Australasian Sleep Research Articles

Australasian Sleep Association 2024 guidelines for sleep studies in adults.

Executive summary: This document is a consensus statement of a subcommittee of experienced sleep physicians and scientists, tasked to review the literature and formulate recommendations on the indications, performance, and reporting of sleep studies, to update clinical practice from the 2017 Australasian Sleep Association (ASA) guidelines for sleep studies in adults (Douglas JA, Chai-Coetzer CL, McEvoy D, et al. Guidelines for sleep studies in adults - a position statement of the Australasian Sleep Association. Sleep Med. 2017;36(Suppl 1):S2-S22. doi:10.1016/j.sleep.2017.03.019). This document moves the focus beyond important discussions outlined in the 2017 guidelines, particularly surrounding the sensitivity and specificity of validated questionnaires and home sleep studies. The 2024 guide outlines the performance of the broad range of sleep testing available for the investigations of sleep disorders in adults including indications, strengths, limitations, and reporting standards.

Diagnosis of Nocturnal Hypoventilation in Pediatric Neuromuscular Disorders: A Survey of Clinical Practice in Australia and New Zealand

Objectives: Nocturnal hypoventilation is a complication of neuromuscular disorders. There are various recommendations for measuring pCO<sub>2</sub> during polysomnography and numerous national and international definitions of hypoventilation that could contribute to significant variations in clinical practice. We therefore aimed to determine clinical practices implemented by Australasian pediatric sleep physicians.Methods: Pediatric sleep physicians completed an electronic survey for information regarding pCO<sub>2</sub> measurements and definitions of hypoventilation that are followed for children with neuromuscular disorders.Results: It was found that transcutaneous measurement of pCO<sub>2</sub> was performed in all centers, with 25% of the centers simultaneously performing capnography. Twelve definitions of hypoventilation were used, including published definitions from the American Academy of Sleep Medicine (AASM) manual and recommendations of the pediatric Australasian Sleep Association/Australasian Sleep Technologists Association. The most commonly used definition of hypoventilation (9/17, 53%) was the 2012 pediatric AASM definition (pCO<sub>2</sub> >50 mmHg for >25% of the total sleep time). There was a discrepancy between centers and individuals within the same center when defining hypoventilation. Answers stating the use of the Australasian definitions (rise in pCO<sub>2</sub> ≥10 mmHg from wake to sleep, average rise in pCO<sub>2</sub> ≥3 mmHg from non rapid eye movement to rapid eye movement sleep) were more frequent when asked specifically via a checkbox (yes/no) compared to free text.Conclusions: These results confirm the heterogeneity and lack of standardization of clinical practice within Australasia when measuring pCO<sub>2</sub> during polysomnography and defining hypoventilation. The Australasian definitions were not used as frequently as anticipated.

P137 Diagnosis of nocturnal hypoventilation in children with neuromuscular disorders by polysomnography – a survey of clinical practice in Australia and New Zealand

Abstract Background Diagnosis of nocturnal hypoventilation requires measurement of pCO2 during sleep, which can occur via exhaled gas (capnography) or transcutaneous methods. Different national and international definitions of hypoventilation exist, which may contribute to significant variation in clinical practice. Methods An electronic survey was completed by pediatric sleep physicians in Australia and New Zealand to determine how pCO2 was measured during polysomnography, what pCO2 data was available to reporting physicians/included in the report and which definitions of hypoventilation physicians use. Results More than two thirds (70%) of physicians indicated that in their centre pCO2 was collected via transcutaneous measurement only and 30% by both transcutaneous and end-tidal measurement. Twelve definitions of hypoventilation were used, including published definitions from the American Academy of Sleep Medicine manual and the pediatric Australasian Sleep Association/Australasian Sleep Technologists Association recommendations. The most commonly used definition was an increase in pCO2 >50mmHg for >25% total sleep time. The percentage of total sleep time with pCO2 >50mmHg was routinely included in the report and/or easily available in the raw data for 70% of physicians. Discussion There was significant variation and lack of standardisation within Australia and New Zealand when measuring and reporting pCO2 during polysomnography as well as definitions of hypoventilation used by pediatric sleep physicians. The Australasian Sleep Association/Australasian Sleep Technologists Association recommendations were not frequently used, possibly due to relevant information not being available to reporting physicians, recommendations being irrelevant and/or outdated and excessive cognitive load associated with remembering multiple definitions.

