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Summary for primary care

Obstructive Sleep Apnoea/Hypopnoea Syndrome and Obesity Hypoventilation Syndrome in Over 16s

NICE

Overview

This Guidelines summary covers the diagnosing and managing obstructive sleep apnoea/hypopnoea syndrome (OSAHS), assessing obesity hypoventilation syndrome (OHS), and assessing chronic obstructive pulmonary disease with OSAHS (COPD–OSAHS overlap syndrome).

This summary does not cover diagnostic tests, lifestyle advice, treatments, managing rhinitis, follow-up and monitoring, or supporting adherence to treatment for people with OHS or COPD–OSAHS overlap syndrome.

For a complete list of recommendations, refer to the full guideline.

Medicines and Healthcare products Regulatory Agency (MHRA) safety alert for Philips ventilator, continuous positive airway pressure (CPAP), and bilevel positive airway pressure (BiPAP) devices: In June 2021, the MHRA issued a national patient safety alert for Philips ventilator, CPAP, and BiPAP devices: potential for patient harm due to inhalation of particles and volatile organic compounds. This applies to all devices manufactured before 26 April 2021.

Obstructive Sleep Apnoea/Hypopnoea Syndrome

Initial Assessment for OSAHS

When to Suspect OSAHS

  • 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.
  • 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.

Assessment Scales for Suspected OSAHS

  • When assessing people with suspected OSAHS:
    • 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 OSAHS have excessive sleepiness.

Prioritising People for Rapid Assessment by a Sleep Service

See also the first recommendation in the section, Information for people with OSAHS, OHS or COPD–OSAHS overlap syndrome on providing information for people with suspected OSAHS who are being referred to a sleep service.
  • 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.
  • 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.

Diagnostic Tests for OSAHS

See also the section, Information for people with OSAHS, OHS or COPD–OSAHS overlap syndrome.
  • Offer home respiratory polygraphy to people with suspected OSAHS.
  • 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.
  • Consider respiratory polygraphy or polysomnography if oximetry results are negative but the person has significant symptoms.
  • Consider hospital respiratory polygraphy for people with suspected OSAHS if home respiratory polygraphy and home oximetry are impractical or additional monitoring is needed.
  • Consider polysomnography if respiratory polygraphy results are negative but symptoms continue.
  • Use the results of the sleep study to diagnose OSAHS and determine the severity of OSAHS (mild, moderate or severe).

Lifestyle Advice for All Severities of OSAHS

Treatments for Mild OSAHS

See also the section, Information for people with OSAHS, OHS or COPD–OSAHS overlap syndrome.

Lifestyle Advice Alone for Mild OSAHS

  • 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 the first recommendation in the section, Lifestyle advice for all severities of OSAHS) can help to prevent OSAHS from worsening.

Continuous Positive Airway Pressure for Mild OSAHS

  • 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):
  • For people with mild OSAHS having CPAP:
    • Offer telemonitoring with CPAP for up to 12 months.
    • Consider using telemonitoring beyond 12 months.
  • 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.
  • 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

  • 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

  • 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.
  • 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.

Treatments for Moderate and Severe 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.
  • Offer fixed-level CPAP, in addition to lifestyle advice, to people with moderate or severe OSAHS.
  • For people with moderate or severe OSAHS having CPAP:
    • Offer telemonitoring with CPAP for up to 12 months.
    • Consider using telemonitoring beyond 12 months.
  • 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.
  • 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.
See the recommendation on reducing the risk of transmission of infection when using CPAP in the section, Treatments for mild OSAHS.

Mandibular Advancement Splints for Moderate and Severe OSAHS

  • 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.
  • 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 recommendations on further treatment options for OSAHS, including positional modifiers and surgery, refer to the full guideline.

Managing Rhinitis in People with OSAHS

  • Assess people with nasal congestion and OSAHS for underlying allergic or vasomotor rhinitis.
  • 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.
  • 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.
  • Be aware that:
    • rhinitis can affect people’s tolerance to CPAP but changing from a nasal to an orofacial mask and adding humidification can help
    • CPAP can worsen or cause rhinitis and nasal congestion.

