#535 Sleep Apnea Update: How to Choose and Interpret Sleep Tests and Prescribe CPAP Therapy

Summary

The Curbsiders Internal Medicine Podcast

Episode #535: Sleep Medicine Update (August 10, 2026)

Main Theme:
This episode covers key updates in the diagnosis and management of obstructive sleep apnea (OSA), featuring expert guest Dr. Anissa Das. The hosts explore practical approaches for identifying, testing, and managing sleep apnea in clinical practice, with discussion on emerging technologies, nuanced interpretations of sleep studies, and the latest treatments—including weight loss medications and alternative therapies to CPAP.

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Key Discussion Points & Insights

1. Defining Sleep Apnea and Epidemiology

• Obstructive Sleep Apnea (OSA) is defined as repetitive, partial or complete airway collapse during sleep, leading to hypoxemia, hypercapnia, sympathetic surges, and sleep arousals (05:48).
• Central Sleep Apnea (CSA) is distinguished by reduced respiratory drive, not an airway obstruction (05:48).
• OSA prevalence increases with obesity, male sex, large neck circumference (>17" for men, >15-16" for women), and features like micrognathia/retrognathia and certain comorbidities (11:55, 13:38).

“Obesity is a very big, big factor... Neck circumference, as you mentioned, is really important...for men, we really talk about it being over 17 inches...”
— Dr. Das [13:38]

2. Role of Wearables and Patient Engagement

• Wearable sleep trackers can supplement history but should be interpreted cautiously—use as a piece of the puzzle, not diagnostic (08:31, 09:28).
• Patients often come anxious about tracker data; clinicians should remain curious and engage with their questions rather than dismissing their concerns (10:12).

“Take the data as a piece of the pie...don’t take the data more than the data is worth.”
— Dr. Das [08:31]

3. Clinical Evaluation & Physical Exam

• Key exam findings: BMI, neck circumference, retrognathia/micrognathia, tongue scalloping, macroglossia, Mallampati score (13:38).
• Uvula enlargement can occur due to chronic airway inflammation from sleep apnea (14:29).

4. Screening Tools & Questionnaires

• STOP-BANG is recommended for primary care screening; criteria are straightforward and often align with insurance requirements (20:04).
• Epworth Sleepiness Scale is used more by sleep specialists to quantify daytime sleepiness (20:04).

5. Sleep Apnea Testing: Home vs. Lab

A. Types of Tests

• In-Lab Polysomnography: Gold standard, full physiological monitoring, especially for high-complexity or CSA risk (22:05).
• Traditional Home Study (Type 3): Measures airflow, effort (thoracic/abdominal), oximetry, often actigraphy (22:05, 27:16).
• PPG/PAT Devices: Peripheral arterial tonometry, measures arterial pulse changes as a surrogate for airway events (23:40, 48:13).

B. Indications for Each Test

• Home Testing:
  • High pre-test probability, straightforward OSA, no substantial comorbidities (25:46).
  • Not suitable for neuromuscular disease, severe lung disease (COPD), CHF, chronic opioid use, or CSA risk.
• Lab Testing:
  • Required if home test negative but suspicion remains high, or if comorbidities present (25:46).
  • Needed for sleep-related movement disorders (e.g., periodic limb movements/restless legs) (30:55).
• Home tests are better at ruling in OSA than ruling out; negative home test in high risk = do lab test (29:32).

“Home sleep studies are better at ruling in sleep apnea than out.”
— Dr. Das [29:32]

6. Sleep Study Interpretation

• Key Terms:
  • AHI (Apnea-Hypopnea Index): Number of apneas/hypopneas/hour of sleep.
  • REI (Respiratory Event Index): Events/hour monitoring time (when sleep time isn’t measured).
  • ODI (Oxygen Desaturation Index): Drops in oxygen by ≥4% per hour.
• 3% vs. 4% Desaturation Criteria: 4% is Medicare standard; 3% increases sensitivity, especially in women, younger/less symptomatic patients (33:36, 37:39).
• Dr. Das suggests emphasizing clinical context: treat based on symptoms and degree of AHI elevation (38:17).
• Positional data critical; sometimes sleep apnea severity under-recognized if patient only sleeps on side during study (45:55).

7. Treatment Approaches

A. CPAP/APAP

• First-line for most moderate/severe OSA.
• APAP range often 6-16 cm H₂O (Dr. Das's practice); adjust based on patient’s weight and AHI (56:56).
• Monitor and narrow pressure range after review of median/95th percentile pressures (58:18).
• Key to success: personalized mask interface, comfort features (ramp, expiratory relief), patient support and curiosity about barriers (62:35).
  • Mask swaps: must be done within first 30 days to maximize insurance benefits.

“You gotta figure out what’s bothering them...if it’s airflow, mask, hard to breathe out...we can fix all those things.”
— Dr. Das [64:24]

B. Oral Appliances

• Mandibular advancement devices—good for mild/moderate OSA, can use in severe if CPAP refused (51:17, 52:15).
• Dental realignment issues mitigated by routine use of “bite plates” post-use (51:19).
• Growing insurance coverage; can be $200–$500 out-of-pocket with insurance, up to $3,000 without (53:29).

C. Positional Therapy

• For positional OSA, can try wedge devices, backpacks/"foam rollers", or newer vibration devices (71:29).
• Evaluate with repeated sleep study after intervention to confirm efficacy.

D. Weight Loss & Pharmacologic Therapy

• Weight loss (behavioral, surgical, or meds like tirzepatide) can resolve or reduce OSA in 30–50% (80:19).
• Reassess OSA after significant weight loss (>20% BMI drop or 6+ months post-bariatric surgery) (81:04).

E. Surgery/Neuromodulation

• Hypoglossal nerve stimulation (e.g. Inspire): Consider only after failure of CPAP/oral devices; ~66% success, not first-line (78:25).
• Ensure patients have explored all non-invasive options before surgery consideration.

8. Long-Term Monitoring & Follow-up

• Stable patients (no weight change, good control, asymptomatic): no need for routine repeat sleep studies (66:45).
• Retriage/retest after significant weight loss or if symptoms recur (68:20).
• Target CPAP download AHI <5, treat number + symptoms, but acceptable up to 10 if large AHI decrease and patient is well (68:27).

9. Future Directions: Endotypes and Precision Sleep Medicine

• Research into OSA "endotypes" (anatomic, arousal threshold, loop gain, muscle responsiveness) may guide more individualized therapies and drug development (75:19).
• Drugs such as AD109 and acetazolamide/carbonic anhydrase inhibitors are under study for different OSA pathophysiologic profiles.

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Notable Quotes & Memorable Moments

• On Wearables:
  “If your watch tells you that you’re sleeping poorly and that’s causing anxiety, that’s another issue. But if...your watch is starting to ping that something else is happening, that might be helpful.”
  — Dr. Das [08:31]

• Mask Fitting:
  “Biggest reason patients hate their machines is the mask interface isn’t the right fit...you only have those 30 days [for insurance swaps].”
  — Dr. Das [62:35]

• Treating the Patient, Not the Number:
  “If your AHI on download is under 10 and you’re asymptomatic and you feel great, I’m not going to...treat you, not your number. But in general I’m shooting for under five.”
  — Dr. Das [68:27]

• On Patient Engagement:
  “We’re trying to reconnect with patients...when they come in and they’re excited about something health wise and you’re just like, oh, that’s stupid, go away—that just...sending people back to the internet for bad information.”
  — Dr. Matt Frank [11:09]

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Important Timestamps

| Time | Segment/Event | |-----------|-------------------------------------------------| | 05:05–09:49 | Case #1; OSA/CSA definition, wearables | | 11:55–15:19 | Physical exam clues, role of uvula/malampati | | 19:38–21:27 | Questionnaires: STOP-BANG, Epworth, Berlin | | 22:05–31:00 | In-lab vs. home sleep testing—when/which/type | | 33:01–38:17 | Sleep study interpretation, 3% vs 4% AHI, REI | | 45:55–48:54 | Report nuances: positional OSA, actigraphy, ODI| | 49:16–59:35 | Treatment options: CPAP, oral appliances, APAP | | 62:35–66:05 | Troubleshooting, ramp, pressure release | | 66:33–69:52 | Long-term monitoring, retitration, apps | | 71:29–74:49 | Positional therapy: foam, vibration devices | | 75:19–78:03 | OSA endotypes, precision medicine future | | 78:03–79:40 | Surgical & neurostimulator options | | 80:19–82:41 | Weight loss/drug therapy, when to re-test | | 82:53–84:21 | Take home points, resource recommendations |

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Take Home Points (from Dr. Anissa Das) [82:53]

• Think OSA with:
  • Refractory hypertension (even without classic symptoms)
  • Recent menopause with new/worsened sleepiness (20% increased risk post-menopause, even without weight gain)
  • Unexplained or new AFib with symptoms—at least screen
  • Patients with prior OSA diagnosis who “hated CPAP”: Let them know there are more options now

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Additional Resources Mentioned

• American Academy of Sleep Medicine – resources for clinicians, especially primary care
• Medscape and Haymarket – large primary care education projects in sleep medicine

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This summary captures the main clinical pearls, nuances in diagnostic approach, emerging therapies, and patient-centered treatment strategies discussed in the episode. It is intended for clinicians seeking a quick but in-depth review and actionable practice updates in sleep medicine.

Transcript

[A]

Hey, before we get to the show, I wanted to remind you to check out our [e-mail] curbsiders. If you haven't signed up yet, sign up now to get ad free episodes, twice monthly, bonus episodes, and a whole bunch of other cool [e-mail] curbsiders okay, Paul, this one's, you know, if you squint, this one makes sense for the topic. All right, Paul, why do people who live in Greece hate waking up at dawn?

[B]

I don't know, Matt. Why do people who live in Greece hate waking up at dawn?

[C]

Paul?

[B]

Because. Wait, has dawn grease out of your way? There's some dishwashing detergent thing there.

[A]

How did you get that? Yes, because dawn is tough on Grease. Paul, you watch too much tv.

[B]

Is that what it is? The Curbsiders podcast is for entertainment, education and information purposes only. And the topics discussed should not be used solely diagnosed, treat, cure or prevent any diseases or cond. Furthermore, the views and statements expressed on this podcast are solely those of those and should not be interpreted to reflect official policy or position of any entity, aside from possibly cash, like more hospital and affiliate outreach programs, if indeed there are any. In fact, there are none. Pretty much. We are responsible if you screw up. You should always do your own homework and let us know when we're wrong.

[A]

Welcome back to the curbsiders. I'm Dr. Matthew Frankoado, here with my great friend in America's primary care physician and pun champion, at least of this episode, Dr. Paul Nelson Williams.

[C]

Hey, Paul.

[B]

I'm so proud of myself. Matt. Hello. How are you?

[A]

I'm doing well. This is an episode on Sleep Apnea. Our guest is the great Dr. Anissa Das, a returning guest. And Paul, before we introduce our other co host and our guest, what is it that we do on Curbsiders? Paul?

[B]

Sure, Matt. Just as a reminder to our audience, we are the internal Medicine podcast. We use expert interviews to bring you clinical pearls and practice changing knowledge, as you alluded to. We are joined by co host and producer of this episode, Dr. Elise Burke. Dr. Burke, how are you?

[C]

I'm doing great. How are you doing, Paul?

[B]

I'm great, thank you for asking. I'm really, really proud of the dawn thing. Why don't. If you're comfortable doing so, why don't you tell our audience who we talk to and maybe a little bit what we talked about?

[C]

Definitely. So tonight we have a fantastic conversation with our guest, Dr. Anissa Das. Dr. Das is a professor in the division of pulmonary critical care and sleep at the OHI State University. She is the Director of the Home Sleep Apnea Testing Program and Vice Chair for Faculty Success at the Department for the Department of Medicine. She has chaired numerous National Board Review courses in sleep medicine. She has been a contributing author of both Chest Seek Sleep Medicine and the Chest SEQ Pulmonary and was editor in Chief of the most recent Chest Seek Sleep Medicine. She was the program chair for the Chess 2023 in Honolulu, Hawaii, and she currently serves on the Board of Regents for chest. Tonight, Dr. Das teaches us who to refer for sleep apnea testing, interpretation of sleep studies, and then treatment of obstructive sleep apnea, including troubleshooting of CPAP devices. So without further ado, let's get to

[A]

it and a reminder that this and most episodes will be available for CME credit for all health professionals through VCU [e-mail] Anissa, welcome back to the show. You've just joined us in our ritual clap, which we do before every recording. The audience has heard you before, but it's been a couple years so they want to know what are you up to these days? What hobby or interests do you have outside of medicine that you're recently enjoying?

[D]

So I actually do have a new hobby. I have recently learned how to do better long distance bike riding. And so I got myself a fancier bike and I and when I say longer distance, I just mean medium distance. And my rule is, is if when we're going over 20 miles, totally happy to do that. But there must be a taco stop so that there's a destination. So I can do 40 miles but there must be a taco stop somewhere along the route.

[A]

Yeah, I mean, I think that just makes sense. I don't see why you wouldn't stop for some sort of food in the middle of a long bike ride. You need that like carrot and stick situation to get.

[D]

I'm all about rewards and it started as tacos and now we seek out taco spots wherever we are in the country to stop.

[A]

Yes. Like what's within a 20 mile radius of where you're starting. That's great.

[B]

I was going to mention Ohio, famous for its tacos. I feel like there must be lots of opportunities in terms of where to go.

[D]

Are you being prestigious?

[B]

It's the Taco State, I think, isn't that motto?

[A]

So we should get onto the main topic because I would really love to explore this taco line of dialogue with you, Paul, but I think we should really get on to the first case because we have limited time with our esteemed guests. So, Elise, would you read our first case from Kashlak?

[C]

Absolutely. So, Mr. Cecil Papp is a 53 year old male with history of hypertension, hyperlipidemia and obesity with a BMI of 37, who presents at the request of his wife for discussion of his snoring. Mr. Papp states his wife is able to hear him snore from different rooms in the house and is concerned because at times he seems to be gasping for air while asleep. Mr. Papp also struggles with fatigue during the day and easily falls asleep while reading a book or trying to watch a movie, even in the early afternoon. On exam, he is noted to have a deviated septum, mild micrognathia, and his airway is consistent with Mallampati Class 3. He has a shirt collar of 18 inches. So can we start with defining sleep apnea and reviewing the differences between obstructive and central?

[D]

Sure. So obstructive sleep apnea is a repetitive complete collapse or partial collapse of the airway causing intermittent hypoxemia, hypercapnia, changes in your sympathetic tone, arousals from sleep. When we think about the difference between obstructive sleep apnea and central sleep apnea, the predominant difference is in the cause of the airway stop, low stoppage. So for obstructive sleep apnea, you're initiating breath, you're trying to breathe, but your airways closed and collapsed so the air can't get through. With central sleep apnea, your stimulus to breathe has actually diminished or decreased, so you're not initiating the breath yourself. They also have different outcomes. Right. So, and I think Today this gentleman, Mr. Papp, is as classic as it could be. In fact, he has all the symptoms for obstructive sleep apnea. So for this gentleman, we would be thinking more obstructive based on the symptoms that he's presenting with when it's not

[A]

so well laid out for you. In a case like this, where are you starting or where would you suggest we start? If we're asking if someone just comes in and says, oh yeah, my partner says I snore and then we look at their BMI is 37, it's a 53 year old guy, what else would you be digging in? Like what parts of the history do you most key in on?

[D]

Sure. So all of those things that you just said are the risk factors for predominantly obstructive sleep apnea. The snoring we tend to see in central sleep apnea that can be from various different causes. Right. So in a patient with comorbid heart failure with a decreased ef, that for sure can be associated with central sleep apnea or chain stokes. Central sleep apnea, which is periodic breathing sort of with that diamond shape. Right. People on chronic opiates can have central apneas. They also, those folks can have obstructive apneas because it suppresses your breathing and your airway tone, but they also also can have central sleep apnea. Patients with neuromuscular disease with decreased ability to initiate the breath. Right. They can have increased risk for central sleep apnea. So I think you would look at some of the comorbidities, and then with central sleep apnea related to congestive heart failure, they actually will have central apneas during wakefulness. Obstructive apneas you do not have during wakefulness. Our airway remains open during wakefulness.

[C]

Right.

[B]

Can I ask, has patient wearables helped or hindered sort of the initial workup? I've had calls about patients who talk about becoming bradycardic while they sleep or they get these sort of reports about the quality of their sleep should any of that stuff. Are we at a place now where we can use that to sort of help decide whom to test or whom not, or does that help build a differential for you?

[D]

Not necessarily between central and obstructive, but I think where we're at right now with the wearables, you're right. I mean, they're exploding. What I tell folks to say is don't take the data more than the data is worth. So take it as a piece of the pie. Right. If you are sleeping fantastically and you're not snoring and you feel great, if your watch tells you that you're sleeping poorly and that's causing anxiety, that's another issue. Right. But if you're noticing that you're snoring and you've recently gained some weight and you're waking up more frequently, and all of a sudden your watch is starting to ping that something else is happening that might be helpful. So I think take it in conjunction as a piece of the information. It probably is worth talking to your primary. So if somebody notices that their oxygen's dropping significantly at nighttime. Right. It's not unreasonable to ask their primary care doc more so that they can. So that somebody can ask them the right questions. Right?

[A]

Yeah, those wearable devices. We talked to Ashley Mason, who's a psychologist that does a lot of sleep stuff, and she was. She was saying, like, a patient came to her and was like, I'M here because I thought I slept good my whole life. And then like this watch is telling me, and she's like, how do you feel? The patient's like, great. And she's like, how do you sleep? She's like, great. She's like, all right, let me take that watch and throw it in the trash.

[D]

Yeah, exactly.

[A]

What you're saying is like, if someone has some risk factors and the watch is like, you're desaturated. You know, your oxygen levels are dropping when you sleep. There's some, you know, some other concerns or it's, I don't know, it's finding arrhythmias, afib, whatever. We're going to investigate that just because that's. We're internists and that's what we have to do.

[D]

You're exactly right. So I actually just did a piece on patient centered care for sleep apnea, and that was sort of the question. Now with Dr. Google and all these other wearables, patients are coming in. Does that bother you? Was the question to me. And I was like, I think so. My favorite show of all time is Ted Lasso. You didn't ask me that as a question, but I'm going to share that with you. And the favorite line is, you know, be curious. And I think that that could not apply to physicians more. So I tell patients when, you know, if you look something up and you're concerned, if you approach it with, you know, I'm curious. I have these, these findings. What do they mean? As opposed to, I know I have this diagnosis and the same goes for me as a physician. I, I should be curious and I want more data. Right. I want to hear patients come in. The AFIB monitors now on the devices are actually fantastic. Right. And people can catch different things. So be curious.

[A]

Yeah. And I think patients, I've just learned we're trying to reconnect with patients after what happened in the past six years or so. And I think when they come in and they're excited about something health wise and you're just like, oh, that's stupid, go away. That is just. We're sending people back to the Internet for bad information. So I think we have to really engage where. Whatever their pathway is into the discussion.

[D]

100% agree.

[A]

So wearables, we can get some useful information and we're going to get into talking about like the devices and everything. But let's. We'll stick to the format because Paul always gets mad at me for skipping ahead sections. Paul, you're the physical exam nerd I'm sure you want to talk about physical exam here, right?

[B]

Well, sure, I'd love to hear Anisa. What? So we mentioned, we mentioned collar size or shirt collar of 18 inches, which I think equates to something like 45 centimeters, 45.7. I guess it works out too. But what as you're sort of initially seeing someone who you have suspicion for sleep apnea, what other physical exam findings are especially important to you?

[D]

Sure. So probably the most robust data we have is for weight. Right. So you are twice as likely to have obstructive sleep apnea if you're overweight and four times as likely if you're obese. So obesity is a very big, big factor for that. Neck circumference, as you mentioned, is really important and there's different thresholds for men and for women. So for men we really talk about it being over 17 inches or 40 centimeters. And for women it's more like 15 to 16 inches as being a risk factor because that's a marker of central obesity. We look at micrognathia, so a small airway also retrognathia more importantly. Right. So if your bottom jaw is more than 3 millimeters, your bottom teeth more than 3 millimeters behind your top teeth, then that might suggest that your airway is more likely to occlude. Why? Well, our tongue is attached to the base of our chin on the inside. Right. And the back of the tongue is one of the main places of collapse. So that soft palate and the base of the tongue is where we have airway collapse. So that's a thing we look for. We also look for tongue crim. So signs. You know how when you look at a pie crust and you see the crimping of the sides of the pie, same thing you see crimping of the edges of the tongue and that can be a sign of macroglossia. So enlarged tongue size. So that's another thing that we'll often look for. And then central obesity in general would probably be another factor.

[A]

What about the malampati scores? I know they. Is that more just an anesthesia thing for intubation or does that help with sleep apnea as well?

[D]

No, it does. I mean we, we record that on all of our new patient visits. So a higher myelopodi score is associated with a more closed off airway. So we talked about the two places where collapse occurs behind the base of the tongue and then behind the soft palate. So that sort of measuring how long that low, that soft palate hangs you also can see any, any of us who've done exams on airways have seen the patient who comes in in the like the first visit and their UV is huge and swollen and super long because they' this all night, right. And they've been pulling on it and it's actually inflamed and your uvula actually swells and adjusts like it swells up at nighttime because they're putting so much negative force on that. So I'll look at that as well.

[B]

I just want to make sure I'm hearing this correctly. So the sleep apnea itself can actually cause enlargement of the uvula just by sort of like the suction, traction and chronic inflammation. Am I hearing this correctly?

[D]

I feel like sleep apnea itself. Inflammation of the airway, I should clarify. Right. And so inflammation of the airway and you, I mean there are patients who will say if they've had a cold and they're so sick, so that causes inflammation. And the on top of that have sleep apnea. It can cause a larger, like it can temporarily be larger. So I've had patients where I've seen them in the morning for visits and it's a little bit larger. It's not massive. Right. You're not going to have somebody with a tiny uvula. Normally that's huge. So I don't want to over exaggerate that. Right. But it's just that it can be the inflammation from the negative pressure can adjust it and it causes increased flow. It also causes increased flow and nasal congestion. Right.

[A]

Paul, you gotta look at like at least a thousand uvulas now and then you're gonna start to pick this up.

[B]

What, what makes you think I haven't looked at a thousand uvulas already? Wano.

[A]

Well, I mean not, not, not with

[B]

that knowledge, not with intent. No, you're right.

[A]

After learning that knowledge, you don't examine people. Paul, give me a break or I'll

[D]

talk and I should clarify. There's not studies that say your uv. I mean that's, that's that, that we just know that you have increased inflammation. Right. And you have a uc. There's not studies that say we've measured his uvula and we. Yeah. So

[A]

Paul, you're going to invent an instrument to measure the uvula now?

[B]

Yeah, sure. Patients will love that. Just me.

[A]

What's the equivalent of what are the beads to measure testes? The orchidometer. We need one of those for the uvula.

[B]

Paul, I'd love where your head's out.

[D]

We should probably back in the day they used to just remove the uvula to treat slip. It doesn't work to treat sleep apnea. Right. That was sort of the treatment was to remove that alone. So although we don't I don't want to upset Paul. I don't want to talk about treatments yet. So.

[B]

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[A]

I want to ask you about questionnaires, though. My sense is I have this theory on the show that most specialists do not use a ton of these scoring systems because they're more made for primary care and you just kind of have it internalized. But there's Stop Bang. There's Epworth's Sleepiness Scale, maybe there's others. You like any of these that you would recommend to people in primary care who might not be as skilled at and might not have seen as many cases as you have?

[D]

Yeah. So you know, I think the most common ones that we think about is the Berlin questionnaire. That was probably one of the older ones. I don't see that one used as much. And the only reason Is so it's 10 questions, but they all have likert scales and so it's harder to assess. Right. The key to a good questionnaire is simple and efficient and you can get the data mostly from the chart. Right. So that people can have things automated, especially in the era of, you know, AI and being able to get information very quickly. So the Upward Sleepiness scale is something that sleep docs use frequently because whether or not a patient is sleepy is very important to being able to know, especially for mild sleep apnea. Mild sleep apnea we treat basically for symptoms, so it's going to be really important to know where those symptoms are. But for a screening assessment, probably the Stop Bang is the easiest to use. It gives you the most bang for your buck. It also incidentally helps us as sleep docs. If you're ordering a Direct a study directly and we need to review the chart to make sure that it meets criteria for insurance coverage. It has all the key things in there. So that's probably one of the easiest things a sleep doc can do. Not a sleep doc, a primary care doc can do as a screening tool.

[A]

Oh, that's great. I can remember that. That's not too bad.

[D]

And if you have an EMR, most EMRs have them automated in there. You just plug it all in.

[A]

So the big thing that I struggle with a little bit nowadays, or that I'm curious, I should say, is which type of test would you do for this patient? Because I've seen now one of my patients recently bought something that goes on his finger and measures arterial stiffness. And he told me that was a home sleep study. I've had other patients, lots of patients were getting home sleep tests. And then there's of course, the in lab testing. So where's your head at with testing? What should we. How should we approach this now in primary care? And you can apply it to this case if that's the easiest way to go through it.

[D]

Yeah. So that's a really good question. I'm going to think about it in buckets and we're going to filter down. Right. So there's sleep testing at the top and then there's two boxes right underneath that. There is in lab sleep testing. That's formal, in lab attended. That's a polysemnogram. That's attended in the lab. You go, you spend the night. Your EEG is monitored. Airway and airflow is measured two different ways. Chest and abdominal effort. Your muscle tone is measured. So we can tell if you're in REM or rapid eye movement sleep. And if something gets dislodged, your oxygen, your heart rate. If something gets dislodged, somebody can fix it. That's the in lab study. That's the gold standard. That box over here. The home studies now have a couple of different boxes. There's the traditional ones, which are the type 3. They have to have one form of effort at least. So thoracic or abdominal. The ones we use at our institution, actually we use both abdominal and thoracic effort. You have to have one form of flow and then oximetry. Many of them, including the one we do, also has actigraphy. So we can use that as a surrogate for measuring sleep, which is a new thing now, body position. So it's looking at just obstructive sleep apnea. So that's where in home sleep apnea test. That's box one underneath there. Box two underneath. Do you see how I think very visually I like it. It doesn't go well for a podcast.

[A]

This will help us make infographics that'll go along with this, which will be made by the time people this perfect.

[D]

I love it. So also under that box is the. The PPG or the photoplesmography. I have to always think about how. How to say that. And so and under and within that is sort of pat or the peripheral arterial tonometry, which you were referring to. That sort of. Some people think of them as separately, or you can kind of think about it as underneath there. So you can think about it a little bit differently. But that is when you're measuring either light waves and you're looking at the changes in arterial tone for how it changes with an obstructive airway. There's the. The. One of the original forms of that was the watch pad. That was a brand that sort of has been out for the longest. Now there's many more that are coming out that are also incorporating AI and they can do algorithms for looking at sleep stages. And you know, there's. So there's. There's additional advances in there, but that is not measuring airflow in and of itself. Those studies are really good when they're done appropriately, which means a doctor is looking at all the raw data and interpreting it. That doesn't always happen. So it's really important. So sometimes you'll get them that are just mail orders. So I know that because patients will say they can actually buy some of these tests online, pay cash, get them done. We don't know how. But the problem is I don't know if somebody. I don't know how. Well, it's been vetted, right. So that's, that's the only problem. So I think sending somebody to a provider that you trust, right. Or a testing unit that you trust and knowing what tests they're getting is going to be really important. They all have great value and they are all having increasing data to support them. But just understanding, you know, how much data you can get out of a given test. The big difference for when we think about which type of a study we should do. Right. So now I'm going to lump the home studies together and versus in lab. Honestly, many insurance cert require that you start with a home sleep test because it's much cheaper. And honestly, I want cheaper for my patients if I can, if it's easier. So I'm not opposed to that. But if you look at the guidelines, the guidelines say home sleep tests are best done in patients who are high risk for sleep apnea. Because you're going to capture it. Right. And they have a high pretest probability, high prevalence, so it's going to be. And that improves your positive predictive value. So there's that. That being said, if you do a test in that population and it's negative, home sleep studies are better at ruling in sleep apnea than out. So if you are a high pretest probability, you do a home sleep test and it's negative, that's a person who should do an in lab afterwards. Those folks who should not do a home sleep test. Patients with significant lung disease. So COPD patients.

[A]

Patients.

[D]

Any form of hypoventilation, neuromuscular disease, heart failure, Anyone at risk for essential sleep apnea. Right, we talked about that. Somebody on chronic opiate, someone with significant heart failure. Those patients, really, we should be doing in the sleep lab. Yeah. Just so that we can monitor them more thoroughly.

[A]

So the two types of the home test, you said the traditional one, and then there's the photoplegmysography. That's the watch or the.

[D]

Well, that's that. And then the pat, which can be embedded in that. So some people would say that there's three. Right. The pat, the ppg. But I think of the PAT as within the ppg, because it's sort of a piece of that.

[A]

Okay.

[D]

Yeah.

[A]

And basically the parts of what someone would wear. Because people ask me this all the time for home sleep tests. So most home sleep tests, they're going to have something to try to measure airflow that might be like a nasal

[D]

prong, but not the PAT or the ppg. They'll literally just have something on their finger and around their wrist.

[A]

But for the traditional ones, okay, so for the traditional home one, they'll have either an abdominal or thoracic strap or both to measure effort. You said oximetry to measure oxygen, heart rate and oxygen, and then something for flow, usually around the nose. Okay. And then what's actigraphy? I should know that, but I don't.

[D]

No, it's measurement of movement. So it's measuring activity. Right.

[A]

And is that like something that clips to their shirt or something? Or is it embedded in the little

[D]

computer that's monitoring the whole thing? And actually, some of The PATs and PPGs have actigraphy as well, and they're measuring that as well, but that's measuring it at the limb as opposed to at the thorax.

[A]

Ah, okay. And then the in lab test, you said that has eeg, usually multiple ways to measure airflow, usually chest and abdominal straps and then muscle tone for REM sleep, eye movements.

[D]

For REM sleep, also eye movements. And then the reason I say two forms of airflow, which is actually important is so most studies use a pressure transducer which goes in your nose and that's really good for measuring hypopneas or decreases in airflow. But if you open your mouth and you mouth breathe, it can read those wrong. Right. It also may not be good at. So for complete cessation of airflow. So a thermistor or a thermocouple will measure changes in temperature and it actually measures both. Both of those. So, so we, we do both of those for in lab studies.

[A]

Okay. And, and right now it does seem like over the past, like I remember when I, you know, was, was coming out of like medical school in my training, I think most people are getting in lab studies. And then it seems like in the past 10 years we've really moved to home sleep testing, which I think is more patient centered in many ways because like you said, it's easier in a lot of ways. But you told us that if it's a high pretest probability, it's good to rule in, but it's not great for ruling out sleep apnea. So if our suspicion remains high, we would still send them back to the lab.

[D]

Right. And again, like the guidelines would suggest, those are the only people who should be doing it and the people who are lower risk should go straight to the in labor. That doesn't happen because that's not how insurance allows it to happen.

[A]

Right.

[D]

So let's say I have a patient who comes in, they don't have a ton of symptoms, maybe a little bit of snoring, maybe they're taking a nap occasionally. So they do have some daytime sleepiness, but they also just had a kid, so they're up at night. So they might have other reasons and they don't have. And they're young and they're not overweight. So I'm like, I want to make sure that I don't think it's going to be sleep apnea, but I want to make sure I'm not missing something big. So that might be a patient. You do a home study on that, you stop if it looks stone cold normal. Right. But if that patient now also is like, no, I'm exhausted in the morning, I keep waking up my bed partner says I stopped breathing in my sleep. Or I also have Horrible hypertension or other things that person may be like, well, if you have a negative study or let's say they're a truck driver, I might be like, we should probably do an in lab study after that if it's negative. So it just really depends on the individual clinical scenario.

[A]

Yeah. And I guess we didn't mention this, but I think periodic limb movements, sleep, restless leg syndrome, like those sort of like parasomnia. I don't know if those are parasomnias, but just those movement things that happen during sleep, Those should also be in lab, I'm guessing.

[D]

Yep. You will not be able to identify any of those with a home study. Those are just for sleep apnea. You got it.

[A]

Okay.

[B]

And before we move on, if I can ask the question I hear all the time and I don't have a good script for this, so I'd love to hear yours. If this comes up is patients are always asking me for the in lab studies, how am I supposed to sleep? Not my bed wired up. It's a really valid question. I don't have a good answer other than it seems to work out okay. I recognize if you capture it, you can be pretty sure you have the diagnosis. But I guess what do you tell patients when they bring that concern up? Because it's one I hear every single time when I'm talking about in lab study.

[D]

I think it's a valid question. I think I address a couple of different things. I say, number one, your airway tone isn't going to change in the lab or at home. And that's really what we're measuring. So if you sleep, we're going to see that. Because I'll be like, what's not my normal sleeping situation? So that's thing one. Thing two, as I tell people, bring something that helps you sleep comfortably. As long as it doesn't have a heartbeat, you can bring it. That's Anisa Das's role, right? So you can't bring a puppy, you can't bring a kid, you can't bring a boyfriend, you can't bring a grandma, but you can bring a lovey. You can bring your own pillow, you can for sure bring your own comforter. I encourage people to do that. I'm like, so bring your own stuff. I think it helps you to sleep better. So that's thing one. Thing two I tell folks is I'm like, if there's ever a day I do not want you to take a nap, goodness gracious, this is the day I want you to get up a Little earlier than you traditionally get up. I want to make sure it's as busy of a day as possible. I want you to have no caffeine in general. I tell people they shouldn't have caffeine after 2pm I'm not sure what you're drinking there, Matt.

[A]

Oh, it's a decaf tea.

[D]

Okay. And so I tell them to do that, and then I also tell them, look, if you only sleep four hours, the beauty of the in lab study is I'm measuring your eeg. I know when you're awake, and I take that out of the analysis. So I'm only analyzing the sleep time. So that didn't exactly answer your question, Paul, but hopefully it gives you some data to get them.

[B]

No, that's really helpful. Thank you.

[A]

Yeah. Well, let's go, Elyse. Let's go to the next part of the case, and then we can, you know, we can always swing back if we think of questions that we missed in that first part.

[C]

Sounds good. So after your initial conversation with Mr. Papp and a stop bang score of 6 indicating high risk for OSA, you decide to proceed with testing because he does not have CHF arrhythmia, opioid use, or any underlying pulmonary or neurologic disease, you decide he is a reasonable candidate for home sleep apnea testing. This shows a respiratory event index REI of 33 concerning for severe sleep apnea. And if you could please just take us through your approach when interpreting home sleep apnea testing as well as in lab tests.

[D]

Okay. For purposes of comparison, let's talk about the traditional home sleep apnea tests, at least for now. So I think. So the first thing that we do is we have a questionnaire for the home. So I'm talking about the home sleep test. We have a questionnaire that goes along with it. So I want to know what the patient thought. That's piece one. If they tell me, I feel like I was awake a lot and they write that time down, I want to be able to have that information as I look at it. Secondly, we do look at the actigraphy, right? So if there's a lot of movement, there's something going on, we need to make sure that that part is marked as wake accordingly so that we're looking at the good data. We looked at the data quality. If the air flows out or we're not being able to measure the oximetry at a certain section, that's going to be taken out of the analysis. So you want to look at good, good data, you need to Have a minimum of four hours of good quality data before you can call really a diagnosis. So once I know that we score it for cessation of airflow, which would be an apnea, and then hypopneas are the decrease in airflow. Hypopneas can be defined two different ways. And so I think as a primary care, and I think this might be another question you might even think about is what should we look at in the report? And so look at how they define sleep apnea and how they define the hypopnea. So you might actually now see on studies, AHI, 4% or AHI, 3%. Yeah, that's something newer that you wouldn't. Yeah, right. So this is newer. And people. So an AHI is your apnea, hypopnea index, how many times per hour you stop breathing or decrease your breathing. Ahi. And there are two definitions for hypotenias. There is the 1A and the. And the 1B. So the 1Ameans. Well, let's start with the 1B. The 1B is you have to have a decrease in airflow and it has to have your oxygen drop by 4% or more. That sort of historically is what we used. And a lot of the cardiovascular outcomes were based on that. And the American Academy of Sleep Medicine found that, hey, we are underestimating sleep apnea, especially in certain patients. So they. There's a new definition which is actually the primary definition as well. Now they say that is a drop in airflow associated with a 3% desaturation or an arousal. Now, you can't measure arousals on a home study necessarily. Right. So that takes that piece out of it. And that's why people will say age at 3% or 4%. So it's telling you how you're going to define it. Why does that matter? It matters for a few reasons. Number one, Medicare in the US only acknowledges the 4%. So that's important. Right. So we. And then you want to know. And so reports usually will say. At the Ohio State University, we actually report both. Usually the main line is based on the 4%, but we always will have the 3% AHI in there as well. So you can look at both. So I would look for that. The other important factor is certain treatments are based on certain AHIs, mild, moderate, or severe. And. And that's often based on a 4%. So you want to make sure that they're looking at that like tirzepatide. Right. So tirzepatide, the GLP1 agonist that is now has an indication for OSA has to have an apnea hypno index of 15 or greater along with a BMI of 30 or greater. And that H I was done in the surmount trial using the 4% criteria. Sorry, I digressed a little bit, but that's juicy stuff.

[A]

I love it. I didn't realize that I saw, I would say I've seen in the past couple weeks it's been like because I've been preparing for this, I've been really paying attention to the reports and there was one that had the AHI 3 and 4% and I did not know what it meant.

[D]

Yeah.

[A]

And then. But they were both so high that it didn't even matter. I was like, oh, this person needs treatment. But that is a little bit confusing. But I guess Medicare is such a big payer that probably a lot of places follow along with that. So we should, we should still put most stock in the H I 4% as A, as a tiebreaker.

[D]

That's going to depend on who you talk to. There's lots of debate, I will tell you. But yes, I mean, so here's what I usually say is if a study is negative, I'll say this sleep study does not meet criteria for OSA based on a AHI 4% of 3.8. Right. Okay, I'll say that. And then you can always look later up there if you wanted to. I think it depends on the patient's symptoms too. Right. And if the patient's super symptomatic. And so this is also good stuff. Gender matters here. So we're starting to get sex, not gender, sex differences. So sex differences for how people present. Women tend to have a lower arousal threshold and they tend to have less significant desaturations. So they might have, they might have a much higher AHI 3% and at a lower age. So I personally the way again so that I'll try to always say the ANISA dos when it just is my personal opinion. Right. So the ANISA dos approach is I tend to go by the 4% unless there's a big difference. Right. So if I'm like, well they're negative by the 4% but the ah at 3% is 27. Like goodness gracious. That or if the patient's really symptomatic, I'm like, I don't want to miss out on giving this patient an opportunity to be treated. So I think it's if there's a little bit of nuance in there. Right. Based on the symptom profile Maybe based a little bit on their sex. Because women, you might want to pay a little bit more attention to milder sleep apnea and more arousal based issues. So those are. Yeah, those are just a few things.

[B]

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[A]

Some other things I wanted to dig into on the report and tell me. There's, there's, there's a lot of. There's ahi, there's REI there. And so the difference between those two, that would be helpful.

[C]

Yeah.

[A]

And then maybe we can get into ODI next. Perfect.

[D]

Love it. I love it. I love it. I love it. Okay, so an REI is analogous to an AHI if your test does not measure time, sleep time. Because an apnea hypopnea index is the apneas plus the hypotenuse divided by total sleep time. That's the definition. So if you don't have something monitoring sleep, you have to say respiratory event index, and that is divided by study time. So a lot of the PPG tests have actigraphy embedded with algorithms. So they will say ahip. So based on the. So they'll adjust it that way. Or a home sleep test, like a type 3, if it involves actigraphy, now might say AHI as well. So if they're saying AHI on a home sleep test, there's some surrogate marker. They're not measuring eeg, but there's some surrogate test to assess for sleep.

[A]

Okay.

[D]

But not the gold standard necessarily of EEG.

[A]

Right. And the type 3 test, that's a home sleep test that includes actigraphy.

[D]

It may or may not. Historically it did not, but now many of them do. So I would say if you looked at the data from even five years ago, none of them had it. Now almost all of them have it. So you don't know. So you have to read. So that's the other thing to look at is. And I get really frustrated when I look at sleep reports and it doesn't say anything about the protocol that was done. It should say the protocol that was done. You should know what they're measuring. So look for that.

[A]

A lot of the times they do seem to have a total sleep time.

[D]

Yeah.

[A]

Like total test time. Total time that they thought the person was asleep. So if they have that, are we assuming that it had some sort of actigraphy in order to determine some form of sleep assessment?

[D]

Yep. Yep.

[A]

Okay.

[D]

I would. Otherwise we call. So prior to when we. For. At least I can speak again for the way we do it. Before we were using an actigraphy assessment for sleep, we had total recording time and total monitoring time. The monitoring time subtracted out anytime that they were upright or anytime there was too much artifact. Right. Now we can use total sleep time because it's upright, but plus we can take out time that is awake based on movement and respiratory changes.

[A]

And then the oxygen desaturation index, they give it to you less than 90, less than 88, maybe even less than 85. They give you ODI 90. They give a couple.

[D]

Sometimes there's lots of things. So there's. Okay, so that's a good. This is a good differential. An ODI is an oxygen desaturation index. That is going to be a number that's not going to be. So that is how many times the oxygen is dropped. So an ODI, 4%. How many times the oxygen's dropped 4%. That might be different than your AHI. Because remember, an apnea doesn't have to have an oxygen desaturation. If you don't breathe for 10 seconds or longer, that counts. No matter what. So it might be a little or if your oxygen drops, but it's not associated with changes in respiratory flow. That might be an oxygen drop but not a hypopnea. Does that make sense? So that gives you. But the ODI and the HI tend to be similar other than the oxygen desaturation indexes are the T90s or the T88s and that's the time spent with oxygen less than that level. Right. 88% SAO2 or 90% SAO2. That can be related to obstructive sleep apnea due to oscillations or it can be due to a chronic lung disease or heart failure where your oxygen is just low. So that really doesn't tell us why a patient is hypoxemic or the pattern with which the hypoxemia is there. So that's the second mode and an up and coming thing is something called the hypoxic burden and that is now being calculated with an algorithm specifically for sleep apnea. And, and it's the amount of dropped oxygen or time where the oxygen to below baseline after a hypopnea events and that's starting to be tied more into cardiovascular outcomes. So I would say stay tuned for the importance of that. We've just now started incorporating that value into our reports.

[A]

So we've, we've talked about a lot of the different pieces of, of the report. I think the one other piece that I want to ask about is the positional, you know, there's some positional reporting and then maybe it would be helpful to have you just sort of say okay, from a report, here's where my eyes like here's what I'm paying attention to in this order so that we can kind of give. For me, it would be helpful to hear how you do that and how you kind of put all these things together when you're sort of making that synthesis statement that you hopefully give to us. If the report doesn't have that synthesis statement, Paul, I'm just like, ah, okay, so I guess it's on me too.

[B]

That's where my eyes go to Matt. Is that.

[D]

Yeah, yeah. So, so as I'm looking at, I'll say so the first line would be that. So let's say Mr. Pat right, this patient meets criteria for severe obstructive sleep apnea based on an hi 4% of 33. Right. I think that's what his H I was. So that would be line one. And then if it happens to be a study that is showing sleep stages and rem Right. I might add in, in REM sleep the AHI was because in REM sleep our, our sleep apnea tends to be worse because we tend to hypoventilate and we're paralyzed with the exception of our diaphragms and our eye muscles. Right. So we tend to not breathe as deeply and our airway muscles collapse more in REM sleep. So I might say, however, in REM sleep it went to such and such. Right. It might have been more severe. I will also often comment, you know, it resolved when the patient was in the non supine position or if it was mild, you might say, hey, overall this patient had mild sleep apnea. However, in the supine position the sleep apnea was severe and they only slept in the supine position for 15 minutes. Therefore this could be an underestimation of true severity. So I think looking at and almost every study is going to give you an overall ahi and then an AHI broke down by supine and non supine. That's helpful. But then also look at what percent of time was in those two positions. I would say when we miss significant sleep apnea, it's often because a patient slept on their side the whole night and didn't sleep on their back because they can't breathe on their back. Right. And then you see, oh gosh, they didn't really have sleep apnea. That's another patient who I'd have go to the lab. Right. Overall their ahi was only 4.5. But that little bit on their back, man, their ahi was 62. I bet we could be missing something here.

[A]

Yeah. So Paul, any other questions about the report or Elise, any questions about.

[C]

I think you answered most of my questions. This is maybe a silly question, but was just thinking for like the PAT models that are just like wrist and finger, how are they measuring? So it's just airflow for the ahi. Is that just based on how are they getting that without the two different measurements of airflow?

[D]

So it's measuring the changes in your arterial tone because when you breathe in against a closed airway that changes your intrathoracic pressure and your blood pressure and your peripheral arterial tone. And then when you open your airway it's going to be different. So it looks at and so it actually has these little marks where it's measuring each little heartbeat and you'll see a change in the slant of it's. I mean it's pretty detailed when you go through like all the different testing of how they do it. So it's measuring obstruction based on changes in your peripheral arterial tone. So it's not measuring airflow at all.

[C]

Oh, okay. Interesting.

[A]

Wild.

[D]

Yeah.

[A]

Paul, you were going to ask something.

[B]

I was not.

[A]

Okay, it looked like you were.

[B]

No, I saw Elise look imminent, so I want to make sure she had a chance to say something. But I do think we should probably transition. To what? Now that we have a report that is suggestive of apnea, then what? I mean, this might be the time to sort of pivot into treatments and sort of how you discuss options with patients.

[D]

Yeah, I think that's good. So this. So Mr. Papp is. Remind me how old he is?

[A]

53.

[D]

Okay, so he's a 53 year old guy with obesity and severe sleep apnea. I would say the first line theory. Well, so we know the gold standard for treatment of sleep apnea is CPAP or positive airway pressure. We tend to offer that as first line, especially for a patient with severe obstructive sleep apnea. Along with Pap therapy should always be weight control. If obesity is a component of that and it always was supposed to be a part of it. But I think all of a sudden it's gotten more attention because we have more options, which is great. So talking about weight loss as another component of that would be really important. When we talk about Pap therapy, the most important thing is making sure the patient's comfortable. They understand there's different mask interfaces and I guess we can get into the more details of that afterward. Part of the second line option would be an oral appliance or a mandibular advancement device that tends to work better with thinner patients with milder to moderate, severe mild or to moderate sleep apnea, especially if it's positional. Although, that being said, there's at least one study that shows you can have 35 to 38% resolution of even severe sleep apnea. So I wouldn't exclude it from a patient with severe sleep apnea, especially if they're not going to use cpap. Right. Because it's. It's non invasive and it's. And it's not a major surgery and it's not irreversible. The downsides of an oral appliance is if you're not using the little bite plates that you're supposed to use in the morning to realign your teeth, it can cause significant dental misalignment and it doesn't work for everybody. It's probably not going to work as well for somebody who comes in with a BMI of 54 right.

[A]

What, the bite plates? Can you.

[D]

Yeah. So a mandibular advancement device basically is made so that over time, you protrude your jaw while you're sleeping to approximately. I mean, and a dentist optimizes it for you. That's made by dentistry, but to approximately 50 to 70% of your total protrusion. So it pulls that bottom jaw forward, increasing the space behind the base of your tongue. Right. What they found was years back, when they first started doing this, over time, patients would take them out in the morning and their teeth wouldn't touch in the back, and it was causing dental misalignment. So what they do now is they say they give them these bite plates and pieces to use for about 10 to 15 minutes in the morning, and that helps to realign and prevent that from happening. So it's super important that patients use that.

[A]

Okay. Paul, did you know that?

[B]

I did not, but I don't know that I've had patients use the mandibular advancement devices all that commonly. Smooth. That's why I haven't seen that.

[D]

I would argue that we should think about them more often. I think in Covid, we. In the. Well, it wasn't because of COVID but in the time of COVID we had a manufacturer go down. So we had. It was very hard to get Pap machines. Then the rest of the distributors were having difficulty because they couldn't get the microchips that were needed to make them. So we couldn't get Pap devices for patients anywhere. So I think we started using oral appliances a lot more in that time frame, and it made people more comfortable with them. The key with an oral appliance is you should do a post test. Once they're optimized, you want to bring them back into a repeat home sleep apnea test and make sure that it's controlled. I do offer it for first line for patients with mild sleep apnea, sometimes even moderate sleep apnea.

[A]

I love it.

[D]

Yeah. But for severe. Really, it's. You know, again, it depends on the. Well, we didn't even talk about endotypes, which we'll wait at the end. If we have time. We could talk about endotypes and precision medicine and sleep.

[A]

And for the advancement devices, I've had patients tell me, oh, it cost $600. I didn't want to do it. Is that. Do you have like a ballpark, like, how hard. What's the wait time to get one and how hard has it been?

[D]

Yeah. If you don't have insurance coverage, it's like three Grand, Yeah. However, it's not covered by dental insurance. It's covered by medical insurance. So that's key. It used to be harder because every dentist would. Not every dentist. That's not fair. A lot of dentists would make them because they reimbursed so high, but very few of them were in network with medical insurances. So it would be. And they would say, well, I'll make it for you, then you can submit it to your insurance. Well, that'd be very difficult for patients. Now there's a huge number of them who are in network with medical insurances. They submit it on the patient's behalf beforehand. The patient knows their out of pocket cost. So there's a huge range based on what payers have. Patients, it's actually covered by some of the Medicaids now, which would be 100% covered. Other payers, the out of pocket cost can typically be anywhere between 200 and $500.

[C]

Okay.

[D]

Ish. I mean, take that with a grain of salt. I don't bill for them, but yeah.

[A]

All right, Paul, what do you want to ask about next?

[B]

I think I would like to hear about actually CPAP titration, which I feel like is something I only have a vague sense of. So can you tell me sort of how that happens, where that happens, and how you think about it as a sleep doctor?

[D]

Sure. So that also has changed probably in the past 10 years. The traditional thing would be. So you would go back to the sleep lab. We would put the patient on CPAP and we keep incrementally increasing the pressure until they no longer had hypotenuse or apneas and their airway was open and their oxygenation was good. Now, there have been advances and there's auto titrating CPAP devices, which means depending on the brand, they either measure flow or pressure and they look for drops in flow or pressure or snoring. And the pressure of the machine will increase automatically throughout the night, up and down. So that's called an auto titrating Pap device or apap. I would say that that has become much more popular and it's actually quite appropriate for the right patient. So the right patient is an otherwise healthy person who has straightforward obstructive sleep apnea. Patients who maybe should do an in lab titration. Anyone who has hypoxemia with an open airway. Remember we Talked about the T88 at the T90 being. It just means your oxygen is low. It doesn't necessarily mean it's because your oxygen is oscillating. So if you see the oxygen's low and it's flat and it's not going up and down with obstructive events, then I'm worried and I'm like, ooh, there could be something else going on here. I'd like to have them go to the lab. If I'm worried about any form of hypoventilation, obesity, hypoventilation, hypoventilation due to medications or neuromuscular disease, those patients might need a more advanced PEP device or they might need an in laboratory titration. If I'm worried about central apnea. So if on the home study or the diagnostic in lab study there was a significant number of central apneas, that patient should probably do an in lab titration. So we can switch them to a different kind of device if needed.

[A]

Can you give us, I believe in the past our guest on sleep apnea gave us like a decent starting range for someone. If you're writing the auto titrating CPAP, I think it was like 5-15cm water or something like that. Do you have, does it differ based if it's a man, a woman, how big the person is? Like, what's a good range? If we're just kind of guessing from a home sleep test?

[D]

So I laugh because I swear like I, I don't do five to 15, I do six to 16 and I'm no. So everyone who. So if you ever see patients on 6 to 16, it's probably somebody I trained because that's in the knees of dysticism. And my reason for it was there's very few people who only need five. I mean it's like almost never and occasionally. And I tend to, you know, I live in the state of Ohio and we have a higher BMI on average, so there tends to be a heavier patients who need. So 6 to 16 is my starting in general. That being said, if I have a patient with a really high BMI and a really high severe sleep AP, high BMI and high AHI, I might start their bottom up a little bit higher. 8. I think more importantly than worrying about not worry, but then overthinking your starting pressure, as long as it's wide enough and that's reasonably wide, is making sure somebody's looking at it after you set them up. So you want to. Ideally within 12 weeks. I mean really ideally, even sooner than that. But I think the guidelines usually say within 12 weeks. You want to make sure that you're looking at them. I usually tell Folks, reach out to me if there's any issues. A lot of the devices have apps. I tell my patients, get the app. So it will tell you what your AHI is. I do not care what the AHI is every single day. What I do care about is what the average is right over a period of time. And so. And when we look at the data, we can actually see what the medium pressure requirement is. And the 95th. The 95th percentile pressure. That means 95% of the time, this pressure or lower is controlling it. So again, anisa dos method is a sediment 6 to 16. They come back, their medium pressure might be 8 and their 95th percentile pressure might be 13. So now I'm going to probably increase their bottom pressure to their median so that they don't have to stop breathing to get to that all the time. And then I might drop the top just above the 95th percentile. So I usually. So the key is you want to narrow it, not necessarily keep it wide. Unless they're perfectly controlled and they're happy, then it's fine. And that's the other thing. If their AHI is elevated, can I

[B]

ask, I do want to get into the troubleshooting stuff, but can I ask, what are we counseling patients in terms of outcomes here? Like, what are we going. I feel like we're told to sort of assess for osa. If we're concerned about secondary hypertension, Are we trying to improve the quality of their sleep and just make them feel better? Like, where are we? Because I feel like the data had historically been kind of mixed in terms of actual cardiovascular outcomes with treatment of cpap. But I guess what are we accomplishing by treating osa? And what do we tell patients that we're going after?

[D]

No, that's solid. And the data is still a little bit mixed. So first and foremost, you're right. I want to improve your quality of life and your sleepiness. So we know that patients who come in sleepy tend to be the most adherent, right? Because they've given the most immediate benefit from it. And actually, there's some ties to those who are sleepy might be more prone to the cardiovascular outcome. So if you tease those guys out, there might be a bigger signal. So that's thing one. Thing two is, despite not having great signals for intervening on cardiovascular outcomes, there's lots of discussion about that, as there always is. So one thought was, you know, you were looking at people who already had cardiovascular disease in these big trials. What if had looked at them naive? Maybe the ship has Already sailed. So if I'm treating you, Paul, who's a young guy who just gets diagnosed with sleep apnea, is otherwise healthy, maybe I could prevent it, you know, in 50 years from ever developing. But if I'm testing you when you already have it, maybe that's differently. There was more of a signal in the stroke population, so potentially preventative for stroke. And then the other data that we have is patients with known atrial fibrillation. If we treat obstructive sleep apnea, that's comorbid, they're less likely to go back into afib even if they've been cardioverted and even if they've been ablated. So that's another good outcome. And then the metabolic stuff. So we know that obstructive sleep apnea contributes to insulin resistance. We know that obstructive sleep apnea makes us resistant to. To leptin, which makes us feel full, and it increases ghrelin, which makes us hungry. And they impair that with I'm tired all the time. Right. So we're fighting against ourselves. Potential perioperative risk. Sleep deprivation from sleep apnea can affect. So we know sleep deprivation is associated with worsened reaction to chronic pain. So improving your sleep quality can improve your pain. Not your actual pain control necessarily, but your ability to tolerate that and to be able to react to that. And then sleep deprivation has also been associated with neurocognitive issues. Right. So improving sleep deprivation from that.

[A]

Yeah, the patients that can get over that hurdle of tolerating the machine, so many of them become like CPAP evangelists. Like, they just feel amazing and they're like, now I can't sleep without this thing. So I try to get people to that point. What are your tips for troubleshooting when you're talking to people about, you know, a new machine, do you tell, like, I've had. We had one. Paul and I were at a conference a couple years ago, and the, the people talking about sleep apnea were like, we tell people, you're going to hate this machine at first, but we're going to get you used to it. And they told them they can watch TV for an hour before they, you know, try to sleep with the thing. But do you have any kind of tips or tricks or things you say to people that seem to work?

[D]

So I, I go back to my statement, be curious. And you have to listen because patients have very, very different experiences. So I tell patients, I'm not sure how you're going to react. I have some patients who, on Their first night in a titration, call me up the next morning and say, I've never slept like this. Can I please have a machine? Can I take one home? Right. For sure. I see those. I have patients like my father who called me after his titration and said, I will be on my deathbed before I put that back on. He uses it now every single night and wouldn't go to bed without it. But, but, so, so those are the reactions. And I tell folks, some people do great initially, Some people, it can take up to four weeks of using it every single night. So my advice is, okay, I want you, the very first night you get it to put it on. And the reason I say that is in most payers will only pay for a new mask every three months. But in the first month of getting CPAP initially, at least in the US you can swap out your mask if it's not right, you want to take advantage of those 30 days if your mask is not comfortable. That's probably one of the biggest reasons patients hate their machines, is the mask interface isn't the right fit. Right? And you only have those 30 days to swap that out initially, then you have to wait till the three months. Well, if you're not using it by three months, your insurance might stop paying for it. So you're in this catch 22. So I tell them to take advantage of that. I do often use for patients who say they have anxiety or they're worried about it. I do the same trick. I say, just for the first time, you put it on, just watch tv. I don't even want you to try to sleep. I want you to just get through an hour of wearing it and then you can try to sleep with it. I actually think that's a great tip for. It's a desensitization tool, right? There is some literature that if you give patients who have a hard time with it a sleep aid for the first two weeks, that that can actually help. That wasn't replicated in other medications. So that's a little. So that certainly isn't something we go to initially, but that's another tool in the toolbox. And then when I say be curious, you got to figure out what's bothering them. So if they're like, doc, I can't stand this thing, okay, is it the airflow? Is it the mask? Is it hard to breathe out? Ask those questions because we can fix all those things, right? If it's the airflow is just too much, when I turn knots blowing my head Off. Well, have you turned the ramp on? Ramp means it starts low and you can go up. Or if it's. Doc, I can never breathe out. Do you have your expiratory pressure release turned on? That means it dips down a bit when you breathe out. I can turn that on, Doc, it's way too hot. Well, maybe we should turn humidity down. Right. So there's all these different things we can do, but you have to be curious first.

[A]

So you said it's external pressure release is a set. Is that like a. Pretty much. Is the ramp and the external pressure release setting, are those pretty standard features on modern machines?

[D]

Yeah. So ramp is pretty standard. And expiratory pressure release has different names on different brands, so they'll have different labels, but they all have some form of that. And the pro, you know, and really, it's a comfort setting. Right. So you want to keep the pressure up. But some people, it makes a life. It makes a massive difference. Some people are like, no, no. I feel like it's breathing for me. I want it to be constant. So I really. You know, I have some colleagues who say, I like to start with it off. I personally like to start with it at 2. So oftentimes there's a couple. It's like a 1, 2, and 3 setting. I'll put it in the middle so that if they don't like it, I can turn it on or up. But that's anisotism. Right? You guys got way more anesthetostisms than you were expecting tonight.

[A]

Look, this show is. We're trying to bring people clinical pearls from experts, so we're doing a great job tonight.

[D]

All right, There you go.

[A]

Yeah. Okay. Well, Paul, what else do you want to know about treatment here? Any burning questions? Elise, do you have other questions about this? I know we haven't talked surgery yet. We talked a little bit about masks, I think, but I know I get a lot of people asking about the surgery, so I want to go there. But, Elise, anything else you wanted to ask about?

[C]

I also wanted to ask about surgery. I think some of my questions were for patients that we meet that have been on CPAP for years, like, how often should we be retitrating them and. And follow up kind of things.

[A]

Yeah.

[D]

Okay, so let's. If it's okay, let me address that one first, because that will be. That will close things up, and then. And then we'll dive a little bit into endotypes of sleep apnea and how that might direct what treatment option we go to. So with regards to repeat assessment, it depends on what you're on. Right. So if I have a, if, if I have Jane Doe who has had moderate obstructive sleep apnea and Jane has had a stable weight for the past six years and she's been on stable settings and I can look at her download and her residual apnea hypopnea index because the machines now tell me if it's controlled is three or two. And I have, and she's adherent to therapy and I still have a copy of her diagnostic study, there is absolutely no reason other than somebody making money to repeat her test right. Now, that being said, if she's gained or lost weight and she's symptomatic, that's a reason to repeat a test. If I think it might be gone because she's lost weight or she's gained weight and it's not working as well, or if she needs a new machine and I don't have access to her old diagnostic study. That's probably the most common reason patients move across the country and they don't have a copy of their study. We're like, we got to get one. Then we would do it. But really you want to do it. So I always tell folks you only want to do a test. And this goes for all forms of medicine if it's going to change your management. Right. So if it's not likely to change management, then there's no reason to do it post operative bariatric surgery. Yeah. Post major weight loss. Yeah, sorry.

[C]

And so you kind of consider it controlled for age less than 5 or what are you happy with when you're reviewing the report?

[D]

So if you look at the American Thoracic Society, they actually say under treatment 10 with that's can be acceptable. And that's because there's some patients who start at like 140. Right. So what I tell folks is if your AHI on your download is under 10 and you're asymptomatic and you feel great, then I'm not going to, I'm going to treat you, not your number. But in general I'm shooting for under five. Right. So I like it under five. Or if they have symptoms and their AHI 7, then I'm going to probably work to, to try to get it lower because that might be symptomatic for them. So I would. And the reason we talk about those numbers 10 to 5 is because the algorithms of the devices kind of fall apart under 10 so they're not as precise when it gets to the bottom end. So I don't want to over treat a false positive. Right. So I go by a combination of symptom control and HI. That doesn't mean that an HI of 5 might not be symptomatic for a patient and I might need to get it down further. It's just if they're not causing problems, I don't over worry about it.

[A]

The downloads you're talking about for continuous glucose monitors, nowadays I have access to the main. My patients, I connect it to my practice and I have a login so I can kind of look in the cloud and see what's going on with my patients, with the various brands. Should we be doing that in primary care if we're seeing a lot of sleep studies? Like, do you have that kind of cloud portal access or are patients having to download it and bring it to you?

[D]

No, we have cloud access and it's the same thing. It's not like I'm getting continuously fed data. I have access to the cloud just like you said. Right?

[A]

Yeah.

[D]

Patients always feel like, well, have you. I've had patients like, I didn't use it last weekend, Thursday. I just wanted you to know it's because I was on vacation. Like, I didn't know.

[A]

You're not like looking at it every day. Who's not behaving?

[D]

Exactly.

[B]

I was like, I wish Santa Claus of CPAP machines.

[D]

Exactly. So I would say, Matt, I think it comes down to what kind of a practice you're in. There are. And there are practices out there that don't have access to sleep medicine. And so. Or the sleep medicine docs are really seeing more complicated patients. So if a patient's stable, then yeah, I actually think there's value in looking at that data or at least troubleshooting it. I often have patients come to me because their docs will say, sort of at least, as you mentioned, they'll be like, oh, you have AFIB now, you need to have another sleep study. I'm like, well, actually you don't because you've had no symptoms and I'm looking at your download and you're perfectly controlled. I actually think this is good. Right. So people have access to those downloads. That's helpful. So I think if you're managing the sleep apnea and you're the one prescribing it, it's helpful to look at. Along those lines, encourage your patients to get the app because it doesn't give you as much data as you get from the cloud, but it will give you. It will Give the patient their leak data, sometimes just with a smiley face or their leak percentage. It will tell them their AHI and they can look at it per day, week or month I believe, depending on the device. So I can give them a lot of baseline data. So even if you didn't have access to it, you could ask them, do you have the app? Let's pull your app up and look at it and you can look at it with them.

[A]

I wanted to ask a question to leave the CPAP for a second about because we talked about positional. You mentioned some people and I saw this patient recently where they supine and they had a severe sleep apnea rating and they spent, let's say out of 400 minutes they spent like 150 minutes supine and their AHI was like 30 and then non supine it was less than 5. So basically if they weren't sleeping supine at all, they wouldn't have sleep apnea. And I know there's some devices that I heard the tennis balls and the fanny pack don't work, but there's, there is some sort of foam rubber thing that you can strap around yourself. And then there's. Now I saw there's some vibration devices that maybe I, I don't exactly, I didn't look too much into how those work. I, I was just going to ask you like, do you like those, are they worth, are they worth prescribing for people?

[D]

So in your scenario where the patient had a really severe sleep apnea on their back and it was gone on their side, those I have a harder time not, not treating with something else just because if they fall on their back for an hour they have, you know, they're going to still have some sleep apnea. But I definitely have folks with like moderate or mild sleep apnea that's predominantly on their back or a little bit worse on their back. And you know, and we do implement positional therapy, we'll do it a couple of different ways, especially for mild, then I don't even need to repeat a study. Right. Because we're only treating them for symptoms. But if it's moderate you could repeat a study like once they've implemented it and they're wearing their foam roller, right. We might be like, well let's do a sleep study, a home study with the foam roller on to see how much it's actually working. There are not head to head trials showing that one's necessarily better than the other, I think. And the other piece is you don't want to do something that's going to wake somebody up. Right. So patients have to sort of figure out what they can sleep with. The cheap version of the foam thing is not just a fanny pack, but so another anisa does ism. Right. For somebody who doesn't have the money, can't afford the foam roller thing, I say get a good hiking backpack. When I say hiking backpack, it means it has to have a snap at the top and a snap at the bottom. So it's going to secure. And then you put a big king sized pillow or oversized pillow and you shove it in there so it's firm but soft. Not somebody else has said a basketball. I'm like, again, the basketball is going to slosh around. So something that's comfortable but firm enough that it prevents you from falling on your sleeping on your back. So there's different things that people can do. But again, not study with the randomized control trial. What we know is, so you'd have to say let's see if it works for you, we can try it, but then let's have you sleep and do a study with it.

[A]

Paul, at the bottom of this shared document I pasted the picture of these vibrating devices. And it looks, it looks like a dog collar that shocks people. It's like, looks like, but it's worn backwards. So the part that looks like it would shock is like at. On this guy's neck in the back.

[D]

Wouldn't it be awful if it was on your throat? That would be so bad.

[A]

Yeah, so it, I guess maybe it vibrates if you try to sleep. Probably uncomfortable it looks like because it's a little bulky sleeping on supine with that. But I guess maybe it starts to vibrate if it's, if it's, if you're supine. I don't know. But that was one of the ones. There's another one that I think goes around the chest and it was on

[D]

the chest that's a common one and it has sort of like a wedge foam thing off the back so you can't roll onto your back.

[A]

But I mean, I think there was one of the vibrating ones that had like a chest plate that looked like it was something that would vibrate. So that was the other one that I didn't put the picture of it here. But yeah, it just seemed like that space of the positional sleep apnea stuff seems to be taking off. So I guess more to, maybe more to come there. So you've mentioned a couple times and this might be the last thing we have time to Talk about the endotypes. You wanted to mention the endotypes?

[D]

No. Yeah, just because as we think about different treatment options. All right, so we're not quite there in sleep medicine because we don't have a good way to decide who has which endotype. But there are four different endotypes and people often have an overlap of different parts. So there's the upper airway collapsibility, so the anatomy, that's the bulk of folks. So Mr. Papp, that was his, he has an obstructive airway due to the anatomy. He's got a big, you know, he's, he's overweight, he has, you know, overjet. So he has a small airway that's collapsing. That's one. The other one is a low, low arousal threshold. This tense, women tend to have a little bit more of this component, meaning that as we fall asleep, our all of our airways destabilize, but they wake up so quickly they have difficulty getting into sleep, so their airway can't get into a controlled rhythm and it can cause these continued cycles. There's a high loop gain. So somebody who over responds, I'm falling asleep, I have an event as I fall asleep, I over breathe and then I under breathe and so, and every time I do that and I decrease my breathing, I have an obstruction and then I over breathe and then it happens. So they actually have periodic obstructive apnea because of decreased trigger. And then the final one is pharyngeal muscle responsiveness. So decreased muscle responsiveness as we fall asleep, we need that tone to keep our airway open. And if it's not responding right, your genioglossus muscle isn't responding the way that we need it to, then that can be a problem. The reason all these are important is that it might lead to different therapies. There's different therapies that target different endotypes. Right. So we know that weight loss, tirzepati, bariatric surgery, diet and exercise are going to work in large part on the P crit and the anatomy. Right. We're going to open up the airway. So that's a portion of that. There's new drugs on the horizon that are addressing both that and the pharyngeal responsiveness. And so that, that's a new drug, AD109, that's, that's being studied. There's also drugs that are being looked at, carbanic carbonic iron hydrase inhibitors that are similar to acetazolamide that will affect stabilizing loop gain. Right. And not having you over breathe and decreasing that. People have used oxygen to do that. So we're entering this era of really being able to do different types of treatments for different types of sleep apnea. We're not there yet, but we couldn't have this conversation without at least giving the teaser that that's.

[A]

I love it. I love it. Okay. And I get a lot of questions about the surgery. I think it's a. It's a sexy idea. Hey, there's a surgery we can do, and you don't need cpap. And then, you know, patients love that. But it seems like there's criteria. And a lot of the times my patients are told, like, you, you know, you're not a surgical candidate.

[D]

Are you talking about the neuromodulations? And there's several kinds now, actually. So there's. There's kinds where they're implanted in your chest, and they sense that there's now some that you can externally place on, and it's more localized, so there's. There's more options. The bottom line is you should only consider neuromodulation if you failed cpap, and that's because it doesn't work nearly as good. So in the. I really think there's a true viability for this in the right patient population. I have a patient with significant sleep apnea. Right. They have, you know, moderate to severe sleep apnea. They have tried cpap. They cannot tolerate it. They've tried an oral appliance. I personally think an oral appliance should be considered. Right. If that's a possibility that either didn't work or it's not an option for them and they're otherwise going to go untreated, then I would actually absolutely consider that. What I don't think it should be is I look at cpap. I don't think I want those. I want this because the outcomes aren't quite that good yet. Right. It's about 66% effective. So a third of folks are not going to have the outcome that they're looking for. But I do think there's an absolute rule for. In the right patients.

[A]

Fantastic. Okay. That gives me plenty to say to people when I get asked that question and more than I knew before I asked it. So I think we need to get to take home points. Paul, Unless you object.

[B]

Well, not object. I have one more. It's just so good. And I have to give Elise credit. She's the one who wrote it. But it's something I think is coming up now. We're seeing such success with weight loss with these medications now. So I'm wondering, I realize it's going to be a case by case basis. Can you sort of quantify who might, you know, I think weight gain is a bit easier to assess. You guys look for symptoms. Okay, this person, we should probably repeat the sleep study. But weight loss, how do you know if they still need cpap and when do you reassess that and what's that look like? And I guess is that even a real consideration?

[D]

That's a good point. And actually that's what's near and dear to me because I work with the bariatric patients and have lots of patients on weight loss meds. So there's a couple pieces of it. So we know that as you lose weight, your apnea hypotenia index improves. Not everybody who loses weight is going to have resolution. I have just this week saw two young thin women who have significant sleep apnea. Right. So it's not going to be everybody. But that's another plug for the auto titrating cpap. So if I put a patient on auto titrating cpap, I can see that. Well, you know what, you used to be requiring a mean pressure or 95th percentile pressure of 14. Now actually you've lost weight and your pressure's reduced. So that gives me a little bit of a data point.

[C]

Right.

[D]

So that's thing one, thing two is before we stop and retest, we might need to reduce the pressures on patients if they're on a fixed pressure because they'll start noticing air leaks. Right. And they're not tolerating it as much. So those are clinical things that we look at when patients. So in a bariatric surgery, when they get to about six months, when they've lost about 80% of the weight that they're going to lose. Ish is when we start talking about doing repeat assessments. In both the DLP1 weight loss and in surgical weight loss. There's a pretty wide range depending on the studies you look at. But in General it's probably 30 to 50% of patients are either resolving their sleep apnea or getting their sleep apnea to a mild one with all other symptoms. Right. Mild sleep apnea without other symptoms we don't necessarily, necessarily have to treat. So so not a non sleeping, mild sleep apnea, who doesn't have other big comorbidities. So that's a pretty significant number. So we start looking at patients and they usually come to us the first Thing I tell anyone who is on is, I don't want you to just decide you don't need it. If you start feeling like you don't need it, let me know. We're going to do a repeat test. I wouldn't, I wouldn't consider it before they lose probably 20% of their weight loss, 20% of their BMI. But then I also have that conversation of, look, if you've got a night without it and you're snoring, I don't want to have to do a million sleep studies on you. So we want to do it when we think it's reasonable. So I think it's a little bit nuanced with the patient kind of how much they had to lose and how much they've lost so far.

[A]

All right. This has been so good. I can't thank you enough. We want you to leave the audience with like two or three take home points and then we'll end the show there.

[D]

Okay. So I would say patients to think about referring that you might not otherwise think of a patient with refractory hypertension. Even if they don't have a ton of symptoms, if they have any sleepiness or snoring, I would think about referring them a woman who's recently gone through menopause and has had worsened sleepiness. Menopause increases a woman's rate and risk for sleep apnea by 20% even without any weight change. So postmenopausal women, I would think about, I would think about somebody with AFIB and no good reason if they have symptoms, at least screening them. Right. And I would think about a patient who said they had a diagnosis and they hated cpap. Make sure they know there's other options now and maybe send them back.

[A]

Fantastic. Anything that you would like to plug any organizations, any, I don't know, anything you're participating in or doing any projects. If not, then people just watch the new season of TED Lasso, which comes out around the time of this episode.

[C]

Probably.

[D]

No, I mean, I would say there is a growth of literature coming out and there's a lot of education coming up geared towards primary care from multiple resources. The American Academy of Sleep Medicine has resources. Medscape, Haymarket, both of them have big projects in there specifically geared towards primary care.

[B]

This has been another episode of the Curbsiders, bringing you a little knowledge food for your brain hole

[C]

holes.

[B]

Yes, just the worst possible outcome. Come. Still hungry for more? Join our Patreon and get all of our episodes ad free, plus twice monthly [e-mail] curbsiders. You can find our shownotes thecbsiders.com and sign for a minute listing at our weekly Show Notes in your inbox. This includes our Curbsiders Digest which recaps the latest practice, changing articles, guidelines and news, and internal medicine.

[A]

Elise, that made me so happy that you said holes instead of yummy. That's just amazing. Just trolling.

[B]

Paul Retirement is imminent and we're committed

[A]

to high value practice changing knowledge. And to do that we need your feedback so you can email [e-mail] a reminder that this and most episodes will be available for CME through VCU [e-mail] Special thanks to our writer and producer for this episode, Dr. Elise Burke, and with some help from our summer intern Dylan Naujan, and to our whole current Curbsider's team. Our technical production is done by the team at podpace. Elizabeth Crowder does our social media, Jen Water runs our Patreon, Chris the Chumanch who moderates our Discord. Stuart Brigham composed our theme music and with all that, until next time, I've been Dr. Matthew Frank Waddo.

[C]

I've been Dr. Elise Burke.

[B]

Just outstanding. And as always, I remain Dr. Paul Nelson Williams. Thank you and goodbye.

[D]

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Sleep Number's new collections are designed to adapt to the changing nature of your life and your sleep needs. Whether it's the personalized comfort of the Comfort Mode mattress, the targeted pressure relief of the Comfort Next mattress, or the climate collection that actively cools or warms to help you fall asleep and stay asleep.

[B]

And now get early access to a our biggest sale of the year. Save 25% on the new Comfort Next Luxe for a limited time only at a sleep number store or sleepnumber.com.