Snooze NewzA newsletter for people with sleep-disordered breathing (SDB) and their families

The stories in this edition of Snooze Newz show how breathing and sleeping disorders can stop you from enjoying

life to the full, or even be life-threatening —and how the proper treatment can give people back their lives. Paul Phillips shares his story of climbing Mt Kilimanjaro with his continuous positive airway pressure (CPAP) machine. Babies Zac and Johanna are having a chance at life thanks to ventilators that keep them breathing despite life-threatening illnesses. Sarah, one of our colleagues here at ResMed, tells us how CPAP has been a crucial part of solving her ‘health puzzle’. Auktje Chudleigh’s ventilator has given her the freedom to get out of her house.

“The costs of treating OSA are miniscule compared to the costs of not treating it.” Zac, Johanna and Auktje cannot survive without their ventilators; Paul and Sarah have obstructive sleep apnea (OSA) which poses fewer immediate problems. However, the risks of leaving OSA untreated are so great that many countries are developing policies to address it. Finland, now has a ten-year program in place for the treatment and prevention of sleep apnea. Their guidelines state that, “If the programme is not implemented, the costs caused by sleep apnea, which has proved to be a national health problem in Finland, will increase significantly.”1 National health bodies in both the US and the UK have recommended that OSA should be treated, and that CPAP is a cost-effective way of treating it.2

The costs of treating OSA are miniscule compared to the costs of not treating it — costs such as motor vehicle accidents, lost productivity at work, and higher incidence of diseases such as diabetes and depression. We spoke to Dr Ral Antic in South Australia and Dr Najib Ayas in British Columbia about the hidden costs of OSA. Despite the size of the problem they remain optimistic, and believe that a gradual growth in community awareness will turn the tide on OSA.

The typical person with OSA is a middle-aged man, but that stereotype is going to have to change. Many women, and children too, are diagnosed with OSA. They have different symptoms to the ‘classic’ adult male, but the disease is the same. We’ve spoken to Dr Arthur Teng and Dr Karen Waters about the symptoms and treatment of children with OSA. Dr Teng and Dr Waters are two very dedicated practitioners, and they reveal the differences between children and adults in this area.

We would like to thank all the people we interviewed who were so generous with their time, and the people who’ve sent us their stories about using their CPAP devices. Thanks for helping us with this edition of Snooze Newz!

Sleep well!

Sherrill Burden, Global editor

References: 1. Laitinen LA, Antalainen U, Pietinalho A, Hamalainen P, Koskela K et al. Sleep apnoea: Finnish National guidelines for prevention and treatment 2002–2012. Respiratory Medicine 2003:97;337–365. 2. National Institute for Health and Clinical Excellence. Continuous positive airway pressure for the treatment of obstructive sleep apnoea/hypopnoea syndrome. NICE, March 2008. AASM Position Statement. Cost justification for diagnosis and treatment of obstructive sleep apnea. Sleep 2000;23(8).

in this issue Children & OSA p2 Men, Women & OSA p7 The Hidden Costs p8 Traveling Hints p10

We give them back their lives

iSSue 11

Auktje Chudleigh moved to Australia from the Netherlands when she was a one year old. She was diagnosed with polio at the age of 11, and after a number of bouts of pneumonia had to sleep in an iron lung. This allowed her to go the entire day without any ventilation. She now requires 24-hour ventilation because she has post-polio syndrome, which has weakened her muscles and makes it very hard for her to breathe on her own. “I can probably stay off ventilation for about 10−15 minutes a day,” she tells us.

She used to have a ventilator with a 5-hour internal battery on her wheelchair. “With the help of a friend I invented a system that allowed two additional batteries to be attached to my wheelchair, giving me 40 hours of battery power,” she explains.

Now that she’s using a ResMed Elisèe 150 ventilator, traveling has become a lot easier. “The size of my old ventilator made it hard to fit into the allocated wheelchair space in buses and taxis. I am now far less restricted because of the smaller Elisèe 150 ventilator.”

Auktje finds the breathing “really comfortable” and has much greater mobility now. “I am no longer housebound and enjoy my new-found freedom through outings about four times a week. My carers are also much happier with the Elisèe 150 because it is much lighter, in comparison to my previous ventilators which were heavy to lift.”

Freedom in a wheelchair: Auktje Chudleigh’s story

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When lullabies aren’t enough: Part 1Talking to Dr Arthur Teng

Adults and children need their sleep. Adults who miss out on sleep will generally be tired and listless during the day. Children who have their sleep disturbed by snoring or sleep apnea are more likely to be hyperactive.

There can be nothing more terrifying for a parent than to see their child stop breathing. This is what happens during sleep apnea, one of a range of sleep disorders that children and adults experience.

