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Obstructive sleep apnoea

TE HA ORA MOE THE BREATH OF LIFE (SLEEPING). Obstructive sleep apnoea. Alister Neill. Sleep health. Sleep that is fully restorative, enabling full potential Achieving optimum total sleep time Major health issues Sleep deprivation (TST < 5 hours/ night) Shift work Sleep Disorders

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Obstructive sleep apnoea

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  1. TE HA ORA MOE THE BREATH OF LIFE (SLEEPING) Obstructive sleep apnoea Alister Neill

  2. Sleep health • Sleep that is fully restorative, enabling full potential • Achieving optimum total sleep time • Major health issues • Sleep deprivation (TST < 5 hours/ night) • Shift work • Sleep Disorders • Sleep apnoea syndromes • Insomnia • Hypersomnia • Narcolepsy

  3. Interests/what I do • A/Prof Department of Medicine • Direct WellSleep laboratory and research group • Respiratory & Sleep Physician, CCDHB (sleep lead) • New Zealand Branch President and Board member Australasian Sleep Association “Raise the profile of sleep disorders” • Classmate (85) Api and Rob Young!

  4. Overview • Sleep breathing disorders • Obstructive Sleep Apnoea (OSA) • How common? • OSA prevalence in New Zealand • What are the societal costs of OSA? • Health pathways • Why it must become a health priority? why the silence ? snoring …it ain’t sexy! • Partnerships

  5. Obesity - is bad news for breathing! • Increased mass loading on chest …reduced lung size • Increased metabolic demand • Lower oxygen levels • Upper airway • Narrows • Changes shape • More collapsible during sleep • Obstructive sleep apnoea • Obesity hypoventilation • Promotes respiratory failure (especially if combined with COPD)

  6. Snoring to OSA SNORING OSA Asking about heavy snoring

  7. Obstructive sleep apnoea Factors promoting OSA Obestiy Craniofacial 40% Ventilatory control triats Fluid shifts Age

  8. 1 2 3 4 Examination Features suggestive • Bull neck ( increased neck circumference) • Small oropharynx • Tonsil hypertrophy • Retrognathia Mallampatiscore

  9. Consequences of OSAS • Impaired quality of life • Excessive daytime tiredness • Impaired concentration, memory & reaction times • Lower mood • Increased risk of accidents: • motor vehicle accident 2 -3 • Industrial / other accidents 2 • Mortality • Renal • Nocturia & impaired renal function

  10. Consequences of OSAS • Cardiovascular disease OR 2.0 • Hypertension • Coronary heart disease & congestive heart failure • SAVE study • ? CVA • Diabetes OR 1.62 • Exacerbate chronic respiratory conditions • Promoting respiratory failure • Overlap syndrome = COPD, obesity & OSA • Exacerbate cardiac failure

  11. Treatment options • Nasal CPAP • Other PAP • Modalities Weight loss • Dietary • Bariatric surgery • Position modification • Oral appliance (Mandibular advancement splints • Upper airway surgery • T &As important in children (tamariki) • Nasal • Palatal (select carefully) • Maxillo-facial & orthodontic

  12. Oral appliances

  13. Nasal CPAP • Successful in 70% (mod to severe OSAS) • Prevents upper airway obstruction (sleep) • Improves symptoms, quality of life, reaction times/ vigilance • Lowers BP (particularly at night) • Improves glucose tolerance (if high user) • Lowers MVA / crash risk • Mild OSAS (only if excessively sleepy) Redline S 1998, Engelmann et al 1999, Barnes M 2002 Sullivan C , Berthon -Jones

  14. CPAP for OSAS: number needed to treatto prevent accident or near miss! 5 patients to prevent accident (95% CI = 3–8) 2 patients to prevent near miss (95% CI = 1–4) Aspirin treatment the NNT • 73 for total myocardial infarction • 278 for fatal myocardial infarction • 256 for ischemic stroke. Lipid lowering drug treatment the NNT • 44 for major coronary event • 66 for stroke Meta –analysis Tregear J Clin Sleep Med. 2009 December 15; 5(6): 573–581.

