OSA episode 
 
 

Charlie: [00:00:00] hello and welcome, listeners, to this month's Respiratory Futures podcast episode. I'm your host, Dr. Charlie Addy, and I'm very excited today to be joined by Dr. Swapna Mandal, who's a consultant in respiratory sleep and ventilation at the Royal Free in London, and also spent many years researching sleep and ventilation at UCL. 
 
 

Charlie: She's led a team which has won Diagnostic Team of the Year at the 2019 BMJ Awards after they cut diagnosis wait times from 239 days to just 40. So I'm sure that Swapna can tell us a little bit more about herself and her journey into respiratory medicine better than I can read her bio. 
 
 

Charlie: Over to you, Swapna. Tell us a little bit about yourself. 
 
 

Swapna: Oh, thank-thanks for the kind intro, Charlie. My journey into respiratory medicine was a pretty straightforward one actually, and a pretty straightforward one into respiratory sleep medicine. I knew that I wanted to do respiratory medicine quite early on in med school. I liked the complexity of respiratory disease and bringing together the complex symptom management and the ability to do [00:01:00] practical procedures. 
 
 

Swapna: And then I started learning about sleep disorders in medical school, which absolutely fascinated me. And so I, as a very sad medical student, decided to do an audit with a respiratory physician on sleep apnea and basically I was hooked. And have now spent my whole medical lifetime researching, managing, treating patients with sleep-disordered breathing. 
 
 

Swapna: So that is my journey into where I am today. 
 
 

Charlie: As someone who does undergraduate medicine, this is music to my ears, that your medical student project inspired your future career. This is brilliant. All those students that I make come and do things with me, hopefully I'm inspiring future respiratory physicians. So as you are literally one of the renowned experts, we're gonna talk about obstructive sleep apnea or sleep-disordered breathing, as you've said commonly out there in the parlances OSA. 
 
 

Charlie: Can you give us a bit of a rundown of where are we with OSA at the moment? What's the journey to diagnosis typically look like for patients? How do they get to you in your [00:02:00] clinic? 
 
 

Swapna: So I think sleep-disordered breathing, let's talk about obstructive sleep apnea most commonly because that's the one that people more often know about is challenging. It's still often under-recognized and under-diagnosed, and I think that's because sometimes the symptoms can be really subtle. 
 
 

Swapna: And so patients are often nudged, and I literally mean nudged into coming to my clinic by bed partners Because their snoring is awful, that's the common reason for patients turning up to my clinic. Some patients do present with common symptoms of sleep apnea, and that can present as fatigue during the daytime, although we know that fatigue is a non-specific symptom or more specifically aligned to sleep apnea, excessive daytime sleepiness. 
 
 

Swapna: That's the hallmark symptom of sleep apnea. But there are lots of other symptoms that are often under-recognized. So for example, patients may present with mood disturbance. It's not [00:03:00] uncommon for me to see patients who have been diagnosed with dementia that actually have underlying obstructive sleep apnea, and if you can treat that, you may well improve the degree of memory loss. 
 
 

Swapna: Depression, difficulty in concentrating. Brain fog is a really common symptom, and that can be mimicked in so many other disorders. Waking up during the night and not knowing why. So all of these are really common symptoms that may be symptoms of obstructive sleep apnea, but equally can be a symptom of something else. 
 
 

Swapna: So sometimes patients have had a long journey to try and get into my clinic. We know that often sleep medicine clinics are receiving a lot of referrals, and they're going up as we recognize an increasing number of patients with sleep difficulties. 
 
 

Swapna: So the waiting lists are sadly long. Lots of people the clinicians like myself, are trying to look at ways of trying to streamline that pathway, and you mentioned the award that my team won. And what we've done is opted to go for a [00:04:00] straight to diagnostic test pathway. So patients are referred in by their GP, and they have their test first, and then given a diagnosis as a first point of call with the clinical team. 
 
 

Swapna: And in some cases, we will often go straight to treatment with these patients. But it's hard because as with many parts of the NHS, it's under-resourced and so there are long waiting times to get to a diagnosis and treatment. 
 
