Sleep studies

• Polysomnography (PSG) or a limited sleep study is often used to measure sleep-wake state and apnoea/hypopnoea episodes to confirm the diagnosis of obstructive sleep apnoea syndrome (OSAS) in adults and children [Randerath, 2018; ARTP, 2019; Savini, 2019; Gottlieb, 2020; NICE, 2021].
  • A limited sleep study can be set up at home, but more complex studies may require an overnight stay in a specialist sleep laboratory.
  • The severity of OSAS is based on the severity of symptoms and the number of apnoea/hypopnoea episodes per hour (the apnoea-hypopnoea index [AHI]). AHI does not correlate well with the severity of clinical symptoms.
  • The diagnosis of OSAS in adults requires at least five episodes of apnoea, hypopnoea, or both events lasting a minimum of 10 seconds per hour of sleep.
    • Mild — AHI 5–14 per hour.
    • Moderate — AHI 15–30 per hour.
    • Severe — AHI more than 30 per hour.
• If access to home respiratory polygraphy is limited,  NICE recommend that consideration could be given to the use of home oximetry for people with suspected OSAS [NICE, 2025].
• The oxygen desaturation index (ODI) is the number of episodes of oxygen desaturation per hour of sleep, and may be a more reliable predictor of adverse cardiovascular outcomes than AHI [HE, 2023]. Overnight pulse oximetry may be used as a screening tool for some people to identify nocturnal desaturation events [Randerath, 2018; ARTP, 2019; Savini, 2019; Gottlieb, 2020].

Specialist treatments

Specialist treatments for confirmed obstructive sleep apnoea syndrome (OSAS) include the use of continuous positive airway pressure (CPAP), intra-oral devices, and/or surgery in selected people.

Specialist treatment for adults with OSAS includes:

• CPAP therapy — may be offered to all people with symptomatic OSAS, and is the first-line treatment for moderate-to-severe OSAS [Francis, 2020; Gottlieb, 2020; NICE, 2021; Akashiba, 2022].
  • Airway pressure may be delivered through a nasal or face mask for airflow delivery at night, and the pressure acts to splint the upper airways to prevent collapse during inspiration.
  • Poor adherence to CPAP is common due to an ill-fitting mask, pressure intolerance, or upper airway symptoms such as nasal dryness or bleeding, or throat irritation. Adherence rates may improve with early patient education and support.
  • There is evidence that CPAP therapy improves daytime sleepiness, fatigue, and quality of life in studies. In addition, it may lower blood pressure, especially in people with resistant hypertension, but there is no confirmed significant benefit on rates of cardiovascular or stroke disease.
  • Treatment is needed long-term unless there is associated weight loss sufficient to cause disease remission.
  • CPAP usage time influences its therapeutic effects with improvement of daytime sleepiness, hypertension and cardiovascular events having been reported, with nightly use for at least 4 hours or more.
• Intra-oral mandibular advancement devices — may be appropriate for people who snore or have mild OSAS with normal daytime alertness. They can also be used as an alternative for people unable to tolerate CPAP, who do not respond to CPAP, or who prefer treatment with an intra-oral device  [Semelka, 2016]  [Dieltjens, 2019; Francis, 2020; Gottlieb, 2020; Akashiba, 2022; Arachchige, 2022; NICE, 2025].
  • Mandibular advancement devices consist of plates made to fit the upper and lower teeth to be worn during sleep, and vary in complexity and cost. They provide forward advancement of the mandible and attached tongue during sleep, to maintain an open upper airway and reduce airway collapsibility. Custom-made titratable appliances made by a dental specialist or maxillofacial surgeon may be most effective.
  • These devices may not be suitable for people with active periodontal disease, untreated dental decay, few or no teeth, and people who experience generalised tonic-clonic seizures.
  • A meta-analysis of 34 randomized controlled trials (n = 1301) found evidence of clinical benefit and reduced apnoea-hypopnoea index (AHI) measurements [Ramar, 2015].
• Upper airways surgery such as tonsillectomy — may be occasionally considered if there is evidence of nasopharyngeal obstruction causing symptoms or where OSAS is severe and the person has been unable to tolerate CPAP or a mandibular advancement device [NICE, 2025]. Very rarely alternative upper airway surgery to reduce the volume or configuration of oropharyngeal soft tissues or bony structures may be recommended if other treatments have failed [Stradling, 2016; Randerath, 2018].
• Additional specialist treatments, such as hypoglossal nerve stimulation, myofunctional therapy, pharmacological interventions, bariatric surgery, and maxillo‑mandibular osteotomy, may be offered in secondary care settings [; Arachchige, 2022].

