Patient Pathways: Respiratory Medicine

Transcription

1 Patient Pathways: Respiratory Medicine Evidence Table: Sleep Apnoea & Snoring Author Year Study type Population Summary of Paper Comments SIGN 2003 Evidence based Clinical Guideline Institute for Clinical Systems Improvement 2004 Evidence Based Healthcare Guideline UK Adults USA Adults Management of Obstructive Sleep Apnoea/Hypopnoea Syndrome in Adults Covers: definition & clinical background ; diagnosis inc. diagnostic tools ; treatment ; referral ; effects of treatment on quality of life ; information for discussion with patients and carers ; resource implications of recommendations. Diagnosis and Management of Obstructive Sleep Apnoea Development group members and reviewers listed Methodology detailed. Appendix 1 Quick reference guide See Appendix 2a for diagnostic algorithm Appendix 2b: treatment algorithm. Appendix 2c: signs and symptoms and recommendations. Expert group selected by the Section on Paediatric Pulmonology of the American Academy of Paediatrics. Laitinen (Expert group appointed by the Finnish Lung Health Association 2002 Systematic Review articles identified 2003 Review and Expert Opinion Children with uncomplicated Obstructive Sleep Apnoea Syndrome (OSAS) - USA Adults with sleep apnoea Finland Framework for diagnostic decision making. Includes definition of OSAS in children and risk factors; prevalence and progression of condition, diagnosis, treatment options and follow-up. Excludes: infants<1yr : patients with central apnoea or hypoventilation syndromes : patients with associated disorders such as Down s Syndrome, cerebral palsy or chronic lung disease. National Guidelines for prevention and treatment year programme for the prevention and treatment of sleep apnoea. Includes: definition. Tables highlight - diagnostic criteria, degrees of severity, symptoms, predisposing factors, diagnostic tools. Discusses: prevalence, causes and risk factors, special features, prevention, consequences, diagnosis, treatment and rehab. Appendix 2d: web resources Method of guideline development included full details available online. Appendix 3a 7 point summary of recommendations for diagnosis and management. Appendix 3b Algorithm for diagnosis and management of uncomplicated childhood OSAS Guideline development methodology not detailed. Appendix 4a Epworth Sleepiness Scale Appendix 4b Checklist for GP when referring for sleep evaluation. Appendix 4c When should other specialists be consulted. Appendix 4d Treatment principles in primary care.

2 Elliott 2001 General Review Nurse practitioners in primary care - USA Primary care assessment and management of sleep disorders. Provides guidance/recommendations for sleep assessment and appropriate management within nurse practitioner role. References available. Appendix 5a Standard Sleep Assessment Parameters Appendix 5b Diagnostic Considerations & Detailed sleep history Appendix 5c Sleep Diary Appendix 5d Sleep Hygiene Recommendations & Behavioural/Pharmacologic interventions for Primary Insomnia. NHS Lothian Unknown On-line referral guidance based on expert opinion Lothian region UK Snoring Includes: sleep apnoea ; sleep disturbance with episodes of snoring apnoea and day time hypersomnolence. Management in primary care advice ; Referral criteria and where to refer to. Direct electronic links to patient information on removal of adenoids and snoring Development methodology, date of development and review date not listed. Guideline provided Appendix 6 Naughton 2002 General Review Australia Adults West 2001 Audit UK Adults Assessment and management of the patient presenting with snoring GPs key role outlined history and examination information ; conservative measures : reduction in weight, alcohol and nasal resistance. Failed conservative measures or suspected moderate to severe obstructive sleep apnoea (OSA) must be referred to sleep disorders specialist. GP follow-up required for moderate to severe OSA for monitoring of long term treatment e.g. CPAP Reducing waiting times for sleep apnoea hypopnoea syndrome(sahs) and snoring using a questionnaire and home oximetry: results of a 2nd audit cycle. Patients with suspected SAHS often referred to a variety of specialists. 1 st audit of patient journey identified lengthy delays therefore an algorithm was formulated for management of respiratory sleep disorders and re-audited. Audit tools: questionnaire (to assess the risk high moderate and low therefore providing basis for further management), Epworth Sleepiness Scale (ESS) and BMI. Results: new management strategy/algorithm - reduced average wait for sleep study by 90 days by prioritising patients. Reduced wait for ncpap trial by 32 days. >50% reduction in ENT clinic visits. References listed Definition: >or = to 5 apnoeas or hypopnoeas per hours sleep + 2 or more symptoms listed in Appendix 7a Appendix 7b mild OSA and moderate to severe OSA symptoms listed References listed. It was noted there was a small increase in number of sleep studies performed and no increase in respiratory clinic workload. In 80% of patients, the only investigations required to make a diagnosis are the questionnaire used and overnight oximetry. Copy of the algorithm requested from authors as not included in paper Appendix 8

3 Sparks 2002 Case Review 100 patients attending GP over 12 month period New Zealand Assessment of snorers in primary care: straight path to treatment. Model for primary care management based on sleepiness and nocturnal hypoxaemia. Problem: whether to refer patient suffering from disruptive snoring to a specialist (& how to decide which specialist) or to advise conservative treatment. Alternative investigations for primary care management - Partner reporting of snoring. Excessive daytime sleepiness ( measured by Epworth Sleepiness Scale (ESS)). Nocturnal hypoxaemia measured by oxygen desaturation index (ODI). Combining both ESS and ODI will provide a system for grouping and subsequent management of potential OSA. References listed. Model does not purport to diagnose patients with Obstructive Sleep Apnoea (OSA) specifically. Requires pulse oximetry

4 Appendix 1

5 Appendix 1 continued

6 Appendix 1 continued

7 Appendix 2a

8 Appendix 2b

9 Appendix 2c

10 Appendix 2d

11 Appendix 3a

12 Appendix 3b

13 Appendix 3b continued

14 Appendix 4a

15 Appendix 4b Checklist for GP when referring for sleep evaluation

16 Appendix 4c When should other specialists be consulted

17 Appendix 4d

18 Appendix 5a

19 Appendix 5b

20 Appendix 5c

21 Appendix 5d

22 Appendix 6

23 Appendix 7a

24 Appendix 7b

25 Appendix 8