Dr Michelle Caldecott and Venerable Rinchen Obstructive Sleep Apnoea Interview

More than 1-in-20 Australian adults who stop breathing during the night are at increased risk of heart disease and a shorter life span, new research reveals.

From today, these people may sleep better and live longer, with the launch of an Australian innovation.

New findings from a decade-long study show people living with obstructive sleep apnea (OSA) with less than 90 per cent oxygen in their blood for long periods during sleep face a 50 per cent increased risk of having a heart attack, stroke or early mortality.

According to Professor David Hillman, Chair, Sleep Health Foundation and Director of the West Australian Sleep Disorders Research Institute, Perth, people living with OSA can reduce associated health risks with correct treatment.

'People with OSA – one of the most common and costly sleep disorders – face an increased risk of early mortality and major health complications and the more severe the sleep apnea, the greater their risk.

'It is now established that if you do not to treat your sleep apnea, you are at greater risk of developing diabetes or heart disease," Prof Hillman said.

'However this risk can be reduced if you remain on appropriate treatment."

People with OSA may from today sleep soundly with the launch of a new generation, Australian-designed, continuous positive airway pressure (CPAP) system mask. The new mask system works together with all CPAP devices, delivering a constant flow of air pressure to help keep the upper airway open.

'The innovations of the AirFit P10 nasal pillows mask make it extremely comfortable and easy to use, which is a great step forward in improving adherence to CPAP therapy," said Sahisha Ketheeswaran, Biomedical Scientist and Clinical Researcher, ResMed.

CPAP is the preferred treatment for OSA due to its proven effectiveness in delivering a fixed, constant amount of pressure throughout the breathing cycle.

'Adherence to CPAP is one of the major obstacles in treating OSA," Prof Hillman said.

'CPAP therapy is highly effective when used regularly and has been shown to reduce serious outcomes of OSA including heart disease, stroke and lower the risk of motor vehicle accidents.

'Some of the reasons cited by patients for not continuing with CPAP treatment, such as pressure sores, mask leakage and airflow-generated noise, are significantly overcome with this new mask. So those who are currently not using CPAP therapy for these reasons should consider trying this new mask," said Ms Ketheeswaran.

According to the new mask's mechanical engineer, Alicia Wells, the mask's nasal pillows allow direct flow of air into the nose to prevent leaking, and minimise contact with the skin, and also feature an extremely soft venting system.

'The new mask is designed for anyone over 30 kilograms. It is lightweight – only 43 grams, or the equivalent of two Caramello Koalas – quiet, and doesn't disturb people with OSA or their bed partners during sleep, making it a more acceptable CPAP mask alternative.

'In addition, our clinical study has found patients using the AirFit P10 nasal pillows mask were sleeping for an average of 40 minutes longer per night than they were previously," Ms Wells said.

According to Prof Hillman, sleep deficiency has a serious impact on overall health and wellbeing in both the short and long-term.

'OSA is caused by repeated obstructions to the throat during sleep, involving a narrowing of the throat, relaxation of the tongue and airway muscles11, leading to reduced oxygen levels and sleep disruption," Prof Hillman said.

'Many people with OSA are unaware they have the condition and therefore a significant proportion of people with the disorder remain undiagnosed.

'Sleep deficiency is serious and can result in reduced cognition, memory and ability to solve problems, as well as mood disorders, depression and a poor quality of life," said Prof Hillman.

IT analyst, avid golfer and father-of-three, Bryan, 53, Sydney, who was diagnosed with severe OSA in 2012, says his quality of life has improved significantly since using the new nasal pillows mask.

'I was waking up a lot during the night, and in the mornings I always had a really dry, parched mouth.

'I would wake up feeling tired and in the afternoon I would be completely overwhelmed with tiredness, to the extent that I would zone in and out mid-conversation," Bryan said.

'My OSA was so severe, I was waking up more than 30 times an hour, or at least once every two minutes.

'I'm told that sort of pressure on my body is equivalent to running a marathon and then trying to survive the next day," said Bryan.

