Diagnostic Assessment — Obstructive Sleep Apnoea
Example 1 of 1 · fictitious patient (Veteran K)
Diagnostic Assessment
Obstructive Sleep Apnoea
BOP Code: 69 of 2022 (Sleep Apnoea)
RH Code: 68 of 2022 (Sleep Apnoea)
ADF History
Veteran K, date of birth 09 March 1984, Australian Army, Combat Engineer (Sapper), enlisted 17 January 2003, medically discharged 22 August 2019. Operational service: Afghanistan, 02 March 2010 to 28 October 2010 (warlike); Middle East Area of Operations, 05 February 2018 to 25 September 2018 (warlike).
Occupational History
As a combat engineer the veteran carried loads of 30 to 45 kilograms on foot, conducted route clearance and searched for improvised explosive devices, and worked in dust, diesel exhaust, smoke and blast environments in extreme heat. Field postings involved disrupted, shift-based sleep in vehicles, shelters and crowded accommodation.
Engineers on route clearance carry a high risk of blast injury, penetrating trauma and exposure to blood and body fluids when providing first aid. The service culture of the period also normalised regular heavy drinking after exercises and on return from deployment.
History
Veteran K, a combat engineer in the Australian Army, sustained a moderate traumatic brain injury, a nasal fracture and a lumbar injury in an improvised explosive device blast in Afghanistan on 04 August 2010, and developed obstructive sleep apnoea with a central component in mid-2014, after a period of marked weight gain, opioid treatment for his back injury and the development of a cardiomyopathy. The condition was confirmed on polysomnography and worsened during his 2018 deployment, when CPAP could not be used.
Timeline
- 04 Aug 2010 — During warlike service in Afghanistan the veteran's vehicle struck an improvised explosive device. He lost consciousness for about 40 minutes, had a Glasgow Coma Scale score of 10 on arrival at the role 3 hospital and post-traumatic amnesia lasting two days. CT showed a displaced nasal fracture and an L1 compression fracture. He was aeromedically evacuated and spent nine days in intensive care, where he required ventilation and developed critical illness neuromyopathy. While providing first aid at the scene he sustained a needle-stick injury from a casualty's cannula. "moderate TBI, nasal fracture, ventilated"
- 06 Dec 2010 — Post-exposure follow-up confirmed HIV infection acquired from the needle-stick injury on deployment. An infectious diseases physician commenced antiretroviral therapy including the protease inhibitor darunavir, which he continued throughout the rest of his service. "HIV seroconversion, darunavir commenced"
- 14 Jan 2011 — A psychiatrist diagnosed posttraumatic stress disorder related to the blast and commenced quetiapine 100 mg at night for sleep and nightmares. Quetiapine continued without interruption to 2019. Alcohol intake was recorded at five to six standard drinks a day, increasing after his return from Afghanistan. "PTSD, quetiapine 100 mg nocte"
- 10 Oct 2013 — His lumbar pain from the 2010 compression fracture deteriorated and he was placed on light duties for twelve months. A pain specialist commenced controlled-release oxycodone 60 mg twice daily (180 mg oral morphine equivalent per day). He was advised to sleep on his back with a pillow under his knees because side-lying aggravated his back pain. Weight 104 kg, height 1.80 m, BMI 32.1, up from 86 kg in 2009. "oxycodone CR 60 mg bd, BMI 32.1"
- 05 May 2014 — Investigation of exertional breathlessness and ankle swelling showed a dilated cardiomyopathy, attributed to sustained heavy alcohol intake, with a left ventricular ejection fraction of 36 per cent. A cardiologist diagnosed heart failure with reduced ejection fraction and commenced amiodarone for runs of ventricular tachycardia. In the same month, autonomic function testing showed cardiovascular autonomic neuropathy, and serum IGF-1 was raised with a pituitary macroadenoma on MRI, confirming acromegaly. "heart failure, EF 36 per cent"
- 02 Jun 2014 — A renal physician confirmed chronic renal failure from HIV-associated nephropathy, with an eGFR below 15 mL/min/1.73 m2 since February 2014, and commenced haemodialysis. Thyroid function tests showed amiodarone-induced hypothyroidism (TSH 18 mU/L, low free T4) and levothyroxine was started. "chronic renal failure, haemodialysis commenced"
- 22 Jul 2014 — At the garrison health centre his partner's report of loud snoring, pauses in breathing and gasping was recorded, with one week of waking unrefreshed and falling asleep in briefings. Epworth Sleepiness Scale 14. Examination showed a crowded oropharynx, nasal septal deviation and a neck circumference of 45 cm. "witnessed apnoeas, Epworth 14"
