Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4566_Библиотеки_им_академика_М_И_Перельмана
.pdf
Circadian disorders
https://t.me/medicina_free
ISWRD is mainly observed in children with neurodevelopmental delays and/or
disorders, or in adults with neurodegenerative diseases. The prevalence of ISWRD
is not known as it frequently occurs with other disorders and there is a lack of
clear-cut diagnostic criteria. Sleep periods of <4 h are typical. Patients are oen
unable to sleep at desired rest times and extremely sleepy at required wake times,
rendering participation in a regular day–night routine impossible. In the treatment
of children and adolescents, the use of melatonin is recommended in addition to
behaviour-modifying measures. In the elderly, the use of light in combination with
physical activity has shown moderate eects. The use of melatonin is currently not
recommended for older people. Unfortunately, to date, not many representative
studies conducted under comparable diagnostic and quality criteria are available, so
clear recommendations regarding the therapy are lacking.
Non-24-h sleep–wake rhythm disorder
Non-24-h sleep–wake rhythm disorder (N24SWRD) is a rare condition and occurs
almost exclusively in people who are completely blind. Rarely, this disorder can also occur
in sighted people; in this case, it is usually caused by a lack of or insucient exposure to
external zeitgebers, especially light. N24SWRD probably occurs in 50–80% of completely
blind people. The lack of synchronisation of the intrinsic circadian rhythm, which usually
does not correspond to the 24-h rhythm but is somewhat longer, and the lack of
external clocks, especially light, lead to recurring nocturnal insomnia and severe daytime
sleepiness. This can be explained by a successive phase shi leading to a slow shi of
the sleep–wake phases. The intrinsic sleep phase is thus recurrently found in the social
daytime. The phases of insomnia and daytime sleepiness are interrupted by phases with
no or few complaints as the intrinsic sleep phase is in the night-time. For the diagnosis
of N24SWRD, actigraphy monitoring over at least 14 days, and preferably longer, is
necessary and should ideally be carried out without involvement in social or professional
schedules. Therapeutically, chronobiotic agents are used (melatonin, tasimelteon). In
addition, regular external clocks (e.g. meals, sporting activity) can be implemented.
Shi work disorder and jet lag disorder
Both shi work disorder and jet lag disorder involve a mismatch of the endogenous
circadian rhythm with external conditions. To be diagnosed with shi work disorder,
patients must complain of excessively disturbed sleep, which may be associated with
daytime sleepiness or daytime fatigue and occur in a temporal relationship to shi work.
Representative epidemiological studies on the prevalence of shi work disorder are
lacking, but it can be assumed that the risk of shi work disorder is significantly increased
in people who regularly work night shis. For diagnosis, sleep diaries and actigraphy
monitoring over at least 14 days should be undertaken. Treatment includes behavioural
therapy (including cognitive behavioural therapy for insomnia (CBT-I)), behaviourmodifying measures (bedtime, rest, darkness), light therapy, and daytime sleep episodes,
as well as drug treatments such as melatonin, sleep-inducing and stimulant medications.
Jet lag is a short-term disturbance of the sleep–wake rhythm. It occurs aer flights
over at least two time zones and manifests clinically as insomnia and sleepiness. The
diagnosis can be made clinically by anamnesis. Adaptation to a new time zone takes
dierent lengths of time for dierent individuals and may also be accompanied by
gastrointestinal and other physical symptoms. Therapy is only necessary in rare cases;
light and melatonin are used.
In cases of only a short stay (<2 days) at a western destination (>2 time zones), keeping
the sleeping times of the place of origin can be helpful.
334
ERS Handbook: Respiratory Sleep Medicine
Circadian disorders
https://t.me/medicina_free
Further reading
• Abbott SM, et al. (2015). Circadian rhythm sleep-wake disorders. Psychiatr Clin N Am; 38:
805–823.
• American Academy of Sleep Medicine (2014). The International Classification of Sleep Disorders:
Diagnostic and Coding Manual. 3rd Edn. Darien, American Academy of Sleep Medicine.
• Lockley SW, et al. (2015). Tasimelteon for non-24-hour sleep-wake disorder in totally blind
people (SET and RESET): two multicentre, randomised, double-masked, placebo-controlled
phase 3 trials. Lancet; 386: 1754–1764.
• Malkani RG, et al. (2018). Diagnostic and treatment challenges of sighted non-24-hour sleep-
wake disorder. J Clin Sleep Med; 14: 603–613.
