David Claman, MD, director of the UCSF Sleep Disorders Center, presents an update on the sleep problems often seen in primary care, from insomnia to restless legs syndrome to obstructive sleep apnea. He offers key questions to ask patients, testing tips and options, and data showing which treatments work; plus, expert insights on complications of sleep apnea.
So let's see. Um, I have no disclosures. I was gonna mention that, um if I was going to recommend a single book for the intellectually curious person, it would be why we sleep. By Matthew Walker. It was on the best seller list a couple of years ago for quite a long time. He's at Berkeley. Very thoughtful. He takes a very purist approach to many sleep issues. Um, but I think it's a very good book on then. I have a number of references that are listed in the talk as we go through regarding Cove in 19. Our clinic is certainly open. We're doing a lot of video visits, but we do in person visits with all the usual screening at the entrance to the building and the masks, and we are open for both lab and home testing. If it's a lab test, we duke over 19 testing in advance. Onda brief outline of the talk will be a little bit about sleep deprivation, talking about insomnia and then are less and Osa. So here's a nice, summery slide from the New England Journal Review of Sleep a few years ago, looking at sleep over the lifespan and what you can see here if you look a total sleep time and some of the different sleeps stages on Ben age. What I wanted to highlight here is that in the cross label here rem sleep. REM sleep is actually quite well preserved with aging, so you can see that it's roughly around 20% or so. And that really doesn't change from roughly the age of around 20. On faras, we have data into the seventies. Um, total sleep time also is fairly well preserved once you retire and you have so much more free time some of the time that people think that sleep is less continuous and less rest ful in as you get older is that you're spending more time in bed. So some of that is awake. What's the function of REM Sleep? Well, we're not really sure, But there is research evidence that rim is involved in memory consolidation. So the idea of studying in the evening and then getting a good night of rest eyes probably better for taking a test or performing the next day. Pulling an all nighter and not having any rim to consolidate your memory may or may not may not be the best approach. Now. Deep Sleep Deep, which we call Delta for Delta waves or N three is preserved and elderly women. There's research that shows that from studies on osteo product fracture groups, but it is reduced an elderly men. So if you're a healthy older woman living in the community, in many ways it appears that sleep patterns or quite well preserved um, the purpose of sleep is still actually unknown. But it likely involves at least a non REM sleep, um, eliminating metabolites and increasing the processing of that so that the brain can return to a healthier level of functioning. And that's part of why getting a good night's sleep is hopefully restored in terms of sleep deprivation. This is a nice older study from the 2003 done in younger military recruits, which looked at the course of seven days of some level of sleep schedule. And so it was seven nights of a fixed schedule, eight hours of sleep per night. If you look for lapses and concentration, generally showed that they performed pretty well over time. But if you look at a week of six hours a week of four hours or a day or two of no sleep at all. You can see how the lapses in concentration accelerated quite a noticeably. And so the conclusion from this and young military recruits is that symptoms of sleep deprivation clearly increase if you sleep six hours or less. And it's a relevant point because one of the more recent sleep surveys showed that on weekdays the average American sleeps about six hours and 51 minutes. Weekends were a little better seven hours and 37 minutes, and this is in a 2023 to 60 year old age group. But what's the most common sleep disorder? Sleep deprivation, for sure. And I think many of us in medicine, myself included, think that we're so resilient that we can withstand sleep deprivation. But for both us, as providers and for patients, you have to pay attention. When do you go to bed? When do you get up? And is it enough to feel rested? So when patients air sleepy, don't just think about snoring and apnea, but also think about sleep deprivation and excessive caffeine. All right, so I'll pause after this for a quick consideration from everyone. What is your preferred sleep Aid for personal use if you're having sleep problems and the choices are zolpidem, melatonin, diphenhydramine, CBD since it's California and the modern era or stay up later. So think about your answer there about what you would do personally, we can't have that. Everyone raise hands, but we can always talk about this later. And as you might imagine, the sleep hygiene approach to this would be to stay up later. Um, it's interesting to give this lecture to residents, and I