So, we may have a choice of streaming or not, or having a problem. So, I will do my best. And I'm gonna apologize right now, I'm gonna be looking down here, so I'm not looking at any of you. Gonna start off by basically saying what we're gonna ask everyone to do is hold your questions to the end. I know if you are watching this through streaming, and again, I apologize that I'm kind of looking down here, but those lights don't work for me. We will be watching, we're monitoring it on the screen, we'll be asking the questions at the end of the session. So, talking about sleep disorders and their impact on the workplace. Gonna start off with a little bit, very little, because there's not a lot really new in the regulatory world on sleep disorders. Talk about that, and then I'd be happy to turn it over to Dr. O'Gile. Many of you heard him a few years ago when we last got together from St. Louis. He'll introduce himself. It's been really a pleasure, and I think he understands us, and that's incredibly important, and it's nice to have a sleep provider, other kinds of specialists, to really understand the impact of safety, the risk assessment, and then how do you communicate both to the employer and the employee of, we wanna get you as safe as we can, but we know you need to be working at the same time. What just happened? So again, we talked the topics, what's new, and then sleep disorders in the workplace. So, medical examiner handbook. Tomorrow afternoon, tomorrow morning, we'll be talking a bit about FMCSA and what's new happening with them. We'll be talking a bit about the medical examiner handbook. For those that are not attending that session, the handbook has gone through multiple iterations, as you well know. The most recent iteration was discussed back in May of 2021. It has been edited, and guess what? It is actually in the process of agency review, which means we will be sent copies, i.e. on the line in the Federal Register, to review and comment. Please, please, please watch announcements that talk about this medical examiner handbook being out for comments. The comments are essential, because what they have done is basically take, for most topics, all of the guidance and just said, this is the condition. This is what it does. This is how it might be treated, and maybe think about these things, A, B, and C, in some of the different conditions, not all consistent. Poor sleep apnea, what's currently in the handbook. Now, keep in mind, originally it said nothing about sleep apnea. Then they put in the 2016 Medical Review Board recommendations, and now they've kind of changed it a little bit, focusing, like they've always done, on moderate to severe sleep apnea. And they give a little background about what is sleep apnea, and why are we worried about it. You would hope that most medical examiners would already know that background. They do remind us over and over again that the Federal Motor Carrier Safety Regulations do not include any requirement for medical examiners on sleep apnea. They don't require you to screen. They don't give you criteria on who can be qualified and who don't. They don't give you any diagnostic studies. They don't give you any criteria. They don't require it. What they do clearly say over and over and over and over again is that sleep apnea is a concern, and medical examiners should use any current best practice in making their evaluation. They should consider the driver's responses. Now, remember, what's the driver's responses? Do you have, have you ever been tested for, have you ever had a sleep study? Well, if they say yes, you probably want to get that information, and to look at the readily available risk factors by looking at them. Now, what's nice is they give you all the risk factors that you want to make sure you ask about. This is looking similar, but not totally like the 2016 Medical Review Board recommendation. Certainly, we talk about episodes of apnea. Dry mouth wasn't in there. Morning headaches wasn't in there. Difficulty focusing wasn't in there. Misses a lot of the objective types of criteria that we could use. As I said, the 2016 Medical Review Board recommendations is what FMCSA originally published in their advanced notice of proposed rulemaking. It's what the FAFRA also included. It's similar to what the FAA uses. So, what am I saying? As a medical examiner, you need to use current best practice. You need to use whatever is evidence-based, or at least evidence-based and, or based on evidence and consensus. Of what criteria should you use in individuals who are in safety-sensitive positions? Now, again, it goes on to say, if an ME observes multiple risk factors, from moderate to severe, we're not worried about mild. They're also totally skip the idea they may have mild sleep apnea, but significantly desaturating. That's an important thing that examiners should consider, something that they have discussed at some of the MRB meetings. If the driver has had a prior sleep study and revealed that it's only mild, then they don't necessarily need another sleep study. However, the examiner may want to consider looking at that actual sleep study and making sure that it actually was mild, and making certain it was a valid study. Home sleep studies will tend to underestimate the severity of sleep apnea. There's also a lot of ways of beating a sleep study. So, if the driver has had a prior sleep study and revealed that it's only mild, there's also a lot of ways of beating a sleep study. And if you look at it, and you see the person's been sitting up all night, the chances are they didn't sleep. And there's a real good chance they didn't have sleep apnea on that study, because they wouldn't have. Talks about it's not a condition that requires testing on a regular basis, doesn't require testing, requires appropriate treatment. And unless the driver reports significant symptoms, there's no reason to retest on a regular basis, perhaps every three to five years, or as deemed necessary by the treating provider. Now, that statement comes out throughout the medical examiner handbook, bases a lot of their information on what does the treating provider recommend. And then, again, it's pretty much the same thing. This is the kind of guidance we're gonna be getting on sleep apnea. Not the MRB recommendations, but asking about symptoms. Now, we think back to when that question first came on the medical examination form, is do you feel sleepy? No. Do you snore? Yes. Then when they all realized that snoring got them a sleep study, nobody snores anymore. So when you ask them questions are, do you feel sleepy, what are you gonna get? An obvious no. They do include narcolepsy and idiopathic hypersomnia, really interesting topics. Because if you think back, narcolepsy has always been disqualifying. The Medical Review Board's recent meeting voted that idiopathic hypersomnia and narcolepsy should be highlighted as being disqualifying. However, in the draft medical examiner handbook, it talks about excessive sleepiness as chronic. It may be abrupt, it may occur unexpectedly, and there's no cure for it. But look at this document from Mayo Clinic to see if maybe that person can be qualified. And it goes on. Results in sleepiness, all the symptoms. Excessive sleepiness is generally sudden. They may have disorientation. And considerations for the medical examiner. So that sounds to me like they're saying the medical examiner can consider qualifying somebody who has idiopathic hypersomnia or narcolepsy. Are the symptoms concerning? Has treatment been effective, safe, and been shown to adequately treat the underlying condition? And then evaluate on a case-by-case basis whether they meet the physical qualification standard. If you think about the standards, narcolepsy really doesn't fall under the pulmonary medical standard. It falls under loss of consciousness, which is also the seizures. It's also where the implantable defibrillators have often been put. And what's really interesting is last week in the Federal Register, the Federal Motor Carrier Safety Administration announced a denial of an application for an individual who wanted an exemption from narcolepsy. So we now have narcolepsy disqualifying and frequently asked questions. Narcolepsy disqualifying by their expert advisory group, the Medical Review Board. And narcolepsy is not really advised by a recent Federal Register announcement. But you need to evaluate it on a case-by-case basis to make your decision. And then just counting, there's a lot more information. Did I go backwards? I think I went backwards, I did. And this is what the MRB said in their meeting in May 2021. Recommendations, everybody unanimously agreed, idiopathic hypersomnia and narcolepsy should be disqualifying. So again, what are your resources? What are your references? This is what the Medical Review Board says. This is what a recent announcement said. I just want to highlight a document that came out from the American Academy of Sleep Medicine. This took a lot of work in getting a lot of sleep docs and a few op docs together and trying to reach a happy, acceptable what screening criteria should be used. Again, FMCSA has not endorsed anything. And what this group came with is, even though there are other criteria that should be considered, a minimum should be that 2016 Medical Review Board recommendation. So that's the recommendation from this expert panel from the American Academy of Sleep Medicine. What's really frustrating to me is seeing a lot of examiners that now are turning to the, oh, the driver has sleep apnea. He tells me he's compliant, never looking at compliance data. Driver has a BMI of 46. I can live with 40, I can live with 39, maybe. 