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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:
COPD–OSAHS overlap syndrome occurs in people who have both chronic obstructive pulmonary disease (COPD) and obstructive sleep apnoea/hypopnoea syndrome (OSAHS). The combined effect of these conditions on ventilatory load, gas exchange, comorbidities and quality of life is greater than either condition alone.
Recommendations in this guideline cover assessment and treatment of OSAHS in people with COPD. For recommendations on the diagnosis and management of COPD, see the NICE guidelines on chronic obstructive pulmonary disease in over 16s and chronic obstructive pulmonary disease (acute exacerbation): antimicrobial prescribing. See also NICE's guideline on community-based care of patients with COPD during the COVID-19 pandemic.
Take a sleep history and assess people for COPD–OSAHS overlap syndrome if they have confirmed COPD with:
features of OSAHS (see recommendation 1.1.1) or
features of nocturnal hypoventilation such as:
waking headaches
peripheral oedema
hypoxaemia (arterial oxygen saturation less than 94% on air)
unexplained polycythaemia.
For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on when to suspect COPD–OSAHS overlap syndrome.
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.
When assessing people with suspected COPD–OSAHS overlap syndrome:
Use the Epworth Sleepiness Scale in the preliminary assessment of sleepiness.
Consider using the STOP-Bang Questionnaire, as well as the Epworth Sleepiness Scale.
Do not use the Epworth Sleepiness Scale alone to determine if referral is needed, because not all people with COPD–OSAHS overlap syndrome have excessive sleepiness.
Offer spirometry to assess the severity of COPD in people with suspected COPD–OSAHS overlap syndrome (see the recommendations on spirometry in NICE's guideline on chronic obstructive pulmonary disease in over 16s).
Be aware that spirometry 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.
For more information, see the UK government guidance on COVID-19: infection prevention and control and local guidance.
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 and tests for suspected COPD–OSAHS overlap syndrome.
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.
When referring people with suspected COPD–OSAHS overlap syndrome to a sleep service, include the following information in the referral letter to facilitate rapid assessment:
results of the person's sleepiness score
how sleepiness affects the person
body mass index (BMI)
severity and frequency of exacerbations of COPD
use of oxygen therapy at home
comorbidities
occupational risk
oxygen saturation and blood gas values, if available
any history of acute non-invasive ventilation.
Within the sleep service, prioritise people with suspected COPD–OSAHS overlap syndrome for rapid assessment if any of the following apply:
they have severe hypercapnia (PaCO2 [partial pressure of carbon dioxide] over 7.0 kPa when awake)
they have hypoxaemia (arterial oxygen saturation less than 94% on air)
they have acute ventilatory failure
they have a vocational driving job
they have a job for which vigilance is critical for safety
they are pregnant
they have unstable cardiovascular disease, for example, poorly controlled arrhythmia, nocturnal angina, heart failure or treatment-resistant hypertension
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.
Measure arterial or arterialised capillary blood gas when the person with suspected COPD–OSAHS overlap syndrome is awake, to assess for ventilatory failure.
Do not delay treatment for acute ventilatory failure to carry out further investigations for COPD–OSAHS overlap syndrome.
Offer respiratory polygraphy, either in hospital or at home, to diagnose OSAHS in people with suspected COPD–OSAHS overlap syndrome.
Consider adding transcutaneous carbon dioxide (CO2) monitoring during sleep to respiratory polygraphy to provide additional information to guide treatment.
Do not use oximetry alone to diagnose OSAHS or nocturnal hypoventilation in people with suspected COPD–OSAHS overlap syndrome.
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 COPD–OSAHS overlap syndrome.
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.
For people with COPD–OSAHS overlap syndrome, follow recommendation 1.4.1 on lifestyle advice for people with OSAHS. Prioritise advice on stopping smoking and follow the recommendations on smoking cessation in NICE's guideline on chronic obstructive pulmonary disease in over 16s.
See also section 4 on providing information for people starting treatment for COPD–OSAHS overlap syndrome.
Consider continuous positive airway pressure (CPAP) as first-line treatment for people with COPD–OSAHS overlap syndrome if they do not have severe hypercapnia (PaCO2 of 7.0 kPa or less).