 

Charlie: Yeah. I recall my days in sleep clinic as a registrar vividly because the first time I did sleep clinic, we were working in the old hospital in Bristol in the BRI, where the sleep clinic was still located in the 70-- It was built in the 1700s, the actual brick building, and we literally had this tiny little waiting room and all of these people just kind of almost sitting on each other's laps in this tiny waiting room in this very old building. 
 
 

Charlie: And as you say, these services have grown. We just had... That we couldn't fit them in. We could physically through the door. So it has definitely been a growth industry and a lot more [00:05:00] awareness and increasing referrals coming through. 
 
 

Swapna: And you can spot the ones that have sleep apnoea because they're snoozing in the waiting room. 
 
 

Charlie: Exactly. They're the ones you have to shout their name four times or go and poke them to get them to come. And in terms of your straight to diagnostic pathway, what tests do they go to straight away? 
 
 

Swapna: That depends on the patient. So we do some triaging when the GP referral comes in. We look at comorbidities, we look at the Epworth score, which is a score of how excessively sleepy somebody is. And we look at some other factors, and depending on that, we determine whether they can have a home wearable device. 
 
 

Swapna: Some of these newer devices that people will have heard of or will be using, like the WatchPAT or the AccuPebble, or whether they need multi-channel polygraphy, which is a very pared down version of full polysomnography but requires using chest and abdominal bands, pulse oximetry, nasal cannula to measure lots of different channels and give us a little bit more [00:06:00] granular detail and information about their sleep-disordered breathing. 
 
 

Charlie: Okay. And what kind of things do you look out for in the referral that would make you think that someone needed the sort of more intensive tests rather than, say, wearing a simple wearable at home? 
 
 

Swapna: That's usually patients with complex comorbidity. So for example, if you have significant heart failure or if you have had a stroke, you are at risk of perhaps having some central sleep apnoea components, for example. So we may want to rule that out in an individual. If there are individuals who have significant obesity and you're concerned about obesity hypoventilation syndrome, then you may want to do a more complex study compared to a simple study. 
 
 

Swapna: In the majority of people, I would say that home wearables are fine to use. But it's just having that knowledge of actually that patient may have something else that's not quite as straightforward as sleep apnoea going on, and do I want a bit more [00:07:00] information to understand what's happening in that patient? 
 
 

Charlie: And then obviously those results are assessed. And within your team, who is assessing the results and interpreting them? 
 
 

Swapna: I'm very lucky. I've got a great team of allied health professionals, physiologists, nurses, physiotherapists and assistant technical officers, and they all contribute to supporting the reporting process. You may know that we have to report to DM01, so that's a criteria where you have to report a sleep study within six weeks. 
 
 

Swapna: So everybody has to work hard at that. But as a consultant team, we also support with reporting studies. So everybody's looking at it, and we use it as a learning opportunity as well to again talk about complex cases 
 
 

Charlie: And it sounds like what you've then got is kind of a diverging pathway after that, where some people where it's very obvious what the diagnosis is will go straight to a treatment pathway, where the others will come for further assessment. 
 
 

Swapna: Exactly. Yep, that's right. So if you need more tests like a capillary blood gas or some [00:08:00] lung function testing, then we would do that first, versus those who could go straight onto treatment for their sleep apnoea. 
 
 

Charlie: Okay. And how do you run your treatment? 'Cause I've seen so many different evolutions in the way, predominantly CPAP, from group starts to all sorts of different ways of delivering this, as you say, to try and improve that, reduce that time, not just to diagnosis, but to treatment. 
 
 

Swapna: Yeah, so the pandemic taught us something, didn't it? It taught us that we had to look at things in a different way. And we, like many other services I'm sure, came out of the pandemic with quite a big backlog of patients who needed treatment. And actually, I was just presenting this last week. 
 
 

Swapna: So we had a very common setup that many other places did, one-to-one setups with a member of the team and the patient. We had been doing small group setups prior to the pandemic, but that all stopped due to CPAP being considered an aerosol generating procedure. 
 
 

Swapna: But we started doing them again because we had this backlog that we needed to get over, and we started off with [00:09:00] very small groups of six, progressed to 20, progressed to 40, progressed to 75. And so we're now doing big group setups where we're setting up 150 patients on CPAP in one day, which is great fun for us as a team and really satisfying to be able to do that. 
 