- 08 Feb 2016 — Diagnostic polysomnography showed moderate sleep apnoea, predominantly obstructive with a central component: apnoea-hypopnoea index 27 events per hour, central apnoea index 6, worse when supine, with oxygen desaturation to 84 per cent. A respiratory and sleep physician confirmed the diagnosis on 11 April 2016 and commenced CPAP. "obstructive sleep apnoea, AHI 27"
- 19 Nov 2018 — After seven months in the Middle East, where his CPAP machine could not be used because accommodation power was rationed and unreliable, he reported marked worsening of daytime sleepiness and two near-miss driving events. Repeat polysomnography on 05 November 2018 showed an apnoea-hypopnoea index of 52 events per hour. BMI 34.0. Alcohol intake about 50 grams a day through 2018. CPAP pressure was increased and bilevel therapy considered. "AHI 52, CPAP not used deployed"
Symptoms
At onset the veteran had loud habitual snoring, witnessed pauses in breathing, choking arousals, unrefreshing sleep, morning headaches and excessive daytime sleepiness, including falling asleep during briefings. After onset the symptoms became nightly, with nocturia and poor concentration, and they worsened markedly during his 2018 deployment.
He now reports ongoing daytime fatigue, poor concentration and irritability despite nightly CPAP, and he no longer drives long distances. Without CPAP his partner reports loud snoring and apnoeas within the first hour of sleep.
Imaging
- 04 Aug 2010 — CT head and facial bones: "Small left frontal contusion. Displaced fracture of the nasal bones with septal deviation to the left."
- 12 Mar 2011 — CT paranasal sinuses: "Healed nasal fracture with fixed septal deviation and bilateral inferior turbinate hypertrophy narrowing the nasal airway."
- 05 May 2014 — MRI pituitary: "12 mm pituitary macroadenoma."
- 05 May 2014 — Transthoracic echocardiogram: "Dilated left ventricle with global hypokinesis, LVEF 36 per cent."
Onset Date
The most likely date of onset of this condition is 15 Jul 2014.
At that date the veteran was serving full time with a field engineer regiment in Australia, on light duties for his lumbar injury. He was taking controlled-release oxycodone and quetiapine, had recently started haemodialysis, and was sleeping on his back on medical advice. Over the following week his partner observed loud snoring and pauses in his breathing, and he began falling asleep in briefings.
This date is appropriate because his periodic health examination of 30 July 2013 recorded no snoring or daytime sleepiness, and he first presented with the symptoms on 22 July 2014, one week later. It falls within uninterrupted full-time service.
For the supine sleeping factors, the 6 months before onset run from 15 Jan 2014 to 15 Jul 2014; he slept supine throughout this period on medical advice following his lumbar injury of October 2013. For the opioid factors, the 2 months before onset run from 15 May 2014 to 15 Jul 2014, during which he took 180 mg oral morphine equivalent per day. For the antipsychotic factor, the 2 months before onset run from 15 May 2014 to 15 Jul 2014, during which he took quetiapine nightly. Heart failure, autonomic neuropathy, chronic renal failure, critical illness neuromyopathy, acromegaly, hypothyroidism, chronic nasal obstruction and obesity were each established before 15 Jul 2014 and present on that date.
For the worsening factors, the period after onset runs from 15 Jul 2014 to the documented worsening on 05 Nov 2018. The 6 months before the worsening run from 05 May 2018 to 05 Nov 2018, during which he drank about 50 grams of alcohol a day, slept supine and took quetiapine and oxycodone, and the 2 months before the worsening run from 05 Sep 2018 to 05 Nov 2018.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Obstructive Sleep Apnoea (ICD-10 G47.33), with a central component, under the Statements of Principles concerning sleep apnoea, Balance of Probabilities No. 69 of 2022 and Reasonable Hypothesis No. 68 of 2022.
Obstructive sleep apnoea is a sleep-related breathing disorder characterised by repeated collapse of the upper airway during sleep, with cessation or reduction of airflow despite continuing respiratory effort. Each event causes oxygen desaturation and a brief arousal, which fragments sleep and produces daytime sleepiness, impaired concentration and mood change. Central sleep apnoea, in which airflow and respiratory effort cease together, can coexist, particularly with heart failure, brain injury and opioid use. Over time sleep apnoea is associated with hypertension, atrial fibrillation, cardiovascular disease and road and workplace accidents.
