Talking Sleep

Oveporexton and the Future of Narcolepsy Treatment

The recent FDA approval of oveporexton represents a major milestone in the treatment of narcolepsy type 1 and the culmination of decades of research into orexin and its critical role in regulating sleep and wakefulness. In this episode of Talking Sleep, host Dr. Seema Khosla is joined by Dr. Emmanuel Mignot, a longtime leader in narcolepsy research and co-recipient of the 2026 Lasker Award for research that helped uncover the role of orexin in narcolepsy. Unlike existing therapies that primarily target the symptoms of narcolepsy, oveporexton is an orexin receptor 2 agonist designed to address the underlying loss of orexin signaling associated with narcolepsy type 1. Dr. Mignot shares his perspective on the science behind this new treatment approach and what the approval could mean for patients and clinicians. Topics include findings from clinical trials, the potential impact on excessive daytime sleepiness and cataplexy, dosing and safety considerations, and how an orexin-targeted therapy may fit into the evolving treatment landscape. The episode also provides perspective on the scientific journey that made this advance possible. Research into the orexin system has transformed the understanding of narcolepsy and opened new possibilities for therapies that more directly address its underlying biology. The discussion considers the significance of translating those discoveries into a treatment for patients, as well as some of the questions clinicians may encounter as oveporexton enters clinical practice. Looking beyond this approval, orexin agonists may have implications that extend beyond narcolepsy. Dr. Mignot offers insight into the continued evolution of orexin research and the potential for this growing area of sleep medicine to shape the future understanding and treatment of sleep and other medical disorders. For sleep clinicians, this episode offers both a closer look at a new treatment option for narcolepsy type 1 and a broader perspective on how decades of scientific discovery can translate into meaningful advances in patient care.

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Using Your Voice to Improve Reimbursement

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes members of the American Academy of Sleep Medicine advocacy team for an inside look at the work being done behind the scenes to support sleep clinicians and advance patient access to care. Joined by Diedra Gray, Tracy Bunge, Eric Albrecht, and Melissa Clark, the conversation explores how physician reimbursement decisions are made and how sleep medicine professionals can help shape the future of the field. Many sleep clinicians have experienced the frustration of declining reimbursement, changing payment policies, and increasing administrative burdens. While it can feel as though these decisions are beyond the influence of individual physicians, this episode highlights the many ways clinicians can contribute their expertise and advocate for sustainable sleep medicine practice. The discussion examines the complex process behind physician payment, including the roles of CPT coding, the AMA Relative Value Scale Update Committee (RUC), Medicare payment rules, and private payer policies. Listeners will gain insight into how reimbursement values are determined, how proposed policy changes are evaluated, and why physician participation in surveys and feedback opportunities is essential to the process. The episode also tackles key issues facing physicians today, including budget neutrality, inflationary pressures on physician practices, and recent reimbursement reductions that affect sleep medicine and other specialties. The guests explain how the AASM works to advocate for fair compensation while ensuring patients continue to have access to high-quality sleep care. Beyond payment policy, the conversation explores legislative advocacy and the role sleep clinicians can play in shaping public policy. From contacting elected officials and participating in advocacy campaigns to supporting legislation that promotes sleep health, listeners will learn how individual voices can contribute to meaningful change. Topics include physician payment reform, sleep health legislation, delayed school start times, permanent standard time, and other policy initiatives important to the sleep medicine community. Whether you're curious about how reimbursement decisions are made, interested in becoming more involved in advocacy efforts, or looking to better understand the forces shaping sleep medicine practice, this episode offers valuable insight into the people and processes working on behalf of sleep clinicians and their patients. Join us for this informative conversation about reimbursement, advocacy, and how your voice can help shape the future of sleep medicine.

