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Sleeping Disorder Problems And Feasible
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Industry
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Final year student, Batch 2009-11
Jyotirmoy School of Business, Kolkata

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Mr. Pankaj Sabharwal

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Asst. Vice President-Healthcare, BOC India Ltd, Kolkata
And
Mr. Krishna B
Senior Manager, Marketing, Healthcare, BOC India Ltd, Kolkata

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2
 ABSTRACT
The success of any business entirely depends on research and marketing strategies applied by the organization
to understand the preferences, market scope and attitude towards the product or services. I have tried to make
the study realistic. The project will give a complete view of sleeping disorder and feasible solutions available in
the hospital industry in the city of Kolkata.

Marketing plays a vital role in a business to make it a success. It is such a topic which cannot be learned
through books only. It needs to be learned through practical exposure. In this project I have tried to find out the
way the company like BOC India Ltd, a member of The Linde Group uses marketing as a key to success. I have
put my best effort to complete this task on the basis of the skill that I have achieved during my one month live
project in BOC India Ltd, Kolkata.

I have done the work independently under guidance from Mr. Pankaj Sabharwal, Asst. Vice President-
Healthcare, BOC India Ltd, Mr. Krishna B. and Senior Manager, Healthcare, BOC India Ltd. I am equally
grateful to Mr Sandeep Bhattacharya, Vice president, Human Resource, BOC India Ltd and Mr Sitangshu
Khatua, Associate Dean and Examination Controller Head of Jyotirmoy School of e Business, Sonarpur,
Kolkata for giving me a chance to work with BOC India Ltd and make this live project possible..

However, I would appreciate if any mistakes are brought to my notice by the readers.

Sohong Chakraborty

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 Contents
INTRODUCTION…………………………………………...…………………….5

COMPANY DETAILS………………………………………...…………………21

OBJECTIVES…………………………………………………………...………..26

RESULTS………………………………………………………………...……….27

DISCUSSION…………………………………………………………..................36

CONCLUSION…………………………………………………...........................38

LIMITATION AND FUTURE SCOPE OF STUDY……………………….......39

REFERENCES…………………………………………………………….…...…40

APPENDIX………………………………………………………………..41

INTRODUCTION
In our daily life, we fail to maintain the age old methods of livelihood our ancestors and forefathers have advice
from time to time and generation after generation. Due to the change in the normal lifestyle and natural habits
and routines of human being, there has been a drastic shift in human nature of sleepiness. This can happen due
to daily over work pressure and meeting deadlines in job, night shift jobs throughout the year (jobs in BPO),
panic, mental stress, anxiety, mental tension, individual’s psychological pressure and even due to watching
daily late night television, spending night-life, obesity, listening loud music, over eating, heavy consumption of

4
alcoholic liquors, consumption of drugs, chemicals and other forms of activities. This creates the disturbance in
normal sleepiness and heads towards sleep disorder problem for a normal man.

A sleep disorder (somnipathy) is a medical disorder of the sleep patterns of a person or animal. Some sleep
disorders are serious enough to interfere with normal physical, mental and emotional functioning. A test
commonly ordered for some sleep disorders is the polysomnography or PSG.

Disruptions in sleep can be caused by a variety of issues, from teeth grinding (bruxism) to night terrors. When a
person suffers from difficulty in sleeping with no obvious cause, it is referred to as insomnia. In addition, sleep
disorders may also cause sufferers to sleep excessively, a condition known as hypersomnia.

Sleep problems cause more than just sleepiness – a lack of quality sleep can cause accidents, affect your
relationships, health, and mental prowess; and make you feel generally “disconnected” from the world. If your
sleeplessness is caused by a tough deadline or a common cold, you might not have trouble getting your sleep
back on track after the deadline or cold go away, but if you have trouble sleeping on a regular basis, this can be
the time to get a health check up regarding common sleep problems and disorders. Consulting doctors can help
you to be well on your way of experiencing healthy, restorative sleep.

Symptoms of sleep problems and disorders

Everyone experiences occasional sleep problems, but getting a good night’s sleep is essential for feeling
refreshed and alert during the day. Lack of sleep might make you feel foggy and unable to concentrate, or just a
lesser version of your normal self. Sleep problems will eventually disrupt your work, family and personal
relationships.

How do you tell if your sleepless night is an isolated occurrence or if it is related to a chronic sleep problem or
disorder? Start by identifying your symptoms. Particular behaviors during the day are telltale signs of sleep
deprivation. If you are experiencing any of the following symptoms on a regular basis, your sleeplessness might
be part of an ongoing problem or sleep disorder.

Sleep Apnea/Sleep Disorders

Sleep apnea is a sleep disorder characterized by abnormal pauses in breathing or instances of abnormally low
breathing, during sleep. The word apnea means "not breathing." Therefore, each pause in breathing, called
an apnea, can last from a few seconds to minutes, and may occur 5 to 30 times or more an hour. Similarly, each

5
abnormally low breathing event is called ahypopnea. Sleep apnea is diagnosed with an overnight sleep test
called a polysomnogram, or "sleep study".

There are three forms of sleep apnea: central (CSA), obstructive (OSA), and complex or mixed sleep apnea (i.e.,
a combination of central and obstructive) constituting 0.4%, 84% and 15% of cases respectively. In CSA,
breathing is interrupted by a lack of respiratory effort; in OSA, breathing is interrupted by a physical block to
airflow despite respiratory effort and snoring is common.

Regardless of type, an individual with sleep apnea is rarely aware of having difficulty breathing, even upon
awakening. Sleep apnea is recognized as a problem by others witnessing the individual during episodes or is
suspected because of its effects on the body (sequelae). Symptoms may be present for years (or even decades)
without identification, during which time the sufferer may become conditioned to the daytime sleepiness
and fatigue associated with significant levels of sleep disturbance.

Sleep apnea is a common and potentially devastating sleep disorder. It is the most common reason that patients
are referred to sleep centers around the country. Patients with the usual form of sleep apnea actually close off
their airway at night.

This airway closure occurs either behind the tongue or behind the nose. Patients continue to make efforts to
breathe. Then after 10 to 120 seconds, the brain, realizing it is not getting any oxygen, actually "wakes up." The
brain then tells the upper airway to open to let some air in.

This is associated with loud bothersome snoring, often described as snorting and gasping. Patients may take a
few breaths of air, the brain goes to sleep again and the cycle may repeat itself several hundred times a night.
Patients are often not even aware that they are doing this (although the bed partner is).

Sleep apnea is dangerous, common, relative easy to diagnose, and treatable. Patients with sleep apnea are at
great risk for heart disease, heart attacks, strokes and high blood pressure. In addition, since the sleep is poor
quality (remember the brain keeps waking up), patients are often sleepy during the day. Sleepiness is associated
with inability to concentrate, remember or think. There is also increased risk in falling asleep while doing vital
tasks such as driving or using heavy machinery.

Medical treatment involves weight loss if the patient is overweight, avoidance of drugs, which increase the risk
of apneas such as sleeping pills, alcohol and sedative medicines, and sometimes sleeping semi-upright.
However, in most cases additional treatment is warranted.

In some cases, Continuous Positive Airway Pressure (CPAP for short) is used to treat patients. CPAP, a
mechanical device worn while sleeping which provides continuous air pressure to keep the airway open, is the

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most recommended treatment for moderate to severe sleep apnea. CPAP can take some getting used to, but
provides effective relief when used correctly.

For this treatment a mask is fit over the nose or over the nose and mouth. The mask is pressurized slightly to
hold the airway open and allow the patient to sleep normally. Newer technology has made the masks relatively
comfortable to use.

Some patients may be candidates for surgery on the upper airway. In the usual upper airway surgery the uvula
(that punching bag in the back of the throat) and some of the surrounding soft tissue is removed to enlarge the
air passage. In other cases a dental device designed to move the lower jaw down and outwards slightly may be
worn at night.

In a few cases, treatment is begun with an emergent tracheostomy when sleep apnea is considered to be
immediately life-threatening. The decision about which form of treatment to use should be decided by the
patient and his/her physician on the basis of the sleep studies and rest of the clinical data.

Sleep apnea is a common sleep disorder that can be potentially very serious, and even life-threatening. In sleep
apnea, your breathing stops or gets very shallow while you are sleeping. Each pause in breathing typically lasts
10 to 20 seconds or more, and the pauses can occur 20 to 30 times or more an hour. During the episodes of
apnea, the sleeper wakes up to breathe again, disrupting sleep, and also suffers from a brief lack of oxygen.

Symptoms of sleep apnea include:

 Frequent gaps in breathing during sleep (apnea)

 Gasping or choking for air to restart breathing, often causing sleeper or partner to wake

 Loud snoring

 Feeling un-refreshed after a night’s sleep and excessive daytime tiredness

The most common type of sleep apnea is obstructive sleep apnea (OSA). Causes of sleep apnea are generally
physical in nature, including excess weight or tissue (sometimes from being overweight or obese), large tonsils
or adenoids, nasal congestion or blockage or a unique shaped head, neck or chin.

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Self help treatments, like losing weight, elevating the head of the bed or sleeping on your side, can also be
effective remedies for mild to moderate sleep apnea. Dental appliances and surgery are other treatment options.

Image shows a Patient connected for a sleep study to determine

degree of apnea. Sensors variously detect brain activity, snoring
sounds, etc. The white bands are to determine expansion and
contraction of chest and abdomen.

Obstructive Sleep Apnea (OSA)

Obstructive sleep apnea (OSA) is the most common category of sleep-disordered breathing. The muscle tone of
the body ordinarily relaxes during sleep, and at the level of the throat the human airway is composed of
collapsible walls of soft tissue which can obstruct breathing during sleep. Mild occasional sleep apnea, such as
many people experience during an upper respiratory infection, may not be important, but chronic severe
obstructive sleep apnea requires treatment to prevent low blood oxygen (hypoxemia), sleep deprivation, and
other complications. The most serious complication is a severe form of congestive heart failure called cor
pulmonale.

Individuals with low muscle tone and soft tissue around the airway (e.g., because of obesity) and structural
features that give rise to a narrowed airway are at high risk for obstructive sleep apnea. The elderly are more
likely to have OSA than young people. Men are more likely to suffer sleep apnea than women and children are,
though it is not uncommon in the latter two population groups.

The risk of OSA rises with increasing body weight, active smoking and age. In addition, patients with diabetes
or "borderline" diabetes have up to three times the risk of having OSA.

Common symptoms include loud snoring, restless sleep, and sleepiness during the daytime. Diagnostic tests
include home oximetry or polysomnography in a sleep clinic.

Some treatments involve lifestyle changes, such as avoiding alcohol or muscle relaxants, losing weight, and quit
smoking. Many people benefit from sleeping at a 30-degree elevation of the upper body or higher, as if in
a recliner. Doing so helps prevent the gravitational collapse of the airway. Lateral positions (sleeping on a side),
as opposed to supine positions (sleeping on the back), are also recommended as a treatment for sleep apnea,
largely because the gravitational component is smaller in the lateral position. Some people benefit from various
8
kinds of oral appliances to keep the airway open during sleep. "Breathing machines" like the continuous
positive airway pressure (CPAP) may help. There are also surgical procedures to remove and tighten tissue and
widen the airway.

As already mentioned, snoring is a common finding in people with this syndrome. Snoring is the turbulent
sound of air moving through the back of the mouth, nose, and throat. Although not everyone who snores is
experiencing difficulty breathing, snoring in combination with other conditions such as overweight and obesity
has been found to be highly predictive of OSA risk. The loudness of the snoring is not indicative of the severity
of obstruction, however. If the upper airways are tremendously obstructed, there may not be enough air
movement to make much sound. Even the loudest snoring does not mean that an individual has sleep apnea
syndrome. The sign that is most suggestive of sleep apneas occurs when snoring stops. If both snoring and
breathing stop while the person's chest and body tries to breathe, that is literally a description of an event in
obstructive sleep apnea syndrome. When breathing starts again, there is typically a deep gasp and then the
resumption of snoring.