Specialist treatment for children with OSAS includes:

• Adenotonsillectomy — may be offered to children with adenotonsillar hypertrophy to correct the anatomic obstruction causing symptoms. This procedure is usually curative in children [Semelka, 2016; Randerath, 2018; Savini, 2019; Gileles-Hillel, 2024].
• CPAP therapy — may be considered in children if adenotonsillectomy is contraindicated or unsuccessful in resolving symptoms [Savini, 2019; Gileles-Hillel, 2024].

Basis for recommendation

The recommendations on referral are based on the National Institute for Health and Care Excellence (NICE) guideline Obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome in over 16s [NICE, 2025], the NICE technology appraisal guidance Continuous positive airway pressure for the treatment of obstructive sleep apnoea/hypopnoea syndrome [NICE, 2021], the European working group report of the Sleep Disordered Breathing Group of the European Respiratory Society (ERS) and the European Sleep Research Society (ESRS) Challenges and perspectives in obstructive sleep apnoea [Randerath, 2018], the British Thoracic Society (BTS) position statement Driving and obstructive sleep apnoea (OSA) 2018 [BTS, 2018], the Japanese Sleep Apnea Syndrome (SAS) Clinical Practice Guidelines [Akashiba, 2022], guidance from NHS England Healthcare professionals guide to obstructive sleep apnoea (OSA) amongst people with a learning disability and autistic people [NHSE, 2024], a systematic review of non-continuous positive airway pressure therapies for OSAS [], and expert opinion in review articles on OSAS in adults [Semelka, 2016; Arachchige, 2022], OSAS in pregnancy [Middleton, 2022], and on OSAS in children [Harrison, 2017; Gileles-Hillel, 2024].

Arranging referral for adults

• The recommendation to arrange urgent referral for professional drivers or if OSAS symptoms impact on safety-critical work is based on NICE guidance and the BTS position statement [NICE, 2025; BTS, 2018]. The BTS statement advises that such cases should be fast-tracked for diagnosis and treatment of symptomatic OSAS within 4 weeks of referral, to allow rapid symptom control and to minimize time off work. It notes that this approach should give drivers the confidence to present with symptoms of suspected OSAS [BTS, 2018].
• The recommendation to arrange urgent referral if a person has cardiopulmonary comorbidities is based on NICE guidance and the European working group report of the ERS/ESRS [NICE, 2025; Randerath, 2018]. The ERS/ESRS report describes an increased disease burden and rates of chronic obstructive pulmonary disease (COPD) exacerbations, together with a higher risk of death in people with COPD or a history of respiratory failure with comorbid OSAS [Randerath, 2018].
• The recommendation to arrange priority referral for people who are pregnant, undergoing pre-operative assessment for major surgery or have non-arteritic anterior ischaemic optic neuropathy is based on a NICE guideline [NICE, 2025] and expert opinion in review articles [Akashiba, 2022; Middleton, 2022].
  