Pediatric Sleep Medicine: Expanding your Practice

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Binal Kancherla, Associate Professor of Pediatrics and Medical Director for the Sleep Program at Texas Children's Hospital, to discuss how sleep medicine practitioners can thoughtfully expand their practice to include pediatric patients. Many adult sleep medicine clinicians have considered adding pediatrics to their practice but weren't sure where to start. Dr. Kancherla has created a comprehensive educational series addressing exactly this question—providing the clinical knowledge and practical framework needed to confidently treat children and adolescents with sleep disorders. The landscape of pediatric sleep medicine has evolved significantly. Diagnostic approaches now include home sleep testing for appropriately selected adolescents, wearable technology, and refined polysomnography protocols specific to developmental stages. Sleep-disordered breathing in children presents differently than in adults, with updated assessment and treatment strategies. Meanwhile, insomnia and behavioral sleep issues in younger children are now understood through a more sophisticated lens that goes beyond simple behavioral management. Pharmacotherapy in pediatrics raises important questions that clinicians treating adults may never encounter: How do you approach melatonin and magnesium supplementation that parents frequently use? What FDA-approved hypnotics exist for children, and when are they appropriate? These practical decisions require understanding pediatric-specific evidence and developmental considerations. Pediatric sleep medicine encompasses conditions rarely seen in adult practice—parasomnias, circadian rhythm disorders in adolescents, restless leg syndrome in children, and pediatric narcolepsy. Recent advances in narcolepsy treatment create new clinical opportunities, though current approvals remain limited to adults, raising questions about future options for children. Beyond disease-specific knowledge, Dr. Kancherla emphasizes building a pediatric sleep-informed practice—understanding workflow differences, family-centered communication, developmental considerations, and how to effectively partner with pediatric specialists and families. Whether you're considering expanding into pediatrics, curious about how pediatric sleep medicine differs from adult practice, or seeking to deepen your understanding of conditions you may encounter, this episode provides clinical guidance and inspiration for professional growth. Join us for this practical conversation about expanding your sleep medicine practice to serve the youngest patients.

Oxytocin and Social Cataplexy

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Carrie Mahoney, a neuroscientist and faculty member in the Department of Neurology at Harvard Medical School and Beth Israel Deaconess Medical Center, to discuss her groundbreaking research on how oxytocin may regulate social cataplexy in narcolepsy. With FDA approval of new narcolepsy medications, understanding the neural mechanisms underlying cataplexy has never been more clinically relevant. Dr. Mahoney's research began with a simple but profound clinical observation: cataplexy attacks occurred reliably when patients laughed with close friends and family members, but rarely when joking with coworkers or strangers. This pattern of emotion-triggered muscle weakness in social contexts prompted investigation into whether oxytocin—the hormone associated with bonding and social connection—might play a role. Dr. Mahoney explains social cataplexy and discusses whether most cataplexy episodes occur in social contexts. She traces how she came to hypothesize oxytocin's involvement, moving from clinical observation to basic science investigation. The research explores how the amygdala—typically associated with fear—also processes other emotional responses including the joy and bonding feelings that characterize close relationships. The episode walks through her research methodology. Using orexin knock-out mice (which model narcolepsy), Dr. Mahoney observed increased cataplexy during social interactions. She then systematically investigated oxytocin signaling in the amygdala to understand the mechanism. She employed advanced neuroscience techniques including chemogenetics and optogenetics—tools that allow precise manipulation and observation of specific neural circuits. The conversation clarifies what these approaches reveal about oxytocin's role in triggering muscle atonia during emotional social situations. A crucial ethical question emerges: If oxytocin facilitates social bonding but also triggers cataplexy, would blocking oxytocin eliminate this important neurochemical? Dr. Mahoney addresses whether targeted intervention might be possible without sacrificing the neurochemical foundation of human connection and social behavior. The research faced significant setbacks during COVID-19, affecting experimental timelines and animal studies. Dr. Mahoney discusses how she navigated these disruptions and the collaborative nature of validating complex neuroscience findings. She co-published this work with John Peever, highlighting how competitive yet collaborative the field must be to advance understanding. An intriguing comparison emerges: Just as AI models solving previously unsolved math problems require human validation, complex neuroscience discoveries need replication and independent confirmation. Dr. Mahoney explains how her research will be validated and what the competitive landscape looks like in basic sleep neuroscience. The ultimate goal is translation to clinical benefit. Would oxytocin-targeted therapy be preventive medication taken before social events, or a daily medication to modulate cataplexy susceptibility? Dr. Mahoney discusses how she communicates detailed scientific findings to patients and clinicians in understandable language, acknowledging the collaboration with science communicators like Kara Weaver. Her research extends beyond cataplexy—orexin knock-out mice are also being used to investigate menopause-related sleep changes, suggesting broader applications of her findings. Whether you're interested in narcolepsy pathophysiology, basic neuroscience approaches to understanding sleep disorders, or how fundamental research translates to clinical treatments, this episode illuminates the meticulous work underlying next-generation narcolepsy therapies. Join us for this fascinating discussion about how curiosity-driven neuroscience research may transform how we treat cataplexy and understand the biology of narcolepsy.

