Talking Sleep

AASM

The vast field of sleep medicine is always evolving. Listen to Talking Sleep, a podcast of the American Academy of Sleep Medicine (AASM), to keep up on the latest developments in clinical sleep medicine and sleep disorders. Our host, Dr. Seema Khosla, medical director of the North Dakota Center for Sleep in Fargo, will take an in-depth look at issues impacting the diagnosis and treatment of sleep disorders. Episodes will feature conversations with clinicians, researchers, sleep team members and other health care experts working to help us sleep well so we can live well.

Play

Open in

21 episodes
fortnightly
Avg 51 min
English

Episodes 21

Newest Oldest Longest

All20 Unplayed20 In progress0 Played0

Counted on this page — what you have heard stays on this device, so it is not something the list can be paged by.

S8 · E16
Yesterday · 49 min
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.
S8 · E15
August 14 · 54 min
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.
S8 · E14
July 31 · 51 min
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.
S8 · E13
July 17 · 50 min
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.
S8 · E12
July 3 · 43 min
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.
S8 · E11
June 5 · 39 min
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.
S8 · E10
May 22 · 51 min
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.
S8 · E9
May 8 · 40 min
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.
S8 · E8
April 24 · 1 hr
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.
S8 · E7
April 10 · 57 min
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.
S8 · E6
March 27 · 34 min
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.
S8 · E5
March 13 · 54 min
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.
S8 · E4
February 27 · 47 min
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.
S8 · E3
February 13 · 52 min
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.
S8 · E2
January 30 · 55 min
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.
S8 · E1
January 16 · 1 hr 8 min
Central Sleep Apnea Treatment: New AASM Guidelines
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.
S7 · E24
Dec 12, 2025 · 53 min
JCSM Year in Review: Top Sleep Research of 2025
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.
S7 · E23
Nov 28, 2025 · 45 min
Live from Disruptors: New Paths in Sleep Medicine
In this special live episode recorded at Sleep Medicine Disruptors in Austin, Texas, host Dr. Seema Khosla sits down with two standout innovators whose technologies captured the spirit of disruptive innovation in sleep medicine. Dr. Jason McKeown from Neurovalens and Dr. Onur Kilic from Bairitone Health present groundbreaking approaches to treating insomnia and personalizing obstructive sleep apnea therapy. Dr. McKeown, a neurologist, introduces his FDA-cleared non-pharmacological treatment for insomnia using vestibular nerve stimulation. He explains how the technology works, why stimulating nerves in this manner is safe, and how it differs from vagus nerve devices. The conversation explores the relationship with cognitive behavioral therapy for insomnia (CBT-I), addresses the placebo effect question, and clarifies whether this is a long-term solution or temporary intervention. Dr. McKeown discusses contraindications including pregnancy and Inspire therapy, potential side effects, and ideal patient populations. Dr. Kilic presents his sensor technology that enables non-invasive assessment of airway collapse location and severity—what he calls an "anatomic PSG." This innovation addresses a critical challenge: predicting which patients will respond to specific treatments like oral appliances, Inspire, or PAP therapy based on individual anatomical collapse patterns. Using a cheek-mounted sensor, the device identifies obstruction levels, differentiates between primary and secondary collapse sites, and detects collapse at the velopharyngeal level. The discussion explores whether this represents a scalable alternative to drug-induced sleep endoscopy (DISE), how it integrates with OSA endotyping, and practical applications during titration studies to identify optimal pressure ranges and guide combination therapies. Both innovators emphasize moving beyond one-size-fits-all approaches toward personalized, anatomy-based treatment selection. Whether you're interested in non-pharmacological insomnia treatments, precision medicine approaches to OSA, or the future of sleep diagnostics, this episode showcases innovative thinking driving the next generation of sleep medicine. Join us for this exciting live conversation from Sleep Medicine Disruptors.
S7 · E22
Nov 14, 2025 · 43 min
Craniofacial Sleep Medicine
