Diaphragm pacing for Central Sleep Apnoea

Treatments for Central Sleep Apnoea (CSA) are limited – that’s why we’re excited about the potential for new treatments such as Transvenous Neurostimulation… essentially, pacing the diaphragm to help you breathe.

Obstructive Sleep Apnoea (OSA) is the upper-airway closure resulting in a drop in oxygenation (oxygen saturations). Central Sleep Apnoea (CSA) is when there is a lack of air flow (breathing) because of reduced effort from your respiratory muscles. i.e the muscles moving your chest wall and diaphragm do not proceed as one would expect.

CSA can occur in many circumstances, including :

  • Heart failure ** (the most common cause)
  • Strokes
  • Opioid use (methadone, morphine)
  • Myotonic dystrophy
  • Renal failure
  • High altitude.

Whilst OSA is almost always treated with CPAP, the success in treating CSA with CPAP is limited. With the departure of ASV as an option in heart failure patients (Serve-HF trial results), diaphragmatic pacing comes at an opportune time.

Costanzo et al (1) looked at those with almost all kinds of CSA (but mainly heart failure), offering them diaphragmatic pacing vs. no-pacing.

At 6 months, more than half (51%) of those with pacing managed to reduce their CSA events by 50%, compared to 11% in those without pacing. There was also an improvement in the Quality of Life Scores, their sleepiness (ESS), and oxygenation.

These very promising results will hopefully one day allow us to provide an alternative treatment for those with CSA.

If you have a Sleep Disorder and would like to see one of our Medical Specialists, give us a call for an appointment now.

1. Costanzo et al. Lancet 2016; 388: 974–82

© APSS 2017

Showcasing the Burnside Sleep Centre

Your sleep study produces over 1,000 pages of data – and that’s why we prefer a local Adelaide centre with staff who are well trained with higher degrees. We prefer not to rely on computer-automation, someone who won’t outsource your important medical data to interstate- or overseas-groups.

That’s why our Sleep Studies are performed at the Burnside War Memorial Hospital.

Burnside Sleep Centre (BSC) is an independent purpose-built six-bed facility within Burnside Hospital, catering to the sleep needs of our community. It’s location is perfect for sleep studies : free parking overnight surrounding the hospital, in a quiet inner-city suburb.

Designed with the comforts of home in mind, each private sleep study room comes with Wifi, a king-single bed, sound proofing, its own ensuite and TV.

BSC staff continue to participate in regular National Quality Control programs (both in-house, and national Q-Sleep), and hold regular meetings with their medical Sleep Committee.

BSC is also one of the very few Sleep Laboratories to offer the full range of Sleep Tests, including :

•  Diagnostic sleep studies
•  CPAP titration studies
•  BiLevel PAP studies
•  Adaptive- or Auto- Servo Ventilation (ASV) titration studies
•  Supplementary Oxygen titration, Carbon Dioxide (TcCO2) monitoring
•  Multiple Sleep Latency Testing (MSLT)
•  Maintenance of Wakefulness Testing (MWT).
•  Specialising in sleep studies for adolescents, adults, and the elderly.

At Adelaide Sleep, in conjunction with BSC, the doctor who sees you is also the doctor who analyses and interprets your complex sleep study. Both Adelaide Sleep doctors and BSC do not have any affiliation with CPAP outlets, CPAP sales, or vested interest in particular treatments.

This is why we believe the Burnside Sleep Centre is the premiere Sleep Centre for diagnostic testing, and we’re excited to refer our sleep studies to Burnside Hospital.

Contact us now for an appointment.

© APSS 2017

Rapid Access to Sleep Services

We’re delighted to announce that our Adelaide Sleep clinic and sleep study services have been extended!

We now have more sessions available and can consult you within days.

Similarly, our sleep study (polysomnography) sessions have increased to almost every night of the week. We can accommodate your schedule much easier and sooner.

With our Rapid Access Sleep Services, we’ll be able to see you, study your sleep, and start treatment immediately.
And for our country patients travelling into Adelaide, we can even see you the following morning with your sleep study results, and start treatment that same day.

For local Adelaideans, your Sleep Study reports are often released to yourself and / or your referrer within 24-48hours of your sleep study.

At Adelaide Sleep, we don’t think it’s fair to make you wait days, weeks, months to have your sleep study. You shouldn’t have to wait for your results either. See us now.

© APSS 2016

Does REM-dependent OSA matter? In Hypertension, it does!