Patient Advocacy in Sleep Medicine

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes three patient advocates who are reshaping how sleep medicine is practiced and funded. Matt Horsnell, living with two sleep disorders and active as an author and panelist; Emma Cooksey, a patient-advocate and host of the Sleep Apnea Stories podcast; and Julie Flygare, a lawyer, author, and founder of Project Sleep, share their transformative advocacy work. While clinicians often think of advocacy as writing letters or making donations, these three demonstrate that patient advocacy encompasses far more complexity and impact. They explain the multiple dimensions of advocacy work: legislative advocacy that influences policy and funding, educational advocacy that raises awareness and understanding, and research advocacy that shapes the scientific agenda. The conversation begins with personal stories—what brought each advocate to this work and how living with sleep disorders motivated their commitment to systemic change. Matt shares insights as someone navigating two sleep conditions, while Emma and Julie discuss how legal training informed their approaches to advocacy and systems change. Legislative advocacy receives detailed exploration. The guests explain how patient voices influence congressional action, regulatory decisions, and funding priorities. They discuss educational advocacy—raising public awareness, changing misconceptions, and helping people recognize sleep disorders they might otherwise dismiss or normalize. Project Sleep, Julie's organization, serves as a centerpiece for discussion. While Project Sleep doesn't fund research directly, the conversation addresses which organizations do fund sleep medicine research and how clinicians and patients can access federal funding mechanisms. The guests provide insights into how disease-specific organizations like Wake-up Narcolepsy secure funding and the lessons applicable to sleep medicine more broadly. Project Sleep's helpline receives attention—what it offers, who it serves, and the critical challenge of sustainability when grant funding ends. The guests discuss Rising Voices, an initiative amplifying patient narratives and lived experience in policy and clinical discussions. A particularly valuable discussion addresses how clinicians can meaningfully engage with patient advocacy. Is this space exclusively for people living with sleep disorders, or can healthcare providers contribute? The conversation explores collaboration opportunities without appropriating patient voices or experiences. The guests address practical questions: How do you sustain advocacy work without becoming discouraged? What does advocacy look like at local versus federal levels? What's on the wish list for sleep medicine advocacy? A recurring theme emerges: sustained funding remains elusive despite growing recognition of sleep disorders' impact on public health. The episode acknowledges that patients bring irreplaceable perspectives to clinical practice, research prioritization, and policy development. Their lived experience of navigating diagnoses, treatments, and healthcare systems provides insights clinicians cannot access through clinical practice alone. Whether you're interested in supporting patient-led advocacy, seeking to collaborate with patient organizations, curious about how to engage in legislative efforts, or simply wanting to understand the power of patient voices in healthcare transformation, this episode provides essential perspectives and practical guidance. Join us for this important conversation with patient advocates who are leading meaningful change in sleep medicine. Episode Correction: During the audio recording, federal funding for circadian research was misspoken as $60 Million. The correct amount is $600 Million. Project Sleep Links https://project-sleep.com/ https://www.instagram.com/project_sleep/ https://www.facebook.com/ProjectSleepAwareness/ https://www.linkedin.com/company/project-sleep/ https://www.youtube.com/user/projectsleepvideos Get Project Sleep’s Print Resources Sent to Your Door! https://project-sleep.com/sleep-info/sleep-resources/#request

Residual AHI vs Objective Testing: Which is Accurate?

