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Sleep Apnoea – Essential Information for Doctors, Nurses and other Clinicians


Update on Sleep Services During Endemic COVID-19 v1.4 26th May 2020 – Click here Sleep_Services_During_Endemic_COVID-19_Version_1.4

Sleep Services During Endemic COVID-19 from the ARTP and BTS

Introduction

Sleep services comprise a series of diagnostic and treatment functions for a wide spectrum of sleep disorders and are run by physiologists/scientists together with a range of specialties
including respiratory, neurology, anaesthesia and others. They consist of testing and treating patients with either (i) sleep breathing disorders or (ii) purely sleep disorders.
The sleep breathing disordered services are high volume services with some 12,000 diagnostic sleep tests per month, many to exclude or confirm the diagnosis of obstructive sleep apnoea.
As for general respiratory physiology, such services closed early and several treatments are associated with infection control issues caused by aerosol generating procedures (AGPs) such
as administration of CPAP and NIV.
As a consequence, there are three issues to consider:

1. The need for physiologists/scientists to continue supporting the acute use of CPAP / NIV on wards as the endemic COVID-19 will now be looked after mainly by respiratory teams
and ITU.
2. The huge backlog that has arisen as a consequence of respiratory/sleep physiology services being closed early, coupled with the huge turnover that normally occurs, leading to
difficulties in restoration of services.
3. Difficulties in the initiation of CPAP and NIV given their AGP nature. This will lead to reduced turnaround times with subsequent inefficiencies due to reduced throughput and
exacerbate the significant backlog that already exists in many sleep departments. Most services in the past have had a variety of pathways, but the reduction of face to face
services has forced changes in pathways that may be better for patients, although this requires formal evaluation. In the interim 18-24 months, these new ways of working now
need to now be established as part of normal business, taking local circumstances into account. However, there needs to be recognition of any financial implications of such changes
with tariffs and commissioning adjusted appropriately.
These matters need to be considered in the setting of workforce capacity. On top of the longstanding staff shortages in respiratory physiology, there are those who are currently absent
from work with COVID-19 or shielding. Additionally, a significant proportion of the workforce is from a B.A.M.E. background, and more senior staff tend to be older with possible associated
co-morbidities.
                                                                                                                                                                                                              
Simple precautions
For patient attendances, if they do occur, similar precautions to respiratory physiology
services need to be considered, as listed:
1. Ensure patients and staff are at the lowest risk by:
● Undertaking a pre attendance questionnaire, including validating the contact app.
● Check the patient’s temperature on arrival at the sleep department. If elevated above 37.3°C, organise swabbing and rebook the patient at a later date.
● Some organisations may pre-swab ahead of any appointments, recognising that there is a significant false negative rate.
● “Hot” and “cold” COVID-19 sites may be considered, recognising there is still a risk of false negative results.
● Social distancing in waiting rooms or ask patients to wait in their car, recognising there is a need for administration time for this.
● Attempt to maintain a unidirectional flow of patients through the department to minimise face to face contact.
● Ensure the environment allows sufficient air exchanges.

2. Full PPE (including FFP3 mask or equivalent) needs to be worn if there is a plan to directly
initiate NIV or CPAP, though alternative methods of initiating these need to be considered. PHE have decreed that both these procedures are AGPs, so full PPE is required.

3. Following the attendance, the equipment and surfaces need to be cleaned and PPE removed, with time allowed for room air to change delaying turnaround times. (“Second”
rooms, where available, can be used alternately).

4. The time between the next patient attending for the next test will be a function of the number of room air changes. PHE recommends 6 Air Changes per Hour (ACH) for rooms
where NIV and CPAP are initiated. Departments need to check the airflow/changes in rooms are adequate to determine how long the room needs to be left empty before reuse
by a new patient. Where the testing room does not meet the PHE recommended air change requirement, or there are significant doubts, the room should be left empty before
cleaning for a period of at least three hours (Ref 1)

Specific process

A. Performing limited sleep studies

This involves patients using a piece of equipment overnight in their own environment to record a variety of different parameters, depending upon the condition being investigated.
As such the equipment needs to be available for the patient, they need to be instructed how to use it, ensuring the kit is returned in a timely fashion with subsequent
cleaning/disposal so it can be reissued.
Departments may wish to consider using pulse oximetry to be posted out as a screening test. Interpretation by skilled individuals is key, recognising that some patients may have
significant sleep problems but do not show overnight desaturation, though, when abnormal with the characteristic pattern, it can reduce the need for other diagnostic tests
with the problems below.

