I am writing from our 30th annual Advances in Diagnosis and Treatment of Sleep Apnea and Snoring course in Orlando, Florida. I have been fortunate to take part in this course for the past 20 years but take no credit for the course format that combines medical, surgical, and dental topics. This multidisciplinary approach is a key part of treating sleep apnea and snoring, but almost no other conferences or courses have the same combination of in-depth discussions that span different fields. Because of this uniqueness, I take the opportunity to share some of what I consider the highlights of the course – or at least the highlights for me as a sleep surgeon. I focus on the nonsurgical talks because I write on surgical topics in other posts on this blog, where I have shared many of the thoughts I presented in talks on topics including drug-induced sleep endoscopy.

Allan Pack, MBChB, PhD from the University of Pennsylvania spoke about the most important studies over the past year. He started by discussing the SURMOUNT-OSA trial. Tirzepatide showed important changes in weight loss that were associated with corresponding large changes in obstructive sleep apnea. Not surprisingly, the improvement in obstructive sleep apnea was associated with the decrease in body weight. Atul Malhotra, MD from the University of California, San Diego was the principal investigator on this trial and spoke about the findings and implications for sleep apnea treatment. The study showed substantial reductions in body weight, with the improvement in obstructive sleep apnea similar to other weight loss approaches (lifestyle changes or surgery), indicating that there are not changes other than weight loss to explain the improvement in sleep apnea. The proportion of study participants under treatment with tirzepatide that had substantial response was 40-50%, with many others having smaller improvements; this compared to a 10-20% figure for the placebo group (who did have monthly visits by a registered dietician).

Dr. Pack later spoke about the risk of obstructive sleep apnea and risks of crash in commercial drivers. In short, there is an increased risk of obstructive sleep apnea in commercial drivers, along with an increased risk of crash in those with obstructive sleep apnea who are not wearing CPAP (but not in those using CPAP). There are some U.S. trucking companies that have initiated programs for evaluation and treatment of obstructive sleep apnea, and in fact a number of European countries have imposed regulations focused on these risks.

Dr. Malhotra also spoke on medications to treat obstructive sleep apnea specifically (as opposed to those that treat obesity and indirectly improve obstructive sleep apnea). The combination of atomoxetine and oxybutynin is in the midst of clinical trials sponsored by Apnimed. To date, these trials have shown intriguing efficacy but have had some side effects (none serious) that have limited their use. Results from two additional trials should be available later this calendar year. Sulthiame (similar to acetazolamide) is a carbonic anhydrase inhibitor has been studied as a primary treatment for obstructive sleep apnea, and the results show some improvement. In fact, this work is the basis for our ongoing trial sponsored by the National Institutes of Health, where we incorporate acetazolamide +/- eszopiclone as rescue therapy for patients undergoing surgery who do not achieve resolution of their obstructive sleep apnea after surgery alone.

Diane Lim, MD, MTR from the University of Miami spoke about the evidence supporting the role that obstructive sleep apnea can play in causing cancer. The molecular biology- and cell-based research – including fascinating work from her team – suggests that chronic intermittent hypoxia (repeated drops in oxygen levels, a feature of obstructive sleep apnea) can increase cancer cell growth and decrease immune suppression. There is more work to do in this area, and one unanswered question is how much intermittent hypoxia is specifically associated with an increased risk of cancer. She later spoke about the connection between obstructive sleep apnea and Alzheimer’s Disease. There is substantial evidence indicating that obstructive sleep apnea is associated with brain volume loss, leading to cognitive impairment. One mechanism is impairment of the normal cleaning of brain metabolism byproducts through what is called the glymphatic system. She stressed the importance of treating patients with mild cognitive impairment to slow or reverse progression before patients reach full-blown Alzheimer’s Disease.

Because insomnia (difficulty falling asleep or staying asleep) is so common – and so common in sleep apnea – I always enjoy and learn much from talks on insomnia. Nalaka Gooneratne, MD, MSc from the University of Pennsylvania is an expert in this field. In his talk, he reinforced the fact that cognitive behavioral therapy for insomnia (CBT-I) is the most effective treatment for insomnia. With my move to UCLA, I have been delighted to work closely with the UCLA Insomnia Clinic, a team with real expertise and experience in this area. Unfortunately, there is an international shortage of specialists who deliver CBT-I, which has led to the development of smartphone app-based CBT-I programs over the past 2 decades. One of these is Sleepio, a program that has been studied in randomized, controlled trials showing benefit. This program was initially (about 15 years ago) available for patients to purchase themselves, but it then shifted to a business model where it sold subscriptions to medical practices or companies. I did not purchase a license and do not know anyone who did, leaving patients without the self-purchase option. I have just learned that Sleepio, like some other apps, now allow patients to purchase their program, typically for a cost of $150-250. Treating insomnia is so important, as multiple studies have shown a substantial increase in mortality with comorbid (coexisting) insomnia and sleep apnea (called COMISA) much greater than for either condition alone.