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Sahil Chopra to discuss research challenging a fundamental assumption: that residual AHI measurements from PAP device downloads accurately reflect whether patients' sleep apnea is adequately treated. Sleep medicine clinicians routinely rely on residual AHI from PAP downloads to determine treatment success, typically targeting an AHI under 5. But what if this metric significantly underestimates untreated sleep apnea? Dr. Chopra's study comparing PAP-determined residual AHIs to cardiopulmonary coupling (CPC)-derived AHIs reveals striking discrepancies: mean residual AHI was 2.4 via PAP download versus 12.1 via objective testing. Even more concerning, 85% of nights showing residual AHI under 5 on PAP downloads had elevated AHI based on objective CPC measurement. Dr. Chopra explains why he chose cardiopulmonary coupling as the comparator metric, using a PPG-based wearable ring worn for 7-10 nights. He clarifies why PAP devices may systematically underestimate residual disease through mask leak, unstable breathing, and periodic breathing patterns. A particularly concerning finding involves residual hypoxia. Dr. Chopra discovered significant hypoxic burden in many patients considered "well-treated" by PAP standards—important since hypoxic burden, not just AHI, drives cardiovascular risk. Dr. Chopra's conclusion isn't that PAP-derived AHI is "bad"—rather, that it shouldn't be the sole metric for assessing treatment efficacy. Even patients with good symptoms may have significant residual respiratory events and hypoxia that PAP downloads fail to detect. Clinical applications are discussed, including when to pursue objective testing and what interventions to consider when objective testing reveals inadequate control despite acceptable AHI. Whether you rely on PAP downloads to assess treatment efficacy, manage patients with residual symptoms, or seek emerging objective metrics, this episode provides essential perspectives on optimizing PAP therapy. Join us for this important discussion that challenges current assumptions about measuring treatment success in sleep apnea.

Sleep and Perimenopause

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Andrea Matsumura, a sleep physician with specialized certification in menopause medicine and national advisor for Monarch MD, to discuss how sleep clinicians can better support patients struggling with perimenopausal sleep disturbances. Since the FDA removed the black box warning on hormone replacement therapy, more patients are inquiring about medications to treat perimenopausal sleep symptoms. Dr. Matsumura, who left traditional practice to pursue menopause certification and now works at the intersection of sleep medicine, mental health, and women's midlife health, provides practical guidance on this increasingly important clinical area. The conversation begins with Dr. Matsumura's career evolution. After training as an internist with a leadership role at Kaiser Permanente and practicing sleep medicine in a group setting, she pursued specialized menopause certification—a credentialing process explained in detail. Dr. Matsumura discusses what menopause certification encompasses, who can pursue it, and her own path into this specialty. She also discusses her work developing specialized supplements for perimenopausal sleep support. The episode systematically addresses how perimenopause disrupts sleep. Rather than focusing solely on hot flashes, Dr. Matsumura explains the full spectrum of sleep-related changes. She clarifies the timeline of perimenopause—when it starts and ends—and discusses less commonly recognized phenomena like menstrual hypersomnia that clinicians may not immediately associate with menopause. A critical discussion addresses patient expectations around hormone replacement therapy. Many patients expect sleep clinicians to prescribe HRT, which raises legitimate concerns for providers unfamiliar with menopause management. Dr. Matsumura provides practical guidance on these conversations and clarifies the role of hormone level testing—addressing the debate between treating symptoms versus checking levels before initiating therapy. The conversation explores the complex relationship between sleep apnea and menopause. Dr. Matsumura explains why and how obstructive sleep apnea may worsen during perimenopause, how to have these conversations with patients, and when referral to OBGYN colleagues is appropriate for collaborative care. Additional topics include the role of hypnotics in perimenopausal sleep disorders, absolute contraindications to hormone replacement therapy, how to initiate HRT when appropriate, and whether restless leg syndrome worsens with perimenopause. Dr. Matsumura addresses common misconceptions about menopause and sleep, helping clinicians understand what practitioners and patients frequently get wrong about this life stage. The episode emphasizes that sleep medicine clinicians don't need to become menopause specialists, but understanding these connections enables better patient care and appropriate referrals. Join us for this important conversation about supporting women's sleep health through midlife transitions.