In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Dave Singh, a former Adjunct Professor in Sleep Medicine at Stanford University, with a PhD in craniofacial cleft palate development, and a third PhD in orthodontics, to explore the evolving field of craniofacial sleep medicine. As founder of REMA Sleep based in North Carolina, Dr. Singh introduces the concept of craniofacial sleep medicine—an etiology-based approach to treating obstructive sleep apnea guided by anthropomorphic features rather than solely AHI severity metrics. Craniofacial sleep medicine represents a paradigm shift from license-based treatment allocation to collaborative, anatomy-driven care where dentists, surgeons, and sleep physicians work together to determine the most appropriate interventions based on individual structural characteristics. Dr. Singh explains why understanding craniofacial structures is crucial for personalizing OSA treatment, including why Asian populations show high OSA prevalence despite lower obesity rates. The conversation provides a comprehensive crash course in assessing craniofacial anatomy: What is retrognathia and what causes it? How can clinicians alter jaw position by adjusting cranial base morphology? Dr. Singh explains the classification system for dental occlusion (Class I, II, and III bites), midface assessment techniques, and the palate evaluation method Dr. Guilleminault taught fellows. He discusses critical anatomical considerations including tongue positioning at rest and during sleep, lateral pharyngeal wall collapse, and cervical vertebrae influence on airway patency. The episode explores both preventive approaches in children and interventions for adults, addressing whether craniofacial modifications require surgery or can be achieved through other means. Dr. Singh discusses palatal expansion, tongue traction techniques, and the physiological components that remain addressable even after skeletal maturity. He also explains age-related changes including loss of muscle tone, bone volume reduction, and maxillary drift that progressively narrow the airway. Intriguing topics include the mechanisms behind why didgeridoo playing and conch shell blowing improve sleep apnea, the role of oromyofunctional therapy as a viable treatment option, evolutionary changes in human dentition that impact airway anatomy, and even the dental stem cell implications for regenerative approaches. Dr. Singh also clarifies surprising facts, such as why mouthguards in contact sports serve purposes beyond tooth protection. Whether you're seeking to understand anatomical contributors to OSA beyond obesity, interested in multidisciplinary treatment approaches, or curious about how craniofacial structure influences treatment selection, this episode provides essential insights into personalized, anatomy-based sleep apnea management. Join us for this fascinating exploration of how form determines function in the upper airway and how understanding craniofacial anatomy can revolutionize OSA treatment strategies.
S7 · E21
Oct 31, 2025 · 1 hr 12 min
Responsible AI Use in Sleep Medicine
In this episode of Talking Sleep, host Dr. Seema Khosla welcomes members of the AASM Artificial Intelligence in Sleep Medicine Committee—Dr. Margarita Oks, Dr. Subaila Zia, Dr. Ramesh Sachdeva, and Matt Anastasi—to discuss their recently published position statement on the responsible use of AI in sleep medicine practices. Artificial intelligence is rapidly transforming healthcare, from AI-assisted sleep study scoring to clinical documentation tools and insurance claim processing. Yet AI is not a monolith—the technology encompasses various types with different capabilities, risks, and regulatory considerations. Matt Anastasi breaks down the different forms of AI clinicians encounter in practice, while the panel explains what "responsible use" actually means in practical terms. The updated position statement, notably shorter and more accessible than previous versions, addresses four major pillars: data privacy, fairness and transparency, infrastructure requirements, and medical-legal considerations. The discussion explores critical questions facing sleep medicine practitioners: How do we understand and trust the AI systems we use? What happens when insurance payors deploy AI to deny claims—should we fight AI-generated denials with AI-generated appeals? Do patients need to be informed when AI is used in their care, and how specific must those disclosures be? The conversation delves into liability concerns that keep practitioners awake at night: If your employer implements AI and it makes an error, who bears responsibility? What about ignoring AI prompts—does that create liability? Dr. Sachdeva explains the concept of vicarious responsibility and how it applies to AI implementation. Practical implementation guidance is provided through discussion of governance checklists, equity considerations in AI deployment, and the limitations of FDA clearance for AI-assisted sleep study scoring. The experts introduce AASM Link and discuss how practitioners can evaluate AI tools beyond marketing claims, ensuring systems are trained on diverse, representative data sets. The episode tackles a fundamental question: Is AI use inevitable in sleep medicine, or can practitioners opt out? The panel offers realistic perspectives on integrating AI responsibly while maintaining clinical judgment and patient-centered care. Whether you're already using AI tools, considering implementation, or resistant to adoption, this episode provides essential guidance on navigating the AI transformation in sleep medicine while upholding professional and ethical standards. Join us for this timely discussion about balancing innovation with responsibility in the AI era of sleep medicine.

Showing 1–20 of 21 episodes