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Transcript of Review Sleep Study August 2010
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Simplifying the Complexity of
Polysomnography -
Understanding the Objective
Measurement of a Sleep Disorder
Dr Darren OBrien
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Scope
Subjective Measures of Sleepiness
Physiologic/Biologic Measures of Sleepiness
Polysomnography (PSG)
Sleep Unit based and Portable (Home)
Diagnostic PSGContinuous Positive Airway Pressure
(CPAP) titration PSG
Multiple Sleep Latency Test PSG
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Sleepiness and Fatigue
Although these terms are used
interchangeably there are differences.Sleepiness refers to the urge to fall asleep.It is the result of a biological need to sleep
that can be irresistible. Fatigue refers tothe reluctance to continue a task as aresult of physical or mental exertion or aprolonged period of performing the sametask.
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The Problem
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Sleepy Driving
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Site Fatigue Management Training Fatigue and Alertness
Personal Costs of Shift work
Fatigue at Work and on the Road
What causes Fatigue?
Roster Assessment
Understanding Sleep Getting to Sleep
Improving Your Sleep
Stop Worrying and go to Sleep!
Sleep and Ageing
Women, Sleep and Shift work Circadian Rhythms, Sleep and Alertness
Getting to Sleep after Night Shift
Staying Asleep After Night Shift
Napping
Alcohol, Drugs and Fatigue
Staying Alert on Night Shift
Managing Shift Change
Healthy Eating for Shift workers
Are you fit for work? Fatigue Assessment, management plan and fatigue profile
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Fatigue Calculators and Questionnaires
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Subjective Measures of Sleepiness
Improve level of knowledge and
awareness May prompt individual action
Subjective tools. Rely on personalhonesty/integrity of the individual to
use them or act on them
Fatigue calculators may provide falsesense of security
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Physiologic Measures Signs of
Sleepiness
Optalert Glasses (1992- )
Optalert's patented technologycontinuously measures drowsiness by
using invisible pulses of light to detecteye and eyelid movement.Tiny light emitters and receivers arebuilt into the frames ofOptalertglasses worn by the driver. The glassesare connected to the Optalert Vehicle
System, installed within the vehicle,which processes all the informationbeing transmitted from the glasses.Whenever Optalert detects the onset ofdrowsiness usually before the driverbecomes aware of it a loud beepingnoise and a voice message warns thedriver immediately.Warnings can include:Level 1 Cautionary warningLevel 2 Critical warning
InattentionSystem warningsGlasses not working
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Smart Cap (2009)
Mining Daily 1 October 2009
Physiologic Measures Signs of
Sleepiness
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Objective measure of signs of sleepiness if
interpreting features correctly Provides potential opportunity for evasive
action to me taken potentially mitigating a
real time accident Will not permit specification or quantification
of a sleep disorder beyond identifying a very
high propensity for sleep in a given
individual
Physiologic Measures
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A PSG is the continuous and simultaneous recording of
multiple physiologic variables during sleep, that is,electroencephalogram (EEG), electrooculogram (EOG),
electromyogram (EMG), electrocardiogram (ECG),
respiratory air flow, respiratory movements, leg
movements and other electrophysiologic variables.
The name is derived from Greek and Latin roots: poli'(many), 'somnus' (sleep), and 'grapho' (to write).
Objective Measure of Sleepiness, Sleep Quality and Sleep
Quantity performed in a sleep unit or at home/in a mine site
donger with a portable PSG unit. Will provide data suitable
for the medical diagnosis of a sleep disorder.
Polysomnography orPSG orSleep Study
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1930 Berger sleep vs. waking Electroencephlogram (EEG) 1937 Loomis EEG of different sleep states
1953 Aserinsky and Kleitman Electro-oculogram (EOG)
1957 Dement & Kleitman describe Rapid Eye Movement (REM) sleep 1959 J ouvet & Michel Electromyogram (EMG) decrease in REM sleep
1968 A manual of standardised terminology, techniques and scoringsystem for sleep stages of human subjects Allan Rechtschaffen and
Anthony Kales 1978, 1980 McGregor,Weitzman, Pollack PSG to include oximetry,
respiratory effort & airflow.
Evolution of Polysomnography (PSG)
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1981 Colin Sullivan developed Continuous Positive Airway Pressuretreatment for Obstructive Sleep Apnoea
1992 ASDA (American Sleep Disorders Association) EEG Arousals:Scoring rules and examples
1999 Sleep-related breathing disorders in Adults: Recommendations forSyndrome Definition and Measurement Techniques in Clinical Research -Report of an American Academy of Sleep Medicine Task Force (SleepVol 22 No. 5)
Evolution of Polysomnography (PSG)
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Sleepy individual Discusses their sleep
problem with General Practitioner or
Sleep Specialist.
