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

• 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