would say about a third of them raise their hand and say, Yeah, I'll just stay up later that way. That way I don't have to take medication, but a lot of our patients feel like, Oh, I need some help and they ignore this behavioral intervention on. I'll come back to talk about some of these after we discuss insomnia from a subjective point of view. Insomnia is the most common complaint if you survey the U. S population generally, but the term insomnia means different things for different people. Um, it could be a sleep onset, you know, they lay down and they can't fall asleep easily. it can be sleep maintenance that they fall asleep. But then they're waking up during the night or I fell asleep. But I woke up a three or four and couldn't get back to sleep where we might worry Maura about depression and effective disorders. Um, so you have to ask people when you say you can't sleep or you have insomnia, what does that mean? And that makes a difference in terms of causes and also interventions, to be honest. So if we look at a differential diagnosis of causes of insomnia, top of the list is psychiatric psychological from either depression, anxiety or other psychiatric conditions. And if you look at the literature on chronic insomnia, about a quarter of people who have chronic insomnia will have some issue in this area. If it's not treated or managed, it all. One of the first steps might be referral to ah, specialist psychiatrist. I think at one medical you have some in house experts that way, which is nice, but that's always a good step toe introduce, and I'll often say to patients the first time I meet them, I'm just meeting you for the first time today. But Do you think depression or anxiety is an active problem that's affecting your sleep? Andi. I try and make it a very, um, low key question, but give them the opportunity to share it if it's relevant. The second big category here is medical illness. So whether that's pain knocked urea from prostate post nasal drip from allergies or Sinus issues or dis me from harder lung problems. If there's a medical issue that's keeping patients from sleeping well, you wanna treat that specifically a supposed to just putting a Band Aid on it with the sleep aid or saying, Oh, sleep hygiene will fix this. So I'm always asking. Is that a physical problem or more of a psychological issue? And then, in general, the two drugs that we focus on? Although there's a long list of both prescription and illicit drugs, toe wonder about our caffeine and alcohol because they're so common and ubiquitous. Caffeine constrain a in your system, typically for 6 to 8 hours, sometimes even longer if patients are fairly sensitive. So classically caffeine in the afternoon or evening will delay sleep onset and cause sleep onset insomnia. Um, coffee in the morning at seven or eight with breakfast shouldn't affect the average person at all. And then alcohol, if you use it at bedtime, may make you drowsy. But it can. When it wears off, it can cause middle of the night awakenings and so, typically both to help with sleep and avoid exacerbating sleep apnea, we say Avoid alcohol for three hours before bed. Now a lot of patients who have insomnia get very stressed and worried about it. And we term that psycho physiological insomnia that they're very tired in the evening, at home, watching television, they decide I'll go to bed and they get under the covers and ding. Their eyes were wide open because they're conditioned to be nervous about sleeping. And that's vory activating. So we often see patients with that. We'll talk about poor sleep hygiene and the next slide that would be napping after work because they're so tired and then they can't fall asleep. And then circadian rhythm issues convene an issue for US jet lag, which all of us suffer from, but it's usually self limited. Shift work is a chronic stress, especially for you know, both medical providers and other industries where people work evenings or the graveyard and then delayed sleep phase would be a night owl who tends to stay up late. I'm not going to focus on circadian rhythm issues in this talk. Um, so here's a good outline of sleep hygiene issues, which is, I think, pretty familiar to many people. If you wanted to recommend a self help book, Say goodnight to insomnia has a nice bit of information, but there's many. Resource is available for sleep hygiene, so we want people to keep a regular bedtime and wake up time. Even on weekends. Be relaxed at bedtime with breathing music or meditation, but unplug from electron ICS. Of course, regular exercise is often helpful, not too close to bedtime. Avoid napping and I put a qualifier. Here is, if you have insomnia, then don't nap. It's going to make it worse. But if you're sleep deprived, napping might be very good, and a short nap right after lunch on the weekends normally should be refreshing and not worsen. Insomnia. Um, don't lie awake in bed feeling worried, anxious or frustrated because this gets you tense and it's the opposite of being relaxed. It tends to keep you Maura wake and avoid alcohol for three hours and