A Sentinel For Sleeping Disorders

With increasing cases of sleep disorders in the country, sleep labs are fast gaining currency in the healthcare industry, reports Jayata Sharma

A patient undergoing polysomnography at the sleep lab of Mumbai's Hinduja Hospital

This is just one example of a single sleep disorder among the 200 prevalent types. Experts say that almost 50 per cent of the Indian population is at the risk of sleep disorders at any given time. And about 12-15 per cent of the Indian adult population right now is suffering from at least one sleep disorder. This is not just data, but a concern for the growing Indian population.

Studies Say

According to a significant study conducted on 700 patients between 35-65 years of age who came to PD Hinduja Hospital, Mumbai, in 2000 for regular health check-ups, eight per cent were found to be suffering from OSA. "This survey, which is the only study on sleep disorder in India, revealed that OSA was most likely among urban men weighing up to 75-80 kg and with collar size of more than 17 inches," states Dr Zarir Udwadia, Head, Pulmonary Department, Hinduja Hospital, Mumbai, who conducted the study.

Another study conducted in Brisbane, Australia, amongst Asians, found that the Indians are at the highest risk of developing sleep disorders, worldwide. The reason? The changing lifestyle of an average Indian, and rising standards of living have resulted in less exercise, more junk food, high stress levels and obesity, all leading to sleep disorders. "Additionally, the respiratory track of Indians is narrower than many people around the world. This is a genetic factor and cannot be reversed," explains Dr Ajit Vigg, Consultant Chest Physician, Breathe Easy Clinic, Apollo Hospital, Hyderabad. Dr Vigg started a sleep lab way back in 1992 at his clinic in Hyderabad called Institute of Sleep Medicine.

However, according to Dr Issac Mathew, Consultant Pulmonologist, Manipal Hospital, Bangalore, "The genetic factors contributing to this are a meagre 0.5 per cent. Most of the cases of sleep turmoil are due to lifestyle changes and obesity."

Who Suffers From Sleep Disorders?

Sleep disorders need not be only due to obesity and cannot be judged only by the body mass index (BMI). Any person who chokes during his sleep due to breathlessness, feels restless all the time, keeps tossing in the bed, and feels sleepy throughout the day, and has heroic snores (which can be heard outside a closed room) is at risk of developing sleep disorders. If doctors have such patients visiting them, they should immediately direct the patient to get tested in a sleep lab, say experts. "Diagnosing and treatment of sleep disorders is utmost important, as this is the gate way to larger problems", says Dr Mathew.

"In many parts of the world, sleep medicine is part of respiratory medicine and pulmonologists are also treating patients," says Dr RK Mani, Director, Department of Pulmonology-Thoracic Surgery and Chief, Medical Intensive Care, Fortis Hospital, New Delhi. Dr Mani had set up a sleep lab in 1996 at New Delhi's Batra Hospital. At present, he sees about 15-20 patients every month.

Why Sleep Labs?

Sleep labs diagnose sleep disorders like OSA, central sleep apnoea, mixed sleep apnoea (combination of obstructive and central), restless leg syndrome, insomnia, narcolepsy and many more. In narcolepsy, a condition most prevalent in children, kids while laughing, playing or involved in other activities, suddenly fall asleep to wake up after a few seconds. "Narcolepsy is a problem which can be totally erased out of a child's life. Sleep labs help in finding the exact reason for this disease," says Vigg.

Sleep apnoea is another common sleep disorder, and OSA is the most common form of it, worldwide and in India too. It is a condition wherein a person stops breathing for 10-100 seconds at a stretch during his/her sleep. Then he wakes up choking and gasping for air. In many cases, it can also lead to sudden death.

These disorders, if left undiagnosed and untreated, can create havoc in a persons' life. The health hazards associated with sleep disorders are: heart attacks, strokes, hypertension, diabetes, and many more cardiovascular and neuromuscular problems. "Interestingly, men above 40 are more susceptible to sleep disorders, though menopausal women also become vulnerable," cautions Dr Manvir Bhatia, Senior Consultant, Neurophysiology and Chairperson of Sleep Medicine at Sir Ganga Ram Hospital, New Delhi. Dr Bhatia had set up a sleep lab at AIIMS, New Delhi in 1997. She used to see about 16 patients per month till 2003, but now about 30 patients per month flock to her for various sleep disorders. The growing number is an indication that sleep disorders are on the rise in the country.