Sleep apnea may be central sleep apnea, where signals from the brain interfere with the regular flow of breathing, or obstructive sleep apnea (OSA), where an obstruction in the upper airway stops the breath from flowing. In adults, obstructive sleep apnea – by far the more common of the two types – usually occurs because the tongue and soft tissue fall towards the back of the throat. The weight of the neck muscles can also restrict breathing, which is why people with large or muscly necks are often found to suffer from OSA. In children, OSA is commonly caused by enlarged tonsils and adenoids.

To find out more about children and their sleep problems we spoke to Dr Arthur Teng, director of the Sydney Children’s Sleep Disorders Clinic. His work at the clinic helps children and their families to deal with OSA, parasomnias (such as night terrors and nightmares), behavioural sleep problems and snoring.

Dr Teng explained that sleep disorders

are not just disruptive for the child and the family, but that they can have long-term consequences. ‘The sooner you fix the sleeping problem, the sooner the child can get back into normal patterns of growth and learning,’ he explained.

Children with untreated OSA, for instance, have high rates of learning difficulties. “These children have poor short-term memory, are crankier and more likely to be hyperactive,” Dr Teng told us. “Unlike adults, who tend to be sleepier during the day, sleepy children are restless and inattentive. They often fail to thrive, have slower language development and can even start to develop conditions such as hypertension (high blood pressure). Whether it’s caused by the disruption of their sleep or the hypoxia (low oxygen levels) that occur during an apnea, children show the effects in the daytime.”

“These children have poor short-term memory, are crankier and more likely to be hyperactive.” Snoring affects between 10–14% of children, and is particularly common in children aged between two and four years. At this age the tonsils and adenoids are relatively large and can create obstructions in breathing. Snoring in children can be softer than in adults and may just sound like heavy breathing. If the snoring is combined with pauses in a child’s breathing or difficulty in breathing during sleep, it may point to OSA.

‘The best thing to do if you’re worried,’ says Dr Teng, ‘is to talk to your doctor. They may refer the child to a sleep unit where they can be assessed with a sleep study. Sleep studies are nothing to be scared of! The child is in a specialist ward with very experienced staff. They are monitored all night long, and most children have their normal night’s sleep. Parents or other carers are encouraged to stay for the night as well to reassure the child.”

A sleep study will locate the problem. OSA is resolved in most cases by removing the child’s tonsils and adenoids. If the OSA persists, the child may need to use a CPAP machine to maintain regular breathing during the night.

Even though this seems like a big step, Dr Teng is very positive. ‘Children can be introduced to CPAP gradually. We give them a mask to wear at home, so they get used to the feel of it, then when they’re ready they go back into the sleep unit and spend a night there with the machine. This is important to get the pressure exactly right and monitor the child’s reactions.’

The benefits of solving a child’s sleep problems show up in improved concentration and learning and can help to ward off long-term complications such as obesity, diabetes and heart problems. And of course, when the child sleeps, the whole family has the chance to sleep as well!

Dr Arthur Teng

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When lullabies aren’t enough: Part 2Talking to Dr Karen Waters

The Children’s Hospital at Westmead, in Sydney’s western suburbs, is a friendly buzzing place. A small girl hobbles around on crutches with fluoro-pink padding and a volunteer guide takes me up to the correct floor. We walk past the Chinese garden with its carefully placed rocks and spreading trees, and my guide tells me that there is always a refreshing breeze in the pagoda.

I’m here to interview Dr Karen Waters. She is the head of the Respiratory Support Service, which includes the Sleep Unit, a program to support children on CPAP and bilevel pressure support devices, and a home ventilation service.

Most of the patients that they see have sleep-disordered breathing (SDB) in one form or another – about 60% have OSA. Others have parasomnias, such as night terrors, or behaviour or sleepiness problems, and some have underlying chronic diseases or progressive weakness from muscular diseases.

The majority of children who need ventilators or flow generators come through this hospital. They might be infants who need monitoring because they have had some sort of breathing problem during sleep, and their sleep study shows that they’re at risk of having it again. At any one time they have 15 or 16 children on oxygen, including newborns who are still on oxygen after they’ve come out of the neonatal nursery. The majority of children are on CPAP. Dr Waters pulls out a folder. “We’ve just done the figures recently,” she says. “We’ve got around 165 kids on CPAP who we continue to monitor. We’ve got 90 kids on bilevel therapy – that’s night-time pressure support from a bilevel device. We have about 16 children on ventilation at any one time. Most often that means that they’ve got a tracheostomy. They need carers in the home because of the high level of health support and technology at home.”

Dr Waters agrees with Dr Teng on the figures for OSA in children, and on the main causes. “About 12% of all

children would have regular snoring and between 3–4% have OSA,” she confirms. “The period of greatest risk is probably between two and six years of age, and it closely responds to the time when their tonsils and adenoids are biggest. First line of treatment is taking out the tonsils and adenoids, but if we get kids with very severe OSA they can have 60–80 apneas per hour and their oxygen desaturation can drop to 50%. In that situation we would put them on CPAP as soon as possible and try to get some recovery of sleep and get them settled before we proceed to surgery. They might also need CPAP after surgery. This generally happens when they have a relatively small airway that continues to obstruct their breathing after the operation.”

