Respiratory Futures talked to Iain Wheatley, a Nurse Consultant in Sleep and Ventilation at Frimley Health/OSA Alliance. Iain shared with us a little about the perioperative sleep apnoea pathway, what it sets out to achieve and how it can be carried out effectively by the respiratory MDT to positively impact patients.
Can you tell us a little bit about the perioperative sleep apnoea pathway, and the steps it involves?
The perioperative sleep apnoea pathway provides a straightforward guide, from initial patient assessment using standard screening tools such as the Epworth sleepiness score (ESS) and the STOP-BANG tool. These help to identify patients who are potentially at a higher risk of having obstructive sleep apnoea (OSA). Having OSA puts patients in a position where they may develop cardiac arrhythmias, have a myocardial infarction, or cerebral vascular accident.
With early screening and following the pathway, suitable anaesthetic procedures can be tailored for patients to reduce risk, and those patients with high screening scores, referral to a sleep service for treatment.
What are the high-level goals of the pathway?
The goal of the pathway is to ensure that the risk of a patient with obstructive sleep apnoea having complications during, or post-surgery are minimised.
Patients screened and who go on to have sleep studies that identify obstructive sleep apnoea may be treated in a timely manner.
The obstructive sleep apnoea is treated early using continuous positive airway pressure (CPAP) to allow surgery to take place in a suitable time scale.
Post operative management of a patient with OSA is safer as the diagnosis is known and treatment can be provided in a post-operative department.
What does the screening/eligibility process for identifying patient suitability look like?
The initial screening should be based firstly on clinical assessment, symptoms, history of snoring, witnessed apnoea, choking in sleep, and daytime sleepiness. Other symptoms may flag possible OSA such as nocturia, waking headaches and insomnia.
Screening tools such as the Epworth sleepiness score and STOP BANG provide these initial questions to lead to further investigation if required.
What impact does the pathway have on patient risk?
The pathway should provide a safe and effective method of allowing risk stratification, so that patients who are at higher risk of having OSA can be tested and treated. In addition, those patients at low or no risk can be managed quickly and effectively.
The pathway provides a basis for ensuring, screening, testing, and treating are provided in an optimal way.
Referral for treatment:
Treatment can be tailored and individualised to a point for patients with obstructive sleep apnoea. In patients with an apnoea and hypopnoea index (AHi) >5/hr and symptomatic the gold standard most effective treatment is continuous positive airway pressure (CPAP) (NICE 2021). In some patients with a milder AHi, lifestyle advice as well as support from smoking cessation, alcohol reduction, weight loss and exercise. A Mandibular advancement splint (MAS) in the patient with mild OSA may also be an option in some cases.
How does the respiratory MDT need to work together to ensure the pathway is followed correctly?
With effective communication across the multi-disciplinary teams, patients who are identified as at risk of having OSA and who are awaiting a surgical procedure can be tested and treated.
To streamline the process where the anaesthetic team do not have their own sleep testing equipment a single access point for referral for sleep studies and outlining priority is beneficial.
Where anaesthetics do have the ability to provide a sleep study then similarly a single point of referral for treatment and the priority pre surgery would help the coordination of ensuring patient treatment is provided in a timely manner.
Critically it is important to consider patient safety and the safety of others at an early stage, excessive sleepiness impacts on other areas of a person's life, including occupation, lifestyle, and driving. The MDT and sleep service involvement will help your patients to navigate managing their sleepiness and sleep apnoea.
Patients commenced on treatment will then need a review of their CPAP therapy, compliance and troubleshooting any problems. Preferably this review is preoperatively and face to face but where time to surgery is critical, modern devices having modem and remote data view checking this can be provided by a telephone/video call.
Postoperatively consider recover facilities and staff expertise with CPAP, which may include high dependency care and increased monitoring. The sleep service may be able to provide support to recovery/HDU staff in managing patients with OSA and their CPAP through training.
Useful resources:
For patients,
- The Sleep Apnoea Trust: Sleep Apnoea Trust - A patient support charity (sleep-apnoea-trust.org)
- The OSA Partnership Group - Obstructive Sleep Apnoea
For professionals,
- OSA Alliance | Facilitating clinical excellence with all in OSA
- Perioperative management of Obstructive sleep apnoea in adults: Perioperative Management of Obstructive Sleep Apnoea in Adults | Centre for Perioperative Care (cpoc.org.uk) (https://cpoc.org.uk/guidelines-resources-guidelines/perioperative-management-osa-adults)
- Guideline NG202, N.I.C.E., (2021). Obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome in over 16s: niceng202er4_bm1.pdf (xfph-tr.nhs.uk)