This episode of the “Sleep Review Conversations” podcast features a roundtable discussion with Russell E. Rozensky, RRT-SDS, RPSGT, CPFT, MS; Shari Angel Newman, RST, RPSGT; and David Westerman, MD. The panelists discuss innovations they’d like to see in CPAP devices as well as promising alternative therapies.
Sree Roy, Sleep Review editor (SR): Hello and welcome. From healthcare publisher Allied 360, this is “Sleep Review Conversations.” I’m Sree Roy, editor of Sleep Review Magazine and sleepreviewmag.com.
This episode’s topic is the future of obstructive sleep apnea (OSA) therapy.
There is significant interest in newer, smaller, more discrete OSA therapies. An article on sleepreviewmag.com about a device that’s in development, a micro-CPAP that weighs less than an ounce, has been shared more than 100,000 times on Facebook alone. Today’s podcast is to talk about these sorts of upcoming innovations. What do sleep medicine practitioners predict will be of the most help to patients and might even be a patient-compliance breakthrough?
We’ll try to avoid mentioning any brand names because we don’t want to endorse or otherwise call out any one brand, but in some cases calling out the brand may be unavoidable, such as if it’s a one-of-a-kind device.
Without further ado, I’ll let our distinguished panelists introduce themselves.
Russell E. Rozensky.
Rozensky: I’m a program director for the polysomnography technology program at Stony Brook University. I’m also currently a board member of the New York State Respiratory Therapy licensing board, which covers both respiratory therapists and polysomnographic technologists.
I’ve been working in sleep technology since 1998.
SR: That’s a very long time. Welcome to today’s program. Welcome, also, to Shari A. Newman.
Newman: Hi, I’m Shari Angel Newman. I’ve been in the field of sleep medicine for almost 30 years. Having started in one hall…one bed in a hall, to now 14 beds of testing here in Spartanburg, South Carolina, the one thing I enjoy so much about my job is the growth and excitement and all the changes that we’ve enjoyed over these many years.
SR: Welcome, also, to Dr David E. Westerman.
Westerman: I’m board-certified in pulmonary and sleep medicine and I’m the medical director of the Northside Hospital Sleep Center, which is a 10-bed sleep lab in its Atlanta campus. I’ve been in sleep medicine for probably close to 30 years, as well. I’ve been on the faculty of the Atlanta School of Sleep Medicine since its inception about 25 years ago.
SR: My first question is, for positive airway pressure devices—commonly known as PAP or CPAP machines—is smaller always better? Shari, let’s start with you.
Newman: I think it depends on the patient and the patient population you deal with. For the fellow that stays home, the retiree, no, I don’t think we need to go smaller; we just think we need to be compliant with what we have.
But of course for travelers, particularly truck drivers, industry drivers, and transportation, yes I think smaller is more helpful, if indeed we can maintain compliance.
Westerman: David Westerman—I think I basically do agree with Shari, but in general, I think the first impression someone has of the device will help with compliance. If someone sees a big device like we had 20 years ago, their initial response may be somewhat hesitant.
Even for the retiree, if the device is more compact, smaller, perhaps lighter, because he or she may have to travel sometimes, I think a smaller device, as long as it can deliver the pressure that it’s meant to do, I think does have a positive impression on a patient from the beginning. In that sense, it may help compliance. Again, the travel devices today are very small, so in terms of where we’re going down the road, that may be a goal that a lot of the manufacturers may want to duplicate.
Rozensky: Russ Rosensky here. I do agree with both of them, as well. I believe it will help for a certain patient population. I do think having the variety of having something a little larger for somebody who is not traveling, and a small unit for somebody who travels a lot. I do think that the major issue, though, is ensuring compliance and ensuring that the data can be retrieved in a timely fashion.
SR: Other than size, what innovations have you seen recently or expect to see in the future with CPAP devices that will truly be a benefit to patients and practitioners? Dr Westerman, do you have any ideas for that?
Westerman: A couple of ideas. One is the humidification. I think the humidifier does add bulk to the device as extra attention that you have to pay to the device to keep it clean, change the water daily. If the humidifier could either be smaller or perhaps a different type of humidification that doesn’t entail having to change the water every day and pay as much attention—some of the travel devices have some sort of moisture-exchange system that is claimed to be effective. I think if the manufacturers would aim in that direction, I think that would help with compliance as well, as long as humidification is effective.
The other area that I think is going to be more and more to the fore, is the technology, particularly the software, the infomatics that you can download from the data. Some patients are very, very focused on not only their compliance, but their performance and utilization….the residual AHI (apnea-hypopnea index). And if these people are particularly goal-driven and have an almost on a day-to-day basis evaluation of their performance, I think that may enhance compliance as well.