About 12% of all children have regular snoring and between 3–4% have OSA. I asked Dr Waters why doctors are so reluctant to take a child’s tonsils out. She told me that studies have shown that children have the same number of throat infections whether they have their tonsils or not. “Probably 80–90% of kids have their tonsils and adenoids out because they are obstructing the airway and causing snoring or apnea. This is very successful in treating OSA in children, with about 80% of kids getting better. The perception is that infections settle after the tonsils are taken out but in fact that may be partly because of their age. Kids get exposed to various infections when they’re three, four and five years old and then gradually that settles.”

The three big symptoms of OSA that parents should be concerned about are:

• regular snoring• children working hard to breathe when

they’re asleep• episodes of apnea or not being able to

breathe.

Other symptoms can include mouth breathing, sweating, restless sleep and daytime behavior problems — what Dr Waters calls ‘going as if they’ve got a motor’. Children with OSA tend to get more frequent upper respiratory infections, and more often get illnesses that end up with them having to visit the doctor for a course of antibiotics. “It’s quite far-reaching,” Dr Waters says. “There are three big areas of concern at the moment. The first would be in cognitive development — problems with learning and concentration. When you do tests you can see that even kids who snore perform poorly compared to kids who don’t snore, whether they have apneas or not. The second issue that’s had quite a bit of attention paid to it is the cardiovascular system, which is the function of the heart and blood vessels, demonstrated by measurements such as blood pressure. The more severe the OSA, the more it affects their blood pressure. And then the last group is what we call the metabolic dysfunctions. If you look at it in adults it’s called the metabolic syndrome. So you might not get the full syndrome in kids but you’ll see something like higher insulin levels or abnormal lipid profiles. That’s a particular concern and we’re already seeing those problems in older kids and teenagers who are overweight.”

> continued on page 4

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The Respiratory Unit sees some children who have a whole range of medical problems. Dr Waters explains: “Their most vulnerable time is in sleep. So kids with progressive muscular weakness, for example, might start to develop respiratory problems in sleep before they actually get daytime problems. If we can catch it early on, and start them on night-time ventilation, their breathing improves. This can reduce their stay in hospital and also improve their quality of life during the day and night.”

Dr Waters is concerned about identifying OSA in all children. “Sometimes parents won’t realise that it’s a problem that can be treated because the child has always breathed like that—since they were a tiny baby. If the child has other problems they’ll just think it’s normal for the child. So whatever other health problems the child may have it’s really important to ask, ‘Does your child snore?’, ‘Do they have trouble breathing when they’re asleep?’. For example,” she says, “kids with Down Syndrome have a high risk for sleep apnea, but you can improve their quality of life by treating the OSA.”

> continued from page 3 When lullabies aren’t enough: Part 2

Supporting a life: Zac’s story

When he was five months old, and still in the Paediatric Intensive Care Unit at the Royal Brompton Hospital in London, the staff and his parents were looking for a way to give him portable ventilation. The ventilator had to be very sensitive to Zac’s breathing, and have an internal battery so he could become more mobile around the hospital—and maybe even go home for the first time. They decided to try a ResMed Elisèe 150 ventilator.

It took Zac a few days, and some tears, to get used to the new device, but he gradually went from using the Elisèe for a few hours during the day to overnight.

Since using the Elisèe full-time, Zac has come out of intensive care and enjoyed his first day in the nursery. Zac will be going home soon and taking his Elisèe with him.

Zac had a tracheostomy when he was three days old and depends totally on a ventilator to breathe. He suffers from a condition that stops his rib cage and spine from developing and prevents him from breathing normally as he can’t expand his lungs.

Johanna’s storyJohanna was born in Sweden three years ago. She suffers from a condition that causes muscle weakness, particularly in the upper part of the chest, so breathing can be very difficult. Since she was two months old Johanna has used ResMed’s Elisèe 150 ventilator to assist her breathing. The Elisèe has been easier to carry and more flexible than other ventilators her parents have used. Recently, Johanna has only required her ventilator at night or if she has an infection. Her family is delighted with her progress.

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Traveling with CPAP … all the way to the top

Although Mt Kilimanjaro lies very close to the equator in Tanzania, Kibo and Mawenzi have permanent caps of ice and snow. The summit, Uhuru peak on Kibo, is 5895 metres above sea level. The trek up the mountain takes 4-5 days and passes from lush rainforest to open moorlands, dotted with giant heathers, before reaching an alpine desert of rocks and dust.

None of these facts were enough to stop Paul Philips from wanting to climb Mt Kilimanjaro. Nor was he put off by the fact that he relies on a CPAP machine to manage his OSA, and that he would be sleeping at altitudes of up to 4700 metres above sea level—but that CPAP machines are designed to operate only up to 2691 metres.

