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Obstructive sleep apnoea–hypopnoea syndrome and obesity hypoventilation syndrome

About

What is covered

This NICE Pathway covers the diagnosis and management of OSAHS, OHS and COPD–OSAHS overlap syndrome in people over 16. It aims to improve recognition, investigation and treatment of these related conditions.
Please note that the following guidance from the DVLA and the UK government is relevant to these recommendations:

Updates

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on obstructive sleep apnoea–hypopnoea syndrome and obesity hypoventilation syndrome in over 16s in an interactive flowchart.

What is covered

This NICE Pathway covers the diagnosis and management of OSAHS, OHS and COPD–OSAHS overlap syndrome in people over 16. It aims to improve recognition, investigation and treatment of these related conditions.
Please note that the following guidance from the DVLA and the UK government is relevant to these recommendations:

Sources

NICE guidance and other sources used to create this interactive flowchart.
Hypoglossal nerve stimulation for moderate to severe obstructive sleep apnoea (2017) NICE interventional procedures guidance 598
Soft-palate implants for obstructive sleep apnoea (2007) NICE interventional procedures guidance 241

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

For people with suspected OSAHS, OHS or COPD–OSAHS overlap syndrome who are being referred to a sleep service, provide information on:
  • the underlying causes of their condition
  • what sleep studies involve
  • why treatment is important
  • what treatments are available
  • the impact of excessive sleepiness on safe driving and occupational risk
  • the Driver and Vehicle Licensing Agency (DVLA) guidance on excessive sleepiness and driving and when there is a legal requirement for the person to notify the DVLA of their condition
  • lifestyle changes, including weight loss, increasing physical activity, and avoiding alcohol excess and sedatives before sleep
  • other sources of patient support.

Rationale and impact

For people starting treatment with CPAP or non-invasive ventilation, provide information on:
  • why it is used and how it works
  • the benefits of continuing with treatment and advice on encouraging adherence
  • how to get support for technical and clinical problems, including side effects, and obtain replacement masks and other parts
  • different masks or other interface options, humidification and how to manage problems with masks
  • how often to expect follow-up appointments
  • how to clean and maintain their equipment
  • taking short breaks from treatment
  • making arrangements for travelling with CPAP or non-invasive ventilation.
Advise people using CPAP and non-invasive ventilation that these are aerosol-generating procedures and they should take appropriate precautions if there is a risk that they may have an airborne infection such as COVID-19.
For more information, see the UK government guidance on COVID-19: infection prevention and control and local guidance.
For people starting treatment with a mandibular advancement splint, provide information on:
  • why they are used and how they work
  • the benefits of continuing with treatment and advice on encouraging adherence
  • possible short-term side effects, such as mild discomfort, hypersalivation and altered bite
  • possible long-term side effects, such as problems with dental occlusion
  • adjusting the device to ensure maximum benefit
  • how to clean and maintain the device
  • maintaining good oral health
  • who to contact for help with problems, for example, if the device breaks or the fit becomes poor
  • how often to expect follow-up appointments.
Consider a positional modifier for people with mild or moderate positional OSAHS if other treatments are unsuitable or not tolerated.
A mandibular advancement splint is an oral device used to treat sleep-related breathing disorders. It is worn over the upper and lower teeth, and holds the lower jaw forward, thereby increasing space at the back of the mouth and decreasing snoring and sleep apnoea. A custom-made mandibular advancement splint is formed from a dental impression taken by a dentist, which is used to make the splint in a laboratory. It is then fitted by a suitably trained general dental practitioner. A semi-customised mandibular advancement splint is formed using a dental impression taken by the patient, which they send to the manufacturer to make the splint.
A mandibular advancement splint is an oral device used to treat sleep-related breathing disorders. It is worn over the upper and lower teeth, and holds the lower jaw forward, thereby increasing space at the back of the mouth and decreasing snoring and sleep apnoea. A custom-made mandibular advancement splint is formed from a dental impression taken by a dentist, which is used to make the splint in a laboratory. It is then fitted by a suitably trained general dental practitioner. A semi-customised mandibular advancement splint is formed using a dental impression taken by the patient, which they send to the manufacturer to make the splint.
Severity of OSAHS is determined using the AHI value, as follows:
  • Mild OSAHS: AHI of 5 or more to less than 15
  • Moderate OSAHS: AHI of 15 or more to less than 30
  • Severe OSAHS: AHI of 30 or more.
A sleep study is a test used to diagnose sleep disorders by recording multiple channels during sleep, such as brain activity, breathing rate, blood oxygen level, heart rate, and eye and leg movements. There are several different types of sleep study:
  • oximetry measures arterial oxygen saturation and heart rate while the person is asleep
  • respiratory polygraphy includes at least 4 channels such as oximetry, breathing rate, apnoeas and hyponoeas, snoring and body position
  • polysomnography, which is more detailed and includes respiratory polygraphy measures combined with assessment of sleep quality and duration using additional brain activity, eye movement and muscle tone signals.
A sleep study is a test used to diagnose sleep disorders by recording multiple channels during sleep, such as brain activity, breathing rate, blood oxygen level, heart rate, and eye and leg movements. There are several different types of sleep study:
  • oximetry measures arterial oxygen saturation and heart rate while the person is asleep
  • respiratory polygraphy includes at least 4 channels such as oximetry, breathing rate, apnoeas and hyponoeas, snoring and body position
  • polysomnography, which is more detailed and includes respiratory polygraphy measures combined with assessment of sleep quality and duration using additional brain activity, eye movement and muscle tone signals.
MHRA safety alert for Philips ventilator, CPAP and BiPAP devices: In June 2021, the MHRA issued a National Patient Safety Alert for Philips ventilator, CPAP and BiPAP devices: Potential for patient harm due to inhalation of particles and volatile organic compounds. This applies to all devices manufactured before 26 April 2021.