Bryan commenced CPAP therapy following his diagnosis to effectively manage his sleeping disorder. His apnea hypopnea index (AHI) score – the numeric measure for the number of occasions a sleep apnea patient wakes up each hour throughout the night – is now 0.7 with the new nasal pillows mask, as opposed to 31 pre-treatment.

'I'm getting the best sleep I've had in a long time. I wake up only about once a night now and can now get through the day much more happily and healthily than before," Bryan said.

Signs of OSA include snoring, choking or gasping while asleep, daytime sleepiness, dry mouth and throat, poor concentration, and memory loss3. While obesity is the most common and most important risk factor for the development of OSA, followed by sex (men are twice at risk of developing of OSA than women) and age, OSA can affect anyone.

Mild OSA is defined as between 5-to-15 apnea episodes per hour; moderate OSA involves between 15-to-30 apnea episodes an hour; while severe OSA involves more than 30 apnea episodes per hour.

Representing a new generation in OSA mask technology, the AirFit P10 nasal pillows mask has a simple, three-part body with a single piece QuickFit™ headgear, nasal frame and key clip pillows that allows the user to slip it on and off quickly and easily. It can be used with a patient's existing CPAP flow generator.

Clinical trial results with the new nasal pillows mask show statistically significant reduction in noisiness and better air diffusion, offering less sleep disruption for patients and their bed partners. Reinforced ease of use, increased breathing comfort and headgear are also listed as major advantages of the new nasal pillows mask.

'If you have been diagnosed with, or suspect you may be living with OSA, talk to your GP," said Prof Hillman.

For more information about the new AirFit P10 nasal pillows mask, call 1300 305 705 or visit www.resmed.com/airfitp10.

Interview with Dr Michelle Caldecott

Respiratory & Sleep Disorders Physician, Austin Health & Epworth Healthcare, Melbourne

Dr Michelle Caldecott is a Respiratory and Sleep Disorders specialist at Austin Health and Epworth Healthcare, Melbourne.

She graduated from the University of Adelaide in 1993 and, after completing specialist training in 2000, set up a private practice in Melbourne.

Currently she is also staff specialist for the Victorian Respiratory Support Service at Austin Health.

Dr Caldecott has previously conducted research into sleep disordered breathing in muscular dystrophy and is currently involved in investigating the impact of severe traumatic brain injury with post traumatic amnesia on sleep.


Question: What is obstructive sleep apnoea?

Dr Michelle Caldecott: Obstructive sleep apnoea is an obstruction of the upper airway, usually towards the back of the throat at night, when people are asleep. It is usually associated with snoring and periodic breathing which is what we refer to as an apnoea.


Question: What are the symptoms of obstructive sleep apnoea?

Dr Michelle Caldecott: An apnoea is a sensation of airflow for at least ten seconds and generally patients with sleep apnoea are often not aware that this is happening although they may wake up a lot, overnight or feel like they're choking overnight. Most patients with sleep apnoea wake up feeling like they haven't had a refreshed sleep. A lot of patients will say they wake overnight, often uncertain why, they will often say it's because they got up to go to the toilet, when in fact they wait for another reason. We also know that the drop in oxygen levels of someone with sleep apnoea actually produces a hormone from a part of the heart called brain natriuretic peptide or BNP which is a diuretic which causes patients to go to the toilet however when we treat their sleep apnoea they don't wake up as much and they don't need to use the toilet, as much.


Question: Can you talk about the risks associated with obstructive sleep apnoea?

Dr Michelle Caldecott: The most prevalent is obesity and with the increased size of the population there is no doubt that we are seeing more sleep apnoea. One of the main things we try and get patients to do is to lose weight as we know if they drop off the weight the instance of sleep apnoea reduces significantly.

There are a number of other risk factors including alcohol and getting older, particularly in women after menopause as there seems to be a hormone which changes in the upper airways. Family history also can be a risk factor for sleep apnoea including genetic predisposition. There are some racial groups and face shapes which are predisposed as well for example the Asian population seem to have a higher incidence of sleep apnoea.