• Morgenthaler TI, et al. (2007). Practice parameters for the clinical evaluation and treatment
of circadian rhythm sleep disorders. An American Academy of Sleep Medicine report. Sleep;
30: 1445–1459.
• Reid KJ, et al. (2015). Jet lag and shi work disorder. Sleep Med Clin; 10: 523–535.
• Roenneberg T, et al. (2007). Epidemiology of the human circadian clock. Sleep Med Rev; 11:
429–438.
• Steele TA, et al. (2021). Circadian rhythm sleep-wake disorders: a contemporary review of
neurobiology, treatment, and dysregulation in neurodegenerative disease. Neurotherapeutics;
18: 53–74.
• Uchiyama M, et al. (2015). Non-24-hour sleep-wake rhythm disorder in sighted and blind
patients. Sleep Med Clin; 10: 495–516.
• Zee PC, et al. (2009). Circadian rhythm sleep disorder: irregular sleep wake rhythm type. Sleep
Med Clin; 4: 213–218.
• Zee PC, et al. (2020). Circadian rhythm sleep-wake disorders. Continuum (Minneapolis, Minn);
26: 988–1002.
335ERS Handbook: Respiratory Sleep Medicine
The medico-legal and
https://t.me/medicina_free
socioeconomic impact of
respiratory sleep disorders
Maria R. Bonsignore, Francesco Fanfulla and Sergio Garbarino
Medico-legal implications
OSA is associated with poor sleep quality and impaired daytime performance. As
such, it carries an increased risk of motor vehicle accidents (MVAs) or occupational
accidents. Untreated OSA patients show a two- to three-fold increased risk of
MVAs compared with healthy subjects. A high risk of MVAs has traditionally been
associated with EDS, which is reported by about half of OSA patients and improves
on treatment, especially in those who are adherent to treatment. However,
sleepiness at the wheel (SW) should be specifically investigated, as it was found
to better predict MVAs and is associated with a high risk of fatal accidents. SW is
also quite common in non-OSA subjects, as shown by a survey of European drivers
which identified male sex, young age, an annual driving distance of >10 000 km
per year, a higher ESS score (>15) and symptoms of sleep apnoea to be predictors
of SW. Drowsy driving is frequently reported by US drivers and is mainly associated
with insucient sleep.
OSA has also been linked with occupational accidents. Commercial drivers are the
largest population at risk, but some studies have examined other workers, such as
firefighters, train drivers and airline pilots. Data are scarce when we look beyond those
who work in the transportation industry. Data are also limited for MVA risk in women
with OSA, as the majority of studies have been conducted in male drivers.
OSA has been included in the revised Annex III of the European Union (EU) Directive on
Driving Licences, the application of which became mandatory for all Member States
Key points
• Untreated OSA is associated with a high risk of MVAs and occupational
accidents.
• CPAP treatment with good adherence eectively reduces the risk of accidents.
• Untreated OSA is costly – it increases the use of healthcare services, decreases
productivity, and has other associated costs, including those relating to
accidents.
• OSA treatment is cost-eective and produces net savings compared with
untreated OSA.
336
ERS Handbook: Respiratory Sleep Medicine
The medico-legal and socioeconomic impact
https://t.me/medicina_free
from 31 December 2015. The Directive states that patients with suspected OSA
should undergo a sleep study, and sleep physicians must assess compliance to CPAP
treatment and/or resolution of EDS in patients with known, treated OSA, before the
driving license can be issued or renewed. Commercial drivers with OSA are subjected
to assessment every year, while non-commercial drivers undergo assessment every
3 years (as a minimum).
According to data from the World Health Organization (WHO), death rates caused by
MVAs have decreased globally by nearly 13% since 2000, with the greatest decline
seen in Europe (−51%). This can be attributed to greater safety on the road and
improvements in car technology. Behavioural factors may also play a role; for example,
elderly patients with EDS may avoid driving at night, thus reducing the risk of a MVA.
However, real-life global positioning system (GPS)-based recordings of vehicles driven
by elderly patients with mild OSA and no cognitive impairment have shown that OSA
severity is associated with adverse driving behaviour.
