Breathing related sleep disorders
- Independent risk factor for high BP and diabetes and associated with heart attack, stroke, unexplained pulmonary hypertension
- Most common
- Obstructive sleep apnoea (OSA) — repeated episodes of throat blockage during sleep
- Periodic breathing especially in heart failure
- May also be non-breathing related sleep disorder — parasomnias (eg sleep walking, restless legs) insomnia (can’t get to or stay asleep), central sleep apnoea (problem with underlying drive to breathe)
- There is no perfect screening tool for sleep related breathing disorders or OSA — one simple tool is STOP-BANG
Risk factors include
- Obesity
- Enlarged tonsils
- Regressed chin
- Alcohol use
- Cardiovascular disease
- Chronic conditions especially high BP, heart failure
Ask
Person and someone who has watched them sleeping, eg partner
- STOP — record one point if person
- Snores
- Is Tired during day
- Has had Observed apnoea (to stop breathing)
- Has high blood Pressure
- Trouble sleeping
- Abnormal movements or activities during sleep
- Suddenly falling asleep at inappropriate times
- Alcohol use
Check
- Calculate age-appropriate REWS
- Adult — AVPU, RR, O2 sats, pulse, BP, Temp
- Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
- Weight, BGL
- U/A
- ECG
- Head-to-toe exam — with attention to
- Masses or blockages — nose, mouth, back of throat, tonsils, tongue
- Heart exam
- lung exam
- BANG — record one point if person has
- B ody Mass Index — more than 35
- A ge — over 50 years
- N eck size — circumference more than 40cm
- G ender — male
Do
- FBC, TFT, urine ACR
- Calculate STOP-BANG score from Ask and Check
- If STOP-BANG score 3 or more AND able to manage treatment — refer for sleep/respiratory service follow up
- If STOP-BANG score 3 or more AND not able to manage treatment — provide advice on weight and alcohol management
- If STOP-BANG score less than 3 — provide advice on weight and alcohol management and consider other diagnoses. If non-breathing related sleep disorder suspected — talk with sleep/respiratory service
- Assess if willing or able to undertake treatment if needed
- For OSA/periodic breathing — often use nasal CPAP with mask worn over face when sleeping. May use upper airway splints, surgery
- Talk about cost of buying device, ongoing treatment costs, power supply and power bill, housing, mobility, person's lifestyle, eg alcohol use
Referral and management
- Respiratory nurse consult to plan and coordinate referral
- Medical consult for referral to sleep specialist
- Sleep specialist will usually do sleep study at home (urban resident) or in hostel (remote resident)
- If sleep study abnormal and person willing/able — trial CPAP 1–2 months. If trial successful — long-term treatment
- May suggest other treatments — splints, surgery, lifestyle changes
Follow-up
- If doesn't get better — talk with sleep/respiratory service
If using CPAP
Most CPAP machines can be monitored remotely via cellular modem — the trial provider or the Respiratory Clinical Nurse Consultant can be contacted for efficacy data reports
- Review at clinic — every 2 weeks during trial THEN every 3 months
- Remind person to always bring CPAP machine and mask with them
- Check
- How many hours a day and days a week machine is used
- Check that the air intake filter is clean
- Is OSA being controlled — machine records this. Look for apnoea hypopnea index (AHI)
- Can person set up equipment and fit own mask
- Is machine generating airflow
- Check face mask for
- Damage to seal against skin
- Blockage to expiratory vent opening — usually at joint between face mask and tube going to machine
- Major leaks — feel for escape of air with mask fitted and machine on
- Check skin under face mask for irritation or damage
- If problems with equipment or management — respiratory nurse consult
- Specialist follow-up — at least once a year OR as per management plan
- If person has equipment — must take machine and mask to appointment