Charles Bae, MD, MHCI from the University of Pennsylvania spoke about new technologies for detection of obstructive sleep apnea. He discussed recently-cleared approaches using artificial intelligence (primarily deep learning and machine learning), including the Onera, Sansa, and SleepImage devices that diagnose sleep apnea as well as the Samsung Watch and Apple Watch that can evaluate the risk of obstructive sleep apnea.

Andrew Goldberg, MD, MSCE, a course c0-founfer and co-director, from the University of California, San Francisco discussed the important role of the microbiome, including that of the gastrointestinal tract, in obstructive sleep apnea. He shared the growing body of evidence showing that sleep apnea can contribute to unfavorable changes in the microbiome, and, in turn, the microbiome can contribute to factors causing sleep apnea and other related health conditions (like high blood pressure and obesity).

Richard Schwab, MD, another course c0-founfer and co-director, spoke about his extensive work at the University of Pennsylvania with MRI and understanding the important role of fat deposition in the head and neck (especially the tongue and fat pads and other muscles around the throat). Their most recent work focuses on MR imaging during natural sleep, and it will be interesting to see what this very early work shows in the years ahead.

Peter Cistulli, MBBS, PhD is a pulmonologist from the University of Sydney who is perhaps the world’s foremost expert in the use of delivered an outstanding talk related to mandibular advancement devices (type of oral appliances) for the treatment of obstructive sleep apnea and snoring, both alone or in combin. He demonstrated that patients may prefer mandibular advancement devices over CPAP, with reasonably high (50% consistently, 30% intermittently) rates of use at 1 year after starting treatment. Unfortunately, long-term use is notably lower as patients discontinue use, a phenomenon also seen with CPAP. I do not mean to criticize these approaches, as we do not have great information on long-term outcomes for surgical interventions.

Jolie Chang, MD from the University of California, San Francisco provided an update on consumer wearables and nearables that can monitor sleep. The technologies have improved markedly, but it remains unclear how useful the data can be to improving health. My own feeling is that their greatest benefit may be that users improve their behavior (increase sleep time to at least 7 hours, for example) with monitoring. I do not mean to dismiss their potential benefits, as some of my patients have used them successfully to provide some clues about response to treatment. However, it has been difficult to use them as primary evaluations because the studies evaluating the technologies are extremely limited, making one question their validity. Dr. Chang stressed that the worst thing is for patients to become overly-focused on their sleep, in some cases developing a condition called orthosomnia, where they are sleeping and feeling well but undertaking extensive steps to address any imperfections in results from monitoring devices.

Lightning Rounds

Over the years, we have incorporated a number of topics of broad interest that may not have much research. These are now covered with short talks grouped together as Lightning Rounds. I spoke about the extremely-limited evidence showing that mouth taping or chin straps can improve snoring. I shared research led by Philip Huyett, MD at Mass Eye and Ear showing that closure of the mouth improves breathing if you have at least a fair amount of nasal breathing (airway open in the nose and behind the soft palate); if you have little nasal breathing, then closing the mouth actually worsens breathing.

From others, I learned that hitting the snooze button (my wife loves it, I only rarely use it) can leave you less drowsy when you do actually get out of bed and may be a reasonable strategy if you are getting enough sleep (at least 7 hours) before the first alarm goes off. Watching TV in the bedroom may be OK if you stick to a regular sleep schedule (basically, if you do not just stay up late watching TV instead of going to bed when you should).

For melatonin, there was a great question about melatonin and timing for Dr. Gooneratne. To enable someone to fall asleep earlier (for example, adjusting their internal clock), one should take melatonin about 4-6 hours prior to bedtime. To improve the ability to fall asleep, taking melatonin 2 hours before bedtime would be good. For those with difficulty maintaining sleep, taking it 30 minutes before bedtime would be better.

All in all, I thought the course was one of our best. It makes me look forward to next year’s course (also in February over Presidents’ Day weekend) even more.