSAHS.

Full details of the evidence and the committee's discussion are in evidence review K: rhinitis.

1.9 Follow-up and monitoring for people with OSAHS

Follow-up for people using CPAP

1.9.2

Offer face-to-face, video or phone consultations, including review of telemonitoring data (if available), to people with OSAHS having CPAP. This should include:

1.9.3

Once CPAP is optimised, consider annual follow-up for people with OSAHS.

1.9.4

Offer people with OSAHS having CPAP access to a sleep service for advice, support and equipment between follow-up appointments.

Follow-up for people using mandibular advancement splints

1.9.5

Offer face-to-face, video or phone consultations, including review of downloads from the device (if available), to people with OSAHS using a mandibular advancement splint. This should include:

  • initial follow-up to review adjustment of the device and symptom improvement at 3 months and

  • subsequent follow-up according to the person's needs and until optimal control of symptoms and AHI or ODI is achieved.

Follow-up for people using positional modifiers

1.9.6

Offer face-to-face, video or phone consultations, including review of downloads from the device (if available), to people with OSAHS using a positional modifier. This should include:

  • an initial consultation within 3 months and

  • subsequent follow-up according to the person's needs until optimal control of symptoms and AHI or ODI is achieved.

Follow-up for people who have had surgery

1.9.7

Offer people with OSAHS who have had surgery:

  • an initial follow-up consultation with respiratory polygraphy within 3 months of the operation and

  • subsequent follow-up according to the person's needs.

Follow-up for drivers with excessive sleepiness

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on follow-up for people with OSAHS.

Full details of the evidence and the committee's discussion are in evidence review L: monitoring.

Monitoring treatment efficacy

1.9.9

Assess the effectiveness of treatment with CPAP, mandibular advancement splints and positional modifiers in people with OSAHS by reviewing the following:

  • OSAHS symptoms, including the Epworth Sleepiness Scale and vigilance, for example, when driving

  • severity of OSAHS, using AHI or ODI

  • adherence to therapy

  • telemonitoring data or download information from the device (if available).

1.9.10

Explore with people using CPAP their understanding and experience of treatment, and review the following:

  • mask type and fit, including checking for leaks

  • nasal or mouth dryness, and the need for humidification

  • other factors affecting sleep disturbance such as insomnia, restless legs and shift work

  • sleep hygiene

  • cleaning and maintenance of equipment.

1.9.11

Consider stopping treatment if OSAHS may have resolved, for example, with significant weight loss. After at least 2 weeks without treatment:

  • re-evaluate any return of symptoms and

  • consider a sleep study.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on monitoring treatment efficacy in people with OSAHS.

Full details of the evidence and the committee's discussion are in evidence review M: demonstration of efficacy.

1.10 Supporting adherence to treatment for OSAHS

1.10.1

Offer people with OSAHS educational or supportive interventions, or a combination of these, tailored to the person's needs and preferences, to improve adherence to CPAP, mandibular advancement splints and positional modifiers.

1.10.2

Interventions to support adherence to treatment for OSAHS should be given by trained specialist staff when treatment is started and as needed at follow-up.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on supporting adherence to treatment for OSAHS.

Full details of the evidence and the committee's discussion are in evidence review N: adherence.