46 and three risk factors. Don't even document anything on it at all. Disapprove the driver for two years. What about the recall? I don't know if you're still seeing a lot of the drivers who are saying, I'm not using my CPAP machine because it's been recalled. Recall took place back well over a year ago, or almost a year ago. No, it didn't, I'm sorry. This is jumping all over me. Recall was first announced back in April of 2021 and in September of 2021, the Medical Review Board held a meeting to discuss the recall and what to drivers and examiners be advised to do in that setting. Well, unfortunately, the bottom line is they came out with nothing official. And as of last week, they still had not published the recommendations from the Medical Review Board. A lot of the discussion centered around whether or not to use oral appliances. And the answer was yes, oral appliances may be okay, especially for moderate, but probably not for severe sleep apnea. Problem is oral appliances cost a lot of money and they take a long time to be made. And the hope was or the expectation was it wouldn't take that long to get a refurbished, to be able to get a replacement machine. I know machines are now available. They're not as difficult as they were six months ago. Discussion, what is severe sleep apnea? A BMI of 20 or a BMI of 30? A lot of people on the MRB kept thinking it was 20 because that was the criteria that was suggested as a, as long as the AHI is below 20 is probably okay, but true definition of severe obstructive sleep apnea begins as AHI of 30 or above, not 20 or above. Final recommendation is still pending. The one thing that the MRB did recommend changing was that it would be okay to use oral appliances in the interim while they're waiting to get their new machine. Now, just a little bit of information on that, and I think Dr. Ajay will talk a bit more. The main concern was not all the machines. It was only one particular brand. It was only certain machines that are made by that company. It was only machines that were cleaned a certain way, an ultrasonic technique. It was not normal soap and water cleaning. What I've begun to do is individuals who say, oh, I can't use my CPAP machine because it's been recalled. Well, first question I have is how do you clean it? Second question I have is, did you apply for a replacement? And if so, when? Third question I have is, what was your compliance prior to the recall? Well, if they weren't using it prior to the recall and they have severe obstructive sleep apnea, I'm gonna be real concerned that they haven't been using it for a much longer time. Certainly if they have mild or moderate and they've been using it up until the recall, I'm gonna feel a lot more comfortable that they really do are trying, but then I want them to go back and talk to their doctor about safety, about other issues. Now, one of the things that had come out earlier was the American Academy of Sleep Medicine put down a protocol which said, if your machine was recalled, what should you do? What should your provider advise you to do? And it included questions like, are you covered under a safety-sensitive position? Are you covered by DOT? And the recommendation was to continue use if you're in a safety-sensitive position where use of your CPAP machine is recommended, especially with moderate to severe sleep apnea. And I think at this time, I'm gonna turn this over. And with Dr. Yojai, I'll tell you about what sleep medicine really is. If I can get you up there. Oh, you can do much better, great. There we go. Great, thank you. Thank you. Let me just wire up. Can you all hear this okay? How's that? Can you hear me better than see me? All right, so it's a distinct pleasure and privilege to be here. Thank you, Natalie, for inviting me. It's great to be with colleagues, and we collaborate in St. Louis with our occupational medicine colleagues directly and frequently. And so we have a really mutual respect of each other in what we're trying to accomplish. So it's always fun to do this and to share information. I've been privileged to be practicing sleep medicine in St. Louis now for 30 years, which I'm almost embarrassed to say. And I founded the Clayton Sleep Institute in St. Louis, which is a national organization. We do clinical research, testing, and management of sleep laboratories for others. So it's been a really enjoyable thing. Let's talk a little bit. So Natalie did a great job of kind of bringing us up to date on regulations, because we're all fighting in the same boat and where we are today. Let's talk a little bit directly about sleep disorders and management. So the first thing we're gonna do is, if you think about what we're trying to balance here, because there isn't any direct legalities or statutory guidance, we have to focus on what are our concerns for us as citizens, and what are the concerns for the drivers, both their safety and their rights. And we have to balance those in some way. I was struck, I was driving from Kansas City to St. Louis. And for those of you that are not familiar with the Midwest, that route from St. Louis to Kansas City on Highway 70 is almost a continuous line of semi-tractor trailers at all times of the day and night. What I was struck by though, I'd gone up there to give a talk and left at four in the morning to come back for a variety of reasons. But how many of our fellow citizens, their occupation is truckers, were out on the road or were in the rest stops were full of people resting. And then there was still nonstop trucks. I find those to be rather heroic parts of our society, because they're out there giving up their bodies and their health to try to keep our society running. And so I view our job is in the most respectful way to help them do that safely and in a healthy way. So that's kind of like where I come from and what we're trying to accomplish. So how much risk should there be? We should prohibit as much, if not all risk that we can. However, if we tighten regulations too much beyond what is necessary, then we increase illegal driving and cause societal problems. So this is a tough situation that we're in. You all are in even a more difficult situation because ultimately, my information just comes back to you and you have to make these critical decisions. Eliminating all risk from disease is really not obtainable, especially in a continuum of disease. So that's why we have to have our intellectual hats on to be apprising. As Natalie was rightly discussing, are they using the therapy and how are they doing? I'm gonna try to give some information about that. And we wanna reduce the risk as much as we reasonably can. Who decides that risk? We just heard about that. The recent standards, which are giving us a little bit of guidance, but leaving it mostly up to us to try to figure out. The carriers sometimes have very specific guidance and we have seen that with some of the physicians that are doing work for specific carriers. They'll have much more stringent guidelines than even the FMCSA. The medical decision. My view is that these are still our patients and so we wanna factor in the holistic look of what the patient's underlying comorbidities are. So sometimes they don't reach that 20 episode per hour threshold, which says in our evaluation, therapy is required for maintenance of DOT. However, we will sometimes put, we do still recommend therapy based on their comorbidities from a medical perspective. And I think it's still