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In Wales on Sunday Dr Keir Lewis, a consultant at Prince Phillip Hospital, Llanelli, and head of the sleep service for Hywel Da Health Board, said the number of people suffering from conditions such as obstructive sleep apnoea (OSA) has risen dramatically in the past 10 years – putting severe strain on the NHS. He also correctly highlights the fatal risk to drivers of this condition, and gives some shocking examples.
Dr Lewis said one of the major problems faced and posed by OSA suffers was their fitness to drive. “We know from US-Canadian insurance claims and driving simulators that untreated people with OSA are five to seven times more likely to suffer a road crash. It’s one of the few conditions that kills people other than the sufferer. I’ve had someone coming in with severe symptoms of OSA but didn’t realise it until the police were called when someone spotted him driving straight across a roundabout. When we monitored his sleeping he was actually stopping breathing 140 times in an hour.”
“I also had a man fall asleep while he was operating a crane and it was only when he fell out and landed in water did he wake up and realised how severe his problem was. And we have treated other people who have fallen asleep behind the joystick of a plane and someone who fell asleep pouring molten metal. It was when he was on the burns unit, that the staff noted him stopping breathing.”
Employing the emergency services to a fatal road accident on a motorway costs taxpayers about £250,000 – the amount Dr Lewis said is enough to run an OSA service for a year – and the risk of accidents is increasing as the population gets more obese. Dr Lewis said: “We think about 80% of people who suffer from OSA are still undiagnosed and even the 10% to 20% who get diagnosed take about eight to 10 years from onset of symptoms to eventual treatment. Because it is a gradual condition people don’t necessarily realise why they are feeling like they do and blame age.”
The BBC reported last week that the NHS is struggling with a “tidal wave” of sleep disorders related to obesity, according to specialists. They report that the number of people being referred for sleep problems in Scotland has risen 25% over the past three years, with about 80% of patients being overweight. Figures for the rest of the UK are not available but doctors at sleep clinics in Scotland say their experience is probably mirrored elsewhere. The DVLA estimates 20% of serious incidents on major roads are caused by sleepy drivers.
Dr Tom Mackay, an expert in sleep disorders, at the Royal Infirmary of Edinburgh says he is facing a “tidal wave” of cases. There are now more new cases of sleep apnoea being diagnosed than lung cancer and emphysema combined. Dr Mackay said: “Over the past five to 10 years we have noticed quite a rise in the number of people being referred to us. That rise seems to be accelerating. We are now seeing 2,500 new patients each year. We are reaching capacity in terms of what we can cope with, and there is an undoubted link with people’s weight. For a man, if you’ve got a collar size of more than about 17.5in (44cm) then that is a marker for too much flesh around your neck. That roughly equates to a waist size of about 36in.”
Dr Mackay urged anyone who thinks they may be suffering from sleep apnoea to get properly diagnosed. The DVLA does not usually remove the driving licence of patients who are undergoing treatment.
Meanwhile the British Lung Foundation is so concerned about the steep rise in cases that it has made sleep disorders a priority for action.
The BBC has made this video report on one patient’s success in beating sleep apnoea through losing weight.
Following the Labour Party leader Ed Miliband’s operation to correct a deviated septum, there has been much speculation that he has merely undergone this operation to improve the sound of his voice.
The political editor of The Guardian, Patrick Wintour, was particualrly dismissive of the medical need for Mr Miliband’s medical procedure, and also seems to grossly underestimate the seriousness of sleep apnoea:
“Ed Miliband had been asleep for an hour, recovering from an operation his team ludicrously continued to insist was solely about tackling a deviated septum in his nose, so making it easier for him to sleep, and possibly for his wife Justine to be spared the odd snore.”
I can only assume that Mr Wintour and his partner have never suffered from sleep apnoea, which as any sufferer will tell you is a serious and chronic condition that can ruin your quality of life, and that of your partner. There is also a growing body of evidence that sleep apnoea contributes to heart disease, and also road traffic accidents.
While this kind of surgery is only undertaken in a minority of cases (CPAP treatment is effective in 90% of cases), it can be an effective treatment for sleep apnoea, and I can only assume that this was the diagnosis Mr Miliband received as his operation was done on the NHS.
