4 July 2018
In my specialty, respiratory and sleep medicine, I think one of the biggest shifts since the NHS came into being, is we know more about the importance of sleep and how it affects breathing disorders.
People used to believe time spent sleeping was time wasted. But over the last few decades we have come to a much better understanding of how important sleep is to our physical and mental wellbeing.
Lack of sleep may be associated with an increased risk of heart disease, diabetes, obesity and even dementia; and respiratory sleep disorders are common.
At the Royal Brompton Centre for Sleep, we deal with problems across the spectrum – from snoring and sleep apnoea to a range of intrinsic sleep disorders: narcolepsy, restless leg syndrome, benign idiopathic hypersomnolence (excessive sleepiness), sleep walking and talking, even sleep eating disorder – right through to treating people who have serious health conditions which affect their lungs and may cause them to stop breathing or under-breathe in their sleep.
Improving life for respiratory patients
I started my career as a respiratory physician, dealing with very ill patients who were struggling to breathe, especially at night.
If I had to pick out what I am most proud of being involved in, using non-invasive ventilation to improve patients’ lives would be the most rewarding one.
Many people who have a problem with their breathing muscles, due to muscular dystrophies and myopathies will find things are always worse a night when muscle function is further reduced. This is also the case in those with other severe chronic disorders such as COPD (Chronic Obstructive Pulmonary Disease) or motor neurone disease.
Before non-invasive ventilation, the only option for someone requiring extra breathing support was to be hooked up to an intensive care ventilator via a tracheostomy, and often they died prematurely.
Now with small portable non-invasive ventilators which patients can use during the night at home, we can reduce hospital admissions, improve patients’ quality of life and, for many disorders, extend their life expectancy
At Royal Brompton Hospital, we were the first team in the UK to use non-invasive ventilation in children with inherited neuromuscular disorders, and published these results in 2000.
Nearly 500 of these youngsters are now transitioning to adult care whereas previously most died of respiratory failure in childhood.
The work we have done at Royal Brompton has had an impact that has gone far beyond just our patients. It has influenced the way patients all over the world are cared for.
Outreach to share knowledge
In the last 70 years and certainly over the course my own career, there has been a big change in the way patients are cared for. Instead of everything being done at the hospital, we now have a key outreach team.
Sharing knowledge is extremely important to us, and we’ve helped a number of hospitals set up their own non-invasive ventilation service now there are lots of hospitals that care for patients who need non-invasive ventilation. And in many cases, patients can use non-invasive ventilation at home, and we can help with starting this.
We also work with colleagues in district hospitals to help wean patients off ventilators who are ‘stuck’ on ventilators in intensive care units (ICU).
A hypothetical example could be a patient in another hospital with a tracheostomy who’d had jaw surgery; he was doing well but he couldn’t be managed on a general ward without ventilatory support. We would work with the surgical team to arrange this help, thereby freeing up a bed in their ICU. The patient is happier and can progress with his recovery faster.
It helps that we have a very strong allied healthcare team: it used to be very top down before: consultants, junior doctors, nurses. Now we have a consultant physiotherapist, hospital practitioner (this is a doctor with a similar skillset to a GP, but who works in a hospital setting), and a consultant nurse who runs the outreach work.
We have clinical physiologists who analyse the detailed sleep studies and set these up. It’s become a much more dynamic, multidisciplinary specialty in recent years – and without doubt an improvement on times gone by.
Our sleep centre
When people have a sleep issue, sometimes it’s not always clear what the problem is. This is where our dedicated sleep centre which opened in 2013 comes into its own.
Our comfortable rooms allow us to run respiratory sleep studies, detailed polysomnography studies - where brain waves, oxygen level in the blood, heart rate and breathing, eye and leg movements are all recorded –and assessment of sleepiness along with sleep-wake activity tests (actigraphy). We can do home sleep studies too.
Obstructive sleep apnoea, for example is a really common problem. It happens when the muscles and soft tissues in the throat relax during sleep blocking the airway. The lack of oxygen triggers the brain to either wake up or to shift into a lighter sleep.
As you would expect, these individuals feel very tired during the day. However, they usually have no memory of interrupted breathing, and may be unaware of a problem, apart from feeling sleepy.
Being tired is only one of the associated problems. Those with sleep apnoea may be more at risk of high blood pressure, vascular problems and diabetes.
We can help with a continuous positive airway pressure (CPAP) device which was first introduced in the 1980s to 90s. These devices prevent the airway closing and deliver a continuous supply of pressurised air through a well-fitting mask.
In a more recent development, for the last few years we have been able to tell how patients are doing at home using remote information from telemonitoring, making this highly convenient.
Each morning via a remote server, the patients’ CPAP machine sends us the data, which means we can check that patients are using the equipment correctly, remotely adjust the pressure setting as needed and ask the patient if they’re experiencing any problems –it’s extremely useful.
Our research projects on sleep and ventilation over the last 10 years have included assessing the benefit of CPAP therapy in elderly patients with sleep apnoea, treating central sleep heart failure (a disorder that occurs during sleep when your brain isn't signalling your muscles to breathe) in heart failure patients and examining the impact of non-invasive ventilation in those with neuromuscular disease and COPD.
We have been able to translate all these results into clinical practice which has rewarding for our patients and families, as well as our team!