Ventilatory support at home for children: A joint position paper from the Thoracic Society of Australia and New Zealand/Australasian Sleep Association.

The goal of this position paper on ventilatory support at home for children is to provide expert consensus from Australia and New Zealand on optimal care for children requiring ventilatory support at home, both non‐invasive and invasive. It was compiled by members of the Thoracic Society of Australia and New Zealand (TSANZ) and the Australasian Sleep Association (ASA). This document provides recommendations to support the development of improved services for Australian and New Zealand children who require long‐term ventilatory support. Issues relevant to providers of equipment and areas of research need are highlighted.

Chinese guideline for the diagnosis and treatment of childhood obstructive sleep apnea (2020).

Chinese guideline for the diagnosis and treatment of childhood obstructive sleep apnea (2020).

225 Sleep Timing and Chronotype in Mothers: Longitudinal Changes and Associations with Wellbeing from Pregnancy to 2 Years Postpartum

Abstract Introduction Women experience significant changes to sleep during perinatal periods. Existing research focuses on sleep duration and quality, but not sleep timing or chronotype (i.e., preferred timing for activity and sleep). This study investigated change trajectories of sleep timing and chronotype from late pregnancy to two years postpartum, and examined longitudinal associations between chronotype and insomnia, sleep-related daytime impairment, and mood. Methods Data were from a 2-arm randomized controlled trial testing behavioral sleep and diet interventions. A community sample of nulliparous women without severe sleep/mental health conditions participated. Women self-reported bedtime, risetime, chronotype (reduced Morningness-Eveningness Questionnaire), Insomnia Severity Index, and PROMIS Depression, Anxiety, and Sleep-Related Impairment over 7 time points: 30 and 35 weeks’ gestation, and postpartum months 1.5, 3, 6, 12 and 24. Results 163 women (mean age 33.35 ± 3.42 years) took part. Mixed effects models controlling for age and group allocation showed that both bed- and risetimes became progressively earlier over time by approximately 20-30 minutes on average (p < .001); chronotype also shifted progressively towards morningness (p < .01). After controlling for covariates (sleep duration and efficiency, mental health history, social support, age, group allocation), greater morningness was significantly associated with lower symptoms of insomnia and sleep-related impairment over time (p-values < .001); longitudinal associations between chronotype and symptoms of depression and anxiety were non-significant (p-values > .65). Conclusion This is one of the first studies to examine longitudinal changes in sleep timing and chronotype from pregnancy to two years postpartum. Sleep timing and chronotype became progressively earlier over the first two postpartum years. The magnitude of changes is beyond what is expected with increasing age. Greater morningness was associated with lower sleep complaints and sleep-related daytime impairment during the postpartum period. The mechanisms underlying these associations require further research. Support (if any) Australasian Sleep Association, Monash University, Australian Government RTP Scholarship and National Health and Medical Research Council.

340 Improving maternal sleep via cognitive behavioral intervention: A randomised controlled trial from pregnancy to 2 years postpartum

