Sleep and respiratory conditions can have a significant impact on a person’s health, function and capacity. In the medico-legal setting, however, understanding these conditions can be particularly complex.

Dr Sakhee Kotecha, Respiratory and Sleep Physician and Lung Transplant Specialist, has more than 15 years of experience across respiratory and sleep medicine, alongside subspecialty expertise in lung transplantation. Her move into medico-legal medicine has provided an opportunity to combine her clinical experience with her interest in problem-solving, attention to detail and the law.

Her experience spans respiratory medicine, sleep medicine and lung transplantation, giving her a broad perspective when assessing complex medical presentations.

Sleep Medicine Is More Than Sleep Apnoea

When people think about sleep medicine, sleep apnoea is often the first condition that comes to mind. However, sleep medicine encompasses a much broader range of disorders.

Dr Kotecha’s practice includes insomnia, parasomnias and sleep-disordered breathing, as well as the interaction between these conditions.

Sleep and respiratory conditions can also overlap. A person may experience sleep apnoea alongside chronic insomnia, for example, making it important to understand how the different conditions interact and affect their daily life.

Sleep itself can have a profound effect on function. When someone isn’t sleeping well, they may experience fatigue, reduced concentration and changes in how they experience and manage pain.

The Complex Relationship Between Pain and Sleep

One of the more challenging areas Dr Kotecha discusses is the relationship between pain and sleep.

Pain can interfere with sleep, while poor sleep can contribute to fatigue and influence how a person experiences and manages pain. In medico-legal matters, this creates a complex picture when determining how different conditions and symptoms relate to an original injury.

The challenge becomes even greater when considering the different workers compensation frameworks and guidelines that apply across Australian jurisdictions.

Dr Kotecha highlights the difficulty of assessing insomnia where pain is reported as a contributing factor, particularly when the applicable guidelines do not necessarily allow sleep impairment to be assessed separately in this context.

At the same time, other factors may need to be considered. Weight gain following an injury, reduced physical activity and the use of certain medications can all potentially influence sleep-disordered breathing.

Understanding these relationships requires careful consideration of the individual’s history and the available evidence.

Why Sleep Assessments Can Be Particularly Challenging

Unlike some respiratory conditions, where objective information such as lung function testing, imaging and functional assessments can provide measurable data, sleep can be more difficult to capture.

A sleep study provides information about a particular night, but no two nights are necessarily the same. Pain, activity, environment and other circumstances can all influence sleep.

This makes a detailed clinical history particularly important when assessing sleep-related conditions.

Looking Beyond the Diagnosis

Dr Kotecha also discusses the importance of looking beyond a diagnosis when assessing respiratory conditions.

Asthma and COPD, for example, may have multiple contributing factors. A person with COPD may have a history of smoking, but they may also have experienced occupational exposures that contributed to their respiratory disease.

Similarly, asthma developing later in life may warrant consideration of potential occupational exposures.

Understanding these potential contributions requires a detailed occupational history and careful consideration of the available evidence.

Occupational Exposures and Lung Disease

Occupational lung disease continues to evolve as research identifies new associations between workplace exposures and respiratory conditions.

Dr Kotecha discusses the importance of considering exposures such as silica, organic solvents and other workplace substances, particularly when assessing complex respiratory matters.

Silicosis remains an important concern, particularly among workers exposed to engineered stone and other silica-containing materials. While workplace safety measures and regulations have evolved, the long-term effects of historical exposures may continue to emerge.

For medico-legal assessments, understanding exactly what a person did in their workplace — rather than simply recording their job title — can be critical.

Leaving No Stone Unturned

One case Dr Kotecha recalls involved a greenhouse worker who developed fatigue and respiratory symptoms. A detailed review eventually identified Legionnaires’ disease associated with a strain found in potting mix.

The case demonstrated the importance of looking closely at the person’s actual workplace activities, medical history and potential exposures.

For Dr Kotecha, this level of detail is central to a good medico-legal assessment. Reviewing relevant medical records, understanding the individual’s history and considering the available evidence can help bring the different pieces of a complex matter together.

Clear Questions Lead to Better Assessments

Dr Kotecha also highlights the importance of clear Letters of Instruction.

Broad questions can make it difficult for an expert to understand exactly what the legal team needs addressed. Specific, focused questions allow the expert to concentrate on the relevant issues and provide an opinion within their area of expertise.

Providing the right documentation is equally important. Depending on the matter, this may include:

• Relevant medical records
• Lung function results
• Imaging
• Functional assessments
• Previous sleep studies
• Historical weight information
• Records documenting workplace exposures

Contemporary records can be particularly valuable when considering changes in an individual’s condition before and after an injury or incident.

The Value of Current Clinical Practice

Dr Kotecha continues to work in clinical practice and remains engaged with emerging research and clinical trials.

She notes that respiratory medicine is continually evolving, particularly in areas such as interstitial lung disease, occupational exposures and autoimmune-related lung conditions.

For medico-legal work, maintaining current clinical knowledge allows an expert to consider the latest evidence when questions arise about diagnosis, causation, treatment and prognosis.

Combining Clinical Experience with Medico-Legal Expertise

After more than 15 years working across respiratory and sleep medicine and completing subspecialty training in lung transplantation, Dr Kotecha brings extensive clinical experience to her medico-legal practice.

Her approach is grounded in rigorous clinical assessment, attention to detail and evidence-based reasoning. Whether assessing sleep, respiratory disease or potential occupational exposures, understanding the full clinical and occupational history can be essential to forming a well-informed opinion.

As Dr Kotecha explains, medicine is constantly evolving, making ongoing learning and engagement with current clinical evidence an important part of expert practice.

Listen to The Consult

Hear the full conversation with Dr Sakhee Kotecha on The Consult, where she discusses sleep medicine, respiratory conditions, occupational exposures and the complexities of providing evidence-based medico-legal assessments.

Listen to The Consult →