If Dr agrees there is need for a sleep
study he or she completes the referral
and faxes or emails it for booking.
PSG A Medical Test
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Polysomnographic Tests
Diagnostic PSG - investigative study to determine ifthere are identifiable problems with the patientssleep
CPAP titration PSG - If a patient is identified ashaving obstructive sleep apnoea, a PSG is performedin which the nurse or technician adjusts the CPAP
pressure level during the study Split Night PSG- Combines a diagnostic study and a
CPAP titration study into one night. The patient is
diagnosed during the first half of the night; CPAPapplied the second half if required by protocol
Multiple Sleep Latency Test (MSLT)
Maintenance of Wakefulness Test (MWT)Both MSLT and MWTs are daytime tests.
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88 Sleep Disorders
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We most commonly find
Obstructive Sleep Apnoea
Insomnia
Narcolepsy
Depression
Periodic Limb Movements insleep
Withdrawal from stimulants
Insufficient sleep syndrome Drug Dependence/Abuse
Medication side effects
Post Traumatic Hypersomnia
Obesity Hypoventi lation
Respiratory Failure
Patients with Night Terrors,REM Behaviour Disorders and
Epilepsy
Physiological measurements undertaken
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Physiological measurements undertaken
during Polysomnography
Sleep EEG (brain signals)
C4 A1, C3 A2
O2 A1, O1 A2
EOG (eye muscle activity)
LOC (left eye) and ROC(right eye)
EMG (chin muscle activity)
EMG s (chin = sub-mental)
Respiration Airflow (Oral -Thermistor,Nasal pressure - Cannula)
Respiratory EffortThorax (Ribcage)
Abdomen (Diaphragm)
Pulse OximetrySaO2 (Oxygen saturation)
Pulse
Body positionTranscutaneous CO2 (whenrequested)
Microphone (snoring)
Cardiac status
ECG
Muscle Activity
EMG leg EMG t (anteriortibialis muscle along shin)
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Setting up for the Sleep Study
Head Measurement
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10-20 System EEG electrode
placement landmarks
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Setting up for the Sleep Study
Site preparation and glue-on ElectrodeApplication
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Setting up for the Sleep Study
Application of Respi-Bands, Legelectrodes and Nasal Cannula
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Setting up for the Sleep Study
Application of Nasal Cannula
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Setting up for the Sleep Study
Connection of Patient to Headbox
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The Diagnostic Sleep Study
Overnight attended monitoring of patientand data signals in the sleep unit
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Sleep Unit PSG?
Portable PSG?
Brief Digression
or
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Performed for over 30 years.
Considered gold standard. Usually conducted within ahospital sleep unit or sleep clinic.
Patient is attended overnight by a Scientist, Nurse orMedical staff.
Patient well being and signal quality/data integrity ismonitored and maintained.
PSG hardware capable of 27+ channels for data capture.
Video monitoring.
Pressure titration of CPAP or Bilevel machines can beperformed by a scientist, nurse or medical staff.
Sleep Unit based PSG
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Performed for approximately 12 years in Australia.
Usually conducted in the patients home after evening clinicset-up. Reduced cost.
Non-attended.
Potential for data loss if lead/s dislodged.
Usually no video monitoring.
2007 - portable PSG hardware invented capable ofmeasuring majority of sleep unit based channels.
Some sleep service providers, chemists and other outletsstill using single or double channel monitoring devices NOT PSG -risk of false positives, false negatives sleepstudy results.
Medicare Australia intervention 2008 - 2010
Portable (home based) PSG
Portable monitoring devices 2010
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Portable monitoring devices 2010
R l ti d B t P ti G id li
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Regulation and Best Practice Guidelines
Portable PSG
Medicare Schedule Advisory Committeefindings March 2010
Regulation and Best Practice Guidelines
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Regulation and Best Practice Guidelines
American Academy of Sleep Medicine
Clinical Guidelines for the use of unattended portable monitors 2007
Objective Testing Our Service
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Objective Testing Our Service
Portable Sleep Study performed with
Somte PSG device
Clinically robust data
capture no false
positive or negativeresults.
Meets Medicare Australia
(2008-2010) guidelines.
14 27 channels including
mult iple EEG for precisesleep staging by scientist.
Meets AASM (2007)guidelines as a Level 2
device.