Abstract Introduction Maternal sleep disturbance is common during pregnancy and postpartum periods. This study evaluated the feasibility and efficacy of a scalable cognitive behavioural therapy (CBT) sleep intervention tailored for these periods. Methods This is a two-arm, parallel-group, single-blind, superiority randomised controlled trial. Nulliparous women without major medical/psychiatric conditions were randomised 1:1 to CBT or active control of equal frequency/duration. All participants received a 1-hr telephone session and automated multimedia emails from the 3rd trimester until 6 months postpartum. Outcomes were assessed with validated instruments at gestation weeks 30 (baseline) and 35 (pregnancy endpoint), and postpartum months 1.5, 3, 6 (postpartum endpoint), 12, and 24. Results 163 eligible participants (age M +/- SD = 33.35 +/- 3.42) were randomised. The CBT intervention was well accepted, with no reported adverse effect. Intention-to-treat analyses showed that compared to active control, receiving CBT was associated with lower insomnia severity and sleep disturbance (two primary outcomes), and lower sleep-related impairment at the pregnancy endpoint (p-values ≤ .001), as well as at 24 months postpartum (p ranges .012-.052). Group differences across the first postpartum year were nonsignificant. Women with elevated insomnia symptoms at baseline benefitted substantially more from CBT (vs control), including having significantly lower insomnia symptoms throughout the first postpartum year. Group differences in symptoms of depression or anxiety were nonsignificant. Conclusion A scalable CBT sleep intervention is efficacious in buffering against sleep disturbance during pregnancy, with long-term benefits to maternal sleep, especially for women with sleep complaints during pregnancy. The intervention holds promise for implementation into routine perinatal care. Support (if any) Data collection was supported by Rob Pierce Grant-in-Aid and Helen Bearpark Scholarship from Australasian Sleep Association, Strategic Grant Scheme from Monash University, and the Royal Women’s Hospital Foundation. Intervention materials were adapted from those developed via a National Institute of Health R01 grant (NR013662). Bei (APP1140299) and Wiley (APP1178487) are supported by National Health and Medical Research Council Fellowships, and Pinnington, Quin, Shen by Australian Postgraduate Awards by Department of Education and Training. The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.

Surgical management of obstructive sleep apnoea: A position statement of the Australasian Sleep Association.

ABSTRACTSurgery for adult obstructive sleep apnoea (OSA) plays a key role in contemporary management paradigms, most frequently as either a second‐line treatment or in a facilitatory capacity. This committee, comprising two sleep surgeons and three sleep physicians, was established to give clarity to that role and expand upon its appropriate use in Australasia. This position statement has been reviewed and approved by the Australasian Sleep Association (ASA) Clinical Committee.

Larger Average Cortisol Awakening Response Is Associated with Poorer Executive Function and Processing Speed in Healthy Adolescents

Background: The cortisol awakening response (CAR) refers to the sharp increase in cortisol secretion following awakening. Cortisol and the CAR have been implicated in several cognitive domains, including executive function, but past results are inconsistent. One explanation is that the CAR is influenced by environmental and psychological factors including sleep and anticipatory stress, which are rarely controlled in studies. Methods: We measured the CAR and cognitive performance in 12 healthy adolescents over 3 days. Participants stayed in a sleep laboratory with strictly controlled environment, sleep, and daily activities. Participants completed a CANTAB cognitive test battery daily, including measures of executive function, processing speed, spatial working memory, learning, and reaction time. The CAR was assessed with saliva samples at 0, 15, 30, and 45 minutes post-awakening, and quantified as the areas under the curve with respect to ground (AUCg) and increase (AUCi). Findings: We found that larger average CARs were associated with poorer executive function (attentional set-shifting) and processing speed (planning/response speed). The CAR was not associated with other cognitive measures. Interpretation: Larger trait CARs may reflect sustained, elevated cortisol, possibly contributing to gradual damage to white matter (affecting processing speed) and brain regions with high glucocorticoid expression (including those subserving executive functions). Alternatively, larger CARs and poorer cognitive performance may be common consequences of an unidentified developmental factor. Funding Statement: The Rob Pierce Grant in Aid from the Australasian Sleep Association, intramural funds (University of Adelaide). Declaration of Interests: The authors have nothing to declare. Ethics Approval Statement: Ethical approval was granted by the University of South Australia Human Research Ethics Committee, and all procedures were performed in accordance with the Declaration of Helsinki.

Complications and safe prescription of interventions for adult sleep disordered breathing in Australia

The American Academy of Sleep Medicine (AASM) identifies continuous positive airway pressure (CPAP), mandibular advancement splint (MAS), adjunctive medical therapy and surgical modifications of the upper airway potential treatment modalities in adult sleep breathing disorders and promotes a number of Guidelines and Consensus Statements to outline the role of such therapies. Specific treatments under each of these “intervention guidelines” are highlighted as standard, option or guideline with stringent literature analyses supporting each—by derivation, treating clinicians in relevant sleep disciplines should be highly trained and credentialed. Unfortunately, in Australia and elsewhere, sleep disorders, including sleep disordered breathing (SDB), are increasingly being managed by those without the necessary training or expertise, and “pop up” sleep clinics are bypassing comprehensive clinician assessment. This Symposium-derived paper highlights the risks and technical considerations related to each category of available intervention. This paper represents the first time such a focus has been published and incorporates CPAP, MAS, medical therapy and surgery in the same document. This paper explores in detail the complications associated with each of the interventions, and emphasises the requirement for meticulous training and experience to predict, identify, manage and resolve all relevant occurrences. The paper is a summation and expansion of proceedings from the Opening Plenary of the Australasian Sleep Association Scientific Conference from October 2017, and features the four key presentations of Professor Matthew Naughton, Professor Peter Cistulli, Associate Professor Nigel McArdle and Professor Stuart MacKay.

A consensus opinion amongst stakeholders as to benefits of obstructive sleep apnoea treatment for cardiovascular health.

Obstructive sleep apnoea (OSA) is a prevalent sleep disorder associated with increased cardiovascular morbidity and mortality. Whether treatment of OSA improves cardiovascular risk remains controversial. Our aim was to determine a consensus opinion of key sleep medicine stakeholder groups as to the cardiovascular benefits of treating moderate-severe OSA. A multidisciplinary panel was assembled from representatives from the Australasian Sleep Association, Sleep Health Foundation, Australasian Sleep Technologists Association, the Sleep Health Foundation Business Council and the Sleep Disorders Australia patient support group. Three statements reflecting areas of controversy related to cardiovascular benefits of OSA treatment were created. A modified RAND/UCLA appropriateness methodology was applied determining the panel's level of consensus and agreement with each statement. Voting results indicated the panel: (1) remained unsure whether moderate-severe OSA treatment improves rates of cardiovascular events/death, (2) agreed that moderate-severe OSA treatment improves blood pressure in patients with hypertension and (3) mostly agreed that moderate-severe OSA treatment improves left ventricular function in patients with heart failure. Consensus of opinion was achieved for statements (1) and (2), but was narrowly missed for statement (3). The panel believed that findings from large-scale randomized trials indicate that treatment of moderate-severe OSA has not been established to improve cardiovascular event or morbidity/mortality rates. Strong evidence supports the ability of treatment to reduce blood pressure. Whilst many panel members believed that treatment improves left ventricular function, some were uncertain of the clinical significance of this secondary endpoint measure derived from lesser quality evidence.

Accuracy of Patient Perception of Supine Sleep.

For clinicians involved in investigating and treating sleep disorders, understanding the accuracy of patient recall of supine sleep would allow informed comparisons between polysomnography (PSG) and patient-reported sleep in patients with supine-predominant obstructive sleep apnea. This study aims to assess the accuracy of patient perception of supine sleep. Prospective observational cohort study, assessing patient perception of total sleep and supine sleep, including duration. Data were analyzed utilizing descriptive statistics, bias-plot (Bland-Altman) analysis, and Spearman correlation (rs) to analyze relationships among continuous data. Total number of patients who underwent PSG was 518, with data from 368 of these patients analyzed. Most of these patients underwent diagnostic PSG (49.2%). Patients were excluded because of missing or incomplete data (n = 133) or immobility (n = 17). Some patients (n = 97, 26%) did not perceive supine sleep, with 34 (35% of those with unperceived supine sleep or 9% of whole group) of these having more than 60 minutes of PSG supine sleep (range 0-305.5 minutes). All "unsure" patients (n = 8, 2.2%) had significant supine sleep recorded (31.5-257.5 minutes). For the presence of any PSG supine sleep, questioning had a sensitivity of 77.9%, specificity 72.7% with positive predictive value of 96.7% and negative predictive value of 24.5%. There was a significant correlation (rs = 0.63, P < .0001) between perceived and PSG supine sleep, but wide limits of agreement (-246.9 to 194.2 minutes). In patients undergoing in-laboratory PSG, the perception of supine sleep predicts the presence of PSG supine sleep. However, questioning patients has a poor negative predictive value and patient estimates of supine sleep duration are inaccurate.

