Stopping the Cycle: Interplay of Obesity and OSA

Dr. Allan Damian (Texas Tech University): Let us get started with our first section. Stopping the Cycle Interplay of Obesity and OSA.

[00:09:08]

OSA and Obesity: A Growing Epidemic

All right. There we go. OSA and obesity, so I call this a co-epidemic. Half of adults with obesity also have OSA, and then about two-thirds of patients with OSA have obesity. I will put a footnote there that when we say half of adults with obesity have OSA, I think that is a relative number, because it might depend on the metric that you use for measuring OSA.

There is many metrics that we use in sleep medicine. One of the most common ones and most well-known is the AHI, apnea hypopnea index. There is a 3%, there is a 4%, but there is also the RDI or respiratory disturbance index. The statistics will vary depending on which one you use or you give credit for. Obesity causes upper airway narrowing via fat deposition, and central adiposity increases airway collapsibility.

In the pathophysiology of OSA and obesity, both fat mass disease and sick fat disease. Both anatomic and physiologic factors play a role. Some of the more traditional or more common risk factors for OSA would include male sex, older age, high BMI, and also anatomic factors such as large tonsils, especially in kids. I see both adults and kids. Large neck circumference. By far, obesity is the strongest modifiable risk factor for OSA.

[00:10:57]

The Vicious Cycle: A Bidirectional Link

There is a vicious cycle between OSA and obesity. I would like to emphasize the first bullet point here: sleep disruption. A lot of people, both patients and physicians, and probably a lot of you here, think that sleep medicine practice is a CPAP dispensing practice. That is simply not true. There is many different categories of sleep disorders, and sleep apnea is just one category under sleep disruption. Sleep disruption can lead to sleep deprivation.

We treat all conditions that are related to sleep deprivation in one way or another. In studies of patients who have had sleep disruption or sleep deprivation, there are a lot of neurocognitive consequences when you are having sleep deprivation. Sometimes it may take one night, it may take several nights. All of those risk factors accrue. In terms of neurocognitive consequences, sleep deprivation or sleep disruption can impair motivation, can impair executive functioning, can impair mood, amongst many other things.

Those are some of the pathways by which it can lead to overeating or making poor choices in life, not only with what you eat, but also with other things in life. Obesity can worsen OSA both through sick fat and fat mass mechanisms. Because of that behavioral loop, it leads to a lot of poor decision-making when it comes to activity and eating. Success is in treating and addressing both conditions.

[00:12:59]

 Treatment Outcomes and Gaps in Care

There are several gaps in care in treating both obesity and OSA, or mainly OSA. Even a lot of us in the sleep world might overlook the fact that even a 10% weight loss can decrease AHI by around 26%. Nowadays, we also have these newer medications for obesity, the GLP-1s and the dual agonists, which not only reduce body weight and other outcomes, but they have been shown to reduce AHI as well.

CPAP limitations. There is challenging adherence and benefits may be linked with adherence. The correct term here is PAP therapy. CPAP is just one type of PAP machine from the many different types of PAP machines that we in sleep medicine manage depending on what the patient might have. There is CPAP, there is BiPAP, there is BiPAP ST, ASV, and then volume assured pressure support, especially for people who have obesity hypoventilation syndrome.

A lot of people get intimidated just with the thought of wearing a mask at night, and many studies have shown that you have to be wearing the mask or you have to be using your PAP device for maybe at least 6 hours each night. Best if you are using it the whole time you are sleeping. I think most payers would only require 4 hours of use, but that is not really sufficient to get the most benefit out of it.

Gaps in care. There is a general underdiagnosis with sleep apnea in general, both obstructive and other types of sleep apneas. Sometimes there is limited PCP confidence. Not so much maybe in recognizing that there ought to be more diagnosis, but in managing patients who have both conditions. There is a lack of integration in general between sleep medicine and obesity management.

[00:15:22]

Wake Up! Poll 3

All right. Let us go to our first wake-up poll. In your current practice, what percentage of your patients meet at least 3 of the following criteria? Male BMI greater than 35, they have hypertension, large neck size, or aged greater than 50. Okay. 10% to 25%. Okay. Is that so 10 to 25% and 26 to 50% have the most answer. Okay.

[00:16:21]

Call to Action

Let us go to the next one. For PCPs and specialists, we need to increase OSA screening, close the gaps in care, and then optimize all the tools that we have in order for us to be able to improve outcomes. Let us move on to the next session. I will turn it over to Dr. McConnell.

[00:16:43]

OSA Screening and Diagnosis in Obesity Management: It Can Be Done!

Dr. Jeremy McConnell (Discover Health Bradenton): Thank you very much, Dr. Damian. Good afternoon, and thank you all for attending this. I think this is really important that we understand how the intersection of OSA and obesity impacts our clinical practices and the patients that we serve. One of the things I like to share just simply is I am a person with obesity and also a person who has obstructive sleep apnea. The intersection of these 2 things is not just clinically interesting to me, but it is also personally interesting to me.

I will say, though, that I do think as colleagues in the obesity medicine space, one of the things that I think I can encourage you to do on Monday morning, when you get back to wherever you come from, is reach out if you have not and contact your local sleep medicine providers, let them know who you are, let them know that you practice evidence based obesity care.

We in the sleep space need you. As you may know, sleep resources are in short supply in most regions and in most markets. It is a challenge, as sleep clinicians, to adopt care of obesity into our practices. In many cases, we lack the time, the resources, knowledge, and education, and we need to lean on our colleagues in obesity medicine to allow us to extend that care to our patients.

I would say that to my colleagues across the country in the sleep space, they are looking for people like you. They want to be able to collaborate with you and identify how they can co-manage these patients. Likewise, as far as diagnostics testing and access to care for OSA, we in the obesity space need our sleep colleagues as well. I would encourage you with that. There are millions of people in the United States and a billion people in the world who have obstructive sleep apnea, and they need access to care. Thank you for your interest and what we can do to help these patients together.

[00:18:30]

OSA in Obesity Management: Screening

How do we do this in a quick fashion? The challenge we all face in our practices today is a lack of time. Perhaps when we are talking specifically about the treatment of obesity, there are a lot of pillars we have to address, lifestyle modification being the most time consuming, of course, medication selection, and comorbidity management. How in the world can we possibly add one more thing to our plate in a 15-minute visit?

What I like to do in practice is find easy ways to use high-impact, high-yield tools to enable this to be very timely. One of the ways in which we can do this is by using validated screening tools. There is a few here in this particular slide. I am going to show you a handout in a moment that you can take with you by scanning the QR code. I encourage you all to access that.

