Sleep Medicine in Syria Facts, Problems and Solutions

Naem Shahrour, MD, FCCPHead, Pulmonary Dept ,.

Alassad University HospitalDamascus University Medical School

Director, jisr Sleep Center

Sleep Medicine in SyriaFacts, Problems and Solutions

Thank YouAntalya, Turkey

Syria

Welcome to Syria

BOSRA HAS THE MOST FANTASTIC THEATRE

OMAYAD MOSQUE:&St. John’s Tomb

AZEM’S PALACE;an example of traditional Syrian Houses

RIVERS AND OUNTAINS

Basic Facts: Sleep Medicine in Syria

Sleep Medicine existed in Syria in 2000Teaching and awareness programs through

lectures at medical school, conferences, symposia and English medical cases started in 2001

Official acceptance as subspecialty by Gv 2002.Official teaching in Medical school in 2004First scientific study on sleep patients

presented in 2004 at Syrian American Medical society conference.

Current situation

2 officially specialized MD’s in sleep

Few MD’s are also interested in the field

There is only one private full PSG lab in the country

There are few portable sleep equipments

ProblemsProblem: we do not have official training in Sleep for MD’s or technicians

Problem: some of the MD’s do not have the appropriate background or expertise to do or interpret the test.

Problem: we do not have enough specialists

1st study

2008Naem Shahrour, MD

Emad Sibai, MD

Prevalence of OSA Ongoing study250 Bus drivers Questionnaires on sleepiness and other symptoms of sleep apnea

Epworth scale was used to estimate sleepiness

8% of drivers slept at least once during driving

Only 5% slept and had Epworth score above 10

Problems:Difficulty of making nation-wide screening:Due to fear of employees at riskLack financial support

We do not have regulation to report

No State or insurance support to diagnose or treat these patients

2nd studyNaem Shahrour, MD, FCCP

Head, Pulmonary Dept ,.Alassad University Hospital

Damascus University Medical SchoolDirector, jisr Sleep Center

MethodsThe study started from 2/2002-5/2004Ninety-seven patients were included. All

patients were subjected to standard polysomnography studies, and 2 had MSLT study for suspected narcolepsy.

Ages ranged from 10-78 yearsPatients were either self-referred, center-

referred or referred from other physicians.

MethodsPatients were monitored by a trained

physician or technician.

Auto and manual Scoring were performed by the observing technicians and reviewed the following day.

Split studies using CPAP were the rule for financial reasons.

Age distribution: No problem

0

5

10

15

20

25

number ofpatients

Demographic Data: Indicate Cultural Implications

0

10

20

30

40

50

60

70

80

90

Married/single M/F

History of Smoking: same for general public

05

10

15

20

2530

35

40

45

Nargila passivesmoking

activesmoking

non-smokers

number of patients

Type of profession: could present an obstacle

professio

professio

profession44%

business22%

workers20%

housewivs 14

Problem: Presenting and Main Symptoms could be misleading

OVERALL SXPRESENTING

SX

0

20

40

60

80

100

GERD

CHEST P

NASAL SX

HEADACHE

D-T SLEEPINESS

FATIGUE

WITNESSED APNEA

DYSPNEA

SNORING

Problem of Centralized Information

0

10

20

30

40

50

60

Residence site

Problem: Referral TypeIs it unawareness or ethical

0 10 20 30 40

percentage of Ptsreferred

Problem: Late presentationInitial Oxygen Desaturation

0

10

20

30

40

50

60

70

100-95 94-90 91-88 87-85 84-80 <80% Initialsat

Percentage ofpatients

With Complications and Associated Diseases

HTN39%DM

9%

Nasal Sx24%

CVA3%

Hypothyroid3%

hypercholest3%

Arthropathy12%

CAD7%

HTN

Nasal Sx

Arthropathy

DM

CAD

Hypothyroid

CVA

hypercholesterolemia

Medications

anti

acid

s

BD0

10

20

30

40

cardiac DM

tota

lBB

CC

BASA

DIU

RE

TIC

SA

CE

IO

TH

ER

S

totalBBCCBASADIURETICSACEIOTHERS

Overall Diagnosis

0

10

20

30

40

50

60

70

80

overallOSA

10-5/h 20-16/h

30-26/h

>35

Non-OSA:Problem with knwoledge

norm

al

Nar

co UA

RS

Dep

ress

ion

Oth

ers

0

2

4

6

8

10

12

normal RLS N-Rmyoclonus

N terror

N of Pts

Problems with CPAP during test:

0

5

10

15

20

25

30

RDI pre-CPAP

RDI post-CPAP

neverresponsive

partialresponsive

could nottolerate

RDIRDI

Pe

rce

nta

ge

of p

atie

nts

Pe

rce

nta

ge

of p

atie

nts

Mean apnea duration: 38 seconds

Mean CPAP of 6.8 cm H2O

Mean CPAP of 6.8 cm H2O

3RD STUDY

Follow-up Naem Shahrour, MD

86 patients2007-2008

Follow-Up up to 1 yearF/U: (41%)

Weight Stable (85%)

Still loosing (8.5%) Gain WT (6.5%) Sleepiness

same (55%) Better (45%)

CPAP

Bought by 85% Not tolerated by 15% Used by 83% Benefit by 92%

ProblemsWith poor Follow-up due to:

sending back pts to referring MD’s, Poverty incompliance

with ineffective weight loss programsAnd Ineffective Home Care FU for

CPAP use.Worst pts had highe RDI

Conclusion and SolutionsSleep disorders, as in the rest of the world, are

expected to be common in Syria.Concept of Sleep Medicine and Sleep disorders

should be further clarified and well presented to physicians and public through an organized awareness programs.

Physicians should be encouraged to recognize OSA early and refer patients for prompt treatments.

CPAP and BIPAP should be readily available, and affordable to patients.

Further and larger scale studies on the epidemiology and impact of sleep disorders in Syria should be conducted.

Specialized sleep clinic and laboratories should be widely available and well staffed and equipped.

Supportive multidisciplinary programs for weight loss, home care, and CPAP training should be offered.

MD’s should be familiar with common symptoms and complications.

MD’s should screen all high risk patients especially with suggestive Sx, smoking, HTN, and obesity

Thank you FEMTOSAntalya, Turkey

D

Most pts are smokers or ex-smokers

Higher RDI associated with typical presenting SX

Treatment

The higher RDI requires more CPAP

Higher RDI requires higher CPAP

Higher RDI Increases SBP

Higher RDI Increases DBP

Weight increases RDI

Thank you FEMTOSAntalya, Turkey