Other indicators include (but are not limited to): hypersomnolence, obesity BMI >30, large neck circumference
(16 in (410 mm) in women, 17 in (430 mm) in men), enlarged tonsils and large tongue volume, micrognathia,
morning headaches, irritability/mood-swings/depression, learning and/or memory difficulties, and sexual
dysfunction.

The term "sleep-disordered breathing" is commonly used in the U.S. to describe the full range of breathing
problems during sleep in which not enough air reaches the lungs (hypopnea and apnea). Sleep-disordered
breathing is associated with an increased risk of cardiovascular disease, stroke, high blood
pressure, arrhythmias, diabetes, and sleep deprived driving accidents. When high blood pressure is caused by
OSA, it is distinctive in that, unlike most cases of high blood pressure (so-called essential hypertension), the
readings do not drop significantly when the individual is sleeping. Stroke is associated with obstructive sleep
apnea. Sleep apnea sufferers also have a 30% higher risk of heart attack or premature death than those
unaffected.

In the June 27, 2008, edition of the journal Neuroscience Letters, researchers revealed that people with OSA
show tissue loss in brain regions that help store memory, thus linking OSA with memory loss. Using magnetic
resonance imaging (MRI), the scientists discovered that sleep apnea patients' mammillary bodies were nearly 20
percent smaller, particularly on the left side. One of the key investigators hypothesized that repeated drops in
oxygen lead to the brain injury.

9
Central sleep apnea (CSA)
In pure central sleep apnea or Cheyne-Stokes respiration, the brain's respiratory control centers are imbalanced
during sleep. Blood levels of carbon dioxide, and the neurological feedback mechanism that monitors them, do
not react quickly enough to maintain an even respiratory rate, with the entire system cycling between apnea and
hyperpnea, even during wakefulness. The sleeper stops breathing and then starts again. There is no effort made
to breathe during the pause in breathing: there are no chest movements and no struggling. After the episode of
apnea, breathing may be faster (hyperpnea) for a period of time, a compensatory mechanism to blow off
retained waste gases and absorb more oxygen.

While sleeping, a normal individual is "at rest" as far as cardiovascular workload is concerned. Breathing is
regular in a healthy person during sleep, and oxygen levels and carbon dioxide levels in the bloodstream stay
fairly constant. The respiratory drive is so strong that even conscious efforts to hold one's breath do not
overcome it. Any sudden drop in oxygen or excess of carbon dioxide (even if tiny) strongly stimulates the
brain's respiratory centers to breathe.

In central sleep apnea the basic neurological controls for breathing rate malfunction and fail to give the signal to
inhale, causing the individual to miss one or more cycles of breathing. If the pause in breathing is long enough
the percentage of oxygen in the circulation will drop to a lower than normal level (hypoxaemia) and the
concentration of carbon dioxide will start building higher than normal level (hypercapnia). In turn, these
conditions of hypoxia and hypercapnia will trigger additional effects on the body. Brain cells need constant
oxygen to live, and if the level of blood oxygen goes low enough for long, the consequences of brain damage
and even death will occur. Fortunately, central sleep apnea is more often a chronic condition that causes much
milder effects than sudden death. The exact effects of the condition will depend on how severe the apnea is and
on the individual characteristics of the person having the apnea. Several examples are discussed below, and
more about the nature of the condition is presented in the section on Clinical Details.

In any person, hypoxia and hypercapnia have certain common effects on the body. The heart rate will increase,
unless there are such severe co-existing problems with the heart muscle itself or the autonomic nervous system
that makes this compensatory increase impossible. The more translucent areas of the body will show a bluish or
dusky cast from cyanosis, which is the change in hue that occurs owing to lack of oxygen in the blood ("turning
blue"). Overdoses of drugs that are respiratory depressants (such as heroin, and other opiates) kill by damping
the activity of the brain's respiratory control centers. In central sleep apnea, the effects of sleep alone can
remove the brain's mandate for the body to breathe. Even in severe cases of central sleep apnea, the effects
almost always result in pauses that make breathing irregular, rather than cause the total cessation of breathing.

10
  Normal Respiratory Drive: After exhalation, the blood level of oxygen decreases and that of carbon
dioxide increases. Exchange of gases with a lungful of fresh air is necessary to replenish oxygen and rid the
bloodstream of built-up carbon dioxide. Oxygen and carbon dioxide receptors in the blood stream
(called chemoreceptors) send nerve impulses to the brain, which then signals reflex opening of the larynx(so
that the opening between the vocal cords enlarges) and movements of the rib cage muscles and diaphragm.
These muscles expand the thorax (chest cavity) so that a partial vacuum is made within the lungs and air
rushes in to fill it.
 Physiologic effects of central apnea: During central apneas, the central respiratory drive is absent, and
the brain does not respond to changing blood levels of the respiratory gases. No breath is taken despite the
normal signals to inhale. The immediate effects of central sleep apnea on the body depend on how long the
failure to breathe endures. At worst, central sleep apnea may cause sudden death. Short of death, drops in
blood oxygen may trigger seizures, even in the absence of epilepsy. In people with epilepsy, the hypoxia
caused by apnea may trigger seizures that had previously been well controlled by medications. In other
words, a seizure disorder may become unstable in the presence of sleep apnea. In adults with coronary
artery disease, a severe drop in blood oxygen level can cause angina, arrhythmias, or heart attacks
(myocardial infarction). Longstanding recurrent episodes of apnea, over months and years, may cause an
increase in carbon dioxide levels that can change the pH of the blood enough to cause a metabolic acidosis.

