Talking Sleep – An AASM Podcast

Welcome to Season Six of Talking Sleep! We are starting the new year by examining that time in our lives when we welcome new lives into the world. We often think about pregnancy as a joyful time. But, for too many women in the U.S., pregnancy leads to significant morbidity and mortality. Our U.S. maternal mortality rate increased from 20.1 per 100,000 live births in 2019 to 32.9 per 100,000 live births in 2021. For black women, this was 69.9 deaths per 100,000 live births. The causes are severe bleeding, infections, and preeclampsia/eclampsia. The CDC indicates that 4 out of 5 pregnancy-related deaths in the U.S. are preventable. Dr. Ghada Bourjeily is here to show us how maternal mortality intersects with sleep medicine. (47:47) Listen now

We routinely see patients with dementia in our sleep clinics but often do not meet them until they present with a sleep complaint such as insomnia or obstructive sleep apnea. We know that sleep and dementia have a bidirectional relationship. Is there a way to identify those who are at higher risk of dementia and intervene earlier? Is there a polysomnographic fingerprint? Should polysomnography be performed in those who are felt to be at higher risk of dementia? How can we, as sleep clinicians, potentially impact the course of dementia? Are there special considerations for our patients who have dementia and a comorbid sleep disorder? Dr. Brendan Lucey help us explore these issues further. (41:40) Listen now

Johns Hopkins colleagues Dr. Rachel Salas and Dr. Sara Benjamin discuss the basics of treating restless legs syndrome (RLS), focusing on an updated algorithm published in the Mayo Clinic Proceedings in 2021 by the Scientific and Medical Advisory Board of the Restless Legs Syndrome Foundation. Topics of discussion include pharmacological treatment options, the risk of augmentation, potential impulsivity, and non-pharmacologic treatments (47:26) Listen now

While sleep disorders are associated with numerous health complications, one area that doesn’t receive much attention is the impact of sleep and sleep disorders on those with sickle cell anemia. A study published in Sleep and Breathing found that children with sickle cell disease and comorbid obstructive sleep apnea had 47% more health complications than those with sickle cell disease who had a lower risk for OSA due to negative OSA screenings or exams. These complications seemed to be related to nocturnal hypoxia. Pain from a sickle crisis also can lead to sleep fragmentation. Dr. Sonal Malhotra discusses the many ways in which she tries to optimize sleep for her patients with sickle cell anemia. (34:10) Listen now

We know that CBT-I is the gold standard treatment for insomnia, but it remains inaccessible for many due to cost or the limited availability of trained professionals. For patients with comorbid mental health disorders, insomnia treatment may improve their sleep and mental health, but sleep restriction therapy may not be the most appropriate modality. Dr. Chris Bojrab is a psychiatrist who has embraced sleep care as a vehicle to improve the mental health of his patients, and he has expertise in neurotransmitters. He discusses pharmacologic treatment of insomnia and some important considerations in those with mental health disorders. (55:15) Listen now

While CPAP devices are similar across manufacturers, there are more significant differences in the advanced modalities of ventilatory support. Dr. Lisa Wolfe is well known for her granular knowledge of mechanical ventilation, including noninvasive ventilation (NIV). She discusses some aspects of NIV that may become pertinent as both sleep labs and patients transition off devices recalled by Philips Respironics. She also addresses concerns related to patients who have complex conditions such as chronic obstructive pulmonary disease (COPD), obesity hypoventilation syndrome, and neuromuscular disease. (42:19) Listen now

There are a handful of direct-to-consumer devices that claim to improve the quality of our sleep by using acoustic stimulation. What is the science behind these devices? Dr. Roneil Malkani is an associate professor of neurology in the Feinberg School of Medicine at Northwestern University. He collaborates with others to study acoustic stimulation during sleep and its impact on sleep architecture. He describes how these devices work and how clinicians should approach them. (39:00) Listen now

