here is to understand the relationship of obstructive sleep apnea and various other medical problems and other sleep disorders, list the diagnostic approaches for diagnosing sleep disorder breathing, specifically sleep apnea, and review some of the treatment options that are out there, again, to make you better, more knowledgeable so you can talk to your patients about what the right approach should be for them. So when we talk about sleep disorder breathing, sleep disorder breathing is really a spectrum of lots of disorders, so there's snoring on the one end, most of what we see is obstructive sleep apnea, but there are other types of breathing problems that can happen at night. There's central sleep apnea that we tend to see with people who have heart failure and brain disease and are narcotics, there are people with hypoventilation, and these are people with lung disorders or morbidly obese individuals or people with neuromuscular disease, and you can have a combination of all of these things. What we're really going to focus on and what you need to know the most about is obstructive sleep apnea, and that's really where we're going to spend our time. I think most of you know, if you think about the back of the airway as a tube that's surrounded by tissue and muscle, you go to bed at night, the upper airway relaxes, and it can snore, which is just kind of, think about it like a flag on a windy day, or it can collapse and it can happen a few times an hour, it can happen once a minute. Why it happens in some individuals versus others is not clear, there are people who are overweight who don't have sleep apnea and there are thin people who do have sleep apnea, so it's really probably a combination of how much extra tissue you have in the back of your throat and how relaxed the airway gets and other medications and or comorbidities that play into that. So we define this as an obstructive apnea, so an apnea is absence of breathing for ten seconds or more, obstructive means you're trying to breathe so there's respiratory effort, but there's a roadblock somewhere above your vocal cords. An obstructive hypopnea is a reduction in airflow that lasts for at least ten seconds, so think about that as a partial obstruction. And then we calculate something called the apnea hypopnea index, which is the number of events, number of apneas and hypopneas per hour of sleep. We define obstructive sleep apnea by an AHI of greater than five events per hour or more, and then we arbitrarily define the severity or classify it as mild, moderate, or severe based on the AHI, so an AHI of five to 14 is mild, moderate is 15 to 29, greater than or equal to 30 is considered severe, but I say this is somewhat arbitrary because there are lots of potential problems for how we define the severity, so specifically presence or absence of associated symptoms, so would you approach somebody differently if they had an AHI of 13 and they're really tired and they're falling asleep versus somebody who has no complaints and is there only because their husband or wife wants them to be there? The answer is yes, because as we'll talk about in a little bit, it's not clear that sleepy people and non-sleepy people are similar in terms of how we should approach them. Degree of hypoxemia, so again, somebody, let's say, who has REM-related obstructive sleep apnea who may have an AHI of 13 but is desaturating to 60% every time they go into a dream sleep, should you be approaching them differently than the patient with an AHI of 12 or 13 who desaturates to 88%? The answer is yes, you should. Their cardiovascular risk is going to be different, but if you just looked at the AHI alone, you'd say they have mild sleep apnea, so you shouldn't just be looking at that, and then there are some potential problems for how we define what sleep apnea actually is, specifically what is a hypopnea, so you should know this because if you're going to be doing home testing in your office or you're interpreting tests, you should know that we define things differently depending on if you're an ASM-associated affiliated lab or who's paying for the test, so specifically CMS, which is Medicare, requires us to use a 4% desaturation for a definition of hypopnea, so reduction in respiratory flow with effort and at least a 4% desaturation, and that's required by Medicare, and it is more reproducible in terms of scoring than what ASM currently says is the recommended definition, which is a reduction in airflow at least 10 seconds with a 3% desaturation or an associated EEG arousal, and their rationale for changing how we define a hypopnea is that we can increase the diagnosis of mild obstructive sleep apnea in symptomatic patients who may benefit from therapy, but it does make it kind of wishy-washy as to what sleep apnea really is, who we should be treating. From a cardiovascular risk standpoint, cardiovascular risk is more tied to what happens with your oxygen levels at night and not your AHI, so when we look at studies that are out there using the AHI 4% or the hypopnea definition where you're desaturating 4% or more is much more tied to cardiovascular risk than those people who use the 3% or less, and it does make a difference. So if you look here, depending on how we define the hypopnea will determine how many people have obstructive sleep apnea. So if you look, the blue is using that 4% definition, and these are the same individuals, just scored differently, right? So what you see here is if you score them with the 4% desaturation, you'll have a lot of people who don't have sleep apnea and less people with mild sleep apnea. If you change the definition in the same individual, all of a sudden you're going to get about 30% more people who have mild sleep apnea. Doesn't really change what happens on the moderate to severe side that much, but you will get people who have a diagnosis of sleep apnea who may or may not need treatment. This is also important from the standpoint of just think about if you do a sleep study on somebody and they're self-insured and they want to get life insurance, they want to get disability insurance, as soon as you have a diagnosis of sleep apnea, your rates are going up. So if you have an AHI of 6 or you have an AHI of 70, it doesn't matter. So you need to think about these things. And when you're going to be treating people, you should look to see what the definition of the hypopnea is. They should be using that on the report. So what should you do? The answer is, if you're an ASM accredited lab, you need to use the 3%, and you need to use 4% for Medicare patients. I bring this up more just so you're aware, because depending on the test that you're looking at or even when somebody's had a test in the distant past and you're repeating the test, you may be defining it differently based on what the hypopnea definition is. So using the 4% desaturation definition, what we see is that over time, the prevalence of obstructive sleep apnea is going up, meaning it's becoming more common. It tends to be more common in men, at least until women go through menopause. So if you take all comers of an AHI of 5 or greater, about 33% of men and about 17% of women have obstructive sleep apnea. When we look at what I would consider clinically significant obstructive sleep apnea, so moderate to severe AHI of 15 or greater, about 13% of men and about 6% of women have what I would consider clinically significant sleep apnea. So meaning more likely to cause symptoms, more likely to increase your risk of cardiovascular disease. Again, for risk factors, so when people are coming to you or you're just screening people in the office, the older you are in general, the higher your risk. Again, men are at higher risk than women until women go through menopause. And then for a given BMI or body mass index, the risk is about the same. And being overweight or obese increases your risk because as you get bigger here, your tongue gets bigger, the tissue in the back of your throat gets bigger, it means the space in the back of your throat gets smaller. But after about age 60, while weight is still important, it is less of a risk factor. And that's probably because there are other medical problems, tissue in the back of your throat gets a little more relaxed, you're on some medications that can also likely add to that problem. And there are certain ethnicities that are at higher risk. There are certain medical problems like heart failure patients, so what happens with kidney failure and heart failure patients, they're not taking their medicine, if they're eating too many potato chips, they're holding on to too much water, their upper airways get swollen with fluid, and their sleep apnea gets worse, it tends to get better when they follow the program, and people with a history of a stroke can affect not just their arms and their legs or their ability to speak, but can also affect the tissue and muscles in the back of the throat. So why do we care? So again, we care because it can disrupt your sleep and make you tired, and I think I mentioned in the last lecture, but remember, just because you're not tired doesn't mean you don't have sleep apnea, and about 50% of people with an AHI of 30 or greater will not have daytime sleepiness, as we typically define it by Epworth Sleepiness Scale or something else. So absence of daytime sleepiness does not rule out the disease. These people are at increased risk for motor vehicle accidents. We do know that, again, they're at increased risk for high blood pressure or hypertension and death specifically related to cardiovascular disease. Again, it is typically tied to how much oxygen or how low your oxygen levels go and for how long. It probably increases your risk for things like atrial fibrillation and other electrical problems in the heart. It may increase your risk for other things like diabetes and metabolic syndrome, although it's not really clear how you can tease apart being overweight or obese and the sleep apnea. Being overweight and obese has a much greater impact on risk for diabetes and metabolic syndrome than obstructive sleep apnea, and in general, the risk for any of these goes up with the severity. So the worse your sleep apnea in terms of your AHI and specifically what we call your ODI or oxygen desaturation index, and your time below 90% increases your risk for all of these things, specifically on the cardiovascular risk side. So the scope of the problem is this is common. It's more common than asthma. It's going to get more prevalent as our population gets older and we get more overweight and obese. It's estimated that most people who have sleep apnea are yet to be diagnosed, which is good and bad. We do know that undiagnosed obstructive sleep apnea can be associated with adverse outcomes that we just talked about, and treatments can improve outcomes. And this is why it's important, and this is why we need to be looking for these individuals. So let's take a case, kind of work through a case for the rest of the time here. So we have a 58-year-old man who's evaluated for 12-month history of loud snoring, gasping during sleep, and progressive daytime sleepiness, has hypertension, obesity, diabetes, depression on physical exam, blood pressure is 130 over 82, pulse rate is 80, his BMI is 36, neck circumference is 18, he's got a low-lying soft palate, and you have a high clinical suspicion that he has obstructive sleep apnea. So which one of the following is the most reasonable initial approach? And you can just say, I'm sure this guy has sleep apnea, let's just put him on an autopap, do an overnight oximetry, so just look at what's happening with his oxygen levels overnight. You can do a home sleep apnea test, or you can do a polysomnogram. So how many people would want to just put him on therapy? How about B, C, D, all right, good. So I think that the right answer is C, so home sleep apnea test. So let's kind of work our way through this here. So the first question is, well, why do we need a test anyway, right? I can make an argument that you've got an obese guy who's gasping and choking, his wife comes in with the video, you could see what's happening, he's tired all day. In my practice, and I'm not saying that you should do this, in my practice, especially with people with high deductibles, I might just put this guy on an autopap, give him a prescription, send them to CPAP.com. You shouldn't do that, but that would not be unreasonable. But again, history alone is not diagnostic. And remember what I said, there's a lot of people out there who may present with snoring, and they don't really believe they have a problem because they're not symptomatic. And even us as expert health providers only get it right 50% of the time. There's not a lot of tools out there that really can help you make the diagnosis of obstructive sleep apnea, so there's no questionnaire that's going to make the diagnosis for you. And probably as important, if you want to get treatment paid for by insurance, you're going to need a test that gives you an AHI that will allow you to get reimbursed for whether it's an oral appliance, CPAP, hypoglossal nerve stimulator, so on and so forth. So these are the types of tests that are out there. This is what's defined by ASM and by most of the insurance companies. A type one test is a standard polysomnogram. A type two test is basically a polysomnogram done in the home, which nobody does because nobody pays for it. And the other three, so type three, four, and other are different types of home sleep apnea tests. So the polysomnogram is what's considered the standard. It monitors brain waves, eye movements, breathing, leg movements, EKG. Again, we define obstructive sleep apnea as an AHI of five or greater. This is what a polysomnogram looks like. This is about five minutes' worth of data. So across the top, you have your EEG leads, you have eye leads, you have chin, you have legs, you have snoring, and then you have flow through the nose and the mouth, and you have respiratory effort across the bottom here, and then these are your oxygen levels. So just to hit home on what's happening from a breathing standpoint, so these are recurrent obstructive apneas, right? So what you see here is effort. So I'm trying to breathe, but there's no air going through my nose and my mouth because there's a blockage somewhere in my upper airway, and here are the oxygen desaturations that we tend to see, which are delayed because you're not breathing. It takes a while for the blood to circulate to get to your finger, which is where we're picking up the oxygen desaturations. So in general, it's considered the standard test, and it has lots of advantages, right? You can diagnose sleep apnea. You can diagnose other sleep disorders. If you have really bad sleep apnea or other sleep disorder breathing problems, you can actually titrate, put them on a CPAP device and titrate them during the test. You can titrate an oral appliance, so there's lots of advantages, but there's lots of disadvantages. They're expensive, and somebody had asked a question after the last talk that I gave in terms of, you know, I guess the question is how often does somebody really sleep well and does it really represent what happens on a normal night, and I would tell you there's lots of people who get four hours of sleep, don't get into dream sleep, have really disrupted sleep, and it's not really a representative of what's going on. In general, for somebody who's going to have really bad sleep apnea, whether you sleep four hours, six hours, eight hours, it probably doesn't make that much of a difference, but don't always believe that the polysomnogram is the greatest test. Even in people who are sent for a CPAP titration, it's not uncommon that we don't find what we consider the optimal pressure because they're just not sleeping that great in a foreign environment. So there are various types of home sleep tests, and you guys are probably doing many of them, and I wanted to kind of go over some of the technology. In general, these are best for people who have a high clinical suspicion for moderate obstructive sleep apnea. A negative test, depending on your clinical suspicion, doesn't rule out the disease, and it's not really clear which one of these devices is best, and we'll talk about, you know, what are the advantages and disadvantages of all of them. You know, one of the reasons we're doing these tests in general is there's now tons of data that support their use. So if you use these tests in the right patient population and all you're really worried about is obstructive sleep apnea, this should be your go-to test or type of test, right? Patients are going to demand this more as their deductibles go up, and now when you're sent for a sleep study and cost or you're charged $4,000 versus a few hundred bucks, patients will demand that this happens. Employers, as they take on more financial risk, will demand that you do these as well, and as payer models change on the medical side to accountable care organizations that are basically, that's capitated, they're taking on risk and they're managing large populations, if I give you the money and say you could do whatever you want, all of a sudden you're going to think portable testing is the greatest thing because your cost per patient per test is going to go way down compared to a fee-for-service, or if you're doing a polysomnogram, you make more money the more tests that you do. And in terms of recommendations, so this is from ASM, so home sleep apnea testing should be done in patients with uncomplicated obstructive sleep apnea with signs and symptoms that put them at increased risk for moderate to severe obstructive sleep apnea. So what's uncomplicated mean? Uncomplicated means patients who don't have other things that can affect their breathing at night. So patients with COPD, patients with heart failure, patients who've had strokes, anybody who's going to be at risk for hypoventilation, central sleep apnea, more complicated things should go to the sleep lab. The majority of people, though, should get some type of home sleep apnea test. So what kind of test should you order? The most common test is something called the type 3 test, or the type 3 home sleep apnea test, and that measures a bunch of different signals. However, with all of these tests, they're home sleep apnea tests. They're not home sleep tests because they're not measuring sleep. They're measuring breathing. There's lots of different ones out there. So there's a nasal cannula that measures flow through the nose. There's a belt that goes across your chest that measures respiratory effort, and there's a pulse ox on your finger that measures oxygen levels, and it measures your heart rate. And that combination of signals by itself is enough, especially in people where you have a high clinical suspicion for more significant sleep apnea, to make a diagnosis. So this is some of the output that you get from these devices. So again, the top is airflow. Here is respiratory effort. Here's heart rate, and here's oxygen levels, and you can see respiratory effort, absence of flow, oxygen desaturation going down. This is pretty common. This is characteristic of what you would see with somebody with more severe obstructive sleep apnea. And when you look at some of the output from the test, you can see what's happening with what position they're in, oxygen levels, various types of respiratory events. In our practice, because I do pulmonary as well, we do a lot of overnight oximetry on people for various reasons. And you can tell just by looking at the oximetry alone that this person clearly has some type of breathing problem. And if you were at my last lecture, you know that REM sleep tends to cycle every 90 to 120 minutes. And you see the oxygen levels dropping down cyclically. And so as this person goes into REM sleep, their obstructive sleep apnea is getting worse because their muscles are more relaxed so they don't act out their dreams. So I could tell you just looking at their overnight oximetry that this person likely has obstructive sleep apnea that's worse than REM sleep. But this is some of the output that you're going to get from these type 3 devices. And like I said, there's tons of data, randomized controlled trials using these types of devices showing that compared to an approach that uses polysomnography and in-lab titration, that using a type 3 device or any kind of portable test with AutoPAP in the right patient group actually results in similar outcomes and lower costs. So how much data do you need? So meaning, do you need more than one night? Again, for those people who are at high risk, the data would suggest one night is enough as long as it's adequate data. The patient says, I slept pretty well. And ASM in their recent paper that came out says that about four hours of recording is enough. But you have to use your judgment. If the patient says, boy, this wasn't representative, you only got four hours of data. And remember, it's not measuring sleep. So you can have four hours of data, and they can be awake for two or three of those hours. It may not be representing what's really happening. In those cases, you may need to repeat the test. And these are some of the advantages and limitations. We kind of went over most of the advantages that there are. In terms of limitations, again, don't measure sleep. Because they're done in an unattended setting, there's the potential for data loss. The auto-scoring algorithms for the type 3 devices in general are not so great. So again, if you have an AHI of 60, it probably doesn't matter if it's 40 or 50 or 60. You're going to treat them the same anyhow. But on the more mild end, I will just tell you that they're just not that great. And you really need to be looking at the raw data and having somebody overscore that. So just don't rely on that. And then something called chain of custody is limited. And so what does that mean? So how do you know when you give them the test that they're doing it on the person who needs the test? So if you're doing this on somebody that is a truck driver, a bus driver, or drives a train, these are not great, because they're going to put it on their wife or their kid or their dog or whatever. You don't know. And there are other devices that are out there that have much better chain of custody that we'll talk about in a couple minutes. So moving on to some of the other devices. So a type 4 device is an unattended test that only measures one or two signals, so less than four. And there's lots of different devices out there. So pulse oximetry would be considered a type 4 test, because it's measuring heart rate and oxygen levels. So the home sleep apnea test on our patient shows an HI of 28 events per hour, desaturation is to 75%, and you have several choices about what to do, and you can put them on an oral appliance, an autopap, have them lose some weight, or prescribe hypoglossal nerve stimulator. The answer is, first line of therapy for this gentleman should be an autopap. So who should be treated? So those with moderate to severe disease, regardless of symptoms, and those with mild disease with symptoms of daytime sleepiness, fragmented sleep, or any type of cardiovascular disease. These are the general recommendations. So when you look at treatment options, really your two main treatment options are going to be pap or an oral appliance. Surgeries are out there, but certainly not going to be the first way you're going to go. You're going to tell everybody to lose weight, but most people won't. There are some people who tend to be worse on their back, but changing body position is not something that's so easy to do. There are emerging therapies like hypoglossal nerve stimulation, which we'll talk a little bit about, and there are some other things that are out there that really never made it. For example, the nasal e-pap company went out of business, the oral negative pressure company, and they never got FDA approval or insurance to approve their device, and therefore that's not used. So CPAP is going to be your primary method of treating people. The way CPAP works is, again, if you think about the back of the airway as a tube that's collapsing across the night, if you apply pressure to that tube, it increases the patency of that tube in a dose-dependent fashion, meaning the more pressure I give you, the bigger your airway is going to get, and it acts as an airway stent. It works. If you use CPAP, it will solve your problem. The problem is that we can't get everybody to use it as much as we would like. When we look at outcomes, so CPAP typically you would think would solve everybody's problem. They think better, their blood pressure would get better, but when we look at the data that's out there, what we see is it clearly gets rid of your sleep apnea across the spectrum of disease. It makes people feel better from a subjective sleepiness standpoint, but when you look across the other outcomes, there are inconsistent benefits, and it probably has more to do with people not using the machine enough as opposed to the treatment itself. It's like if I treated your hypertension and you only took your medicine every other day, it's not going to work, right? And actually, when we look at cardiovascular risk, cardiovascular risk, again, is tied to what's happening with your oxygen levels. Sleep apnea tends to get worse in REM sleep, which is at the end of the night, so if you're only using your CPAP for four hours a night, you're not getting the same cardiovascular benefit. I would tell you if you're going to use it for four hours a night, don't go to sleep with it. Put it on the last four hours. You'll probably get more benefit out of it. And from a cardiovascular standpoint, if people were to ask you, CPAP may reduce cardiovascular morbidity and mortality, but that's predominantly based on observational studies. It probably can make your blood pressure better, but there are lots of other contributing factors like being overweight and having diabetes. It's pretty rare that if I put somebody on CPAP, all of a sudden they're not going to need to take their blood pressure medicine anymore. It probably can help reduce the incidence or recurrence of atrial fibrillation, but there's no randomized control data looking at that. It can improve heart function in patients who have systolic congestive heart failure. In patients who do not have daytime sleepiness, which may be a different phenotype, there is no data to show that it actually does anything for cardiovascular morbidity or mortality. It's not even really clear that people without daytime sleepiness we should be treating based on the data that's out there. And we don't have much data from a cardiovascular standpoint in people with mild obstructive sleep apnea. CPAP, because it can make you sleep better and feel better and improve neurocognitive function, it does result in a reduction in motor vehicle accidents. It does not improve your weight, so you would think I'm sleeping better, I should be losing weight, but some data that's out there would suggest that that doesn't happen. It may improve your lipid profile, but the data on that also is not so great. And as we go down the line, the bottom line is, from a cardiovascular standpoint, besides it making you feel better and maybe making your blood pressure better, we just don't have enough data to say that it really improves any of these other outcomes. And specifically, in that group of people who are not tired, even with severe disease, it's not really clear that there's any benefit to treating them with anything. So the correct answer to the question was auto CPAP. So what is it? It's devices that adjust the pressure across the night. They detect snoring and other types of sleep disordered breathing. These are used for treatment, not for diagnosis, and this is what it looks like. So this is a regular CPAP, gives you continuous pressure across the night. AutoPAP will adjust the pressure up and down across the night with its goal to get you to the lowest mean pressure that you can get to. Again, just like home sleep apnea testing, people who are autoPAP candidates are those with uncomplicated, moderate to severe sleep apnea. Those people who we think might be better candidates, those who require higher pressure, CPAP intolerant, not really clear that autoPAP makes any difference at all. And we shouldn't be using it in that same group of people that were not using home testing because they have other types of breathing problems that occur during sleep and the algorithms within an autoPAP device are not adequately designed to take care of that. In terms of the outcomes with this, results in lower mean pressures, similar outcomes. So it's not better than CPAP. It's as effective as CPAP for these individuals and its main use is to avoid the sleep lab. So in the right hand, you go from home testing to autoPAP to similar outcomes and saving a lot of money for the patient. And so you can avoid the sleep lab for these individuals and it works great. So again, recommended for patients with uncomplicated, moderate to severe sleep apnea, not recommended for other people. Similar outcomes to CPAP and shouldn't be considered first line therapy as opposed to sending people to the sleep lab for a titration. This comes out from the American Academy of Sleep Medicine from 2019 in terms of recommendations for PAP, but it basically is saying exactly what I showed you in that one slide, that it clearly improves daytime sleepiness, can make you sleep better. It's suggested for other things like hypertension and improving quality of life. But the data on that is just not that great. So just because we prescribe CPAP therapy doesn't mean people will use it. We define CPAP adherence by using your device four hours a night by greater than 70 on 70% of the nights or more. That was something that was put in a paper in 1993 and that's what all the insurance companies now use and that's what most of the studies that have looked at CPAP adherence use. In general, people will say they use their machines 60 to 90% of the time based on that definition, but most people overestimate their use. We do know that patients tend to overestimate their use by about 60 minutes per night. And in general, most people will have their adherence patterns determined early on, first days to weeks of therapy. When we look at interventions that improve outcomes, the only ones that do are you, right, or your respiratory therapist. But somebody who knows about it, who's going to be able to work with them, educate them, give them behavioral therapies, all the technologies, heated humidification, BiPAP, AutoPAP, using nasal steroids, hypnotics, telemedicine, even using a sleep specialist has never been shown to consistently improve adherence for patients on CPAP. It's all about educating them and working with them. You don't need me to do it. I have respiratory therapists in my office who are much better than I am at fixing problems for people who can't use their CPAP devices. So despite early follow-up, frequent office visits, mask changes, humidification, doing an in-lab pap titration, he can't use the CPAP machine and he's interested in other treatment options. And so what's the next step? The next step is he needs to see one of you guys because I think an oral appliance is really the best way to go here. And I'm not going to talk too much about oral appliances because you guys probably know more than I do, but they work by either moving the jaw forward or moving the tongue forward or a combination of both. They're typically recommended for people with mild to moderate sleep apnea. People with severe sleep apnea can use them, but they probably should have a trial of CPAP first. They're very difficult for us to predict who's really going to benefit from them. We would think that people with lower BMI, younger, less severe apnea, but we only get it right about 50% of the time. You guys may be better than me, but it's not clear. Determining efficacy, in general, you want to get their jaws about 50% to 75% of their maximum protrusion. That typically takes several weeks to do. You should do some type of an objective test to make sure that it's working, whether you send them to the sleep lab or you're doing a home test on the person. It really depends on how they're feeling and how bad their apnea is. I would tell you, my personal opinion, if somebody with mild sleep apnea who's predominantly a snorer, that you give them an oral appliance, they feel better, they're not snoring anymore, they don't need to go back for an objective test. But recommendations are they should have some type of an objective test, and they should have ongoing dental follow-up with you guys, because these things can move their teeth. My impression and recommendations, in general, are they're typically well-tolerated. Even people who have problems with their jaws or TMJ or whatever, over time, it tends to get better. Again, I make sure that they follow up with you, even if they're doing well over time or a dentist, to make sure that things don't need to be adjusted and we're not causing harm in terms of their bite. The biggest disadvantage, I would tell you, is cost. Again, depending on where you work or whatever, at least in my area, these things can cost or they're charged anywhere from $1,000 to $3,000. Insurers may pay for them. Most of the insurers will want a trial of CPAP first, because they know it'll work and it's typically cheaper. So, in general, they're best for mild to moderate sleep apnea, can be used in patients with more severe disease but who fail CPAP therapy. In general, CPAP is better for reducing the AHI and improving oxygenation, but people tend to feel just as good with an oral appliance, probably because they're using them all night long, so your effective treatment time is probably about the same as somebody who's using a CPAP for four or five hours a night. And again, you should do some objective testing. And so, moving on to the last part here, just a couple more minutes. So, listen, doc, I have a high deductible on my insurance. My local dentist is charging $3,000 for an oral appliance. I can't afford that and I'm looking for a permanent fix. What about surgery? And there are various surgeries that are out there. I would tell you upper airway surgery, I don't send anybody for it. I can count on, like, two fingers the number of people I would send for upper airway surgery over the course of the year, and I see hundreds of new patients a year. In terms of weight loss, great to recommend it. Most people aren't going to do it. And when you look at some of the surgical weight loss data, what you find is people lose weight. Their sleep apnea improves. They typically don't lose enough weight to get rid of their sleep apnea. So even if they're feeling better after they've lost weight and then they have their weight loss maintenance, you want to make sure that you do some type of an objective test to make sure that their sleep apnea is gone or certainly significantly improved. So okay, since the upper airway surgery is not an option and weight loss will take a long time, what about the upper airway stimulator device? Am I a good candidate for that? So many of you know there is a device out there. It's called the Inspire device. It's basically like a pacemaker for the upper airway. It's implanted into the chest. When it's turned on, it causes the tongue to move forward and the upper airway muscles to become less relaxed. It's been FDA approved since 2014. It was people who had a BMI of greater than 32 were excluded from the trial. So that's something to think about. In general, it works pretty well if you do it in the right group of individuals. The main thing right now that's keeping it from expanding is the cost. The cost of the implant by itself is like $23,000 and that's just for the device, not the OR time and so on and so forth. And all the data is specific to the Inspire device. This is some of the outcomes. So this was the group, you know, they had AHIs that averaged a little over 30. After 12 months of therapy, you could see that it worked pretty well. And in one group, they turned it off and you can see that sleep apnea went back to where it was before. So again, you're not training the upper airway muscles to work better. You got to keep using this on a nightly basis. And they have data now going out 36 months and I think now we're almost at the five-year data to show that this is an effective therapy that lasts over time. In general, most people are not going to be candidates for it because again, we don't really know how people are going to do if their BMI is 32 or above and many people with obstructive sleep apnea have a BMI that's in that range. Most patients aren't going to want the implant. In our office, we can get most people either adherent to PAP or on an oral appliance so they don't need this. Cost is the main issue. And actually, if you're going to get it done, you want to get it done in a place that does a lot of it because places who do a lot of it, just like most surgeries, tend to have better outcomes. I don't think we need to talk about this part. So there's a couple other things that are out there, nasal EPAP, positional therapy. We talked about that. In general, these are going to be things that are going to be add-ons and not primary treatments. And then finally, oxygen. We had talked about low oxygen levels increasing your risk of cardiovascular disease, but the bottom line is that oxygen by itself, at least with the data that we have, is not a primary therapy. You can't get it paid for for obstructive sleep apnea. And in the one or two trials that have compared CPAP to oxygen, CPAP tends to be better. So take-home points, home sleep testing and AutoPAP should be the way to go in most of the patients that you see who don't have comorbidities that can affect their breathing at night. CPAP improves daytime sleepiness, will resolve your sleep disordered breathing in terms of cardiovascular outcomes. The data is not so great, and it's probably tied to reduction in adherence. Medical appliances best for patients with mild to moderate disease can be used for severe disease, but you should try CPAP first. Upper airway surgery, typically not recommended. Weight loss can help. Most people won't lose enough weight. You should do a test afterwards to figure out if they still have significant sleep disordered breathing. Hypoglossal nerve stimulation has a role in the management, but it's something that probably I'm going to prescribe as opposed to a primary care doc or a non-sleep specialist. And then finally, some of these other therapies that are out there really don't have any role currently as primary therapies, and there are currently no medications that are approved for primary treatment. Thank you very much for your time.

obstructive sleep apnea

diagnostic approaches

continuous positive airway pressure

oral appliances

surgery

hypoglossal nerve stimulation

cardiovascular risk