Sleep Apnoea and Snoring

Scope

There is a spectrum of severity increasing from occasional snoring through to loud snoring, then mild increasing to severe obstructive sleep apnoea (OSA). Surgical interventions for snoring are often ineffective and cases of simple snoring should not be referred. However, snoring may be a symptom of other pathology which requires further investigation and treatments.

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

Please note referral criteria are applicable in this referral. Referrals submitted without this information will be returned.

Related guidelines:

Allergic Rhinitis

Assessment

History and Examination

  • Nasal obstruction
  • Co­morbidity e.g. obesity, hypothyroidism, ischaemic heart disease, cerebrovascular disease, diabetes, hypertension
  • Smoking history
  • Alcohol consumption
  • Medication history
  • Consider psycho­social impact
  • Assess
    • BMI
    • Nasal airway patency
    • Tonsil and tongue base

Red Flags

  • Symptoms or signs suggestive of oropharyngeal neoplasm e.g: unilateral tonsil and tongue enlargement

Investigations

Obstructive Sleep Apnoea

Snoring with an Epworth Sleepiness Score 12 or more a referral to Respiratory Sleep Medicine Service is appropriate.

Referrals must be accompanied by completed Epworth Sleepiness Score.

Management

Obstructive Sleep Apnoea

  • Significant OSA causes daytime 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 work
    • Evening coffee
    • Restless leg syndrome - Consider referral to Neurology
    • Narcolepsy - Consider referral to Neurology
Prior to referral please consider the following:

The available treatments for OSA are CPAP (Continuous positive airway pressure therapy) 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.

Patients usually only tolerate the treatment if they have sufficient somnolence to impact on their quality of life. The degree that warrants treatment is therefore determined by the patient and their lifestyle. The Epworth score is a helpful measure in conjunction with clinical assessment, scores 11 or less suggest sleep apnoea is unlikely, 14 or more suggests moderate – severe OSA

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.

It is vital that patients with OSA and daytime insomnolence sufficient to impair driving, or the use of machinery, are told to cease immediately, pending treatment

Snoring

Referral is not indicated for simple snoring unless there are features that raise concern of more serious pathology.

As many as 50% patients referred to snoring clinics do not have significant symptoms

Marital disharmony frequently masquerades as a snoring problem

The partner's sleep patterns may be the real problem

Occasionally enlarged tonsils can cause snoring or OSA, and surgery may help

Nasal pathology needs exclusion. Look for:

  • Nasal Polyps
  • Allergic Rhinitis
  • Deviated Nasal Septum

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.

Mandibular splints and CPAP are effective for many with snoring but are usually unacceptable to the patient. (Unlike OSA patients)

Patients with an Epworth Sleepiness Score of 11 or less complaining of the impact of snoring should be counselled without referral to secondary care and advice should be given on implementing the following lifestyle changes where appropriate:

  • Weight reduction if above recommended BMI
  • To stop smoking (offer to refer the patient to smoking cessation services)
  • Reduce or stop evening alcohol intake
  • Keeping the nose clear (including therapies such as nasal sprays or strips)
  • Partners using ear plugs whilst asleep to minimise sleep disruption
  • Self-training to alter their sleep position to avoid lying on back (e.g. sewing lump into back of pyjamas/nightdress as temporary training method).
  • Obtaining a mandibular advancement device to be worn at night from their dentist. The patient must be advised that this device is not funded by the NHS.

Referral

Referral Criteria

Please note referral criteria are applicable in this referral. Referrals submitted without this information will be returned.

Obstructive Sleep Apnoea

Prior to referral exacerbating factors should be considered; Obesity, alcohol, night sedation and smoking should be corrected where possible

Refer to Respiratory
  • Snoring with an Epworth Sleepiness Score 12 or more
  • Completion of Epworth score is a prerequisite of referral to this service
Refer to Neurology

If Hypersomnolence without OSA.

Refer to ENT

Referral is not indicated for simple snoring unless there are features that raise concern of more serious pathology

  • Enlarged tonsils – see tonsillectomy commissioning policy
  • Nasal pathology:
    • Nasal Polyps resistant to treatment
    • Allergic Rhinitis resistant to treatment
    • Deviated Nasal Septum

Referral Instructions

Referral to Respiratory

e-Referral Service selection:

  • Specialty: Sleep Medicine
  • Clinic Type: Sleep Apnoea/Sleep Disordered Breathing
  • Service: DRSS-Northern-Sleep Medicine-NEW Devon CCG- 99P
Referral to ENT

e-Referral Service selection

  • Specialty: ENT
  • Clinic Type: Snoring (not sleep Apnoea)
  • Service: DRSS-Northern-Ear Nose and Throat-NEW Devon CCG- 99P
Refer to Neurology

e-Referral Service selection

  • Specialty: Neurology
  • Clinic Type: Not Otherwise Specified
  • Service: DRSS- Northern-Neurology - NEW Devon CCG-99p

Referral Forms

DRSS referral form

Supporting Information

Patient Information

MyHealth patient information - sleep-apnoea and snoring

Pathway Group

This guideline has been signed off by the Northern Locality on behalf of NEW Devon CCG.

Publication date: November 2017

 

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