Glossary

(apnoea-hypopnoea index: the number of apnoeas and hypopnoeas per hour, measured during a multi-channel sleep study)
(a complete pause in breathing, defined as lasting 10 seconds or more on sleep study; an obstructive apnoea is caused by blockage of the upper airway, whereas a central apnoea occurs when there is no respiratory effort)
(a complete pause in breathing, defined as lasting 10 seconds or more on sleep study; an obstructive apnoea is caused by blockage of the upper airway, whereas a central apnoea occurs when there is no respiratory effort)
body mass index
carbon dioxide
chronic obstructive pulmonary disease
(chronic obstructive pulmonary disease—obstructive sleep apnoea–hypopnoea syndrome overlap syndrome)
(continuous positive airway pressure)
Driver and Vehicle Licensing Agency
(a reduction in breathing, defined as lasting for 10 seconds or more on a sleep study; an obstructive hypopnoea is caused by partial obstruction of the upper airway)
(a reduction in breathing, defined as lasting for 10 seconds or more on a sleep study; an obstructive hypopnoea is caused by partial obstruction of the upper airway)
(decreased breathing or under breathing during sleep, which can lead to varying severities of ventilatory failure [low oxygen levels and raised carbon dioxide] – it can be caused by obesity, underlying lung disease, neuromuscular weakness and some medications such as opiates; severe hypercapnia can be caused by nocturnal hypoventilation)
(oxygen desaturation index: the ODI is defined as the number of episodes of oxygen desaturation per hour of sleep)
(obesity hypoventilation syndrome)
(obstructive sleep apnoea–hypopnoea syndrome)
partial pressure of carbon dioxide
(an intervention to encourage patients not to sleep on their backs; there are several devices available such as the tennis ball technique, lumbar or abdominal binders, semi-rigid backpacks, full-length pillows and electronic sleep position trainers)
(an intervention to encourage patients not to sleep on their backs; there are several devices available such as the tennis ball technique, lumbar or abdominal binders, semi-rigid backpacks, full-length pillows and electronic sleep position trainers)
(a type of OSAHS that is affected by the person's sleep position; people with positional OSAHS have anAHI at least twice as high when lying face up [supine] as lying on their side [laterally])
(the use of information and communication technologies to monitor patients remotely and transmit data related to their health; it is used to provide information including respiratory events, pressure requirements, mask leak and adherence)

Paths in this pathway

Pathway created: August 2021 Last updated: August 2021

© NICE 2021. All rights reserved. Subject to Notice of rights.

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