Rozensky: Russ Rozensky here. I think another thing that will enhance compliance is the ease of the CPAP unit, specifically the humidifier, to easily come apart so that that way the person can clean, sterilize, and maintain the device accordingly. I think the big concern of some patient populations—and I’ve seen this in the field—where people are very diligent on ensuring that the device is thoroughly and properly cleaned. One thing I would love to see down the road would be some sort of basic infrared or UV light technology used so this would ensure that as the CPAP pressure goes to the patient, that it is basically sterilized in case they haven’t had a chance, or their water got a little contaminated, or something happened, that they would not risk an infection.
Newman: On that line, this is Shari. I would love to see the device manufactured with some type of antimicrobial process. We use antimicrobials in central lines and other types of products. I think it would be wonderful if some wonderful engineer could develop the box itself to have that antimicrobial process built in so that that could help to keep that patient compliant and healthy.
SR: The next topic I want to discuss is the murmurs that I’ve been hearing about custom CPAP masks on the horizon. Meaning masks that are specifically made for one patient’s face. Are patient-specific CPAP masks a worthy pursuit? Would you like custom masks to become the standard of care in the future? Russell, what do you think?
Rozensky: I think not necessarily the standard of care, but the option for patients I think would ensure or assist with compliancy down the road. I have seen many patients and, from personal experience, family members, where they get a mask and…it’s very close, but it’s just not right. Having the ability to custom-mold the seal specifically I think would ensure a lot better compliance. Better seal, less problems as far as leaks around the eyes, nose, things like that, and I think that would ensure that if I don’t have those issues, I’m going to use it more often.
Newman: This is Shari. Custom masks aren’t new. They’ve been around for many, many, many, many years. We experimented with those 25 years ago. For certain applications they can be helpful. But we need to also be mindful of the face that bodies change, faces change as we age, and we want to be able to customize and continue to customize, if necessary. That’s just another tool in our tool belt to add to compliance.
Westerman: I would agree with all that’s been said. The option of having a custom mask, the fact that the contours of the face change, particularly with weight loss, and that’s what we encourage our patients to strive for.
A big factor is going to be cost. I recall that there was a prosthodontist in the Atlanta area, who several years ago, did have custom masks as an option in the practice, but the cost was prohibitive. When I say prohibitive, thousands of dollars.
As perhaps it gets more commercialized and the price comes down, I think it will be an important part of our armamentarium because, after all, compliance is crucial. The interface is the point of contact. Having said that, it’s also the durability. If you have to change a custom interface with just the silicone material or the equivalent on a regular basis, some patients are going to have oilier skin than others, there’s going to be an issue of mucus affecting the pliability, so cost does become a big factor. But I do agree for some patients, it should be an option.
SR: On another note, there are obviously alternative therapies other than CPAP devices. What do you expect to be much more prominent 10 years from now than they are today, regarding alternative therapies? Are there any clinical trials for OSA therapies that should be watched closely? Shari, what are your thoughts on alternative therapy growth?
Newman: We have to take a hands-on approach to the individual. Not everyone’s one size fits all. I think we really need to have quality physicians, quality dentists, and orthodontists so that we can look at that person and that personal need.
We know that oral appliances are really doing a great job and moving forward. The different surgical procedures are growing and getting better. I think, though, the scary thing for me as a frontline person is the number of OCSTs (out of center sleep tests) and other things resulting in these auto-adjusting mail-to-patients. Without that individual, that professional sleep medicine physician providing that individual care to tailor it to that patient’s need.
Westerman: I would like to just step in if I may, to endorse exactly what Shari said about the autotitrating units being dispensed in kind of a blanket fashion by physicians who probably don’t know some of the in-depth issues regarding sleep and don’t know the alternatives. One size doesn’t fit all.
I’ve seen patients that have had a home sleep test and then the provider of the home sleep test gives as an alternative or recommendation an auto-titrating unit, but that patient may need BiPAP. Auto-titrating units don’t necessarily eliminate the significant desaturations, so in that particular area I think I would agree that patients should be evaluated by a sleep physician. They can have the initial evaluation certainly through a primary care physician’s office, but then sent along to a sleep physician. That’s been a bit of a soapbox on my part.
