Alister Neill TE HA ORA MOE THE BREATH OF LIFE SLEEPING Sleep health Sleep that is fully restorative enabling full potential Achieving optimum total sleep time Major health issues Sleep deprivation TST lt 5 hours night ID: 777222
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Slide1
Obstructive sleep apnoea
Alister Neill
TE HA ORA MOETHE BREATH OF LIFE (SLEEPING)
Slide2Sleep health
Sleep that is fully restorative, enabling full potentialAchieving optimum total sleep time
Major health issuesSleep deprivation (TST < 5 hours/ night)Shift workSleep Disorders Sleep apnoea syndromesInsomnia
HypersomniaNarcolepsy
Slide3Interests/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!
Slide4Overview
Sleep breathing disordersObstructive Sleep Apnoea (OSA)
How common? OSA prevalence in New ZealandWhat are the societal costs of OSA?Health pathwaysWhy it must become a health priority? why the silence ?
snoring …it ain’t sexy! Partnerships
Slide5Obesity - is bad news for breathing!
Increased mass loading on chest …reduced lung size
Increased metabolic demandLower oxygen levelsUpper airway Narrows
Changes shapeMore collapsible during sleepObstructive sleep apnoeaObesity hypoventilationPromotes respiratory failure (especially if combined with COPD)
Slide6SNORING
OSA
Snoring to OSA
Asking about heavy snoring
Slide7Obstructive sleep apnoea
Factors promoting OSA
Obestiy
Craniofacial 40%
Ventilatory
control
triats
Fluid shifts
Age
Slide8Slide9Examination
Features
suggestive
Bull neck ( increased neck circumference)Small oropharynxTonsil hypertrophy
Retrognathia
Mallampati
score
1 2 3 4
Slide10Consequences of OSAS
Impaired quality of life
Excessive daytime tirednessImpaired concentration, memory & reaction timesLower moodIncreased risk of accidents:motor vehicle accident 2 -3
Industrial / other accidents 2 MortalityRenal Nocturia & impaired renal function
Slide11Consequences of OSAS
Cardiovascular disease OR 2.0
HypertensionCoronary heart disease & congestive heart failureSAVE study? CVADiabetes
OR 1.62Exacerbate chronic respiratory conditionsPromoting respiratory failure Overlap syndrome = COPD, obesity & OSAExacerbate cardiac failure
Slide12Treatment
options
Nasal CPAPOther PAPModalities Weight lossDietaryBariatric surgery
Position modificationOral appliance (Mandibular advancement splintsUpper airway surgeryT &As important in children (tamariki)Nasal
Palatal (select carefully)Maxillo-facial & orthodontic
Slide13Oral appliances
Slide14Nasal CPAP
Sullivan C ,
Berthon
-Jones
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
Slide15CPAP 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.
Slide16Slide17Significance
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 agedriving distanceexcessive daytime sleepiness (EES 16) short habitual sleep ≤ 5 hours/
nighthypnotic use increased risk. Successful treatment with CPAP reduced risk.
Slide18Sleep
Apnoea Tsunami
– How common?Two new studies 2015
Slide19New Zealand Deprivation Index
(Crampton P et al)
OSAS symptoms vrs NZ deprivation Index
Prevalence obesity (%)
Harris R, PhD University of Otago
Ministry of Health - Publication
Slide20First author (Year)
N
Age range
(Years)
Women
Men
AHI/RDI
AHI/RDI
≥ 10
≥ 10
≥ 15
Young et al. (1993)
626
30-60
5
(2.4-7.8)
15
(12-19)
9.1
(6.4-11)
Bearpark et al. (1995)
309
40-65
N/A
10
(7-13)
Not given
Mihaere et al. (2003)
Māori
166
30-60
5.40
(0.9-2.7)
16.69
(6.8-26.5)
11.86
(3.5-20.2)
Mihaere et al. (2003)
non-Māori
192
30-60
0.91
(0-6.2)
5.85
(0.8-10.9)
3.04
(1.1-13.8)
Obstructive
Sleep Apnoea
Prevalence
Slide21K Mihaere,Harris, P Gander, P Reid, W Hla, A M Neill.Sleep 2009 7:949-56
Sleep/Wake Research Centre, Wellsleep, Eru P
ōmare Ma
ori Health Research Centre
Prevalence of Obstructive Sleep Apnoea
M
a
ori cf other New Zealand adults
*
weighted by the Wellington population proportions of age, gender and ethnicity.
