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In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Abhishek Goyal, Professor and Head of Respiratory Medicine in Dehradoon, India, and Dr. Prakhar Agarwal, a pulmonologist in private practice in Bhopal, India, to discuss their research comparing fixed CPAP versus auto-titrating CPAP (APAP) on blood pressure control and autonomic nervous system response.
For years, difficult-to-treat hypertension has been recognized as an indication for sleep studies, reflecting the assumption that treating sleep apnea improves blood pressure. But does the method of PAP therapy matter? Beyond achieving a residual AHI under 5, are there treatment nuances that could optimize cardiovascular outcomes? Dr. Goyal and Dr. Agarwal's research addresses these questions, building on landmark work by Dr. Pepin examining fixed versus auto-titrating PAP therapy.
The motivation includes both clinical and economic considerations. A 2021 Portuguese study examined cost implications, and similar economic pressures exist in India where APAP is significantly more expensive than fixed CPAP. The study used a crossover design comparing fixed CPAP to APAP, measuring blood pressure dipping patterns and autonomic response to assess cardiovascular effects.
The results have prompted Dr. Goyal to reconsider his clinical practice regarding pressure selection, raising important questions: If fixed CPAP offers superior blood pressure outcomes, should the standard practice of prescribing APAP devices be reconsidered? This challenges assumptions about adaptive algorithms and raises questions about prioritizing cardiovascular outcomes beyond AHI reduction.
The episode contextualizes these findings within India's unique healthcare landscape, exploring surprising OSA incidence data and examining whether craniofacial anatomy or arousal patterns differ from Western populations. Dr. Agarwal discusses how pressures are typically determined and the practical differences between APAP 4-20 versus narrow-range settings.
Whether you're prescribing PAP therapy for hypertension, optimizing cardiovascular outcomes, or seeking evidence-based approaches to pressure selection, this episode provides important international perspectives.
Join us for this discussion that may prompt reconsideration of how we set PAP pressures and what outcomes we should prioritize.
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In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Daniel Buysse and Dr. Todd Arnedt, both members of the AASM clinical practice guideline committee, to discuss the newly released guidelines on combination treatment for chronic insomnia disorder in adults.
Unlike previous guidelines, this new guidance specifically addresses what happens in real-world clinical practice: patients often request both cognitive behavioral therapy for insomnia (CBT-I) and pharmacotherapy, or arrive seeking medications while clinicians advocate for behavioral interventions. The guidelines provide evidence-based recommendations for navigating these combination treatment scenarios, incorporating patient preferences in ways previous guidelines did not.
The conversation explores the guideline development process, including how committee members were selected and how diverse professional backgrounds enriched the discussion. Dr. Buysse and Dr. Arnedt explain why patient preference wasn't adequately reflected in original practice guidelines and how this updated version addresses that gap.
The first recommendation receives detailed examination: In adults with chronic insomnia, the AASM suggests combination treatment with CBT-I plus medication over medication alone (conditional recommendation, low certainty of evidence). The experts clarify which medications were examined, including whether dual orexin receptor antagonists (DORAs) were included, and explain why evidence certainty is low despite numerous studies. Pharmaceutical sponsorship creates methodological differencesâPSG outcomes, fixed time in bed requirementsâthat complicate interpretation. The high placebo response in insomnia trials adds another layer of complexity.
Critical implementation questions arise: What does "combination therapy" actually mean? Should both treatments start simultaneously, or should one precede the other? Can patients start medications while awaiting CBT-I appointments given typical access delays?
The second recommendation appears paradoxical: The AASM suggests against combination treatment over CBT-I alone, yet recommends combination over medication alone. Dr. Buysse and Dr. Arnedt explain this nuanced positionâCBT-I alone remains superior, but for patients who prioritize rapid total sleep time improvement over daytime symptom reduction, combination therapy may be reasonable.
The conversation addresses whether treatment order matters and whether clinical (not just insurance-driven) logic suggests a medication hierarchyâzolpidem before eszopiclone, the role of trazodone, when to consider ramelteon. A crucial question emerges: What about patients who refuse or cannot access CBT-I? How do these guidelines apply when the preferred behavioral treatment is unavailable or unwanted?
Throughout, the experts emphasize that guidelines inform but don't dictate clinical decisions. Patient preferences, values, and individual circumstances must shape treatment plans. The guidelines provide evidence-based frameworks while acknowledging the complexity of real-world insomnia management.
Whether you're treating chronic insomnia, navigating patient requests for medications, addressing CBT-I access barriers, or seeking evidence-based approaches to combination therapy, this episode provides essential guidance.
Join us for this important conversation about balancing behavioral and pharmacological approaches to chronic insomnia in clinical practice.
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In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Lee Neilson, Assistant Professor of Neurology at the University of Iowa and staff neurologist at the Iowa City VA specializing in movement disorders, to discuss his groundbreaking research examining whether obstructive sleep apnea represents a modifiable risk factor for Parkinson's disease.
Dr. Neilson's ambitious study analyzed records from 13 million patients within the VA system to investigate whether OSA is associated with higher risk of neurodegenerative disorders and whether treating sleep apnea might help delay the onset of dementia. The conversation traces the research design from initial hypothesis through methodology, explaining how he narrowed this massive dataset and defined both OSA diagnosis and Parkinson's disease progression.
