Talking Sleep

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Imran Iftikhar and Dr. Rami Khayat to discuss groundbreaking research on adaptive servo-ventilation (ASV) and the newly released AASM clinical practice guidelines for central sleep apnea treatment. Dr. Iftikhar presents his innovative approach to analyzing ASV data through meta-analysis combined with trial sequential analysis, offering fresh insights into the statistical reliability of existing research beyond traditional systematic reviews. His work addresses lingering questions about ASV efficacy and safety that have persisted since the controversial SERVE-HF trial results challenged previous assumptions about this therapy. Meanwhile, Dr. Khayat, who served as vice-chair of the AASM task force, walks through the comprehensive evidence-based recommendations covering the full spectrum of central sleep apnea treatments. The guidelines address critical clinical decisions: When should CPAP be used over no treatment? Who requires BPAP with backup rates? Why does the task force recommend against BPAP without backup rates for central sleep apnea? What role do oxygen, acetazolamide, and transphrenic nerve stimulation play in treatment algorithms? The conversation delves into practical considerations including differences between ASV device algorithms from various manufacturers, the clinical impact of current device availability issues, and findings from Dr. Parthasarathy's bench study. The experts tackle the complex question of ASV use in patients with reduced ejection fraction and clarify important distinctions between primary central sleep apnea and treatment-emergent central sleep apnea (TECSA). This episode addresses the evolving landscape of central sleep apnea management, helping clinicians navigate evidence-based treatment decisions in an era of changing technology and updated safety considerations. Whether you're treating patients with heart failure, complex sleep-disordered breathing, or emerging central events during PAP therapy, this episode provides essential guidance for optimizing care. Join us for this comprehensive update that translates complex research findings into practical clinical applications.

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

In this discussion, Dr. Gulcin Benbir, a neurology professor from Turkey specializing in sleep disorders, and Dr. Lourdes Del Rosso, a UCSF sleep physician and RLS guidelines task force member, shine a light on periodic limb movement disorder (PLMD). They reveal that 30% of patients with obstructive sleep apnea still experience significant limb movements even after treatment. The duo explores the relationship between PLMD and restless legs syndrome, iron levels' role in treatment, and whether PLMs are merely symptoms or contributors to more serious health issues.

Dr. Luca Baldelli, a neurologist from the University of Bologna and Treasurer-Elect of the International REM Sleep Behavior Disorder Study Group, sheds light on groundbreaking research in predicting neurodegenerative diseases among RBD patients. He discusses how simple autonomic reflex tests can identify those at higher risk for conditions like Parkinson's disease. The conversation highlights the significance of monitoring cardiovascular autonomic dysfunction and explores practical applications for clinicians in managing RBD, potentially transforming patient prognoses.

Dr. Natalie Hauglund, a postdoctoral fellow at the University of Oxford, discusses her groundbreaking research on zolpidem and its effects on the glymphatic system, vital for brain waste clearance. Her study reveals that zolpidem reduces this process by 30%, raising concerns about long-term cognitive health. They delve into the unexpected benefits of microarousals during sleep, linking them to better brain clearance. Hauglund challenges current prescribing practices, questioning the trade-offs between medicated sleep and potential neurodegenerative risks.

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

Dr. Jared Saletin, a sleep researcher at Brown University, delves into the intriguing link between sleep and ADHD. He reveals how poor sleep can mimic ADHD symptoms and discusses the significant impact of sleep deprivation on children's attention. With insights from fMRI studies, he explores whether better sleep habits could alleviate ADHD symptoms. Saletin also suggests practical strategies for improving children's sleep and the potential benefits of aligning school schedules with circadian health. This discussion sheds light on sleep as a modifiable factor in managing ADHD.

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

In this episode, Dr. Seema Khosla explores the critical issue of clinician burnout with Dr. Venktesh Ramnath, Associate Clinical Professor at UC San Diego. Moving beyond typical wellness advice, Dr. Ramnath offers practical strategies for addressing burnout at its systemic roots rather than treating it as an individual failure.  The conversation examines how to recognize true burnout versus temporary fatigue and challenges the common rhetoric about "resilience" that shifts responsibility from broken systems to individuals. Dr. Ramnath shares his personal burnout experience and discusses whether dramatic career changes are necessary before making meaningful improvements to professional satisfaction.  Discover actionable steps for reducing burnout, including negotiating with leadership, establishing horizontal professional networks, and eliminating low-value work. Learn how coding efficiency relates to burnout and understand the emerging role of "health architects" in creating sustainable medical workplaces.  The discussion also addresses Dr. Ramnath's public response to demands for federal employee productivity reporting, techniques for constructive workplace conversations, and practical advice for saying "no" effectively—a crucial skill rarely taught in medical training. Whether considering a job change or trying to improve a current position, this episode provides essential guidance for creating a more sustainable medical career. 

Dr. Safia Khan, a women's sleep expert and editor for "A Clinical Casebook of Sleep Disorders in Women," shares fascinating insights into the unique sleep challenges women face throughout their lives. She discusses how pregnancy and menopause disrupt sleep patterns differently in women compared to men. Dr. Khan emphasizes the underdiagnosis of sleep disorders and the importance of tailored assessments and treatments, including cognitive behavioral therapy and the management of conditions like sleep apnea and PCOS. She also explores the critical role of iron deficiency screening in adolescent girls.