Synopsis
Identify clinically important obstructive sleep apnoea, choose an appropriate sleep study, and link symptom control, cardiovascular risk, device adherence and driving safety.
- OSAHS is recurrent upper-airway narrowing or collapse during sleep causing apnoeas, hypopnoeas, arousal and often intermittent hypoxaemia.
- Ask about witnessed pauses, choking, loud snoring, unrefreshing sleep, morning headache, nocturia, impaired concentration, irritability and daytime sleepiness rather than snoring alone.
- Risk rises with obesity, male sex, age, craniofacial or upper-airway anatomy, alcohol, sedatives and endocrine or neurological conditions, but lean people can also have important OSAHS.
- Questionnaires estimate pre-test probability and sleepiness; they do not diagnose OSAHS or replace a sleep study.
- NICE recommends home respiratory polygraphy as the first-choice diagnostic test for most adults with suspected OSAHS.
- A negative home study does not end assessment when symptoms are strong, sleep time was short, sensors failed or another sleep or ventilatory disorder remains possible.
- Severity is not the AHI alone: excessive sleepiness, oxygen burden, comorbidity, driving risk and functional impairment change urgency and treatment.
- Offer CPAP according to NICE severity and symptom impact, with early troubleshooting of mask, pressure, leak, dryness and nasal obstruction.
- A customised mandibular advancement splint is an alternative for suitable people, particularly mild OSAHS or CPAP intolerance, but requires adequate dentition and dental oversight.
- Apply current DVLA rules precisely: impaired driving from sleepiness requires stopping driving, and notification duties depend on severity, sleepiness and licence group.
Key red flags
Unintended sleep during conversation, work or driving, near-misses and reduced vigilance indicate functional danger; ask directly because patients may use caffeine or activity to conceal symptoms.
Marked obesity, daytime hypoxaemia, raised bicarbonate, morning headache, oedema or awake hypercapnia suggests OHS or COPD overlap and requires carbon dioxide assessment rather than simple OSA testing alone.
Investigation priorities
Estimate pre-test probability, impairment and urgency.
Management branches
Snoring, witnessed events, non-restorative sleep or daytime impairment suggests OSAHS.
- Document nocturnal events, sleep opportunity, daytime sleepiness, near-misses, occupation, licence group, alcohol, medicines and relevant comorbidity.
- Advise immediate driving cessation when sleepiness could impair driving and explain current DVLA responsibilities without promising a licensing outcome.
- Examine BMI, neck and upper airway, blood pressure and cardiorespiratory signs, looking specifically for awake hypoventilation or structural disease.
- Refer with appropriate priority for home respiratory polygraphy, using hospital testing when home testing is unsuitable or the presentation is complex.
Key medicines
Continuous positive airway pressure therapyUse the sleep-service-selected fixed or auto-adjusting pressure every time the person sleeps, with the fitted mask and humidification plan.CPAP is device therapy rather than oxygen or ventilation for awake hypercapnia. Address leak, pressure sores, aerophagia, dryness and nasal obstruction; do not judge adherence from one night or stop because symptoms improve.
Customised mandibular advancement splintWear the dentist-fitted, progressively titrated device during sleep according to the sleep and dental team's individual schedule.Requires sufficient healthy teeth and periodontal support; can cause jaw discomfort, salivation and bite change. Over-the-counter devices are not equivalent, and objective response review may be needed.