Critical methodological details emerge: How was OSA diagnosedâthrough sleep testing, and using 4% or 3% hypopnea criteria? How did the study differentiate between mild and severe sleep apnea? How was Parkinson's disease identifiedâthrough clinical notes, medication records, or longitudinal follow-up? Dr. Neilson clarifies whether the analysis included only PD or extended to other neurodegenerative disorders like Alzheimer's disease.
The core findings receive extensive examination: Did CPAP therapy have a modifying effect on PD risk? After adjusting for confounding factors including BMI, diabetes, depression, and hypersomnia, which variables mattered most? What was the number needed to treat to prevent one case of Parkinson's disease? Could hypoxic burden be examined as a potential mechanism?
Intriguing tangential discussions explore whether idiopathic RBD can be distinguished from trauma-related RBD and whether these represent separate pathological processes. The conversation takes an unexpected turn into the neuroprotective effects of smoking in Parkinson's disease, with Dr. Neilson explaining proposed mechanisms and drawing parallels to ischemic preconditioning that might occur with OSA.
The episode addresses severity gradientsâdid OSA severity correlate with PD risk? It also tackles a fundamental question: Does treating sleep apnea delay dementia onset or actually prevent it? Dr. Neilson discusses whether non-PAP therapies were examined and addresses a critical ethical concern in sleep apnea research: Is it irresponsible to withhold treatment from symptomatic patients, and did this study focus on non-sleepy individuals or include all OSA patients regardless of symptoms?
This research has profound implications for how sleep medicine practitioners frame the importance of OSA treatment with patients and families. Beyond addressing immediate symptoms like sleepiness, treating sleep apnea may reduce long-term neurodegenerative riskâa compelling motivation for adherence that extends beyond quality of life to disease prevention.
Whether you're counseling patients about the importance of OSA treatment, interested in the sleep-neurodegeneration connection, or seeking evidence-based approaches to discussing long-term benefits of therapy, this episode provides essential insights.
Join us for this important conversation about how the work sleep medicine practitioners do every day may profoundly impact patients' neurological futures.
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In this episode of Talking Sleep, host Dr. Seema Khosla welcomes David Messerschmitt, a retired computer and signal processing engineer, and Stuart Crisp, a retired process control engineer and educator, to discuss patient-facing open-source PAP platforms and how informed users leverage detailed data to optimize their sleep apnea treatment.
This episode represents a departure from the typical clinical expert format. After eight seasons focusing on sleep medicine professionals, these engineer-patients reached out to share how platforms like Sleep HQ and OSCAR have transformed their understanding and management of sleep-disordered breathing. Both are power users who have helped thousands of fellow patients navigate complex PAP data, representing a patient empowerment movement that many clinicians may not fully appreciate.
David and Stuart explain what Sleep HQ and OSCAR are, how these platforms differ from standard clinical downloads, and what data visualization capabilities they offer. The platforms integrate multiple data streamsâhigh-resolution flow rate data from PAP device SD cards, pulse oximetry from wearable rings, and sleep architecture from devices like Apple Watchâcreating a comprehensive picture that goes far beyond what's typically reviewed in clinic appointments.
The conversation explores sophisticated analysis techniques these informed patients employ: identifying upper airway resistance syndrome through inspiratory flow limitation and heart rate spikes, distinguishing sleep onset versus wake onset events, detecting REM-related apneas, and recognizing positional apnea patterns. Stuart and David discuss "Somnopose," chin tuck events, and what they call "high-level waveform forensics"âdetailed signal analysis that reveals subtle breathing pattern abnormalities.
A crucial discussion addresses whether these patient communities represent antagonism toward the medical establishment or an unmet need that sleep medicine should embrace. The guests emphasize their desire for collaboration, not confrontation, and offer insights into how clinicians can better partner with informed, data-driven patients who arrive with detailed self-analysis.
Whether you're encountering patients who bring detailed PAP data to appointments, curious about what these platforms reveal that standard reports don't, or seeking to better collaborate with informed patient communities, this episode provides essential perspectives from the patient side of sleep medicine.
Join us for this unique conversation that bridges the gap between clinical expertise and patient empowerment in sleep apnea management.
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In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. David Kent, Associate Professor and Director of Sleep Surgery in the Department of Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center, to discuss the evolving landscape of hypoglossal nerve stimulation for obstructive sleep apnea treatment.
With the recent FDA clearance of a new hypoglossal nerve stimulator, patients now have three device options available or coming soon. Dr. Kent, whose research explores upper airway neurophysiology and novel OSA treatments, helps clinicians understand the fundamental differences between these devices and how to select the most appropriate option for individual patients. He discloses his past consulting relationship with Inspire and current consulting role with Nyxoah to provide transparent context for the discussion.
The conversation begins with the foundational premise of hypoglossal nerve stimulation and why it effectively treats obstructive sleep apnea. Dr. Kent traces Inspire's evolution since its 2013 FDA approval, explaining the current implantation process and how the technology has advanced over the past decade.
A significant focus is placed on Genio, with Dr. Kent explaining how its design resembles a cochlear implantâbreaking down this comparison for pulmonologists and other non-surgical specialists. Critical distinctions emerge: Genio uses bilateral stimulation versus Inspire's unilateral approach, lacks a respiratory sensor, and employs an external rechargeable battery. Dr. Kent clarifies the practical implications of these differences, including how pulse delivery is timed without respiratory synchronization, what external battery charging means for daily use, smartphone Bluetooth connectivity, and MRI compatibility considerations.