These 3 different specific screenings, the STOP-Bang questionnaire, the Epworth Sleepiness Scale, and the Berlin Questionnaire are all validated tools to help us to identify patients very quickly who might screen for a higher likelihood for having OSA. I use these in my intake questionnaires. In terms of my new patient questionnaire, the STOP-Bang components are all there. We also include an Epworth Sleepiness Scale to assess excessive sleepiness.

Although the Epworth does not correlate with the risk of obstructive sleep apnea, it is an important tool when trying to identify who is more symptomatic from their obstructive sleep apnea. The Berlin Questionnaire is a validated tool to screen for, and it does have positive predictive value as it relates to those people who would rule in for sleep apnea. I incorporate at least the STOP-Bang into my intake questionnaire, and we will go over what is included in STOP-Bang in a moment.

It has 4 objective measures and 4 subjective measures, and it is a very easy and facile thing to do with your patients. Many times, in some cases, depending upon the electronic health record that you use, it may be integrated already into some of the macros and workflows that you may already have. Because of the prevalence of obstructive sleep apnea in people with obesity, it is recommended that we screen all people with obesity simply because of the likelihood and the prevalence associated with it. All right.

[00:21:00]

OSA Bootcamp Practice Tool

This is what the practice tool looks like. I would encourage you if you can, to take a snapshot of that. It will take you directly to a website where it has a downloadable PDF. We wrote this with the intention of using something as a decision-making tool that you could have as part of your day-to-day practice. Once you become facile with it, it becomes second nature as far as screening and identifying people at risk, what to order from a diagnostic perspective, and then some management tools once you identify someone who does indeed have OSA. Clickers a little bit tricky to work with here. Sorry. All right.

[00:21:45]

Patient Case: 48-Year-Old Man - Initial Encounter

Let us move to a case-based presentation. We will talk about these components within that. In this particular case, this is a 48-year-old man. This is the initial encounter with a chief complaint of "I am exhausted all the time even when I sleep." From the beginning, indicating non-refreshing or non-restorative sleep, who really wants to lose weight, but it has been hard with their job. Now, we all understand this from a lifestyle and social impact factors that, for some individuals that can be a barrier.

He works as a traveling sales manager and has a primary complaint of excessive daytime sleepiness, loud snoring, fatigue, and low morning energy. Just show of hands, is this a common type of presentation that you might see in your practice on a day-to-day basis? I did not mention this earlier, but my background is in family medicine, and so when I was working in my family medicine practice, fatigue was always one of those top complaints. You are going, well, "What do I do with this? What direction do I take?" Do not ignore the sleep disorder.

Has a past medical history of hypertension, prediabetes, GERD, chronic low back pain. He is a former smoker and has a BMI currently of 37kg/m². Currently prescribed lisinopril, omeprazole, and ibuprofen. In terms of vital signs, weight is 122kg, height is 5 feet 11 inches, blood pressure of 142 over 86, a pulse of 78 beats per minute. On physical exam, neck circumference was 18.5 inches.

One thing that we probably ought to do in our practices when our patients present for obesity care, I know that it is ubiquitously understood to measure waist circumference. I also encourage you, if you have the tape measure out, let us get a neck circumference at the same time. One practical pearl as to why that is really important. Because if you submit for permission or pre-certification to get a home sleep test or some diagnostic, they are going to ask you for the neck circumference.

They are also going to ask you for their Epworth Sleepiness Scale score. Having those 2 components already helps you. They will ask you for the body mass index as well. These different components oftentimes are necessary for getting approval for testing. If you are there, let us get the information that we need right from the get-go. In terms of general appearance, the individual has obesity, appears fatigued or tired.

I think when we talk about oral exam and the components of physical exam, which I think are really important at helping us to identify individuals who have obstructive sleep apnea. One of the very first things I tend to look at is the look from the door. My neck circumference is 16.5in, and I like to say if yours is bigger than mine, then that is okay. You get a point right there.

The second is I like to look at a side profile of your face, looking specifically for retrognathia. Is their jaw retro set? Just a bit. What that does essentially is it confers a more narrowed or anterior-posterior space in the oropharynx. When we talk about obstructive sleep apnea, most often the structure that is obstructing the airway is the base of the tongue.

If an individual has an anatomic configuration, if you will, of a short or a shallow anterior or posterior space, the tongue does not need to fall back very far to cause an airway obstruction. If they have retrognathia, it will already be somewhat recessed. It is a greater, shall we say, propensity for airway collapse in those individuals.

Then, looking at their oropharyngeal exam. Looking to see how much room is there from a lateral perspective, so not just anterior-posterior depth, but also from the tonsillar pillars. How much room is there? Then, taking a look at the mandible. Many times people will have a narrowed mandible. The tongue cannot sit down and lay flat in the floor of the mouth. Therefore, it is displaced upward and posterior.

We also know from studies using volumetric MRI scanning that there is a correlation with tongue fat mass deposition. As individuals gain weight, they can develop an ectopic fat mass of their tongue, which also creates more macroglossia. You might look for lateral scalloping of the tongue margins on the lateral aspects of the tongue whereby the tongue is pressing against the teeth. Then additionally, looking at the position of the tongue and if it occupies something we call the Mallampati score, looking at how much room that tongue is occupying in the floor of the mouth. There are many different ways you can look at people and make a very quick determination based on their medical history and based on their physical exam, that this is a person who likely has sleep apnea.

[00:26:39]

Small Group Discussion

We are going to move into some small group discussions based upon the information that we just had. Dr. Damian, I know is going to work in the audience. What we would like to encourage you to do is to take this time and look at these questions that we just had, talk amongst yourselves, amongst the table, and look at the different questions that they have here, just as a decision-making and thought process related to the case study we just had.

Meanwhile, we do have an online audience, so it is going to look a little weird because I am going to switch to talk to them and discuss some of these things. While you guys are talking about this, we will spend a couple of moments doing that, and then we will come back and reconvene and talk a little bit more about the aspects of this.

Dr. Damian: Do you guys have any questions? Let me know if you have any questions.

Dr. McConnell: Okay. Welcome to everybody on the online audience. It is always a little bit awkward to speak to people we cannot see. While you may not see it here, there is a group of about 300 people in the room who are contemplating these questions. A few things I would probably like to talk about as it relates to managing these patients and looking at patients who are at high risk. The physical exam features and the clinical picture, the patient really can help us to identify patients extremely quickly as to who is at high risk.