caffeine for at least eight hours, as I said before. Now, if you just give people the rules of sleep hygiene, it turns out that it can help some people. But it doesn't give a very mindful or insightful approach to people. So the rial, uh, so I'm going to skip the slide. So the rial paradigm now for insomnia is cognitive behavioral therapy. And part of this is that the rules of sleep hygiene or less effective than, um or comprehensive approach? And here's a reference. If you see a psychologist for weekly sessions of CBT, it will include sleep restriction spending less hours in bed stimulus control toe on lee. Be in bed when you're sleepy, as opposed to awake toe watch TV. Relax ation to combat the tension, cognitive therapy that can be individualized for the patient and their issues mindfulness so that they're non judgmental about what they're doing on not criticizing themselves for staying up to later watching TV and then the sleep hygiene. So you can see there's multiple modalities here that can be included, and this is certainly the most thorough approach to helping a patient with chronic insomnia. And here's a nice slide that shows from a recent a research group looking at patients with depression who are stable on their anti depressants for six weeks. And they were enrolled either in CBT and the dark squares or self help in the I'm sorry, um, self help instructions in the dark and then the CBT and lighter graph here. And you can see that insomnia scores over the course of six weeks improve our reduced much more significantly in the CVT group and Depression scores, um, get reduced as well, even though there's no change in their anti depressant medicines. Um, and with CBT sessions at three month follow up, 61% had remission of both insomnia and depression in the C v T I group, compared to self help. And certainly this is something that's been recognized in psychiatry. Um, but it's typically done by psychologists. So for anyone with chronic insomnia, I would certainly focus on C B t. I as the best approach. Now I have one sort of complicated slide here that I'm going to summarize briefly, but here's a nice reference. If you wanted to read Maura about specific neurotransmitters. There's a lot of activating neural transmitter systems, including norepinephrine, serotonin and histamine, as well as or xon that are activating on Ben in terms of the pathway that dampens down and inhibits awakening. It's usually Gabba as one of the main components. And so I like to show this just so that you're aware that there's various pharmacologic targets and I generally would say medications or preferable, preferably only if necessary. Certainly for short term problems. You could give someone a small prescription, but focus them on stress reduction and behavioral approaches. Hypnotics like zolpidem and S Opa Clone or Lunesta haven't affinity for the Alfa one sub unit of the Gabba, a receptor. They're typically not active metabolites. They're viewed as certainly safer than sedatives, even though they're in the same schedule for class. Sedatives are typically the benzodiazepines like lorazepam. They reduce anxiety, but they do have a longer half life and then have mawr habit forming potential but very common in psychiatry. Then there sedating antidepressant Trazodone works more or by serotonin ergic mechanisms. Marta's up in both your editor, Allergic and Sarah in Ergic. They're longer acting so they can be used for sleep maintenance, insomnia. I would personally never used these for sleep onset insomnia because they're more likely to cause hangover drowsiness. Then we have the anti histamines because in the CNS, histamine is an activating the neurotransmitter family. Diphenhydramine is probably pretty common. It's in what's in most of the Tylenol PM and similar formulations. Aan den low dose docks open, which is marketed a silent or also works through a histamine receptors. So there's a number of mechanisms here in sleep. We tend to prefer to avoid anti histamines because you wake up with the dry mouth and they have longer duration. Aziz well, but I know it's commonly used. Then there's melatonin, and typical melatonin is short acting, so it's most helpful for sleep onset. Um, there is a melatonin receptor. Um, it doesn't tend to provide long term benefit, and the typical sleep dose that we recommend would be one or 3 mg. I see people come in on 10 and 20 mg, and I don't think there's any pharmacologic basis for such a high dose CVD. There's minimal research works through the cannabinoid receptor, and then the new your erection receptor antagonist. Super excellent has been around for a little bit limericks until show data in a second on day work through the erection or hypothalamic mechanism, briefly on cannabinoids. There's just a lot of different cannabinoids. CBD is the one that's been talked about mainly for sleep, because it's sedating and has no euphoria. But interestingly, the When you look at research and CBD for insomnia, it's very hard to find any good data. Since the FDA views this as you know, illegal, it's hard to get funding. It is somewhat