 

Charlie: I've got this vision of you kind of in a big lecture theatre with 150 patients. Yeah. But equally, it's telling everyone everything they need to know in one go. And actually, I don't know what your patient feedback says, but there's kind of a peer support thing there, isn't it? 
 
 

Charlie: Of I'm not alone, there's all these other people, and everybody else is going through this with me, and that's always a good thing for patients, isn't it? To feel like they're part of a group or a cohort of people going through something together. 
 
 

Swapna: Yeah, absolutely. The feedback has been really positive about these setups and there've definitely been some bromances that have come out of because they're, big groups of people sitting near each other and talking about what symptoms they had and, laughing about the mask. 
 
 

Swapna: It, it's really [00:10:00] great for some individuals. 
 
 

Charlie: Oh, yeah. And I was gonna say, I can just imagine the bromances and the kind of "No, you can do it. Come on." Let's do it together." It takes the fear factor away, doesn't it, a little bit as well, when you can see other people going through it. 'Cause no matter how 
 
 

Charlie: good CPAP is, the first time that someone puts a mask on your face, it is always gonna feel strange and alien, isn't it? 
 
 

Swapna: Yeah. It's hard. Again, if you take that pandemic comparison, we all had to get used to wearing masks everywhere, didn't we? And I don't think anybody particularly liked it, but it's something you get used to over time. But yes, your first experience, even in the acute inpatient setting when you're setting patients up on NIV, that first attempt is so key. 
 
 

Charlie: Yeah. 'Cause it's just an odd thing to put on your face, isn't it? And then to feel pressure with it and it's just your part of your brain will automatically go, "No, this doesn't feel right." And the analogies are so funny. I've had people say to me, "It feels like I'm sticking my head out of a window or going scuba diving." 
 
 

Charlie: Just different things because it's just the sensation, isn't it? [00:11:00] But I still remember the number of sleep clinics where people then come back down the line, and they were hugging their CPAP machines and going, "You're not gonna take this away. I need it." Because it's transformative, isn't it, as a treatment? 
 
 

Charlie: Because it works so well for the vast majority of people, how do you follow those people up? So they get set up in their big group of 150. How do they then get followed up, or how often do you see them? 
 
 

Swapna: That sort of depends a little bit on the patient. We have some early telephone calls or check-in their data. The great thing is now all of these devices have modems in them, so we're getting a wealth of data coming back to us. So they have some early check-ins just to see how they're getting on with it and some phone calls. 
 
 

Swapna: As a consultant, we often don't see these patients until quite a time later because members of the allied health professional team will be seeing them. In between there may be some mask changes, there may be, that encouragement, just trying to inch it up [00:12:00] or, maybe you need a humidifier to get over the dryness that you're experiencing. 
 
 

Swapna: The, all the, that sort of early troubleshooting that the team do. And then, some people, as you say, take to it like a duck to water and you don't need to worry about them and we've developed our own form of patient-initiated follow-up for those individuals. 
 
 

Swapna: Other people it's useful just to keep an eye on them a bit more regularly. I mean, sadly it cannot be as regularly as we like, but again, we've got the data coming through so we can bring them in sooner if we need to. But we see them a bit more regularly just to make sure they're getting the right support and they're not- Drifting downwards in terms of their CPAP use. 
 
 

Swapna: Many of the patients who are asymptomatic may have been nudged into my door by bed partners and therefore don't have much in the way of symptoms themselves, putting on what they perceive as this horrible mask can be a little bit of a challenge for them. 
 
 

Swapna: And so if they're not deriving any benefit, it's difficult for them to use a device that they're not seeing any physical benefit, although we know it's benefiting them in the long [00:13:00] term. 
 
 

Charlie: Yeah. A-and that's just that reassurance, isn't it? And engagement with the team to say, "Stick with it, let's look out for what your symptoms..." 'Cause they probably have symptoms, they just may not realize them, and obviously, their partners may well be very strongly encouraging them, saying, "This is definitely better. 
 
 

Charlie: I'm getting some sleep myself." So they're often helpful. A-and then in terms of one of the reasons that we were talking today was we were-- there's the new position statement around OSA and particularly one of the things that I remember very vividly from my sleep clinics is people worrying about driving and the DVLA, and particularly people where driving is their life or part of their job. 
 