If a limited multi-channel sleep study is deemed necessary, it could be:
● Performed using disposable equipment, organised through a third party.
● By sending the department’s equipment out by courier.
● Patients attending the sleep laboratory (or a collection point) as they did previously.

If the department’s equipment is used, then, on return, some parts will need to be disposed of as high risk; e.g. nasal cannula, whilst other parts will need cleaning if not single
patient use; e.g. effort bands. The recording device will need to be rigorously cleaned according to manufacturer’s instructions.
All this will delay the normally rapid turnaround. So, to maintain efficiency during the endemic COVID-19 period, several more items of diagnostic equipment will need to be
available to departments, at significant additional cost. Tariff and commissioning will need to reflect this new inherent inefficiency.
The use of a range of limited sleep study devices is available and, to date, none has any clear infection protection and control advantage over the other.

B. Reviewing the patients with results
Given the widespread use of telephone and video consultations that have occurred in the current COVID-19 pandemic arrangements, this should be the main way wherever possible
of undertaking the clinical history, communicating the results of the sleep study and determining a management plan. Whether this “first appointment” will be performed by
medical staff or physiologists/scientists will depend upon local arrangements, but this will significantly reduce footfall of patients in sleep departments. To enable such innovation
providers need to invest in appropriate technology.
It needs to be recognised that, in some instances, review of the patient face to face may be required (e.g. to examine the upper airway with regards to consideration of any
obstructing lesions and the possibility of an advancement device). Appropriate precautions need to be in place as documented above and FFP3 mask and visor worn given
the risk of coughing during inspecting the mouth/throat/airway.
For patients with other “pure” sleep diagnoses (e.g. narcolepsy, parasomnias, etc.), management advice and follow up should be by virtual means where possible.

C. Initiation of CPAP
While, in a small number of organisations, this may be arranged through third parties, many patients are initiated onto CPAP through either group or individual appointments
within sleep departments. This will be an explanation with the patient of the underlying  problem, finding the correct interface, advice on cleaning the equipment and then patients
starting CPAP in the presence of sleep staff.

If this process is to continue, it has to be recognised that this is a high risk AGP scenario and full PPE needs to be in place, with appropriate cleaning of the environment and
sufficient air changes before other patients can use the room. An alternative process is to educate the patient and mask fit but not to apply the mask
with the unit turned on. CPAP should be started in the patient’s home with, access to online or written/interactive media and supported by phone or virtual advice. Under such
circumstances, given the close proximity to the patient during assessing the correct interface, a FFP3 or equivalent mask together with visor and gloves should be used. A
standard apron will be sufficient.

If patients try the “sensation” of CPAP at pressure on a non-vented mask and circuit staff should wear full PPE including FFP3 mask even if for a brief period.

D. Follow up of CPAP patients
Previously, patients would attend clinic regularly for a variable number of times to check CPAP adherence; a pre-requirement for DVLA at 1 -3 years depending upon their class of
driving licence. Over recent times, technology has enabled both monitoring and the ability to change the device settings remotely. There should be a concerted move to technology enabling
follow-up by reviewing CPAP (e.g. usage, amount of leak, etc.) by interrogating the equipment and a phone call with the patient. This will allow adherence issues to be addressed, explanations to patient questions, and a clear plan for withdrawing CPAP if not used. This has proved very successful to many sleep services in the pandemic phases of COVID-19.
Where patients have older machines without this facility, posting in the smart cards and subsequent phone review may be necessary, until we move to smart technology in all newly issued machines. Switching machines to enable remote monitoring may be more cost-effective in the long term.

There needs to be recognition within organisations that while this may reduce footfall in departments, clinics should be pre-booked, and time is established in physiologists/scientists job plans for this occur. Given this equipment is more expensive, the commissioning of the service and the tariff needs to reflect this change in practice that minimises staff and patient risk by limiting patient attendance.