  • Several physiological adaptations to pregnancy can impact on both sleep quality and sleep disordered breathing, and several studies have demonstrated a correlation between the development of new snoring or abnormal breathing during sleep in pregnancy with worse maternal and fetal outcomes (including gestational hypertension, pre-eclampsia, stillbirth/neonatal death, preterm birth and low birth weight [<2500 g]) [Middleton, 2022].
• Recommendations on when to arrange routine referral are based on the European working group report of the ERS/ESRS, which notes that once OSAS is confirmed, excessive daytime sleepiness is rapidly resolved by appropriate specialist treatment [Randerath, 2018].
• The recommendation to arrange an urgent referral for adults with a learning disability or autism is based on guidance from NHS England [NHSE, 2024].
  • This guidance highlights that assessment and diagnosis may be difficult in people with these conditions, and therefore recommends referral to a hospital sleep service for a formal assessment.
  • The guidance also states that untreated OSAS can impact on mental health as well as causing significant risks to physical health. so treatment should be prioritised for people with a learning disability and autistic people, who often face health inequalities and the risk of premature mortality.

Sleep studies

• Considering home oximetry:
  • The advice to consider home oximetry if respiratory polygraphy is limited is based on a NICE guideline [NICE, 2025]. NICE also advise that oximetry alone may be inaccurate for differentiating between OSAS and other causes of hypoxaemia in people with heart failure or chronic lung diseases. 

Specialist treatments — Continuous positive airway pressure (CPAP)

• CPAP treatment is effective for OSA, with CPAP treatment recommended as the first choice for patients with strong clinical symptoms such as daytime sleepiness due to OSA, and for moderate to severe cases [Akashiba, 2022].
• CPAP therapy significantly reduces excessive daytime sleepiness and driving risk in people with OSAS, however treatment has a limited impact on reducing cardiometabolic risk for most people, but may benefit people with high compliance to treatment and some patient subgroups [Randerath, 2018].
• The NICE guideline provides details of meta analyses that have demonstrated statistically significant greater reductions in daytime sleepiness with CPAP compared with placebo or usual care, as well as a reduction in arterial blood pressure compared with placebo or usual care, greater improvements in the Apnea-Hypopnea Index (AHI) and minimum oxygen saturation during sleep in favour of CPAP compared with dental devices, and considerable reductions in the rate of road traffic accidents. Meta-analyses of studies comparing CPAP and placebo or usual care investigating health related quality-of-life related outcomes did not identify any statistically significant improvements with CPAP overall, though individual studies have described improvements in health subscales for bodily pain, emotional role, mental health, general health, physical function, social function and vitality [NICE, 2021].
• Expert opinion in a review article also notes that CPAP therapy has been shown to be superior to intra-oral devices in reducing apnoea-hypopnea indices (AHI), arousal indices, and oxygen desaturation, particularly in people with moderate-to-severe OSAS, although outcomes for quality-of-life indices appear to be similar to intra-oral devices [Semelka, 2016].
• Adherence to CPAP therapy appears moderate to high over the short to medium term, with ranges of 64–83% (mean 71%) adherence up to 12 months, 68–90% (mean 79%) for 12 months or more [NICE, 2021].
• Where CPAP adherence is affected due to upper airway side effects, such as nasal and mouth dryness, and CPAP-induced rhinitis, specialists may be able to offer a heated humidification device [NICE, 2021].

Specialist treatments — Intra-oral mandibular advancement devices

• Intra-oral mandibular advancement devices may improve certain quality of life aspects (specifically mental and physical), and may improve some cardiovascular risk factors for people with OSAS [Akashiba, 2022].
• The NICE guideline advises that specialists can consider the use of customised or semi-customised mandibular advancement splints as an alternative to CPAP, where CPAP has not been tolerated or declined, when the person is aged 18 or over, they have optimal dental and periodontal health (specifically listing people with active periodontal disease or untreated dental decay or few or no teeth), and do not have generalised tonic-clonic seizures [NICE, 2025].
• The NICE guideline provides details of the evidence concerning the efficacy and safety of mandibular advancement splints, which were provided from several separate studies where the quality of the evidence varied from moderate, to very low quality (evidence quality mainly downgraded due to risk of bias, indirectness and imprecision). In moderate severity OSAS, the evidence suggests a clinical benefit for mandibular advancement splints when compared to a placebo for AHI and quality of life scores in the physical domain, and a benefit for mandibular advancement splints when compared to CPAP in critical quality of life outcomes after 12 months of treatment [NICE, 2025].

