We have just completed the 26th Annual Advances in Diagnosis and Treatment of Sleep Apnea and Snoring course in San Francisco, California. I wanted to share some interesting updates and new topics from the course. I have truly enjoyed being a co-director of the course and look forward to it every year, learning so much myself. Although there are many excellent talks related to surgery, here is a summary of some of the non-surgical topics.
Changing the Practice of Sleep Medicine
Allan Pack, MBChB, PhD and Samuel Kuna, MD from the University of Pennsylvania spoke about their experiences and pioneering work showing new approaches to management and treatment of the growing number of patients with sleep disorders, compared to the decreasing number of sleep medicine providers. Dr. Pack led the University of Pennsylvania to implement processes similar to many other chronic diseases like high blood pressure or diabetes. At Penn, primary care providers were empowered to manage the most straightforward patients (obstructive sleep apnea without other conditions), escalating a patient to a sleep medicine provider with less-straightforward patients or those who did not do well with the typical pathway (for example, CPAP for obstructive sleep apnea).
Dr. Kuna has done tremendous clinical care and research utilizing telemedicine, primarily through the Veterans Affairs medical system, to provide support to new CPAP users and with other innovative approaches. These approaches have been adopted and developed by Dennis Hwang, MD in the Kaiser Permanente system as well as some other innovators (one private company has a research study ready for publication). CPAP manufacturers do offer patients and providers the ability to monitor CPAP usage, enhancing care and showing a likely benefit in CPAP usage. I believe that telemedicine can replace the time, expense, and hassle for patients to travel for provider visits, but right now many insurance companies do require an in-person visit for most steps in the care pathway. That may change in the years ahead. For patients who might be considering surgery, an in-person examination is ideal for a thorough surgical evaluation. However, often I can obtain quite a bit of information through a video consultation (for example, on Skype) that can serve as an initial evaluation or as a follow-up discussion, especially in those who have to travel from a distance.
Obstructive Sleep Apnea and Cognitive Decline
Dr. Pack gave a fantastic talk on the growing evidence behind obstructive sleep apnea and cognitive decline. Moderate to severe obstructive sleep apnea is associated with an increased risk of developing cognitive impairment (dementia). Research has also shown that obstructive sleep apnea is associated with widespread changes in the structure (anatomy) and function (connections) in the brain. This may explain some of the difficulties in thought processes (memory, performance of complex tasks) that occur in obstructive sleep apnea. What is not known is whether treatment of obstructive sleep apnea can prevent the development of cognitive impairment and whether treating those who already have cognitive impairment or Alzheimer’s Disease either improves or prevents worsening of these conditions. This topic is close to my heart, as I recently have started working with an incredible team at the USC Stevens Laboratory of Neuroimaging (LONI) and submitted a research grant application to the National Institutes of Health to explore some of these questions.
Obstructive Sleep Apnea, Obesity, and Type 2 Diabetes
Obesity and type 2 diabetes mellitus are both extremely common in obstructive sleep apnea. It is unclear how these all are related, but much work is being done to determine what are the causes of each of these. Robert Lustig, MD from the University of California, San Francisco has been a major critic of sugar in food and drink products. He delivered a passionate, provocative, and scientific presentation about the hazards of dietary sugar, pointing to substantial evidence for fructose as the culprit in the development of type 2 diabetes. For decades, clinicians have implicated obesity as the key in the development of type 2 diabetes, but his work and the work of others has challenged this paradigm.
Dr. Kuna then spoke about clinical trials in obstructive sleep apnea and diabetes. In short, most research about health effects of obstructive sleep apnea has focused on cardiovascular disease (blood pressure, heart attack, and strokes). There have been some excellent studies about type 2 diabetes, showing that CPAP treatment can improve some measures of insulin resistance (precursor to type 2 diabetes). Interestingly, obstructive sleep apnea (especially severe obstructive sleep apnea) is associated with newly-diagnosed type 2 diabetes, although it is not clear that treatment of obstructive sleep apnea improves type 2 diabetes. To answer this last question, Dr Kuna and his team are part of a proposed 10-site Diabetes Prevention with Airway Pressure (DPAP) study, but this has not yet started.