Slide22M
ild
≥ 5 to15 events /h, Moderate ≥ 15 to 30 events/h
Severe ≥ 30 events/hSyndrome if EDS ESS > 10 Prevalence of sleep-disordered breathing in the general population by age and gender:
the HypnoLaus study
R
Heinzer
et
al The
Lancet Respiratory Medicine
,
3,
4
, 2015, 310–318
Slide23OSA disease burden
Slide24Slide25Slide26Slide27OSA societal costs
NZ$
90 Million p/a of untreated OSA age 30-60 (lowest estimate 40 - 90 million)
Treatment of OSA highly cost-effectiveNZ$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
Slide28Public heath initiatives
Weight lossSmokingAlcohol/ other sedating drugs
Slide2910% increase in body weight=
30% increase in OSA severity see
Young T et al, AJRCCM 2002
Slide30How?
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 hungryVELD (very low calorie diet)Supervised by endocrine DeptMotivated $3 / mealClear evidence of substantial weight lossSwedish obesity studyGastric reduction / bi-pass surgery
Slide31CPAP therapy in NZ
Is funded by NZ DHBs for OSA
Variation in selection criteriaHow CPAP is initiated mattersrange of reported use ratesWellSleep 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 / nursePatient
related
Slide32Whyte K et al (abstract)
Despite having more severe OSAS CPAP acceptance appears to be lower in Maori and Pacific people
Slide33Ethnicity, 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=0.05No difference in compliance by NZDep quintilesNZiDep reduced compliance in quintile 5 (lowest SES) p=0.02
Slide34CPAP adherence lower if high level of socio-economic deprivation (NZiDep)
J Bakker, O’Keefe, Neill, Campbell Sleep 34, 11, 2011
Slide35Focus Groups --- Barriers
to referral/CPAP and improvements
No prior knowledge of OSA or CPAP in all groups a barrier to initial referralFinancial barriers to treatmentOverwhelmed with amount of informationImportance of successful role models
Lottery Health Grant
Pacific Health Services Hutt Valley DHB
Tu Kotahi Māori Asthma Trust
WellSleep patients
Slide36Management pathways
in New Zealand
ASA 2013 Brisbane Scientific Meeting Assoc. Prof Alister Neill
Slide37Vary significantly
UK --NZ--Europe---Canada----Australia----USA
accepted discouraged ASDA 1994
TSANZ 1994 AASM, ATS, ACCP 2003 TSANZ/ASA 2005 AASM Task Force 2008
GUIDELINES FOR PORTABLE MONITORING (PM)
Australasian Sleep
Assoc
Guideline 2013
Slide38Main diagnostic test for ? OSAS
Attended full PSG
Attended split PSG
Unattended lab PSG
Unattended level 3
Oximetry
AUCKLAND
WAIKATO
GISBORN
MID CENTRAL
BAY OF PLENTY
2007
2010
2007
Slide39Funded via District Health Boards
21 DHBs invited to take part
(3 DHBs refer to DHBs)18/18 (100%) response rateClinical Lead & Service Manager surveyed
A Stock-take of publically-funded sleep services in Aotearoa New Zealand (2010)Pathirana, KE., Paine, S-J., Gander, PH., Neill, A
Sleep and Biological Rhythms
; 8: A70, 2010
Slide40All (18/18) who responded had OSA diagnostic pathway
In 2/3rd by referral to another providerOnly 3/18 listed sleep disorders as
priorityOnly 2/17 DHBs had sleep service accreditation (ASA/TSANZ), now 3/ 17
Provision of Care for OSASleep and Biological Rhythms
; 8: A70, 2010
Slide41Diagnostic Study
Number of
DHBs
(n/18)Number of patients per yr /100,000(average)
Average
waiting time
(range)
Level 1
Attended PSG
9
217
2-62 weeks
Level 2
Unattended PSG
5
74
4-12 weeks
Level 3 sleep
study:
14
139
1-22 weeks
Level 4 sleep
study:
Single/dual recording
7
305
0-12 weeks
Structure of Services for OSA:
Diagnostic Studies
Sleep and Biological Rhythms
; 8: A70, 2010
Slide42Specified budget for the management of OSA
10/18 DHBs Range = $60k - $3.1MFunding from sources other than the DHB = 4/17 DHBs
Funding was sufficient to utilise service to capacityYes 9/17No 8/17Funding needs to meet growing demand
Available Resources: FundingSleep and Biological Rhythms; 8: A70, 2010
Slide43Provision of Care:
Other Sleep Disorders
Sleep Disorder
Number of DHBs (n/18)
Investigation
Treatment
Long Term Follow Up
Insomnia
3
9
1
Parasomnias
9
8
3
Narcolepsy
12
10
8
Neurologic Sleep Disorders
11
8
6
Circadian Rhythm Sleep Disorders
6
4
2
Sleep-Related Movement Disorders
9
8
2
Daytime Somnolence
11
8
4
3/17 DHBs reported funding for sleep disorders other than OSA
Sleep and Biological Rhythms
; 8: A70, 2010
Slide44Proposed OSA Diagnostic Algorithm
Taken from: GUIDELINES FOR SLEEP STUDIES IN ADULTS 2013
Prepared for the
Australasian Sleep Association (Draft)
Slide45“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 PublicUrban vs remote
Slide46The future
Increasing demand and use of portable studies
Integration servicesSleep centres will provide a range of sleep tests including – In-lab & home testing
Improve access to diagnosis and treatmentMaori and Pacific IslandersLow socioeconomic areasExpand clinical workforceSleep Physicians & PhysiologistNurse led clinicsPrimary
care
Slide47What else can be done?