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PSG Analysis
Study data is scored bya qualified Sleep Scientist
and reported by Sleep Physician
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Diagnostic Sleep Study Signals
Upper
Pane
LowerPane
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Awake
Awake - eyes closed
EEG Alpha waves 8-
13Hz
EOG Reflects EEG
EMG highest level ofrecording
Awake - eyes open
EEG small amplitude,
mixed frequency
EOG blinks
EMG highest level ofrecording
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Stage 1 Sleep
EEG: Slower activity than wake, can see eachdistinct wave.
EOG: Rolling eye movements, sinusoidal wavesin opposing directions
EMG: Slightly reduced from wake
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Stage 2 Sleep
K complex
Sharp negativewave followedby positive.
Spindle
12-14Hz
>0.5 seconds
duration
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Stage 2 Sleep
EEG: Presence of spindles or K-complexes
EOG: No movements but may reflect EEG activity
EMG: Slightly reduced
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Stage 3 Sleep
EEG: 20-50% of the epoch has waves 75V in
amplitude, of frequency less than 4 cyclesper second.
EOG: No movement. May reflect EEG waves.
EMG: Slightly reduced.
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Stage 4 Sleep
EEG: more than 50% of the epoch has waves75V in amplitude, of frequency less than4 cycles per second
EOG: No movement. May reflect EEG waves
EMG: Slightly reduced.
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REM Sleep
Sawtooth waveLow amplitude wavewith sawtooth
appearance
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REM Sleep
EEG: small amplitude, mixed frequency. May have
sawtooth waves. Resembles awake with eyesopen.
EOG: rapid eye movements in opposing directions.
EMG: reduced to lowest level of recording.
N l Sl A hit t
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Normal sleep cycle:
Stage 1 4%
Stage 2 38%
Stage 3 4%
Stage 4 16%
REM 16%
(Mathur and Douglas, 1995)
Normal Sleep Architecture
8 hours
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Bruxism
Rhythmic muscle activity, reflected in
EEG/EOG channels
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REM Behaviour Disorder
Increased EMG, reflected in EEG/EOG
Di ti Sl St d Si l
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Diagnostic Sleep Study Signals
Upper
Pane
LowerPane
Wh t h h i di id l
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What happens when an individual
has obstructive sleep apnoea?
Normal
Airway
Wh t h h i di id l
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Snoring
What happens when an individual
has obstructive sleep apnoea?
S
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Snoring
Wh t h h i di id l
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Air flow
limitation
What happens when an individual
has obstructive sleep apnoea?
H
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Hypopnoea
Wh t h h i di id l
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Apnoea
What happens when an individual
has obstructive sleep apnoea?
Wh t h h i di id l
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What happens when an individual
has obstructive sleep apnoea?
Ob t ti Sl A
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Obstructive Sleep Apnoea
Obstructed
Airway
2 minutes
Ob t ti Sl A
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Obstructive Sleep ApnoeaDrop in
oxygenlevel to 82%
(normal
>95%)
as a result
of the
obstructed
airway
Ob t ti Sl A
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Obstructive Sleep Apnoea
Arousalfrom sleep
due to
obstruction
and
brain
stimulating
patient tobreathe
What happens hen an indi id al obstr cts?
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What happens when an individual obstructs?
OSA haemodynamic and autonomic effects
Morgan et al, 1996.
Effects of obstructive sleep
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Hypertension
Coronary artery disease
Congestive heart failure
Transient Ischaemic Attacks/
Cerebrovascular Accidents
Atrial FibrillationType 2 Diabetes/ Insulin resistance
Effects of obstructive sleep
apnoea
Severity of Obstructive Sleep Apnoea
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Severity of Obstructive Sleep Apnoea
Total number of complete cessations (apnoea) and partialobstructions (hypopnoeas) of breathing occurring per hour
of sleep. These pauses in breathing must last for 10
seconds and are associated with a decrease in oxygenationof the blood.
Respiratory Disturbance Index (RDI) 30 /hr Severe
Severe patients can obstruct over 150 times per
hour (over 1000 times per night).