Australasian Sleep Association position statement regarding the use of psychological/behavioral treatments in the management of insomnia in adults

Insomnia disorder is a high prevalence condition with a high disease burden, which, left untreated, can increase risk of poorer health outcomes. Due to Insomnia's tendency towards having a chronic course, long-term treatment approaches are required to reduce the impact of Insomnia over time. After reviewing the available literature, The Australasian Sleep Association (ASA) recommends Cognitive Behavior Therapy for Insomnia (CBT-I) as a first line treatment in the management of Insomnia. The ASA notes that in addition to CBT-I, there is emerging evidence for the use of Mindfulness Based Therapy for Insomnia when used in combination with behavioural techniques (MBT-I). CBT-I should be used whenever possible, and medications should be limited to the lowest necessary dose and shortest necessary duration. CBT-I, whilst the most effective long-term treatment, does not work for everybody across all circumstances, so there will be circumstances in which other treatments are required (e.g., pharmacotherapy). Improving access to CBT-I is an important issue which will involve raising awareness of the effectiveness of CBT-I, increasing the number of trained practitioners, and the development of effective low intensity treatments that can be offered in the first instance.

The management, privacy and medico-legal issues of electronic CPAP data in Australia and New Zealand: Electronic CPAP data management in Australia and New Zealand

Study objectiveContinuous Positive Airway Pressure (CPAP) is considered to be the gold standard treatment for obstructive sleep apnoea (OSA). CPAP monitoring systems allow tracking of patient CPAP adherence and treatment efficacy, by measuring residual sleep-disordered breathing, hours of CPAP use, and mask leak etc. The American Thoracic Society (ATS) published a position paper in 2013 highlighting issues of interpreting CPAP data such as a lack of consistency between CPAP manufacturers data algorithms, legal implications of CPAP data and implications for CPAP adherence. This paper extends on this work by investigating these issues in an Australasian context. MethodA review of current literature on CPAP monitoring systems, privacy and security of CPAP data for major Australasian CPAP providers, and CPAP adherence was undertaken. A legal review was also commissioned for issues related to privacy and security of CPAP data. ResultsCPAP manufacturers' utilize different algorithms for respiratory event detection and clinicians need to be aware the implications for interpreting CPAP data. Australasian CPAP manufacturers have created security/privacy policies with the intent to follow relevant legislation to protect patients' CPAP data, however they do need to be constantly reviewed and updated to avoid data breaches and changes to agreements. No guarantees can be provided by the Australasian Sleep Association on CPAP manufacturers’ compliance with these policies and there is the potential for some degree of liability for physicians and CPAP providers associated with CPAP data. Lastly, providing patients with feedback on their CPAP usage and OSA management appears to have positive influence CPAP adherence. ConclusionsCPAP data provides many opportunities to increase OSA patient care and to help patients self-manage this chronic condition. However, issues relating to lack of standardization of CPAP parameters, privacy, security, and legal implications will need to be managed in this changing technologic and clinical environment.

A sleep specialist's voice on sleep medicine-personalized medicine and sleep apnea.

Professor Doug McEvoy (Figure 1) has been at the forefront of sleep medicine in Australia for over 25 years—as an academic, government advisor, and chairperson and member of national and international scientific advisory and professional committees. He is Director of the Adelaide Institute for Sleep Health, one of Australia’s leading clinical and research sleep medicine centers, and is a Practitioner Fellow of the National Health and Medical Research Council. He is a past President of the Australasian Sleep Association and is a founding Board member of the Sleep Health Foundation. For many years Doug has been a mentor and guide to emerging Australian and New Zealand clinicians and scientists in sleep medicine. In the last ten years alone his department has trained over 20 PhD students and sleep specialists, many of whom are now making significant contributions to the professional development of sleep medicine internationally and successfully forging their own independent research careers. Doug’s major research roles currently are as Principal Investigator of the international Sleep Apnea cardio Vascular Endpoints study and as Theme Leader in “personalized sleep medicine” in the Australian Cooperative Research Centre in Alertness, Safety and Productivity.