SW is reported by ∼40% of OSA patients but is not always associated with subjective
EDS. Near-miss accidents are considered markers of MVA risk, and their occurrence
is predicted by the ESS score, depression, habitual sleep duration and the oxygen
desaturation index (ODI) in OSA patients. However, subjective EDS may not be
referred to or perceived by patients, and evaluation of objective EDS requires timeconsuming tests (discussed further in chapter on 6 of this Handbook, ‘Monitoring
sleep and wakefulness’). When compared with subjects who have a normal sleep
latency (>33 min) at the maintenance of wakefulness test (MWT), the risk of
reporting near-miss episodes or accidents increases by 3.2-fold in subjects with a
sleep latency of 19–33 min, and by over five-fold in subjects with a sleep latency
of <19 min. The risk is particularly high among subjects who do not perceive falling
asleep during the MWT test.
Commercial truck drivers represent a high-risk population due to: increased prevalence
of OSA; high exposure to MVA risk; and oen-insucient sleep. A longitudinal study
in the USA examined the results of a preventive programme oered to truck drivers,
which included free OSA diagnosis and treatment. Drivers with OSA who adhered to
CPAP treatment showed a crash rate similar to that of non-OSA controls; in drivers
with OSA who did not adhere to CPAP treatment, the risk of a serious crash increased
five-fold. In the latter group, a high percentage of drivers le their job. However, privacy
regulations do not allow for warnings concerning potentially dangerous drivers. The
legislation on commercial drivers is a very delicate issue, which must balance public
safety with privacy regulations and economic issues.
Socioeconomic impact
Sleep disorders are common and costly medical problems, which constitute a public
health issue that has been recognised worldwide. Around one third (and perhaps
more) of the population suer from sleep disorders of some kind and/or abnormal
daytime sleepiness. At least 10% of the population is aected by clinically significant
sleep disorders of public health importance, which have a variable impact depending
on many factors, e.g. sex, and socioeconomic and ethnic dierences. Underdiagnosis
and undertreatment of OSA leads to serious health and socioeconomic issues. OSA is
oen associated with comorbidities, such as psychiatric disorders and cardiovascular,
cerebrovascular and respiratory diseases, obesity, diabetes, metabolic syndrome and
endocrine dysfunction. OSA also heavily impacts personal, family and social life, with
negative eects on well-being.
337ERS Handbook: Respiratory Sleep Medicine
The medico-legal and socioeconomic impact
https://t.me/medicina_free
Table 1. Categories of economic cost
Financial costs
Healthcare system services
Hospital services
Out-of-hospital services
CPAP therapy
Medical research
Treatment of conditions attributable to sleep disorders
Productivity losses
Reduced employment
Absenteeism
Presenteeism
Premature mortality
Informal care
Nonmedical cost of accidents
Deadweight loss
Non-financial costs
Loss of quality of life
YLDs
YLLs
#
: where the subject is at work but has a low productivity.
#
Estimating the cost of OSA and its secondary outcomes
Sleep breathing disorders such as OSA and related complications require specific
expenditure for diagnosis and treatment. The financial cost of sleep breathing
disorders is associated with: use of the health system, productivity loss, use of informal
care provisions outside the healthcare system; the nonmedical costs of accidents; and
deadweight losses (table 1).
The health system cost is the expenditure for sleep disorder care and for the
outcomes of sleep disorders. These costs include hospital care, health practitioners,
pharmaceuticals, diagnostic tests, health aids and appliances, aged care, research,
community and public health, and capital and administration.
Productivity losses may arise from reduced employment due to early retirement
or another reason for withdrawal from the workforce; temporary absenteeism;
presenteeism, where the worker is at work but shows a low productivity; and
premature mortality.
Informal care costs are estimated by considering the time spent providing assistance
and support to aected subjects by family and friends, outside the healthcare
system.
The nonmedical costs of accidents include those relating to MVAs and workplace
injuries: legal fees, inquiries about workplace safety, home aids and equipment, respite
care, travel and travel delays, correctional services, vehicles that are unavailable or
being repaired, insurance administration, non-vehicle property damage, and fire and
emergency services.
Deadweight loss deals with the cost of the ineciencies associated with both the tax
levy to finance public services (such as welfare payments and health system costs)
and with the loss of tax revenue (which includes personal income tax, consumption
tax, company tax and state taxes).
