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BMJ No 7104 Volume 315 Letters Saturday 9 August 1997 Obstructive sleep apnoea Review was misleading and may deny cost effective treatment to patients Editor, John Wright and colleagues' review of obstructive sleep apnoea(1) and the accompanying comments in Editor's choice(2) and This week in the BMJ(3) have serious adverse implications for many thousands of patients with a severely disabling condition. The review concentrates on the putative association with cardiovascular morbidity and mortality and on treatment with nasal continuous positive airways pressure. The unfortunate juxtaposition of these two topics will mislead readers into assuming that treatment with continuous positive airways pressure is aimed at preventing such complications. The authors fail to explain that treatment with continuous positive airways pressure is given primarily for relief of disabling daytime sleepiness. We agree that the evidence for a causal relation with vascular disease is tenuous. Unfortunately, however, Wright and colleagues equate morbidity with cardiovascular morbidity and fail to acknowledge the profound morbidity associated with severe sleepiness. The resulting impression is unduly negative, and casual statements such as: `This may not be a disease after all' (2) or not `a separate disease entity'(1) (whatever that means) are potentially highly damaging. Obstructive sleep apnoea cannot be dismissed as merely a manifestation of obesity, as many patients with serious symptoms are not overweight. Because of this mistaken assertion the authors suggest that greater emphasis should be put on weight reduction than on treatment with continuous positive airways pressure. However, there is much less evidence for the effectiveness of dietary treatment than there is for continuous positive airways pressure. Even in obese patients with obstructive sleep apnoea it is inappropriate to deny immediate, inexpensive treatment with continuous positive airways pressure while awaiting an outcome that is rarely achieved.(4) Wright and colleagues emphasise the need for further placebo controlled studies of continuous positive airways pressure, but the choice of an appropriate placebo is less clear than they assume. Use of a subtherapeutic pressure shows only whether pressure itself has beneficial effects. This approach is not relevant to everyday practice, where the appropriate comparison is between the status quo (or an alternative intervention) and any beneficial effect of continuous positive airways pressure, offset by the inconvenience and discomfort of the associated paraphernalia. However many controlled studies are performed, this decision will inevitably remain a matter of trial and error in individual patients. The investigation and management of patients with obstructive sleep apnoea in the United Kingdom lags noticeably behind several other countries, including North America, France, Germany, and Australia. We are extremely concerned that the negative attitudes expressed in the BMJ will be seized on by NHS purchasers as a reason not to fund effective and inexpensive treatment for a large number of disabled patients. G J Gibson Chairman of executive K Prowse President British Thoracic Society, 6th Floor, North Wing, New Garden House, London EC1N 8JR References 1 Wright J, Johns R, Watt I, Melville A, Sheldon T. Health effects of obstructive sleep apnoea and the effectiveness of continuous positive airways pressure: a systematic review of the research evidence. BMJ 1997;314:851-60. (22 March.) 2 Editor's choice.Deep and shallow truths. BMJ 1997;314 (22 March). 3 This week in the BMJ. Evidence that sleep apnoea is bad for health is weak. BMJ 1997;314 (22 March). 4 Wooley SC, Garner D M. Dietary treatments for obesity are ineffective. BMJ 1994;309:655-6. Home | Current issue | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline