Abstract Introduction Central respiratory events, including hypoventilation and apneas, are caused by compression of the brainstem in Type 1 Chiari malformations (CM1). Central sleep apnea (CSA) occurs in 15-34% of children with CM1, and compensated central hypoventilation is present in 15%. Other potential complications of CM1 include nystagmus, headaches, and, in rare and devastating cases, a risk of sudden unexpected nocturnal death. We describe a case of an adolescent with CSA due to CM1 that improved with surgical decompression. Report of case(s) A 17-year-old female with a history of ADHD presented to Sleep Medicine clinic with daytime fatigue and brain-fog. No significant snoring was noted, and she had an Epworth sleepiness scale (ESS) score of 16. The initial home sleep test had a central apnea-hypopnea index (AHI) of 21 and an obstructive AHI of 6.5. Subsequent polysomnography (PSG) showed predominantly central sleep apnea with a combined AHI of 42.6 (central AHI 41.6), and the patient was managed on Bilevel ST 12/6 RR 10. She had modest improvement in her daytime symptoms. As she had no history of underlying central nervous system pathology, her CSA was initially presumed to be idiopathic. However, 2 years later, she developed recurrent debilitating headaches and downbeat nystagmus, so an MRI of the head was completed. This showed CM1 with tonsils 32 mm below the foramen magnum; therefore, surgical decompression was performed via craniectomy and C1 arch removal with duraplasty. Postoperatively, the patient had reduction of headaches and nystagmus and denied daytime fatigue without the use of Bilevel PAP therapy, and ESS was reduced to 8. Subsequent PSG showed no significant sleep apnea with the combined AHI of 4 events/hr (central AHI of 3.2 events/hr) without any PAP therapy. She was able to discontinue use of Bilevel therapy and continued to feel improvement in her fatigue. Conclusion This case demonstrates that in an otherwise healthy adolescent patient with unexplained central sleep apnea, a type 1 Chiari Malformation could be a profound cause that should be considered during evaluation. Surgical decompression can improve associated symptoms and significantly improve central sleep apnea to the extent that the patient may not need continued PAP therapy. Support (if any)

Carbon dioxide (CO2) levels change during sleep in patients with obesity hypoventilation syndrome (OHS), obstructive sleep apnea with coexistent OHS, and respiratory failure. Transcutaneous carbon dioxide monitoring (TCM) during polysomnography (PSG) provides both continuous and non-invasive estimation of the CO2. TCM can be helpful in early recognition of hypoventilation. Untreated hypoventilation is associated with high morbidity and mortality. Recognizing hypoventilation and initiating appropriate treatment interventions can help lower this burden of morbidity and mortality. Despite TCM’s potential benefits, it’s not always included during PSG and not used at all sleep centers. Arterial blood gas (ABG) sampling before PSG can be helpful in determining the accuracy of the CO2 measurement using TCM at sleep onset during PSG. There is no current consensus on when ABG sampling should be performed before PSG. We are obtaining ABG sampling within 48 hours before the PSG at our center and will evaluate the accuracy of pTCO2 measurement with PaCO2 from ABG with the timing of the ABG sampling. Starting in early March 2024, as a quality improvement effort, we added ABG sampling within 48 hours and included TCM during the PSG for patients who presented at an community-based academic sleep center for clinical evaluation for hypoventilation. We are collecting demographic variables including age, gender, body mass index range and cardiovascular and pulmonary comorbidities. We plan to evaluate the association between 1) the PaCO2 and 2) bicarbonate from the ABG with the 3) sleep onset and peak TCO2. To date, 30 patients seeking clinical evaluation for hypoventilation who completed ABG sampling within 48 hours before PSG and TCM during the PSG. 67% of the patients are female. Mean age of 51 ± 15.4 years and a BMI of 40.79 ± 10.73kg/m2. We will plan to continue this quality improvement effort until March 2025. Results to be shared. ABG sampling within 48 hours before PSG and TCM during the PSG is feasible and might help with early recognition of hypoventilation.

Abstract Introduction Some OSA patients have sleep associated hypoxemia, defined as time spent with oxygen (O2) saturation ◻88% for > 5 minutes (T88). Positive airway pressure (PAP) is the gold standard treatment for OSA. Apnea-Hypopnea index (AHI) estimation from PAP download (DL) is used by clinicians to determine the treatment efficacy. Overnight oximetry with PAP therapy is usually used to check for resolution of hypoxemia. During the COVID-19 pandemic, we used WPAT to check for resolution of hypoxemia in OSA patients who were prescribed PAP therapy. However, this practice change allowed us to compare the AHI measured simultaneously by WPAT and PAP DL Methods A retrospective study of 42 patients from August - November 2021 seen at University of Minnesota Sleep Clinic. All patients had a previous diagnosis of OSA and sleep associated hypoxemia confirmed by either Noxturnal [Nox MEDICAL] HSAT or PSG. All patients were being treated with either CPAP or bilevel PAP. Single night of HSAT was obtained with WPAT 100 (Itamar Medical) while simultaneously using PAP at their usual prescribed settings. PAP data included usage time, adherence, 30-day and same night AHI. WPAT data included total AHI, rapid eye movement related AHI, and T88 Results Of the 42 patients, 60% were males with mean age 58.8 ± 14.6 years, body mass index (BMI) 38.9 ± 9.6 kg/m2 and Epworth sleepiness scale 10.7 ± 5.1. We identified an elevated AHI (≥ 5) with WPAT in more than half of the patients though hypoxemia resolved, ESS improved and OSA was optimally controlled with AHI< 5 per PAP DL. There was a significant difference between the AHI on WPAT and same day PAP DL (AHI; 7.9 ± 12.2; p =0.0006). There was moderate correlation with BMI (r=0.51; p= 0.0017) and poor correlation with central AHI on WPAT (r = 0.29; p= 0.10) Conclusion There was discrepancy between AHIs with results from WPAT and PAP DL measured during the same night. Higher residual WPAT AHI could have significant implications with regards to validity of the algorithm used in these devices. This can potentially lower the threshold for performing titration PSGs to ensure optimal treatment of OSA Support (if any)

Background and Objective:Respiratory care is often embedded as a component of the overlapping management strategies in many patients with neuromuscular disease (NMD). Implementation of respiratory care strategies requires a sensitivity to the nature of the disease, the vulnerability during rapid eye movement (REM) sleep and complicating comorbidities specific to each patient. Care must adjust to progression of the disease as well as the comfort and preferences of the patient. Clinical presentations are usually heterogenous based on the specific NMD and overall course of the disease making diagnosis and respiratory care challenging. The aim of this review was to review the state-of-the-art evidence-based clinical practices and updates in the management of respiratory complications in patients with NMDs. Methods:We conducted a search on the PubMed and Medline databases using these keywords: secretions, neuromuscular disease, neuromuscular disorders, non-invasive ventilator, neuromuscular respiratory weakness, respiratory failure. The specified timeframe began from 1980 to 2024. Key Content and Findings:Timely use of non-invasive ventilation and overall respiratory care is most important as emerging evidence shows some benefits with improved mortality in this group of patients. In some settings, comorbid complications that dictate need for airway management and oral diversion may have a more profound impact on mortality than the effectiveness of ventilatory support that are chosen. A multidisciplinary team approach to care has been shown to improve the quality of life and survival in these patients in centers of excellence. Patients should have the ability to access services provided by neurology, pulmonology, speech pathology, sleep medicine, cardiology and respiratory therapy services. Conclusions:The cornerstone for management of respiratory failure and sleep disordered breathing in NMD is non-invasive ventilation (NIV). Initiation of this support and other respiratory cares need to be timely, and patients may have very subtle symptoms during the early stages of the disease which makes it challenging in recognizing the onset of respiratory muscle stress and fatigue. Close attention to these symptoms as well as respiratory and radiologic parameters is essential for appropriate incorporation of these cares.