The episode tackles important clinical questions: Is bilateral hypoglossal nerve stimulation superior to unilateral stimulation? Does complete concentric collapse (CCC) matter as a contraindication, and if conflicting data exists about CCC exclusion criteria, how should this inform patient selection? Is drug-induced sleep endoscopy (DISE) necessary for all candidates? Dr. Kent discusses how the STAR trial differed from the DREAM trial and how pandemic timing affected patient outcomes and data interpretation.
Looking toward the future, Dr. Kent provides insights into Aura6000, expected to be available in 2027, and discusses his research on ansa cervicalis stimulation as a potential complementary approach, acknowledging that hypoglossal nerve stimulation alone may not be the complete solution for all patients.
A particularly valuable discussion addresses setting realistic patient expectations. Dr. Kent shares his experience with patients who arrive with preconceived notions about Inspire based on marketing or word-of-mouth, requiring significant time to align expectations with reality. He walks through his clinical conversations comparing Inspire versus Genio, helping clinicians develop frameworks for these nuanced discussions.
Whether you're counseling patients about device-based OSA treatment options, trying to distinguish between available technologies, or preparing for the expanding landscape of hypoglossal nerve stimulation, this episode provides essential comparative insights.
Join us for this comprehensive discussion about the past, present, and future of implantable OSA therapy.
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In this episode of Talking Sleep, host Dr. Seema Khosla explores growing concerns about microplastics in human health and what they may mean for patients using positive airway pressure (PAP) therapy. She is joined by Dr. Thais Mauad, a pathologist based in SĂŁo Paulo, Brazil, and Dr. Michel Cahali, an otolaryngologist, whose recent research examines the presence of microplastics and inflammatory mediators in the nasal airway of PAP users and nonâusers.
The conversation is framed by alarming findings from recent highâprofile studies showing microplastics in carotid artery plaque and even in the olfactory bulb of the human brain â discoveries that raise important questions about how these particles enter the body and their potential longâterm health effects. Dr. Mauad discusses her work on microplastics in neural tissue and explains how these particles may interact with inflammatory pathways, while Dr. Cahali describes their collaborative research evaluating microplastic deposition in the nasal airway.
A key focus of the discussion is whether PAP therapy itself contributes to microplastic exposure. The guests walk through their study design, control population, and findings, including the reassuring conclusion that PAP users did not demonstrate higher levels of microplastics in the nasal airway compared with controls. They also address important nuances, such as equipment age, material degradation, and how exposure may differ throughout the respiratory tract.
Beyond PAP therapy, the episode expands into a broader conversation about how plastics are manufactured, the role of additives and soâcalled âforever chemicals,â and how responsibility for reducing plastic exposure has historically shifted to consumers rather than manufacturers. Drs. Mauad and Cahali reflect on what these findings mean for sleep medicine professionals and discuss practical steps the sleep community can take â from clinical practice to advocacy â to reduce plastic exposure in health care settings.
Whether youâre concerned about the safety of PAP devices, interested in emerging research on microplastics and inflammation, or looking to better understand how environmental exposures intersect with sleep health, this episode provides important scientific context and thoughtful perspective on an issue that extends far beyond the sleep clinic.
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In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Reena Mehra, professor in the Division of Pulmonary, Critical Care and Sleep Medicine at the University of Washington in Seattle, and Dr. Dennis Auckley, professor in the Division of Pulmonary, Critical Care, and Sleep Medicine at MetroHealth Medical Center, Case Western Reserve University in Cleveland, to discuss the newly released AASM clinical practice guidelines for evaluating and managing obstructive sleep apnea in hospitalized adults.
The guidelines address a significant gap in inpatient care: how to systematically screen for sleep apnea in hospitalized patients, prioritize high-risk groups, determine when and where to perform testing, and ensure appropriate outpatient follow-up. Dr. Mehra and Dr. Auckley explain the impetus behind developing these guidelines and the PICO question process used to examine existing evidence, acknowledging the challenges of working with limited data in this emerging field.
The conversation systematically walks through the four key recommendations: in-hospital screening for OSA as part of an evaluation and management pathway, use of inpatient PAP treatment for newly diagnosed or untreated moderate-to-severe OSA, availability of sleep medicine consultation, and implementation of discharge management plans to ensure timely diagnosis and effective outpatient management.
Practical implementation receives extensive attention. How should patients be screenedâusing STOP-Bang or facility-specific methods? Should screening be built into the EMR? Which patient populations and hospital units should be prioritized? Who performs the screeningâsleep navigators, nursing staff, or hospitalists? Can sleep consultations be conducted via telemedicine at the bedside? The experts emphasize the critical need for a program champion and comprehensive education initiatives.
Dr. Auckley shares invaluable lessons from his experience creating an inpatient sleep program, discussing what he wishes he'd known before starting and practical insights gained through implementation. A particularly frustrating issue receives attention: patients who bring their own PAP devices to the hospital but never have them set up or used during their stay. The guidelines address this common scenario and provide frameworks for ensuring treated patients continue therapy during hospitalization.
Legal liability considerations are explored: What responsibilities exist for untreated patients diagnosed with OSA during hospitalization? What about high-risk patients who haven't been formally diagnosed? The experts discuss strategies for ensuring outpatient follow-up, recognizing that effective discharge planning is essential for translating inpatient identification into long-term management.
Whether you're considering establishing an inpatient sleep program, frustrated by gaps in hospital-based sleep apnea care, or seeking evidence-based approaches to identifying and managing OSA in hospitalized patients, this episode provides essential guidance and practical implementation strategies.
