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REMEDY : BNSSG referral pathways

Obstructive Sleep Apnoea & Sleep Service

Checked: 24-04-2018 by hana.cavill Next Review: 23-04-2019

Service Overview

The OSA service provides assessment for patients with suspected OSA and other sleep disorders, which are predominantly respiratory based, although they do see some of the other 84 recognised sleep disorders.

Assessments may include overnight oximetry in the home, polysomnography within the sleep unit, or Actigraph studies in the home.

Treatment pathways may include lifestyle changes (advice given), continuous positive airway pressure (CPAP), or alternatives where appropriate.

CPAP services are provided to patients within Bristol, Weston, Bath and the surrounding area.

Ongoing management of CPAP patients is provided by a multidisciplinary team of physiologists and a clinical scientist and respiratory physicians.

Paediatric referrals (under 16) should be referred to the Bristol Children's Hospital respiratory clinic 

Adults (16 years upwards) should be referred to either UHBristol or NBT depending on the possible sleep disorder likely to be present. However there is often overlap between sleep disorders, so referral to UHBristol in the first instance may be appropriate and the referral will be triaged by the clinical team and if thought to be more likely for NBT, the referral can be forwarded on to them.

Symptoms may include daytime sleepiness, noted sleep disruption/disturbance, observed sleep-breathing problems, etc.

Clinical Knowledge Summaries has advice on assessment and management of obstructive sleep apnoea and includes advice on management in primary care.

Referral Guidance

Criteria Based Access for CPAP treatment of Obstructive Sleep Apnoea syndrome

CPAP treatment is now subject to a Criteria Based Access policy.

The policy gives advice on assessment and conservative management of patients with obstructive sleep apnoea.

The Epworth Sleep Score is advised as part of the assessment - a score of greater than 10 indicates abnormal daytime sleepiness.

Latest advice from the funding team (January 2019) is that this policy does not currently apply to referrals for sleep studies but the pathway may help clinicians in assessing and referring patients appropriately.



Sleep Studies

Referral for sleep studies can be made via eRS and are not yet subject to the above INNF policy. However the policy does include a pathway which makes suggestions about conservative management in primary care that should be considered prior to referral.

In order to have an effective pathway and to manage numbers better, several elements would help the delivery of the policy and these should be addressed in all referrals for sleep studies.

  • Assessment of need – the patient should have a history that fits with OSA, significant functional impairment and that the treatment would be acceptable to and manageable by the patient

  • History – fatigue and sleepiness that is significant (Epworth score may help quantify), a strong history for obstructive sleep apnoea (multiple waking episodes in the night, with element of apnoea and airway obstruction where witnessed) scoring in itself is not an indication for referral. For referral also a history that includes, weight, BMI, collar size, employment including HGV/PSV driver, medication history including analgesia, sedatives, gabapentin, pregabalin, and significant co-morbidities eg COPD, heart failure. If the patient has been advised not to drive please highlight this in the referral.   

  • Significant functional impairment – in order to fit criteria for referral the patient will need to have significant functional impairment from the symptoms they describe. This is not a diagnostic service for apnoea or fatigue but an assessment to effectively manage significant impacting symptoms.

  • Acceptable and manageable treatment – patients should not be referred if they are either too frail to use or manage the mask treatment, or where they are clear that the treatment would not be acceptable to them.

Conservative measures should be tried ahead of referral including referral to Tier 2 services for weight loss from primary care for appropriate patients. Alcohol reduction should be considered. Medication review including moving away from strong analgesia, sedatives and meds such as pregabalin and gabapentin where possible. If these do not improve symptoms and patient has significant functional impairment then referral is appropriate.

Conservative measures may be inappropriate in patients with life threatening or high risk comorbidities or in HGV / PSV drivers. (Adam Whittle suggests wording of 'Those with severe symptoms of sleepiness affecting employment, driving safety or other key activities'.)

Advice on OSA and driving

See Clinical Knowledge Summaries for Advice on Driving

The DVLA advice on Excessive sleepiness - including obstructive sleep apnoea syndrome may also be helpful. There is also link to a patient leaflet 'Tiredness can kill'