Sleep Apnoea
Location on Choose and Book: ‘Sleep Medicine’ Specialty
& ‘Sleep Apnoea/Sleep Disordered Breathing’ Clinic Type
Link to useful website – www.sleep-apnoea-trust.org
Clinic address
Practice address
Clinic Tel No
Practice Tel No
Patient’s Name
D.O.B
Patient address
Height
Age
Sex
Referring Clinician
NHS. No
Home Tel No
Mobile
Work
E-mail
Weight
BMI
Inclusion Criteria
A score of 10 or more using the Epworth Sleepiness Scale, plus 3 or more of the following:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Loud snorer
Patient experiences waking with choking/obstructive episodes
Patients working life severely affected by daytime sleepiness
Patients driving severely affected by daytime sleepiness
Spouse has noticed episodes of stopping breathing (although any snorer will have
occasional such events, especially supine)
Regularly waking un-refreshed in the morning
Personality change / decreased libido / nocturia
Small pharynx on visual inspection
Neck circumference over 17.5 inches (thus usually but not always overweight)
When referring patients please enclose:
Completed Epworth questionnaire (see below)
Completed Bed Partner questionnaire (see below)
Exclusion Criteria
Date written
Review date
Author & lead clinician
Version
13.5.2015
13.5.2017
[email protected]
1
page 1 of 3
Epworth score of less than 10 : Manage in Primary Care, only refer if persistent problems
Chronic fatigue/sleepiness: Refer to Chronic Fatigue clinic
NB. Shift work, insomnia, depression and poor sleep hygiene can all cause day time
sleepiness
Specific information needed at the time of referral
History including referral criteria applying to this patient
Specific information needed when the patient is seen
Completed Epworth Questionnaire (see embedded documents)
Partner Questionnaire
Space for free text letter
Exceptions (please delete if not applicable)
For the very occasional patient that doesn’t meet the criteria but the referrer is still thinks
this is the right clinic – the referrer must explain clearly why
Date written
Review date
Author & lead clinician
Version
13.5.2015
13.5.2017
[email protected]
1
page 2 of 3
Current medication
Allergies
Summary of relevant medical history
Relevant social circumstances
_____________________________________________________________________
Document details
Details of consultation
Dr Will Elston – Derby respiratory Consultant
Dr Ian Lawrence – GP and SDCCG Planned Care Chair
Contacts
Christine Urquhart – [email protected] tel 01332 868 876
Tina Pottrell – [email protected] – tel 01332 868 924
Keywords
Sleep; apnoea; Epworth; tiredness;
Is it provider or CCG specific?
Provider specific – Derby Hospitals
Document history
Date written
Review date
Author & lead clinician
Version
13.5.2015
13.5.2017
[email protected]
1
page 3 of 3
Sleep Apnoea
Questionnaire for bed partner
We are looking to see whether your partner has any trouble with their breathing
while asleep, and it would be very helpful if you could answer the following
questions:
QUESTION
ANSWER
1.
Does your partner sore loudly in their sleep?
Yes/No
2.
Is the snoring sufficiently loud to wake you at night?
Yes/No
3.
Has the noise been so bad that you have had to sleep in another room?
Yes/No
4.
Does your partnership stop breathing during their sleep?
5.
Can you estimate how many times your partner stops breathing during
the average night?
Yes/No
1-10
11-20
>20
6.
Have you ever felt the need to wake up your partner to see if they are alright
7.
Is your partner restless in their sleep?
Yes/No
Yes/No
Has your partner’s personality changed lately?
8.
Yes/No
8a.
If so in what way
9.
Does your partner fall asleep easily during the day?
Yes/No
10.
Has your partner ever fallen asleep when driving a car?
Yes/No
11. Any other comments?
DIARY
Time recording started:
Time recording stopped:
Did you get up during the recording?
Yes/No
If yes, when?
How well did you sleep?
Date written
Review date
Author & lead clinician
Version
13.5.2015
13.5.2017
[email protected]
1
page 4 of 3
Name
Date
HN
DOB
Height
Weight
BMI
EPWORTH SLEEPINESS SCALE (ESS) SCORE
How likely are you to dose off or fall asleep during the following situations, in
contrast to just feeling tired?
For each of the situations listed below, give yourself a score of 0-3 where:
0= would never doze
1= slight chance
2= moderate chance
3= high chance
Work out your total score by adding up your individual scores for situations 18 (if you have not been in the following situations recently, think about how
you would have been affected?
SITUATION
1.
2.
3.
4.
5.
6.
7.
8.
SCORE
Sitting and reading
Watching television
Sitting inactive in a public place e.g theatre, meeting
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon
Sitting and taking to someone
Sitting quietly after lunch (no alcohol)
In a car, while stopped in traffic
TOTAL
.
Date written
Review date
Author & lead clinician
Version
13.5.2015
13.5.2017
[email protected]
1
page 5 of 3
Date written
Review date
Author & lead clinician
Version
13.5.2015
13.5.2017
[email protected]
1
page 6 of 3