more established for chronic pain. Here's a reference for that. I did find one case, Siri's from Colorado and a psychiatry clinic published in the permanent E Journal. Andre had 100 patients in a psychiatric clinic. They did have a standardized dose of CBD, which, of course, is hard toe come up with. Most patients report improved anxiety, but for some, patients have got worse. Similarly, for sleep quality, most improved, But some did not improve and got worse. So there's just very little literature. My approach, usually for CBD, is to tell on individual patient. It's fine to try it if it helps you feel better. Great. Um, there's not much research I can quote to support that. It's highly likely toe work, and we don't always know the dose, depending on where you get it. But I'm open to patients using. And then, you know, I do have occasional patients who say it works better for them than prescription medications, but it's just very poorly studied. I do wanna make one public service announcement that vaping is bad. Here's a a necks ray picture showing Elektronik vaping associated lung injury. And I like to make this plug because, um, you know, now we're not supposed to just ask about smoking products, but do you Vape cigarettes? Do you Vape marijuana? And uh, please don't because we don't think it's good for your loans. Here's the study on Limber Excellent, which is one of the erection receptor antagonists. It's similar, although a different drug than super excellent. Um, and I wanted to make a couple of comments about this study because I think it's interesting and helpful. They had a very large study. There were 3500 patients. They had a placebo group of 200 then the treatment arms roughly 250 or so in each was either low doses open them er or two different doses of one more X and five or 10 mg. And they had very good completion of the study for patients. And if you look at one month of treatment, I'm just going to focus on this part of the slide for sleep efficiency. If you look at this green bar here, this is the placebo group and s o the common here the placebo group improves, which is consistent with prior insomnia research. There's a rich insomnia literature that patients who have insomnia tends toe wax and wane. Over time, a stress levels wax and wane over time. So it's very idle and insomnia research to have a placebo group. And here you can see sleep efficiency goes up by 6 to 8% over the course of a month. Just being in a study, you know, helps of course, um limber. Excellent. The study drug in question was superior to placebo. And you can see the zolpidem e r line. This was the 5 mg of limber, excellent and blue. And then the gray was 10 mg of limericks, and these were all superior to placebo. Um, lumber. Erickson has a half life of quite a few hours, 17 to 19. They did test it for driving impairment and found that there was no significant driving impairment. Super Accent has a shorter half life of around 12 hours. So, um, I have not had any great success with Super Accent. I've had a few patients who've tried it. I think it's pretty common in psychiatry, and I'm sure you're going to get some questions in the coming months if you haven't already about this noose from pain, All right, so I'm going to shift gears away from insomnia now and say which blood test is recommended for restless leg syndrome. And we have TSH, dopamine, Chariton, CBC and creatine. Ding ding ding. Well, hopefully all of you are familiar with the idea that iron deficiency will worsen, are less. It's become a question that's part of, um, Internal Medicine Board review courses. And sometimes I think appears on the internal medicine boards. Um, and so, um, if you were going to do a blood test for this, you would do the Chariton. If you wanted to be really thorough, you could do iron saturation and transparent as well. Since ferreting could be an acute phase reactant, but the ferret in is the basic test toe look for so briefly about restless leg syndrome. Restless leg syndrome is a clinical diagnosis based on awake symptoms, and the combination of symptoms we look for is some type of discomfort. Hurt that the patient will say, You know, I lie down in bed, my legs air uncomfortable. It's distressing. They might say that it's a creepy crawly sensation, but it's often hard to describe. And then this uncomfortable feeling is accompanied by sleep onset insomnia. So the classic are less. Patient will take 30 to 60 to 90 minutes to fall asleep because their legs are uncomfortable and they cannot lay still. So the restlessness is characterized by an urge to move its induced by rest, most commonly at bedtime. There's a circadian rhythm pattern to the restlessness. It's relieved by movement worse at night because of that circadian effect, and so patients typically don't have a much trouble in the daytime. So if you're patient comes in and says I'm having this leg restlessness, I can't fall asleep. It's taking 1 to 2 hours. You can make a clinical diagnosis, causes It can be genetic and run in families where it would be autism, a dominant in the classic case. But