NICE guidance - treatments for moderate and severe OSAHS (obstructive sleep apnoea/hypopnoea syndrome)

Last edited 09/2021 and last reviewed 09/2021

Treatments for moderate and severe OSAHS (obstructive sleep apnoea/hypopnoea syndrome)

Use the results of the sleep study to diagnose OSAHS and determine the severity of OSAHS (mild, moderate or severe)

• continuous positive airway pressure (CPAP) is recommended as a treatment option for adults with moderate or severe symptomatic obstructive sleep apnoea/hypopnoea syndrome (OSAHS)
  • moderate to severe OSAHS can be diagnosed from patient history and a sleep study using oximetry or other monitoring devices carried out in the person's home. In some cases, further studies that monitor additional physiological variables in a sleep laboratory or at home may be required, especially when alternative diagnoses are being considered
    • severity of OSAHS is usually assessed on the basis of both severity of symptoms (particularly the degree of sleepiness) and the sleep study, by using either the apnoea/hypopnoea index (AHI) or the oxygen desaturation index
      • OSAHS is considered mild when the AHI is 5-14 in a sleep study, moderate when the AHI is 15-30, and severe when the AHI is over 30
  • offer fixed-level CPAP, in addition to lifestyle advice, to people with moderate or severe OSAHS
  • for people with moderate or severe OSAHS having CPAP:
    • offer telemonitoring with CPAP for up to 12 months
  • consider using telemonitoring beyond 12 months
  • consider auto-CPAP as an alternative to fixed-level CPAP in people with moderate or severe OSAHS if:
    • high pressure is needed only for certain times during sleep or
    • they are unable to tolerate fixed-level CPAP or
    • telemonitoring cannot be used for technological reasons or
    • auto-CPAP is available at the same or lower cost than fixed-level CPAP, and this price is guaranteed for an extended period of time
  • consider heated humidification for people with moderate or severe OSAHS having CPAP who have upper airway side effects such as nasal and mouth dryness, and CPAP-induced rhinitis
    
    
• mandibular advancement splints for moderate and severe OSAHS
  • if a person with moderate or severe OSAHS is unable to tolerate or declines to try CPAP, consider a customised or semi-customised mandibular advancement splint as an alternative to CPAP if they:
    • are aged 18 and over and
    • have optimal dental and periodontal health
  • be aware that semi-customised mandibular advancement splints may be inappropriate for people with:
    • active periodontal disease or untreated dental decay
    • few or no teeth
    • generalised tonic-clonic seizures
      
      
• Positional modifiers for OSAHS
  • consider a positional modifier for people with mild or moderate positional OSAHS if other treatments are unsuitable or not tolerated
  • be aware that positional modifiers are unlikely to be effective in severe OSAHS
  • positional modifier
    • 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
  • positional OSAHS
    • a type of obstructive sleep apnoea/hypopnoea syndrome (OSAHS) that is affected by the person's sleep position. People with positional OSAHS have an apnoea-hypopnoea index (AHI) at least twice as high when lying face up (supine) as lying on their side (laterally)
      
      
• Surgery for OSAHS
  • consider tonsillectomy for people with OSAHS who have large obstructive tonsils and a body mass index (BMI) of less than 35 kg/m2
  • consider referral for assessment for oropharyngeal surgery in people with severe OSAHS who have been unable to tolerate CPAP and a customised mandibular advancement splint despite medically supervised attempts

Reference:

• NICE (August 2021). Obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome in over 16s