Sleep Medicine's Environmental Footprint and Impact

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Laura Donahue, an assistant professor of sleep medicine at Vanderbilt University with a background in internal medicine and a researcher in sustainable healthcare, to discuss the environmental impact of sleep medicine practice and practical strategies for reducing carbon footprint and medical waste. Recent environmental challenges—heat waves exacerbating insomnia, wildfires affecting respiratory and sleep health—highlight how climate directly impacts patient wellbeing. But do sleep medicine clinicians have an obligation to reduce their own environmental footprint? Dr. Donahue explores this question, examining the waste generated by sleep testing, PAP therapy, and ongoing supplies. The conversation begins with foundational concepts: How does climate change impact sleep health? What exactly constitutes medical waste, and how does it differ from carbon footprint? Dr. Donahue explains methods for calculating carbon footprint and how the US healthcare system compares globally. She introduces life cycle analysis—a comprehensive tool for understanding environmental impact across product lifecycles. Sleep lab waste assessments receive detailed attention. Dr. Donahue walks through how to conduct a waste audit of sleep facilities and why examining both carbon footprint and waste matters, acknowledging that these metrics don't always move directionally. Her research on PAP device waste, conducted with Dr. Morgenthaler, revealed substantial environmental costs associated with standard OSA therapy—findings that prompted examination of alternatives. Telemedicine emerges as a potential sustainability strategy. Dr. Donahue compares carbon footprints of virtual versus in-person sleep consultations, exploring how practice model choices affect environmental impact. However, the analysis doesn't focus solely on PAP therapy—hypoglossal nerve stimulators and other non-PAP treatment options receive consideration as alternatives with potentially different environmental profiles. SHAPE, an organization dedicated to helping healthcare providers examine their carbon footprint and waste generation, receives discussion. Dr. Donahue explains SHAPE's mission and practical resources available to sleep medicine programs. She provides concrete guidance on reducing environmental impact: waste audits, supply chain evaluation, and transitioning to circular economy models where possible. A particularly relevant discussion addresses plastic waste from CPAP devices and consumable supplies. Dr. Donahue explains how waste audits serve as the first step toward identifying reduction opportunities and discusses strategies for minimizing single-use plastics in sleep medicine practice. The episode acknowledges that sustainability requires institutional commitment and individual awareness. Dr. Donahue emphasizes that small changes—from supply selection to practice model design—accumulate to meaningful environmental impact. Whether you're interested in sustainable healthcare, concerned about medical waste, seeking to reduce your sleep practice's carbon footprint, or wanting to better understand climate impacts on sleep health, this episode provides practical guidance and evidence-based approaches. Join us for this important conversation about environmental responsibility in sleep medicine practice.

Daylight Saving Time: Advocating for Sleep Medicine

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Karin Johnson, Professor of Neurology at UMass Chan School of Medicine–Baystate and expert on circadian rhythm policy, to discuss two competing legislative bills addressing permanent time change in the United States. Two bills currently before Congress present starkly different solutions: the Sunshine Protection Act for permanent daylight saving time and the Sunshine for Our Kids Act for permanent standard time. Both campaigns use compelling language that makes their position sound obvious, complicating decisions for policymakers and clinicians alike. Dr. Johnson reviews the AASM's official position on daylight saving time and what research reveals about time change effects—both short-term consequences of bi-annual clock transitions and long-term health impacts of permanent DST, particularly on adolescent mental health and circadian rhythm disruption. She explains what happened during the 1974 experiment with year-round daylight saving time and why that experience remains relevant today. The conversation details both the Sunshine Protection Act and the Sunshine for Our Kids Act, including their legislative progress and specific provisions. Dr. Johnson clarifies which approach sleep medicine clinicians support and provides practical guidance on advocacy. An intriguing discussion explores a proposed compromise to move clocks by 30 minutes and leave them there—why didn't this gain traction? Dr. Johnson also reveals how industry influence shapes policy, discussing candy companies' historical support for daylight saving time and other commercial interests that complicate what should be a health-based decision. Dr. Johnson emphasizes that permanent standard time better aligns with human circadian biology, particularly for adolescents whose naturally delayed circadian rhythms suffer under permanent DST. Whether you're seeking to understand these competing bills, advocate for science-based policy, or interested in how medical evidence influences legislation, this episode provides clarity on a complex issue with direct health implications. Join us for this important conversation about how sleep medicine can influence public health policy.