How Sleep Labs Function

Sleep study is a process where, the patient, for two consecutive nights, has to sleep without any sedative. On the first night, a trained technician studies the nasal flow, the loudness of snores, pulse rate, heartbeat, respiratory function, chest movement, leg movement, the abdomen movement and oxygen saturation. This is done by attaching sensors to the head, face, chest, abdomen and legs, and is executed with the help of polysomnograph monitors. Polysomnography, the gold standard for diagnosing sleep disorders, was discovered by an Australian professor, Colin Sullivan about 25 years back.

"In patients of sleep disorders, oxygen saturation can drop down to 50-80 per cent, which is life threatening" - Dr KK Ramalingam Founder of KKR ENT Hospital Chennai

Normally, oxygen saturation is at 100 per cent. "In patients of sleep disorders, the level can drop down to 50-80 per cent, which is life threatening," warns Dr KK Ramalingam, Neurosurgeon and Founder of KKR ENT Hospital, Chennai.

The next morning, the referring physician will receive a complete computerised sleep report, which defines and diagnoses the sleep disorder. According to the type of problem detected, the treatment is designed for the patient. "There is no permanent cure for OSA, but research is still on to find out alternate, non-surgical cures," informs Dr Udwadia.

After monitoring the severity of the patient's problem the next night, air pressures are adjusted in the Continuous Positive Airway Pressure (C-PAP) equipment to see how it works on him. Later, the patient has to buy the C-PAP costing from Rs 30,000 to Rs 45,000, depending on specifications. "The best part about this method is that it does not involve any kind of surgery," says Dr Udwadia. An average 20-25 per cent of new users of C-PAP are found each year in India.

Is a C-PAP the only solution for sleep disorders? No. "The other way out is to exercise and lose weight," says Dr Ramalingam. "In addition, one needs to abandon junk food, quit smoking and alcohol," suggests Dr Vigg.

What A Sleep Lab Consists Of

There can be different types of specifications for a sleep lab. Sleep labs can consist of 4, 16, 18 or 24-channel polysomnograms. The important features of a sleep lab are Electroocugram (EOG), Electroencephalogram (EEG) and Electromyogram (EMG). The EEG monitors the brain, EOG is for monitoring eye movements, and the EMG is to monitor muscle movements. Besides, hospitals can have additional features, like auxiliary sensors, chest bands, abdominal bands, pulse oxymeter and many more.

A sleep lab should ideally consist of two adjoining rooms. If not two rooms, a separate cubicle for the technician should be arranged. The patients must be monitored for the whole night wherein he/she should sleep for a minimum of seven hours. The cost of setting up a sleep lab ranges from Rs 10 to Rs 25 lakh, depending on the number of channels installed.

Why The Concept Remains Unknown

Sleep labs have existed in India for almost 14 years now. However, the concept has still not picked up pace. Many doctors are still ill-informed about this condition. Why? Earlier, the MBBS curriculum did not include sleep disorders. Like the lay person, doctors too thought this was not a major problem. "In addition, numerous doctors are unaware of the concept as they do not keep themselves abreast of the latest findings and techniques in the field of medicine," laments Dr Udwadia.

"Awareness level about sleep disorder is abysmally low in the country" - Dr RK Mani Fortis Hospital New Delhi

But with growing awareness amongst patients, mainly due to communication tools like the Internet, the concept has come into the limelight. Currently, all metropolitan cities of India are equipped with sleep labs. "The concept is yet to bloom though, as no steps are taken to spread awareness on a large scale," avers Dr Ramalingam, whose hospital receives around 30 patients every month for diagnosing various sleep disorders. "Since the awareness level is abysmally low in the country, we pick up patients based on symptoms," says Dr Mani.

Looking Ahead

Even as the concept is slowly coming into focus, the point of concern is dearth of trained staff to handle sleep labs. "It is imperative to have trained people who would record and interpret data and give logical prognosis," says Dr Bhatia. This is important as any permanent cure for sleep disorder is not visible in the near future. "It will take another two decades for a permanent non-surgical solution to be discovered," feels Dr Udwadia.

Right now, the only preventive and curative measure is to keep body weight under control and indulge in regular exercise. Else, the day is not far when India, which has become the diabetes capital, will become the hub for sleep disorders too.

With inputs from Sapna Dogra, New Delhi
jayata@expresshealthcaremgmt.com