Online magazine Health Matters has published an article on the importance of monitoring patient feedback for the medical revalidation process for doctors that the General Medical Council will begin in 2012:
“In whatever way the structure of the NHS evolves over the next decade, the challenge will be to juggle financial constraints and growing patient power. It is those GP practices and hospital departments that can create a seamless customer experience, automatically gaining customer feedback throughout the process – that will be best placed to respond to the challenges of the new health economy. By continually monitoring real-time patient feedback, healthcare organisations can analyse performance on an on-going basis, share best practice and transform services to specifically meet the needs of the patient. Using interactive touch screen technology healthcare organisations attain insight that will greatly assist them in refining service levels as revalidation looms.”
I use the Jayex QI Interactive system in my clinic to do just that, and strongly believe that this is not just a tool for revalidation, but that patient opinion should be used to guide the future of the NHS. Access to detailed patient feedback can enable consultants like myself to transform services to specifically meet the needs of the patient. By continually monitoring patient feedback all year round in real-time, doctors can analyse performance on an ongoing basis, and share best practice across the NHS.
As I stated in a recent news release on patient satisfaction, patient power should be at the heart of the NHS. Healthcare is a service industry, but it doesn’t seem to behave like one. If you’ve got no evidence that you are delivering a good service to your patients, then it is impossible to review and improve upon. As the article argues:
“In an increasingly patient-centric NHS, there is a clear need to improve understanding of the customer experience, from the difficulties of making appointments to feedback on the cleanliness of the waiting environment or a demand for specific local services. The ability to capture information in real-time ensures problems can be rapidly flagged-up and proactive changes made.”
While it’s surely beneficial that the leader of the Labour Party Ed Miliband being diagnosed with sleep apnoea will increase awareness of the condition in the UK, I hope that people don’t get the impression that surgery is the best, or most common, solution. CPAP is the safest and most tried and tested solution to sleep apnoea and is recommended by NICE.
Surgery is not usually a first option for helping Obstructive Sleep Apnoea sufferers and in my practice only about 11% of all patients have surgery. However in some cases, especially children, the cause for Obstructive Sleep Apnoea might be enlarged tonsils or adenoids. Removing them, therefore, removes the problem. Mr Miliband does not seem to be in this category though as the Daily Telegraph reported last week:
“It had long been assumed that he merely had enlarged adenoids – fleshy parts behind the nose that can affect the voice… However on Friday a spokesman denied reports that he was having an adenoidectomy, and instead disclosed that Mr Miliband is suffering from sleep apnoea, a potentially serious condition that affects the breathing while asleep, which is made worse by a problem with the partition in his nose, known as a deviated septum. He will undergo a surgical procedure, most likely one known as a septoplasty, to reshape the cartilage and bone in his nose. This should make his breathing easier and may also make his voice clearer.”
Saw this interesting article in the Wall Street Journal on a new snoring prevention device. I agree with Richard Schwab that there needs to be more studies in to safety and effectiveness if it is to be compared to the CPAP gold standard:
“A variety of nasal devices are being marketed for sleep apnea and snoring. Most of them are simple nonprescription “nasal dilators” that fit in the nostrils and prop them open to improve air flow. Those devices can provide some benefit for snoring but don’t do much for sleep apnea where the problem is in the throat, not the nose, says Lawrence Epstein, chief medical officer of Sleep HealthCenters, a network of sleep-medicine clinics and centers.
The Provent, which hit the U.S. market in 2008, is a patch with a tiny valve that fits in your nostril. The valve is open when you breathe in, but closes partially when you breathe out, providing a resistance, the company says, that results in increased pressure in the airway, which helps keep the throat open. While a nasal device eliminates the hassle of being tethered to a machine, some patients have trouble adjusting to the resistance of the valve when exhaling, which can give a momentary feeling of suffocation, doctors say. In studies, published or soon-to-be presented at meetings, 59% to 80% of patients tolerated the device.
Two recently published studies, funded by Ventus, have shown the Provent to be effective for those who can tolerate it. A study published February in Sleep Medicine looked at 59 patients who couldn’t use CPAP or were using their machines less than three hours a night. Of those patients, 47 were able to tolerate the Provent. Of those, 56% had their sleep apnea reduced to a level the researchers considered clinically significant. In those patients, the number of times they stopped breathing per hour decreased to 12 from 32 at the end of five weeks.
A 250-patient study, published April 1 in the journal Sleep, found the Provent more effective than a sham device in a broad range of patients who had never used the CPAP.
“I think there needs to be more studies,” says Richard J. Schwab, co-director of the Penn Sleep Center at the University of Pennsylvania Medical Center. He says he would like to see an imaging study that shows improvement in the size of the airway while sleeping.”