Specialist treatments — Surgery

• The NICE guideline advises that there are no other treatment options for people with severe OSAS who cannot tolerate CPAP and mandibular advancement devices. The guideline therefore recommends that surgery for the right people, may improve their quality of life, but these people should have fully explored other treatment options under medical supervision for a sufficient period of time [NICE, 2025].
• The NICE guideline also highlights the potential risks of surgical intervention in people with severe OSAS, and stressed that a personalised approach is required to decide which people may be the most appropriate candidates for surgery [NICE, 2025].
• A systematic review identified a single randomized controlled trial (RCT) investigating the effect of gastric banding compared with weight reducing diet on OSAS outcomes. The authors of the systematic review concluded that obese patients with OSAS who have not been able to improve their weight despite participating in a comprehensive weight reduction programme may benefit from bariatric surgery evaluation where there are no contraindications [].

Specialist treatments — Emerging treatments

• Emerging treatments such as hypoglossal nerve stimulation, myofunctional therapy, and medication therapy may be used in secondary care and investigated in clinical trials [; Arachchige, 2022]:
  • Hypoglossal nerve stimulation can involve the implantation of a neurostimulator or use of a non-invasive electronic device that delivers an electric current to the distal branch of the hypoglossal nerve, resulting in genioglossus muscle contraction thereby preventing the tongue from causing airway obstruction during sleep [Arachchige, 2022]. This therapy may have benefits for people with symptomatic OSAS who cannot be sufficiently treated with more standard treatments (such as CPAP) [].
  • Myofunctional therapy includes oropharyngeal exercises, circular breathing and muscle training via electrical stimulation. There is limited evidence available for these interventions, a systematic review identified only six small RCTs, with the findings suggesting only small and probably temporary advantage over more established treatments [].
  • Medications such as pitolisant, solriamfetol, carbonic anhydrase inhibitors, and a combination of atomoxetine oxybutynin have been studied in clinical trials [; Arachchige, 2022]. Pitolisant and solriamfetol are not currently recommended by the National Institute for Health and Care Excellence (NICE) [NICE, 2022a; NICE, 2022b], and the combination of atomoxetine oxybutynin has not been assessed.

Basis for recommendation

The recommendations on primary care management are based on the European working group report of the Sleep Disordered Breathing Group of the European Respiratory Society (ERS) and the European Sleep Research Society (ESRS) Challenges and perspectives in obstructive sleep apnoea [Randerath, 2018], the American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM) publication Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015 [Ramar, 2015], the Japanese Sleep Apnea Syndrome (SAS) Clinical Practice Guidelines [Akashiba, 2022], guidance from NHS England Healthcare professionals guide to obstructive sleep apnoea (OSA) amongst people with a learning disability and autistic people [NHSE, 2024], two Cochrane systematic reviews on the effect of positional therapy on OSAS [Srijithesh, 2019] and on interventions to improve usage of continuous positive airway pressure (CPAP) [Askland, 2020], two meta-analysis studies and a network meta-analysis examining the effects of exercise on OSAS [Iftikhar, 2024; Lin, 2024; Tang, 2024], the Driver and Vehicle Licensing Agency (DVLA) guidance Assessing fitness to drive: a guide for medical professionals [DVLA, 2025], the British Thoracic Society (BTS) position statement Driving and obstructive sleep apnoea (OSA) 2018 [BTS, 2018]; a systematic review of non-continuous positive airway pressure therapies for OSAS []; and expert opinion in review articles on OSAS [Stradling, 2016], on OSAS in adults [Semelka, 2016; Gottlieb, 2020; Arachchige, 2022], on OSAS in children [Harrison, 2017], and on intra-oral devices [Dieltjens, 2019; Francis, 2020].