Live from SLEEP 2026: The Future of Sleep Pharmacotherapy

In this special live episode recorded from the SLEEP 2026 annual meeting in Baltimore, host Dr. Seema Khosla welcomes Dr. Sanjay Patel, director of the clinical sleep program at University of Pittsburgh Medical Center, to discuss groundbreaking medications for sleep disorders poised for FDA approval in 2026 and 2027. The pharmaceutical landscape for sleep medicine is undergoing unprecedented transformation. Dr. Patel surveys the emerging drug pipeline that will fundamentally change how clinicians treat obstructive sleep apnea, narcolepsy, and idiopathic hypersomnia. For obstructive sleep apnea, Dr. Patel discusses AD-109 (atomoxetine and R-oxybutynin), explaining the mechanistic rationale and practical considerations including use with tirzepatide. The Incannex drug combining dronabinol and acetazolamide receives analysis for different patient populations, and sultiame is discussed as a carbonic anhydrase inhibitor option. A critical framework emerges: Should treatment be symptom-based or airway-focused when PAP-intolerant patients present? Tirzepatide, the GLP-1 agonist FDA-approved for moderate-to-severe OSA, receives comprehensive coverage including muscle loss concerns, long-term use, and emerging oral GLP-1 options. Retatrutide, the triple-hormone agent combining GLP-1, GIP, and glucagon, is also discussed. The episode's most exciting segment focuses on orexin agonists for narcolepsy. Three pharmaceutical companies—Alkemeres, Centessa (purchased by Lilly), and Takeda—are developing these mechanistically novel agents. Dr. Patel clarifies how these medications differ, discusses why one medication disrupted nocturnal sleep (suggesting continued roles for oxybates), and addresses how clinicians will choose between similar medications. Dr. Patel emphasizes a fundamental question: Should the field prioritize symptom management versus airway patency for OSA, and mechanistic approaches versus symptom management for narcolepsy? Whether you're interested in emerging OSA treatments, narcolepsy innovations, or the future of pharmacological sleep medicine, this live episode provides essential updates on medications that will soon reshape clinical practice. Join us for this exciting conversation about how sleep medicine will transform in the coming years.

Fixed PAP vs APAP: Impact on Blood Pressure and Autonomic Response

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.

Insomnia Combination Treatment: New AASM Guidelines

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 differences—PSG outcomes, fixed time in bed requirements—that 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 position—CBT-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 hierarchy—zolpidem 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.

OSA and Parkinson’s Risk: Can CPAP Change Outcomes?

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 diagnosed—through 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 identified—through 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 gradients—did 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 risk—a 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.

Community PAP Therapy: Engineering Better Sleep Apnea Care

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 streams—high-resolution flow rate data from PAP device SD cards, pulse oximetry from wearable rings, and sleep architecture from devices like Apple Watch—creating 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"—detailed 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.

Comparing Hypoglossal Nerve Stimulators for OSA

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.

Microplastics, PAP Therapy, and What the Science Shows

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 São 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 non‑users. The conversation is framed by alarming findings from recent high‑profile studies showing microplastics in carotid artery plaque and even in the olfactory bulb of the human brain — discoveries that raise important questions about how these particles enter the body and their potential long‑term 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 so‑called “forever chemicals,” 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 — from clinical practice to advocacy — to reduce plastic exposure in health care settings. Whether you’re 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.

Inpatient Sleep Medicine: New AASM Guidelines

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.

High Altitude Central Sleep Apnea: Diagnosis and Treatment

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.

Are Hypnotics Safe in Untreated OSA? Insights for Clinicians

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.

Wearable Sleep Tech: Clinical Use and Best Practices

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes three members of the World Sleep Society's consumer health technology task force—Dr. 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 contexts—from 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.