Classic SleepCast

Second Opinions and the Rise of REPAP: Part II


Barry Krakow MD - December 05, 2016 - Expert Insight
We attempted our first submission of the REPAP paper with a leading sleep journal, which summarily rejected the work for many of the reasons described in the previous post. The reviewers emphasized methodological weaknesses as well what in our opinion appeared to be obvious confusion about how sleep centers currently address CPAP failure. One of the first complaints described in the rejection letter was at odds with what most people think or know about the practice of sleep medicine: “The practice of mask changes, mode and pressure changes are the usual treatment for patients who re-present to sleep clinic and are willing to retry CPAP.” No doubt the reviewer did not carefully review our work, because we explained our sample comprised second opinion patients who failed CPAP at their original sleep centers, yet from these patients’ perspectives there was no additional support or suggestions regarding changes in mask, modes or... Read more

Second Opinions and the Rise of REPAP: Part I


Barry Krakow MD - November 21, 2016 - Expert Insight
In prior work on this site and elsewhere we have put forth the necessity to use sleep lab retitration protocols as a mainstay of practice to solve the problem of CPAP failure. In this post, we will delve into the history on the development of this concept, which has culminated most recently in the acceptance of our first peer-reviewed, research paper on the REPAP approach (REPAP stands for repeat, rescue, retitrations to reverse CPAP failure). Our paper will appear online in the next few months in the journal Respiratory Care, after more than ten years of effort to bring to fruition.1 Our story begins in 2005 in the third year of operations at our new private sleep center, Maimonides Sleep Arts & Sciences. Initially, we were treating all patients with CPAP, auto-CPAP, and a few patients with CFLEX. With careful analysis of the airflow curve in the sleep lab, we... Read more

Sleep Onset Insomnia and Advanced PAP Therapy


Barry Krakow MD - November 11, 2016 - Expert Insight
In prior posts, we discussed how treatment of sleep onset insomnia with PAP therapy showed mixed results and delved into our research on the potential for greater improvements using advanced PAP devices (ABPAP and ASV) in these patients. With the very recent publication of our research paper, “A Novel Therapy for Chronic Sleep-Onset Insomnia: A Retrospective, Nonrandomized Controlled Study of Auto-Adjusting, Dual-Level, Positive Airway Pressure Technology,” we can now dig much deeper into our study methods and the precise details of the results to understand the clinical relevance of this hypothesis-generating study. This term for the study refers to its design not being at the highest level of evidence, which would have been a randomized controlled trial comparing ASV or ABPAP to a CPAP device as one example. Our nonrandomized design means the claims we offer are not proof ASV or ABPAP effectively treats sleep onset or early insomnia; instead,... Read more

Complex Insomnia vs COMISA


Barry Krakow MD - November 07, 2016 - Expert Insight
Summarizing the final points from the last post, a term like COMISA is sufficient when talking about the larger picture in a public health discussion, but clinically we need terms to educate both physicians and patients. The term “comorbid insomnia” will be in use for a long time, because so many healthcare providers will continue to believe the main or obvious co-occurring condition is the dynamic partner in the co-morbidity. For sleep physicians, I would speculate the term “complex insomnia” will carry a certain cachet, because it was derived specifically from the construct of chronic insomnia patients who possessed no awareness of a breathing connection to their bouts of sleeplessness. In our long-term clinical research experience, these patients are astonished to learn a sleep breathing condition is a primary component of their problem, and our impression has been that millions of insomniacs suffer both disorders. For these reasons, I believe... Read more

Comorbid Insomnia, Complex Insomnia, or COMISA?


Barry Krakow MD - October 27, 2016 - Expert Insight
Selecting a term matters. In the early 1990s I launched a large research project to measure the impact of imagery rehearsal therapy on chronic nightmare patients, while simultaneously training to increase my clinical experience in sleep disorders medicine and completing my board certification with the AASM. It is around this time we first suspected sleep apnea was more common among insomnia patients. The more I encountered OSA/UARS patients in clinic, the more I realized the “classic” presentation of OSA did not fit the majority of patients. Instead, patients often presented with many other sleep symptoms or different types of sleep disturbance complaints, and the picture often appeared as if the individual suffered from a current psychiatric condition that perhaps was the real or primary cause of the sleep disturbance. In other words, OSA/UARS was not the obvious chief complaint in patient’s mind. For the next two decades, we published nearly... Read more

Inside sleep apnea


October 25, 2016 - Consequences of Sleep Apnea
This video shows what happens inside your body if you snore or have sleep apnea. Sleep apnea causes frequent interruptions in breathing as you sleep. It disrupts your rest, which can pose serious health risks. Loud snoring is often a symptom of sleep apnea. You snore when your tongue falls back against the back of your throat and it vibrates as you breathe in and out. In apnea, your throat muscles relax so much that they block your airway. When this happens, you can stop breathing for ten seconds or more. Carbon dioxide builds up and causes your brain to signal you to wake up. You do, briefly, and begin to breathe normally again. These brief interruptions can happen many times an hour and can severely hurt your health. Read more on WebMD.   Read more

ESRS Conference Update


Barry Krakow MD - October 20, 2016 - Expert Insight
September 15th Symposium on Comorbid Insomnia and Sleep Apnea Earlier this year, I joined with other experts in the field who are researching comorbid insomnia and sleep apnea—something we describe as “complex insomnia”—to deliver a symposium in Bologna, Italy at the annual European Sleep Research Society (ESRS) conference. The talks were attended by a few hundred participants and were well-received, although candidly I want to emphasize this topic remains too far out on the cutting edge and many sleep researchers and other sleep professionals still show difficulty digesting the clinical relevance and importance of this extremely common co-morbidity. I base this view anecdotally on the audience Q & A generated after each talk, which I believe showed little curiosity and even less in the way of corroborative experiences. Nonetheless, the symposium will hopefully prove to be a good start in raising our colleagues' awareness and planting new seeds of discovery.  Each talk... Read more