E. Full polysomnography (PSG)
Full polysomnography and the associated daytime studies of MSLT and MWT are key to managing a wide spectrum of sleep problems, though are used proportionately less than limited studies. It is estimated that they make up about 5-10% of NHS sleep services in the UK.
In all these studies, electrodes are applied to the skin of the scalp, around the eyes, and chin to enable the staging of sleep. While MSLT and MWT are daytime studies, they are invariably proceeded by full polysomnography the previous night. The operational  standards for overnight studies are applicable to the daytime ones. For PSG, the study is performed overnight and records a variety of measurements to fully stage sleep, record breathing patterns, cardiac status, limb movements, video, etc. Given the close proximity of the physiologist/scientist to the patient in applying the through the night to adjust electrodes, etc., and then to remove them the following morning, the issues below need to be considered in addition to standard infection control procedures:
i) The Patient
The precautions listed above in [1] need to be in place and should include swabbing, isolation after swabbing, administration of a questionnaire on the afternoon of the study and checking the individual’s temperature on arrival.
ii) The Physiologist/Scientist
During set up, PPE should include a visor/goggles, water-repellent mask or equivalent, gloves and apron. Such equipment should be used if the patient needs to be reviewed in the night and when taking the equipment off the following morning.
iii) The Environment
There should be sufficient air changes as listed above (see latest PHE guidance) though this may be difficult for many sleep laboratories as they are part of the
organisations structure and “hard wired”. After the study, the room needs to be thoroughly cleaned and not used for a period recommended by infection control.
iv) The Equipment
Following the test(s), the nasal cannula and disposable effort bands should be disposed of as high risk waste as should other equipment where possible. Any
equipment that cannot be disposed of should be cleaned as per local infection control/PHE guidance recommendations, recognising there are a variety of different
sorts of equipment, so specific rules cannot be stated.

Future work needed
Uncertainty about the financial aspects of the service
Agreement on funding for remote monitoring, video-consultations/appointments, peripatetic services and testing/treating in the patient’s home. All to include PPE expenses.
Audit of non F2F and remote monitoring in CPAP adherence
● Retrospective audit of services should be simple but needs coordinating nationally
via professional bodies (ARTP, BTS).
● Patient satisfaction audit on non F2F contact for management of sleep patients.

Acknowledgment
This document has been developed with expert colleagues from the British Sleep Society and
British Thoracic Society and reflects a broad range of opinion. As new evidence becomes
available, the document will be revised to reflect this.
References
1. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1.
van Doremalen N, Bushmaker T, Morris DH, et al. N Engl J Med 2020; 382:1564-1567


Guidance regarding coronavirus (COVID-19) and Obstructive Sleep Apnoea (OSA):

for people who routinely use continuous positive airway pressure (CPAP), their families and health care workers, 20th March 2020 
Complied by Dr Sonya Craig and Dr Sophie West with the OSA Alliance (incorporating British Thoracic Society, British Sleep Society, Association for Respiratory Technology and Physiology, Sleep Apnoea Trust Association).

General advice

Patients with OSA should follow the government advice re COVID-19:                         https://www.gov.uk/government/topical-events/coronavirus-covid-19-uk-government-response.

There is no data yet regarding the risk of OSA alone in terms of COVID-19 susceptibility.

Home advice

  • People with OSA should continue to use their CPAP at home as normal.
  • There is no evidence that using CPAP makes you more likely to catch COVID-19, and nothing to suggest that CPAP will make you more unwell if you do catch it.
  • If a CPAP user becomes unwell with symptoms suggestive of COVID-19 (new cough and fever > 37.8 C), please follow government guidance regarding self and household isolation.
  • We do not know whether CPAP makes virus spread worse within a household. This will be something you will need to consider when deciding whether or not to continue using CPAP if you are self-isolating with symptoms of COVID-19. You may wish to distance yourself from vulnerable household members by changing bedrooms or stopping CPAP for a short time.
  • Any respiratory infection, particularly with a blocked nose, can make it more difficult to use CPAP. Try and persist, but if wearing CPAP makes you feel worse (e.g. by increasing coughing and disturbing sleep), then stop using it until your respiratory symptoms improve. Sleeping more upright, avoiding alcohol and using a mandibular advancement spilt if you have one, may help as alternatives to CPAP in reducing OSA a little in this period. Your OSA symptoms are likely to worsen over the week, but will resolve when you restart CPAP.
  • Routine hygiene is adequate for infection control: changing machine filters routinely, cleaning surfaces, cleaning mask and tubing with hand-hot soapy water (washing up liquid) and washing hands regularly.
  • Masks and machines should not be shared.
  • Please use the telephone number/email address provided by your sleep centre for urgent issues with your equipment or sleep/OSA related symptoms. Do not attend in person unless instructed to do so. Please be aware the team may not be able to respond quickly, as staff may have been moved to Emergency Services.
  • Please look after masks and tubing carefully as there may be a temporary shortage in the future.
  • A reminder that DVLA says anyone with excessive sleepiness having or likely to have an adverse effect on driving must not drive.

Sleep out-patient advice for hospitals

  • Routine out-patient visits should be avoided unless urgent.
  • Remote monitoring and telephone consultations may be an option for some.
  • Posting of masks and equipment from Sleep centres should be encouraged, without patients attending.