Having said that, the alternative approaches do include oral appliances, and they’ve come a long way. They’re lighter, they’re more durable; one manufacturer even has a compliance chip built into it. The dentists have become much more adept and perhaps proficient in fitting the patients. There’s an American Academy of Dental Sleep Medicine and there are some dentists who have devoted their practices entirely to fitting oral appliances. That is an alternative approach that we’re going to see more and more of. They’re not without complications—temporomandibular joint problems, bite problems, for example—but I think we’re going to see a lot more. Again in the appropriate patient, it should be offered as an alternative.
Perhaps Russell’s got a couple of extra words and just a couple of other areas we can talk on in the future. Perhaps he wants to jump in at this point.
Rozensky: I do agree that, to me, the goal is to treat the patient. CPAP has historically been a gold standard, but alternate therapies, surgeries, oral appliances, mandibular positioning devices….You hear about children going for the palatal expanders. All of those are very good options in treatments for various sleep disorders, and I believe that the big component is that the sleep physician or the sleep clinic, the laboratory with the physicians on staff, should have the well-rounded approach to have the patients aware that there are multiple treatment options, depending on the severity of the disorder and properly educating the patient. If the patient is not properly educated, they can be steered directly where it becomes almost a cookie-cutter routine…CPAP, CPAP, CPAP because that’s what we do here. I do believe a patient needs to be properly educated on alternate therapies and having the staff on board to properly educate the patient, the success, the treatment, and complications of those alternate therapies.
Westerman: One area we haven’t spoken about and perhaps we should touch on is an alternative treatment, is the surgical approach, which generally speaking shouldn’t be first line except perhaps in kids with very large tonsils or anyone who’s got a significant mandibular malformation. Those would be primary.
We’ve got the new stimulatory procedure, the stimulation of the genioglossus muscle. That is appropriate in a subset of patients. There have been some studies that have shown it to be useful. I don’t think it’s widely utilized. I have not had the opportunity to send any patient for the procedure. I’m not sure that it’s covered by insurance at this time, but I think as with time, you’re going to have these procedures perhaps becoming more widespread and perhaps more acceptable.
Several other procedures have come and gone, but I think looking at an alternative to CPAP and perhaps even an oral appliance and some sort of surgical procedure is still going to be on the horizon.
SR: I’d just like to close by asking each of you to share your closing remarks about the future of obstructive sleep apnea therapy, where you think it’s going, what we should be paying attention to. Russell, let’s start with your closing thoughts.
Rozensky: As far as I believe with obstructive sleep apnea, I still believe that in this country and globally, it is an underestimated disease process. I do believe, unfortunately, that a lot of people do not recognize the signs and symptoms. Physicians might not be asking the proper screening questions. I do believe that it will eventually become something as routine—screening wise—as far as you go in for your physical once a year, they’ll do an EKG and check out your blood work and cholesterol. I think that down the road in the next couple years, a decade at most, they’ll actually look at routine sleep screenings as a preventative therapy. This way we can decrease hypertension, cardiac disease, stroke.
SR: Excellent. Shari, what closing remarks would you like to share today?
Newman: I’m blessed to have worked in an institution for these many years and one of the challenges we face is the long-term patient. I have patients we’ve been treating now for 25, 30 years. Their continued quest for help, and maintaining their CPAP, maintaining their treatment, their therapy, and involving that in an EMR system so that when these folks may be hospitalized—they may be cared for in another facility—we want to make sure that we have an ability in the future I think through a cloud technology, so that we can know “Okay, this patient needs X, Y, Z.” So as they go in and out of the hospital, as they age, as their life progresses, we can not only diagnose them, but we can maintain quality health as they progress through life.
Sree: Excellent. Dr Westerman, your closing thoughts?
Westerman: My closing thoughts are very similar to what’s been echoed, so let me just add one or two things. I think that PAP therapy is still going to be the most widely-utilized treatment for obstructive sleep apnea. I think the devices need to be simple, perhaps smaller, although we’ve discussed that. Travel becomes a significant part of a lot of people’s lives, even vacation travel or camping. Some sort of device with a battery back up that’s relatively light or a device that’s chargeable for several days. I think that’s an important part of where we should be going.
I also think that one area that’s perhaps been neglected that’s aligned to obstructive sleep apnea is snoring. The snoring population is huge, certainly compared with the sleep apnea population. That’s a significant social problem and one that perhaps has a lot of options, but surgery doesn’t always work. I know they’ve got some very small devices that they’re looking at, and I know there’s one company who’s trying to raise money to develop something with a microchip device that’s very small, fits in the nares, and perhaps something of that size would be applicable for those who snore. I think that’s an area that’s still untapped and has a lot of wide application.
SR: Thank you. Thank you to all of today’s panelists for your insights on OSA therapies. Visit us at www.sleepreviewmag.com for the latest news on obstructive sleep apnea.