referral guidelines for sleep apnoea and snoring patients - Plymouth ...

REFERRAL GUIDELINES FOR SLEEP APNOEA AND SNORING PATIENTS
Introduction:
‣ There is a spectrum of severity increasing from mild snoring through to
moderate, then severe obstructive sleep apnoea (OSA).
‣ Most adults snore intermittently,
‣ 24% of men and 14% of women are habitual snorers.
‣ 5% of men have OSA. It is severe in 0.3% of adults.
‣ Both snoring and OSA are predominantly, but not exclusively, weight related
conditions.
OSA:
Significant OSA causes day-time somnolence. This increases the risk of personal
injury, especially when driving. Hypertension, strokes and myocardial infarction
rates are all increased.
Other causes of daytime somnolence need exclusion: These include:
‣ Poor sleep habit
‣ Shift Working
‣ Hyperthyroidism
‣ Evening coffee
‣ Excess or evening alcohol
‣ Restless leg syndrome ) Refer to
‣ Narcolepsy ) Neurology
Snoring:
If allergic rhinitis or nasal polyps are suspected, a trial of topical nasal steroid spray
for 3 months should be tried.
Nasal alar collapse may be treated with nasal paper strips.
Marital disharmony frequently masquerades as a snoring problem. The partners
sleep patterns may be the real problem.
Mandibular splints are effective for many with snoring but are usually unacceptable
to the patient. Further information on these can be found at www.sleepro.com,
www.snorban.co.uk or obtained from many local dentists
Occasionally enlarged tonsils can cause snoring or OSA, and surgery may help.
Please check before referral.
Palatal surgery is very painful post operatively and has poor results in obese
patients. Up to 30% of patients will acquire a permanent sore/gravelly feeling at the
back of their nose/palate.

Nasal pathology needs exclusion. Look for:
‣ Nasal polyps
‣ Allergic rhinitis
‣ Deviated nasal septum
WHEN AND WHERE TO REFER:
Prior to referral the above differential diagnoses should be considered and
exacerbating factors such as obesity, alcohol, night sedation and smoking should be
corrected.
1. Snoring only: Do not refer to secondary care unless nasal pathology
indicated.
2. Significant OSA: Refer to the Chest Clinic after addressing risk
factors.
3. Hyper somnolence: Refer to Neurology.
PRIOR TO REFERRAL PLEASE CONSIDER THE FOLLOWING:
OSA
The available treatments for OSA are CPAP or mandibular splints. (Surgical
treatments have unpredictable results. It is possible that they might make the use of
CPAP more difficult).
These treatments are only suitable for moderate and severe cases, where
somnolence is significantly affecting lifestyle.
Patients usually only tolerate the treatment if they have sufficient somnolence to
impact on their quality of life. The degree of somnolence that warrants treatment is
therefore, determined by the patient and their lifestyle. The Epworth score is a
helpful measure, scores less than 12 are normal, 14 or more suggests moderate –
severe OSA. (See sample questionnaire).
Occasional nocturnal apnoeas may cause alarm to the sleeping partner but if the
frequency is low then there will be no ensuing daytime somnolence and no need to
treat. Reassurance without referral is sufficient.
Mild or occasional symptoms of OSA do not require referral, as it is unlikely that
treatment will be accepted. There is no evidence of long-term health risk for this
group.
Review of risk factors often leads to improvement, particularly obesity and alcohol
excess. (Trials of Orlistat or Sibutramine are recommended together with dietary and
lifestyle advice)

It is vital that patients with daytime somnolence sufficient to impair driving, or
the use of machinery, are told to cease immediately, pending treatment. This
particularly applies to bus and lorry drivers who should be signed off and
referred urgently.
THE EPWORTH SLEEPINESS SCALE
How likely are you to doze off or fall asleep in the following situations in contrast to
just feeling tired? This refers to your usual way of life in recent times. Even if you
have not done some of these things, try to work out how they would have affected
you.
Use the following scale to choose the most appropriate number for each situation.
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Situation
Chance of Dozing
Sitting and reading
Watching TV
_______________
________________
Sitting inactive in a public place (eg a theatre or a meeting) ________________
As a passenger in a car for an hour without a break
________________
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
________________
________________
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic
________________
________________
TOTAL (max. 24)