Are you asleep yet?

I don’t do a lot of sleep medicine. It’s never appealed to me. But I work in a relatively small department, so it’s inevitable that I will see people with sleep apnoea, and have to deal with it. In all senses.

We have a relatively small population to serve – about 450,000 across the whole of Tayside, but a prevalence of 4% means a lot of patients with sleep apnoea. The prevalence of ‘tiredness’ must trend towards 100%, so referrals into the system are numerous. Myriad. Legion. Over 100 a week, so I’ll go with legion.

Everyone gets limited polysomnography now. Overnight oximetry seems to diagnose the problem in a small few, but essentially everyone went on to get limited PSG anyway, so we just do that now. The test takes a long time to report. The computer does a lot of the work, but the technicians have to go through it, and highlight apnoeas. A long, tedious process, I’m sure.

Anyone with a normal study is dispatched at a virtual clinic review. Everyone else comes up to clinic, is seen by a consultant, and gets another appointment to come back and get a CPAP machine, and off they go.

Surely there’s a more straightforward way to deal with this large burden of investigation, reporting, clinic appointments? As a ‘non-enthusiast’, I wonder why we don’t just give everyone a trial of treatment? The outcome we’re chasing is decrease in daytime somnolence, so rather than go through the laborious process of limited PSG, reporting, and clinic review, why don’t we just give everyone who’s somnolent a CPAP machine to trial for a week? My sleep interested colleagues tell me that the response to CPAP is dramatic, so patients would know very quickly if it works. I also see how uncomfortable it must be, so anyone in whom it doesn’t work, would quickly hand it back, I think.

That shortens the pathway, doesn’t it? Patient falls asleep in the daytime. Gets CPAP machine in the post. It either works and they keep the machine, or it doesn’t and they hand it back.

I’m sure I’m over-simplifying a very complex and fascinating sub-speciality area. But it does seem to occupy a lot of our time, and anything that speeds up the process has to be worth a thought?

The other problem I don’t have an answer for is what to do with people who have sleep disordered breathing, but no daytime somnolence. Stopping breathing overnight is clearly a common occurrence, and we can obliterate that, but are we only treating the partner’s anxiety, rather than an actual disease? I floated this on sister site Doc2Doc a year or so ago – it was a very polarising question. There were sleep enthusiasts who told me very firmly that anyone with a raised AHI should, nay MUST, get a CPAP machine, and be treated aggressively. They couldn’t tell me why, as the outcome measure of somnolence is hard to monitor when the patient it not sleepy in the first place. Others asked the question of why bother to do the test, a view with which I clearly hold much sympathy.

As I write this, a colleague is poring over limited PSG reports, many of which are normal, but the majority will get a review appointment, and a trial of treatment for their equivocal limited PSG. I look over and my heart sinks. But I suspect he feels the same when he sees me leave to go to adolescent asthma clinic…

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