Th Sl R t N l St d
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Cn.A
Ob.A
Mx.A
Hyp
Uns
+5+5
+5
+5
+5
The Sleep Report Normal Study
REMMOV AWK
1234
SaO2
100
50
FL
BR
Time
Hrs
Epoch
0:09:48 7:09:48
0
1
1
121
2
241
3
361
4
481
5
601
6
721
7
841
120
20
Architecture
Arousals
SaO2
Heart Rate
RespiratoryEvents
Body Position
Time
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The Sleep Report Obstructive Sleep Apnoea
REMMOV AWK
1234
SaO2
100
0
Cn.A
Ob.A
Mx.A
Hyp
Uns
+5
+5
+5
+5
+5
120
20
FL
BR
Time
Hrs
Epoch
22:08:58 6:08:58
0
1
1
121
2
241
3
361
4
481
5
601
6
721
7
841
8
961
Architecture
Arousals
SaO2
Heart Rate
RespiratoryEvents
Body Position
Time
CPAP Continuous Positive Airway
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Considered Gold Standard treatment forObstructive Sleep Apnoea.
Air passes through a mask into the patientsnose and/or mouth, and into the throat, where
the slight pressure acts as a splint to keep thepatients airway open and prevent obstruction.
CPAP Continuous Positive Airway
Pressure
CPAP Continuous Positive
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CPAP Continuous Positive
Airway Pressure Titration PSG
CPAP pressure titration PSG:
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At 2214hrs the patient is obstructing
on 4cm.
CPAP pressure titration PSG:
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At 2238hrs patient continues to obstruct,
pressure is increased to 8cm and then 9cm.
CPAP pressure titration PSG:
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At 0128hrs on 13cm in SWS, consistent
airflow shape and normal oxygen level.
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CPAP
Works -
Airway
CT
Scan
CPAP pressure titration PSG:O ti l
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Entire night summary
Arousals reduced to normal
range
Sleep
architecture
consolidated
Optimal
oxygenation
maintained
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Effects of OSA and CPAP
Marin et al, Lancet 2005
Daytime PSG
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Daytime PSG
Multiple Sleep Latency Test(MSLT)
Measures the rapidity of the patient falling asleep Conducted the day after a Diagnostic Study Subject while lying down is asked to sleep (20
minutes)
If the patient falls asleep in 20 minutes, he is givenanother 15 minutes to get into REM stage
Measures Sleep Latency (time taken to fall asleep)
Measure REM Latency Important in the diagnosis and confirmation ofNarcolepsy
Repeated 5 times every 2 hours throughout the day
MSLT Nap 1
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MSLT Nap 1
MSLT Nap 2
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MSLT Nap 2
MSLT Nap 3
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MSLT Nap 3
MSLT Nap 4
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MSLT Nap 4
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Diagnosis of Narcolepsy = mean sleep latency < 10 mins
with 2 or more REM periods in any of the naps
MEAN SLEEP LATENCY REM ONSETS (in 5 naps)
10-15 min MILD 0-1 NORMAL
5-10 min MODERATE > 2 ABNORMAL
< 5 min SEVERE
Multiple Sleep Latency Test
Conclusion
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Polysomnography (PSG) can be viewed as animportant adjunct to existing fatigue
management training and subjective and other
physiologic measures of sleepiness.
PSG is an objective measure of sleepiness,sleep quality and sleep quantity in addition to
other variables. PSG permits the medical diagnosis of an
underlying sleep disorder.
Conclusion
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Not all Portable (Home) sleep study devices
and sleep services in Australia meet current
Medicare guidelines.
Not all sleep services will provide local accessto a Sleep Physician for consultation. Not all sleep services will be able to perform all
of these tests. Not all sleep services will provide ongoing
support for patients commencing treatment.
The onus is on each organisation to locate a sleep service
that can meet the above criteria and provide optimal testing
and treatment pathways.
Wesley
HospitalRespiratory and Sleep
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Moranbah
Medical
CentreMoranbah
St Vincents
HospitalToowoomba
Pindara Private
Hospital
Benowa
St Stephens
Hospital
Maryborough
DarwinPrivate
Hospital
Pioneer
Valley PrivateHospital
Mackay
(12 years in
2010)
St Andrews
Private
Hospital
Toowoomba
(12 years in
2010)
John FlynnPrivate
Hospital
Gold Coast
(12 years in
2010)
Kawana
Private
HospitalSunshine
Coast
Wesley
MedicalCentre
Brisbane
Hospital
Brisbane
(21 years
in 2010)
RiverCity
Private
HospitalBrisbane
p y p
Specialists
Sleep
Investigation
Units
Respiratory and Sleep
Specialists
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John Flynn
Hospital
Tugun
Blackwater
Moranbah Tieri
Bundaberg
Sunshine Sleep
and
Hearing
Stanthorpe
Health and Daily
Living Solutions
Mackay
Pioneer Valley
Hospital
Gladstone Surgical
and Health
Equipment
Specialists
Portable
SleepServices
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Questions/Discussion?