Talking Sleep

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 implant—breaking 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.

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 screened—using 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 screening—sleep 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.

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Mark Boulos, Dr. Khullar, and Dr. Mak for an in‑depth 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 when—and whether—to 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 apnea—particularly 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 (CBT‑I), initiate PAP therapy, or consider medications first? They walk through what is known about how different hypnotic classes—including z‑drugs, GABAergic agents, trazodone, and DORAs—affect respiratory drive and sleep architecture. The discussion extends to special circumstances such as REM‑related OSA, where increased REM sleep induced by certain medications may have unique implications. The episode also considers broader emerging questions: Do DORAs improve apnea–hypopnea 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 GABA‑based medications or wakefulness‑impairment targets? Throughout the conversation, the guests emphasize evidence-based takeaways, including the central finding that DORAs do not appear to worsen OSA‑related 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.

In this season 8 premiere of Talking Sleep, host Dr. Seema Khosla welcomes three members of the AASM guideline committee—Dr. 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 University—to 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 AHI—including 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.

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 severity—what 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.

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes members of the AASM Artificial Intelligence in Sleep Medicine Committee—Dr. Margarita Oks, Dr. Subaila Zia, Dr. Ramesh Sachdeva, and Matt Anastasi—to 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 monolith—the 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 claims—should 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 prompts—does 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.

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 Apnimed’s 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.

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 relationship—while 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.

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Greg Burek, a psychiatrist and former Marine, and Dr. Dmitriy Kogan, associate professor of medicine at the Medical College of Wisconsin and program director for the sleep medicine fellowship program, to discuss the unique sleep challenges facing military veterans and first responders. The conversation explores how military and first responder training fundamentally changes individuals, creating an "adrenaline-focused" mindset that profoundly impacts their relationship with sleep and health. Dr. Burek provides insider insights into the stages of military service and the concept of "sacrifice" as a unifying characteristic among veterans, while explaining why many veterans may minimize or dismiss their service experiences. The guests introduce the BRAVE program, an innovative initiative designed specifically for military veterans and first responders to address the "invisible wounds of service"—PTSD and TBI—and their complex interactions with sleep disorders. Unlike traditional VA programs, BRAVE takes a specialized approach to understanding how military culture and experiences create unique sleep medicine challenges. The discussion covers critical clinical topics including insomnia management in veterans, the frequent use of clonidine as a treatment option, REM behavior disorder presentations that may differ from civilian populations, and the intricate relationships between PTSD, TBI, sleep-disordered breathing, and nightmare disorders. The experts address whether these sleep disturbances stem from combat trauma, brain injury, or the military experience itself. This episode provides essential insights for healthcare providers treating veterans, including practical approaches to asking about TBI history, understanding military culture's impact on patient care, and recognizing when specialized referrals may be beneficial. Whether you're a sleep medicine practitioner, mental health professional, or healthcare provider serving veteran populations, this episode offers valuable perspectives on culturally competent care for those who have served. Join us for this enlightening discussion that bridges military culture and sleep medicine to improve care for our veterans and first responders.

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Luca Baldelli, a neurologist from the University of Bologna and Treasurer-Elect of the International REM Sleep Behavior Disorder Study Group, to discuss breakthrough research on predicting which RBD patients will develop neurodegenerative diseases. Building on the AASM's updated RBD guidelines, Dr. Baldelli presents compelling evidence for using simple autonomic reflex testing to identify patients at highest risk for phenoconversion to conditions like Parkinson's disease and dementia with Lewy bodies. His research demonstrates that objective autonomic testing, particularly orthostatic assessments, can reveal early neurogenic orthostatic hypotension that precedes overt neurodegeneration by years. The conversation explores practical clinical applications: How can sleep medicine practitioners implement these screening protocols? What constitutes abnormal autonomic function in RBD patients? How do we interpret changes over time, and when should patients be referred for neurological evaluation? Dr. Baldelli shares his longitudinal monitoring framework that could transform how we counsel RBD patients about their future risk. This episode addresses critical questions about biomarker development in prodromal neurodegeneration, the timeline of autonomic changes, and evidence-based approaches to patient discussions about prognosis. Dr. Baldelli also discusses current research initiatives and potential therapeutic interventions for high-risk patients. Whether you're a sleep medicine physician, neurologist, or researcher interested in neurodegenerative diseases, this episode provides essential insights into improving early detection and patient care in RBD. Join us for this informative discussion that bridges sleep medicine and neurology to enhance clinical decision-making and patient outcomes.

In this episode of Talking Sleep, Drs. Michelle Cantwell and Aaron Glick discuss the updated American Academy of Dental Sleep Medicine (AADSM) Standards for Practice. Dr. Michelle Cantwell received her DMD through the University of Pittsburgh's School of Dental Medicine, where she also completed a three-year residency in prosthodontics. Following dental school, she served as a lieutenant commander in the US Navy. She is a diplomate of the ABDSM and the president-elect of the AADSM. She works in the pulmonary and sleep medicine department of WellSpan Health. Aaron Glick, DDS, FAGD, FICOI, D.ABDSM, is a dentist who has committed his practice to dental sleep medicine. He has been recognized as a “Top 10 Dentist to Watch” and works clinically utilizing teledentistry for efficient patient care. Dr. Glick educates fellow practitioners as the Mastery Program Director at the American Academy of Dental Sleep Medicine, focusing on mandibular advancement devices. Additionally, he is on the faculty at the University of Texas Health Science Center at Houston School of Dentistry. He actively lectures nationally and publishes on obstructive sleep apnea and technology. He enjoys all technologies and has a medical device and software programming background

In this episode, Dr. Seema Khosla examines the complexities of central sleep apnea (CSA) with sleep medicine experts Dr. Vaishnavi Kundel, Dr. Rami N. Khayat, and Dr. Aneesa Das. The discussion moves beyond basic definitions to explore the critical limitations of home sleep apnea testing in accurately detecting CSA and when in-lab polysomnography becomes essential. The conversation addresses important clinical distinctions between post-arousal, transitional, and mixed apneas, challenging common assumptions about their significance and treatment approaches. The panel provides clarity on various CSA etiologies, including heart failure-related periodic breathing, medication-induced central apneas, treatment-emergent CSA, and neurological disorders. Discover evidence-based perspectives on treatment strategies, including updated views on adaptive servo-ventilation since the SERVE-HF trial, indications for phrenic nerve stimulation, and the potential of combination therapies. Learn when to consider alternative approaches like dead-space ventilation, supplemental oxygen, and acetazolamide, either alone or as part of hybrid treatment plans. The discussion also examines practical clinical questions: Does distinguishing between obstructive and central apnea matter if treatment approaches overlap? When should patients with suspected CSA undergo in-lab studies versus home testing? What guidance should clinicians follow for patients with ejection fractions below 45%? Whether you're managing complex sleep disorders or encountering CSA in primary care, this episode provides essential insights for optimizing patient outcomes through accurate diagnosis and appropriate treatment selection.