CPAP Blog

Bill Bolton, a bit of a sleep forum legend, posted this interesting bit of research, published in the American Journal of Respiratory and Critical Care Medicine. Universities around the world combined efforts to establish the ease of access to diagnosis and treatment of patients with suspected sleep apnoea.

I can tell you the not-so-surprising results in one short sentence. The UK comes out worst!

With 84 sleep labs on just short of sixty million people and in those clinics just 170 polysomnography beds we are nowhere near as well equipped to handle the growth in OSA prevalence as nations like Belgium, Australia or Canada.

They estimated some 25,000 new patient sleep studies (that’s not including necessary follow-ups for existing OSA patients) per year, or 42.5 studies per 100K population. In the other countries featured, this number is higher yet they all cope much better in terms of raw numbers.

It gets worse… Waiting times in the UK (as we know) are off the scale. Where in Belgium a suspected patient can expect to be tested and treated in around 2 months, in the UK it can vary from between 7 and 60 (!) months. In other words, between half a year and 5 years! In Australia and the US you would also have to be unlucky to wait more than a year.

The research abstract puts it as follows:

Waiting times vary widely across the country with no clear geographic trends. The average time for a nonurgent referral to be seen by a specialist is around 6 months (range, 2–24 months) and for a sleep study thereafter around 4 months (range, 0–48 months). Thereafter the delay for a CPAP titration is 4 months (range, 3–6 months). Thus, the overall wait from referral to CPAP averages approximately 14 months.

At the current rate, if you insist on public services instead of private, your wife gets to enjoy 14 months of more snoring and you get to live the regrets of 14 months more of walking around with potentially fatal blood oxygen levels.

At the Edinburgh Royal Infirmary the routine works out like this:

General practitioners refer half of the patients to this service and hospital specialists the other half. Sleep studies are ordered by one of two sleep physicians. To deal with the mismatch of demand and capacity, all referral letters are reviewed and prioritized by one of the sleep specialists. All patients living within 100 miles (160 km) are offered home-limited sleep studies, and only those with equivocal results get polysomnography. Patients living beyond 100 miles get split-night studies if their Epworth sleepiness score exceeds 11 (total score = 24) or if they report sleepiness when driving. Night nurses are cleared to start titrating CPAP if a sleepy patient’s apnea–hypopnea index (AHI) exceeds 20 after 2 hours of good sleep.

From that excerpt you can see that with a bit of exaggeration (inflated Epworth score or mention falling asleep when driving - may have licence implications though) you may get helped faster (referral priorization) and more thoroughly (full polysomnography). I don’t recommend gaming the system as you will delay others’ needs but you can see how and why people would.

Having said that, how it’s done in Edinburgh is not representative of the rest of the UK:

These practices differ from those elsewhere in the United Kingdom. Overall, in the United Kingdom around two thirds of all “sleep studies” are oximetry alone and 20% are limited sleep studies, with only 10% being full polysomnography studies. […] Oximetry alone studies are especially prevalent in England. Some general practitioners refer patients to otolaryngologists, who have no specific training in sleep, because of the long waiting times.

An otolaryngologist, for your information, is an Ear Nose and Throat (ENT) doctor. Fancy being diagnosed for your sleep issues by someone who knows more about ears than sleep? And by only measuring blood oxygen levels without looking at apnoea events?

If you are interested in how the other countries compare to ours, please continue reading here. This table tells it all it a nice format.

In summary for the UK with Canadian figures in brackets for comparison:

• Population: 58.8m (31.4)
• No. of sleep labs: 84 (100)
• No. of sleep beds: 170 (440)
• No. beds per 100,000 people: 0.3 (1.4)
• No. sleep studies per year: 25,000 (116,000)
• No. studies per 100,000: 42.5 (370.4)
• Waiting time in months: 7-60 (4-36)

Does this come as a surprise to you? What is the way forward? Are you contemplating moving after reading this? Whatever your thoughts, post them as a comment below or discuss your views in the forums.

If you suspect you, or someone you know, may be suffering from sleep apnoea then please take this questionnaire which will help determine whether this is indeed the case. It may take away some of the doubts you may have.

The BBC reports that those who don’t get enough sleep (as well as those with too much) double their risk of cardiovascular disease. The article quotes research from the University of Warwick and University College London regarding death rates over two decades among over ten thousand civil servants.

The risk of heart disease doubled among those who slept just 5 hours a night compared to those on 7 hours. Interestingly, a similar increase in risk was found among those sleeping 8 or more hours each night.

Those who cut their sleeping from seven to five hours a night had twice the risk of a fatal cardiovascular problem of those who stuck to the recommended seven hours a night - and a 1.7 increased risk of death from all causes.

Researchers also linked the lack of sleep with an increased risk of weight gain, high blood pressure and type 2 diabetes. Considering most obstructive sleep apnoea patients tend to be overweight, with high blood pressure and a lot of them pre-diabetic, linking OSA wouldn’t be that far-fetched either.

Even when a sleep apnoea patients spends 7 hours in bed with his or her eyes shut, you can argue getting just 4 to 5 hours sleep effectively, taking into account the apnoea events, repeated waking up and stress on the body. Untreated obstructive sleep apnoea therefore means sub 7 hours sleep and hence double the risk of fatal cardiovascular problems.

Dr Neil Stanley, a sleep expert from Norfolk and Norwich University Hospital, said while public health messages focused on diet and exercise, people were given very little information about the need to get proper amounts of sleep.