Question: How is obstructive sleep apnoea diagnosed?

Dr Michelle Caldecott: After we've taken the history from the patient and they've explained they snore or wake up feeling tired or describe periodic breathing then we conduct a sleep study. A sleep study involves the patient attending a sleep lab or a home sleep study which has been made possible with portable monitoring equipment. To conduct the sleep study we roughen a few patches of hair to attach electrodes to the scalp and the legs to measure EEG (brain wave activity) when the patient is awake or asleep and if they're asleep we can determine if they're in REM sleep or non-REM sleep. We also have a nasal pressure monitor for the patient to wear to measure air flow, the oxygen signal monitor that is worn on the finger and leads across the chest and the abdomen. These tests allow us to look for the signals and signs of sleep apnoea and other sleep disorders.


Question: Why are men at twice the risk of developing obstructive sleep apnoea than women?

Dr Michelle Caldecott: It comes back to the position of the tongue base as often men have quite a bulky tongue base in the back of their throat and we know that sleep apnoea is partly due to the tongue position and also the face shape. Most of the men we do see with sleep apnoea are carrying excess weight however I think it's purely the different face shapes of men verse females.


Question: How can obstructive sleep apnoea now be treated?

Dr Michelle Caldecott: The treatment that applies to everyone are lifestyle strategies including weight loss, cutting back alcohol, getting enough sleep to avoid overtiredness and avoiding sleeping on the back. There are patients with sleep apnoea with such severity that they need therapy and the most effective therapy is a mask and a machine or CPAP (continuous positive airway pressure).

For more information I suggest the Australasian Sleep Association: http://www.sleep.org.au/ as it is a well-regarded site and we send our patient there for information, contacts and brochures.


Question: What is the CPAP, nasal pillows mask?

Dr Michelle Caldecott: CPAP is a pressure device that creates a nematic splint which is delivered by an interface (nose or nose and mouth) to deliver a positive pressure to splint the upper airways. It's not oxygen and it works as long as the patient wears it. CPAP is a treatment not a cure. Unless there are other reversible factors such as weight loss CPAP is a long-term treatment for most patients.

Interview with Venerable Rinchen

Buddhist Nun sleeping soundly, Cairns

Buddhist Nun, Venerable Rinchen, 59, Cairns, has devoted much of her life to the Buddha's teachings.

She runs a busy Buddhist centre in Cairns and performs volunteer palliative work.

Despite her relatively calm existence, Rinchen struggled for many years with constant fatigue and loud snoring, which caused her problems when sharing rooms on meditation retreats.

When driving home one day, Rinchen experienced a micro-sleep and was forced to pull over to the side of the road. She promptly called her GP and was subsequently referred for a sleep test, which led to her diagnosis of severe obstructive sleep apnea (OSA). This is her story.

'Before being diagnosed with OSA, only my force of will kept me going," Rinchen said.

'While meditation gave me sufficient energy to get through the day, my quality of life was suffering due to a lack of sleep.

'I was always extremely tired to the extent that I was falling asleep during my daily rituals, including meditation, visualisation practice and prayer recitations," said Rinchen.

'Getting up and going in the morning was really hard."

Completely unaware of the medical disorder, OSA, and its associated health complications, Rinchen continued to push through each day until one day, when leading a meditation retreat, a woman asked if she could use a powerpoint to connect her continuous positive airway pressure (CPAP) machine to help her sleep and minimise her snoring.

Curious about the woman's medical condition, Rinchen enquired about the machine and its use.

'I had no idea OSA existed until a lady attended my meditation retreat and requested to hook up her CPAP machine to minimise her snoring.

'This got me thinking. So I asked her a lot of questions to learn more," Rinchen said.

Rinchen had many symptoms associated with OSA including snoring, chronic tiredness, weight gain and falling asleep at the wheel.

'Although I was officially diagnosed with OSA in December 2009 following a sleep test, I suspect I've been living with OSA for about eight-to-nine years now," said Rinchen.

Rinchen's sleep test revealed she was waking up between 80-to-100 times per hour. 'When the doctors confirmed I was living with severe OSA, they couldn't understand how I was still continuing to function," Rinchen said.