Using the STOP-Bang questionnaire is the tool that I would use most often. As I stated earlier, S stands for snoring, O stands for observed or witnessed apnea events, which is probably the most important factor in the STOP-Bang questionnaire that I think predicts for a higher risk of the presence of obstructive sleep apnea. T, I miss the T, but T is for tired. People who complain of non-refreshing sleep or excessive daytime sleepiness that can be a significant component that relates to that. P is for blood pressure. Do they have hypertension?

The B is for body mass index greater than 35, A is for age greater than 50 years, N is for neck circumference, so in females greater than 16 inches and in men greater than 17 inches. G stands for gender, so if they are male, they would have a point assigned for that. The sum of these points is on these 8 different metrics. Each one of these items gets 1 point. If they have a score that is greater than 4, they are considered to be high risk for obstructive sleep apnea. There is a direct relationship between the positive predictive value of that score and the likelihood for obstructive sleep apnea.

I think that is a practical tool. I use it as a documentation assistance in my practice, and what we would like to do as far as trying to get certification, or the need for testing justification used in that case. I would encourage you to use that. Document that in your clinical encounters, because it really helps you identify very quickly who is at risk. Now that we find patients who are perhaps suspect for this, we want to talk about how the OSA may impact their obesity and metabolic health.

I think this is, quite frankly, why I got into sleep medicine in the first place was the understanding and discovery that disturbed sleep increases ghrelin, reduces leptin, which in turn can drive more eating, increase caloric intake. Also, these patients oftentimes are just tired, and they are not necessarily apt to engage in physical activity in the way that we might recommend. It makes it difficult for those patients to increase their caloric expenditure.

As a result, their caloric expenditure is reduced and their want and desire to eat is greater. As an impact for that, that can drive weight gain in individuals with undiagnosed or untreated OSA or anything that causes sleep disturbance, like what Dr. Damian said earlier. I always begin this conversation with patients and let them know that one of the weight related conditions is obstructive sleep apnea that may be hindering their progress in terms of weight loss, or at least theoretically, can get in the way of their progress with weight loss, and then identifying if they have OSA is going to be important to their overall management because of the crossover cardiometabolic risk associated with OSA.

I know there might be a couple of questions that have been shared from the online participants. If you have any, please put them in the chat feature or into the Q&A so we can answer those in the few minutes that we have before we go back to the general audience. One thing I think is also important, and Dr. Damian mentioned this, is the impact of weight reduction on apnea severity. We have known for a few decades, actually, it is not necessarily new information, that with weight reduction, you can see an improvement in apnea hypopnea index.

The metric we typically use is based on a study from 2000, the Wisconsin Sleep Study, and what it showed was that 10% weight reduction reduces AHI by about 22%. In individuals who perhaps have borderline moderate OSA, helping them to have modest weight reduction of 10% of body weight can substantially improve their obstructive sleep apnea and even possibly put it into remission in such a way that they could perhaps not need treatment through other modalities.

I think the challenge that we always have as clinicians is when we identify a patient who has obstructive sleep apnea, and concomitant obesity is where do we begin? We are going to talk about that in the latter portion of this presentation. My view on it is that we should look at it as a 2-disease state model. When we identify an uncontrolled new condition associated with obesity, we do need to implement treatment as we are working on their weight reduction strategy and follow those patients longitudinally.

If there are not any questions, I will share some additional clinical advice and direction on what we should do in some of these patients. I think one of the things we can look at as obesity medicine clinicians is who is going to be responsible for managing these patients once we identify that they have a problem with obstructive sleep apnea, and what direction we should take in their management? The way I approach it is really based upon disease state severity, comorbidities, and the patient's preferences. With conditions or patients who have a higher AHI, they have more severe obstructive sleep apnea, and they also perhaps have significant comorbidities, I will be more aggressive in terms of addressing that.

Speaker 3: There should be a couple of questions, again.

Dr. McConnell: I do not see any.

Speaker 3: I see. Okay. One minute you will have questions. Just a second.

Dr. McConnell: All right. I know there has been some questions submitted. Technical support is helping us to figure that out. As I was stating, in patients who have a higher AHI, I will be more aggressive with trying to get their AHI under control. Meanwhile, work on their weight reduction strategy if they have significant co-morbid risk factors, for instance, established cardiovascular disease. If they are significantly symptomatic with excessive daytime sleepiness, then I will initiate treatment for their OSA, meanwhile working toward weight reduction.

Then we will then also address the longitudinal care with that patient because we may need to have some concomitant management with that. I am having a little bit of trouble actually seeing the questions. I am not sure what we can do about that. I apologize if the technical component is not working the way we would like it to. We are winding down into the session for this portion, and so what we are going to do here in a moment is come back to the broader audience. Here are the questions. In resource-constrained settings, are there ways to prioritize patients for sleep studies? Yes.

We will talk about the use of home sleep testing, but I think home sleep testing is probably the most facile way to get people tested and diagnosed. Using home sleep testing that can be shipped directly to patients and then, therefore accessing that care faster is a better way to go about it. Let us see. Okay. Coming back to the stage. Okay. We are going to reintroduce the broader audience.

Dr. Damian: Just to recap, I think there were some interesting questions. I think ESS Berlin Questionnaire and STOP-Bang, I think they are pretty common enough that a lot of EMRs would have those questionnaires embedded. My medical center uses a particular software, which is pretty common. I am not going to go into brand names, but there are many different versions of each software or EMR. There might be a case where you would have to ask for it to be available to your institution. Then, a lot of these questionnaires, especially STOP-Bang and ESS, there are versions for kids and teens. It is just the wording of some of the questions, but they are essentially asking for the same questions. You can use them for kids and adolescents as well.

Dr. McConnell: That is a really good point in terms of how we actually use those in practice. I want to just highlight the second bullet point here and really discussing how untreated OSA may impact obesity and metabolic health. I was an obesity specialist before I became a sleep specialist, and it was that fact there that drove me to be interested in sleep disorders. Then did not think I would make a career out of it, but I did. It was fun. A lot of fun. I think that is important that we recognize those connections.

Many of our patients do not know these things, and we need to teach them some of that fundamental basic science of how their sleep disturbance can affect their weight trajectory and their efforts toward weight reduction. Many times, people do not want to get tested. Many times they are apprehensive about even considering testing because they are afraid we are going to put the Darth Vader mask on them. Let us face it.

That piece of information that your sleep disorder may be hindering your weight loss progress can be very motivating. They go, "Oh." If you have a patient who is not responding the way that you would like them to, they are not achieving the goals, perhaps, examine their sleep. Examine that as one of the core components that may be hindering their progress. All right.