338
ERS Handbook: Respiratory Sleep Medicine
The medico-legal and socioeconomic impact
10
OSA cost in billion US$
loss
system
care
accident
https://t.me/medicina_free
Non-financial costs are associated with negative changes to well-being and premature
death (table 1). In particular, they relate to the less tangible costs of reduced quality
of life as result of pain and suering, and premature death measured in terms of
disability-adjusted life years (DALYs). The years of healthy life lost due to disability
(YLDs) are based on the disability weights for OSA and its attributable conditions. The
years of life lost due to premature death (YLLs) are the product of the number of deaths
related to OSA and its attributable conditions, and the standard life expectancy at the
age when death occurred. The sum of the YLDs and the YLLs provides an estimate of
the DALYs lost as a result of sleep disorders.
The economic burden of OSA
Extensive economic data are now available from dierent areas of the world. A report
commissioned by the American Academy of Sleep Medicine (AASM) estimated that
in 2015, the annual economic burden of undiagnosed sleep apnoea among adults
in the USA was ∼US$149.6 billion. The estimated costs include US$86.9 billion
in lost productivity, US$26.2 billion in MVAs and US$6.5 billion in occupational
accidents. Untreated/undiagnosed OSA has an annual cost of US$30 billion, due to
increased healthcare utilisation and medication costs relating to comorbidities and
mental health. In contrast, costs relating to diagnosed OSA include US$0.8 billion
for diagnosis, testing and follow-up, US$6.2 billion for non-surgical treatment
(CPAP and oral appliances) and US$5.4 billion for surgical treatment, with a total
annual cost of US$12.4 billion. Therefore, treatment costs of diagnosed OSA are
∼33% of non-treatment costs, with resulting significant net cost savings.
The economic costs of common sleep disorders, including moderate-to-severe OSA,
insomnia and restless legs syndrome (RLS), were assessed in Australia for the period
2019–2020. The overall cost was estimated to be US$35.4 billion (US$13.1 billion
for OSA, US$13.3 billion for insomnia and US$9.0 billion for ALS). The financial
component was US$10.0 billion, which is equivalent to 0.73% of the Australian gross
domestic product. The nonfinancial cost of US$25.4 billion represents 3.2% of total
burden of disease for the year. The dierent components of costs associated with
untreated OSA are shown in figure 1.
Attributable
Direct
Total
8
6
4
2
0
Deadweight
Figure 1. OSA-associated costs split according to the dierent components. Data from
Streatfeild (2021).
Health
Informal
Non-medical
Productivity Wellbeing
339ERS Handbook: Respiratory Sleep Medicine
The medico-legal and socioeconomic impact
https://t.me/medicina_free
63% of the total health system costs were directly caused by sleep disorders, 13%
were from attributable depression, a further 13% were from workplace injuries, 4%
were from MVAs, 2% were from coronary artery disease, another 2% were from CHF,
1% were from cerebrovascular disease, and a final 1% were from type 2 diabetes. The
health system costs were primarily due to OSA (57%), followed by insomnia (30%)
and RLS (12%).
The economic burden of OSA in the adult population was recently assessed in
Italy using a cost-of-illness analysis, which evaluated the economic cost of 26
clinical conditions found to be significantly influenced by OSA. These conditions
were found to contribute to an economic burden of €10.7–€32.0 billion per year.
Impaired quality of life due to OSA under-treatment was found to be €2.8–€9.0
billion per year. These costs are substantially higher than those currently linked to
the diagnosis and treatment of OSA (€234 million per year). The main contributors
to economic burden are direct healthcare costs, which account for >50% of the
total cost, followed by indirect costs (∼38%) and direct non-healthcare costs (4%).
The total economic burden of OSA in Italy ranges from €13.8 billion per year to
€41.3 billion per year.
An encouraging scenario was noted in a recent Finnish study, which demonstrated
that the increasing prevalence of OSA can be eciently controlled. Despite an overall
increase in primary and secondary care evaluation for sleep apnoea from 1996 to
2018, there was a significant decrease in the societal cost per patient aer a national
revision of diagnostic, treatment and follow-up routines.
Conclusion
OSA represent a significant risk factor for MVAs and occupational accidents. This risk
considerably decreases if patients with severe OSA regularly adhere to treatment.
Commercial drivers represent a group at particularly high risk, but evaluation of the risk of
MVAs requires complex testing. Near-miss accidents, the occurrence of SW and episodes
of microsleep during MWT have been recognised as markers of increased MVA risk.
The huge socioeconomic impact of OSA has profound consequences for individual and
public perspectives. However, increasing awareness of the disease may lead national
health organisations to implement appropriate diagnostic and treatment strategies.
There is increasing evidence of the high cost of OSA, but a better understanding of the
economic data is required, particularly the cost of premature death and retirement.