Paul was diagnosed with sleep apnea and started using CPAP in 2002. When he was invited to climb Mt Kilimanjaro by a long-standing Swiss friend, who had recently recovered from bowel cancer, he wasn’t going to let a little thing like OSA stand in his way. He contacted ResMed’s David Knox to find out if the machine would operate satisfactorily at a high altitude.

Paul was able to reconfigure his CPAP machine using David’s advice. He also purchased five battery cells (weighing 3 kgs each) to supply the power for the five nights he would be sleeping on the mountain.

Paul says, “I programmed my CPAP machine at different altitudes each night and slept like a baby all the way through the night. The machine never failed.”

Paul, along with 12 friends and 51 local porters, successfully climbed Mount Kilimanjaro, all the way from the rainforest at its base to Gilman’s Point, where the track meets Uhuru peak. He was awarded a certificate by the government of Tanzania to celebrate his achievement.

Paul is living proof that a diagnosis of sleep apnea need not get in the way of life’s great adventures.

Mt Kilimanjaro is the tallest mountain in Africa. It consists of three volcanic cones, Kibo, Mawenzi and Shira. Kibo is dormant but active, with strong sulphur smells still evident at its peak. It last erupted just 200 years ago.

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Finding the pieces in my health puzzle

Two years ago I was living life to the fullest, enjoying my work, contributing passionately, socializing actively, travelling as much as I could … and taking my health for granted.

Then I began to feel quite run down. My anxiety levels went up along with my heart rate. I thought it was probably stress and lack of fitness so I took a holiday and stepped up time at the gym.

Things did not improve. I went through every degree of feeling weak—tiredness, fatigue then ‘drop-dead exhaustion’. I arranged an appointment with my general physician (GP), and before going along created a ‘health map’ of my symptoms, personal and family health history. Despite my understanding of sleep apnea, sleep problems did not feature at all. There were too many other symptoms to think about.

Tests in May 2007 revealed I had Graves’ disease. I responded well to the medication, but many of the symptoms persisted. I had lost a lot of weight before the diagnosis, but put it all on again (and then some!) after treatment started.

In December 2007, new tests revealed that I had low Vitamin D levels. I improved with Vitamin D supplements but continued to have long bouts of feeling unwell. I still did not pay any attention to my sleep and my husband did not notice anything either (perhaps because he is a snorer!).

Since I have a family history of diabetes, my blood sugar and insulin resistance were also being monitored. My persisting fatigue and other symptoms were now attributed to insulin resistance. Each condition in itself appeared to be manageable but the combination was enough to knock me out.

Finally, I discussed my diagnosis and symptoms with a colleague who is a sleep specialist. She promptly asked whether I had been tested for sleep apnea. Not in the last two years, was my answer. I mentioned it to my GP and was tested. This time my AHI (apnea–hypopnea index) was 16—high enough to require treatment.

Starting CPAP therapy is usually a bit daunting. It took some learning, and a very good clinician to help me through the initial setup and familiarization. I am fortunate to be working in a place where I can query the sleep experts directly. The support of a partner, loved ones, friends and colleagues is absolutely priceless.

I have been using my CPAP device for just over five months now, while continuing my other medication. I am now off the medication for Graves’ disease to check whether or not it is in remission. While my fingers are crossed, for now I am relieved that different aspects of my health puzzle—awake and asleep—are being treated and I’m on my way to rediscovering myself!

Sarah has been writing about sleep apnea for nearly ten years now, but she didn’t think that it might be a very significant piece of her own health puzzle.

“WHILE My FINGERS ARE CROSSED, FOR NOW I AM RELIEVED THAT DIFFERENT ASPECTS OF My HEALTH PUZZLE—AWAKE AND ASLEEP—ARE BEING TREATED AND I’M ON My WAy TO REDISCOVERING MySELF! “

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insomnia comes from Venus, snoring comes from Mars: men, women and OSA

Many people don’t realise that they have OSA until their health is badly affected by something like heart disease or high blood pressure. One study estimates that one in every five adults has at least mild OSA, and one in every 15 adults has at least moderate OSA.1 Even fewer women than men with OSA are being diagnosed and treated. According to some studies as many as four men are diagnosed with OSA to every one woman.2 While women are physically slightly less prone to apneas,3 the major difference lies in recognising their symptoms. Women are less likely to have a ‘classic’ history of apneas and heavy snoring, so their OSA is less likely to be picked up.

For many men, the first sign of OSA is snoring. Typically, their snoring and disturbed breathing wakes their partner, who persuades them to consult their doctor.