 

Charlie: What do patients have to do in regard to notifying the DVLA? And what is the latest update now changing things for people with sleep disorders, breathing, and OSA? 
 
 

Swapna: It used to be quite fuzzy, didn't it? You had this diagnosis of OSA. Should the patient be told to tell the DVLA? Should they be allowed to drive? It was a little bit difficult for both patients and clinicians to know [00:14:00] what to do. With the updates, what has happened is there's been a shift away from just having a diagnosis of sleep apnea to having a focus on whether the sleep apnea is causing them symptoms. 
 
 

Swapna: So are they excessively sleepy during the day, and is that therefore impacting their driving? So that's the real importance now. It's do they have OSA syndrome, OSAS, so 
 
 

Swapna: OSA with excessive daytime sleepiness. And so if you have moderate to severe obstructive sleep apnea with excessive daytime sleepiness you need to report to the DVLA. 
 
 

Swapna: The patient needs to report to the DVLA. So that's an important fact there. It's not on the clinician to do the reporting. We have to advise the patient to do the reporting. And they don't need to stop driving unless their condition isn't controlled within three months. So it's just about [00:15:00] informing the DVLA. 
 
 

Swapna: The other useful thing that's happened is that there used to be a multitude of forms available for patients. There's now just one form which you can either print off or do online, and there's a filter question on it. And that's where it's really important that as clinicians we're giving the right advice. 
 
 

Swapna: And the filter question is Does your condition cause you excessive sleepiness? And if you answer no to that, you don't need to fill in any more of the form as a patient. 
 
 

Charlie: Yes, which is much better. 
 
 

Swapna: Exactly. So - then also the DVLA is not being inundated with lots of patients that don't need to complete forms and we don't need to complete forms for patients that are not sleepy. 
 
 

Swapna: I used to spend a lot of time on DVLA forms writing not sleepy on them because poor patients had reported themselves when they didn't need to 
 
 

Charlie: Yes. And then there were definitely patients who were kind of there going I'm not really sleepy. Am I sleepy?" And, they're very honest patients, aren't they? And then they get [00:16:00] themselves in a pickle going... So having that kind of filter of I am or I'm not is quite helpful for them, isn't it? 
 
 

Charlie: Rather than writing lots of things on a form of on a Tuesday, if I did this..." That, 'cause patients are lovely, aren't they? And they want to be honest with people like the DVLA. 
 
 

Swapna: Yeah. 
 
 

Charlie: . So that is definitely a step forward and feels a lot more intuitive and streamlined for both sides. In terms of the changes, obviously, some of that is just to make it easier, for everybody that's involved. 
 
 

Charlie: Were there other reasons why they've made these changes, or was it just about trying to improve the process for everybody? 
 
 

Swapna: As I said, the DVLA were probably overwhelmed by the number of referrals coming in or reports coming in. And the other thing to comment on is that the differentiation between those of us who just have a regular license to those professional drivers who might be driving in an HGV, and actually we want to be able to prioritize those patients not only for treatment, et cetera, but also to make sure that we're not stopping their livelihoods. 
 
 

Swapna: That often has in the past stopped patients from seeking [00:17:00] a diagnosis because they're worried that their license is going to be taken away from them. And also I think, there used to be a whole host of forms and even as the clinical team, we used to get slightly differing forms from the DVLA to complete, and it was a little bit confusing. 
 
 

Swapna: But there's now one form that captures all conditions. And it's the same for clinicians. There's one form. So I think it's about streamlining and digitizing the process and helping reduce that delay in letting patients know whether or not they can drive. 
 
 

Charlie: Okay. And so for us, when we're seeing those patients, what we just need to do is direct them essentially to the DVLA website, follow the appropriate links Answer the filter question. Fabulous. And is there some clear guidance or websites out there for patients that's accessible information for them? 
 
 

Charlie: Because you say to try and support them with coming forward if they think they've got symptoms. 
 
 

Swapna: Yep. So the DVLA themselves obviously have a lot of information on the website. It's one of the U-u.gov websites that will take you to that if you [00:18:00] Google DVLA sleep apnea, it comes up. But there's also patient-focused websites. So for example SATA, the Sleep Apnea Trust Association, have a lot of information on their website or Hope to Sleep. 
 