Advising on lifestyle measures

• The recommendations on weight loss are based on the European working group report [Randerath, 2018], two systematic reviews with meta-analyses on the effects of exercise [Iftikhar, 2024; Lin, 2024; Tang, 2024], the Japanese SAS guidelines [Akashiba, 2022], and expert opinion in review articles [Semelka, 2016; Stradling, 2016; Harrison, 2017; Francis, 2020; Gottlieb, 2020; Arachchige, 2022].
  • The European working group report recommends lifestyle measures are used in the management of OSAS, especially if continuous positive airway pressure (CPAP) or other specialist treatments do not fully resolve symptoms. It states CPAP therapy should be combined with weight loss, and cites evidence of improved blood pressure control, insulin resistance, and lipid profile compared with when treatments are given alone. In addition, it highlights the benefits of bariatric surgery in selected obese patients [Randerath, 2018]. Similarly, the Japanese SAS guidelines highlight the additive effects of combined CPAP and weight loss on improving blood pressure among obese people with moderate to severe OSAS [Akashiba, 2022].
  • Weight loss has been shown to decrease critical closing pressure of the airway, reducing the likelihood of pharyngeal collapse during sleep [Semelka, 2016; Gottlieb, 2020].
  • Expert opinion in a review article recommends weight loss in children with obesity for long-term management of OSAS [Harrison, 2017].
  • Two meta-analysis studies and a network meta-analysis have demonstrated improvements in OSAS symptoms among adults who undertake exercise [Iftikhar, 2024; Lin, 2024; Tang, 2024].
    • The first meta-analysis of 11 small studies (n = 217) found a statistically significant reduction in the apnoea-hypopnoea index (AHI) following supervised exercise training, with a reduction in the severity of sleep apnoea symptoms when the weekly duration of aerobic exercise reached 100 min/week [Iftikhar, 2024].
    • The second meta-analysis combined data from up to 12 studies (n = 264 adults), and showed a reduction in AHI, reduced Epworth sleepiness scale (ESS) scores, and lower body mass index (BMI) in people with OSAS undertaking exercise (aerobic and/or resistance training). The authors concluded that the effect size of exercise on these outcomes was lower than what would be expected with CPAP, oral devices or surgical procedures, but comparable to body weight and diet control [Lin, 2024].
    • The network meta-analysis included data from up to 24 studies (including up to 956 adults with OSAS). Aerobic exercise, combined exercise and oropharyngeal exercise were all found to improve Apnoea Hypopnea Index (AHI), Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) scores. Respiratory muscle training was found to improve PSQI and ESS scores. In the network meta-analyses, a combined exercise regime (aerobic and resistance) was found to be the most effective intervention in improving AHI scores, while oropharyngeal exercise was the most effective at improving PSQI and ESS scores, although there were no statistically significant differences between the interventions for any of the outcomes analysed [Tang, 2024].
• The recommendation on smoking cessation is based on the Japanese SAS guidelines [Akashiba, 2022] and extrapolated from expert opinion in a review article [Francis, 2020].
• The recommendation on alcohol consumption is based on expert opinion in review articles [Gottlieb, 2020; Arachchige, 2022].
• The recommendation on sleeping position is based on the European working group report [Randerath, 2018], the Japanese SAS guidelines [Akashiba, 2022], a Cochrane systematic review of positional therapy for OSAS [Srijithesh, 2019], a systematic review of non-continuous positive airway pressure therapies for OSAS [], and expert opinion in review articles [Francis, 2020; Gottlieb, 2020; Arachchige, 2022].
• A Cochrane systematic review of five short-term studies of positional therapy compared with control including no intervention (n = 251) found moderate-certainty evidence that positional therapy significantly improved ESS scores, and low-certainty evidence of a reduction in AHI. There were no significant differences between the two groups on other outcomes such as quality of life or cognitive function [Srijithesh, 2019].
• A systematic review of non-continuous positive airway pressure therapies for OSAS found that CPAP showed a slightly better effectiveness compared to positional therapy, while the compliance on CPAP is somewhat lower [], but sleep disturbance is common and compliance may still be poor [Randerath, 2018].
• The Japanese SAS guidelines notes that sleeping in a lateral position rather than supine may reduce apnoea episodes [Akashiba, 2022], however expert opinion from a review article highlights that studies on not sleeping in a supine position have shown mixed results [Francis, 2020]. The Japanese guidelines recommend that patients with mild cases (along with those who have difficulty with standard treatment such as CPAP treatment), whose apnoea has been confirmed to reduce with sleeping in a lateral position, may benefit from altering their sleeping position [Akashiba, 2022].