The story for women is very different. The first sign of OSA for women is often insomnia, or symptoms such as fatigue or mood disturbance.4 Women with OSA also have significantly more problems than men with symptoms such as restless legs and palpitations at night, depression, nightmares and hallucinations.5

Other symptoms, such as difficulty falling asleep, lack of energy and night sweats, are also more common in women than in men. Women are more likely to try to solve their sleep problems themselves by using prescription and over-the-counter medications.6

OSA has serious effects on many aspects of a person’s health. Women with OSA are more likely than men to be obese, and to have

conditions such as fibromyalgia (a musculoskeletal disorder in which sufferers experience widespread pain, sore muscles, chronic fatigue and poor sleep14), migraine, depression, and irritable bowel syndrome.7

younger women have a physical advantage over men when it comes to OSA. The shape of their face, the way body-fat is distributed and the way in which hormones affect breathing all favour women.8 The upper airway, which collapses during an apnea, also differs between men and women, becoming significantly longer in boys than in girls after puberty.9

However, hormonal changes have a marked effect on women’s sleep patterns. This is particularly noticeable after puberty, in menstruation, pregnancy and menopause.10 After menopause, women’s rates of OSA are similar to men’s. OSA at this stage of a woman’s life is more likely to be severe11 and is strongly related to hypertension (high blood pressure).12 There also appears to be an association between OSA and the condition pre-eclampsia, in which women in the late stages of pregnancy experience sharp rises in blood pressure and swelling in their hands, feet and face. When pregnant women with hypertension and chronic snoring used nasal CPAP with their standard prenatal care, they had better blood pressure control and improved pregnancy outcomes.13

Women are so good at looking after others that they can forget to look after themselves. Men and women need good sleep, nutrition and exercise for a happy and healthy life.

The typical cartoon for obstructive sleep apnea (OSA) shows a man snoring blissfully in bed while his partner sits bolt upright, her hands clapped to her ears. Like all stereotypes this doesn’t show the full picture. Women also get OSA, but they don’t always snore.

References:

1. Young T, Peppard Pe, Gottlieb DJ. epidemiology of Obstructive Sleep Apnea: A population health perspective. Am J Respir Crit Care Med. 2002;165:1217-1239. 2. Bozkurt MK, Oy A, Aydın D, Bilen SH, ertürk iO, Saydam L, Ozgen F. Gender differences in polysomnographic findings in Turkish patients with obstructive sleep apnea syndrome. Eur Arch Otorhinolaryngol. 2008;265(7):821-824. 3. Jordan AS, Wellman A, edwards JK, Schory K, Dover L, MacDonald M, Patel SR, Fogel RB, Malhotra A, White DP. Respiratory control stability and upper airway collapsibility in men and women with obstructive sleep apnea. J Appl Physiol. 2005;99(5):2020-7. 4. Collop NA, Adkins D, Phillips BA. Gender differences in sleep and sleep-disordered breathing. Clin Chest Med. 2004;25(2):257-68. 5. Valipour A, Lothaller H, Rauscher H, Zwick H, Burghuber OC, Lavie P. Gender-related differences in symptoms of patients with suspected breathing disorders in sleep: a clinical population study using the sleep disorders questionnaire. Sleep. 2007;30(3):312-9. 6.Wahner-Roedler DL, Olson eJ, Narayanan S, Sood R, Hanson AC, Loehrer LL, Sood A. Gender-specific differences in a patient population with obstructive sleep apnea-hypopnea syndrome. Gend Med. 2007;4(4):329-38. 7. ibid. 8. Orth M, Kotterba S, Rasche K, Walther JW, Schultze-Werninghaus G, Duchna HW. [Sleep apnoea in women?--The forgotten gender] [Article in German] Pneumologie. 2007;61(11):725-9. 9. Ronen O, Malhotra A, Pillar G. influence of gender and age on upper-airway length during development. Pediatrics. 2007;120(4):e1028-34. 10. Krishnan V, Collop NA. Gender differences in sleep disorders. Curr Opin Pulm Med. 2006;12(6):383-9. 11. Dancey DR, Hanly PJ, Soong C, Lee B, Hoffstein V. impact of menopause on the prevalence and severity of sleep apnea. Chest 2001;120(1):151-5. 12. Gislason T, Benediktsdottir B, Bjornsson JK, Kjartansson G, Kjeld M, Kristbjarnarson H. Snoring, hypertension, and the sleep apnea syndrome. An epidemiologic survey of middle-aged women. Chest 1993;103(4):1147-5.1 13. Poyares D, Guilleminault C, Hachul H, Fujita L, Takaoka S, Tufik S, Sass N. Pre-eclampsia and nasal CPAP: Part 2. Hypertension during pregnancy, chronic snoring, and early nasal CPAP intervention. Sleep Med. 2007;9(1):15-21. 14. Branco J, Atalaia A and Paiva T. Sleep cycles and alpha-delta sleep in fibromyalgia syndrome. J Rheumatol 1994;21: 1113-7.

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Sleep-disordered breathing — the hidden costsA landmark study by Access Economics found that sleep-disordered breathing (SDB) had cost Australia $7.494 billion (US) in 2004 alone.1 Even more startling was the finding that only 2% of this amount was spent on treating sleep disorders themselves. The rest was spent on the effects of SDB, such as associated diseases, loss of productivity, and motor vehicle accidents.

Gerald Burghaus didn’t need a research report to tell him that OSA has far-reaching effects beyond snoring at night. Here’s what he told ResMed’s past vice-president, Ron Richard.