The diagnosis followed the 2010 blast injuries, weight gain and opioid treatment from 2013, and the development of cardiomyopathy and renal failure in 2014. It began on 15 July 2014, was confirmed on polysomnography in February 2016 and worsened in 2018.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
15 July 2014.
When did the veteran first present to a health / medical provider for this condition?
22 July 2014.
When was the condition confirmed / formally diagnosed?
08 February 2016.
When did the veteran first present to you (or your practice) for this condition?
12 March 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed by diagnostic polysomnography on 08 February 2016, which showed an apnoea-hypopnoea index of 27 events per hour with predominantly obstructive events despite continuing respiratory effort, a central apnoea index of 6, positional worsening when supine and oxygen desaturation to 84 per cent. This meets the Statement of Principles definition of obstructive sleep apnoea, and the central events meet the definition of central sleep apnoea.
The clinical picture was consistent: habitual snoring, witnessed apnoeas, an Epworth Sleepiness Scale score of 14, a BMI above 30, a neck circumference of 45 cm and a crowded upper airway with nasal septal deviation. A respiratory and sleep physician confirmed the diagnosis on 11 April 2016 and commenced CPAP, with a clear symptomatic response. Repeat polysomnography on 05 November 2018 confirmed worsening to an apnoea-hypopnoea index of 52.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
Legislation: the clinical onset of this condition was on 15 July 2014, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Afghanistan in 2010, where the blast injuries, the needle-stick injury and the posttraumatic stress disorder arose, and in the Middle East in 2018, where the condition worsened.
Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Balance of Probabilities — Statement of Principles concerning Sleep Apnoea, No. 69 of 2022
Causative factors
Factor 9(1): having heart failure at the time of the clinical onset of sleep apnoea; — MET
- A cardiologist diagnosed heart failure with reduced ejection fraction on 05 May 2014, with a left ventricular ejection fraction of 36 per cent, from a dilated cardiomyopathy caused by sustained heavy alcohol intake established during service. The heart failure was present on 15 July 2014, the date of onset. Fluid shifting from the legs into the neck when lying down narrows the upper airway, and heart failure destabilises the control of breathing during sleep.
Factor 9(2): having a central nervous system lesion or disorder from the specified list of central nervous system lesions or disorders at the time of the clinical onset of sleep apnoea; — MET
- The veteran sustained a moderate traumatic brain injury in the blast of 04 August 2010, with loss of consciousness for about 40 minutes, a Glasgow Coma Scale score of 10 and post-traumatic amnesia of two days, and a frontal contusion on CT. Moderate to severe traumatic brain injury is on the specified list. The injury was present, with persisting effects, at the onset of sleep apnoea on 15 July 2014.
Factor 9(3): having autonomic neuropathy at the time of the clinical onset of sleep apnoea; — MET
- Autonomic function testing in May 2014 showed cardiovascular autonomic neuropathy, which the treating physician attributed to chronic alcohol use disorder that developed during service. It was present on 15 July 2014.
Factor 9(4): having chronic renal failure at the time of the clinical onset of sleep apnoea; — MET
- The veteran's eGFR was below 15 mL/min/1.73 m2 from February 2014, and he began haemodialysis on 02 June 2014 for HIV-associated nephropathy, the HIV having been acquired from a needle-stick injury while providing first aid on 04 August 2010. Both limbs of the definition of chronic renal failure were met before the onset on 15 July 2014.
Factor 9(5): having a neuromuscular disease affecting the diaphragm, other respiratory muscles or upper airway muscles at the time of the clinical onset of sleep apnoea; — MET
- The veteran developed critical illness neuromyopathy during his nine days of ventilation in intensive care after the 2010 blast. A fluoroscopic sniff test and respiratory function testing showed residual diaphragmatic weakness, which persisted to the onset of sleep apnoea on 15 July 2014.
Factor 9(6): having acromegaly at the time of the clinical onset of sleep apnoea; — MET
- Acromegaly was confirmed in May 2014 by a raised serum IGF-1 and a 12 mm pituitary macroadenoma on MRI. Soft tissue enlargement of the tongue and pharynx was noted on examination. The acromegaly was present at onset on 15 July 2014.
Factor 9(7)(a): for obstructive sleep apnoea only: having hypothyroidism, including Hashimoto thyroiditis that has resulted in hypothyroidism, at the time of the clinical onset of obstructive sleep apnoea; — MET
- Thyroid function tests on 02 June 2014 showed hypothyroidism, with a TSH of 18 mU/L and a low free T4, caused by amiodarone prescribed by Defence-funded specialists for ventricular tachycardia. The hypothyroidism was present at onset on 15 July 2014.
Factor 9(7)(b): for obstructive sleep apnoea only: having chronic obstruction or chronic narrowing of the upper airway at the time of the clinical onset of obstructive sleep apnoea; — MET
- The nasal fracture sustained in the blast of 04 August 2010 healed with a fixed septal deviation, and CT of 12 March 2011 showed the nasal airway narrowed by the deviation and turbinate hypertrophy. The nasal cavity is part of the upper airway as defined. This chronic narrowing was present at onset on 15 July 2014 and was confirmed on examination on 22 July 2014.
Factor 9(7)(c): for obstructive sleep apnoea only: being obese at the time of the clinical onset of obstructive sleep apnoea; — MET
- The veteran's BMI was 32.1 on 10 October 2013 and remained above 30 to the onset on 15 July 2014. His weight rose from 86 kg in 2009 after the service-related lumbar injury forced a year of light duties and inactivity.
Factor 9(7)(d): Being in a supine position when sleeping for at least the 6 months before the clinical onset of obstructive sleep apnoea; — MET
- From October 2013 the veteran slept on his back on medical advice because side-lying aggravated his service-related lumbar injury. He did so throughout the 6 months before onset, from 15 January 2014 to 15 July 2014. The 2016 sleep study confirmed position-dependent apnoea.
Factor 9(8): for central sleep apnoea only, taking a long-acting opioid at an average daily morphine equivalent dose of at least 120 milligrams for at least the 2 months before the clinical onset of central sleep apnoea; — MET
- The polysomnogram showed a central component with a central apnoea index of 6. The veteran took controlled-release oxycodone 60 mg twice daily, 180 mg oral morphine equivalent per day, from 10 October 2013, prescribed for his service-related lumbar injury. This continued throughout the 2 months before onset, from 15 May 2014 to 15 July 2014.
Worsening factors
Factor 9(9): having heart failure at the time of the clinical worsening of sleep apnoea; — MET
- Heart failure with reduced ejection fraction persisted after onset and was present when the sleep apnoea worsened in 2018, with the apnoea-hypopnoea index rising from 27 to 52 events per hour on repeat polysomnography on 05 November 2018.
Factor 9(10): having a central nervous system lesion or disorder from the specified list of central nervous system lesions or disorders at the time of the clinical worsening of sleep apnoea; — MET
- The moderate traumatic brain injury of 2010 remained present when the sleep apnoea worsened in November 2018.
Factor 9(11): having autonomic neuropathy at the time of the clinical worsening of sleep apnoea; — MET
- Cardiovascular autonomic neuropathy persisted and was present at the documented worsening in November 2018.
Factor 9(12): having chronic renal failure at the time of the clinical worsening of sleep apnoea; — MET
- The veteran remained on haemodialysis for chronic renal failure when the sleep apnoea worsened in November 2018, and fluid overload between dialysis sessions was documented during his deployment.
Factor 9(13): having a neuromuscular disease affecting the diaphragm, other respiratory muscles or upper airway muscles at the time of the clinical worsening of sleep apnoea; — MET
- Residual diaphragmatic weakness from critical illness neuromyopathy was present when the sleep apnoea worsened in November 2018.
Factor 9(14): having acromegaly at the time of the clinical worsening of sleep apnoea; — MET
- Acromegaly remained biochemically active, with a raised IGF-1 in October 2018, when the sleep apnoea worsened.
Factor 9(15): consuming an average of at least 30 grams of alcohol per day for at least the 6 months before the clinical worsening of sleep apnoea; — MET
- The veteran drank an average of about 50 grams of alcohol a day throughout 2018, including the 6 months before the worsening, from 05 May 2018 to 05 November 2018. Alcohol relaxes the upper airway muscles and blunts arousal from apnoeas.