TE HA ORA MOE
National Respiratory StrategyRespiratory and Sleep Health National priorityASA, ASTAWork-force developmentPartnerships
Maori Health, Pacific Health Integration with primary careMinistry of Health Increase Health System investment
Slide48Thanks
Slide49Comments
“
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”
Slide50“Demand-Capacity Chasm”
Flemons W, Douglas N, Kuna S, Rodenstein D, Wheatly JAmJ Respir Crit Care 2004
Country
Studies/yr/100K
Waiting time
Main Sleep Study
United Kingdom
42.5
7-60 months
Oximetry (2/3
rd
)
Belgium
177.2
2 months
Attended PSG
Australia
282
3-16 months
Attended PSG
United States
427
2-10 months
Split night PSG
Canada
370
4-36 months
Split night PSG
Capacity required
Dx and treat OSA
2,310
Waiting times are excessive
Current resources inadequate to deal with future demand
Capacity is limited by funding models
Slide51Mid Central DHB
Large, predominantly rural catchment areaIntegrated sleep service developed in 2006
Specific project fundingSleep trained GPs Initial assessment and oximetryOrganise further studies and refer for treatment
Provide long-term community follow-up622 patients managed from 2006-2009Significant improvements across serviceWaiting times and ? cost
Service Lead Dr Alistair Watson
Slide52Tairawhiti DHB
Remote, most deprived district in NZ
64% of population in decile 8-10
50% of population Maori
Development of CNS-led service in 2008
CNS involved at outset, across all areas of OSA management
Chronic condition model of disease for OSA
Physician support from regional hub
Sleep Physician Clinic 2 monthly
(acknowledge Natasha Ashworth)
Slide53Tairawhiti: Volumes and Costs
2000-2008
36 volumes per annumNo data regarding follow upsCosts = $204,000 per annum or $5667 per patient2009-2013102 new referrals per annum
430 follow ups per annumCosts = $156,000 per annum or $293 per patient Includes 0.7 FTE CNS
Slide54Cantebury DHB
CDHB Sleep Service
Christchurch Hospital “hub”2 PSG beds (2 nights/week), 2 part time Sleep Physicians, 1.5 CNS, 4 Sleep physiologistsProvides sleep services to CDHB, WCDHB, SCDHBSleep Pathway developed in 2008
Sleep Assessment by CNS/Community Approved ProviderSleep history, targeted examination, ESSDiagnostic oximetry/flow-based screening studyWeekly case discussion before triagingAbility to progress to next appropriate step with more accuracySevere OSA rapidly identified and treatment expedited
Michael Hlvack & team
Slide55CDHB Sleep Pathway - Pros
Large volumes through service~1500 patients reviewed in MDM/yr
40 CPAP trials/month1 week wait for urgent CPAP trialOverall 1/3 patients returned to GPHealthpathways.org.nz for primary care infoModel easily applied to other remote areas
Slide56CDHB Sleep Pathway - Cons
Choke points moved due to increased throughput Long wait for higher level studies
Increased demand on limited sleep physician timeLimited long-term review for patients on CPAPCommunity CPAP MOC in development Primary care follow-up inconsistentNo action taken for 43% of patients returned to GP careNeed for shared electronic record
Slide57Wellington
Services to three DHBs
Sleep physician led serviceMDTClinical Nurse SpecialistClinical Physiologist
Standardised referral form (prioritisation) & determine investigation pathwayDirect to in-lab (reg review, split study)Direct to portable study (level 3 or 2)Sleep Clinic assessment
Slide58WellSleep: Diagnostic Polysomnography
(within 50 km of lab)