[00:38:24]

Patient Case: 48-Year-Old Man - Initial Encounter

Let us go back to the case. We have that here. Number 1, the first step would be to screen. This is using the tool. If you downloaded the tool, you will see that these little pop-up clouds that you will see on this document correspond to what is on the tool. Number 1 screen for OSA symptoms, snoring, excessive daytime sleepiness, and Epworth score greater than 10, and the presence of witnessed apnea.

I think the presence of witnessed apnea, someone else who saw you stop breathing, is a very compelling and very important piece of history to note. All right. Bedpartner histories do make a big difference. The other one that we see a lot of times is when patients are under sedation, let us say for an endoscopy procedure, for example, where a healthcare provider, part of the care team, witnessed it happening because they were under sedation in a simulated sleep environment. That carries a lot of weight from a positive predictive value from a symptom standpoint.

Then the third about witnessed apnea, which I think is interesting, many patients who have obstructive sleep apnea will physically feel their airway collapse as they are fading into the twilight of sleep. They may be supine, or perhaps they are reclined watching television or something, and they nod off a little bit, and just in that early twilight of sleep feel that collapse of the airway, and they might startle themselves awake. I would consider that to be a witnessed apnea. It was witnessed by the patient just in that early stage of falling asleep.

The second component. If OSA symptoms are present, then assess the patient to see if they are more complicated or not. What are we talking about here? There are certain conditions for which performing an in-lab diagnostic polysomnogram is more appropriate. Those conditions are very specific. They, by the way, will correlate with your insurance payer criteria. Just letting you know. If you happen to look at a particular payer criteria for home sleep testing versus in-laboratory sleep testing, they will list it for you. Just a very quick and easy checklist.

Number 1, the first one that we look for is New York Heart Association 3 or 4 congestive heart failure. Those patients are at much greater risk for complex apnea of both combination of central and obstructive, and they should be studied in the laboratory. Patients who are on oxygen for any reason should be studied in the laboratory. Patients with severe COPD should be studied in the laboratory. Patients with a BMI of greater than 40 with evidence or symptoms consistent with obesity hypoventilation syndrome should be studied in the laboratory. Patients under 18 should be studied in the laboratory.

People who have behavioral disorders during sleep that could cause harm to themselves or a bed partner, we call those parasomnias. Things like sleepwalking or acting out their dreams, where there might be kicking or punching or hitting, those types of disorders have to be evaluated in a laboratory setting for the polysomnography video-related to observe that. Those are some of them. I would also add people on chronic opioid therapy. They are a greater risk for central sleep apnea. That is an indication to study in the laboratory. I am just rattling them off at the top of my head. Am I missing any? My colleague.

Dr. Damian: In general, neurologic disorders, seizures.

Dr. McConnell: Yeah. That is a great one. Neuromuscular disorders as well.

Dr. Damian: Neuromuscular disorders, congestive heart failure. Yeah.

Dr. McConnell: This is the big one. While that might represent a relatively, depending on your patient population, a segment within the population, it is appropriate to have those folks studied in the laboratory for all the others. Home sleep testing is a great tool. We are going to talk about the pros and cons of that in a moment. I joke about this and I say on MTV, the first video on MTV was Video Killed the Radio Star. If you recall that if you are of that age like I am, it is my generation.

Home sleep testing has really supplanted the role of the sleep laboratory in many communities. It was first validated and used. The first position paper on it was in 2007. We are almost 20 years into the story of using home sleep testing. Remember that is a very easy, facile tool that you can have access to in your practice because it can be done remotely. Quite simple.

When you look at diagnostic testing, it has all these criteria that are listed here as a decision tool to help you to determine what is perhaps right type of test for your patient. One thing to understand about home sleep testing. Home sleep testing does not rule out obstructive sleep apnea. Let me say that for the people in the back home, sleep testing does not rule out obstructive sleep apnea. It was intended to catch the moderate to severe cases.

If it is positive, it is positive. If it is negative, it does not mean that this person does not have apnea. The current guideline is recommended to perform an in-laboratory study. I know you get these reports that might say things like no sleep apnea observed, etc. When I do my interpretations, I will say no sleep apnea observed. Inconclusive study. Particularly, in the setting where the pretest probability for the condition is higher.

If a person does have symptoms of loud snoring, witnessed apneas excessive daytime sleepiness, and you are looking at this person, you are going, "They have got to have sleep apnea." Think that perhaps it is a false negative, which occurs in up to about a third of studies. It is important. That is probably one of the biggest management mistakes that I see is, "I was told that I do not have apnea." No. It is not sufficient to rule it out. I think that is very important.

[00:44:30]

Wake Up! Poll 4

Okay. Let us move into the polling questions. These are just areas to assess knowledge base for individual for the audience here, of course. The first one, based on the patient you just discussed, what is your next step after OSA screening that revealed the patient is high risk?

A. Educate on sleep hygiene, reassess at the next visit;

B. Refer for an in-lab sleep study;

C. Order a home sleep test; or

D. Start CPAP based on clinical suspicion;

All right. Let us see how this reported out. All right. Based on the patient we just discussed, what is your next step? 48% referred for in-lab sleep studies.

Now, clinically that is not a wrong answer. It is not a wrong answer. This individual that we discussed previously did not have any significant high-risk factors that would warrant necessarily doing a polysomnogram in a laboratory setting. It is not wrong to do it. It is still the gold standard test. It still is. That has not changed, but access to laboratory settings, of course, in your local environment may be challenging. When you think about how am I going to get this person quickly diagnosed and then initiate treatment for them? Home sleep apnea testing is probably preferred in this type of case. Remember, a home sleep test is not a screening test. It is a diagnostic test. Many of our colleagues tend to think that it is a screener that then buys you a ticket to the laboratory. 90% plus of our adult patients with OSA never see the inside of a laboratory.

[00:46:21]

Panel Discussion

A couple of questions here. This is just to go back and forth a little bit. Do you have any thoughts specifically on these particular questions?

Dr. Damian: I think we have mentioned earlier, if you are suspecting a central sleep apneas mainly because of neurologic disorders or a cardiac condition, then you do want to lean more towards the PSG as opposed to the home sleep test. The sad reality is sometimes this is limited by the payer, and unless you do a home sleep test as the initial test, they will throw everything at you to prevent you from getting the patient to the sleep study.

Dr. McConnell: That is true. I am going to move on just because I know we are a couple of minutes behind schedule.

[00:47:10]

Effects of Sleep Apnea

I want to talk about the effects of sleep apnea and what happens. Essentially, what I describe this to patients I love to use a sagittal cross-section diagram like what you see here on the lower right. I literally show it to them. This is what is happening in the case of obstructive sleep apnea. Mind you, we do not call it awake apnea. If you stop breathing while you are awake, that is a 911 problem. It means you have got some nice, healthy chicken breasts stuck in your airway. It is sleep apnea.

