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Snoring and Obstructive Sleep Apnoea in Adults

This guideline applies to adults aged 16 years and over.

 

Introduction

As many as 1 in 4 adults snore1. It is due to a partial obstruction of the upper airways located anywhere from the nose to the vocal cords. It is most common during sleep due to reduced muscle tone. Isolated snoring can be disruptive but is not usually harmful to health. It can be controlled, not cured.

Obstructive sleep apnoea (OSA) is due to a total obstruction of the upper airways while asleep. The apnoea will trigger wakening, typically with a loud snore or snort, leading to disturbed sleep, waking unrefreshed and excessive daytime somnolence.

 

Red Flag Features

Symptoms suggestive of Obstructive Sleep Apnoea (OSA):

  • Witnessed apnoeas, nocturnal choking episodes, waking up gasping
  • Waking unrefreshed
  • Excessive daytime sleepiness/somnolence, impaired alertness
  • Irritability and/or impaired concentration

 

Key Features of Assessment


 

Risk factors for OSA

  • Overweight
  • Male
  • Increasing age
  • Large neck (collar size 17 inches or more)
  • Sedative medications
  • Alcohol and/or smoking
  • Family history
  • Nasal congestion e.g. due to septal deviation or nasal polyps
  • Abnormal upper airways and/or small lower jaw
  • Menopause

 

Complete the Epworth Sleepiness Scale (ESS).

  • Score interpretation:
    • 10 or less: normal daytime sleepiness
    • More than 10: abnormal daytime sleepiness
    • 18 or more: warrants urgent referral to Sleep Service

 

Investigations

Check Thyroid Function Tests at time of referral.

 

Management

For all:

  1. Provide patient information on:
  2. Give lifestyle advice on weight loss, exercise (reduces OSA symptoms alone in absence of weight loss3), alcohol reduction, smoking cessation, sleep hygiene and advise sleeping on side.
     
  3. Review medications and consider stopping drugs with sedative side-effects.
     
  4. Treat rhinitis if applicable.
     
  5. Consider a mandibular advancement device (MAD), such as SnorBan (self-purchase OTC).

 

Additional management for suspected OSA:

  1. Monitor for and manage any associated comorbidities, including hypothyroidism, IHD, AF, cerebrovascular disease, diabetes, hypertension, and depression.
     
  2. Discuss fitness to drive implications (pg. 119).
     
  3. Discuss the use of CPAP if considering referral.

 

CPAP is only effective treatment for established OSA. Explain:

  • improves daytime somnolence, fatigue and quality of life. May also lower BP but no benefit on cardiovascular or cerebrovascular disease3.
  • treatment is usually needed long-term unless there is weight loss sufficient to bring about remission of disease4.

 

Advice and Guidance

In cases of diagnostic uncertainty, consider seeking Respiratory Medicine Advice and Guidance.

Consider seeking ENT Advice and Guidance for consideration of surgery1:

  • if OSA thought to be due to structural nasal pathology (i.e. polyps or septal deviation)
  • to improve compliance with CPAP.

 

Referral

Snoring

Surgery for isolated snoring is not routinely commissioned and is therefore not an indication for secondary care referral.

 

Obstructive Sleep Apnoea (OSA)

Urgent Adult Respiratory Sleep Service Referral

Features of OSA and:

  • Sleepy whilst driving
  • Hazardous occupations e.g. pilots, bus or HGV drivers
  • Confirmed diagnosis, or objective signs, of respiratory failure (such as COPD) or heart failure
  • Epworth Sleepiness Scale score of 18 or more

 

Routine Adult Respiratory Sleep Service Referral

  • Patient would consider the continuous use of CPAP mask, and
  • Symptoms suggestive of OSA and/or
  • Epworth Sleepiness Scale score of more than 10

The Epworth Sleepiness Scale is good at identifying high risk patients but has a poor negative predictive value to exclude OSA, therefore referrals with low scores will not be cancelled5.

 

Exclusions

  • Snoring alone
  • General thoracic referrals
  • Patients who have already been referred and seen within the community

 

Required information

  • BMI within 12 months
  • Epworth Sleepiness Scale score
  • Documented discussion of patient’s willingness to consider CPAP therapy

 

Supporting Information

For professionals:

British Snoring and Sleep Apnoea Association

NHS Inform – Obstructive Sleep Apnoea

For patients:

British Snoring and Sleep Apnoea Association

ENT UK – Snoring and Sleep Apnoea

 

References

  1. Kernow CCG Commissioning policies – snoring in the absence of obstructive sleep apnoea
  2. British Snoring and Sleep Apnoea Association – what is sleep apnoea?
  3. Iftikhar, I., Kline, C. and Youngstedt, S. (2014) Effects of exercise training on sleep apnoea: a meta-analysis. Lung192(1),175-184. Exercise recommendation
  4. NICE CKS – Obstructive Sleep Apnoea Syndrome
  5. Myers KA, Mrkobrada M, Simel DL. Does This Patient Have Obstructive Sleep Apnoea? The Rational Clinical Examination Systematic Review. JAMA. 2013;310(7):731-741. doi:10.1001/jama.2013.276185. Not snoring alone

 

Page Review Information

Review date

23/05/2024

Next review date

23/05/2026

GP speciality lead

Dr Laura Vines

Contributors

Dr James Pickering, Respiratory Consultant & Sleep Service Clinical Lead

Ms Aileen Lambert, ENT Consultant Surgeon

Mr Neil Tan, ENT Consultant Surgeon