Encouraging adherence with specialist treatment

• The recommendation on encouraging adherence with treatments is based on a Cochrane systematic review on usage of CPAP therapy [Askland, 2020], the European working group report [Randerath, 2018], the AASM/AADSM clinical practice guideline [Ramar, 2015], and expert opinion in review articles [Semelka, 2016; Dieltjens, 2019; Gottlieb, 2020; Arachchige, 2022].
  • A Cochrane systematic review of 41 studies (9005 adults) found high-certainty evidence that behavioural interventions increased usage of CPAP when compared with usual care, with low-certainty evidence of symptom improvement but likely no effect on quality of life. There was moderate-certainty evidence that supportive interventions also increased CPAP device usage, with associated small improvements in reported symptoms [Askland, 2020].
  • The European working group report cites evidence that use of intra-oral devices in mild-to-moderate OSAS can improve symptoms, despite a reduced effect in lowering AHI [Randerath, 2018].
  • The AASM/AADSM clinical practice guideline highlights the importance of follow up for people using mandibular devices to monitor efficacy, check for adverse effects, and encourage compliance [Ramar, 2015].
• Guidance is provided from NHS England highlighting that people with a learning disability and autistic people with OSAS may be at increased risk of complications if they or their carers do not understand the importance of consistently using a CPAP machine. The guidance also states the importance of reviewing compliance within primary care. Where non-compliance is identified in primary care, a review in secondary care is recommended [NHSE, 2024].

Monitoring for and managing associated conditions

• The recommendations on monitoring for and managing associated cardiometabolic conditions and depression are based on the European working group report [Randerath, 2018] and expert opinion in review articles [Semelka, 2016; Stradling, 2016; Gottlieb, 2020]. They are also pragmatic, based on what CKS considers to be good clinical practice.

Advising safety-critical workers and issuing fitness for work statements

• The advice about employee legal responsibilities with informing their employer if their health is impacting their ability to perform their role safely is based on Section 7 of the Health and Safety at Work Act 1974 [HSWA, 1974].
  • This section of the act states that it is the duty of every employee, while at work, to take reasonable care for the health and safety of himself and of other persons who may be affected by his acts or omissions at work.
• Guidance for healthcare professionals about issuing a statement of fitness for work ('fit note') is provided by the UK Government's Department for Work and Pensions (DWP) [DWP, 2023].
  • The fit note should cover the duration that the patient is likely to be unfit for work duties and provide advice for the patient and their employer to help them stay in, or return to, work.
  • The length of a fit note should be based on clinical judgement. In the first six months of a person’s health condition, a fit note can only be issued for a maximum of three months at a time.
  • The guidance about when to reassess a person's fitness to work is pragmatic based on the expected time it would take for CPAP therapy to improve symptoms of sleepiness.

Basis for recommendation

The information on driving regulations is taken from the Driver and Vehicle Licensing Agency (DVLA) guidance Assessing fitness to drive: a guide for medical professionals [DVLA, 2025] and the British Thoracic Society (BTS) position statement Driving and obstructive sleep apnoea (OSA) 2018 [BTS, 2018].

Drivers who do not have excessive sleepiness

• The information for drivers who do not have excessive sleepiness is extrapolated from the DVLA guidance [DVLA, 2025]. It is also based on the BTS position statement, which notes that there is a risk that asymptomatic people or people with mild obstructive sleep apnoea syndrome (OSAS) without excessive sleepiness may stop driving unnecessarily without being given accurate information on driving regulations [BTS, 2018].