Mixed apnea and complex sleep apnea

Some people with sleep apnea have a combination of both types. When obstructive sleep apnea syndrome is
severe and longstanding, episodes of central apnea sometimes develop. The exact mechanism of the loss of
central respiratory drive during sleep in OSA is unknown but is most commonly related to acid-base and
CO2 feedback malfunctions stemming from heart failure. There is a constellation of diseases and symptoms
relating to body mass, cardiovascular, respiratory, and occasionally, neurological dysfunction that have a
synergistic effect in sleep-disordered breathing. In some cases, a side effect from the lack of sleep is a mild case
of narcolepsy (EDS) where the subject has had minimal sleep and this extreme fatigue over time takes its toll on
the subject. The presence of central sleep apnea without an obstructive component is a common result of
chronic opiate use (or abuse) owing to the characteristic respiratory depression caused by large doses of
narcotics.

Complex sleep apnea has recently been described by researchers as a novel presentation of sleep apnea.
Patients with complex sleep apnea exhibit OSA, but upon application of positive airway pressure the patient
exhibits persistent central sleep apnea. This central apnea is most commonly noted while on CPAP therapy after

11
the obstructive component has been eliminated. This has long been seen in sleep laboratories and has
historically been managed either by CPAP or Bi-Level therapy. Adaptive servo-ventilation (ASV) modes of
therapy have been introduced to attempt to manage this complex sleep apnea. Studies have demonstrated
marginally superior performance of the adaptive servo ventilators in treating Cheyne-Stokes breathing;
however, no longitudinal studies have yet been published, nor have any results been generated that suggest any
differential outcomes versus standard CPAP therapy. At the AARC 2006 in Las Vegas, NV, researchers
reported successful treatment of hundreds of patients on ASV therapy; however, these results have not been
reported in peer-reviewed publications as of July 2007.

An important finding by Dernaika et al. suggests that transient central apnea produced during CPAP titration
(the so-called "complex sleep apnea") is "…transient and self-limited. The central apneas may in fact be
secondary to sleep fragmentation during the titration process. As of July 2007, there has been no alternate
convincing evidence produced that these central sleep apnea events associated with CPAP therapy for
obstructive sleep apnea are of any significant pathophysiologic importance.

Research is ongoing, however, at the Harvard Medical School, including adding dead space to positive airway
pressure for treatment of complex sleep-disordered breathing.

Snoring
Snoring, which is sometimes confused with sleep apnea, can be a significant obstacle to quality sleep both for
yourself and your partner.

Snoring is caused by a narrowing of your airway, either from poor sleep posture, excess weight or physical
abnormalities of your throat. A narrow airway gets in the way of smooth breathing and creates the sound of
snoring. The snoring noise doesn’t necessarily that the airway is obstructed, as it is in sleep apnea. Snoring may
accompany sleep apnea, but not always.

There are many self help remedies and cures for snoring. If you are a mild snorer, sleeping on your side,
elevating the head of your bed, or losing weight may stop the snoring. Consulting a doctor on the problem may
be ideal before trying self made remedies. Don’t give up trying to find a solution for your snoring – it will
make you and your partner, sleep better and may also boost relationship.

Restless Legs Syndrome (RLS) and Periodic limb Movement Disorder (PLMD) in Sleep

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Restless legs syndrome (RLS) is a disorder causing an almost irresistible urge to move the legs (or arms). The
urge to move occurs when resting or lying down and is usually due to uncomfortable, tingly, or creeping
sensations in the legs or affected limbs. Movement eases the feelings, but only for a while.

Periodic Limb Movement Disorder (PLMD) is a related condition involving involuntary, rhythmic limb
movements, either while asleep or when awake. While most people who have Restless Legs Syndrome also
have PLMD, only some people with PLMD also have RLS.

RLS can occur on its own or be related to other medical conditions, such as anemia, kidney disease, pregnancy,
thyroid problems, Parkinson’s or alcoholism. RLS may run in families.

Alternative therapies, lifestyle changes, and even nutritional supplements have proven helpful for RLS and
PLMD sufferers.

Restless legs syndrome (RLS) is characterized by an intolerable, internal itching sensation occurring in the
lower extremities that causes an almost irresistible urge to move the legs. The sensation is commonly described
as a "creepy" or "crawly" sensation and is typically relieved by movement of the legs or walking around. When
movement stops, however, the sensations frequently return. The abnormal sensations are more common in the
late afternoon or evening hours.

In some patients, this problem persists into the nighttime and may prevent patients from getting a restful night's
sleep. Pregnancy and iron deficiency are associated with an increased frequency of this disease. In many
patients, RLS is extremely distressing. Further, RLS is more common than previously thought, affecting 5-10%
of adults and increasing with age.

Almost all patients with restless legs syndrome have a problem called period limb movement disorder. In this,
there are leg (sometimes arm) movements occurring at regular intervals during the night. These movements may
fragment sleep, leading to poor quality, non-refreshing sleep. Periodic limb movement disorder can also occur
as an isolated problem, often reported by the bed partner.

Luckily, in most people, restless legs syndrome and periodic limb movement disorder are relatively easily
treated. Treatment commonly includes the incorporation of both aerobic and leg stretching exercises. Leg
stretching or even yoga exercises can be done prior to bedtime to alleviate symptoms and may be all that is
needed in mild cases. Iron replacement therapy is used if patients are iron deficient. Drugs used to treat
Parkinson's disease are very effective in treating most cases. These include the drug pramipexole (Mirapex) and
ropinirole (Requip). Medications, such as valium-type medications, such as clonazepam (Klonopin) or analgesic

13
medications related to morphine and opium, can be also be used. In some cases, anti-seizure medications may
be effective.

Narcolepsy
Narcolepsy is a neurological disorder that causes extreme sleepiness and may even make a person fall asleep
suddenly and without warning. Specific causes of narcolepsy are not known but people with narcolepsy are
lacking hypocretin, a brain chemical which regulates sleep and wakefulness.

The “sleep attacks” experienced by people with narcolepsy occur even after getting enough sleep at night, and
make it difficult for people to live normal lives. Falling asleep during activities like walking, driving or working
can have dangerous results.