Therefore, a lot of people who have sleep apnea may not be aware that they have it because they are asleep. Why does this happen? When you are awake, our brain is sending signals to dilate the oropharyngeal musculature so that the airway remains open and the jaw and the tongue in a forward position. Once we fall asleep, that neurological input, if you will, reduces. It dampens down, the airway collapses, and the tongue and jaw can recess and collapse off the airway. When that happens, it causes airway closure, which then causes a drop in their oxygen saturations.

If you have ever seen this on a diagram or seen it in live in a sleep study, it just starts to go. It is just a precipitous drop very, very quickly. The brain senses that, causes this. You are not breathing, fight or flight response, come on, let us go. Sends a signal to pop the airway back open, and then oxygen within 2 or 3 breaths is very quickly restored. 90% plus of the time, it does not cause the patient to awaken. We will see patients who will stop breathing 30, 40, 50, 60 times an hour. They will tell you, how can that even be possible? I would know. I laugh and say you would not necessarily.

They may awaken and stir, but by the time they awaken and stir, the event is already over. They may not have good recall when they are in this groggy, drowsy state. That causes a sympathetic response, which increases heart rate, increases blood pressure, increases overall sympathetic activity, which recurrent over and over again causes arousals from sleep.

Maybe not full awakenings, but causes a disturbance in their sleep architecture, which can have an impact on their daytime function, their cognitive function, mood, memory, and so that can also be a component of it. Those arousals and that sympathetic overdrive that occurs recurringly over the course of weeks to months to years to decades is why we see the health consequences associated with it. That cycle just repeats.

[00:49:53]

Diagnosing and Treating OSA

Diagnosing and treating OSA. We use the apnea hypopnea index as our metric to determine the severity of apnea. When I speak with patients about this I say this is how many times per hour you stop breathing. Normal is up to 5 episodes an hour. Most people are surprised to hear that when you tell them on an 8-hour night, you can stop breathing 40 times, and we call that normal. We define apnea as a greater than a 90% reduction in airflow, measured by a thermistor or a nasal airflow cannula that lasts for at least 10 seconds.

There is another subset. The hypopneas or underbreathing, is a 30% reduction in airflow, which is characterized by a partial airway obstruction that lasts for at least 10 seconds, but it is associated with an oxygen desaturation or associated with an arousal on cortical EEG when we are measuring this in the laboratory. We take the sum of those events, and then we divide it by the number of hours of recorded sleep time, and that gives us the apnea hypopnea index.

Treatment is recommended in all patients who have an AHI of greater than 15, with or without the presence of symptoms or comorbidities. Treatment is recommended in individuals who have an AHI between 5 and 14, what we call mild OSA, which is a misnomer in a sense that has that AHI plus either of the following so symptoms of excessive daytime sleepiness, insomnia, sleep disturbance, cognitive impairment, or if they have significant comorbidities of hypertension, ischemic heart disease or a mood disorder. I would add to that insomnia as well. That is in the first portion.

If they have those additional symptoms, then a trial of therapy or a recommendation for therapy is appropriate in that mild setting. We classify this as mild from 5 to 14, moderate 15 to 29, and severe greater than 30. This has practical implications for our patients or our clinicians who are treating obesity because of the on-label indications for somehow how we get coverage for some of the things we want to use more on that later.

[00:51:58]

Patient Identification for OSA

We look at uncomplicated patient cases, these are individuals who lack conditions that increase the risk for non-obstructive sleep disorders. Specifically, they do not have significant heart or lung disease, neuromuscular disorders, stroke, or chronic opioid, or opioid use. They have no significant non-respiratory sleep disorders such as narcolepsy, parasomnias, or sleep-related movement disorders that would affect the evaluation of HSC accuracy, and they have no environmental or personal barriers to effective HSAT data acquisition or interpretation.

Some of our patients lack, perhaps, the cognitive ability to perform a home test. That would be another reason to perhaps do it in the laboratory. Then, in complicated patients, it is really the inverse. Individuals who have significant cardiorespiratory disease, potential respiratory muscle weakness, or neuromuscular disorder if they have known awake hypoventilation or suspicion for sleep-related hypoventilation that would be appropriate for laboratory chronic opioid use and stroke or severe insomnia might be others.

[00:53:02]

Diagnostic Testing: What, When, and for Whom?

What, when, and why, and whom? We touched on these items already a little bit, so I am going to speed through them. In laboratory polysomnography, which is the gold standard, is ideal for patients who are more complex cases, comorbid sleep disorders, or perhaps even sometimes safety-sensitive jobs, where the implications of that AHI may be much more significant related to their job performance. For example, DOT-certified, truck drivers, licensed pilots from the FAA, those roles.

Then, the disadvantage of polysomnography is the logistics to physically go there and have it performed. It is not invasive. It does not hurt. It is just simply a bunch of electrodes, and you sleep and we watch you. Home sleep testing has significant advantages. It is more cost-effective. It is more convenient for the patients. For those patients who say, "I am not going to get tested because I do not want to do a sleep study," and I say, "How would you like to do it at home?" "In that case I will do it."

Some of our technologies do break down the barriers that patients might have in terms of that. One pitfall, it may underestimate severity, which is why there is a higher false negative rate. There are different models and different distribution ways in which companies that support this. You can order it, they can ship it to the patient's home. Some of them are disposable. They link up and sync up to an app on their phone. The data is basically loaded to the cloud, and then I get a message in the morning that says, "You have got a study to read." It is pretty facile in how that can take place.

[00:54:38]

Order, Interpret, Act!

If uncomplicated, order an HSAT. If complicated, order PSG. How do you interpret the data based on the metric of AHI, and then decide how you want to manage this? Sometimes we might conclude that this is outside the scope of what I want to handle. That is okay. We say, treat or refer to someone who will. We are all accustomed to doing that. I would highly recommend identifying, as I said earlier, sleep specialist in your community with whom you can collaborate on handling these types of cases. All right. I am going to turn it over to Dr. Damian for the next section.

Dr. Damian: This next section, I think a lot of the slides are pretty straightforward. Just to answer another question earlier, home sleep testing is not approved for use in kids. We only have PSGs in kids. For adults, there is a choice of the home sleep test or the in-lab testing. For kids, it is pretty straightforward. You do not have to argue with the payer or the insurance. It is usually an immediate authorization. All right.

[00:55:58]

Implications of New OSA Treatment Options

Let us talk about implications of the newer OSA treatment options.