“It was about 4½ years ago that I had a heart attack at the age of 56. This was also after I had increasing problems with constant yawning throughout the day and even dozing at the wheel. After the heart attack, my doctor ordered the sleep study and my tests were terrible. Since using the AutoSet™ T my life has really changed. No longer the yawning, I can drive all day with no dozing, and the doctor says it is a relief on my heart. I just took an early retirement from a high-stress job, and thanks to that decision and my sleep therapy, I am having a happy retirement. It sure is crazy what a little sleep can do.”

The Access Economics report, Wake up Australia: the value of healthy sleep, was the first attempt, worldwide, to track the total costs associated with sleep disorders. According to one of the study’s authors, Dr Ral Antic,2 the study showed that “sleep disorders and their impact are under-estimated, under-diagnosed and under-managed.” However, he is not pessimistic. “There is opportunity to change the community’s health by improving its recognition and management of sleep disorders,” he told us. “We have the potential to have a much greater impact on sleep disorders.”

“Sleep disorders and their impact are under-estimated, under-diagnosed and under-managed.” Dr Ral Antic

OSA: the risk factorImportantly, Dr Antic points out that “OSA is not a disease, but a risk factor.” It is the results of having OSA that cause the problems—through external consequences such as accidents, or the development of serious health conditions such as hypertension, congestive heart failure, stroke, diabetes or depression. Nearly a quarter of the total cost of SDB in Australia in 2004—close to two billion dollars—was spent on work-related injuries associated with sleep disorders. This figure covers everything from disturbance of production, to funerals for those fatally injured at work. In the United States there are four deaths for every 100,000 workers per year—in 2005 there were 5702 work-related fatal injuries.3

Dr Najib Ayas4 is a leading Canadian researcher into the public health and safety consequences of sleep disorders and fatigue. Even he has been surprised by the difference in safety levels between people who have OSA, and those who don’t. “you would expect that people who were sleepy would be more subject to lapses in concentration,” he told us. “But what did come as a surprise was the magnitude of the impact of OSA, particularly for more severe motor vehicle crashes associated with injury or where pedestrians have been knocked down. There was a five-fold increase in these accidents for people with OSA. One study5 showed that treatment with CPAP would have prevented over half of these crashes and saved about 1000 lives.”

‘This is an issue for us’Dr Antic believes there is “lack of general awareness in the community, government and the health sectors that OSA is a risk factor for so many of our major diseases. People are not recognising the importance of sleep, and are not willing to do something about the potential for harm that OSA presents.” Many studies into the costs of sleep-disordered breathing show that CPAP is not only an effective treatment for OSA, but it is cost-effective as well. By treating OSA and reducing its consequences, overall health costs could be reduced, but there has been little action from governments to take this preventative action.

It is up to the community to alert governments to the need for funding, according to Dr Antic. “Governments are driven by crisis, and if a community is loud enough about a particular issue, governments will follow. On the whole, policy can most effectively be changed by the community. The sleep fraternity doesn’t own the problem—its role is to be a technical adviser. Government’s role is to advise and resource the community. And it all has to start with the community demanding action. If we look at smoking rates we can see that they didn’t start to decrease until the community said, ‘this is an issue for us’.”

Sleeping on the jobDr Ayas agrees that the whole community needs to be involved in solving the problems caused by sleep disorders and fatigue, and highlights the role that employers can take. “I don’t think employers on the whole are aware of the problems of OSA, or how its

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References:

1. Hillman D, Murphy A, Antic R, Pezzullo L. The economic cost of sleep disorders. Sleep 2006;29(3):299–305.

2. Dr Ral Antic is the Director of the Department of Thoracic Medicine at the Royal Adelaide Hospital, South Australia. He is also Head of both the Sleep Program and the COPD Program at the RAH and Clinical Senior Lecturer at the University of Adelaide. He is State Director of the South Australian TB Service and Senior Visiting Respiratory Specialist for five regional hospitals. Interview with Dr Antic conducted 26 May 2009

3. Anon. Fatal Occupational Injuries – United States. MMWR Morbid Mortal Wkly Rep 2005;56(13):297–571.

4. Dr. Najib Ayas is Associate Professor of Medicine in the Respiratory and Critical Care Divisions at the University of British Columbia, and is attending staff in the ICU at Providence Healthcare and in the Sleep Disorders Program at UBC Hospital. Interview with Dr Ayas conducted 28 April 2009.

5. Sassani A, Findley LJ, Kryger M, Goldlust E, George C, Davidson TM. Reducing motor-vehicle collisions, costs, and fatalities by treating obstructive sleep apnea syndrome. Sleep 2004;27(3):453–458.

treatment can help productivity,” he says. “It makes logical sense that a sleepy worker will be less productive, but the data on productivity is largely subjective.”