Symptoms of narcolepsy include:

 Intermittent, uncontrollable episodes of falling asleep during the daytime

 Excessive daytime sleepiness

 Sudden, short-lived loss of muscle control during emotional situations (cataplexy)

Narcolepsy may be genetic, but it also appears to be influenced by environmental triggers. Treatment requires a
combination of medication, behavioral treatments, and counseling.

Narcolepsy is a chronic sleep disorder that commonly begins during adolescence and is characterized by
excessive daytime sleepiness with the occurrence of sleep attacks. Narcolepsy can run in families, but can occur
in the absence of any family history as well. There are several other characteristic symptoms that may or may
not be present, including cataplexy, sleep paralysis and hypnogogic hallucinations.

• Cataplexy is the sudden loss of muscle tone, commonly associated with strong emotions. It may
be a subtle sensation of weakness or a complete loss of strength with a fall to the ground.

• Sleep paralysis is a sensation of not being able to move on waking, usually for a few seconds.

• Hypnogogic hallucinations are very vivid and sometimes violent or bizarre sensations, almost
dreamlike, that occur on waking or falling asleep.

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The treatment of narcolepsy and its associated symptoms commonly requires a combination of behavioral
modification and drug therapy. Many patients with narcolepsy will do well with naps scheduled at specific
times during the day. Stimulant medication may be used to alleviate symptoms of daytime sleepiness. Other
medications, such as certain anti-depressants, are used to treat cataplexy. A new promising treatment for
cataplexy using a drug called sodium oxybate has recently become available. Treatment for each patient must
be individualized and each patient with his/her physician needs to discuss this on a case-by-case basis.

Poor Sleep Habits

Poor sleep habits (referred to as hygiene) are one of the most common problems encountered in our society. We
stay up too late and get up too early. We interrupt our sleep with heavy drinking, drugs, chemicals, work, and
we over-stimulate ourselves with late-night activities such as television watching soap and serials, late night
films and other activities. This type of activities makes the normal sleeping habit disturbed and the human are
reluctant towards attaining a normal night's sleep. Many of the human natural habits are not followed which are
"common sense," but it is surprising how many people fail to follow these.

Insomnia
Insomnia is the inability to sleep or inability to sleep well at night. Many different medical and mental health
problems cause insomnia. Insomnia may be situational, lasting a few days to weeks, or chronic, lasting for more
than 1 month.

Around 9-12 percent of the American population report chronic insomnia. In severe cases, patients experience
fatigue, sleepiness, difficulty concentrating and difficulty with thinking. Many sufferers feel that they have been
robbed of the joy of life. Insomnia may be a symptom of breathing problems at night like sleep apnea, of
medical illness like heart failure, a side effect of medications, or a symptom of severe anxiety or depression
illness.

While short-lasting insomnia periods are well treated with medication, chronic or long-lasting insomnia may not
respond well to medications. Thus, throwing sleeping pills at many patients with chronic insomnia is not an
effective way to treat the problem.

An evaluation by the patient's personal physician or a sleep specialist often helps get to the root of the problem.
Many patients respond well to what is called "cognitive behavioral therapy." In this form of therapy, incorrect
ideas about sleep are corrected. In addition, relaxation and behavioral techniques may be used to help patients
15
fall asleep. This combined with treatment of any underlying disorders is often the best way to treat the
devastating symptom of insomnia.

Sleepwalking/Somnambulism
Sleepwalking, also referred to as somnambulism, is characterized by walking or other physical activities during
sleep. Sleepwalking is common in children -- up to 15 percent of children have had this problem -- but can
occur at any age. In children, it can be associated with sleep deprivation or anxiety. In adults, it is more
commonly associated with other medical disorders, medication use, or anxiety or depressive disorders.

Clinically, the person may simply sit up with their eyes open, appearing to be awake, or they may engage in a
complex task. Episodes can last from seconds to minutes. Contrary to popular belief, it is safe to wake a
sleepwalker, but they may be confused and disoriented on waking.

There is no specific treatment except to avoid triggers if known, or treat anxiety or depression. If severe, short-
term use of sedatives may be considered. Otherwise it is best to keep the person safe and out of harm's way. We
often advise families to make sure the windows are closed and that there is no possibility of sleepwalking
leading to danger for the patient.

Sleep Disorders in Medical Illnesses

Many medical illnesses are associated with disturbances of sleep. Patients with chronic lung disease may
experience low oxygen levels at night that disturb sleep. Patients with asthma may develop wheezing or
shortness of breath at night, usually in the early morning hours. Patients with heart failure may develop
abnormal breathing at night, which disturbs sleep much in the way that sleep apnea does. Patients with
Parkinson's or other neurological diseases may develop disturbed sleep.

Many people with mental illnesses, notably depression, anxiety, post-traumatic stress syndrome, and panic
attacks, develop profound sleep disturbances. Insomnia is a common symptom in many people with these
problems. Evaluation and treatment by a health care provider skilled in these disorders, usually in conjunction
with evaluation by a sleep specialist, often brings about great improvement.

General principles of treatment

Treatments for sleep disorders generally can be grouped into four categories:
16
 • behavioral/ psychotherapeutic treatments

• rehabilitation/management

• medications

• other somatic treatments

None of these general approaches is sufficient for all patients with sleep disorders. Rather, the choice of a
specific treatment depends on the patient's diagnosis, medical and psychiatric history, and preferences, as well
as the expertise of the treating clinician. Often, behavioral/psychotherapeutic and pharmacological approaches
are not incompatible and can effectively be combined to maximize therapeutic benefits. Management of sleep
disturbances that are secondary to mental, medical, or substance abuse disorders should focus on the underlying
conditions.

Medications and somatic treatments may provide the most rapid symptomatic relief from some sleep
disturbances. Some disorders, such as narcolepsy, are best treated pharmacologically. Others, such as chronic
and primary insomnia, may be more amenable to behavioral interventions, with more durable results.

Chronic sleep disorders in childhood, which affect some 70% of children with developmental or psychological
disorders, are under-reported and under-treated. Sleep-phase disruption is also common among adolescents,
whose school schedules are often incompatible with their natural circadian rhythm. Effective treatment begins
with careful diagnosis using sleep diaries and perhaps sleeps studies. Modifications in sleep hygiene may
resolve the problem, but medical treatment is often warranted.