Join us for this important discussion about bringing systematic sleep apnea evaluation and management into the inpatient setting.
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In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. David McCarty, a sleep physician based in Colorado and Chief Medical Officer for REBIS HEALTH, to discuss the unique challenges of diagnosing and treating central sleep apnea at high altitude.
Living and practicing sleep medicine in Colorado has given Dr. McCarty extensive experience managing altitude-related central sleep apnea, a condition that affects many residents and visitors to elevated regions. The conversation begins with fundamental questions: Is central sleep apnea normal at altitude? What physiological mechanisms drive its development? Dr. McCarty explains the prevalence patterns across different elevations, from Denver's mile-high altitude to extreme elevations like 10,000 feet, and whether there's a threshold where everyone develops central events.
Practical diagnostic considerations receive detailed attention: Should patients be tested at their home altitude? How are titration studies conducted in high-altitude settings? What testing equipment best identifies central apneas, and should central hypopneas be scored? Dr. McCarty discusses the high prevalence of treatment-emergent central sleep apnea (TECSA) at altitude and how many patients present with mixed obstructive and central patterns, complicating treatment decisions.
The episode provides essential guidance for clinicians whose patients travel to high altitude destinations. What PAP adjustments should be made? How should EPR (expiratory pressure relief) settings be modified? Dr. McCarty walks through his decision-making framework for when to treat altitude-related central apnea, emphasizing the importance of patient education before ascension.
Treatment options are systematically reviewed: pressure adjustments, the role of BPAP therapy, when to consider ASV, acetazolamide use, and supplemental oxygen. Dr. McCarty discusses whether pre-emptive treatment is appropriate for patients planning high-altitude travel and provides practical protocols for managing both residents who live at altitude and visitors experiencing acute exposure.
The conversation emphasizes patient-centered approaches, considering not just the physiological aspects of altitude-related breathing disturbances but also the practical realities of treating patients in mountain communities and preparing lowland residents for high-altitude adventures.
Whether you practice in elevated regions, have patients who travel to altitude destinations, or simply want to understand the physiology behind altitude-related central sleep apnea, this episode provides essential clinical guidance.
Join us for this informative discussion about a condition that affects millions living at or traveling to high elevations.
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In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Mark Boulos, Dr. Khullar, and Dr. Mak for an inâdepth discussion on a topic that has challenged clinicians for decades: Are hypnotics safe for patients with untreated obstructive sleep apnea (OSA)?
As new therapeutic options emerge and our understanding of comorbid insomnia and sleep apnea (COMISA) evolves, clinicians are increasingly confronted with nuanced decisions about whenâand whetherâto use hypnotic medications. The guests unpack the latest evidence and share insights from recent studies, including research evaluating dual orexin receptor antagonists (DORAs) such as lemborexant in individuals with sleep apnea.
The conversation begins with a review of hypnotic medication classes and explores which agents may be safer in untreated OSA, and which still raise concerns. The panel discusses a recent lemborexant study, its design, population characteristics (including BMI and OSA severity considerations), and whether industry sponsorship played a role. They clarify that while the study did not focus specifically on COMISA, it sheds light on how DORAs perform in people with sleep apneaâparticularly in terms of respiratory metrics.
The experts tackle the practical clinical dilemma of treatment sequencing in COMISA: Should clinicians begin with cognitive behavioral therapy for insomnia (CBTâI), initiate PAP therapy, or consider medications first? They walk through what is known about how different hypnotic classesâincluding zâdrugs, GABAergic agents, trazodone, and DORAsâaffect respiratory drive and sleep architecture. The discussion extends to special circumstances such as REMârelated OSA, where increased REM sleep induced by certain medications may have unique implications.
The episode also considers broader emerging questions: Do DORAs improve apneaâhypopnea index (AHI) even without PAP? Can hypnotics be used strategically to improve sleep continuity without worsening respiratory parameters? And will future insomnia care rely on identifying phenotypes that respond differently to GABAâbased medications or wakefulnessâimpairment targets?
Throughout the conversation, the guests emphasize evidence-based takeaways, including the central finding that DORAs do not appear to worsen OSAârelated metrics, offering reassurance for clinicians who might consider using a hypnotic in a patien with untreated OSA. .
Whether you regularly see patients with comorbid insomnia and untreated sleep apnea or simply want clarity on the evolving role of hypnotics in this population, this episode offers practical, research-grounded guidance for clinical decision making.
Join us for this important discussion on how hypnotics can be used safely and thoughtfully in patients with untreated OSA.
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In this episode of Talking Sleep, host Dr. Seema Khosla welcomes three members of the World Sleep Society's consumer health technology task forceâDr. Michael Chee, Professor and Director of the Center for Sleep and Cognition at the National University of Singapore who chaired the guideline-writing task force; Dr. Mathias Baumert, an associate professor leading the biomedical engineering discipline of the school of Electrical and Mechanical engineering at Adelaide University in Australia, and Dr. Cathy Goldstein, professor of neurology at the University of Michigan. to discuss their global recommendations for the use of consumer sleep technology and wearable health trackers.
Consumer wearables have become ubiquitous in clinical practice, with patients routinely sharing device data. While some clinicians have historically dismissed this information, attitudes are shifting as technology improves and rigorous research examines sensors, algorithms, and data quality. Dr. Chee explains that the recommendations are designed for multiple audiences: end-users, clinicians, researchers, and manufacturers, with specific guidance for each group.