“Certain professions are becoming more aware. I think the trucking industry is taking this issue more seriously, as are police and firefighters. I was recently shown an article on sleep apnea in a RCMP [Royal Canadian Mounted Police] newsletter. When people are carrying guns, the implications of losing concentration because of sleepiness are magnified.”

“When people are carrying guns, the implications of losing concentration because of sleepiness are magnified.” Dr Najib AyasMuch of the research into OSA at work has been carried out on blue collar workers, but Dr Ayas points out that there is a simple reason for this: “I think that the nature of a blue collar worker’s job might lead to OSA being more noticeable. Workers who are operating machines, driving a truck or car, or walking around on scaffolding at a construction site might be more likely to notice reductions in vigilance compared to people sitting at a desk. Also, the more physical nature of blue collar work may make sleepiness more noticeable and more immediate. If a desk-worker is sleepy their work will suffer, but it may not get noticed for some time.”

So people with desk jobs should be careful too? yes, says Dr Ayas. “I also think people in sedentary jobs should be concerned about the effect their job is having on their health. Just looking at the connections between OSA and obesity shows that these people should be trying to increase their physical activity. At the other end of the spectrum, elite athletes such as professional football players have to think about their health once they retire from their sport. Many find it hard to adjust their eating habits even though they aren’t exercising for eight hours a day.”

Taking CPAP to the truckiesTruck drivers are traditionally male and overweight, putting them in a high risk group for SDB. Canadian and US studies confirmed that up to 78% suffer from SDB, and in Australia the figure was 55%.

A testing program conducted by ResMed at one of America’s biggest trucking companies, Schneider, put high-risk drivers onto a CPAP program. Six months later, the company found that accidents were down by 73%. After 12 months of treatment there was a reduction of over 57% in total medical expenses and a massive 91% reduction in hospital admissions. The retention rate for drivers employed by Schneider more than doubled. The benefits to Schneider were so great that the company now pays the full cost of sleep studies and treatment for the 28% of its drivers considered to be at risk of OSA.

Schneider is now a model for the entire American trucking industry and in 2007 won the National Sleep Foundation’s Health Sleep Community Award. Economists have estimated that treating all US drivers suffering from OSA would save $11.1 billion (US) in collision costs and 980 lives per year.

The US Department of Transport is considering legislation to make testing mandatory for at-risk drivers in the transport industry.

10 Snooze Newz

Handy hints for travelersYou might not be aiming for Mt Kilimanjaro, but you can still travel with your CPAP (or VPAP) device. Here are some tips for happy traveling …

• All ResMed CPAP devices have a universal power supply so they can be used around the world—even on aircraft. If you are using a device that is not from ResMed, you should check with the manufacturer to find out if it can be used internationally.

Flying with your CPAP:

- Check with your airline to be sure they will let you use your CPAP device while flying. Some airlines will actively assist you when you’re on board.

- Ask your travel agent to contact the airline with your request well in advance of the flight. you may need to provide the airline with a copy of your sleep report or a letter from your doctor as evidence. you may also need to show this evidence at security, when you are boarding the aircraft.

- you may need a specific adapter to use the power outlets on a plane—ask the airline.

- When traveling economy, ask for a seat near a power outlet so that you can plug in your device.

- When traveling business class, power outlets are typically available near the armrests at each seat.

- Do not use your humidifier when flying.

- In some countries, baggage is restricted on domestic flights, and airlines may classify your CPAP as one piece of

baggage, even though it is medical equipment. Check the restrictions for your chosen airline well in advance.

- Make sure you use the travel bag that comes with your CPAP device, or use a good quality protective bag to keep your CPAP safe.

- Security officials in most countries are familiar with CPAP devices. It will need to be scanned, but this does not harm it.

• Once you’re in your hotel room, you will need an appropriate adapter for the power outlet, and it’s wise to carry an extension cord as well.

• Remember to take your CPAP’s user instructions with you so you can change the clock in each new time zone (if necessary).

Camping with your CPAP:

- your device can be plugged into a battery (preferably a deep-cycle or marine battery) using a converter or inverter. Portable battery packs are also available from many commercial outlets. There is a guide to battery use on the ResMed website, or contact your nearest ResMed office (see page 12).

ResMed’s service team will be happy to answer any queries about using your device.

SECURITy OFFICIALS IN MOST COUNTRIES ARE FAMILIAR WITH CPAP DEVICES. IT WILL NEED TO BE SCANNED, BUT THIS DOES NOT HARM IT.

Snooze Newz 11

ResMed celebrates its first 20 years

The challenge wasn’t just to make the devices more convenient, but also to make them more effective. With the development of the ResMed algorithm, flow generators can now ‘read’ a person’s breath, detecting an apnea as it develops and adjusting the pressure to prevent it.

Masks have also come a very long way in this short 20 years. They are lighter, more flexible and far more comfortable.

ResMed continues to invest around 7% of its revenues into research and development of flow generators, masks and monitoring devices.

