New NICE OSA Guidelines
1. Background and links to NICE guidelines and supporting material.
On 20th August, the National Institute for Clinical Excellence (NICE) published new guidelines on Obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome in over 16s. This can be found on the NICE website. You can also find the supporting evidence, tools and resources as well as all the stakeholder comments that we received during consultation and the responses to these comments. The comments were invaluable in helping us to develop and refine the guideline. We have also produced an equality impact assessment to support the guideline.
The recommendations from this guideline have been included in the NICE Pathway on Obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome in over 16s, which brings together everything we have said on Obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome in over 16s in an interactive flowchart. There is brief information about the guideline for people using services, carers and the public at ‘Information for the public’.
2. OSA Alliance Study Day itinerary, 30th September
3. OSA Alliance Study Day video link
NICE Guidelines on OSAHS OHS and OSAHS-COPD Overlap Syndrome – Workshop session 1 Recognising possible sleep-disordered breathing in your patients.
NICE Guidelines on OSAHS OHS and OSAHS-COPD Overlap Syndrome – Workshop session 2 Treating OSA.
NICE Guidelines on OSAHS OHS and OSAHS-COPD Overlap Syndrome – Workshop session 3 Non CPAP therapies for OSAHS.
NICE Guidelines on OSAHS OHS and OSAHS-COPD Overlap Syndrome – Workshop session 4 Treating OHS and OSAHS-COPD Overlap Syndrome.
4. CPD Points
This workshop has been approved for participants to obtain 4 CPD points. To apply please visit the Royal College of Physicians CPD site. We are not issuing certificates but can provide a hard copy of the itinerary and an email to confirm attendance if required.
5. Written Q&As
Discussion of newly released NICE guidelines on OSAHS, OHS and OSAHS-COPD-overlap syndrome in over 16s and its implementation.
Q&As answered in written form – the remaining questions were answered live and can be found in the recordings of the Q & A sessions
Q. In acute ventilatory failure where NIV is given, is there a suggested timeframe to see when hypercapnia is persisting?
Anita Simmonds: Would check ABG before discharge, but otherwise review at 2-4 weeks.
Q. In the acute setting of likely OHS/OSA overlap how long after initial use of NIV (assuming acidosis improved and patient stable) should respiratory polygraphy be performed (ref 2.5.6). Is it best to dc and do at 4/42 or do it as an inpatient when only just off NIV within a few days?
Anita Simmonds: Probably 4 weeks, it takes a while to resolve.
Q. UVPPP removed anatomical obstructions permanently. MAD appear to do a similar thing on a temporary basis. Why should the latter be more successful than the former?
Anita Simmonds: Good point but don’t think can assume achieving the same effect. May be upper airway stimulation coming from MAS each night?
Q. Is there any potential benefit of oropharyngeal exercises in managing OSAHS?
Anita Simmonds: We didn’t cover this as insufficient RCTs so far.
Q. What positional modifiers have you access to or recommend patients to purchase outside of NICE being able to recommend a specific device?
Annabel Nickol: NICE does not recommend a specific device. However, two different devices are presently under evaluation in RCTS, so more evidence to come. I suspect if these devices work they will work better than tennis balls, pillows .. or a nudge in the back by one’s bed partner.
Q. How are people determining a positional component? We use a TST of > 20% in the supine position.
Ian Stone: Typical definition is > 20% TST supine position, 2x number of events supine vs non-supine.
Q. What at re the thoughts on the role of positional modifiers if combined with MAD?
Annabel Nickol: It’s an excellent question but there is insufficient data to inform this choice. However, reasonable to take a pragmatic view in an individual for whom CPAP is not tolerated, Trials are underway re: positional devices.
Q. Is there a role for pharmacological agents for treating sleepiness for OSAHS despite optimal CPAP or patients unable to tolerate CPAP?
Anita Simmonds: This was not included in our scope (and not enough data yet).
Q. My understanding as a non-ENT specialist is that long-term intranasal steroid use may lead to a risk of nasal septum perforation, which may be prescribed for the treatment of CPAP-related rhinitis. Do the panel have any comments as regards this?
Bhik Kotecha: Internasal steroid sprays in some individuals cause nose bleeds and repeated cauterisation can cause perforation but the spray itself is unlikely to cause the septal perforation if epistaxis does not occur.
Q. Was the limited sleep study manually scored or was an automatic analysis used?
Sophie West: Both – automatic download and then brief manual review.
Q. Would you still recommend using the Epworth Sleepiness Score whilst doing teleconsultations? Are the panel satisfied that the ESS is validated over the telephone?
Anita Simmonds: I would. It has been used in other telephone-based studies. But use ESS as part of the wider assessment – as Sophie says ESS > 10 is not a prerequisite for referral.
“If the driver of the truck that killed my nephew had been diagnosed and referred for fast track treatment of OSA when he visited his GP to complain about being tired all the time, Toby would still be with us”.