Special equipment may be required for treatment of several disorders such as obstructive apnea, the circadian
rhythm disorders and bruxism. In these cases, when severe, an acceptance of living with the disorder, however
well managed, is often necessary.

Some sleep disorders have been found to compromise glucose metabolism.

For mild cases of sleep apnea, a treatment which is a lifestyle change is sleeping on one's side, which can
prevent the tongue and palate from falling backwards in the throat and blocking the airway. Another is avoiding
alcohol and sleeping pills, which can relax throat muscles, contributing to the collapse of the airway at night.

For moderate to severe sleep apnea, the most common treatment is the use of a continuous positive airway
pressure (CPAP) device, which 'splints' the patient's airway open during sleep by means of a flow of pressurized
air into the throat. The patient typically wears a plastic facial mask, which is connected by a flexible tube to a
small bedside CPAP machine. The CPAP machine generates the required air pressure to keep the patient's
airways open during sleep. Advanced models may warm or humidify the air and monitor the patient's breathing

17
to insure proper treatment. Although CPAP therapy is extremely effective in reducing apneas and less expensive
than other treatments, some patients find it extremely uncomfortable. Many patients refuse to continue the
therapy or fail to use their CPAP machines on a nightly basis. The CPAP machine assists only inhaling, whereas
a Bi-PAP machine assists with both inhaling and exhaling and is used in more severe cases.

In addition to CPAP, dentists specializing in sleep disorders can prescribe Oral Appliance Therapy (OAT). The
oral appliance is a custom-made mouthpiece that shifts the lower jaw forward, opening up the airway. OAT is
usually successful in patients with mild to moderate obstructive sleep apnea. OAT is a relatively new treatment
option for sleep apnea in the United States, but it is much more common in Canada and Europe. Its use has led
to increasing recognition of the importance of upper airway anatomy in the pathophysiology of OSA.

CPAP and OAT are generally effective only for obstructive and mixed sleep apnea which has a mechanical
rather than a neurological cause.

For patients who do not tolerate or fail nonsurgical measures, surgical treatment to anatomically alter the airway
is available. Several levels of obstruction may be addressed, including the nasal passage, throat (pharynx), base
of tongue, and facial skeleton. Surgical treatment for obstructive sleep apnea needs to be individualized in order
to address all anatomical areas of obstruction. Often, correction of the nasal passages needs to be performed in
addition to correction of the oropharynx passage. Septoplasty and turbinate surgery may improve the nasal
airway. Tonsillectomy and uvulo-palato-pharyngo-plasty (UPPP or UP3) is available to address pharyngeal
obstruction. Base-of-tongue advancement by means of advancing the genial tubercle of the mandible may help
with the lower pharynx. A myriad of other techniques are available, including hyoid bone myotomy and
suspension and various radiofrequency technologies. For patients who fail these operations, the facial skeletal
may be advanced by means of a technique called maxillamandibular advancement, or two-jaw surgery (upper
and lower jaws). Technically, this is accomplished by a surgery similar to orthognathic surgeries addressing an
abnormal bite. The surgery involves a Lefort type one osteotomy and bilateral sagittal split mandibular
osteotomies.

Sleep Medicine

Due to rapidly increasing knowledge about sleep in the 20th century, including the discovery of REM (Rapid
Eye Movement) sleep and sleep apnea, the medical importance of sleep was recognized. The medical
community began paying more attention than previously to primary sleep disorders, such as sleep apnea, as well
as the role and quality of sleep in other conditions. By the 1970s in the USA, clinics and laboratories devoted to
the study of sleep and sleep disorders had been founded, and a need for standards arose.
18
Sleep Medicine is now a recognized subspecialty within internal medicine, medicine,
pediatrics, otolaryngology, psychiatry and neurology in the United States and many other developing and
developed countries of the world. Certification in Sleep Medicine shows that the specialist: "has demonstrated
expertise in the diagnosis and management of clinical conditions that occur during sleep, that disturb sleep, or
that are affected by disturbances in the wake-sleep cycle. This specialist is skilled in the analysis and
interpretation of comprehensive polysomnography, and well-versed in emerging research and management of a
sleep laboratory."

Competence in sleep medicine requires an understanding of a myriad of very diverse disorders, many of which
present with similar symptoms such as excessive daytime sleepiness, which, in the absence of volitional sleep
deprivation, "is almost inevitably caused by an identifiable and treatable sleep disorder", such as sleep apnea,
narcolepsy, idiopathic central nervous system (CNS) hypersomnia, Kleine-Levin syndrome, menstrual-related
hypersomnia, idiopathic recurrent stupor, or circadian rhythm disturbances. Another common complaint is
insomnia, a set of symptoms which can have a great many different causes, physical and mental. Management
in the varying situations differs greatly and cannot be undertaken without a correct diagnosis.

Sleep dentistry (bruxism, snoring and sleep apnea), while not recognized as one of the nine dental specialties,
qualifies for board-certification by the American Board of Dental Sleep Medicine (ABDSM). The resulting
Diplomate status is recognized by the American Academy of Sleep Medicine (AASM), and these dentists are
organized in the Academy of Dental Sleep Medicine (USA). The qualified dentists collaborate with sleep
physicians at accredited sleep centers and can provide oral appliance therapy and upper airway surgery to treat
or manage sleep-related breathing disorders.

In the UK, knowledge of sleep medicine and possibilities for diagnosis and treatment seem to lag.
Guardian.co.uk quotes the director of the Imperial College Healthcare Sleep Centre: "One problem is that there
has been relatively little training in sleep medicine in this country – certainly there is no structured training for
sleep physicians."] The Imperial College Healthcare site shows attention to obstructive sleep apnea syndrome
(OSA) and very few other sleep disorders.