important for us to keep that on, that medical hat on. They're still our patients. So how to diagnose. This continues to change. This is a sort of the classic, right? The gold standard. This is a full polysomnogram. This is a picture of one of our sleep lab rooms. It's like a nice hotel room. Those are select number beds. You can see the TV is over the bed so the patients can't watch TV in bed, I might add. They have a recliner. We get them all wired up and we took that picture out. We get them all with the electrodes and we put them to bed around 10 o'clock. What are the advantage of this? First of all, we get complete measurement of all the physiologic data. and we know within 30 seconds of when they're actually sleeping, which is a big thing, right? We don't know that with other modalities of therapy. We can also look at other sleep disorders. So if we're concerned they have things like narcolepsy or they might have idiopathic hypersomnia or they're tired or sleepy but what they really have is periodic limb movements of sleep or they have some other illness, it allows us to do that. Also we have a technologist monitoring the study. So we know for certainty from a chain of custody perspective there is no chain of custody. We have someone sitting with the patient and they can troubleshoot the study to make sure that you're getting the highest quality electronic signals and data. Disadvantages, of course the patient must come to the sleep laboratory. There are frequently insurance considerations. It's becoming more and more difficult to get polysomnography ordered but there are ways to do that. However, at least from an independent perspective, the cost side of that is narrowing quite a bit. So if you have a relationship with your independent sleep facility, that is something to be considered. It is narrowed dramatically to a home study. Home sleep study or limited channel testing, this is a much different look, isn't it? If you look at this, it's simply a belt, typically thoracic or thoracic and abdominal, what looks like an oxygen tube but it's really a flow sensor. It's actually really probably the most uncomfortable part of the whole thing. It's more uncomfortable really than the therapy, something we have to remind patients. Patients frequently think we're treating them during this, which is interesting. And then an oximeter probe usually on their finger. So this sort of study now for chain of custody, if it's a DOT situation, we do have chain of custody and we do put a chain, a lock chain so the patient, we put the device on the patient, it is secured, and then we remove the device the next day when they come back. So if it's going to be for one of our occupational medicine colleagues, that's the process that we have to go through. Advantages, they don't have to stay in the sleep laboratory. It's accurate relatively for moderate to severe obstructive sleep apnea and it may cost less and it should cost less. But not in all markets, so you need to do that evaluation as well. So sometimes, depending on what your market is, you might be able to get a full polysomnogram for a price that's very close to what a home sleep study may cost. What are disadvantages? This is only a screening study for obstructive sleep apnea. It does not detect any other sleep disorders. Now again, for the utilization that you're having at that moment, that may be an adequate route to go and that's fine. Probably 70% of the tests we order now are initially home sleep apnea studies. So that's fine. The reliability is not known fully in patients with other medical comorbidities, so you want to have a good sense of that. Higher failure rate, so two things to think about with home sleep studies. One, there is a technical failure rate. In other words, they take the device home and it fails. In our hands, that rate's quite low. In our operation, it's about 1% to 2% because we have the patients come in, we fit them for it, we then put it in a little carrying case, and all they have to do is clip it back on. You still are going to have some failure rates. Sometimes it's not done correctly. Sometimes the battery fails. I mean, we all have electronics at home and we understand that. So most of the mail-in devices are going to be somewhere in the range of 5% to 10%, these services that mail them to you. So that's an issue that we have to accept with this. The other part of it is, what is the accuracy? And false negative rates are quoted different studies, but around 20% is what we tell folks. So if you get a negative study, maybe one out of six, one out of five of those folks could still have obstructive sleep apnea that the test misses for a variety of reasons. As Natalie was alluding to, if they slept poorly that night, or something happened at their home. I mean, you're all in medicine, you understand life happens, right? That something happens, a child gets sick, something goes on, and they don't really sleep much on their study. So you need to do that conversation after the study the next day. There is some stress associated with many patients. The idea that they have to test themselves concerns them. And then the key is, and that's why we have the chain of custody issue is, we need to make sure the person we think is taking the test is actually the individual taking the test. So at least gets rid of the chain of custody issue. Whether they choose to stay up all night is another issue that each of us has to factor in in every clinical situation, because that is the way to quote, beat the test. Just showing you what that chain of custody looks like. Most of you have probably seen this before, haven't you? So we put that on the patient, it's tamper-proof, we put it on, and then we have them come back and we take it off the next day. So if you're using home sleep testing, I would encourage you to talk to your provider and have that discussion, because I'd be a bit uncomfortable if we weren't doing this, just based on ways around, as much as I respect our fellow citizens who are having their job, when it comes to that issue of, I might lose my job if I get test positive on this, some behaviors can become easier to perform. And we want to make it clear that we're not out to get them to lose their job, we just want to have them keep their job but be even safer. This gives you an idea of what it looks like. So we already talked about this. So if you have a high clinical suspicion and negative test results, it is completely reasonable and advised to either repeat a home study or do an in-lab polysomnogram. If the person is covered by commercial insurance, we really don't have any problem getting repeat home sleep studies done in high clinical risk patients. It's usually not an issue at all. We do hundreds of studies per month, I may repeat one or two or three studies a month, because for each of the patients, these aren't, a few of them are DOT drivers, so remember they're clinical patients, but the question I ask them if they have a negative study, we take more time discussing a negative test or a mild test with a patient than a severe test, because if they have severe apnea, we know what we're going to do. We all understand that. But one question I ask them is, how did they sleep? Everyone gets asked that question, and then because they don't know, I ask them that before I ask anything else about their home study, and then if it's negative, the question that I use is, in your heart of hearts, do you really think you have sleep apnea or not? And guess what? The people who say, I think I have it, I retest them, almost all of them have obstructive sleep apnea. It just missed it that night. That's what we're called to do, so I would not be timid for any of you to reorder another night on a home study if they have a good clinical story and you're concerned about it or order a polysomnogram. So some devices do capture a sleep indicator of sleep or even brain waves themselves. That's not the majority of devices that are out there, so be cautious about that. Most of the devices that your providers are going to be using don't have these capabilities. These are some of the other data and other machines that are out there. We're down to some studies actually can be just that limited. So when to treat? Any questions about testing? The technology, microchips, all that stuff's getting smaller and smaller. The technology's getting better and better, but you all have very specific needs that we need to attend to. So we want to make sure we're working with you during that process. So when to treat? Are you saying that little device on someone's