GPAtlas🧭 When to suspect
Suspect obstructive sleep apnoea (OSA) in a patient – classically an overweight, middle-aged man – who reports the cardinal triad of:
• Loud habitual snoring
• Witnessed apnoeas: a bed partner describing pauses, gasping or choking during sleep
• Excessive daytime sleepiness that persists despite adequate time in bed
Supporting features include morning headache, poor concentration, low mood and nocturia.
It is worth holding two terms apart. OSA describes the breathing events found on a sleep study, whereas obstructive sleep apnoea/hypopnoea syndrome (OSAHS) – sometimes called OSA syndrome – means those events plus daytime symptoms, usually sleepiness.
This distinction matters for driving advice, because Driver and Vehicle Licensing Agency (DVLA) duties turn on excessive sleepiness, not on the sleep-study finding alone.
In general practice:
• Raise suspicion, including in patients who are not obese
• Screen and refer for an objective sleep study
• Above all, act first on the sleepy driver
Severity is graded by the apnoea–hypopnoea index (AHI), the number of apnoeas and hypopnoeas per hour of sleep.
| AHI (events per hour) | Classification | Typical direction of treatment |
|---|---|---|
| < 5 | Normal | No OSAHS on this measure |
| 5 to < 15 | Mild OSAHS | • Lifestyle ± mandibular advancement splint • Continuous positive airway pressure (CPAP) if symptomatic and first-line is insufficient |
| 15 to < 30 | Moderate OSAHS | CPAP first-line, alongside lifestyle |
| ≥ 30 | Severe OSAHS | • CPAP first-line • Ensure prompt treatment |
Raise suspicion most strongly with:
• Obesity, especially central, with a large collar size
• Male sex
• Middle or older age
• Post-menopausal status in women
Other contributors are:
• Upper-airway and craniofacial anatomy (retrognathia, micrognathia, macroglossia, enlarged tonsils)
• Alcohol and sedatives
• Smoking
• Hypothyroidism and acromegaly
• A family history
In children, the commonest cause is adenotonsillar hypertrophy. Suspect it with:
• Habitual snoring
• Mouth breathing
• Restless sleep
• Behavioural and school difficulties
Source: NICE NG202
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