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Respiratory Referral Guidelines

Referral guidelines for patients with possible lung cancer

Please view the information under 'NHS e-Referrals Service - Referral Forms' where you will find the 2 week wait referral form for suspected lung cancer.

 

Referral guidelines for patients with possible sleep apnoea

GHNHSFT Sleep Service

The function of the Sleep service in Gloucestershire is to meet the needs of patients who are suspected of having Sleep disordered breathing (SDB) providing both diagnostic and ongoing monitoring services for patients who suffer from excessive daytime sleepiness

The primary function of the service is to assess patients for

Obstructive sleep apnoea (OSA)

Obesity hypoventilation syndrome (OHS).

The team is led by the respiratory Consultants and includes Specialist Respiratory Physiologists, nurses and support staff.

The service is not aimed at diagnosing or treating:

Simple Snoring (Snore but not sleepy) – Refer to ENT Surgeons
Sleep Hygiene problems
Excessive daytime sleepiness excluding OSA
Insomnia
Parasomnias (episodic behaviors /experiences from sleep)
Insomnia not secondary to psychiatric disorders
Restless leg syndrome
Periodic limb movement disorder
Circadian rhythm disorders:

  • Shift work disorders
  • Delayed or advanced sleep phase disorder
  • Jet lag syndrome
  • Non 24 hour sleep wake cycle disorders.

**Patients experiencing these symptoms would need referral to Oxford or Bristol to ensure appropriate investigations and access to management tools can be provided.

1. Referral

One of the key components to a successful service is a good quality referral, we have designed an aid (based around the STOPBANG Questionnaire) to help you evaluate your patients risk and whether they may benefit from referral into the sleep service. To access the tool just click on the link below.

GP Referral Tool

Cardinal Features of sleep apnoea:
Excessive daytime sleepiness despite an adequate amount of time in bed asleep.
Is the patient falling asleep against their will?
Is the patient falling asleep at work?
Is the patient falling asleep whilst driving?

Other features consistent with sleep apnoea:                  Predisposing factors:
Snoring                                                                                   Increasing age
Unrefreshed upon waking                                                      Male gender
Choking episodes at night                                                      Obesity
Witnessed apnoeas                                                                Sedative drugs
Nocturia                                                                                  Smoking
Impaired memory/concentration                                             Alcohol consumption

2. Examination

The following make the diagnosis more likely:
Obesity
Large tonsils
Retrognathia
Poor nasal patency

Associations:
Myxoedema
Acromegaly
Hypertension
Neuromuscular Disease

Prior to referral please consider the following:

  • Is the patient sleepy despite spending and adequate amount of time in bed (asleep)
  • Are there any other factors likely to interfere with sleep (shift work/anxiety/drugs)
  • Patients who are overweight should be encouraged to lose weight
  • Reduce alcohol intake and encourage smoking cessation
  • Depression (difficulty getting to sleep and early waking)
  • Narcolepsy (usually sleepy from a young age)
  • Periodic Limb movement disorder (history of leg jerks during sleep from partner)
  • Neurological Conditions (previous head injury, Previous encephalitis)
  • Assess for Diabetes, Thyroid function, Vitamin B12 deficiency.
  • The available treatments for OSA are Continuous positive airway pressure (CPAP) or for some mandibular advancement splints (surgical treatments have unpredictable results and are rarely appropriate. It is possible that they might make the use of CPAP more difficult)
  • These treatments are better suited for moderate and severe cases
  • Patients usually only tolerate the treatment if they have sufficient somnolence to impact on their quality of life. The degree that warrants treatment is therefore, determined by the patient and their lifestyle.
  • Occasional nocturnal apnoea’s may cause alarm to the sleeping partner but if the frequency is low then there will be no ensuing daytime somnolence and no requirement to treat. Reassurance without referral is generally sufficient.
  • Mild or occasional symptoms of OSA can make treatment unsuccessful or unlikely to be accepted. There is no evidence of long-term health risk for this group.


3. The Service Process

The key components of the service are a subjective assessment of sleepiness, an objective measurement followed by a clinical assessment and, if required, a trial of CPAP therapy.

 Subjective assessment – This will be a guided questionnaire for the patients to complete prior to undertaking a sleep study. The outcome of this questionnaire will help to determine whether a sleep study is required and whether the service can meet the expected needs of the patients referred in.

 Objective Measurement – This will involve an overnight multi-channel portable polygraphy sleep study which will be review by both a Respiratory Physiologist and a Sleep Consultant.

Clinical Assessment - The patient’s questionnaire and results from the sleep study will be reviewed at a multi-disciplinary meeting and a clinic appointment will be made where necessary based on clinical urgency.

Once a clinical assessment has taken place a decision to trial therapy may be made, this will be communicated by the requesting Consultant to the GP and patient by letter. Should a study be un-suggestive of SDB then the Consultant may just write back to the referring GP and patient confirming this and offering further advice.

Continuous positive airway pressure (CPAP) therapy entails a flow generator device (this would be provided on permanent loan to the patient) which the patient will use alongside a mask to wear every night. The device will blow air creating a pneumatic splinting of the upper airway thus supporting the airways and helping to ensure the airways remain open. This helps to normalise breathing and relieve symptoms associated to OSA. In some cases NIV may be required to treat the patient.

Once established on therapy a patient will remain under the care of the Physiology team in the Lung Function Department for annual reviews and assessment of compliance and adherence to therapy along with ensuring that the equipment is maintained in a usable manner.

Patients already established on CPAP therapy / New to area

Patients established on CPAP therapy who are new to the area and wish to transfer their care to us may be referred direct to the follow up service in the Lung Function Department by emailing a referral with as much information as possible around the previous diagnosis to:

lung.function@glos.nhs.uk