Follow-up and Monitoring for People with OSAHS

Follow-up for People Using CPAP

  • Offer face-to-face, video or phone consultations, including review of telemonitoring data (if available), to people with OSAHS having 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 and apnoea–hypopnoea index (AHI) or oxygen desaturation index (ODI) is achieved.
  • Once CPAP is optimised, consider annual follow-up for people with OSAHS.
  • 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

  • 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

  • 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

  • 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

Monitoring Treatment Efficacy

  • 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).
  • 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.
  • 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.

Supporting Adherence to Treatment for OSAHS

  • 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.
  • 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.

Obesity Hypoventilation Syndrome

Initial Assessment for OHS

When to Suspect OHS

  • Take a sleep history and assess people for OHS if they have a BMI of 30 kg/m2 or more with:
    • features of obstructive sleep apnoea/hypopnoea syndrome or
    • features of nocturnal hypoventilation such as:
      • waking headaches
      • peripheral oedema
      • hypoxaemia (arterial oxygen saturation less than 94% on air)
      • unexplained polycythaemia.

Assessment Scales for Suspected OHS

  • Use the Epworth Sleepiness Scale in the preliminary assessment of sleepiness in people with suspected OHS.
  • Do not use the Epworth Sleepiness Scale alone to determine if referral is needed, because not all people with OHS have excessive sleepiness.

Prioritising People for Rapid Assessment by a Sleep Service

See also the first recommendation in the section, Information for people with OSAHS, OHS or COPD–OSAHS overlap syndrome.
  • When referring people with suspected OHS 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
    • BMI
    • comorbidities
    • occupational risk
    • oxygen saturation and blood gas values, if available
    • any history of emergency admissions and acute non-invasive ventilation.
  • Within the sleep service, prioritise people with suspected OHS 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 recommendations on diagnostic tests, lifestyle advice, treatments, managing rhinitis, follow-up and monitoring, and supporting adherence to treatment for people with OHS, refer to the full guideline.

COPD–OSAHS Overlap Syndrome

Initial Assessment for COPD–OSAHS Overlap Syndrome

When to Suspect COPD–OSAHS Overlap Syndrome

  • Take a sleep history and assess people for COPD–OSAHS overlap syndrome if they have confirmed COPD with features of OSAHS (see the first recommendation in the section, Initial assessment for OSAHS) or features of nocturnal hypoventilation such as:
    • waking headaches
    • peripheral oedema
    • hypoxaemia (arterial oxygen saturation less than 94% on air)
    • unexplained polycythaemia.

Assessment Scales and Tests for Suspected COPD–OSAHS Overlap Syndrome

See the recommendation on reducing the risk of transmission of infection when using CPAP in the section, Treatments for mild OSAHS.

Prioritising People for Rapid Assessment by a Sleep Service

See also the first recommendation in the section, Information for people with 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 recommendations on diagnostic tests, lifestyle advice, treatment, managing rhinitis, follow-up and monitoring, and supporting adherence to treatment for people with COPD–OSAHS overlap syndrome, refer to the full guideline.

Information for People with OSAHS, OHS or COPD–OSAHS Overlap Syndrome

When providing information, follow the recommendations on enabling patients to actively participate in their care in NICE’s guideline on patient experience in adult NHS services and putting shared decision making into practice in NICE’s guideline on shared decision making.

  • For people with suspected obstructive sleep apnoea/hypopnoea syndrome (OSAHS), obesity hypoventilation syndrome (OHS) or chronic obstructive pulmonary disease–obstructive sleep apnoea/hypopnoea syndrome (COPD–OSAHS) overlap syndrome who are being referred to a sleep service, provide information on:
    • the underlying causes of their condition
    • what sleep studies involve
    • why treatment is important
    • what treatments are available
    • the impact of excessive sleepiness on safe driving and occupational risk
    • the Driver and Vehicle Licensing Agency (DVLA) guidance on excessive sleepiness and driving and when there is a legal requirement for the person to notify the DVLA of their condition
    • lifestyle changes, including weight loss, increasing physical activity, and avoiding alcohol excess and sedatives before sleep
    • other sources of patient support.
  • For people who have been diagnosed with OSAHS, OHS or COPD–OSAHS overlap syndrome, repeat the information provided at referral (see the first recommendation in this section) and give additional information on:
    • choosing the best treatment for the person
    • the practicalities of travel.

For recommendations on information related to treatment of OSAHS, OHS, or COPD–OSAHS overlap syndrome, refer to the full guideline.

References

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