We know that there are a billion people in the world with undiagnosed obstructive sleep apnea (OSA) and that it simply isn’t practical to have every person undergo a sleep study. Are there other methods that might be more efficient identifying those at the highest risk of OSA? Laura Castillo is a chemist who has studied biological matrices to identify biomarkers for obstructive sleep apnea. Her research involves analyzing sweat and she has found that there are specific markers for those with severe OSA and those without any OSA. Dr. David Gozal has been working in this field for many years and has published extensively. He has also studied urine proteomics as a method to identify sleep disordered breathing in children. (43:13) Listen now

The world of sleep medicine has had several large recent disruptions with COVID-19 and the Philips Respironics recall. These haven’t been the only ones. If we look back almost a decade, sleep medicine was disrupted by the SERVE-HF results and field safety notice for ResMed ASV devices. Another trial was conducted around the same time as SERVE-HF but utilized Philips ASV devices. Those results have now been published and provide some insight into the use of peak-flow-triggered ASV for those with an ejection fraction of 45% or below. Dr. Douglas Bradley is here to share his results and to offer his thoughts on the use of ASV. (37:07) Listen now

After nearly three years, the Department of Justice and the Food and Drug Administration have finally agreed to the terms of a consent decree with Philips. It states that Philips Respironics cannot manufacture or distribute new sleep and respiratory care devices in the U.S. market until certain criteria are met, unless the devices are classified by the FDA as “medically necessary.” The scope of the recall is far larger than just consumer PAP devices. This impacts sleep diagnostics – including Alice polysomnography systems, home sleep apnea test platforms, and in-lab titration devices. Here to help us understand the specifics of the consent decree are Drs. Peter Gay, Aneesa Das, and Robert Owens. (53:34) Listen now

Despite having more treatment options than ever before, narcolepsy remains significantly underdiagnosed. Is there a potential clue on the polysomnogram (PSG) that we are overlooking? Dr. Alyssa Cairns and her team are exploring the biophysiological phenotypes of sleep disorders, specifically central disorders of hypersomnolence. She discussed how she combed through half-a-million sleep records and looked at the predictive value of a sleep-onset REM period (SOREMP) on PSG for a future diagnosis of narcolepsy. (49:43) Listen now

The Actiwatch is a popular actigraphy device that is no longer sold or supported by Philips. Its discontinuation coincided with the launch of the AASM’s “Act on Actigraphy” campaign, which highlights the importance of actigraphy testing for sleep disorders and urges payers to reimburse health care professionals for this medical service. Dr. Paul Raymond, vice chair of the AASM Coding and Reimbursement Advisory Committee, discusses reimbursement for actigraphy, its clinical use, and current and future options for device selection. (30:53) Listen now

Remote patient monitoring codes have been active for a number of years. These have largely been used to monitor blood glucose levels via a continuous glucose monitor or to adjust heart failure medications via a connected digital scale. Dr. Charles Bae and Dr. Gabriela de Bruin discuss whether sleep medicine professionals should also use remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) codes in the sleep clinic. (40:18) Listen now

As technology continues to permeate every aspect of our lives, the subset of sleep-related technology continues to expand. The AASM Emerging Technology committee continues to assess both clinical and consumer sleep technology. We have previously discussed consumer and clinical sleep technology that largely centered around snoring and OSA. In this episode, we talk with committee members Drs. Shalini Paruthi and Sachin Shah about the latest sleep technology for insomnia. (40:36) Listen now

There are currently 40 states with legalized medical marijuana. Twenty-four of these also have legalized recreational marijuana. Many people report using cannabis to help them to initiate and maintain sleep. Is there any data to support this? Is cannabis safer than prescription sleep aids? What should we know about cannabis and sleep? Dr. Bhanu Prakash Kolla discusses the impact of cannabis on sleep and its potential use to treat sleep disorders. (30:20) Listen now

