Classic SleepCast

Second Opinions and the Rise of REPAP: Part V


Barry Krakow MD - May 11, 2017 - Expert Insight
The impetus to develop the REPAP protocol derives from the recognition CPAP failure often emerges because continuous pressurized air provokes expiratory pressure intolerance (EPI) when settings are raised to titrate out RERAs. In accordance with AASM standards, a sleep laboratory must attempt to titrate out RERAs, the most difficult to treat of the three main breathing events (apneas, hypopneas, RERAs). To solve this problem, we learned several years ago the sophisticated algorithms embedded within the auto-adjusting technology of ABPAP and ASV coupled with an assist through the manual override of the sleep technologist were sufficient meet AASM standards to eliminate RERAs without triggering EPI. Although we alluded to this phenomenon in our initial PAP-NAP paper1 published in 2008, it was not until four years later we provided more definitive data2 and commentary3 on the topic to explicitly point out the failure of the CPAP mode of air delivery. Since then and more recently... Read more

Second Opinions and the Rise of REPAP: Part IV


Barry Krakow MD - May 04, 2017 - Expert Insight
As we revisit the REPAP protocol, you will find a short summary of topics in the recently posted third installment that covers the two earlier REPAP posts I and II. REPAP III covered the interesting academic system through which the manuscript traversed in its various revisions in order to be accepted for publication. In this fourth installment, we now discuss the paper itself as well as details that are clinically relevant to patients seeking second opinions and to sleep professionals who provided help to these struggling individuals.  The REPAP paper has a lengthy introduction with much of the content already discussed in the other posts, and it refers to the background that led us to formulate a REPAP protocol (repeat, rescue, retitration). However, two points are worth mentioning again. First, we still must contend with the failure of the sleep medicine community to publish regularly on the topic of second opinions; and second, we... Read more

Where should the insomnia patient begin?


Barry Krakow MD - April 17, 2017 - Expert Insight
The popular trade magazine Sleep Review: The Journal for Sleep Specialists recently published a story on the symposium last year in Bologna, Italy at the European Sleep Research Society meeting where Christian Guilleminault, Erla Björnsdóttir, Leon Lack and I each presented on the topic of comorbid insomnia and sleep-disordered breathing (aka “complex insomnia” or COMISA). The story was written by Alexander Sweetman, a graduate student working with Dr. Lack, and covers pragmatic issues regarding not only the connection between the two disorders, but also raises important questions on the ordering of treatment for these conditions. Two key themes throughout Sweetman’s piece involved the extent to which PAP therapy might favorably influence different types of insomnia, and as a corollary, at what point in treatment should CBT-I (cognitive-behavioral therapy for insomnia) be offered to patients with co-morbid OSA/UARS. Some of the interesting points put forward in the presentations as well as during... Read more

Second Opinions and the Rise of REPAP: Part III


Barry Krakow MD - March 23, 2017 - Expert Insight
As the REPAP paper has just been published, now is a good time to finish up our earlier series on this innovative protocol. Briefly to summarize key points from the earlier works: 1) second opinion research is rare to non-existent in the sleep literature; 2) the use of retitrations to reverse CPAP failure is only slightly more evident in research publications; 3) the nature of CPAP failure is mostly defined by non-technological factors; whereas the notion of a technological solution for CPAP rejection is rarely considered in the literature or sleep medicine practice; 4) the key objective finding in second opinion patients is known as expiratory pressure intolerance (EPI), the problematic and uncomfortable sensation of breathing out against fixed (CPAP) pressure coming in; 5) sleep medicine professionals in general and reviewers of sleep research papers in particular show a lack of awareness or simply do not consider the potential for... Read more

Racing Thoughts at Bedtime: Revisiting the Respiratory Threat Matrix Model of Chronic Insomnia


Barry Krakow MD - March 02, 2017 - Expert Insight
In the prior post on the Respiratory Threat Matrix Model, we delved into many facets of this theory, which you can read about here. In this post, we will focus on a few key points about this theory especially is it relates to the concept of threat. Not being able to breath or suffering through a temporary episode of struggling to breathe is a mind-boggling event like very few other experiences in one’s life. Instantaneously, the potential for the loss of your life can overwhelm your consciousness inducing a state of panic and abject fear. There is no way to overestimate how emotionally painful and physically frightening you would feel in the instant you might believe you cannot re-establish your breathing. As described in the earlier posts on racing thoughts and ruminations, these events are arguably the most terrifying experiences you might suffer, because you actually feel or believe you... Read more

Racing Thoughts at Bedtime: Causes and Cures


Barry Krakow MD - February 21, 2017 - Expert Insight
When we ask patients about the content of their racing thoughts, the common answers revolve around past or future events and the related worries about what has happened or what will happen. The circumstances are almost always about work problems, relationship issues, or concerns about health or finances. Other topics emerge, but they often lead back to these major categories of stressors in one’s life. A closer inspection of this content invariably reveals a deeper or more primal emotional basis for the worry in which the concern equates to some type of threat. You are worried about a conversation you had with your boss and wonder if you overstepped your role or boundaries in your efforts to offer constructive criticism. Depending upon how well you communicated, you may be confident in having provided sound feedback. But if you are prone to worry you will soon develop racing thoughts about the... Read more

Racing Thoughts at Bedtime: The Single Greatest Cause of Insomnia


Barry Krakow MD - February 08, 2017 - Expert Insight
The inability to turn off one’s mind is the most frequently reported complaint of individuals who cannot fall sleep or return to sleep in the middle of the night. This factor is so prevalent, anywhere from 80 to 90% of insomniacs will report racing thoughts and ruminations as the chief cause of their insomnia. “I just can’t turn off my mind,” or “my engine just won’t shut down,” are common refrains among these folks, ranging from children to adolescents to adults to the elderly. Racing thoughts and ruminations are the primary target of the pharmaceutical industry when developing prescription or over-the-counter (OTC) sleep aids. While the pharmacology is designed with a goal to create the feeling and sensation of sleepiness, the effectiveness of the drug can be measured by how effectively it overcomes the frenetic mental state. To be sure, there is no drug to eradicate racing thoughts (although some... Read more
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