[00:56:07]

Evolution of OSA Management: Devices and Beyond

PAP therapy is the gold standard, but not always the gold answer. As I have mentioned earlier, there is many different types of PAP machine. CPAP is the most basic type. I think it is very important to mention that sometimes there might be subjective indications for moving from a CPAP device to a BiPAP device. It is very important that you work with your patient in matching them with the best PAP device, or at least get them referred to a sleep specialist who can probably do further studies.

It is not only the AHI that we are treating when we are having the patient do home PAP treatment. We have to pay attention also to the gas exchange problems that are identified, especially in an in-lab sleep study. PAP therapy is a traditional first-line treatment option for moderate to severe OSA. Personally, in my practice, I offer PAP therapy to all my patients, even those with mild OSA.

It can improve the metrics AHI or the daytime symptoms, and overall quality of life. I would also add also behavior and mood. Depending on who we ask, which database we look at, adherence may be 30% to 60%. I think some of the newer databases, they are saying there is an adherence of about 70% to 80%, but still that leaves behind around what? 30% or 20% of patients unable or maybe unwilling to use a PAP device. There is conflicting evidence on cardiovascular event reduction.

I think a lot of the older studies they studied people who are on CPAP but are using it for only an hour, 2 hours, 4 hours. As I have mentioned, most insurances will require that patients use the PAP device for at least 4 hours. But the newer studies are showing that the patients do not get benefit from it until they have been using it for 6 hours at night or for the whole time they are sleeping. There is such a thing as REM-related sleep apnea or REM-predominant sleep apnea.

You have the bulk of your events during REM stage sleep, which comes every one and a half to 3 hours, and REM gets longer and more intense as the night progresses. Usually, it is the last episode of REM, which is the most intense, which you have the least muscle tone. We all tend to have the most cardiopulmonary instability. If you are only using your CPAP device for 4 hours, you miss that window.

That is why stroke and heart attack, the prime time is typically between 4:00 and 6:00 a.m. in the morning, and accidents are typically between 6:00 and 8:00 a.m. You get the most of the official logic effects of sleep apnea towards the end of sleep, and the neurocognitive consequences after you wake up, before the circadian cycle picks up. When you are navigating through the effects of hypoxemia throughout the night.

There is also some studies that have been showing that there is possible weight gain due to reduced energy expenditure or increased appetite. Some of the newer studies it is showing that it is because of the neurobehavioral consequences of sleep apnea, of untreated, and also undertreated sleep apnea. Even if they are on a PAP device, if they are not wearing it consistently or the pressures are not adjusted for them, they are not going to get the most benefit from it.

[01:00:31]

Weight Loss in OSA Management

Here is one study where they compared just plain education and lifestyle intervention, and you see the graphs there on the right. There was a significant change in weight, also a significant reduction in AHI with that change in weight after the intervention. Weight loss is recommended for all patients with OSA and overweight or obesity. There is clearly a reduction in the AHI, together with a reduction in the weight. OSA is a chronic condition, so we rarely see resolution.

We sometimes see patients who we may be able to wean down to a mandibular advancement device, maybe even positional therapy, but they still have sleep apnea. Bariatric surgery, greater than 75% of patients saw improvement or achieved remission in their OSA. I have several patients who have undergone bariatric surgery, and some of them are on the dental device, or low CPAP, or low-pressure CPAP, or positional therapy. The ASM recommends that we perform repeat testing, at least a home sleep test, before we wean them off PAP therapy.

[01:02:03]

Incretin-Based Therapies for Obesity and OSA

We come to some of the newer medications for obesity, since obesity is a risk factor for OSA, and there is excess adipose tissue, and there is dysfunction of this adipose tissue. Can weight loss consistently improve AHI, and can these medications be part of our choice of therapy?

[01:02:31]

SCALE Sleep Apnea Trial: Study Design

I am going to be running through these slides. We are going to be presenting 2 landmark studies on some of these GLP and double agonists. The first one is the SCALE Sleep Apnea trial. It is a multicenter, double blind, placebo-controlled randomized phase III trial. Patients are all adults, BMI 30 and greater, no PAP therapy before, no prior anti-obesity medications, and they were randomized and followed up.

[01:03:09]

SCALE Sleep Apnea Trial: Weight Loss and Change in AHI

These are the results, and you can see big difference in the change or drop in AHI on the left and then on the right. As the weight went down, the AHI went down as well. There is a big difference compared to placebo.

[01:03:34]

SURMOUNT-OSA: Study Design

The next study is the SURMOUNT-OSA. It is an international and likewise double blind, placebo-controlled, randomized phase III trial. Again, all adults with moderate to severe OSA, one or greater self-reported dietary effort that did not result in weight loss, prior PAP for the previous 3 months, or no PAP for greater than 4 weeks before screening. These patients were likewise randomized.

[01:04:12]

SURMOUNT-OSA: Outcome by Cohort

For cohort 1, no PAP therapy, there was a significant change in the AHI and in cohort 2, with PAP therapy, likewise, there was a significant change in AHI in comparison to placebo. For cohort 1, 25 events per hour versus 5 events per hour, and likewise for cohort 2, 29 events per hour versus just 5 events per hour.

[01:04:48]

SURMOUNT-OSA: Additional Findings for Both Cohorts

Some of the additional findings, greater mean weight loss with tirzepatide, treatment difference of 16.8% in cohort 1, improvement in a lot of other outcomes, especially daytime symptoms and functional outcomes, improvements in measures of inflammation such as high sensitivity CRP, systolic blood pressure, and then there was a good safety information, safety profile. The most common adverse events were mild to moderate GI. There is a boxed warning of increased risk of thyroid C-cell tumors. Tirzepatide significantly reduced AHI body weight and hypoxic burden, as well as improved quality of life in adults with moderate to severe OSA, irrespective of baseline PAP therapy status.

[01:05:53]

Call to Action

Nowadays, we would advocate for multimodal care with our patients, so treating both sleep apnea and obesity simultaneously. Okay. I am going to turn it over to Dr. McConnell.

[01:06:08]

Skill Building in OSA Management

Dr. McConnell: Thank you. All right. Given all this information and what we are doing in our practices today in individuals with obesity and OSA, how should we manage these individuals now that we identify?

[01:06:17]

Patient: 48-Yr-Old Man, Case Continued

Let us go back to the case. We did this 48-year-old man. The case continues. The patient had the home sleep test, which showed an AHI of 28 events per hour with an oxygen saturation nadir of 84%, with 15% of the total sleep time spent with oxygen saturation below 90%. There is some prolonged hypoxemia associated in this case. Sleep efficiency was limited to 76%. There were no central apneas observed, and you can see the laboratory values here as well in this particular case. All right.