Excessive daytime sleepiness is a significant problem for many people who have obstructive sleep apnea (OSA), and persistent sleepiness occurs in some patients despite effective treatment of OSA. Dr. Kingman Strohl and Dr. Lucas Donovan discuss this common clinical scenario, provide tips for the evaluation of persistent sleepiness, and talk about the wake-promoting medications that are available as treatment options. (54:46) Listen now

AI is popping up everywhere — when we open a PDF, use an AI scribe, or look something up with Chat GPT. We all interface with AI daily and may not even realize it. This can become very complex and somewhat mysterious. How can we use AI in a sleep medicine practice? Is it trustworthy? Will we all be replaced by AI someday? The AASM has an AI committee tasked with these questions. In this episode, we talk with committee members Dr. Margarita Oks and Matt Anastasi about a SWOT analysis on the use of AI-enabled technology in sleep medicine. (50:01) Listen now

We have long known about the bi-directional relationship between anxiety and insomnia, and traditionally we’ve been taught that treating anxiety will treat insomnia. Since that time, more data have emerged on the importance of treating insomnia in the context of anxiety. Dr. Leisha Cuddihy, Dr. Sara Nowakowski, and Dr. Michael Grandner discuss how they have noticed a pattern of anxiety about insomnia that doesn’t always respond to traditional cognitive behavioral therapy for insomnia (CBT-I) and other behavioral interventions. (50:28) Listen now

Dr. Richard Blackburn is a sleep psychologist who is attempting to improve access to cognitive behavioral therapy for insomnia (CBT-I) and other behavioral therapies for sleep disorders. He has a psychologist training program as well as a telemedicine practice, and he hopes to increase the availability of sleep behavioral therapy by increasing the pipeline and expanding access via telemedicine. He explains his model and discusses other behavioral interventions to consider for patients with sleep disorders. (53:29) Listen now

The AASM is introducing a new service-based accreditation model and updated Standards for Accreditation, which will take effect in January 2025. Based on feedback from members and accredited programs, this accreditation model provides greater flexibility to accommodate all practice types, making it easier to manage, add, and remove accredited services. Changes to the Standards for Accreditation were also made to remove barriers and promote administrative and operational efficiencies in sleep practice management. In this episode, AASM Accreditation Committee Chair Dr. Fady Jamous and AASM Director of Accreditation Ray Anthonijsz help explain some upcoming changes to AASM accreditation programs. (46:52) Listen now

There was a recent consensus statement from the Society of Anesthesia and Sleep Medicine and the Society for Obstetric Anesthesia and Perinatology on the screening, diagnosis, and treatment of obstructive sleep apnea (OSA) in pregnancy. For too many, a sleep evaluation is deferred until the pregnancy is over, with the idea that pregnancy-related sleep disorders will resolve at the end of the pregnancy. This leaves so many with sleep disorders undiagnosed and untreated. Dr. Louise O’Brien has tried to bridge this gap. She works in the Division of Sleep Medicine in the Department of Neurology, as well as the Division of Maternal and Fetal Medicine in the Department of Obstetrics and Gynecology at the University of Michigan. She is here to share her experience locally, but also globally when it comes to sleep health during pregnancy. (45:43) Listen now

In this episode of Talking Sleep, Drs. John Winkelman and Andy Berkowski discuss the updated AASM clinical practice guideline for the treatment of restless legs syndrome and periodic limb movement disorder. (54:40) Listen now

Our Host

Seema Khosla, MD, is board certified in internal medicine, pulmonary disease, critical care medicine, and sleep medicine. She works in Fargo, North Dakota, where she is the medical director of the North Dakota Center for Sleep.

Dr. Khosla is chair of the AASM Public Awareness Advisory Committee. She previously served on the AASM Task Force on Sleep Telemedicine, which developed a position paper for the use of telemedicine for the diagnosis and treatment of sleep disorders, and chaired the AASM Consumer and Clinical Technology Committee, which developed a position statement on the use of consumer sleep technology in clinical practice. Dr. Khosla also was co-chair of the AASM Sleep Medicine Trends course.