The conversation addresses practical considerations: the assumption that users have good perfusion, how bed partners can influence movement detection, and the fundamental truth that the best device is one patients will actually wear properly. The panel discusses recent FDA regulatory changes and clarifies whether guidance applies only to non-FDA cleared wellness devices or has broader implications.
The experts systematically review various metrics from wearables. They introduce TATS (total attempted time in sleep) and explain what clinicians should know about sleep onset and offset detection.
The episode emphasizes the call for standardized Fundamental Sleep Measures and greater transparency about test populations used in device validation. Dr. Baumert discusses the need to co-create benchmarks for measurement accuracy across different contextsâfrom persons with normal sleep to shift workers to those with sleep disorders.
Whether you're skeptical about consumer wearables or seeking guidance on interpreting patient-generated data, this episode provides evidence-based recommendations for moving forward responsibly.
Join us for this important discussion about embracing consumer sleep technology while maintaining clinical rigor.
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In this season 8 premiere of Talking Sleep, host Dr. Seema Khosla welcomes three members of the AASM guideline committeeâDr. Rami Khayat, Professor and Division Chief of Pulmonary, Allergy & Critical Care Medicine and Director of Penn State Health Sleep Services; Dr. Shirine Allam, Professor of Medicine at Emory University and Program Director for the Pulmonary and Critical Care Fellowship at the Atlanta VA Medical Center; and Dr. Christine Won, Medical Director of Yale Centers for Sleep Medicine and Professor of Medicine at Yale Universityâto discuss the newly released AASM clinical practice guidelines for central sleep apnea treatment.
The conversation begins with the rigorous process behind guideline development, clarifying the distinction between evidence-based recommendations and expert opinion. The panel systematically walks through each recommendation, addressing CPAP use across various CSA etiologies including primary CSA, heart failure-related CSA, medication-induced CSA, treatment-emergent CSA, and CSA due to medical conditions.
A surprising recommendation against BPAP without backup rate generates discussion about why backup rates matter and why heart failure patients are excluded from certain BPAP recommendations. The experts tackle the controversial topic of adaptive servo-ventilation (ASV), explaining why it's now conditionally recommended even for heart failure patients despite SERVE-HF trial concerns. They clarify that newer ASV algorithms differ from devices used in that study and emphasize the importance of patient-provider shared decision-making and treatment at experienced centers.
Practical implementation guidance covers oxygen therapy for heart failure and high-altitude CSA, including insurance coverage challenges. The panel discusses acetazolamide use across multiple CSA etiologies, providing concrete advice on prescribing and follow-up protocols. Transvenous phrenic nerve stimulation receives attention as an option for select patients, with candid discussion about its invasive nature, accessibility limitations, and high costs.
The episode addresses the shift toward viewing CSA treatment as chronic disease management, including billing code G211 implications. The experts emphasize that guidelines guide but don't constrain clinical judgment, stressing the importance of monitoring beyond AHIâincluding patient symptoms and quality of life improvements.
Whether you're treating patients with CSA, navigating insurance coverage, or seeking clarity on when ASV is appropriate, this review provides essential guidance for implementing evidence-based CSA treatment.
Join us for this season premiere that translates complex guidelines into practical clinical applications.
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In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Safwan Badr, the newly appointed editor of the Journal of Clinical Sleep Medicine and sleep medicine physician at Wayne State University, for an in-depth review of the most impactful articles published in JCSM during 2025.
Dr. Badr discusses his vision for the journal and the editorial selection process, then guides listeners through key research findings shaping clinical practice. The conversation highlights both highly popular papers and important studies that deserve more attention from practicing clinicians.
A significant focus is placed on research confirming that traditional 4% hypopnea criteria and CMS definitions systematically underestimate sleep apnea in women, with expanded diagnostic criteria helping mitigate these gender disparities. The episode explores groundbreaking research on sleep architecture and Alzheimer's disease, examining how lower slow wave sleep and REM sleep correlate with brain atrophy in AD-vulnerable regions, particularly the inferior parietal lobe.
Consumer sleep technology receives critical examination through a meta-analysis comparing wrist-worn devices to polysomnography, revealing significant limitations in accuracy. Dr. Badr discusses implications for physicians and consumers who increasingly rely on these devices. Mental health intersects with sleep medicine through research showing that nightmares and insomnia in the acute aftermath of trauma predict suicidal ideationânearly half of acute trauma patients with both conditions experience suicidal ideation within two months, highlighting urgent need for early interventions.
Additional topics include Canadian research on CBT-I effectiveness during pregnancy and findings from the TODAY study examining obstructive sleep apnea's relationship with glycemic control and cardiovascular risk in young adults with youth-onset type 2 diabetes.
Whether you're looking to stay current with evidence-based practice changes, interested in emerging research on sleep and neurodegeneration, or seeking to understand gender disparities in sleep medicine, this year-in-review provides essential updates.
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In this special live episode recorded at Sleep Medicine Disruptors in Austin, Texas, host Dr. Seema Khosla sits down with two standout innovators whose technologies captured the spirit of disruptive innovation in sleep medicine. Dr. Jason McKeown from Neurovalens and Dr. Onur Kilic from Bairitone Health present groundbreaking approaches to treating insomnia and personalizing obstructive sleep apnea therapy.