In this context, studies on health economic analysis need to be performed in
specific population groups – women, older adults, children, dierent racial groups,
and patients with varying OSA severity. It is also important to address the economic
impact of OSA and OSA treatment in those with comorbidities – patients with HF, type
2 diabetes mellitus and depression – as well as the economic aspects of interventions
to increase CPAP treatment adherence, including cognitive behavioural treatment
and remote monitoring. Analyses of the cost–benefit ratio of OSA treatment should
also include the employer’s perspective, e.g. the impact on workplace productivity as
well as accident and injury risk.
A global approach, in which the impact of OSA is estimated in various healthcare
delivery systems and populations, may help to improve allocation of limited healthcare
resources and mitigate the planetary socioeconomic impact of sleep apnoea.
340
ERS Handbook: Respiratory Sleep Medicine
The medico-legal and socioeconomic impact
https://t.me/medicina_free
Further reading
• American Academy of Sleep Medicine. Economic Impact of Obstructive Sleep Apnea. https://
aasm.org/advocacy/initiatives/economic-impact-obstructive-sleep-apnea/ Date last accessed:
4 January 2023.
• Arita A, et al. (2023). Advanced emergency braking system reduces the risk of motor vehicle
collisions caused by falling asleep while driving in patients with untreated obstructive sleep
apnea. J Sleep Res; 32: e13713.
• Bioulac S, et al. (2017). Risk of motor vehicle accidents related to sleepiness at the wheel:
a systematic review and meta-analysis. Sleep; 40: zsx134.
• Bonsignore MR, et al. (2021). European Respiratory Society statement on sleep apnoea,
sleepiness and driving risk. Eur Respir J; 57: 2001272.
• Bonsignore MR, et al. (2022). Epidemiology, physiology and clinical approach to sleepiness at
the wheel in OSA patients: a narrative review. J Clin Med; 11: 3691.
• Borsoi L, et al. (2022). The invisible costs of obstructive sleep apnea (OSA): systematic review
and cost-of-illness analysis. PLoS One; 17: e0268677.
• Bragazzi NL, et al. (2022). Planetary sleep medicine: studying sleep at the individual,
population, and planetary level. Front Public Health; 10: 1005100.
• Burks SV, et al. (2016). Nonadherence with employer-mandated sleep apnea treatment and
increased risk of serious truck crashes. Sleep; 39: 967–975.
• Fanfulla F, et al. (2021). Determinants of sleepiness at the wheel and missing accidents in
patients with obstructive sleep apnea. Front Neurosci; 15: 656203.
• Garbarino S, et al. (2015). Motor vehicle accidents and obstructive sleep apnea syndrome:
a methodology to calculate the related burden of injuries. Chron Respir Dis; 12: 320–328.
• Garbarino S, et al. (2016). Co-morbidity, mortality, quality of life and the healthcare/welfare/
social costs of disordered sleep: a rapid review. Int J Environ Res Public Health; 13: 831.
• Gonçalves M, et al. (2015). Sleepiness at the wheel across Europe: a survey of 19 countries.
J Sleep Res; 24: 242–253.
• Mattila T, et al. (2022). Changes in the societal burden caused by sleep apnoea in Finland from
1996 to 2018: a national registry study. Lancet Reg Health Eur; 16: 100338.
• Streatfeild J, et al. (2021). The social and economic cost of sleep disorders. Sleep; 44: zsab132.
• US National Sleep Foundation (2022). New data from the National Sleep Foundation show
a majority of Americans drive while drowsy. https://www.thensf.org/new-data-from-thenational-sleep-foundation-show-a-majority-of-americans-drive-while-drowsy/ Date last
accessed: 4 January 2023.
341ERS Handbook: Respiratory Sleep Medicine
Organisational aspects in
https://t.me/medicina_free
sleep clinics
Maria R. Bonsignore, Marta Amata and Giuseppe Adamo
Historically, the organisation of sleep clinics and laboratories has been centred on
patient access to the clinic, and subsequent diagnostic and therapeutic management.
Full PSG, in the laboratory or at home, is the gold standard for diagnosis of sleep
disorders, followed by titration of PAP therapy for SDB in the laboratory or at home,
and follow-up visits at the clinic. The standard procedures for accredited sleep centres
in Europe, issued by the European Sleep Research Society, were a major step for
standardisation of care throughout European sleep centres.