Factor 9(16)(a): for obstructive sleep apnoea only: having hypothyroidism, including Hashimoto thyroiditis that has resulted in hypothyroidism, at the time of the clinical worsening of obstructive sleep apnoea; — MET
- Thyroid function tests in October 2018 showed persisting hypothyroidism, under-replaced while he was deployed, at the time the obstructive sleep apnoea worsened.
Factor 9(16)(b): for obstructive sleep apnoea only: having chronic obstruction or chronic narrowing of the upper airway at the time of the clinical worsening of obstructive sleep apnoea; — MET
- The fixed septal deviation and turbinate hypertrophy persisted at the worsening in November 2018, and nasal obstruction was recorded as making CPAP harder to tolerate.
Factor 9(16)(c): for obstructive sleep apnoea only: being obese at the time of the clinical worsening of obstructive sleep apnoea; — MET
- The veteran's BMI was 34.0 on 19 November 2018, when the worsening was documented.
Factor 9(16)(d): Being in a supine position when sleeping for at least the 6 months before the clinical worsening of obstructive sleep apnoea; — MET
- He continued to sleep supine because of his lumbar injury throughout the 6 months before the worsening, from 05 May 2018 to 05 November 2018, including in deployed accommodation.
Factor 9(17): for central sleep apnoea only, taking a long-acting opioid at an average daily morphine equivalent dose of at least 120 milligrams for at least the 2 months before the clinical worsening of central sleep apnoea; — MET
- Controlled-release oxycodone at 180 mg oral morphine equivalent per day continued throughout the 2 months before the worsening, from 05 September 2018 to 05 November 2018, and the central apnoea index rose to 11 on the repeat study.
Factor 9(18): inability to obtain appropriate clinical management for sleep apnoea. — MET
- During his deployment from February to September 2018 the veteran could not use his CPAP machine because power in his accommodation was rationed and unreliable, and no alternative was provided. The sleep apnoea went untreated for seven months and worsened, with the apnoea-hypopnoea index rising from 27 to 52. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Sleep Apnoea, No. 68 of 2022
Causative factors
Factor 9(1): having heart failure at the time of the clinical onset of sleep apnoea; — MET
- Heart failure was diagnosed on 05 May 2014 from an alcohol-related cardiomyopathy. The drinking escalated after, and as a way of coping with, his warlike service in Afghanistan in 2010 and the posttraumatic stress disorder that followed. The heart failure was present at onset on 15 July 2014.
Factor 9(2): having a central nervous system lesion or disorder from the specified list of central nervous system lesions or disorders at the time of the clinical onset of sleep apnoea; — MET
- The moderate traumatic brain injury was sustained in an improvised explosive device blast on warlike service in Afghanistan on 04 August 2010 and was present at onset on 15 July 2014.
Factor 9(3): having autonomic neuropathy at the time of the clinical onset of sleep apnoea; — MET
- Cardiovascular autonomic neuropathy, confirmed in May 2014, resulted from chronic alcohol use disorder that developed after his warlike service in Afghanistan. It was present at onset on 15 July 2014.
Factor 9(4): having chronic renal failure at the time of the clinical onset of sleep apnoea; — MET
- Chronic renal failure from HIV-associated nephropathy, requiring haemodialysis from 02 June 2014, followed HIV infection acquired from a needle-stick injury while giving first aid on warlike service on 04 August 2010. It was present at onset on 15 July 2014.
Factor 9(5): having a neuromuscular disease affecting the diaphragm, other respiratory muscles or upper airway muscles at the time of the clinical onset of sleep apnoea; — MET
- Critical illness neuromyopathy with diaphragmatic weakness followed ventilation in intensive care for the blast injuries of 04 August 2010 on warlike service, and persisted to onset on 15 July 2014.
Factor 9(6): having acromegaly at the time of the clinical onset of sleep apnoea; — MET
- Acromegaly was confirmed in May 2014 by a raised IGF-1 and a pituitary macroadenoma on MRI, and was present at onset on 15 July 2014.
Factor 9(7): taking an antipsychotic drug for at least the 2 months before the clinical onset of sleep apnoea; — MET
- The veteran took quetiapine 100 mg nightly from 14 January 2011, prescribed for posttraumatic stress disorder arising from the 2010 blast on warlike service, and continued it throughout the 2 months before onset, from 15 May 2014 to 15 July 2014. Quetiapine causes weight gain and reduces upper airway muscle tone during sleep.