[01:06:53]

Patient Interview

On interview, the patient says, I know I need to lose weight, but my job makes it hard. I have heard about shots that help with weight. Would that work for me? I am open to CPAP, but only if there is no other options. I hear that a lot in my practice. Then lastly, I would rather try something that can help with both my weight and sleep. This is where the intersection of these 2 disorders. I usually have a frank conversation with patients, and I remind them that sleep apnea is a weight-related condition.

In the inverse, this case was someone who was presenting for advice on weight reduction. In the sleep medicine space, these patients are coming in for OSA, and we are diagnosing them with OSA. We have to interject the conversation about weight. Make the connection that is a weight-related condition. I always ask permission to talk about it, and then I inform them. Here is the words I use. You may not be aware, however, modest weight reduction can significantly improve your obstructive sleep apnea. Recent studies are showing us that it is possible to alleviate the condition completely, putting it into resolution, and maybe you will not need to use CPAP.

The next thing I tell them is related to this. I tell them, in your overall health care, because of obesity, hypertension, and ow obstructive sleep apnea, your best medicine is modest weight reduction. I like to use the word modest because I think it plants a word in their head that makes them think, "Oh, jeez, you are going to tell me I need to lose £75 and I cannot even possibly fathom that." We know 10% weight reduction yields a 22% improvement in AHI.

I use that number all the time, and I tell them, "Your starting weight is £230, that is £23. Do you think over the course of the next 6 to 12 months we can accomplish a £23 weight loss?" They will say, "Yes, I think I can do that. I think I can do that." My goal is to engage them in the conversation about addressing their obesity and use this disorder as a little bit of a wake-up call that we need to take action because it will have an impact on your future health. I went back a little too far. All right.

[01:09:05]

Small Group Discussion With Poll 5

We are going to break into the small group discussion. We are running a little bit behind, so we are going to try to do this a bit quicker I think. Does this patient meet criteria for obesity management medications? I think there is a poll question for you to complete there. You are obesity experts so you should know the answer to this one pretty easily. For the online audience, of course, the implementation of these medications specifically to address their obesity and their OSA concomitantly is really the direction we want to take. We know that, of course, with interventions that can impact obesity, we can also impact the AHI. It is a common strategy we use in our practice all the time, and I would say it is no different than how we might approach a patient with type II diabetes and obesity, or very simply, very similar to what we might see with hypertension and obesity and concomitant. With that, that is the direction I would usually take with my patients and what I would prefer to do on a day-to-day basis. What is really exciting, I think, is the newer agents help us to achieve better outcomes in terms of the patient care and direction of these comorbidities. I am going to pivot back to the room in general here. Going back to that question, you can see that obviously, the vast majority of you would initiate anti-obesity medication therapy at that point in time.

[01:11:00]

Small Group Discussion With Poll 6

The second question of course is would you initiate tirzepatide?

A. Yes;

B. No;

C. Not sure;

A few points we want to maybe discuss or take a look at is why tirzepatide, why specifically, based on the current data and evidence we have, would a GLP-1 receptor agonist be an option? What makes it appropriate for this patient? Yes or no. Would shared decision-making conversation, how would you counsel the patient in terms of the options related to their treatment choices? Clearly this patient is a candidate for tirzepatide on the basis of their OSA, their obesity, and would be an off-label use of that medication. What I found in the clinical trials, if you look at the data, it is really interesting. The average age at start was about 50. These patients had severe obstructive sleep apnea. There was about a 50% improvement in their AHI, so on average they went from around 50 for an AHI down to about 25. The take-home point on that is that half of patients achieve disease resolution.

However, half did not. I think it is important that longitudinally we keep very close tabs on these patients, that we manage them in sequence. What we usually recommend in our practice is reassessing their AHI at 10% weight loss intervals. All right. Would you use tirzepatide in this patient? First of all, yes, of course it would be an appropriate indicated option for this patient with moderate obstructive sleep apnea and the presence of obesity. A couple of key points I want to make about the SURMOUNT-OSA trial. In SURMOUNT-OSA trial, the average AHI at the trial start was 51. Just to give you an idea, two-thirds were in the severe category, one-third were in the moderate category, and at the end of 1 year, what the study showed was that the average AHI reduction was approximately 50%. They went from a starting AHI of about 51 down to about 26. About half of those individuals in the trial achieved disease resolution. It is pretty impressive. What are some of the take-home messages that we need to take when you are counseling your patients in a shared decision making? Number 1, the AHI reduction did not happen instantaneously. These are individuals who have severe OSA. It is going to be a longitudinal treatment plan, and so as a general rule these individuals should stay with their treatment modality that they are currently using longitudinally.

Number 2, if 50% achieved resolution, 50% did not. They may have improvement in their disease burden but they may not have full resolution. I think we have to be practical with our patients and describe that information to them. The third point, if weight reduction improves AHI what does weight gain do to AHI? It increases it. What do we know about the discontinuation of a medication like tirzepatide, and there is clinical trial data to support this? Weight is typically regained. We need to counsel our patients that if we are going to use this as a tool to improve their BMI, improve their weight, improve their and treat their obesity, if weight is regained, the AHI will go back up. That is what we would predict to see. I think it is real important to have those points of dialogue with patients so that they can make an informed decision about which direction is right for them.

[01:14:37]

Small Group Discussion With Poll 7

Would you consider delaying PAP therapy to see weight loss effect alone or in combination at this point in time? There is another poll question for you.

A. Delay PAP therapy;

B. Combine both obesity treatment in conjunction with OSA treatment; or

C. Not sure;

Hopefully, you have a chance to answer this one. Points to discuss here. What type of lifestyle support would we want to integrate with this? What would be our monitoring plan? Then when would we reassess their AHI? We will talk about those components. 90% of you said would combine now. I think the key point here is that you have an individual who is symptomatic from their obstructive sleep apnea. That would be 1 factor that would weigh heavily in my mind. Number 2, the disease was moderate. They had a significantly elevated AHI. When I am talking to colleagues about this, I relate this to finding a patient who you see for the first visit for obesity, and they have a blood pressure of 180 over 100. Are you going to say, well, let us get you started on a medication management plan and then follow your blood pressure over the next 3 months while we can see your blood pressure improve?

That would not be appropriate. You have identified now another health issue that needs to be addressed, and so most of us, I think, clinically would advise initiating both treatment options obesity and treating OSA. There is considerable dialogue and debate as to what is the cut-off age where we could take obesity treatment as the primary treatment for this individual with concomitant OSA and obesity. I think most of us would agree, just in general, that if the AHI is below 15 mild apnea, that perhaps taking the route of treating obesity first might be the appropriate thing to do. But always have to take into account patient preferences as well as their co-morbid risk factors, and what would that look like if they had unmitigated risk associated with OSA if you choose not to treat it in the beginning.