the secondary ones usually are related toe iron deficiency, which is why in pregnancy it becomes more common but also neuropathy. Renal Failure in Parkinson Here's a nice review article looking at treatment options. So if the ferret in level is below 75 even though for 30 40 50 is all in the normal range, we would recommend giving iron for 4 to 6 months. Try to get the ferret in over 100 usually a little bit of vitamin C to aid in the absorption of the iron supplements. Symptoms can be worse with anti depressants. And so if you put a patient on an anti depressant and they come in and say my legs were just so jumpy and uncomfortable, I feel worse. That could be your relationship on. Then you might have to decide whether to stop the antidepressant or not, depending on their underlying depression. Um, caffeine and alcohol can make it worse, but typically the behavioral treatments that we want to focus on our stretching before bed. A short bath, usually a warm bath although I do have the rare patient who says a cold bath is better for them and many patients will end up on medications. Usually we're going to recommend either dopamine ergic agents, preemie pixel or Penarol your bedtime or gabapentin tin, especially if the patient has some degree of pain and neuropathy. The gap repentant can be a good choice. Clonazepam and opiates air usually 3rd and 4th line in our clinic. They are on the list of options, but you know it's nicer to avoid the scheduled drugs, obviously, and creamy pecs. Alondra Penarol, especially at low doses, are pretty well tolerated and generally quite helpful. So just remember, it's a clinical diagnosis and then the last topic area to cover for today and give time for the Q and A At the end, Um, is to talk about sleep apnea. So, um, the classic obstructive apnea, if you look at airflow, is the company's of the airflow will be blocked. If you look at effort for breathing from the thoracic and abdominal muscles, you can see there's effort. In this example. There's paradoxical respiration. Um, the oxygen saturation at the end of the apnea does drop down There's typically a delay from when the breathing we start to when the D saturation needier occurs. But after the apnea is ended and airflow resumes, you'll see an e g arousal, which is what the brain reactivates to reopen the airway. Hi Pop Nias Air. Part of the apnea Hypothermia index. Now where it's shallow breathing, not complete cessation of airflow but with shallow breathing. You still see effort. You still see the e g arousal and you still see the oxygen saturation Eso These is the mechanism by both atheism hypotheses condenser upped sleep. So the key os a definition classically for us is the apnea. Hypothermia index, which includes Apne, is, um hi Pop Nia's and this is the number of apnea is on high pop Nias per hour of sleep on average. And the power of the formal sleep study is that you know the hours of sleep from egg determination and this gives you a vory accurate number. Now a normal H I is less than five. A mild index would be 5 to 14 episodes moderate 15 to 29 severe over 30. For any of you who have ordered sleep studies, I'm sure you're used to looking at these numbers. The more severe group is probably Atmore risk for cardiovascular morbidity. I'll present some data about that. Mild patients are a little bit more of a challenge to manage because some of them will try CPAP and like it. But the acceptance rate is much less, and I'll show data on that also. So which of the following is not in the stop bang questionnaire apnea witnessed apnea falling asleep while driving, being tired with fatigue, hypertension or B m I over 35. All right, ding ding, ding ding. Interestingly, falling asleep at the wheel is not in stop bang but pauses in breathing or apnea. Being tired. Fatigue, hypertension and b m i. R. Here's the stop bang, and there's a reference of to a link snoring, tired, observed apnea and hypertension or pressure. That's the stop component and then b m I, over 35 age over 50 bigger necks and male gender. So if you have yes to five, take questions, then that's a high score and high risk. A low risk would be 0 to 2. I know you have a lot of younger patients, but I'm 62. So I snore. Or at least my wife tells me that I do. I'm thinner, thankfully, but I'm over 60. I'm over 50 and I mail, so I have a score of three off the top. Just because of these factors, I have had sleep studies and I have a normal h I. But you can see that it's non specific in some ways, but you're just looking for risk assessment. So for clinical predictors, we used the Epworth Sleepiness scale as a measure of sleepiness. But this is not validated as a predictor of apnea. The Berlin questionnaire is validated in, uh, internal medicine Snoring apnea fatigue. This does include sleepiness at the wheel and hypertension, and stop bang is validated in anesthesia. With the measures that I mentioned, Oh, esa and hypertension, there's a clear association. There's numerous cohort and observational studies, and then the Wisconsin sleep cohort. The higher the H I, the higher the likelihood