Summary & Recommendations
OSA is the most common form of sleep-disordered breathing.
The summary includes a description of the risk factors, symptoms, diagnosis (questionnaires and sleep studies), and treatment options.
Offer education about management of the risk factors and consequences of OSA
- Excessive sleepiness
- Fatigue
- Snoring
- Witnessed breathing cessation
- Sleep disruption and frequent awakenings
- Nocturia
- Disruption of concentration, memory and executive functions
- Depressed mood
- Decreased work performance
Daytime sleepiness, a symptom of some but not all patients with OSA, is common in the general population and therefore other causes should be excluded including sleep restriction or other disorders that may require separate advice and management.
Common risk factors
- Male gender
- Age over 50 year
- Overweight and obesity
- Excess alcohol consumption
Additionally for females:
- Post-menopause
Less common risk factors
- Enlarged tonsils
- Craniofacial abnormalities (e.g. small mandible)
The prevalence of OSA is increased in patients with:
- Type 2 diabetes
- Hypertension
- Cardiovascular disease
- Prescribed opioids (mainly a risk factor for central sleep apnoea)
- Sedative medications
Manage cardiovascular/ metabolic comorbidities, and insomnia (with cognitive behavioural therapy (CBTi))
Untreated OSA is a risk factor for motor vehicle accidents - Assessment fitness to drive
Advice should be provided to all patients suspected of having symptomatic OSA. Patients who report having a recent fall-sleep accident or near-miss accident should be advised to stop driving until the diagnosis is established and treatment initiated.
- Hypertension
- Cardiovascular disease
- Insulin resistance
- Impotence
- Insomnia
- Restless legs or periodic limb movements
OSA with co-morbid insomnia should consider having the insomnia treated.
DIAGNOSIS
A diagnosis of OSA is based upon patient history, physical examination and the use of questionnaires and a sleep study.
History
- Sleep behaviours (snoring, arousals, sleeping position)
- Quantity and quality including nocturnal and daytime complaints and physical symptoms
- Hypertension
- Cardiovascular disease
- Cerebrovascular disease
- Diabetes mellitus
- Thyroid disease
- Depression
- Family history of OSA and CPAP use
Physical examination
- BMI > 30kg/m2
- Waist circumference: male > 102cm, female > 88cm
- Neck circumference: male > 42cm, female > 39cm
- Mouth-throat assessment (Mallampati score)
History and physical examination are furthermore suited to establish complaints and comorbidity factors.
Questionnaires to assess OSA include assessment of sleepiness using the Epworth Sleepiness Scale (ESS) and the likelihood of OSA using OSA50 or STOP-Bang.
GP referral for a home-based or laboratory study
1.
2. | AND one of; OR |
Sleep studies
Primary choice: Home Sleep Study Polysomnography | Secondary choice: Sleep Laboratory Polysomnography |
OSA can be diagnosed during asleep study conducted either in a laboratory or at home during which the Apnoea-Hypopnoea Index (AHI): Number of apnoeas/hypopnoeas lasting 10 seconds or more per hours will be determined.
The apnoea-hypopnoea index (AHI; events per hour) provides an indication of the severity of OSA and has implications for the management plan. Clinically relevant is symptomatic with excessive daytime sleepiness symptoms and/or cardiometabolic comorbidities. Of note, normal AHI values may be increased markedly in the elderly. Patients with positional OSA (apnoeas attributed to a supine sleep position) tend to have less severe OSA.
The pathway to having a sleep study can be through referral to a sleep or respiratory specialist or via direct referral from the GP (if Medicare criteria are met).
Mild
OSA
- Monitor and re-assess
- Consider treatment or referral if highly symptomatic
Moderate
OSA
- Confirmed Symptomatic OSA
- Suitable for Management in Primary Care
Severe
OSA
- Confirmed Symptomatic OSA
- Suitable for Management in Primary Care
TREATMENT
All patients with OSA should be offered education about management of the risk factors and consequences of OSA. Patients with OSA should be offered advice to minimise alcohol intake and to avoid sedative medications and opioids. Those with overweight/obesity should be offered advice to reduce their body weight.
Patients with confirmed moderate (AHI > 15-30) or severe (AHI > 30) OSA should be offered treatment with continuous positive airway pressure (CPAP), including ongoing adherence support. If unable to tolerate CPAP patients can be offered treatment with a mandibular advancement splint (MAS).
Patients with mild OSA (AHI > 5-15) are usually not treated with CPAP, unless they are symptomatic (OSAS) and have a high ESS, i.e. excessive sleepiness, or other relevant symptoms.
Patients with positional OSA should be offered advice about treatment with positional therapy/ use a posture control device. Of note: a sleep study with position-monitoring is required to determine patients with supine-predominant OSA.
CPAP, when compared to control, reduces AHI and daytime sleepiness and improves depression, anxiety and quality of life. CPAP treatment reduces blood pressure, particularly nocturnal systolic blood pressure, to a small extent in patients with OSA, and a larger extent in patients with moderate to severe OSA and resistant hypertension.
CPAP should however not be seen as a replacement for pharmacological therapies or lifestyle advice for hypertension and other CVD risk factors. CPAP has not been shown to be associated with improvements in the risk of CVD morbidity and mortality, or HbA1c and insulin sensitivity in patients with type 2 diabetes and OSA.