Dr. McKeown, a neurologist, introduces his FDA-cleared non-pharmacological treatment for insomnia using vestibular nerve stimulation. He explains how the technology works, why stimulating nerves in this manner is safe, and how it differs from vagus nerve devices. The conversation explores the relationship with cognitive behavioral therapy for insomnia (CBT-I), addresses the placebo effect question, and clarifies whether this is a long-term solution or temporary intervention. Dr. McKeown discusses contraindications including pregnancy and Inspire therapy, potential side effects, and ideal patient populations.
Dr. Kilic presents his sensor technology that enables non-invasive assessment of airway collapse location and severityâwhat he calls an "anatomic PSG." This innovation addresses a critical challenge: predicting which patients will respond to specific treatments like oral appliances, Inspire, or PAP therapy based on individual anatomical collapse patterns. Using a cheek-mounted sensor, the device identifies obstruction levels, differentiates between primary and secondary collapse sites, and detects collapse at the velopharyngeal level.
The discussion explores whether this represents a scalable alternative to drug-induced sleep endoscopy (DISE), how it integrates with OSA endotyping, and practical applications during titration studies to identify optimal pressure ranges and guide combination therapies. Both innovators emphasize moving beyond one-size-fits-all approaches toward personalized, anatomy-based treatment selection.
Whether you're interested in non-pharmacological insomnia treatments, precision medicine approaches to OSA, or the future of sleep diagnostics, this episode showcases innovative thinking driving the next generation of sleep medicine.
Join us for this exciting live conversation from Sleep Medicine Disruptors.
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In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Dave Singh, a former Adjunct Professor in Sleep Medicine at Stanford University, with a PhD in craniofacial cleft palate development, and a third PhD in orthodontics, to explore the evolving field of craniofacial sleep medicine. As founder of REMA Sleep based in North Carolina, Dr. Singh introduces the concept of craniofacial sleep medicineâan etiology-based approach to treating obstructive sleep apnea guided by anthropomorphic features rather than solely AHI severity metrics.
Craniofacial sleep medicine represents a paradigm shift from license-based treatment allocation to collaborative, anatomy-driven care where dentists, surgeons, and sleep physicians work together to determine the most appropriate interventions based on individual structural characteristics. Dr. Singh explains why understanding craniofacial structures is crucial for personalizing OSA treatment, including why Asian populations show high OSA prevalence despite lower obesity rates.
The conversation provides a comprehensive crash course in assessing craniofacial anatomy: What is retrognathia and what causes it? How can clinicians alter jaw position by adjusting cranial base morphology? Dr. Singh explains the classification system for dental occlusion (Class I, II, and III bites), midface assessment techniques, and the palate evaluation method Dr. Guilleminault taught fellows. He discusses critical anatomical considerations including tongue positioning at rest and during sleep, lateral pharyngeal wall collapse, and cervical vertebrae influence on airway patency.
The episode explores both preventive approaches in children and interventions for adults, addressing whether craniofacial modifications require surgery or can be achieved through other means. Dr. Singh discusses palatal expansion, tongue traction techniques, and the physiological components that remain addressable even after skeletal maturity. He also explains age-related changes including loss of muscle tone, bone volume reduction, and maxillary drift that progressively narrow the airway.
Intriguing topics include the mechanisms behind why didgeridoo playing and conch shell blowing improve sleep apnea, the role of oromyofunctional therapy as a viable treatment option, evolutionary changes in human dentition that impact airway anatomy, and even the dental stem cell implications for regenerative approaches. Dr. Singh also clarifies surprising facts, such as why mouthguards in contact sports serve purposes beyond tooth protection.
Whether you're seeking to understand anatomical contributors to OSA beyond obesity, interested in multidisciplinary treatment approaches, or curious about how craniofacial structure influences treatment selection, this episode provides essential insights into personalized, anatomy-based sleep apnea management.
Join us for this fascinating exploration of how form determines function in the upper airway and how understanding craniofacial anatomy can revolutionize OSA treatment strategies.
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In this episode of Talking Sleep, host Dr. Seema Khosla welcomes members of the AASM Artificial Intelligence in Sleep Medicine CommitteeâDr. Margarita Oks, Dr. Subaila Zia, Dr. Ramesh Sachdeva, and Matt Anastasiâto discuss their recently published position statement on the responsible use of AI in sleep medicine practices.
Artificial intelligence is rapidly transforming healthcare, from AI-assisted sleep study scoring to clinical documentation tools and insurance claim processing. Yet AI is not a monolithâthe technology encompasses various types with different capabilities, risks, and regulatory considerations. Matt Anastasi breaks down the different forms of AI clinicians encounter in practice, while the panel explains what "responsible use" actually means in practical terms.
The updated position statement, notably shorter and more accessible than previous versions, addresses four major pillars: data privacy, fairness and transparency, infrastructure requirements, and medical-legal considerations. The discussion explores critical questions facing sleep medicine practitioners: How do we understand and trust the AI systems we use? What happens when insurance payors deploy AI to deny claimsâshould we fight AI-generated denials with AI-generated appeals? Do patients need to be informed when AI is used in their care, and how specific must those disclosures be?
The conversation delves into liability concerns that keep practitioners awake at night: If your employer implements AI and it makes an error, who bears responsibility? What about ignoring AI promptsâdoes that create liability? Dr. Sachdeva explains the concept of vicarious responsibility and how it applies to AI implementation.
