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 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.

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. 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.

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 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.

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 episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Safwan Badr, the newly appointed editor of the Journal of Clinical Sleep Medicine and sleep medicine physician at Wayne State University, for an in-depth review of the most impactful articles published in JCSM during 2025.

Dr. Badr discusses his vision for the journal and the editorial selection process, then guides listeners through key research findings shaping clinical practice. The conversation highlights both highly popular papers and important studies that deserve more attention from practicing clinicians.

A significant focus is placed on research confirming that traditional 4% hypopnea criteria and CMS definitions systematically underestimate sleep apnea in women, with expanded diagnostic criteria helping mitigate these gender disparities. The episode explores groundbreaking research on sleep architecture and Alzheimer's disease, examining how lower slow wave sleep and REM sleep correlate with brain atrophy in AD-vulnerable regions, particularly the inferior parietal lobe.

Consumer sleep technology receives critical examination through a meta-analysis comparing wrist-worn devices to polysomnography, revealing significant limitations in accuracy. Dr. Badr discusses implications for physicians and consumers who increasingly rely on these devices. Mental health intersects with sleep medicine through research showing that nightmares and insomnia in the acute aftermath of trauma predict suicidal ideation—nearly half of acute trauma patients with both conditions experience suicidal ideation within two months, highlighting urgent need for early interventions.

Additional topics include Canadian research on CBT-I effectiveness during pregnancy and findings from the TODAY study examining obstructive sleep apnea's relationship with glycemic control and cardiovascular risk in young adults with youth-onset type 2 diabetes.

Whether you're looking to stay current with evidence-based practice changes, interested in emerging research on sleep and neurodegeneration, or seeking to understand gender disparities in sleep medicine, this year-in-review provides essential updates.