 

Swapna: They're great charities that support patients with this aspect. They can always contact their clinical team. But it's important when we're seeing patients and writing letters after a clinic appointment that we're just really clear with that process. This patient has OSA with or without excessive sleepiness that's affecting their driving. 
 
 

Charlie: Okay. And that makes it easy for them, doesn't it, to answer the questions? And do you think, obviously, podcast is part of it, but it's helpful for us to get that out to primary care as well in terms of ensuring that those referrals still come in for those patients because the benefits are big, aren't they, of treatment? 
 
 

Swapna: Yes. I mean, the data out there for sleep apnea is huge. And whilst there is always contrary data when you look hard enough and there have been some big studies. But you know, there is definitely a [00:19:00] link between sleep apnea and cardiovascular disease, cerebrovascular disease, metabolic disease. 
 
 

Swapna: So the benefit is not just being able to treat the patients and help their symptom burden, but it's also about future risk 
 
 

Charlie: I think that's probably something that unless you work in I guess, in sleep clinic, it's a world that's evolved so much, hasn't it, over the years, and our understanding of it has evolved, and as you say, the understanding of the symptoms and the other things has evolved as well. Where do you think we're going in the world of sleep apnea at the moment? 
 
 

Charlie: 'Cause clearly this is, different even from when I was a registrar. Things are much more streamlined. We're doing it much more efficiently and in a very patient-focused manner. Where are we going next, do you think? 
 
 

Swapna: I think sleep medicine is entering that era of personalized medicine, which is really exciting for those of us that are in it. There are drug treatments that are going to come out soon and that's great because that's the question that all patients ask me, "Isn't there a tablet that I can take or something else?" 
 
 

Swapna: There are other options for [00:20:00] treatment that are advocated by NICE. So for example, mandibular advancement devices. There's hypoglossal nerve stimulation for a subset of patients. But yeah, the precision medicine thing is really interesting. We've got a little bit of a way to go in order to be able to endotype patients so to understand what their pathophysiological process is that's causing their sleep apnea. 
 
 

Swapna: But once we can do that easily, we'll be able to hopefully say, "Hello, Mr. Bloggs. You have this type of sleep apnea, therefore we can recommend this treatment for you," rather than going to everybody, "Actually, we have to give you CPAP because we know that's what works, and that's the treatment we have in our armory." 
 
 

Charlie: And this is-- I think it's just the whole shift of respiratory medicine, isn't it? It's going that way towards that very personalized precision medicine and trying to help the individual in front of you as to what the - risk factors are. Yeah. So it's really interesting, isn't it? 
 
 

Charlie: And I think sleep and ventilation as a specialty has come into its own really over the past few years, hasn't it? Of [00:21:00] something that, trainees are actually coming to us going, "I really want to do sleep ventilation. It's really interesting. There's trials and other things." Rather than there's poor me going, "Oh, crikey, I much prefer sputum. 
 
 

Charlie: If I have a choice, I'll take the sputum over the snoring." But you know, I'm aware that I'm a bit strange. But - are you seeing that? Are you seeing more interest coming through from our more junior colleagues? Particularly, you've also seen a massive expansion of the team, haven't you, involved in sleep medicine? 
 
 

Swapna: Yeah, I think so. I think as you say, respiratory medicine has become, like a lot of other specialties, has become super specialized now. I don't ask me about sputum. I don't know about it. But ask me anything you like about sleep and ventilation. Yeah, I think people are understanding that it's really important and again, that actually there's so much we can do for patients now. 
 
 

Swapna: We can be so nuanced in some aspects of the care and how we deliver it and it is very exciting. Newer modes or different modes of ventilation are coming out different CPAP devices. There's lots of areas to work in, and the direct [00:22:00] team, yes, has grown, but actually it's become much more of a multidisciplinary... 
 
 

Swapna: I mean, it always has been a multidisciplinary team, but I think, lots of respiratory sleep clinics are seeing the benefit of working with their ENT colleagues, for example. We probably - in the future do need to think about also working with our neurology colleagues and thinking about the psychological aspects of sleep. 
 
 

Charlie: I mean, sleep is fascinating, isn't it? Once you start digging into it and you do, as you say, within the, your more standard referrals, there's always those slightly odd, as you say, more neurological ones where people are coming through with parasomnias or very disturbed sleep and trying to unpick some of those more complex patients is really challenging, but also really interesting, isn't it? 
 