of hypertension. So if you have an H I in the mild range, the odds ratio for hypertension is two. And if you're moderate to severe, the odds ratio is closer to three, certainly for difficult to control hypertension, We like to recommend testing because if you're on three or more medications to control hypertension than the prevalence of, let's say is 70 to 80% now. The cardiovascular complications of osa can include hypertension, as I just mentioned heart failure, which can worsen heart. The ESA, if it's untreated, can worsen heart failure. Also stroke pulmonary hypertension. There's an association with a fib, and if you have apnea and treated with CPAP, it reduces the recurrence of a fib after cardioversion. Here's a reference for that from 2003. So there was a recent study, the save trialing Can CPAC reduced cardiovascular events? Uh, if you treat it on. This was an open label study published in the New England Journal four years ago. 2700 patients with Moderate to Severe OS A and H I of 29. They Onley selected non sleepy patients an average Epworth of seven, which is normal, who had some prior cardiovascular history. There see 80 or cerebral vascular disease and randomize them thio, CPAP versus control with the follow up of close to four years, or a number of Asian centers that were included in this. If you had severe sleepiness. It was not deemed ethical to randomize you to a control arm, and so they didn't take sleepy, severe patients. The overall results was that C path did not prevent the primary cardiovascular endpoints, even though the patients on CPAP had improvement in daytime sleepiness and reduction and snoring. Um, the average CPAP use was 3.3 hours, which most of us would say is not really enough. That's certainly a limitation. And there is evidence that sleepy patients are at more risk of cardiovascular complications, and those patients were excluded. But nonetheless, this was a big study and was certainly widely reported. And here's those survival curves. For the end point, you can see that usual care and CPAP had similar outcomes, both for overall incidents of events and also, uh, any kind of complication. Eso This study, with its limitations, didn't prove that CPAP reduced events. Unfortunately, um, you could still say that may be in severe patients that might make a difference. This was reviewed in the U. S. Preventive Task force. Here's a reference from 2016, and Terry Young in the Wisconsin Sleep cohort did see that untreated apnea was associated with higher cardiovascular mortality. And there was a study in Spain from Marin as the lead author, with similar results. Now this is the Marine study, and I like to show this on dial do this fairly briefly. But what they did in Spain was they had a clinic population of patients, the patients who did not get treated. They tried CPAP, didn't like it and return. The unit gave them a control group, which is very unusual. It's not a R C T, but you can see if you look at the incidents of either fatal cardiovascular events or non fatal. The Red Line is patients with severe Osa and H I, over 30 who were not on C Path, and they had mawr fatal and non fatal events compared to the other groups, including a CPAP treatment group. So an H I over 30 is viewed as the the highest risk group, and I tend to make that group of priority in terms of really making sure that we're thorough and careful with C PATH compliance Now home testing is a popular question these days, and we've used it for quite a few years and has been approved for the past decade by Medicare. The main limitation is that the H I is less accurate than a formal studies, since the actual numbers of sleep hours is estimated and usually overestimated in the home test. Um, the formal study is typically my preference, although especially with Cove in many patients, to find the home testing idea vory appealing. If a home test shows apnea, we can prescribe auto CPAP. Um, I was just discussing this with Kourtney and Michelle before we started. If you want to refer a patient to us directly for a home sleep test, but you don't want us to do a consultation, we do require that you send your clinic notes with a history and physical. So the best thing for us is if you send the referral and the H and P together, then it's all nicely prepared as a package, and we don't require any other information. If the patients going to need CPAP and you do a direct referral, then we'll assume that you'll take over for doing the sea path or request a consultation at that point in time and this approach, using home tests to go toe auto CPAP is best validated and severe patients who are sleepy, but we often use it in mild cases where it's less validated now. Treatments for CPAP can include that. My four conservative treatments are weight loss, which can reduce the H I, um, to some degree, not usually curative. Unless you lose more than 20 to 25% of your weight. Avoid out hall near bedtime postural training. And, uh, some younger, thinner patients will respond very well to postural training and avoid sleeping on on their back on Lee. Sleep on