COMPANY DETAILS
BOC India Limited (BOC India), a member of the Linde Group operates in two segments: Gases and Related
Products and Project Engineering. The Gases and Related Products segment comprises of gases in bulk,
packaged gases and related products. Gases in bulk consist of liquid oxygen, nitrogen and argon and the
packaged gases consist of compressed industrial, medical, electronic and special gases packaged in cylinders.
The segment therefore, covers customers in tonnage, bulk, packaged gases and healthcare segments. Project

19
Engineering segment comprises manufacture and sale of cryogenic and non cryogenic vessels, as well as
designing, supplying, testing, erecting and commissioning of projects.

Global expertise adapted for the Indian needs - this is the mantra which BOCI has been using for the last 75
years to satisfy its customers. We supply more than 20,000 gases and mixtures - that make steel plants more
efficient, help conserve our environment, preserve food, help hospitals to sustain lives and in general……make
our customers more productive. The company started operations in India in 1935 as the Indian Oxygen and
Acetylene Company. It has since evolved into a subsidiary of the Linde Group, bringing you the best
international technology and safety standards, while catering to the needs of a wide variety of industries.
More than 20 production facilities, including one of Asia's largest air separation units; 40 warehouses and
depots; 100 dealers; more than 100 dedicated tankers in the distribution fleet; all this and more give BOC a
geographic reach which puts us close to our customers in any part of India. BOC India now has four focused
business areas:-Industrial Gases, Medical Gases, Specialty Gases and Projects.

Why BOC is the best as the gas specialist?

10 reasons why you should choose BOC India as your Gases Specialist

History

20
 9) What kind of sleep disorder do the patients suffer from?

According to the responses from 27 hospitals I got these statistics:-

• 18 hospitals said patient suffer from chronic sleep disorder problems.

• There was no response regarding patient suffering from transient and short term sleep disorder.

• 5 hospitals couldn’t say regarding the patient’s suffering stage.

• 4 hospitals refused to comment on this matter.

21
 DISCUSSION
Findings facts and Scope with logic and recommendations

After completing the survey I found out that:-

• 78% of the responding hospitals/health centre receive enquires or cases related to sleeping disorders
which includes all the top Multi-specialty, Super-specialty, Nursing homes and Clinics. Therefore the
awareness of sleeping disorder problem in patients (target audience) is known to them and is growing in
numbers. 15 to 20 patients per month visits both at Calcutta Medical Research Institute (CMRI), at
Ekbalpur and Medica ENT, at Mukundapur a clinic specialized for ENT problems only. Again 10-15
patients per month visits Apollo Gleneagles Hospital, at Kadapara. 8-10 patients/month visits both at
Rabindranath Tagore International Institute of Cardiac Science (RTIICS) and Advanced Medical
Research Institute (AMRI) at Dhakuria. Other health care institutes receive monthly footfalls but less in
numbers. But still it is a good sign that most of the hospital receives sleeping disorder cases. With
awareness programs like health related seminars and knowledgeable advertisements through media
(TVC, radio and newspaper) this numbers can increase.

• 22% of the hospitals at Kolkata have setup of sleep lab. They have procured by Purchasing, Donated (by
NGO or other organization) or on Rental basis. From this logic we find the market has a huge
potentiality as patients are more than sleep lab availability. Again availing the sleep lab is a costly affair
as the overnight sleep study monitoring system can charge anywhere from Rs.4500/- to Rs 10000/-
which can’t be availed by patients from diversified economical backgrounds. Advanced Medical
Research Institute (AMRI), Desun Hospital and Heart Institute, Apollo Gleneagles hospital, Medica
ENT and Calcutta Medical Research Institute (CMRI) has their own lab set up. AMRI, Desun, CMRI
and Apollo Gleneagles have purchased their own lab monitoring system in their premises. Medica ENT

22
 gets it by other ways (i.e., outsourced). Desun Hospital receives less footfalls as they are a new in the
market. Fortis Hospital has a sleep lad but not under operation.

• The sleep study machines are manufactured by Siemens, Philips, GE, Somnomedics Wireless System,
Viasys and other such companies which are generally not disclosed by health care institutes but have
been known by verbal discussions with lab technicians and other stuffs. Lab technicians generally
manage the sleep lab devices. Companies itself generally sets up the lab and provides services till the
warranty (1 yr) last.

• 41% of the hospitals have visiting consultants, 26% of the hospitals have full time consultants and 7% of
the hospital has both visiting and fulltime consultants for sleeping disorder problem. If these all are
added up, then 74% of the hospitals have consultants for sleeping disorder problem which means that
the consultants are available and are good in number. Medicinal products for sleeping disorder can be
pushed in the market through consultants towards the targeted audience.

• With growing number of patients getting aware of sleeping disorder problem, the market potentiality
seems to be good in near future. Low cost treatment procedure can be a hit in the market. Cost of c-pap
which has to be bought by patients cost around Rs. 35000/-. Most of the patients avoid taking due to the
cost based affair but 10 out of 27 hospitals prefer c-pap first and then bi-pap if necessary looking at
treatment required as per patients treatment procedure and necessity. Other treatments include
Mardibular Advancement Splint, Surgery(Laser radio frequency or hyoid suspension)

• The average age of patients facing sleep disorder problem are between 41-50 yrs and face chronic
sleeping disorder problems. Transient and short term sleeping disorder problems are still over looked by
patients.

• 11 out of 18 nursing homes/health care institute refer patients to other hospitals where sleep monitoring
system is available which means that with tactful dealing these hospitals can be tapped for treating
sleeping disorder problems. 4 hospitals which refused to give details regarding refer of patients to other
23
 hospitals and 5 hospitals which already has their own sleep study labs are eliminated from 27 to get the
number 18. This means 61 % of the hospitals refer cases to other health care centers.