Factor 9(8)(a): for obstructive sleep apnoea only: having hypothyroidism, including Hashimoto thyroiditis that has resulted in hypothyroidism, at the time of the clinical onset of obstructive sleep apnoea; — MET
- Amiodarone-induced hypothyroidism was confirmed on 02 June 2014. The amiodarone treated ventricular tachycardia from the cardiomyopathy linked to post-deployment alcohol use. It was present at onset on 15 July 2014.
Factor 9(8)(b): for obstructive sleep apnoea only: having chronic obstruction or chronic narrowing of the upper airway at the time of the clinical onset of obstructive sleep apnoea; — MET
- The nasal fracture from the blast on warlike service on 04 August 2010 healed with a fixed septal deviation narrowing the nasal airway, shown on CT on 12 March 2011 and present at onset on 15 July 2014.
Factor 9(8)(c): for obstructive sleep apnoea only: being obese at the time of the clinical onset of obstructive sleep apnoea; — MET
- The veteran's BMI was 32.1 from October 2013 to onset. The weight gain followed inactivity from the L1 compression fracture sustained in the blast on warlike service, and weight gain from quetiapine prescribed for deployment-related posttraumatic stress disorder.
Factor 9(8)(d): for obstructive sleep apnoea only: being in a supine position when sleeping for at least the 6 months before the clinical onset of obstructive sleep apnoea; — MET
- He slept supine on medical advice throughout the 6 months before onset, from 15 January 2014 to 15 July 2014, because side-lying aggravated the L1 compression fracture sustained on warlike service.
Factor 9(8)(e): for obstructive sleep apnoea only: taking protease inhibitors as antiretroviral drugs for human immunodeficiency virus infection before the clinical onset of obstructive sleep apnoea; — MET
- The veteran took the protease inhibitor darunavir from 06 December 2010 for HIV infection acquired from a needle-stick injury on warlike service, continuously up to and beyond the onset on 15 July 2014. Protease inhibitors cause central fat redistribution, including around the neck.
Factor 9(9): for central sleep apnoea only, taking a long-acting opioid at an average daily morphine equivalent dose of at least 75 milligrams for at least the 2 months before the clinical onset of central sleep apnoea; — MET
- Controlled-release oxycodone at 180 mg oral morphine equivalent per day, for the L1 compression fracture sustained on warlike service, was taken throughout the 2 months before onset, from 15 May 2014 to 15 July 2014. The polysomnogram showed a central component.
Worsening factors
Factor 9(10): having heart failure at the time of the clinical worsening of sleep apnoea; — MET
- Heart failure persisted and was present when the sleep apnoea worsened during his warlike service in the Middle East, documented on 05 November 2018.
Factor 9(11): having a central nervous system lesion or disorder from the specified list of central nervous system lesions or disorders at the time of the clinical worsening of sleep apnoea; — MET
- The moderate traumatic brain injury from warlike service in 2010 was present at the worsening in November 2018.
Factor 9(12): having autonomic neuropathy at the time of the clinical worsening of sleep apnoea; — MET
- Cardiovascular autonomic neuropathy was present at the worsening in November 2018.
Factor 9(13): having chronic renal failure at the time of the clinical worsening of sleep apnoea; — MET
- Chronic renal failure on haemodialysis was present at the worsening in November 2018, with fluid overload documented in the Middle East.
Factor 9(14): having a neuromuscular disease affecting the diaphragm, other respiratory muscles or upper airway muscles at the time of the clinical worsening of sleep apnoea; — MET
- Diaphragmatic weakness from critical illness neuromyopathy was present at the worsening in November 2018.
Factor 9(15): having acromegaly at the time of the clinical worsening of sleep apnoea; — MET
- Active acromegaly, with a raised IGF-1 in October 2018, was present at the worsening.
Factor 9(16): consuming an average of at least 30 grams of alcohol per day for at least the 6 months before the clinical worsening of sleep apnoea; — MET
- The veteran drank about 50 grams of alcohol a day throughout the 6 months before the worsening, from 05 May 2018 to 05 November 2018, much of it during his warlike service in the Middle East.
Factor 9(17): taking an antipsychotic drug for at least the 2 months before the clinical worsening of sleep apnoea; — MET
- Quetiapine continued nightly throughout the 2 months before the worsening, from 05 September 2018 to 05 November 2018.