finger is adequate for a sleep study? It is one of the technologies being looked at and being tested. I would not consider it adequate for your needs. I'm just trying to show you the latest, greatest. So some of the things we're going to talk about today are really like kind of what's coming because this is an audience that knows a lot about current therapy. So I'm going to hit current therapy, but try to hit some things that are kind of coming. Thank you. I didn't mean to mislead you in any way. When to treat on guidelines? So anyone that's had an accident related to fatigue, any card holder with an AHI greater than 20, they have to be treated per the guidelines we have now. Greater than five events per hour. So an event, 10 seconds, lack of breathing for 10 seconds or greater when they're sleeping because the air pipe's being obstructed. Five or less is normal, five to 15 is mild, 15 to 30 is moderate, right? So between five and 20, if they have other clinical comorbidities or symptoms, we recommend that they get treated. Whether you make that a criteria for them having their card, that's where we have to collaborate. So uncontrolled hypertension, I would add to this atrial fibrillation. Probably one of the number one reasons for referral right now to us is atrial fibrillation. In fact, right before I came in here, I had a primary care doctor texting me for somebody who has new onset atrial fibrillation, could I get them tested right away? It's now, and I think Jack at the American College of Cardiology, I think they're recommending now, a new onset atrial fibrillation, if any clinical signs at all, they all should be tested for obstructive sleep apnea. So what we also have done is started doing Epworth sleep scales on every DOT driver at every exam. So when they come for their annual follow-up, if you were in my referral base, we would give you the downloaded data with my signature on it and the date. We would give you, document their Epworth scale in the note and document their examination. So I think that's kind of where we are. If they're asymptomatic between five and 20, then that's just a conversation for you to have with that patient. But the way the regs are currently that are suggested, it's not required to keep their card. And if they start therapy, this is a little nuance, if they start therapy under 20, to have that conversation that we're not going to penalize them for stopping therapy. And that was an issue years ago, we had that come up several times. So some of the treatments. What's CPAP? First of all, it's positive airway pressure. C stands for continuous. You all know this, so I don't mean to be so rudimentary, but I like to make sure we're all at the same place. Most of what we prescribe now, especially with home sleep apnea testing, is auto-adjusting PAP. So APAP, so to speak, versus the C. Sometimes we narrow it or we bring them in and do a continuous positive. Bi-level, BiPAP is actually a brand name, bi-level is the ability to adjust inspiratory and expiratory pressures separately, which is a great therapy. It isn't better, it's just different. But there are people who need that, one, to resolve their obstructions, two, sometimes it's a comfort mode for them. But it's the minority of patients. And then there's other modalities that become ventilatory. The amount of air is custom for each patient. So there are folks who like to set everybody up. The machines typically can go four to 20 centimeters of water pressure. It's not how I do it, but I do know a lot of people do that, and I'm not throwing shade on them. I like to get the pressure range as narrow as possible for a variety of reasons, some of which are just my own predilection for that. But I don't like the machine to have the ability to go up high for unknown reasons. So it's kind of beyond the scope of this lecture. But there is reasons to narrow the pressure down. If a patient on an auto-adjusting device tells you that the pressure is going up too higher, it's blowing off their face. We have seen in some of the devices, I call it runaway pressure. If you narrow the pressure down, again, this is maybe a little bit too technical for doing in the occupational medicine office. But ironically, in that group of patients, it'll become easier for them. The pressure, for some reason, is misreading the respiratory effort and causing them to elevate the pressure suddenly, and the patients find it uncomfortable. And I'm happy to talk about that a bit offline if you'd like. What's the new face of CPAP or PAP? Because one of the big things we see now is what I call PAP salvage therapy. People that have failed PAP in the past, whether it was five, 10, or 15 years ago, they come to see all of us, and they're like, I really want to do this, but I can't tolerate the therapy. I want to share with you that that, except in a small percentage of patients, we can get these folks to tolerate it now. The interfaces or the masks are so much smaller, so much more comfortable, and if we just give them a little bit of work and effort, the vast majority of these folks, we can salvage them onto successful therapy and have them keep their job. So the machines are much smaller, they're quieter, now they Bluetooth, much better humidification. All of you know about heated hoses and the adjustment in humidification, right? So one of the little things, the hoses now, from the machine to the mask, have electrical coils in them, and they'll heat it. Why do we heat the hoses? We don't heat it to warm the water. We're heating it because hot air can carry more water. And so that allows us to deliver much more humidification to their air passages. So one of the things, when their PAP gets set up, that I've learned, because the S on my forehead, I tell people, it's not for Superman. If there's a mistake to be made, I've made it. So I've learned over the last few years, when they set people up on their machines, almost universally, they fail to tell the patients how to adjust the humidification and how to adjust the temperature on the humidification. And those are two critical issues that many patients need for success. So if they can adjust that, increase the water delivered to their sinuses, they do better. Humidification is a patient comfort mode. I have no role in that. My role is to get the patients engaged so they can manage it themselves. If a patient doesn't use humidification and uses PAP, that's fine. It doesn't affect their therapy. It only affects what we want, which is their adherence to therapy, for many patients. There's many masks. This is how small some of the PAPs are now. Some of these masks, if you just take a peek, rest assured, anyone shiver, I'm not going to go over every mask. It could cause all kinds of stress. If you just take a peek at how tiny these little masks are, they continue to get smaller and smaller. A couple of things that have changed patient adherence dramatically, one, not only the size and the comfort, the swivel on top of the head, have many of you seen that? So instead of the hose coming off here, it goes and swivels up here. So the patient can roll around in bed and it doesn't torque or pull at all. For many patients, that's been a game changer. There are also other nuanced options, which I'd encourage you or your provider to know about. If you look at number three, three from the left, that's a thing called a tap PAP. Many colleagues don't know what that is, but what it is, if you notice, there's no head gear there. It's a small mouthpiece that's formed in the patient. It's loosely fitting. It's not like an oral appliance. They're using that as basically an anchor. So they wear that. They have nasal pillows. That's it for their head gear. So for patients that have reasons of tolerance, or if they have neuralgia in their face, or they can't tolerate having the head gear, this is an option to think about. These are subtle things that most folks aren't brought up to speed on, and it might allow you to get success in someone who's trying to keep their job. Let's talk about the recall. So Natalie did an amazing job on the recall, so I'm not going to regurgitate all of that. Here's where we are. So the initial recall notice, did any of you see the notices? You did. You were unfortunate enough to see that, right? So it said initially, stop your CPAP and call your doctor. Now one of the things I would share to you, and I've done some consulting and was in some of the business newspapers about this, is we are in the same rowboat as the patients. We don't have any information. The manufacturers did not talk