Sleep apnoea services are overwhelmed by the large number of patients requiring treatment and follow-up. New solutions are needed to manage the growing caseload. Centralized call centers using telemonitoring of CPAP machines and home sleep studies with wireless data transmission could help by allowing remote patient support and diagnosis, reducing the burden on clinic resources. These approaches aim to improve access to care for the many people affected by undiagnosed sleep apnoea.

1. Sleep Apnoea – new approaches to managing
the burgeoning national caseload
John Stradling
Emeritus Professor of respiratory Medicine
Oxford University
Conflict of interests statement – I do some consulting work for ResMed UK

2. Outline of presentation
• What is sleep apnoea and why is it an important disease?
• What is the current patient pathway?
• Why is there a crisis in sleep apnoea services?
• What needs to change?
• What new solutions are out there?
• Other areas in sleep apnoea management that could benefit
from new technology

3. What is sleep apnoea and why is it an important disease?
• Sleep apnoea - breathing repeatedly stops during sleep producing major adverse
physiological changes, but SLEEPINESS is the dominant symptom
• Patients with this condition stop breathing often hundreds of time a night, of
which they are not aware, and as a consequence suffer from unexplained daytime
sleepiness
• Of major concern is that this sleepiness leads to a myriad of deleterious
consequences, of which falling asleep driving is one of the most concerning
• There is an extraordinarily effective treatment called continuous positive airway
pressure (CPAP) which patients use most nights, for most of the night
• This treatment abolishes the symptoms and has been strongly endorsed by NICE
(TA139)

4. Each fatal accidents cost the community nearly £2 million pounds (DofT figure)

5. What is sleep apnoea and why is it an important disease?
• Sleep apnoea - breathing repeatedly stops during sleep producing major adverse
physiological changes, but SLEEPINESS is the dominant symptom
• Patients with this condition stop breathing often hundreds of time a night, of
which they are not aware, and as a consequence suffer from unexplained daytime
sleepiness
• Of major concern is that this sleepiness leads to a myriad of deleterious
consequences, of which falling asleep driving is one of the most concerning
• There is an extraordinarily effective treatment called continuous positive airway
pressure (CPAP) which patients use most nights, for most of the night
• This treatment abolishes the symptoms and has been strongly endorsed by NICE
(TA139)

6. CPAP
Compliance
with CPAP is
better than
with anti-
hypertensives
and asthma
therapy

7. What is sleep apnoea and why is it an important disease?
• Sleep apnoea - breathing repeatedly stops during sleep producing major adverse physiological
changes, but SLEEPINESS is the dominant symptom
• Patients with this condition stop breathing often hundreds of time a night, of which they are
not aware, and as a consequence suffer from unexplained daytime sleepiness
• Of major concern is that this sleepiness leads to a myriad of deleterious consequences, of
which falling asleep driving is one of the most concerning
• There is an extraordinarily effective treatment called continuous positive airway pressure
(CPAP) which patients use most nights, for most of the night
• This treatment abolishes the symptoms and
has been strongly endorsed by NICE
http://www.nice.org.uk/guidance/ta139
• NICE has recommended fast tracking vocational drivers following an initiative by the OSA
partnership, to try and ensure such patients are diagnosed, treated and back on the road
within 4 weeks. http://cks.nice.org.uk/obstructive-sleep-apnoea-syndrome#!scenario

8. Current patient pathway
GP suspects sleep apnoea
Referral to hospital sleep unit
Sleep study and outpatient assessment
Put on CPAP if indicated
Immediate follow up
+ extra appointments if needed
Annual follow up

9. Why is there a crisis in sleep apnoea services?
• Sleep apnoea is common. Sleep apnoea, benefitting from treatment with CPAP,
affects about 2% of the adult population
• This equates to about a million people, and the best estimate of patients currently
on CPAP is 230,000
• This means that there are still 770,000 patients undiagnosed
• It is recommended that all patients on CPAP are followed, at least annually to ensure
treatment remains efficacious and all problems are solved to ensure good
compliance, (NICE, IMPRESS (BTS), ARTP, BLF)
• Routine follow-up alone of current patients would thus lead to 230,000 outpatient
appointments a year, which at a cost of £120 per appointment would cost the
country £28 million!
• We are victims of our own success and services are now overwhelmed

10. April 2015
9,700
Figures from the Oxford Sleep Clinic

11. What needs to change?
When staff running sleep units are asked -
“what is the biggest load that impacts on your service?”
It is the routine follow-ups, interim patient phone calls, and
emails etc. that crush the service
These are mainly relatively simple problem solving, providing
information, replacement masks, broken kit etc
Without this service load of relatively ‘simple’ tasks they could
concentrate on the more skilled activities within the sleep unit.