Whilst we know that Severe OSA is associated with cardiovascular risk, a significant ‘grey area’ exists. This grey area is where the evidence for cardiovascular risk is less obvious…

OSA is usually worse in REM : it’s a well known phenomenon. REM sleep is associated with more hypotonia (less muscle tone) and your tongue base will be more prone to collapsing… and that will lead to worsening oxygen desaturations (drop in oxygen levels).

When OSA occurs entirely in REM, does it lead to worse health outcomes?

Mokhlesi et al (1) looked at the association between OSA during REM Sleep and Hypertension (high blood pressure). Sleep Data from the Wisconsin Sleep Cohort was analysed, in conjunction with ambulatory blood pressure monitoring.

Those with higher REM-AHI (worse OSA in REM) were more likely to develop hypertension.

OSA outside of REM was not a significant predictor of hypertension.

• Take-home message : REM-dependent OSA is associated with Higher blood pressure issues down the track.

If you have high blood pressure, we’d recommend an in-hospital sleep study. Ring us for an appointment now.

1. Mokhlesi et al. Am J Respir Crit Care Med. 2014.

© APSS 2016

CPAP for OSA can lower the risk of Car Accidents

There is a wealth of data that acknowledges poor sleep (namely poor sleep due to Obstructive Sleep Apnoea (OSA)) being associated with Motor Vehicle Accidents, and now there is evidence that fixing OSA with CPAP will lessen your risk of car accidents.

In a Swedish Study performed by Karimi et al (1), MVA rates were monitored in the those with OSA, and then those with OSA on CPAP. This was compared to the risk of MVAs from the general population as provided y the Swedish Traffic Accident Registry.

They came to some predictable (and not so predictable) conclusions :

•  Untreated OSA increases your risk of car accidents
•  Using CPAP for OSA reduces that risk considerably

Surprisingly, the ‘severity’ of OSA did not entirely correlate with MVA risk… Suggesting it’s more than just about how Severe someone’s OSA is.

Treating OSA won’t make you a formula-One driver, but will at least lower your risk of a Car Accident in everyday driving. If you’d like to see one of our Medical Sleep Specialists, contact us for an appointment.

1. Karimi et al. Sleep. 2015.

© APSS 2016

Cancer and OSA – an unlikely link?

Does having Severe OSA increase your risk of Cancer? Looking back on the years of Obstructive Sleep Apnoea (OSA) research, we’ve been eagerly watching this unexpected link.

This association has not been studied widely. We’ve known for a long time that repeated intermittent hypoxaemia (low blood oxygen levels) can result in demonstrable problems to the human body – increasing your heart attack risk, stroke risk, Atrial Fibrillation risk, and even cognitive decline.

Martinez-Garcia et al has published both in the Am J Respir Crit Care Med (2013) and Sleep med (2014) with data suggesting those with OSA have an unusually high link to Cancer.

They found that Severe OSA measured by a drop in Oxygen Saturations below 90% (TSat90) and now the Apnoea Hypopnoea Index (AHI) is independently associated with increased cancer mortality. This was even after correcting for confounding variables, particularly true in those below the age of 65, and men.

This is however not a firm causal-link… but not beyond the realm of possibility. More research needs to be done in this field, and we’ll be watching that space closely. Drop us a line and we’ll be able to discuss your sleep in more detail.

Campos-Rodriguez, Martinez-Garcia et al. Am J Respir Crit Care Med. 2013.
Martinez-Garcia et al. Sleep Med. 2014.

© APSS 2016

CPAP prevents Atrial Fibrillation (AF) in OSA

Previously we described how those with Obstructive Sleep Apnoea (OSA) have a 4-fold increased risk of Atrial Fibrillation (AF)… and how it also significantly increases the risk of recurrence to AF even after procedures such as cardioversion and cardiac ablation.

There is now evidence that treating OSA with CPAP can significantly decrease AF recurrence.

Shukla et al performed a meta-analysis across seven large cardiac studies, totalling over 1000 patients with OSA+AF. If you have OSA+AF, and use CPAP, then your relative risk (RR) is reduced by a tremendous 42%. This was completely independent of whether or not you underwent cardiac ablation!

This confirms our understanding of why OSA is such an important and underestimated condition. CPAP prevents atrial fibrillation recurrence in those with OSA.

We recommend that everyone with AF should consider an in-hospital sleep study.

Contact us now if you’d like to discuss this further.