to us at all. So we have to figure out what to do, which is what's in the best interest of our patients, and we're doing this together. So this is one of those really difficult situations where we're called to say, what is the risk? So when the initial recall got brought out, I'm sure you all can just visualize this, I'm getting called at like 2 in the morning about what they should do about their machines. I'm like, I'm not sure what they should do at 2 in the morning. But in any case, our initial guidance has been the same as what it is now. The new FDA and Philips guidance is continue your machine, but talk to your provider, which is a prudent approach. Two things we ask our patients, one, are you having any trouble? Because the main thing people are looking on is there's a small percentage of patients that were getting some debris in the hose of their mask. Because as you know, the issue is hardening of the sound foam that was wrapped around the motor. And so if that flaked off and got into the motor, you could blow that into the hose. So if people have that, we tell them to stop their machine immediately. Otherwise, there is a filter that you can buy on Amazon, or any, and you can get it, and you can put in the hose if they're concerned about that. Or if they're very uncomfortable and anxious, we have them stop their machine and we try to get them a new one, or get them another mode of therapy. But if they have moderate to severe apnea at a minimum, and they're not having problems, the risk benefit from our perspective was to continue your device, which is consistent with the guidance that we've all been given. Now, in the particular issue of the drivers, that becomes more of an acute issue. We're over a year into this. My understanding is that Philips, who is the only manufacturer affected by this, so Philips Respironics, the understanding I have is they're trying to get all the US recalled machines, which number over two million, replaced by the end of this year. And our patients are getting machines, just to be very clear about that. They're telling us now. But the key is you have to register. So one, each patient that comes in, if they're on that device, we ask them, have they registered their device? And if they haven't, we ask them to do that and share with them how to do it. It's very easy. You just go to the Philips.com website, hit in CPAP recall, and you put in your serial number of your machine. It tells you right then if your machine's been recalled or not. It's very simple. So if it's not recalled, it's a non-issue. If they're using another brand, it's not an issue either. And that's exactly what Natalie was talking about. PAPs are becoming available. People are getting PAP. There was just some delay. There's still a bit of a delay in our market. I assume it's similar to your markets. But if they're a driver, if they're severe, calling your durable medical equipment provider, they've been very good about helping us make sure folks continue therapy. And we are told Philips is prioritizing people that have occupational risk. And so if you have questions on that, I hope you'll ask. I am happy to answer those. Talk about oral appliances. What do they do? They project the dental, the mandible forward. They have their tongue retaining devices. There's many different types. I'm not an expert on the types. I'm an expert on what the result of that type is. Compliance is reported as high as 77% nightly. Side effects, some folks just can't tolerate it. It's uncomfortable. They report excessive salivation, changes to occlusion. That's a significant issue, which is why we don't do oral appliances. We have sleep dentists do them. There can be minor complications of jaw, mouth, and TMJ pain that can occur. So these are all, as we say with therapy, nothing's free. Every therapy's gonna have its potential downstroke. So these are potential side effects. Advantages, it's not invasive. Not much stuff to carry. So if you travel a lot, that's very appealing. It's not obtrusive to the bed partner typically. And it's reversible. You take it out and now you're fine. So there is a lot to be said for this form of therapy in the right patient. And we indeed use it a fair amount. Here's the indications. Snoring. So if a patient's just got snoring and not apnea, there are oral appliances that can be used that aren't quite so robust and quite so expensive. And if they're not, candidates for positional therapy or weight loss. For obstructive sleep apnea, mild to moderate, those are preferable appliances. We tell every patient with mild to moderate sleep apnea that this is one of the options they should consider. I present all the options to the patients based on their severity with a completely even tone. I try not to bias patients on their therapeutic choices because I want them to hear all the choices. And then I wait for them to ask, I call it the fateful question, right? What's the fateful question? What would you do, right? Then you can kind of go into more editorial. But I think everybody deserves to hear all those things. Then some CPAP non-responders, people that have failed CPAP, reasonable thing to think about. But most people, if they're moderate to severe, should consider PAP initially. And these are some of the recommendations. Here's the big issue I'd bring from this, is anyone who gets an appliance should have a repeat study of some variety. Our practice is typically home sleep apnea study with the appliance in. We need to prove whether they're occupational-related or not that the therapy's effective. And that's one of the biggest fall-downs. And home sleep apnea testing is so easy and so inexpensive, there's really no reason not to do that. So that's the big take-home for me. Any of these non-PAP-related therapies, we need follow-up documentation, whether they're a driver or they're occupational or not. And then resolution of their symptoms. If their main symptom is daytime sleepiness, let's get some documentation upwards about the best we have that they're no longer symptomatic or it's improved. Here's a quick study. This was an interest study, looking at responders and how they respond based on severity of apnea with an oral appliance, mild, moderate, and severe, based on their level of events. And if you look, the apnea-hypopnea reduction for severe apnea, moderate to severe, you start to see that as the apnea score gets worse, the ability to cure them, if you want to call cure being below five, is going to go down. So sometimes we don't have to have perfection. And this is where a little bit of the art comes in. If somebody stopped breathing 30 or 40 times an hour, they weren't able to tolerate PAP, and we can get their apnea-hypopnea index down to 10, I'd say live to fight another day, declare victory, and move on if the patient's clinically improved. And so then we have this issue of efficacy and adherence, right? So we're looking at outcomes and we're constantly balancing which side's better. We know that the therapies work, but who's gonna be adherent? The ongoing debate was people with appliances were much more adherent to therapy than those with PAP. Have you all heard that before? Right? I see the few people that are still awake are nodding their heads. All right, so that's kind of the urban legend, right? And I'm pro-therapy, so to me, I'm just as pro-appliance as I am pro-PAP. I'm pro-patient. And I'm gonna show you something on that adherence data in just a second. This is the one, there are more appliances like this being developed. So this has a computer chip in it. So if we wanted to do an appliance and be able to document that they're using that appliance for regulatory reasons, this does exist. There's a computer chip that monitors that they're wearing the appliance. Here's what another appliance looks like. So this just gives you a little idea what it's measuring. It's measuring temperature, whether they have it in, and that gives you a report that will tell you that they're wearing it. Remember, we still need the documentation to make sure that we know when they wear it, it is efficacious. So that's why you need that follow-up home study so at some point to know that, okay, they're wearing it every night, we have some evidence of that, but when they wear it, it's working. So if we look at adherence, this is an interesting study, right? So mandibular advancement adherence is better than CPAP. They just looked at 40 patients over 12 months. What they found was that their subjective compared to their objective, mandibular advancement patients, they were very sure that