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Obstructive sleep apnoea

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g3745 (Published 17 June 2014) Cite this as: BMJ 2014;348:g3745

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Re: Obstructive sleep apnoea

Reply to: Obstructive sleep apnoea
BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g3745 (Published 17 June 2014)
Cite this as: BMJ 2014;348:g3745
1. Michael Greenstone, consultant1,
2. Melissa Hack, consultant2
Author Affiliations
1. 1Castle Hill Hospital, Cottingham, East Yorkshire HU16 5JQ, UK
2. 2Royal Gwent Hospital, Newport, Gwent, UK

Dear Sir /Madam
We were pleased to see an overview of Obstructive Sleep Apnoea (OSA) in the BMJ as awareness amongst General Practitioners and Hospital specialists is very poor. We feel much more recognition of the condition should take place as it is estimated that we are only treating about 20% of those with the condition1.

The Department of Health OSA working group lead by Martin Allen of which we are members considered the following as key themes/issues for further consideration but were not emphasised sufficiently or not considered in the review by Greenstone and Hack.
1. A recommendation to replace the Epworth Sleepiness Scale with the STOPBANG questionnaire to support effective referral from primary care and subsequent treatment;
2. Raising awareness of comorbidities e.g. obesity, diabetes, cardiovascular disease and OSA in primary care and the potentially targeting these high risk groups;
3. Promoting the benefits of an MDT approach to management. The main stakeholders are ENT, Respiratory and to a lesser extent anaesthetists and maxillofacial clinicians; From April 2013 there has been a uplift in tariff prices for MDT Clinics
4. There is a lack of consensus regarding the issue of using flexible nasendoscopy on every patient. To our mind it this is the only way to effectively examine the upper airway, the obstruction or narrowing of which can result in OSA. The working group, after lively discussion, included it as a core part of the clinical workup. This procedure will more readily identify those patients with potential surgically correctable causes of OSA.;
5. There is variability in access to mandibular devices through the NHS;
6. It was considered essential to target and identify those at risk of RTAs;
7. There is poor management of the transition between paediatric and adult services;
8. Education in OSA is lacking in both primary care, secondary care and in public health circles.

The fact that OSA is a NICE Technical Assessment 139 was not mentioned- It is legally binding on all commissioners to fund an OSA service in England and wales

In June 2013, The American Academy of Sleep Medicine recommended that all type 2 diabetics and hypertensives should be routinely screened for OSA. Their rational is that seven in 10 people with Type 2 diabetes also have obstructive sleep apnoea, and the severity of the sleep disorder directly impacts diabetes symptoms; the more severe a diabetic’s untreated sleep apnoea, the poorer their glucose control. In addition between 30 and 40 percent of adults with high blood pressure also have sleep apnoea, which is even more prevalent in those with resistant hypertension. Approximately 80 percent of patients that do not respond to hypertensive medications have sleep apnoea.

There is a call from the Sleep Apnoea Trust that all HGV drivers, with suspected OSA, should be fast tracked as part of a good sleep service and about 40% of services offer this facility.

According to The British Thoracic Society (BTS) Impress document, oximetry alone can confirm severe OSAS but has significant rates of both false negatives and false positives, such that Respiratory PSG is now preferred as the primary investigation in many departments

Although PSG (Polysomnography) is thought to be the “Gold Standard” there are problems with it such as the first night effect and the high costs. New technologies are now available to perform an overnight Tier 3 study at home. These provide data on sleep architecture as well as respiratory parameters.

We should be refocusing our primary aim of looking at cerebral effects of hypoxia (hypersomnolence) when we know hypoxia has cardiovascular and metabolic effects on glucose metabolism? Extrapolating the effects of severe cerebral apnoea/hypoxia logically leads to the consideration that at least some patients with dementia maybe the consequence of severe recurrent and profound desaturations? The graphically stunning maps of disease produced by Steier et al( 1) should cause us to pause and think about disease prevalence and inter-relationships between OSA, diabetes ,hypertension, obesity and aging.

Although Mandibular Advancement Devices (MAD) are effective in selected patients they should be fitted properly by a specialist dentist embedded in an OSA service as there are long term risks of teeth moving and temporomandibular joint problems. Even edentulous patients can be fitted by a skilled dentist. We agree that post MAD sleep studies should be undertaken to prove efficacy.

There are several exciting areas of development in OSA. Key ones include its association with glaucoma and dementia.

References

1. Predicted relative prevalence estimates for obstructive sleep apnoea and the associated healthcare provision across the UK
Joerg Steier,1,2 Alistair Martin,3 Judy Harris,3 Ian Jarrold,3 Darien Pugh,4
Adrian Williams1,2
Thorax published online September 23, 2013
doi: 10.1136/thoraxjnl-2013-203887

2. NICE technology appraisal guidance 139 www.nice.org.uk/TA139
3. The estimated undiagnosed disease burden of obstructive sleep apnoea in West London glaucoma patients. Dr. T. E. Yap1, Dr. E. M. Normando2, Prof R Dhillon, Dr M Oko, Prof B Bloom, Prof. M. F. Cordeiro2 The European Glaucoma Society poster presentation 2013

Competing interests: No competing interests

23 June 2014
Michael Oko
ENT Consultant
Prof Ram Dhillon, Northwick park Hospital
Dept of Health OSA Working Group
Pilgrim Hospital, Sibsey road Boston PE21 9QS