I agree wholeheartedly with Dr Stanley. Articles in main stream media like this one on the BBC website help raise awareness of sleep problems such as sleep apnoea. I hope people who recognise the symptoms and habits mentioned take pro-active action and get a sleep study done at their nearest clinic and seek suitable treatment such as Continuous Positive Airway Pressure (CPAP).

Steve Poceta from over at Revolution Health posted his views on this matter here.

We discussed Sleep Apnoea in drivers before when we dug up some frightening statistics regarding the prevalence of sleep disorders amongst drivers in Britain. As this is such an important topic and often asked about in the various forums, we decided to dedicate another post to the matter of Sleep Apnoea and driving cars or trucks.

There are many good sources on the web benefiting drivers with sleep disorders. A good starting point is the road safety charity aptly named Brake. They list a staggering amount of scary statistics, pointing out the large groups of people endangering our roads on a day to day basis. They estimate that one in ten road accidents are down to driver sleepiness; that statistic alone warrants utmost caution among those who know they aren’t sleeping well. Brake quotes:

Sleep scientist Melanie Marshall says, “Untreated, undiagnosed sleep apnoea individuals are more lethal on our roads than individuals who have been drink driving.”

Brake has great further information on Driver Tiredness, Driver Stress & Emotions, Risks for Older Drivers and Laws regarding Death by Dangerous Driving. They also have PDF documents for fleet managers containing information about how they can assist their drivers in road safety. Those relevant to sleep disorders include Stress & Distractions and Driver Assessment & Monitoring.

If you are unsure whether you are just not sleeping well temporarily or a sleep disorder might cause your sleepiness symptoms, take this free online screening test and discuss the results with your doctor. If a clinical diagnosis confirms you have a sleep disorder like Obstructive Sleep Apnoea (OSA) you are obliged to inform the DVLA.

Group 1 licence holders (car/ motorcycle) diagnosed with sleep apnoea must stop driving until the symptoms have been controlled and confirmed by medical opinion.

Group 2 licence holders (LGV) diagnosed with sleep apnoea must stop driving until the symptoms have been controlled, and must have ongoing treatment. Licensing reviews will be carried out regularly, usually annually.

The Driver & Vehicle Licensing Agency (DVLA) has many pages on their website dedicated to tired driving and Sleep Apnoea in drivers. This PDF leaflet called “Think! Tiredness can kill!” explains the implications of Sleep Apnoea for drivers. Their D9 form tells us:

If you have ever had or presently suffer from any of the following
conditions you must write to the Drivers Medical Group, DVLA,
Swansea SA99 1TU or telephone on 0870 600 0301 with the nature
of your condition, as it may affect your fitness to drive.
FAILURE TO DO SO IS A CRIMINAL OFFENCE PUNISHABLE
BY A FINE OF UP TO £1,000.

• …
• Narcolepsy or sleep apnoea syndrome
• …

The DVLA’s medical section has all the information you need including how tell them about your sleep disorder and what happens next. Your licence can be accordingly issued, revoked or refused. In some cases they may contact your doctor, arrange to be examined or ask you to undergo a driving assessment or test. They aim to resolve most medical enquiries within 15 working days. CPAP users tend to get their licence re-issued after they confirm with the patient’s doctor that the CPAP therapy is having the desired effect.

Some people may feel opposed to risking their licence by telling the DVLA or even by seeing their doctor. After all, some rely on driving to pay their bills and food. It is important to realize the full extent of the risks you expose yourself and other road users to if you keep on driving whilst sleepy, fatigued or lethargic. It’s not just yourself who can be harmed or killed. Think about your children in the back seat or the car behind you.

UPDATE: There is a scheme called “Access to Work” run by the Employment Service (ES) which can help people with disabilities and those who’s licence has been revoked for medical reasons to regain access to work. A good write-up can be found here and an evaluation here.

The Government has produced various leaflets and posters to hit home the risks you pose. You can see some of them here and here.

Some of the slogans designed to make you take direct action:

• [Disabled Parking Sign] Every Hour A Driver With OSA Makes Someone Else Eligible To Park Here
• Daddy Used To Drive A Big Lorry, Then He Fell Asleep
• Bet You Wish You’d Crashed At A Mate’s
• You Drive For A Living But You’d Kill For Some Sleep?
• Think You Can Do The Job With Your Eyes Closed?

You can watch a video or listen to audio by the THINK! Road Safety initiative here. Also read their publication called “Wake up to the signs of tiredness” here.

If you are worried about nodding off whilst at the wheel, we urge you to do the following:

1. Take this online test today.
2. Consult your doctor and if need be, get referred to a Sleep Clinic to get diagnosed.
3. Based on the outcome of the sleep lab test, consider your sleep disorder treatment options. This can range from surgery or dental splints to CPAP or lifestyle changes and weight loss.
4. Don’t forget to tell the DVLA about your test results.
5. For some forms of treatment you may have to join the queue on the NHS waiting lists though most are available privately as well.
6. Once receiving treatment, arrange a follow-up with your doctor or sleep clinic to confirm the symptoms have sufficiently reduced.
7. Now re-apply for your drivers license, if applicable.
8. Don’t drive when feeling tired!

If you have any questions about OSA, CPAP and driving please leave them in the comments below or discuss them with fellow drivers in our forums.