Because of the large number of patients requiring sleep studies, home respiratory
polygraphy (HRP) progressively gained space, especially for the diagnosis of SDB in
patients with a high clinical probability of OSA, according to the guidelines issued by
the American Academy of Sleep Medicine (AASM) in 2007. The ready availability of
recordings from PAP devices enabled the download of important data, such as delivered
pressure, occurrence of leaks and number/type of residual events, with progressive
movement of the titration process from the laboratory to the patient’s home, even
though the sleep clinic remained the place for decisional steps and prescription of PAP
devices or alternative treatments, such as mandibular advancement devices (MADs),
positional therapy or upper airway surgery. This process applied to the vast majority of
patients, and produced a significant cost saving; complicated cases were, and still are,
managed in the sleep laboratory.
Key points
• The organisation of sleep clinics and laboratories is changing, especially aer
the SARS-CoV-2 pandemic, due to the large-scale application of telemedicine
services.
• Technology is undergoing rapid evolution, not only for telemonitoring PAP
treatment, but also for obtaining full sleep studies at home.
• The shi towards telemedicine requires: education of personnel; investment
in technology and data safety; collaboration between sleep clinics and home
providers; and recognition of the service in terms of reimbursement.
• A patient-centred approach should be preserved, independently of the
management model chosen.
342
ERS Handbook: Respiratory Sleep Medicine
Organisational aspects in sleep clinics
https://t.me/medicina_free
This organisational structure held, with some variability between European countries
according to national rules, until the severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) pandemic revolutionised the field. Until that time, the application
of telemedicine to the sleep field was limited to research. However, telemedicine
appeared well suited to the management of SDB, as telemonitoring of PAP treatment
would directly bring to the physician’s computer the same information previously
downloaded from PAP devices, with time and money savings for the patient. Many
initial studies used telemonitoring in the first 3 months of PAP treatment, when
the probability that patients may quit treatment is especially high. In this context,
telemonitoring allowed early identification of problems, and reinforcement measures
by sleep clinic personnel, in order to support the patient in the delicate early phase
of PAP treatment. However, a visit to the clinic would still be needed in case of
intolerance to pressure, persistence of symptoms, emergent CSA, or changes in body
weight requiring adjustment of therapeutic pressure.
Changes in the management of SDB during the pandemic
The SARS-CoV-2 pandemic revolutionised sleep healthcare. During the initial lockdown,
sleep laboratories sharply decreased their diagnostic and therapeutic activities, and a
shortage of personnel mandated reallocation of sleep nurses and technicians to where
they were needed most. Patients, especially in the pre-vaccination period, tended to avoid
any access to clinics or hospital. Moreover, the possibility of SARS-CoV-2 transmission
through sleep monitoring devices sharply decreased access to SDB diagnosis.
Changes in the organisation of sleep services were implemented worldwide to cope
with this new and prolonged situation, and a conditional reopening of sleep services
was suggested according to the epidemiology of the infection, with more restriction
in periods of high circulation of the virus, and less intense precautions during periods
of moderate–low risk of infection. This strategy allowed a gradual restart of the usual
activities.
Some positive aspects of the pandemic were reported by research articles. For example,
during the lockdown, poorly adherent patients improved their PAP use, possibly due to
fear of SARS-CoV-2 pneumonia. Such studies were possible because of the progressive
diusion of telemonitoring of PAP devices, especially in the USA. The possibility of looking
at the data of millions of OSA patients revealed interesting data, previously not available,
on socioeconomic aspects of PAP compliance, or dierences in PAP use between men
and women and according to age. Dierent trajectories of treatment-emergent CSA
(TECSA) were defined in patient subgroups. Finally, it became clear that reinforcement
of patient motivation was easily achieved by using new technologies; for example,
apps that give the patient the ability to revise their own data on CPAP treatment, or
personalised educational material accessible through the web. Such solutions can
increase the knowledge of patients, who can actively participate in the management of
their health problems, with a positive impact on compliance to treatment.
Current and future management of SDB
The SARS-CoV-2 pandemic forced the sleep field, both locally and on a larger scale,
to rethink the organisation of the sleep clinic and laboratory, according to the new
perspectives and technologies that were boosted by the pandemic.
Telemedicine is a broad term, including dierent utilisation of information and
communications technology services applied to health. According to the World Health
343ERS Handbook: Respiratory Sleep Medicine
Соседние файлы в папке Библиотека им академика М.И. Перельмана