they were highly adherent to therapy. But when we studied, when they were studied, they consistently overestimated their adherence. CPAP users, on the other hand, consistently underestimated their therapeutic use. And at the end of the day, there was no significant difference. So one study, small numbers, but what I would say is it gets back to the fact that just we need to do what the patients will do and what's best for them. And then, of course, you have to do, you have to manage that within the confines of your regulatory requirement. Delay to effective has already been discussed. It has to be custom fabricated. So it takes weeks to months from diagnosis to being on therapeutic oral appliance versus a positive air pressure device. We should be able to have a patient on a device with anywhere from a few days to a week or more. So that's, from a speed standpoint, if someone needs to be on therapy immediately or near immediately, then you've got the big choices to go with positive air pressure. And then if they wanna look at a device later, that's kinda how it would lay out. And of course, the repeat sleep study. Remember, we're gonna skip over that. So are they able to sleep with the appliance? Is it comfortable? Even after people, they think they want them, sometimes they're not comfortable and they don't use them. They fit very tightly on their teeth. Some people, after they get them, find that that can be a bit challenging. Any gasping or choking? These are just a few of the questions. And pain? They're frequently titrated to snoring and pain. Surgical intervention? Really not. Surgery isn't usually any more considered first-line therapy. Surgery is still done for some patients. But there's typically, you know, uvula, palatal surgery, mandibular, maximum mandibular advancement surgery, which can be very effective. But these are therapies that are gonna take months to a year or more to execute. But again, I want you to know that these things exist. Palatal expansion? Very interesting therapy. Typically had been done in children, right? Because the suture in their palate wasn't closed yet. There is some work being done in adult palatal expansion, which is quite interesting. But I think for the sake of our subject today, probably isn't gonna be helpful in a patient immediately. In an adult, it's gonna take quite a bit of time. Weight loss can be very effective, especially in the mild to moderate patient. Patients, we typically tell them they have to lose about 10 to 15% of their current body weight, so they don't have to become the supermodel body, okay? But we need to set some goals for them. We typically, if they want weight loss as primary therapy, we embrace that. We work with them. The key is to set goals and to have accountability for the goals. We have their positive study, so we can always go back and treat them. So that's the clinical patient. You all have, if you have occupational needs, this isn't gonna be the therapy immediately for that patient. But again, I'm sharing with you all therapies as it relates to being people who take care of folks, right? So it takes some time, it takes some discipline. Incredibly rewarding, I might add, when it works. It's difficult to accomplish when they're sleep deprived. So sometimes we'll use therapy like PAP as a bridge to weight loss. Get them feeling better, then really work on the behavioral aspects of weight loss, and then retest them when they get to their goal weight. It's a great way to go. Positional therapy, frequently overlooked. So if you get your studies, even a home sleep study, it will tell you the amount of time and events supine versus lateral. If they are supine predominant, that's a bumper. If you look at the left picture, that thing's called a remedy. It's a big bumper that you strap on, very inexpensive. And it's tough to sleep with that bumper to sleep on your back. You can do it with tennis ball t-shirts. We've had these things before. This is called Night Balance. We did some of the work on this. It's a little device that fits underneath you that both works to get you off your back, and it does record the time off your back. I'm gonna show you one of those downloads. So about a third to just under half of patients may meet the criteria for exclusively positional sleep apnea. So it's something to be aware of. This is if you look at positional belts compared to PAP. The apnea hypopnea index is reduced quite satisfactorily by avoiding sleeping on your back in that group of patients. This is a Night Balance download, so there is the possibility in some patients this might be something that could be a favorable therapy for monitoring. Certainly worth a discussion. Excite OSA, have any of you seen this yet? Very interesting therapy. It's only been approved about nine months by the FDA. It's approved for snoring and mild obstructive sleep apnea. So think about your tongue as a big muscle. This is effectively how I like to call it. It's not what the company calls it, but you all know what a TENS unit is. More than any group. This group would probably know, right? It's effectively a TENS unit for your tongue. They're giving you rhythmic electronic muscle stimulation. You lay that little fork on your tongue. You do it 20 minutes a day for six consecutive weeks, then twice a week thereafter. Very interesting, right? So, and then here's one of the studies. 70 patients, they had a 95% reduction in snoring. Apnea IPOD index reduced from around 10 down to below five. And their sleepiness scale was reduced. So kind of reasonable data. Patient selection, we're learning how to use this. We are using it. I used it myself personally for snoring. It's easy to use. I mean, 20 minutes, you're reading your newspaper, your iPad or whatever, and it's got a little app and it reminds you to use it. Tells you when it's done. It's quite easy to use. So I think you're gonna see this maybe in some of these milder patients. At this time, it's not gonna be appropriate for the patients who would fall in that 20 events per hour or greater realm that you're very concerned about from the standpoint of a DOT. But it is a new therapy that's out there and I want you to know about it. Hypoglossal nerve stimulator. You all have had a lot of interest in this. This is the so-called Inspire. So indications which are important to know. 22 or above. AHI 15 to 65. Failed CPAP therapy. The free of concentric collapse of the palate has to be done by the ENT. That's visualized by them. And a BMI less than 33. Some may go as high as 35. So we have people coming in, I don't know in your market, but they're advertising nonstop in our market and patients are coming in, they don't really understand what it's about, but they wanna know if they qualify. Most of them don't qualify just based on these criteria alone, but I think this could be an important issue for you all to understand, especially for folks that have severe sleep apnea who are failing PAP and their job's on the line. And some insurance companies are covering this. So this does give you, this is the data. Shows significant reduction in apnea hypotenuse index. Look at that out three years. And they have daytime sleepiness reduction as well. This is their pooled data. So what it is, they have durable results. But again, people have to wanna go through surgery and then they have to qualify. Obviously it has to be covered by their insurance and then they still have to turn the thing on. It's like a pacemaker with a remote control. This is something else that's being looked at. This is a negative pressure. We're just looking at this now and the patient puts it on and it basically applies negative pressure to your throat, opening the airway. Isn't that fun? So this is like kind of going back to the polio days of the negative pressure ventilation. So we'll see how this works out, but maybe there's a time we'll be able to bring this to you as another alternative solution. Their initial data is 74% reduction in AHI. 70% of the patients thought this was acceptable treatment. And many, 88% of them preferred it over the other method of treatment. Inspire is a DOT compliant. So if you go down to the bottom, I think these are the issues that are gonna be important to all of us, right? So you can print out a usage report to show the medical examiner you're using the prescribed therapy and by proving the compliance, there should not be issues. So has anyone in here seen a patient yet using the device for clearance? Great. Any concerns? Is it okay? And then last, telemedicine. We are ready for telemedicine visits. So when