Practical implementation guidance is provided through discussion of governance checklists, equity considerations in AI deployment, and the limitations of FDA clearance for AI-assisted sleep study scoring. The experts introduce AASM Link and discuss how practitioners can evaluate AI tools beyond marketing claims, ensuring systems are trained on diverse, representative data sets.
The episode tackles a fundamental question: Is AI use inevitable in sleep medicine, or can practitioners opt out? The panel offers realistic perspectives on integrating AI responsibly while maintaining clinical judgment and patient-centered care.
Whether you're already using AI tools, considering implementation, or resistant to adoption, this episode provides essential guidance on navigating the AI transformation in sleep medicine while upholding professional and ethical standards.
Join us for this timely discussion about balancing innovation with responsibility in the AI era of sleep medicine.
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In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Doug Kirsch, Medical Director of Atrium Health Sleep Medicine and Clinical Professor in the Department of Neurology at Wake Forest School of Medicine, and Dr. Fariha Abbasi-Feinberg, president-elect of the AASM and private practice physician with Millennium Physician Group in Fort Myers, Florida, to introduce PLATOâa groundbreaking longitudinal assessment tool for obstructive sleep apnea.
The Epworth Sleepiness Scale has been a cornerstone of sleep medicine practice for decades, yet clinicians universally acknowledge its limitations in capturing the full patient experience. Similarly, PAP adherenceâwhile important and part of Medicare's MIPS programâtells only part of the story about treatment success. During his AASM presidency, Dr. Kirsch recognized the need for a more comprehensive metric and convened an expert advisory panel to develop a better solution.
The conversation traces PLATO's development journey, which Dr. Rosen described as "Doug's baby with a prolonged gestation." Starting with 44 potential questions and utilizing the ICON methodology, the panel carefully refined the tool to capture domains beyond simple sleepinessâincluding quality of life, functional impairment, and symptom burden that the Epworth overlooks. Dr. Kirsch and Dr. Abbasi-Feinberg explain the validation process, how the tool discriminates between OSA severity levels, and why certain seemingly similar questions about sleepiness were all retained.
The episode addresses practical implementation questions: How is PLATO scored? Why do the first two sections use 5-point scales while the final section uses 10 points? Is it free to use, and how does one access it? Will it integrate into electronic health record systems like Epic? Most importantly, how should clinicians use this toolâwill it replace the Epworth for Medicare requirements, or does it serve a different purpose?
The discussion also explores how PLATO relates to the recent AHRQ report on OSA treatment outcomes and why the tool focuses on patient-reported symptoms rather than solely cardiovascular endpoints. Dr. Kirsch shares his vision for PLATO's future, including hopes for foundation grants to further study the tool and demonstrate that treating OSA and its associated sleepiness meaningfully improves patient outcomes.
Whether you're frustrated with current assessment limitations, interested in value-based care metrics, or seeking better ways to document treatment efficacy beyond adherence data, this episode provides essential insights into a tool that may reshape how we measure success in sleep medicine.
Join us for this important discussion about moving beyond PAP adherence and Epworth scores to truly capture what matters to our patients.
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In this bonus episode of Talking Sleep, host Dr. Seema Khosla offers an exclusive preview of the upcoming SleepMedicine Disruptors course, taking place November 14-15 in Austin, Texas. She speaks with Steve Van Hout, executive director of the AASM, and Dr. David White, professor of medicine part time at Harvard Medical School, about the groundbreaking innovations reshaping sleep medicine.
Steve Van Hout explains what makes the Disruptors conference unique compared to other AASM meetings like Trends and the annual SLEEP conference. Designed to bring together clinicians, researchers, technology innovators,and venture capitalists, Disruptors aims to foster cross-industry collaboration and encourage investment in sleep medicine innovations. The conference features innovation award presentations similar to Shark Tank pitches with the audience voting on their favorites, keynote speakers, and discussions about emerging technologies that promise to transform how we diagnose and treat sleep disorders.
Dr. White provides an in-depth preview of his presentation on pharmacotherapy for obstructive sleep apnea, sharing exciting developments in multiple drug candidates. He discusses Apnimedâs AD-109, a combination of atomoxetine and R-oxybutynin, which has completed two phase three studies showing approximately 50% reduction in AHI across six-month and one-year trials involving over 650 patients each. With FDA submission planned for early 2026, this medication could reach the market by late 2026.
The conversation explores other promising agents including Incannex's combination of dronabinol and acetazolamide, carbonic anhydrase inhibitors like sulthiame (recently licensed by Apnimed), and innovative potassium channelantagonists that could be delivered via nasal spray for localized upper airway effects with minimal systemic absorption. Dr. White discusses the potential for poly therapy approaches, combining medications with devices like mandibular advancement devices or positional therapy, drawing parallels to how hypertension and diabetes are managed with multiple treatments.
The episode tackles important questions about the future of sleep medicine: Will pharmacotherapy replace PAP therapy, or will hybrid approaches become standard? What AHI reduction is clinically meaningful for cardiovascularprotection and symptom improvement? How will pricing and insurance coverage affect accessibility? They emphasize that while these medications may not replace CPAP entirely, they offer promising options for patients who struggle with existing therapies.
Whether you're a sleep medicine practitioner interested in emerging treatments, an entrepreneur exploring innovation opportunities, or simply curious about the future of sleep disorder management, this episode provides essential insights into the rapidly evolving landscape of sleep medicine.
Join us for this forward-looking conversation about innovation, investment, and the technologies poised to disrupt traditional sleep medicine practice.
