Obstructive Sleep Apnoea Syndrome

Assess the symptoms above in the history.

Examine for contributing/exacerbating factors:

• BMI
• BP
• Neck circumference (collar size)
• Micrognathia (small jaw)/retrognathia (abnormal jaw positioning with mandible set back from the maxilla)
• Signs of respiratory disease

Bloods:

• FBC, U&E, TFT, HbA1c, ferritin, B12, bicarbonate (a normal bicarbonate is helpful in suggesting against ventilatory failure)

Scores can be helpful. An Epworth score of > 10 suggests 'abnormal' somnolence. 

Guidance from DVLA and BTS suggests that cessation of driving may not be necessary pending assessment.

Patients should be advised, with documentation, that it is their legal responsibility not to drive if sleepy, and to consider whether their excessive sleepiness has, or seems likely to have, impact on safe driving. They should be directed to DVLA sleepiness guidance - 'Tiredness can kill: Advice for drivers (INF159)'.

If there have been symptoms when driving, especially involving accidents or near misses, then they should be advised to stop driving (but the legal responsibility remains theirs).

They should NOT be advised to notify DVLA until the diagnosis is confirmed.

• Patients with overweight or obesity should be advised on weight loss. 10-15% weight loss results in a 50% reduction in OSAS symptoms so weight loss should be the key treatment for these patients, including referral to weight management clinic, if appropriate.
• Advise stopping smoking
• Advise reducing alcohol
• Advise on sleep hygiene (Sleepio app can be helpful)

Refer patients with abnormal Epworth score (>10) and history suggestive of OSAS to sleep clinic via SCI Gateway...DGRI...Respiratory Medicine...Sleep Study

Patients with normal Epworth score (< 11) but still with a very good history of apnoeas and history suggestive of OSAS, particularly those who you feel may be minimising their symptoms.

Useful information in referral letter (helps with prioritisation):

• Are they a professional driver?
• Documented Epworth score
• Details of significant co-morbidities such as unstable cardiac disease
• Document that you have advised re driving
• Details of sleep pattern - patients with erratic sleep patterns as cause of sleepiness should deal with that first

Patients who are professional drivers or with significant co-morbidities will be seen urgently so it is important to ensure this is clear in the referral.

Do not refer:

• Patients with insomnia
• Patients with poor sleep hygiene/erratic sleep patterns as cause for sleepiness
• Patients with snoring alone
• Patients under 16 - refer to paediatrics instead

It is best to discuss patients with a potential parasomnia with respiratory first as they may be best referred to the tertiary sleep clinic in Edinburgh.