their sides and pay attention to nasal Peyton C from allergies with congestion. Because if your nose is congested number one it will worsen snoring and often apnea. But number two if we're going to try CPAP, we prefer nasal masks as opposed to the bigger full face masks on. Then the nose has to be open for that toe work. Um, most patients do well on CPAP, although 10 to 20% might end up on high level, depending on their study. In their tolerance and auto, CPAP is certainly fairly common now. Orel appliances would be second line, um, but they can be used were more open to using them with mild or moderate OS A bond. Then there's a range of surgeries. The palate surgery usually has a low success rate, but in pediatrics and younger adults with big tonsils, tonsillectomy is actually a very effective treatment and pediatrics. So if you have patients under the age of 30 who are thin, please look in their oral fair ings. Please see if their tonsils or big, because if they are, they might actually be a very good candidate for surgery. And I harp on this with our fellows to really get people to take a good look in the bearings. The new surgery for OS A is thehyperfix Glassell. Nerve stimulation, and the theory here is that one possible mechanism of obstruction is if you're Haifa, Glassell, Nerve and the Ferrin. JAL muscles are not as active as they should be. So could we stimulate them to be more active? And the way this works is to give unilateral stimulation with a battery powered neuro stimulator inserted under the right clavicle, preserving the left clavicle for a future pacemaker if needed. There's a small incision that the HIPAA glass all nerve and the wire is tracked between the two locations, and this is where the stimulation occurs. To get the Gina glasses muscle toe, open the airway further, but you also need a sensing lead in the intercostal muscles so that when the intercostal muscles are active, that's when you stimulate the hyper glassell nerve and you turn the stimulator on at night. When you get up in the morning, you turn it off because you don't need it while you're awake, and that preserves the battery for a longer life. But this is something that we do have a knee anti surgeon Dr Julie Chang, who does these implants. It's certainly selective Onley for patients with moderate to severe apnea who fail CPAP. There's a number of other qualifications, but I showed this picture and most patients say no. I don't think I want an implant for that, But it is one of the new surgeries. Here's a picture of CPAP with nasal pillows, which is probably, you know, close to 50% of our mask interfaces now, um, and the mouth is uncovered with nasal CPAP just realized that, um, cpap is site non specific, and that's important to note because with CPAP you're going to put positive airway pressure in the nasal pharynx, the aural faring Syria and the retro Gossel area of the base of the tongue. So with CPAP, it doesn't matter where the obstruction is. We can open it up. Um, that's why it's a highly effective treatment. But it's an ongoing treatment in the average patient, and I alluded to earlier that compliance was best in severe apnea. This is looking at, you know, one year, two years, three years and four years. But look how much it drops off and mild apnea. So mild apnea has the lowest compliance, moderate in the middle and severe the highest. If you have a mild patient, it's fine to try CPAP. But if they can't use it, keep in mind that you need to look at the alternatives like Orel appliances, positional therapy or surgery. Possibly these days we do get data from the CPAP. We can see that what the H I is on treatment. All these green bars is a patient who is 100% compliant. Um, the next one is somebody who clearly didn't use it very well, and I just like to show these for contrast, because you can see there's very few green bars, which is over four hours. This patient, for the number of our nights over four hours was only 17% so clearly not doing very well. But this is the kind of data that we review at CPAC follow up and one encouraging note. In terms of CPAP. This was a publication a couple of years ago and chest by a tool Mel Holt drug, who's down at UCSD and has done a lot of OS A research. And they looked at a big database run by one of the CPAP companies and patients who had signed up for what they called active patient engagement with an Internet database program. And what they found was that if patients signed up for this active patient engagement arm that they had 87% or adherent to see path after the first 1 to 3 months, and that's a much higher adherence than has previously been reported in the literature. Whereas for usual care, um, it was about 70% well, even 70% is better than ah, lot of the literature would suggest, So I want to stay in some ways We're doing better with CPAP compliance now than we used to, and part of that may be smaller machines, the nasal pillows, if that's comfortable for the patient. Um, but even with these improvements, they're still a role for the alternative treatments for patients who are not compliant.