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In this episode of Talking Sleep, host Dr. Seema Khosla sits down with Dr. Anita Shelgikar, current president of the American Academy of Sleep Medicine, neurologist, and sleep fellowship program director at the University of Michigan, for a transparent look at how the AASM makes critical decisions that shape the field of sleep medicine.
Ever wondered how clinical practice guidelines are developed and why updates take so long? Dr. Shelgikar pulls back the curtain on the comprehensive process behind guideline creation, from topic selection to evidence review to final publication. She explains how the AASM prioritizes which guidelines need updating and how members can influence these decisions.
The conversation addresses pressing concerns facing sleep medicine practitioners: the ongoing review of home sleep apnea testing codes, declining reimbursement rates, and the financial viability of sleep medicine practices. Dr. Shelgikar discusses the AASM's advocacy efforts, recent legislative wins and setbacks, and strategies for improving the value proposition of polysomnography in an evolving healthcare landscape.
Looking toward the future, the discussion explores emerging trends including the potential for inpatient sleep medicine services, the shift toward chronic disease management models, and new technologies like acoustic stimulation. Dr. Shelgikar shares insights on how the field might evolve beyond its traditional testing-focused approach and adapt to changing reimbursement structures.
The episode also demystifies AASM governance: How are committees formed and sunset? Why can't every volunteer serve? What happens during board meetings? Is board membership reserved for academics? Dr. Shelgikar provides practical guidance on how members can engage more meaningfully with the organization and influence its direction.
Whether you're a longtime AASM member curious about organizational decision-making or a newer member seeking to understand how to get involved, this episode offers valuable transparency into the processes that shape sleep medicine policy and practice.
Join us for this informative conversation that bridges organizational leadership with frontline clinical concerns in sleep medicine.
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In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Faisal Ali, professor of dermatology at the University of Central Lancashire and consultant dermatologist specializing in Mohs micrographic and laser surgery, to explore the fascinating connections between sleep and skin health.
Drawing from recent research published in Clinical and Experimental Dermatology, Dr. Ali explains how sleep serves as a critical regulator of skin physiology, affecting everything from skin surface pH and transepidermal water loss to blood flow and temperature regulation. The conversation delves into the complex interplay of circadian rhythms, hormones, and inflammatory cytokines that govern both sleep patterns and skin homeostasis.
The discussion covers how sleep deprivation accelerates skin aging as an extrinsic factor alongside sun exposure and pollution, with compelling evidence from studies showing that good sleepers have significantly better skin aging scores and improved recovery from UV exposure. Dr. Ali explores the bidirectional nature of this relationshipâwhile poor sleep worsens skin conditions, dermatological disorders like atopic dermatitis, psoriasis, and rosacea can severely disrupt sleep through mechanisms including the itch-scratch cycle and inflammatory processes.
The episode addresses practical clinical concerns including the higher prevalence of sleep disorders in patients with conditions like hidradenitis suppurativa and rosacea, the role of obstructive sleep apnea in various skin conditions, and evidence-based approaches to breaking the itch-scratch cycle that disrupts sleep in dermatological patients.
The conversation also tackles common sleep treatment-related skin issues, from CPAP mask irritation and "maskne" to headgear-induced hair loss, providing practical guidance for managing these complications. Dr. Ali discusses proper skincare routines for CPAP users, including the safety of retinol use under masks and strategies for preventing pressure-related skin breakdown.
Whether you're a sleep medicine practitioner encountering dermatological complaints, a dermatologist treating patients with sleep disruption, or simply interested in optimizing both sleep and skin health, this episode provides evidence-based insights into this often-overlooked connection.
Join us for this comprehensive discussion that bridges dermatology and sleep medicine to enhance patient care and understanding.
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In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Imran Iftikhar and Dr. Rami Khayat to discuss groundbreaking research on adaptive servo-ventilation (ASV) and the newly released AASM clinical practice guidelines for central sleep apnea treatment.
Dr. Iftikhar presents his innovative approach to analyzing ASV data through meta-analysis combined with trial sequential analysis, offering fresh insights into the statistical reliability of existing research beyond traditional systematic reviews. His work addresses lingering questions about ASV efficacy and safety that have persisted since the controversial SERVE-HF trial results challenged previous assumptions about this therapy.
Meanwhile, Dr. Khayat, who served as vice-chair of the AASM task force, walks through the comprehensive evidence-based recommendations covering the full spectrum of central sleep apnea treatments. The guidelines address critical clinical decisions: When should CPAP be used over no treatment? Who requires BPAP with backup rates? Why does the task force recommend against BPAP without backup rates for central sleep apnea? What role do oxygen, acetazolamide, and transphrenic nerve stimulation play in treatment algorithms?
The conversation delves into practical considerations including differences between ASV device algorithms from various manufacturers, the clinical impact of current device availability issues, and findings from Dr. Parthasarathy's bench study. The experts tackle the complex question of ASV use in patients with reduced ejection fraction and clarify important distinctions between primary central sleep apnea and treatment-emergent central sleep apnea (TECSA).
This episode addresses the evolving landscape of central sleep apnea management, helping clinicians navigate evidence-based treatment decisions in an era of changing technology and updated safety considerations.
Whether you're treating patients with heart failure, complex sleep-disordered breathing, or emerging central events during PAP therapy, this episode provides essential guidance for optimizing care.
Join us for this comprehensive update that translates complex research findings into practical clinical applications. - Mehr anzeigen