1.Shukla et al. JACC Electrophysiol. 2015.

© APSS 2015

Blue light and Body Clock Problems

Does your body clock feel as though it isn’t running at 24hours? Are you sleeping too early, too late, or all over the place? Then perhaps you have a Circadian Rhythm Disturbance (CRD) and blue light therapy may be able to help you.

Your body clock (Circadian Rhythm) runs at slightly longer than 24hours, but most of us can realign our body clock if needed, with the help of external cues called zeitgebers. When your central body clock generator malfunctions, or those external cues do not help as well as they should, then you could develop a Circadian Rhythm Disturbance (CRD).

The commonest CRD is Delayed Sleep Phase and is commonly seen in the young. Free Running Rhythm (now known as Non-24-Hour Sleep Wake Rhythm) and Advanced Sleep Phase can also disrupt your sleep.

If you can’t control your sleep-time, or wake-time, you’ll arise unrefreshed and subsequently become tired, sleepy, and performing at school or work will be difficult.

The typical adolescent with a CRD will be difficult to rouse in the morning, sleeps in often, falls asleep at school, under-performs during testing, and won’t go to sleep at an appropriate time.

Realigning your body clock is easy, and includes the use of sleep timing methods, blue light therapy, and Melatonin. This re-entrainment program should only be performed after exclusion of other sleep disorders, and under the direction of a Specialist in this field. A home sleep study or use of a CPAP machine won’t be able to address Circadian Rhythm problems.

If you think that your Circadian Rhythm isn’t what it should be, call us for a consultation.

© APSS 2015

OSA, poor sleep linked to memory loss, poor concentration

We have long known that a poor night’s sleep will impair your next-day functioning, but in recent times we’ve had ever-increasing evidence that many Sleep Disorders are truly to blame. Sleep deprivation, poor sleep, and constantly-disrupted sleep will impair your skills the next day.

A recent article (Varga et al, J Neurosci. 2014) looked at one of the most common sleep disorders and it’s effects on how your brain functions.

Those with Obstructive Sleep Apnoea (OSA) were found to have poorer memory and spatial navigation… compared to when they had treatment for their OSA. Their cognition was slower, memory recall slower.

Consulting with our Adelaide sleep doctors, we’ve learnt that this is not surprising, given that :

•  OSA is usually much worse in REM sleep
•  OSA can inherently reduce your REM sleep
•  OSA can dramatically reduce your sleep efficiency
•  Recurrent OSA can starve your brain of oxygen throughout the night
•  Constant pauses in breathing will keep waking you up in the night
•  Disrupted sleep will cause memory loss, poor concentration

When you translate this to the real world, this means mistakes and reduced productivity during the day, lapses in concentration during time-critical events, and recurrent micro-sleeps as you try and catch up on lost sleep.

“My concentration and ‘snappiness’ isn’t what it used to be”
“I keep forgetting my keys and people’s names”
“I need to write everything down now”

Don’t let poor sleep deprive you of the important things in life, call us now.

© APSS 2015

RLS Treatment associated with gambling, Impulse Control Disorders

One of the most common sleep disorders is The Restless legs Syndrome (RLS), and one of the common treatments is associated with Gambling and Impulse Control Disorders (ICDs).

RLS is a common sensorimotor disorder, typically amenable to treatment with dopamine agonist therapy. Dopamine agonists are mainly used for Parkinson Disease, but they have an important role in treating RLS.

These medications include pramipexole (Sifrol), ropinirole (Repreve), cabergoline (Cabaser, Bergoline), pergolide (Permax), and levodopa (Kinson, Madopar).

One of the unfortunate unpredictable side effects is that of Impulse Control Disorders (ICDs). These include :

•  Compulsive gambling (casino, pokies, tele-lotteries)
•  Compulsive shopping
•  Hypersexuality
•  Intermittent Explosive Disorder
•  Punding
•  Kleptomania (stealing)

More recently, there have been legal proceedings regarding some medications and ICDs.

We’ve known about this for some time, and we published the first Australian cohort of RLS patients with ICDs. We’ve looked after one of the largest groups of RLS patients in Australia, we routinely manage these problems effectively, and can adjust medications / medication-types as required.

RLS is easy to treat, and also easy to monitor even in the setting of potential side effects. And if Dopaminergic agents are not suitable, we have many more alternative medications at hand.

Call us now if you’d like to discuss this further.

© APSS 2015