Targeted Case Finding for OSA within the Primary Care Setting

The aim was to determine the feasibility of using an unattended 2-channel device to screen for obstructive sleep apnea in a population of high-risk patients using a targeted, case-finding strategy. The case finding was based on the presence of risk factors not symptoms in the studied population. The study took place from June 2007 to May 2008 in rural and metropolitan Queensland and New South Wales. Family doctors were asked to identify patients with any of the following: BMI > 30, type 2 diabetes, treated hypertension, ischemic heart disease. Participants applied the ApneaLink+O2 at home for a single night. The device recorded nasal flow and pulse oximetry. Data were analyzed by proprietary software, then checked and reported by either of two sleep physicians. 1,157 patients were recruited; mean age 53 ± 14.6, M/F% = 62/38, mean BMI = 31.8, obesity = 35%, diabetes = 16%, hypertension = 39%, IHD = 5%, Mean Epworth Sleepiness Scale score (ESS) = 8.3. The prevalence of unrecognized OSA was very high: 71% had an AHI > 5/h, 33% had an AHI > 15/h, and 16% had an AHI > 30/h. The ApneaLink+O2 device yielded technically adequate studies in 93% of cases. The study shows that a "real world" simple low cost case finding and management program, based on unattended home monitoring for OSA, can work well in a population with risk factors and comorbidities associated with OSA, independent of the presence of symptoms. The prevalence of unrecognized OSA was very high.

An open letter to the sleep and circadian rhythms community: Presidents’ viewpoints of the World Sleep Federation (WSF)

An open letter to the sleep and circadian rhythms community: Presidents’ viewpoints of the <scp>W</scp>orld <scp>S</scp>leep <scp>F</scp>ederation (<scp>WSF</scp>)

Oral Presentations

Journal of Sleep ResearchVolume 20, Issue s1 p. 17-26 Free Access Oral Presentations First published: 30 September 2011 https://doi.org/10.1111/j.1365-2869.2011.00952.xAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume20, Issues1Special Issue: Sleep DownUnder 2011, sleep and the city, Australasian Sleep Association and Australasian Sleep Technologists Association, 23rd Annual Scientific Meeting, Sydney Convention Centre, 27-29 October 2011October 2011Pages 17-26 RelatedInformation

Oral presentations

Sleep and Biological RhythmsVolume 7, Issue s1 p. A15-A28 Free Access Oral presentations First published: 09 September 2009 https://doi.org/10.1111/j.1479-8425.2009.00410_2.xAboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Volume7, Issues1Special Issue: Abstracts of Visions of the Night: Sleep, Science and Research on the World Stage. Australasian Sleep Association and Australasian Sleep Technologies Association 21st Annual Scientific Meeting, 8–10 October 2009, Sofitel Hotel, Melbourne, Victoria, AustraliaOctober 2009Pages A15-A28 RelatedInformation

Strategies for developing sleep research

The Australasian Sleep Association (ASA) is seeking to develop a strategic research plan to improve the sleep health of Australians and New Zealanders, and to contribute to scientific understanding and clinical practice worldwide. To develop the plan, the ASA Research Committee undertook two projects: (i) a membership survey to establish the research activities, interests, and priorities of members; and (ii) compilation of an electronic library of citations of sleep-related research that involved one or more Australia-based or New Zealand-based researchers. Although the intent had been to develop an investigator-initiated research agenda for the ASA, these two projects revealed that such an approach would not provide a comprehensive and systematic research base to improve sleep health in Australasia. In particular, membership research interests were considered insufficient to adequately address public health issues relevant to the populations of Australia and New Zealand, clinical research for non-respiratory sleep disorders, and pediatric sleep research. The identification of these gaps raises a tension. If the ASA is to endorse additional research priority areas that are not major interests among its members, then additional research funding needs to be found, to avoid competing with the interests of members for limited existing research funding. To address this problem, a series of recommendations are offered to improve the proportion of existing health research funding that is directed towards sleep research, and to develop sources of new funding for sleep research.