things shut down in 2020, the next day we went 100% virtual. So we really embrace this. I think it's a great thing, especially for sleep apnea care. I love seeing patients in person if you can't tell, but it is great to be able to do this. And if people are working and it's their annual visit, we can do everything by video. Someone not having to take off a half day of work to come for a visit and save all that is really rewarding for all of us. It has been very effective for follow-up visits. patients are quite satisfied with that. And then think about pharmacologic therapy. Not ready yet. We are doing work on this. There's combination therapy being looked at. These are all medicines that are out in the market. These have been studies that have been done, animal studies that are being translated into people looking at some of these drugs. The norepinephrine reuptake inhibitor, muscarinic blockers and combinations. Some of the combinations use drobinol. We'll see where that goes. The data is not in yet, in phase two trials. This is 17 subjects using these data. Did see a 32% improvement, but they had some sleepiness. Anybody get any questions on this? Yeah. Based on the current evidence, it is not recommended. I do get these questions. I'm not comfortable being in this area of medicine. There's no recommendation or data for use at this point. So I don't weigh in on it with the patients. Just tell them there isn't any data right now. So I think it's gonna take a while for us to get data in those areas. Regardless of the treatment modality, we must have a follow-up study documenting efficacy of therapy. And we have to have a method of documenting adherence and compliance for you all to be able to issue cards in a comfortable manner. Annual follow-up for efficacy and compliance I think is still mandatory. Best to remind that minimum of 30 to 60 days prior to annual appointment. We still get folks who show up, God bless them. They come in, it's like they're DOT cards the next day and they need to be seen and the waiting room's full. We do our best to accommodate them. But there is this sort of like, you know that this is gonna come every year. CPAP remains the best overall treatment option for the patients that we have to deal with in this arena. Dental appliance can be effective and used with monitoring. But I think we need to get better monitoring technology and it's being worked on. We're doing some work right now. Other alternatives we talked about. I hope you find them interesting, whether you're using them or not. I mean part of my goal since you give me the privilege of being up here and sharing some time with you is to just share what's going on outside the occupational world because some of this I'm hoping we will be able to bring to bear on your patients as time goes along. With that, thank you for being so great and I'll look forward to questions. We'll have. We have. Oh, thank you. Okay. Couple of questions from online is, have you heard of the Airing Micro CPAP device? What's it called? The Airing, A-I-R-I-N-G. Micro CPAP. I cannot say that I've heard of that. Okay. And can you describe the differences between PAP, APAP, and CPAP? So we talked. So just think about PAP, positive airway pressure. And then the letter in front of it is just telling you the mode. So C is for continuous mode. A is for auto adjusting or auto adapting mode. Bi-level is for inspiratory and expiratory separated. And then things like auto servo, ventilatory mode, those sorts of things are really turning the PAP machine into a ventilator. Okay. If a driver has sleep apnea and has a sleep study, uses CPAP, feels much better on the CPAP, and wants to keep using the CPAP, is there any reason to order a repeat sleep study every few years? And the Academy has come out with recommendations. The only reason to do another study is if there's a reason to do another study. So a person who's got documentary evidence to be using their device, it's evident and it's therapeutic both on the devices, downloaded data, and by them clinically, I do not see any reason to do another study. Okay. And if you have any questions, please come to the podium. And if you're online, please go ahead and write your questions in. How do you screen for Chain-Stokes respiration? I'm sorry, sir. How do you screen for Chain-Stokes respirations? So that's really an interesting question. So for Chain-Stokes, Chain-Stokes is a form of central sleep apnea, of course. And one is primarily history. If the patient gives us a history of having underlying cardiac disease, neurologic disease, and by the way, chronic use of opioids, then instead of a home sleep apnea test, we really need them to come in for a polysomnogram. It is one of the things that would suggest a home sleep study is not the proper testing for that individual patient. We do sometimes pick up Chain-Stokes on a home sleep apnea test, but if we do, we bring them into the sleep lab to do anything further. We can see the increasing rate of sleep apnea of the increasing breath rate and then the stoppage in breathing frequently on a home study, but it isn't as easy to diagnose as when we have them in the sleep lab, sir. Thank you. Great question. Any other questions? Dr. Gillis? Can you talk a little bit about Inspire, more about it? And it's not a matter of just implanting the device, turning it on. There's like a process. There is. And I've had, over the last five years, I've probably had five to 10 people get it implanted, and I've only had one that has successfully gone all the way through. Yeah, I really appreciate you asking that question. I want to thank you because, so I want to say that it's another modality of therapy. I'm not at all opposed to that as a modality of therapy. However, so far, I find its application to be much more limited than is being made out by all the promotion of it. And I don't blame the individuals for promoting it. They have a business, they're trying to promote their business. But there is a process to it. First and foremost, the patient needs to be evaluated by the Inspire surgeon. There's usually one or two in each city. And they have to be decided whether they're a proper candidate. Candidate selection is clearly an important part of that process, especially initially. After that, then they have to undergo the placement, which is surgical procedure. Then they have to come in and have the thing turned on in the lab and have the amount of stimulation adjusted properly so it's resolving the apnea. And then they have to use it and it has to be followed and proven to be efficacious. That process takes weeks to months at a minimum. And some of that is getting it approved by insurance and whatnot. So I think it's a fascinating technology. It's got a place in our treatment continuum, but it isn't a reflex go-to. And to the credit of the individuals involved, one of the clear things is they have to have failed CPAP before. So if the patient hasn't tried therapy otherwise, they don't pass go. They have to try that therapy first. So it's a very timely question and it's an important issue because both the intensity of the care and the economics of it are such that these are big weighty issues that we need to deal with. So thank you very much. Other? We have one more from remote. A sleep doctor cleared a driver with sleep apnea just on oxygen. Thoughts about that? If the person has sleep apnea that's severe enough that they meet the criteria to need therapy for driving, I would not consider that adequate therapy at this time. Yeah. That may be important. That may be adequate for their health because that's all they can do, but it'd be difficult to prove that they were adequately treated from a sleepiness perspective. Would this be a potential treatment in someone? And I'm just asking. Yeah, yeah. Who has mild sleep apnea, AHI of nine, but desaturates. If they won't do anything else, in other words, if the person's like, I can't do the PAP, I'm not gonna do that as a last ditch effort just to do something, it's reasonable. It's not considered adequate therapy because it doesn't do anything of the obstructions. And you have to be a little cautious. In some apneic patients, oxygen can worsen apnea. So we want to always be a little careful about reflexively using it. It does come up. That's a very practical question. And I'll throw another one in there. It means I can. We're sleep docs, our op docs, are looking at a sleep study. And if we're looking for desaturations, what should be the number where we start to get concerned and say, okay, well, AHI is 19, but the desaturation