'After my sleep test, I returned to the sleep clinic overnight to trial CPAP treatment. 'The following morning, I felt like I'd had the best night's sleep in my entire life," recalled Rinchen.

'I woke up with so much energy, it was amazing."

Since commencing CPAP treatment, Rinchen's quality of life has significantly improved. 'I'm no longer over-tired. In fact I've got so much more energy, I can now run many different projects and retreats.

'I've also been able to shed some weight now that I'm exercising regularly and following a good diet," Rinchen said.

'Because my OSA is under control, I can now relax when I embark on a retreat, knowing that I won't be disturbing people with my snoring."

Rinchen recently began using the new AirFit P10 nasal pillows mask, as her previous mask had passed its use-by date.

'I visited my local CPAP centre recently to enquire if they had any new OSA masks because my old mask was leaking, was tight on my face and was literally driving me nuts," said Rinchen.

'The consultant informed me that a new mask was arriving later that week that I could trial. 'As soon as the AirFit P10 nasal pillows mask arrived, I began trialling it," Rinchen said.

'Wearing the mask on the first night felt like heaven, because it was so much lighter than my previous mask and sealed so well.

Rinchen is now sleeping soundly and comfortably with her new nasal pillows mask. 'The new nasal pillows mask is so comfortable and quiet. In fact, I keep wondering if it's working because it's just so quiet."


Question: When were you diagnosed with obstructive sleep apnoea?

Venerable Rinchen: I was diagnosed with OSA in 2009.


Question: Can you talk about the symptoms you were experiencing?

Venerable Rinchen: I would wake very tired from a supposed good night's sleep, I would be sleepy throughout the day and struggle to do the things that were required of me to do.


Question: How did obstructive sleep apnoea affect you on a daily basis?

Venerable Rinchen: I run a fairly busy Buddhist Centre and work within the palliative care sector as a volunteer and in other community organisations so it was only through the force of my meditation practice that I could keep doing what I was doing.


Question: How was obstructive sleep apnoea affecting your work?

Venerable Rinchen: As it got worse it made it very challenging to keep my energy up.


Question: How did you previously treat your obstructive sleep apnoea and were these treatments successful?

Venerable Rinchen: I thought I just had a snoring problem till I was diagnosed so tried all the nasal sprays, nasal clips etc but to no avail.


Question: How does the CPAP, nasal pillows mask work?

Venerable Rinchen: I had been using a different nasal pillow prior to the one I have now and it worked ok but I went to my cpap retailer recently to see if they had anything new on the market as I was having problems. They were just about to release this new one so I waited for a trial one to try. I went in the next day, credit card in hand ready to buy it was so brilliant. So lightweight, so easy to fit and barely if any leakage. I have been using it now for over a month and absolutely love it.


Question: How long did it take to get used to wearing the CPAP machine?

Venerable Rinchen: It took me a couple of weeks to get used to the machine but only one night to get the benefits of a good night's sleep.


Question: What differences have you noticed when using the CPAP, nasal pillows mask?

Venerable Rinchen: I have always used a pillow mask as I find they are the most comfortable and also the least intrusive in terms of feeling claustrophobic.


Question: How does obstructive sleep apnoea affect you on a daily basis now you use the CPAP, nasal pillows mask?

Venerable Rinchen: My quality of life improved significantly once I started using CPAP, and this quality has been enhanced recently by a change of mask to the new pillow mask.


Question: What advice do you have for others diagnosed with obstructive sleep apnoea?

Venerable Rinchen: My advice people with sleep apnoea is to really persevere with the machine until you are familiar with it and get used to sleeping with it as it will make such a difference to your life. I would also advise them to try the pillow masks, I did a few training techniques to stop myself from mouth breathing in the first month as it was a little bit tricky to start with but now I rarely do this. There have been several instances where I have not been able to use my machine (power blackouts) and I can honestly say it was noticeable the difference in energy levels the next day and that feeling of not having enough sleep.


Interview by Brooke Hunter