12. What new solutions are out there?
Centralised call centres benefitting from:
• Economies of scale
• Recruiting issues, larger staff pool buffers holidays/sick leave etc
• High standard approach to all patients and their problems across the country
• Staff training becomes a continuous activity within the call centre
• Can help both large and small services, delivering the same service to patients
• Full range of replacement kit, rapid response times to send out
• Extended working hours
• Comprehensive database allowing rapid identification of who is calling and their
details
Country-wide service provided by a company in cooperation with the sleep unit
Several such services already in operation, but currently low take-up by NHS
– perverse incentives limit this avenue

13. What new solutions are out there?
Telemonitoring:-
When a patient rings up with a problem, instantly being able to interrogate
their CPAP machine would allow most problems to be solved there and then
CPAP machines monitor:
• Usage – i.e. how much is the patient using the treatment
• Mask leak – a common problem that can be addressed
• Residual sleep apnoea – is the system working
• Any machine faults – might explain the patient’s problem
This used to require patient attendance at the clinic to collect this information
Then there were data cards that could be sent back in the post
Now this can be done remotely via wireless/mobile phone technology
Provides instant information to the person answering the call
The settings on the machine (e.g. pressure) can be adjusted remotely as well

14. Immediate follow up of patients recently starting CPAP
The first few days following the introduction of CPAP are critical
• Patterns of usage are set within the first week
• Important to identify early ‘failing’ patients
Good
Not very good
Printouts from ResMed AirViewTM, part of ResMed Air Solutions

15. Display of patients recently starting CPAP
Printouts from ResMed AirViewTM, part of ResMed Air Solutions
Current ResMed CPAP machine with
built in Wireless communications

16. Example of a Unit adopting
telemonitoring
• Sleep Clinic, 1 consultant and 4 clinicians
• 500 new CPAP set-ups/year, 2,000 on CPAP already
• Overload, failing to meet 18 week treatment target
• “There was no scope for extra staff to cope with
rapidly increasing demand” Claire Goulden
Introduced AirView TM, part of ResMed Air Solutions in October 2014
• They were able to replace current routine follow-ups with targeted phone
calls, or appointments, only for those who needed this input
• They were able to quickly identify new patients experiencing problems and
spend more time on them
• Far fewer outpatient appointments and thus far less patient inconvenience
• Time saved allowed time to be spent with more complex patients, such as
those needing NIV
They had full management support for what was clearly a better system

17. Other areas in sleep apnoea management that could
benefit from new technology
Given that OSA is:-
• Very common
• Under-diagnosed
• For which there is a highly effective treatment
• Been around a long while (cf hypertension, diabetes)
It should and will become much more a primary care issue
Simple home screening equipment - now fully accepted for sleep apnoea
diagnosis
Needs simple, reliable devices
Results need to be easily available to a variety of clinicians, GPs, consultants,
sleep nurses, sleep technicians involved in the patients’ care

18. Home sleep apnoea diagnosis – e.g. ApneaLink™Air
• Can be uploaded to the cloud so that other clinicians in any location can see
the data instantly
• This facility would be particularly appropriate when the GP does the sleep
study and the consultant needs to see the sleep study when assessing the
patient later

19. Abbreviated summary page to
help with referral decisions
Full data display for the
sleep centre clinician
ResMed ApneaLink™Air - results

20. Conclusions
Sleep services are in crisis, they need new ways of working to solve
the ever increasing numbers of patients starting CPAP and requiring
follow-up
The best solution requires large centralised call centres and CPAP
machines equipped with wireless technology
Sleep apnoea is underdiagnosed and waiting lists for diagnostic
services are growing
Home sleep studies by GPs, with wireless technology for
transmitting the results to the sleep centre, provides a solution