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I recently attended the European Sleep Research Society conference in Maastricht. It was big. Four days of masterclasses, lectures and posters, with thousands of sleep scientists, plus pharma and CPAP companies showing their wares to clinicians. It was too much to take in as a whole, but three themes stood out: sleep apnoea (how extensive it is, how much of it goes undiagnosed, especially in women), the effect of morning light on the body, and the prospect of drug treatments for narcolepsy and sleep apnoea.
I was there because a pilot study of the Zeez Sleep Pebble was being presented. It’s a study of 25 people with insomnia-spectrum disorders, some of whom also had obstructive sleep apnoea which was being treated using a CPAP. First, some background.
What is obstructive sleep apnoea?
In obstructive sleep apnoea (OSA), the airway narrows or closes repeatedly during sleep. Breathing stops for ten seconds, five or more times an hour. Oxygen levels dip, the brain rouses you into lighter sleep, the airway reopens, and the cycle starts again. You may not remember any of it. You just wake exhausted.
“Obstruction” can happen in several places:
The throat and soft palate. The muscles that hold the airway open relax in sleep, and the walls collapse inwards.
The tongue. In some people it falls back and blocks the airway, particularly when lying on the back.
Tonsils and adenoids. Enlarged ones narrow the space.
Jaw and facial structure. A small or set-back lower jaw, or a narrow palate, leaves less room, whatever the person’s weight.
The nose. Chronic blockage makes the whole system work harder.
Weight and neck fat. Extra tissue around the airway adds to the problem, although it is not the only cause.
Central sleep apnoea is a different condition. The airway is open, but the brain doesn’t send the right signals to breathe. Most people with sleep apnoea have the obstructive kind.
Sleep apnoea isn’t restricted to overweight, middle-aged men who snore. In women the picture is often different: fatigue, poor sleep, anxiety, low mood, even nightmares. Those can get put down to stress or menopause, and apnoea is never investigated. Estimates of women with OSA vary considerably, with one study finding that 50% of women aged 20 - 70% had OSA [4]. A lot of people may be walking around with a treatable condition and no idea.
Why treatment matters
It is tempting to see apnoea as a snoring problem or a nuisance. It isn’t. Untreated, it is linked to high blood pressure, heart disease, stroke, type 2 diabetes and depression. Sleepiness also raises the risk of accidents, which is why the DVLA expects drivers with symptomatic apnoea to tell them.
Treatment depends on severity and on the cause of the obstruction. For moderate and severe apnoea, the standard treatment is CPAP: a mask delivering gentle air pressure to keep the airway open. Others include mandibular advancement devices (made by a dentist, they move the jaw forward), sleeping on your side, cutting alcohol, weight management and, for some, surgery.
CPAP is a treatment, not a cure. It works when it is worn. Many people find that hard. Their mask may be uncomfortable, the hose gets in the way, and sometimes, as one woman told me, their partner hates it. Using it reliably is the difficult bit.
What is COMISA?
Many people with sleep apnoea also have insomnia. The combination is called COMISA: co-morbid insomnia and sleep apnoea. It isn’t rare. Estimates of how common it is vary widely, depending on how insomnia is defined and which group is studied, but it seems to be around 30 - 50% of those with OSA.
COMISA tends to be worse than either condition alone, for sleep, mood and daytime function. It is also awkward to treat. If you fix only the breathing, a pattern of poor sleep may persist. If you fix only the insomnia, the apnoea is still there. Someone can be on CPAP, getting enough oxygen, and still sleeping badly. That is the group I’m most concerned about.
A Zeez Sleep Pebble can’t treat sleep apnoea. Our need to breathe is stronger than our need to sleep. If your airway is blocked, you need an airway treatment. But once someone has dealt with their oxygen levels, perhaps with CPAP a poor sleep pattern, perhaps one that developed in response to the disrupted breathing, may persist. That isn’t good. And it is where we think the Pebble might help.
The Zeez Sleep Peble pilot study
The Institute of Sleep Science in Kolkata carried out pilot study of the Zeez Sleep Pebble in 25 adults with insomnia-spectrum symptoms, including COMISA. Those with sleep apnoea were using CPAP but still sleeping poorly. The study looked at feasibility, safety and efficacy. It was presented as a poster at the ESRS conference in Maastricht and published on 19th October with other abstracts.
The primary outcome was a change in the Epworth Sleepiness Scale (ESS), a widely used questionnaire that measures daytime sleepiness. The mean score fell from 12.4 to 5.1, a drop of 7.3 points. That moves the group from above the threshold for excessive sleepiness to well within the normal range.
I’m tremendously proud of this, and we must be careful about what it shows. It was a 25 person pilot. It tells us that the study is feasible, that no safety concerns were reported when the Zeez Sleep Pebble was used alongside CPAP or alone, and that it looks promising. It doesn’t prove that the Pebble works. It does make the case for a full, controlled trial.
We also hear from Zeez users who use the Pebble alongside CPAP and tell us their sleep has improved. That isn’t evidence. But it is enough to make us want to find out properly.
What we at Zeez would like to happen next
If you’re a clinician who treats people with sleep apnoea, and some of your patients are still sleeping poorly despite good CPAP use, I’d like to hear from you. We would welcome the chance to work with you on trialling the Pebble alongside CPAP.
If you have treated sleep apnoea and still struggle to sleep, talk to your sleep team or GP about your poor sleep pattern as well as the apnoea. They are separate problems, and both deserve attention. The Pebble is something you might consider alongside your treatment.
If you’re exhausted and can’t work out why, ask your GP about sleep apnoea, by name. Unrelenting fatigue, morning headaches, a dry mouth on waking, and sleep that never feels restorative are all worth mentioning. Know someone who is like this? Please talk to them, and send them this post.
We would also love to hear what you make of our results. You can message us here.
The Zeez Sleep Pebble is not a treatment for sleep apnoea. It is a wellness product designed to prompt a good sleep pattern. If you suspect that you have sleep apnoea, see your GP.
References
Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol 2013;177(9):1006-14. doi:10.1093/aje/kws342
Heinzer R, Vat S, Marques-Vidal P, et al. Prevalence of sleep-disordered breathing in the general population: the HypnoLaus study. Lancet Respir Med 2015;3(4):310-8. doi:10.1016/S2213-2600(15)00043-0
Young T, Palta M, Dempsey J, et al. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993;328:1230-5.
Franklin KA, Sahlin C, Stenlund H, Lindberg E. Sleep apnoea is a common occurrence in females. Eur Respir J 2013;41:610-5.