 

Charlie: 'Cause sleep's so important to all of us in terms of our day-to-day life and wellbeing. 
 
 

Swapna: Yeah. I mean, we all know if you don't have a good night's sleep or you're traveling and if you're jet-lagged, I mean, it makes it really hard for you to function the next day, doesn't it? And so these poor patients with sleep apnea and other sleep disorders that are basically chronically sleep [00:23:00] deprived because they're not getting good quality, restful sleep it is horrendous. 
 
 

Swapna: And actually, if we as clinicians can manage these patients a bit more holistically and, point them in the right direction, even if they don't have sleep apnea but they might have poor sleep hygiene or insomnia, that's a really important thing for us to do. 
 
 

Charlie: Do you think we ask about sleep enough? When we see those people with those non-specific symptoms, do you think it's somehow low down our list of things we ask about? Is that why some of those patients take time to come to you? 
 
 

Swapna: I think that definitely used to be the case. I think there's increasing recognition even within other areas of respiratory medicine. We know patients with COPD have often poor sleep quality, and is that due to their COPD or is it due to something else that's undiagnosed? So I think we're getting better at asking it. 
 
 

Swapna: I think patients are getting better actually. They're more cognizant of sleep issues. And again, I think that has been something that's come out of COVID a little bit to some degree. I mean, lots more [00:24:00] people are wearing commercial wearable tech. And so we do get a lot of my Apple Watch says this. 
 
 

Swapna: I'm worried about this on my sleep efficiency. So I think that's a good thing, actually. If I had my way, everybody should have a sleep test, but that's not going to be possible. So I think it is definitely something that's increasingly recognised by both clinicians and patients. 
 
 

Charlie: Yeah. As you say, there is a lot of public conversation, isn't there, around my sleep quality and what am I doing, and sleep hygiene and you can hear that in other podcasts which are not medical related, but people are talking about those kind of things because of the wearable tech and the different things that are out there. 
 
 

Charlie: I guess the awareness has changed, hasn't it? Which is brilliant, but it also means that's why you've got to start a hundred and fifty people in one go 
 
 

Swapna: Yes. 
 
 

Charlie: many people coming 
 
 

Swapna: Yeah, definitely. 
 
 

Charlie: I think it's great, and I think the new position statement is really good, and I think it's good that it's just triggered a general conversation for us about sleep, and it's really feels like we're going in the right [00:25:00] direction to be patient-focused with that and to support them with managing their disease, but also living their lives and all of those other things. 
 
 

Charlie: If you had one take-home message to take from people from the podcast today around sleep, driving, sleep medicine, what would that take-home message be? 
 
 

Swapna: I think the first thing is to just stop and think because what you say to the patient is going to impact their life potentially. So I think it's don't panic. It's not they have sleep apnea, they must report. It's let's think this through logically. Just take that 30 seconds. Do they have the excessive sleepiness? 
 
 

Swapna: Is it affecting their driving? If not, they don't need to report. And if they do need to report, reassure the patient, support them in the best way you can and just make sure they know that as long as they stick to treatment, they're going to be fine. The DVLA, I don't think want to take away patients' licenses. 
 
 

Swapna: They want to keep people in employment and all of that stuff. This system is to support [00:26:00] patients to continue what they're doing, but hopefully in a more healthy way. 
 
 

Charlie: And that's a great summary. And thank you so much for joining us. It's been lovely to speaking with you and think about this in the round. And I was having a little look pre-podcast at our Respiratory Futures. We've got a lovely website page on the position statement and some links to some of the places that you've mentioned. 
 
 

Charlie: So if any of the listeners want to look, please go and have a look at that. And we always ask our listeners, that if anybody wants to let us know about anything or any suggestions for future podcasts or any feedback, do get in contact with us podcast@respiratoryfutures.org.uk. 
 
 

Charlie: Next month we'll be back to think about more latest developments in respiratory medicine. And hopefully I won't talk about sputum too much to too many people. I seem to drop it into every podcast. But it's brilliant for me. 
 
 

Charlie: I love talking to all the different experts in respiratory medicine. So we're always keen to hear people's thoughts about what they want to hear about. See you all next month. Thank you for joining us.