Factor 9(18)(a): for obstructive sleep apnoea only: having hypothyroidism, including Hashimoto thyroiditis that has resulted in hypothyroidism, at the time of the clinical worsening of obstructive sleep apnoea; — MET
- Hypothyroidism, under-replaced during the deployment, was present at the worsening in November 2018.
Factor 9(18)(b): for obstructive sleep apnoea only: having chronic obstruction or chronic narrowing of the upper airway at the time of the clinical worsening of obstructive sleep apnoea; — MET
- The post-traumatic septal deviation from the 2010 blast persisted at the worsening and was worsened by dust exposure in the Middle East.
Factor 9(18)(c): for obstructive sleep apnoea only: being obese at the time of the clinical worsening of obstructive sleep apnoea; — MET
- The veteran's BMI was 34.0 at the worsening, documented on 19 November 2018.
Factor 9(18)(d): being a supine position when sleeping for at least the 6 months before the clinical worsening of obstructive sleep apnoea; — MET
- He slept supine throughout the 6 months before the worsening, from 05 May 2018 to 05 November 2018, including in deployed accommodation in the Middle East.
Factor 9(18)(e): for obstructive sleep apnoea only: taking protease inhibitors as antiretroviral drugs for human immunodeficiency virus infection before the clinical worsening of obstructive sleep apnoea; — MET
- Darunavir continued throughout the period before the worsening in November 2018.
Factor 9(19): for central sleep apnoea only, taking a long-acting opioid at an average daily morphine equivalent dose of at least 75 milligrams for at least the 2 months before the clinical worsening of central sleep apnoea; — MET
- Oxycodone at 180 mg oral morphine equivalent per day continued throughout the 2 months before the worsening, and the central apnoea index rose from 6 to 11.
Factor 9(20): inability to obtain appropriate clinical management for sleep apnoea. — MET
- On warlike service in the Middle East from February to September 2018 the veteran could not use CPAP because accommodation power was rationed and unreliable, and the condition went untreated for seven months and worsened.
The % contribution of the causes is 100% and significant.
Sequelae
The obstructive sleep apnoea is a sequela of the veteran's accepted conditions: the post-traumatic nasal septal deviation, the obesity that followed his lumbar injury, and the long-acting opioid and antipsychotic treatment of his accepted lumbar injury and posttraumatic stress disorder.
Unintended Consequence
Met. The central component of the sleep apnoea is an unintended consequence of controlled-release oxycodone, and the hypothyroidism contributing to the obstruction is an unintended consequence of amiodarone, both prescribed and paid for by the Commonwealth while the veteran was serving (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. During his deployment from February to September 2018 the veteran had no reliable power for CPAP and no alternative treatment was offered, so his diagnosed sleep apnoea went untreated for seven months. The apnoea-hypopnoea index rose from 27 to 52 and he had two near-miss driving events. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational constraints that prevent prescribed treatment amount to an inability to obtain appropriate clinical management. The delay of almost 19 months between his first presentation in July 2014 and the confirming sleep study in February 2016 is also indicative of barriers to care.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 04 Aug 2010, Trauma admission and CT report, Role 3 hospital, Afghanistan
- 06 Dec 2010, Specialist letter, Infectious diseases physician
- 14 Jan 2011, Psychiatric assessment, Consultant psychiatrist
- 12 Mar 2011, CT paranasal sinuses, Radiologist
- 30 Jul 2013, Periodic health examination, Medical Officer, Garrison health centre
- 10 Oct 2013, Pain medicine consultation, Pain specialist
- 05 May 2014, Echocardiogram and cardiology consultation, Cardiologist
- 05 May 2014, MRI pituitary and endocrinology consultation, Endocrinologist
- 02 Jun 2014, Renal medicine consultation, Renal physician
- 22 Jul 2014, Outpatient health record, Medical Officer, Garrison health centre
- 08 Feb 2016, Diagnostic polysomnography report, Sleep physician
- 11 Apr 2016, Specialist consultation, Respiratory and sleep physician
- 05 Nov 2018, Repeat polysomnography report, Sleep physician
- 19 Nov 2018, Specialist follow-up, Respiratory and sleep physician
- Statement of Principles concerning Sleep Apnoea (Balance of Probabilities) No. 69 of 2022, Repatriation Medical Authority
- Statement of Principles concerning Sleep Apnoea (Reasonable Hypothesis) No. 68 of 2022, Repatriation Medical Authority