Innovation highlightsMirage™ Nasal Mask

Released in 1997, the Mirage Nasal Mask featured an adjustable forehead support and a nasal cushion in a small, light design to minimize visual impact. Its soft-edged shaped vent was quieter than other masks, it was easier to fit, and more likely to fit well.

AutoSet™ T

The AutoSet T was produced in 1999. Its use of the auto-adjusting algorithm resulted in lower average treatment pressure, minimizing leak problems and patient discomfort. Variants of this algorithm are still used in all ResMed AutoSet devices.

Mirage Swift™

In 2004 ResMed launched its first nasal pillows system, the Mirage Swift. It was lighter, more flexible and provided a clear field of vision. The pillows were comfortable and the headgear adjustment was exceptionally easy to use.

S8™

The S8 series, released in 2005, changed the perception of flow generators. It was unobtrusive and made travelling easy, while providing enhanced functionality in a quieter, compact package.

ResMed celebrated its 20th anniversary in 2009. Twenty years of innovation and creativity in design and engineering have taken ResMed from the boxy and bulky early Sullivan™ devices – the first weighed 6.75 kilograms to today’s streamlined S8 Lightweight™ II – weighing just 1.3 kg.

12 Snooze Newz

United States ResMed Corp. Poway CA USA Tel: +1 858 836 5000 or 1800 424 0737 Fax: + 858 836 5501 reception@resmed.com

Australia ResMed Ltd Bella Vista NSW Tel: +61 2 8884 1000 or 1800 658 189 Fax: +61 2 8883 3114 reception@resmed.com.au

Belgium Tel: +32 153 05673

China Tel: +86-10-68492133

Egypt Tel: +20 3 546 8825

Finland Tel: +358 0 9 8676 820

France Tel: +33 4 26 100 200

Germany Tel: +49 0 89/99 01-00

Greece Tel: +30 210 876 4817

Hong Kong Tel: +852 2366 0707

India Tel: +91 11 2645 3592

Italy Tel: +39 0331 931707

Japan Tel: +81 3 5840 6781

Netherlands Tel: +31 348 41164

New Zealand Tel: + 0800 073 7633

Norway Tel: +47 67 11 88 50

Portugal Tel: +351 210 865 760

Singapore Tel: + 65 657 25845

South Africa Tel: +2711 793 2356

Spain Tel: +34 916 393 579

Sweden Tel: +46 520 420 110

Switzerland Tel: +41 61 564 70 00

United Kingdom Tel: +44 1235 862 997

Snooze Newz publication is the subject of copyright owned by ResMed Ltd 2009-11-26, all rights reserved.

Requests for permission to reproduce contributions from Snooze Newz should be addressed in writing to the editor:

theeditor@resmed.com.au

Snooze Newz is a trademark and servicemark of ResMed Ltd.

Snooze Newz is intended to serve as a forum for topics of interest to people with SDB and their families. Contributions by the editor and authors may contain information or opinions that have not been verified for accuracy or completeness by their authors or the editor.

you should make your own independent inquiries before relying on Snooze Newz contributions and accordingly neither the ResMed Group of companies nor the editor offer to, nor will accept liability for, the consequences of any reliance you may place on Snooze Newz contributions. Opinions by authors in Snooze Newz contributions are not intended to be the opinions of, nor are they endorsed by, the ResMed Group of companies or the editor.

While the editor has striven to make correct attributions of authorship and to acknowledge ownership of copyright any omission or error is unintentional and the editor invites the notice of any suspected omission or error.

Mirage, AutoSet T, Mirage Swift, S8, Swift FX, Swift LT for Her, Elisèe are trademarks of ResMed Ltd. © 2009 ResMed Ltd. 1013656/1 09 11

An iMPORtAnt nOte tO YOu, the ReADeR

Global leaders in sleep and respiratory medicine www.resmed.com

new products from ResMed: something for everyone

The right kind of support can make all the difference to CPAP treatment. Whether you are new to treatment or have been a user for many years, there are times when you need expert advice and encouragement.

ResMed’s sleepVantage* program is designed to help you get the most from your treatment at all times. Contact your local ResMed office to find out more about FREE MEMBERSHIP to sleepVantage and its exciting benefits.

* Currently sleepVantage is only available in Australia and the UK.

ResMed’s Worldwide Offices:

Swift™ FX Nasal Pillows SystemA comfortable mask is the key to effective CPAP therapy. The Swift FX is super-soft and flexible, moulding lightly to your face. Adjusting the headgear and self-guiding nasal pillows is easy and intuitive, letting you find the perfect fit. Your mask stays in place the whole night through, delivering your therapy even when you move during sleep.

Swift LT™ for HerThe Swift LT for Her is the first mask designed specially for women. it combines the revolutionary design of the Swift LT with the particular features that women have asked for. it’s light—no forehead support and weighing only 2.3 oz (67 g) – it seals softly and securely with a rotating barrel that lets you customize your best seal, and it’s easy to fit and clean. The width of the mask frame is 50% smaller, making it perfect for side sleeping. And it’s the quietest nasal pillows system on the market.