First line treatment
- Lifestyle/Weight Loss Advice
- Continuous Positive Airway Pressure (CPAP)
- Monitor symptoms, CPAP adherence and treatment response
- Improve adherence, when required, by
- Education
- Behavioral therapy
- Peer support
- Telehealth (individual, peer-to-peer, group format)
CPAP troubleshooting
- Mask is comfortable
- Humidification is operational
- Offer ongoing treatment adherence support
- CPAP refusal or poor adherence
Second line treatment
- Refer to Dentist/Orthodontist for Treatment with Mandibular Advancement Splint (MAS) if clinically appropriate
- Monitor symptoms, MAS adherence and treatment response
- MAS refusal, unsuitable or poor response
Refer to sleep specialist when:
- Patient does not fulfil ESS and OSA50 criteria with a high suspicion of a sleep disorder (OSA or other sleep disorder)
- Patient has complex OSA;
i. ESS 16 or more
ii. Sleepiness-related accident or significant risk
iii. BMI 45kg/m2 or more
iv. Alcohol abuse
v. Chronic opioid use
vi. Neuromuscular disease
vii. Significant respiratory disease (severe COPD)
viii. Heart failure
- Patient has symptoms suggestive of a condition requiring more extensive monitoring e.g., parasomnia, narcolepsy, periodic limb movement disorder
- Cause of excessive daytime sleepiness is still unknown
- Poor treatment (Continuous Positive Airway Pressure (CPAP) and Mandibular Advancement Splint (MAS)) response
- Patients with OSA who are commercial drivers
RECOMMENDATIONS
- All individuals with overweight/obesity and obstructive sleep apnoea (OSA) should be offered advice to reduce their body weight
- All individuals with OSA should be offered advice to minimise alcohol intake and to avoid sedative medications and opioids.
- All individuals with OSA should be offered education about the risk factors and consequences of OSA
- Individuals with confirmed moderate OSA should be offered advice about treatment with continuous positive airway pressure (CPAP), or mandibular advancement splint (MAS) if unable to tolerate CPAP
- Individuals with confirmed severe OSA should be offered advice about treatment with CPAP
- All individuals with OSA treated with CPAP should be offered ongoing adherence support
- Individuals with confirmed severe OSA should be offered Ear Nose Throat (ENT) specialist referral for consideration of upper airway surgery if intolerant of CPAP and/or MAS inappropriate
- Individuals with OSA should be offered advice about treatment with positional therapy/ use apositional posture control device
AHI - Apnoea-Hypopnoea Index
BBTi - Brief Behavioural Therapy for Insomnia
BMI - Body Mass Index (kg/m2)
BQ - Berlin Questionnaire
CBTi - Cognitive Behavioural Therapy for Insomnia
CELL - Coblation Endoscopic Lingual Lightening
COPD - Chronic Obstructive Pulmonary Disease
CVA - Cerebrovascular Accident
CPAP - Continuous Positive Airway Pressure
CSA - Central Sleep Apnoea
DASS - Depression Anxiety Stress Scale
DBAS - Dysfunctional Beliefs and Attitudes about Sleep
DBP - Diastolic Blood Pressure
DIMS - Difficulties Initiating and/or Maintaining Sleep
DISE - Drug-Induced Sleep Endoscopy
DISS - Daytime Insomnia Symptom Scale
ENT - Ear Nose and Throat
ESS - Epworth Sleepiness Scale
FOSQ - Functional Outcomes of Sleep Questionnaire
FSH - Follicle-Stimulating Hormone
FTP - Friedman Tong Position
GP - General Practitioner
HANDI - RACGP Handbook of Non-Drug Interventions
HGNS - Hypoglossal Herve Htimulation
ISI - Insomnia Severity Index
K10 - Kessler Psychological Distress Scale
MAD - Mandibular Advancement Device
MAS - Mandibular Advancement Rplint
MBS - Medicare Benefits Schedule
MMA - Maxillomandibular Advancement Surgery
MRA - Mandibular Repositioning Appliance
ODI - Oxygenation Desaturation Index
OSA - Obstructive Sleep Apnoea
PLMD - Periodic Limb Movement Disorder
PT - Positional Therapy
PTSD - Post-Traumatic Stress Disorder
PSG - Polysomnography
QSQ - Quebec Sleep Questionnaire
REM - Rapid Eye Movement
RFTB - Radiofrequency Thermotherapy of the Tongue Base
SBP - Systolic Blood Pressure
SCI - Sleep Condition Indicator
SE - Sleep Efficiency
SF36 - Short-Form (36) Health Survey
SMILE - Submucosal Minimally Invasive Lingual Excision
SNRIs - Serotonin-Norepinephrine Reuptake Inhibitors
SOL - Sleep Onset Latency
SSRI - Selective Serotonin Reuptake Inhibitors
TFTs - Thyroid Function Tests
TIB - Time In Bed
TORS - Transoral Robotic Surgery
TST - Total Sleep Time
UPPP - Uvulopalatopharyngoplasty
WASO - Wake After Sleep Onset