  15. Significance • One of the best studies of crash risk attributed to OSA comes up with interesting conclusions. • MVA risk was 2.5 times higher in OSA sufferers c.f the gen population. • Identified other Important risk factors for crashes Old age driving distance excessive daytime sleepiness (EES 16) short habitual sleep ≤ 5 hours/ night hypnotic use increased risk. • Successful treatment with CPAP reduced risk.

  16. Sleep Apnoea Tsunami– How common? Two new studies 2015

  17. OSAS symptoms vrs NZ deprivation Index Harris R, PhD University of Otago Prevalence obesity (%) New Zealand Deprivation Index (Crampton P et al) Ministry of Health - Publication

  18. Obstructive Sleep ApnoeaPrevalence

  19. Prevalence of Obstructive Sleep ApnoeaMaori cf other New Zealand adults * weighted by the Wellington population proportions of age, gender and ethnicity. K Mihaere,Harris, P Gander, P Reid, W Hla, A M Neill.Sleep 2009 7:949-56 Sleep/Wake Research Centre, Wellsleep, Eru Pōmare Maori Health Research Centre

  20. Prevalence of sleep-disordered breathing in the general population by age and gender: the HypnoLaus study Mild ≥ 5 to15 events /h, Moderate ≥ 15 to 30 events/h Severe ≥ 30 events/h Syndrome if EDS ESS > 10 R Heinzer et al The Lancet Respiratory Medicine, 3, 4, 2015, 310–318

  21. OSA disease burden

  22. OSA societal costs • NZ$90 Million p/a of untreated OSA age 30-60 (lowest estimate 40 - 90 million) • Treatment of OSA highly cost-effective • NZ$94 per QALY ($56-$310) • Based on cost derived investigation / treatment pathway (Wellington CCDHB, WellSleep lab) • 50 / 50 mix home and in-lab testing HM Scott, WG Scott, K Mihaere, P Gander International Review of Business Research Papers Vol.3 No.2. 2007

  23. Public heath initiatives • Weight loss • Smoking • Alcohol/ other sedating drugs

  24. 10% increase in body weight = 30% increase in OSA severity seeYoung T et al, AJRCCM 2002

  25. How? Public health Childhood obesity strongly related to increased hrs TV watching and reduced total sleep time. Advertising and high Carb treats Its OK to feel hungry VELD (very low calorie diet) Supervised by endocrine Dept Motivated $3 / meal Clear evidence of substantial weight loss Swedish obesity study Gastric reduction / bi-pass surgery

  26. CPAP therapy in NZ • Is funded by NZ DHBs for OSA • Variation in selection criteria • How CPAP is initiated matters • range of reported use rates • WellSleep pathway focus on first month of therapy (70% success rate > 4 hrs/ night) • Can be as low as 20-30% in poorly supported pathways (Predict study vrs NZ experince) • Work force • Sleep Physiologist / nurse • Patient related

  27. Despite having more severe OSAS CPAP acceptance appears to be lower in Maori and Pacific people • Whyte K et al (abstract)

  28. Ethnicity, CPAP adherence, SES • Median compliance 5.63hr/night (IQR 2.55) – not different to non consenters • Māori vs non Māori 4.68 vs 5.33hr/night p=0.05 • No difference in compliance by NZDep quintiles • NZiDep reduced compliance in quintile 5 (lowest SES) p=0.02

  29. CPAP adherence lower if high level of socio-economic deprivation (NZiDep) J Bakker, O’Keefe, Neill, Campbell Sleep 34, 11, 2011

  30. Focus Groups --- Barriers to referral/CPAP and improvements • No prior knowledge of OSA or CPAP in all groups a barrier to initial referral • Financial barriers to treatment • Overwhelmed with amount of information • Importance of successful role models • Lottery Health Grant • Pacific Health Services Hutt Valley DHB • Tu Kotahi Māori Asthma Trust • WellSleep patients