Consider non-invasive ventilation instead of CPAP for people with COPD–OSAHS overlap syndrome with nocturnal hypoventilation if they have severe hypercapnia (PaCO2 greater than 7.0 kPa).
Consider heated humidification in addition to CPAP for people with COPD–OSAHS overlap syndrome and upper airway side effects such as nasal and mouth dryness, and CPAP-induced rhinitis.
Be aware that CPAP and non-invasive ventilation are aerosol-generating procedures 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 NICE's guideline on community-based care of patients with COPD during the COVID-19 pandemic, the UK government guidance on COVID-19: infection prevention and control and local guidance.
Consider supplemental oxygen for people with COPD–OSAHS overlap syndrome if hypoxaemia persists once control of apnoea and nocturnal hypoventilation has been optimised by CPAP or non-invasive ventilation, and address any additional underlying causes of hypoxaemia where possible.
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 COPD–OSAHS overlap syndrome.
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 I: oxygen therapy.
For people with COPD–OSAHS overlap syndrome, follow the recommendations on managing rhinitis in people with OSAHS.
Tailor follow-up to the person's overall treatment plan, which may include lifestyle changes and treating comorbidities. It may also include discussions about care planning (for example, COPD exacerbation action plan and advance care planning) for those with severe COPD. See the recommendations on self-management in the NICE guideline on chronic obstructive pulmonary disease in over 16s and tailoring healthcare services for each patient in the NICE guideline on patient experience in adult NHS services.
Offer face-to-face, video or phone consultations, including review of telemonitoring data (if available), to people with COPD–OSAHS overlap syndrome having non-invasive ventilation or CPAP. This should include:
an initial consultation within 1 month and
subsequent follow-up according to the person's needs and until optimal control of symptoms, apnoea–hypopnoea index (AHI) or oxygen desaturation index (ODI), oxygenation and hypercapnia is achieved.
When non-invasive ventilation or CPAP (with or without oxygen therapy) has been optimised for people with COPD–OSAHS overlap syndrome and their symptoms are controlled, consider 6‑monthly to annual follow-up according to the person's needs.
Offer people with COPD–OSAHS overlap syndrome having non-invasive ventilation or CPAP access to a sleep and ventilation service for advice, support and equipment between follow-up appointments.
Ensure follow-up is in line with Driver and Vehicle Licensing Agency guidance on assessing fitness to drive.
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 COPD–OSAHS overlap syndrome.
Full details of the evidence and the committee's discussion are in evidence review L: monitoring.
Assess the effectiveness of treatment with CPAP or non-invasive ventilation in people with COPD–OSAHS overlap syndrome by reviewing the following:
symptoms of OSAHS and nocturnal hypoventilation, including the Epworth Sleepiness Scale and vigilance, for example, when driving
severity of OSAHS, using AHI or ODI
improvement in oxygenation and hypercapnia while awake and asleep
adherence to therapy
telemonitoring or download information from the device (if available).
Explore with the person their understanding and experience of treatment, and review the following:
mask type and fit, including checking for leaks
nasal and mouth dryness, and need for humidification
other factors affecting sleep disturbance such as insomnia, restless legs and shift work
sleep hygiene
cleaning and maintenance of equipment.
Be aware that some symptoms associated with COPD such as cough and wheeze, and certain medications such as theophyllines, may adversely affect sleep quality.
For people with COPD–OSAHS overlap syndrome having supplemental oxygen therapy, review whether this is still needed after treatment with non-invasive ventilation or CPAP has been optimised.
Consider stopping CPAP or non-invasive ventilation and using a symptom-management approach for people with COPD–OSAHS overlap syndrome who have severe COPD if, despite treatment optimisation, CPAP or non-invasive ventilation does not improve their symptoms or quality of life, or adds to the burden of therapy.
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 for people with COPD–OSAHS overlap syndrome.
Full details of the evidence and the committee's discussion are in evidence review M: demonstration of efficacy.
Offer people with COPD–OSAHS overlap syndrome educational or supportive interventions, or a combination of these, tailored to the person's needs and preferences, to improve adherence to CPAP and non-invasive ventilation.
Interventions to support adherence to treatment for COPD–OSAHS overlap syndrome 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 COPD–OSAHS overlap syndrome.
Full details of the evidence and the committee's discussion are in evidence review N: adherence.