Advice for a person with OSA who routinely uses CPAP who is unwell and admitted to hospital due to suspected/confirmed COVID-19

  • Bring your CPAP machine into hospital with you.

DO NOT USE YOUR CPAP UNLESS INSTRUCTED BY STAFF: you may be asked not to use CPAP for OSA on an open ward if you have suspected COVID-19, until COVID-19 screening results are back.                                  If you use CPAP for Obesity Hypoventilation Syndrome (OSA, obesity plus respiratory failure) requiring CPAP to maintain ventilation, this should be continued but will need an isolation area (such as side room or negative pressure area), so please be guided by medical staff caring for you.

  • To decrease any risks of infection from CPAP whilst you are in hospital: your usual mask, which has a vent to allow you to breathe out, may be changed. The new temporary mask will not have this vent, but a bacterial/viral filter can also be added along with an exhalation port in the tubing.
  • DO NOT USE your humidifier with your CPAP machine in hospital due to increased droplet spread.

For a copy of this information please click here    OSA Alliance CPAP COVID 19 advice 20 3 20

For advice on how to sanitise, clean and maintain your CPAP equipment, please refer to the “Living With Your CPAP” leaflet or the equivalent A4 Patient Information Sheet (for home printing), by clicking the links below:

Living With Your CPAP – Questions to Frequently Asked Questions for those new to CPAP treatment – Feb 2019

Living With Your CPAP – A4 – Sep 2019


VERY IMPORTANT DVLA GUIDANCE

If, after a sleep test, you  diagnose a patient with mild, moderate or severe OSA and NO EXCESSIVE SLEEPINESS then do NOT advise them to contact the DVLA.

If, after a sleep test, you diagnose a patient with moderate or severe OSA WITH EXCESSIVE SLEEPINESS then advise them to contact the DVLA.

If, after a sleep test, you diagnose a patient with mild OSA WITH EXCESSIVE SLEEPINESS  which is still present after 3 months,then advise them to contact the DVLA.

The DVLA has no rules concerning compliance other than:

  • control of condition

  • sleepiness improved

  • treatment adherence

The DVLA will need medical confirmation of the above and the driver must confirm review to be undertaken every three years the minimum for Group 1 car and motorcycle and annually for Group 2 bus and lorry.

There are no rules from the DVLA concerning level of AHI or hours on CPAP, only that medically the patient is clinically assessed to meet the above three conditions.

DRIVING
The British Thoracic Society (BTS)  have published a revised Position Statement on Driving and Obstructive Sleep Apnoea (OSA) 2018. All Clinical Staff should follow the advice provided by the BTS in this Position Statement, in conjunction with the revised DVLA Guidance published in March 2019 “Assessing fitness to drive – a guide for medical professionals  March 2019”

Click here   BTS Position Statement on Driving & Obstructive Sleep Apnoea (OSA) 2018

Click here Assessing Fitness to Drive – A Guide for Medical Professionals – March 2019

The recent problems with DVLA seem to be stabilising. But for the time being SATA continues to advise that you do not advise patients who drive and you suspect to have sleep apnoea and have not been diagnosed through consultation and sleep test with an appropriate Sleep Clinic,  to telephone, email or use the online medical reporting system to contact the DVLA, but to write and keep a copy. A mistake can easily lead to an unecessarily revoked licence

The much clearer explanation of the new rules published by the DVLA and updated in March 2019 and read in conjunction with the BTS Position Statement will lead to a much better understanding by patients and clinicians of their position as regards informing the DVLA.

AIRLINES
We have been informed that you are now being frequently asked about flying and CPAP. SATA has up to date information on all the airlines flying from the UK, with a simple traffic light guide as follows:

Airlines in Green – allow CPAP used on seat power where available, otherwise batteries
Airlines in Yellow – specify battery use at all times (even when power is available)
Airlines in Red – No CPAP usage allowed, or no positive information on website

GMC CONFIDENTIALITY
We also include the latest version of the General Medical Councils Guidance on Patient Confidentiality, both to inform patients and keep clinicians updated.

NICE
SATA was instrumental in lobbying for the provision of treatment for Sleep Apnoea resulting in its recommendation by NICE (National Institute for Health and Care Excellence)

Please make your selection below:

Assessing Fitness to Drive – A Guide for Medical Professionals – March 2019
Confidentiality_Patients_fitness_to_drive_and_reporting_concerns_to_DVLA_or_DVA.pdf_70063275
NICE (National Institute for Health & Care Excellence)

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