  31. Management pathways in New Zealand ASA 2013 Brisbane Scientific Meeting Assoc. Prof Alister Neill

  32. GUIDELINES FOR PORTABLE MONITORING (PM) • Vary significantly UK --NZ--Europe---Canada----Australia----USA accepted discouraged ASDA 1994 TSANZ 1994 AASM, ATS, ACCP 2003 TSANZ/ASA 2005 AASM Task Force 2008 Australasian Sleep Assoc Guideline 2013

  33. Main diagnostic test for ? OSAS 2010 Attended full PSG AUCKLAND 2007 Attended split PSG 2007 BAY OF PLENTY WAIKATO Unattended lab PSG GISBORN Unattended level 3 Oximetry MID CENTRAL

  34. A Stock-take of publically-funded sleep services in Aotearoa New Zealand (2010)Pathirana, KE., Paine, S-J., Gander, PH., Neill, A • Funded via District Health Boards • 21 DHBs invited to take part (3 DHBs refer to DHBs) • 18/18 (100%) response rate • Clinical Lead & Service Manager surveyed Sleep and Biological Rhythms; 8: A70, 2010

  35. Provision of Care for OSA • All (18/18) who responded had OSA diagnostic pathway • In 2/3rd by referral to another provider • Only 3/18 listed sleep disorders as priority • Only 2/17 DHBs had sleep service accreditation (ASA/TSANZ), now 3/ 17 Sleep and Biological Rhythms; 8: A70, 2010

  36. Structure of Services for OSA: Diagnostic Studies Sleep and Biological Rhythms; 8: A70, 2010

  37. Available Resources: Funding • Specified budget for the management of OSA • 10/18 DHBs • Range = $60k - $3.1M • Funding from sources other than the DHB = 4/17 DHBs • Funding was sufficient to utilise service to capacity • Yes 9/17 • No 8/17 • Funding needs to meet growing demand Sleep and Biological Rhythms; 8: A70, 2010

  38. Provision of Care: Other Sleep Disorders 3/17 DHBs reported funding for sleep disorders other than OSA Sleep and Biological Rhythms; 8: A70, 2010

  39. Proposed OSA Diagnostic Algorithm Taken from: GUIDELINES FOR SLEEP STUDIES IN ADULTS 2013 Prepared for the Australasian Sleep Association (Draft)

  40. “There is not one solution” • The best diagnostic and management pathway for OSA varies depending on circumstances and funding models • Australia vs USA vs NZ • Private vs Public • Urban vs remote

  41. The future Increasing demand and use of portable studies Integration services Sleep centres will provide a range of sleep tests including – In-lab & home testing Improve access to diagnosis and treatment Maori and Pacific Islanders Low socioeconomic areas Expand clinical workforce Sleep Physicians & Physiologist Nurse led clinics Primary care

  42. What else can be done? • TE HA ORA MOENational Respiratory Strategy • Respiratory and Sleep Health National priority • ASA, ASTA • Work-force development • Partnerships Maori Health, Pacific Health Integration with primary care • Ministry of Health • Increase Health System investment

  43. Thanks

  44. Comments • “I could have done this under insurance, but I decided to be bloody minded and make the state pay for it…but I was not clear what the limitations of that were” • “I used the resources, I had a person that’s been on this machine for sixteen years so she weaned me into what I’m supposed to do” • “There’s a lot of information especially with the pamphlets and that, the video…some people might find that a bit overkill…” • “mine’s like a security blanket…I feel so secure with it” • “the benefits to me have not been as great as I might have hoped, but my wife just loves that mask” • “If there’s a tangi I’ll take it with me, I don’t care who’s watching, at least I’ll wake up feeling good” • “have someone who’s been through it and has used CPAP for awhile….come in and talk to somebody for 10-15minutes that’s about to start the process…assure somebody that you do get used to it”

  45. “Demand-Capacity Chasm”Flemons W, Douglas N, Kuna S, Rodenstein D, Wheatly JAmJ Respir Crit Care 2004 • Waiting times are excessive • Current resources inadequate to deal with future demand • Capacity is limited by funding models

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