Obstructive Sleep Apnoea Syndrome (OSAS)

Referrals are vetted by Respiratory consultants with a subspecialist interest in OSAS. Patients are sent an appointment for an overnight sleep study which is performed in the patient’s own home. They are also asked to complete a detailed proforma.
*Please note there is currently a significant waiting time for home sleep study of around 9 months (Feb 2023).

What happens when sleep study complete?
Virtual clinic: A clinical member of the OSAS team reviews the sleep study result and the patient questionnaire with the following outcomes:

• NOT OSAS – Letter to patient (copied to GP) advising discharge from service with lifestyle advice to patient. 
• Definitely OSAS - Appointed directly to Respiratory nurse-led clinic for trial of CPAP initiation (this could be 'group initiation', if patient agrees, to shorten time to treatment).
• Equivocal – Appointed to Respiratory Consultant Clinic to discuss likelihood of condition and any proposed management.

Sleep nurse clinic CPAP trial: 
Patients are contacted by letter and asked to call the respiratory booking team to arrange an appointment in Nurse Led sleep clinics. Options for clinic attendance are ‘Near Me’ video calls, Face to face and group clinics. Patients requesting ‘Near Me’ are required to collect the equipment from Ninewells hospital respiratory department. All clinic types offer an educational appointment and are advice on how to commence therapy, after this point patients are monitored remotely to ensure they are managing therapy and followed up by virtual call in 10 days. Further follow up is undertaken at 1 months or 6 months depending on efficacy of therapy and compliance. Ongoing review can be initiated by either the sleep team or the patient. Information is uploaded onto clinical portal to advise of outcome.?

Existing patients:

• Patients who have OSAS, and have failed CPAP treatment previously (within 2 years) can be referred directly to the sleep nurse service for further trail of CPAP – please note therapies have not changed for treatment so patients MUST be prepared to retry the same treatment - TAY.sleepservice@nhs.scot
• Patients who have OSAS and continue on treatment but are struggling can be referred directly to the sleep nurse service TAY.sleepservice@nhs.scot or patients can contact the message service 01382 740736.
• Patients who have OSAS and require new equipment should be encouraged to contact the service either using email TAY.sleepservice@nhs.scot or telephone the message service: 01382 740736.

Those who would consider the continuous use of a CPAP mask at night and have symptoms suggestive of OSAS:

• Clear history of excessive daytime sleepiness is key (presence or absence of this primarily dictates whether treatment required, over and above sleep study findings). 

Additionally:

• Persistently unrefreshed after sleep.
• Waking up gasping / witnessed frequent apnoeas.
• Epworth Sleepiness Score ≥10/24 is suggestive but not diagnostic. 
• STOP BANG score ≥5/8 indicates high risk. 
• (Other associated symptoms include sleep fragmentation, headaches, nocturia, worsening memory and/or concentration).

Common comorbidities:

• Elevated BMI
• Persistent hypertension
• Cardiovascular disease: atrial fibrillation and stroke in particular
• Acromegaly
• Hypothyroidism
• Facial abnormalities, e.g. retrognathia

Refer URGENTLY those:

• Who are sleepy whilst driving or working with machinery, or are employed in hazardous occupations (for example pilots or professional drivers). Advise the person not to drive until they have been assessed by a specialist. (Recreational driving or commuting do not warrant an urgent referral, but sleepy drivers do still need to avoid driving - see DVLA guidance).
• With signs or respiratory failure, symptomatic hypertension or unstable cardiovascular disease.

Refer ROUTINELY those:

• With symptoms suggestive of OSAS including evidence of excessive daytime sleepiness. 

Please include in referral details:

• Recent BMI within last 12 months,
• Epworth sleepiness score and/or STOP BANG score.
• Assurance that other common reasons for daytime sleepiness have been explored and addressed, in particular
  • Haemoglobin level
  • Thyroid function
  • Renal function
  • Blood glucose
  • Cardiac disease (ECG)
  • Sedative medication review 
  • Depressive illness
  • Alcohol excess
• Confirmation of patient's willingness to contemplate CPAP therapy. Information regarding this and other aspect of OSAS is available here - Treatment for OSA (Asthma+Lung UK)

Please do not refer if:

• No daytime somnolence (very excessive tiredness/fatigue can be considered if other features of OSAS present)
• Witnessed apnoea, waking up choking, or gasping in the absence of daytime somnolence. Patients (and any bed partner) can be reassured this is common in the general population, but of no clinical consequence in the absence of daytime somnolence. 
• Snoring alone.
• Symptoms limited to disturbed sleeping patterns.
• Unwillingness to accept CPAP treatment. 
• Insomnia (the Sleepio App has been approved by NICE for self-management.)
• Other parasomnias, e.g. sleep walking. These should be referred to neurology if required. 

SCI Gateway/Respiratory/Sleep Apnoea.

SCI Gateway advice.
Patients already on therapy TAY.sleepservice@nhs.scot

NHS Tayside sleep service webpages
NICE Clinical Knowledge Summary
NHS Inform Sleep Apnoea
Sleep Apnoea Trust
British Lung Foundation information about CPAP
Treatment for OSA (British Lung Foundation)
Epworth sleepiness score
DVLA information for professionals about fitness to drive