[01:16:47]

Rest Assured and Bring It All Together

These are all just timeline factors. The main point that I would like to emphasize about this is you have to think longitudinally. Both conditions, obesity and OSA, are chronic conditions, and so we have to think about when would it be appropriate. I want to mention repeat testing. The current practice guideline is to repeat a sleep study at 10% weight loss intervals. That is an ASM clinical practice parameter guideline, and the payers in general follow that parameter. I want to point that out because even if you have a patient who is starting out with relatively severe OSA, as you are working with them on a weight reduction plan, you might ask yourself, well, what is the likelihood that they actually have resolution of their sleep apnea? Should we even bother looking at it? I will tell you, as a person who has obesity and have managed thousands of people over my career, having a number that shows the fruit of their labor, going from an AHI of, say, 30 to begin with, down to maybe a 15 is really valuable and motivating to the patient.

Just in comparison to lipid values or perhaps A1-C values, people want to see what that number is. Even if you would predict that maybe their apnea is still present, getting a number can help sometimes because it is a tool to say you are you are doing it. We are making progress here. Let us stay the course, let us make sure that we are making in achieving our treatment goals and targets. Obviously, I think 90% of people said initiate both. How do you prioritize weight loss versus immediate symptom control, and what was the most challenging part of developing this type of plan? I mentioned this: tirzepatide is a powerful tool for OSA. In the sleep medicine space, just to share with you, this was landmark. I am telling you, you go to the conferences, and this is like what everyone was talking about. It is a big deal. It really represents a treatment paradigm shift, because it is the first and only medication that is ever been approved to treat OSA, so a big deal.

We do not yet know how is this going to play out in the real world of clinical practice. There is a lot of question marks to really decide who is the right candidate, how long will they stay on therapy, and so on and so forth, which would have a lot to do with our management decisions. But I do think that partnering with your local colleagues who do work in this space, I think is really important. As I stated earlier, our sleep medicine colleagues definitely want and need the input from people in this room to help with those patient management steps. All right.

[01:19:24]

Posttest 1

Post-test questions. Okay. If you would indulge us just for a few minutes. Posttest number 1. After this program, how often do you plan to assess for obstructive sleep apnea when evaluating patients with obesity? This helps the planners to determine whether or not this is an effective educational experience. What do we see here? If you take a look at the bottom, just go straight to always. 33% of you said always, 81% in the post said always. Yeah. I think it is a strong point. We do need to be looking for these cases because, as stated earlier, it is estimated that 80% of people with obstructive sleep apnea are undiagnosed. All right. Let us go to question 2.

[01:20:22]

Posttest 2

A 56-year-old man with obesity, with a BMI of 35, hypertension and type 2 diabetes presents with loud snoring, witnessed apnea during sleep, persistent daytime fatigue. Which screening tool would be the most appropriate for use at this visit to assess for OSA?

Okay. Yeah. STOP-Bang was the predominant one. It is ease of use. It is really key. Okay. Next question.

[01:21:17]

Posttest 3

A 49-year-old man with obesity, hypertension, moderate OSA has been using CPAP but reports poor tolerance and discomfort. His primary care provider recently started him on tirzepatide. What is the most appropriate response to him asking if he can stop his CPAP now that he is on medication? Okay. No. CPAP should be continued while monitoring weight glycemia symptoms. Excellent. Very consistent pre-post there. All right.

[01:22:05]

Q&A

We are going to move into a question-and-answer section now. We do have some responses from all of you based on iPad submissions, but also some of the virtual ones. Does anything jump out at you, Dr. Damian, as something you might want to address?

Dr. Damian: We have this question. Do you also encourage weight loss for kids the same way with adults? My short answer would be yes. First of all, treatment for sleep apnea in kids is different from adults. Our first line therapy is typically tonsillectomy or adenotonsillectomy. But guess what? Obesity is a risk factor for post-operative complications post tonsillectomy. Of course, success of CPAP therapy relies with consistent use, and that can be a challenge with a lot of children. At least where I trained, we had an adult sleep medicine, adult obesity practice, pediatric obesity, and pediatric sleep medicine. We would cross-refer patients for co-management.

Dr. McConnell: That is terrific. One of the questions that is listed here is when achieving significant weight loss and planning to repeat a sleep study, should it be an in-lab polysomnogram or will an HST suffice? That is a great question. Most often we will use a home sleep test, and simply because of its relative ease of use, access cost is simplicity of use. One caveat I might have on that is if you are going to do a repeat home sleep test, use the same type and device of home sleep test that was used in the initial diagnostic. Because sometimes these tests are not exactly comparing apples to apples, so we find that that would be appropriate. If they had an indication that warranted doing an in-laboratory sleep study, we would probably still repeat a laboratory-based sleep study to assess their progress because of their medical co-factors their co-morbid risk factors. Do you want to take another one? Another question.

Dr. Damian: Another question: how often should you be sending patients to ENT who have a deviated septum or high Mallampati score for evaluation and treatment? I think this is a relative question because some patients who start CPAP or PAP therapy in general, if they are having difficulty tolerating the device or using the device because of the nasal septal deviation. Then I would send them to ENT for further surgical management. At least the ENT group that I work with in my practice they are very conservative unless the patient has difficulty breathing at baseline, or if they do not, then they usually will wait for the start of CPAP therapy before deciding if they want to do surgery or not.

Dr. McConnell: Those are great points. There was one here. I want to touch on this as a question that addresses specifically sleep-related complaints in women. This is very important. Any guidance on management of OSA and sleep disturbances associated with peri and postmenopausal women in overweight and obesity? One of the things that we know is that pre-menopause, the risk of OSA in men exceeds that which we would see in women. But once a woman reaches menopause, her risk for OSA equals that of men. Risk of OSA goes up, and we do not want to forget that. The second piece to that, that I would mention is that the symptomatology that women tend to present with is different than the symptomatology that men tend to present with. Men tend to present with the rhonchus, snoring, loud, gasping, choking types of clinical presentation. Women tend to present more with complaints of sleep disturbance and insomnia complaints. Non-refreshing sleep awakening from sleep multiple times at night.

In general, they will tend to present with a lower AHI but different symptomatology. When you are treating women in the perimenopause and post-menopausal phase, if they are complaining of sleep disorders, do not forget to think about the possibility of obstructive sleep apnea, and just because she is female does not mean she cannot have OSA. It is something that we need to need to be thinking about.