• Treatment of sleeping disorder is mostly done by Pulmonologist under ENT department. Proper
treatment of OSA is taken care by the pulmonologist where as General Physician recommend sleeping
pills to any sleeping disorder patients. Patients suffering from CSA are rare. Among 27 hospitals, 8
hospitals specialize in Pulmonologist (ENT) for treatment of sleeping disorder where as 4 hospitals
specialize in Neurology for treatment of sleeping disorder. 2 hospitals say it depends on both the
department of ENT and Neurology for treatment of sleeping disorder. 2 hospitals say it depends on
General Physician. 1 hospital says it depends on both the department of Cardiology and Neurology for
treatment of sleeping disorder. 1 hospital says it depends on both the department of Cardiology and ENT
for treatment of sleeping disorder and 1 hospital depends on Cardiologist for treatment of sleeping
disorder problem. Neurologist deals with patient with chronic insomnia.

• The pressure prescribed for various sleep disorder patients is between the 5cm of water to 15 cm of
water which depends on the individual patient anatomy of airway. The pressure also depends on the
Body Mass Index (BMI) of patients and hypothyroidism,

CONCLUSION

At the end of the LIVE Project the ultimate understanding what I got during this one month, treatment of
sleeping disorder has a huge market potentiality. In the near future, the size of the market will literally grow
keeping the fast pace life and ever changing habits and routines of human being, in mind in this 21 st century.
This has been a life time opportunity and a great learning experience for me regarding the study of health care
institutes in Kolkata. Regarding the report, after all the data analysis work I understood that the sleeping
disorder problem and feasible solutions available in today’s hospital industry which is discussed in the report
has a significant impact on the market for treatment. The procedure of the treatment and available remedies are
very costly affair and can’t be afforded by the middle class, lower middle class people and below poverty line

24
(BPL) consumers/patients. Therefore a cheap remedy for treatment of sleeping disorder patients can be a
feasible solution in today’s hospitality industry.

LIMITATIONS AND FUTURE SCOPE OF STUDY

The limitation of the report:

• The sample size can be increased in future

• Bias decision of the participants can have a hugely impact on the research work.

• Consumers who are not interested to give their details or refused can have an impact on this research
work.

• All hospitals did not allow us to get proper responses on our survey. Many consultants were reluctant to
give details on the pressure prescribed.

• The collected samples are based on medical institutes in the city of Kolkata only. The medical institute
in the outskirts of Kolkata and other cities like Howrah, Durgapur, Asansol, Siliguri, Burdawan, Malda
and Haldia could have probably given a better view.
25
In future the scope of the study can be done in a better way by exploiting the limitations to get a better view.

REFERENCES

Websites:-

1) www.wikipedia.com

2) www.boci.com

3) www.yellowpages.com

4) www.justdial.com

Books:-

1) Journal of sleep and sleep disorder research by American Academy of Sleep Medicine and the sleep
Research society

2) The journal of abnormal psychology volume X 1915-1916 by Richard G. Badger

3) Common causes of sleep disruption and daytime sleepiness by Helen S Heussler

26
 APPENDIX
Questionnaire
Dear Sir,

I am a PGDM student working on an internship project dealing with sleeping disorder problems and
feasible solutions available in today’s hospital industry. This data collection is being done purely for
academic purpose only and your responses will be treated with strict confidentiality.

I will be grateful to you on spending few minutes of your vital time on this procedure.

Thanking You.

S no: ……………. Date …………..

Name of the Hospital ………………………………………………..

Address……………………………………………………………….

27
…………………………………………………………………………

City……………………………… Pin………………………………..

Tel………………………………. e-mail……………………………..

Bed Strength………………………. ICCU Beds………………………..

Typhe Trust Govt Super Spl Multi Spl Nur Home Clinic

Tick in the following according to the daily facts available:

1) Do you have any cases reporting / enquiring for sleep disorder problem in your institute?

A) Yes B) No

If any appx number of cases per month …………………………………………….

2) Do you have a visiting consultant for this problem or a full time consultant for sleep disorder problem in
your institute?

Visiting Full time

Either case no: of cases ………………..…….…….……………………………………..

Name of Consultant …………………………………………………………………………….

3) Which is the department investigating sleep disorder problem in your institute?

Name of Dept ……………………………. Consultants name …………..

28
 If any other details……………….…….……………………………………..

4) If no, then which hospital do you recommend your patients for treatment of sleeping

Disorder?

Details………………………………………………………………………………

5) If yes, then which specialized sectors of treatment of sleeping disorder do you deal with?

A) Cardiologist B) Interventional Cardiologist C) Pulmonological Disorder

D) Asthmatic Disorder E) Neuro …………………………..

Any others, please recommend……………………………..

6) Do you have a sleep lab within your premises?

A) Yes B)No

Product manufactured by…………………. Sold by…………………………..

7) If yes, who manages the lab?

Details…………………………………………………………………………….

8) Who has set up the lab ? Company or independent consultant / pvt party
29
 Details………………………………………………………………………………..

9) How much time does a patient need to spend for the treatment of sleeping disorder?

A) 1-2 hrs B) 2-4 hrs C) 4-6 hrs D) 6-8 hrs

10) How many cases do you get every month?

Details………………………………………………………………………………

11) Who analyzes the results after the treatment?

Details……..……………………………………………………………………….

12) What kind of charges is taken for this kind of treatment and what is the average duration of treatment
process?

Details……….…………………………………………………………………………...…

………………………………………………………………………………………………

………………………………………………………………………………………………

30
13) What is the average age of patients appearing for the treatment?

A) Below 20 yrs B) Between 21-30 yrs C) Between 31-40yrs D) Between 41-50 yrs

E) Above 50 yrs

14) What are the types of equipment do you recommend to patients after test ?

A) C-Pap B) By-Pap C)Any others…………………………………………

15) How do you get these equipments?

A) Purchased B) Rental basis C) Donated (by NGO or other organization) D) Any other
ways…………………….

16) What kind of sleep disorder do the patients suffer from?

A) Transient (2-3 days) B) Short term (Less than 3 weeks) C) Chronic (more than 3 weeks)

17) What is the pressure prescribed for various sleep disorder disease?

Details………………………………………………………………………………………

31
…………………………………………………………………………..…………………

…………………………………………………………………………………………….

a. Any other point you find necessary to add……………………………………….

…………………………………………………………………………………………………..

32