is fill in the blank. I'm concerned even though that's not above 20. Yeah, so that's a meaty question, right? So there's a couple things we look at. One is the severity of the desaturations. So when you look at the tracing, so if you look at the oximetry tracing, and on your home studies, you should be able to see the oximetry tracing. And you want to look at, I mean, just go back to all of our original training. Look at that tracing. If the desaturations are very severe and consistent, not artifactual, you can tell if it just drops down like a lead weight and pops right back up, that's probably suspicious for artifact. But if they have severe scalloping and they're dropping down to 50%, 60%, and their amount of time below 80%, say like 15 or 20% desat, I'd be concerned about that. So if they're dropping to 50 to 60%, and if they spend 15% of the time below 80%, those would be magic numbers. I think about that, yeah. Okay, perfect, thank you. Could you quickly comment on what examiners might look at on the compliance reports beyond the four hours and the 70%? For example, would the examiner might be concerned that this driver hasn't been back to the sleep lab in a while and they may need their cap adjusted, or also maybe when that cap report is not entirely truthful? I noticed how you slipped quickly in there too. So, and if I'm back here sometime, I better bring up, I should have put that in the slides. So that's really important. So a couple things to look on the reports. One, you get a numerical download, and you also get a graphic download, right? So one thing on the graphic download that's concerning, if they only have one machine, is when they have big gaps in use. And so if the person's using it every night, I always tell people they're my perfect scores. They have 365 nights of use out of 365 monitors. Those people are golden. They're doing it. But when you see they have like, they took all of the month of July and August off of their pap machine, and their appointment is in November, and they restarted pap therapy in September 1st. That's a conversation we need to have, right? So that's looking at the sort of graphic representation. Next is looking at the apnea hypotenuse index, because again, a device is not a sleep study. So if that index is below 10, say, or five, for sure, below five, you should have a degree of comfort with that, as long as the person's clinical presentation is consistent with that. So what do I mean? If the person says, and of course, they're gonna probably tell me this, maybe more than you, but hey, look, I'm feeling tired again, or there's something going on, then it's reasonable to at least bring them in for a pap check sometimes, where their symptoms are not concordant with what their download says, right? So that's kind of a clinical issue. The other issues, patients get focused on leak of their mask, by the way. I don't know if you're getting this. The apps that they get on their phones now really beat up on them about leaks. But we're treating, all of us aren't treating air leak, we're treating events. So if their events are okay, and their leaks are going up, I would encourage patients focus on that as long as they're feeling good. Focus on their events being okay. But if they're starting to have more events and you're seeing big alterations in their pressure, that their pressures are varying, like how much pressure the machine's getting if they're on autopap, then that's a conversation you should probably have with the sleep docs. Sometimes those are the ones where I narrow the range to see if I can get it so they can tolerate it. They usually have pap intolerance from that. So if that person tells you that the pressures are bothering them, and you're seeing something in the pressure range that is changing, that's something you can intervene on. It's a subtle thing. We've just studied a series of patients, we're gonna try to write a paper on this, we haven't seen it. So what happens is those, see you said quickly. The autopaps are really just math equations, right? That's what an algorithm is, it's a math equation. And so the math equation sometimes misreads something in their breathing pattern, whether it's the slope, or the pause, and it starts to escalate their pressure, but they don't really need more pressure. And so these are very small percentage of patients, but when you're seeing a lot of the same thing, those small percentages start to show up. So sometimes you can pick that up as well, and it's easy to fix. That's a tough little thing, because they don't admit to, nope, everything's fine, I'm good, I'm good. I document symptoms or lack thereof when I do my exams, but inevitably in 98 times out of 100, they're good to go. Yeah, it's. But then I get a report from a sleep doc, and I get a new one. But hopefully their F-worths are correlating, even as sort of unreliable as F-worths are, it's still something that we can do, because you're not gonna be able to bring these people in for napping tests usually. A related comment, leaks can also come from the water tank and not the mask. Changing the water tank can at times correct leak. The question was, changing the water tank out, can that help out correcting if there's a leak? If there's a leak in the mask, a mask leak, or a leak in the tank? A leak in the tank. Oh, yeah, the tank should be replaced. They have a senescence. They should be replaced, I think, once or twice a year. Every insurance company in Medicare has a tank replacement as part of their deal, so they need to have them changed. What about the substantial weight loss? Person loses a significant amount of weight should they go in for a new sleep study, and if so, what percentage? Yeah, so the number we typically tell is about 15%. If you look in your diagnostic codes, there is a weight loss of more than 10% of your body. It's my favorite code to put in a patient chart. So if they do that, and they're like, I think I wanna try again, we'll do a follow-up home study on them. But if they have a bigger goal, and they're still seeing benefit from their device, I usually let them go to goal, whatever their goal weight is. But sometimes, when they get to certain points, they're like, I'd like to be retested. Now, one caveat on this is, again, that S on my forehead. I used to get all excited, and I'd say, let's do this home study to see if you don't need your CPAP anymore. And they'd have a sleep study that showed they didn't need CPAP. And the patients were horribly upset, because guess what? They loved their CPAP. And now, I just inadvertently harm them, because now the insurance company is not gonna pay for their supplies. So I simply ask them, again, right? If there's a mistake, we can make it. So I asked them, if I told you you didn't need your machine anymore, would that be a good thing or a bad thing? And the ones who say, and you'd be surprised how many of them it is, no, I can't go to sleep without my machine. I want my machine. I don't relook at them. But if they say, yeah, I'm excited, we retest them. And with a home study, if you retest them and their index has gone down, but they're still not in an acceptable place, it's just another marker. When they lose more weight, you can retest them again. Home studies just cost hundreds of dollars. It's not an expensive medical test as medical tests go. And that's huge encouragement for patients. Getting people off therapy is wonderful when it happens. So yeah, that's how I would do it. What's the utility of wakefulness testing? The MWT, for example, like minutes of wakefulness test. So if a person says they're sleepy with pap therapy, so sleepy, still on pap, they're using CPAP and they say they're sleepy, by and large, the insurance companies accept that as document or evidence. If the reverse is true and you want to prove safety, then that's at least something objective that you can give them. Is it perfect? It's not perfect, but it's the best measure that we have. So if there's an issue of proving it, if they're one of these, what we would call a zero failure job, like you're the pilot of Air Force One or something, we need to prove that they're not sleepy, then you have to do either a sleep study with an MSLT or an MWT. Well, thank you. Thank you very much, Dr. O'Gile, for joining us again. Thank you. And thank you all, and I apologize for the beginning with the lights. Thank you. Thank you.

sleep disorders

workplace

sleep providers

safety and risk assessment

sleep apnea

drivers

narcolepsy

idiopathic hypersomnia

home sleep studies

CPAP

Philips CPAP machines recall