Free AccessLetters to the EditorApproaching year 3 of the Philips recall: what have we learned? Snigdhasmrithi Pusalavidyasagar, MD, John Poma, MBA, JD, Muna Irfan, MD, Robert Stansbury, MD, Conrad Iber, MD, Lynn Marie Trotti, MD Snigdhasmrithi Pusalavidyasagar, MD Address correspondence to: Snigdhasmrithi Pusalavidyasagar, MD, FAASM, Department of Medicine/PACCS Division, 420 Delaware Street SE, MMC 276, Minneapolis, MN 55455; Email: E-mail Address: [email protected] Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota Search for more papers by this author , John Poma, MBA, JD Patient Advocate, Massachusetts General Hospital, Boston, Massachusetts Search for more papers by this author , Muna Irfan, MD Department of Neurology, Veterans Affairs Medical Center, Minneapolis, Minnesota Search for more papers by this author , Robert Stansbury, MD Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, West Virginia University School of Medicine, Morgantown, West Virginia Search for more papers by this author , Conrad Iber, MD Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota Search for more papers by this author , Lynn Marie Trotti, MD Department of Neurology, Emory School of Medicine, Atlanta, Georgia Search for more papers by this author Published Online:August 1, 2023https://doi.org/10.5664/jcsm.10638SectionsEpubPDF ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutINTRODUCTIONWhile struggling to address the impact of the global coronavirus disease 2019 (COVID-19) pandemic on our patients, the sleep medicine community could hardly imagine the challenge ahead: an unprecedented medical device recall for the Philips Respironics positive airway pressure (PAP) devices and home ventilators. As we approach the recall’s third year, we are concerned about the questions that remain unanswered about its impact on our patients.Approximately 25 million devices were recalled, making it one of the largest medical device recalls.1 National organizations provided support when possible. The American Academy of Sleep Medicine issued an important statement and provided regular updates, including webinars, for the sleep community. The Journal of the American Medical Association regularly covered the recall, including examining the regulatory policy breakdown.1Leaders offered their guidance and experience. Morgenthaler et al2 shared a thoughtful patient-centered guide for rapid responses to medical device recalls outlining important components for sleep centers to consider in their own efforts. Owens et al3 authored a helpful statement on behalf of the American Thoracic Society identifying additional key steps for clinical teams. Tondo et al4 recently shared their experience switching patients with obstructive sleep apnea to different devices.All of these contributions helped the sleep medicine community find its way. However, despite sleep centers’ heroic efforts to provide care, we still know very little about the impact of the recall on patients globally. A coauthor to this Letter was a PAP user for more than 20 years at the time of recall—who faced impossible choices about their sleep, risks associated with continuing therapy or stopping, and ultimately, their quality of life.We must share our experiences. Recognizing that strategies implemented by a single sleep center may not be generalizable, due to differences in resources, patient populations, and access, we believe that publishing will be valuable in identifying lingering problems from the recall and potential solutions. In particular, it seems likely that the recall could have worsened existing inequities in sleep health, yet little has been published on the impact of the recall on health disparities. Our sleep medicine colleagues and patients in the global South are facing the same device safety issues but may be experiencing the recall effects in different ways.Therapy adherence is a lingering concern in sleep medicine, despite several advancements in technology. We believe that there is a high probability that PAP discontinuation increased during the recall for complex reasons, including device shortage, understandable concern, distrust of device safety, and, possibly, distrust of sleep medicine professionals who prescribed the PAP devices prior to the recall. We are unaware of any published data on our patients’ perspectives about these challenges or their evolving perspective on alternative treatment options due to the recall.Our hope is that the global sleep medicine community will begin to seek and share our patient experiences during the recall. We should also share our clinical experiences managing patient care during the recall, so we can better understand and debate the impact of this tremendous challenge and, importantly, be better prepared for the future.DISCLOSURE STATEMENTAll authors have seen and approved the manuscript. Mr. Poma serves on the Board of Trustees for LifeSpire of Virginia without compensation. Dr. Stansbury previously consulted with ResMed on design of new drugs or devices, clinical trials, the use of specific agents, or other research-related activities with honoraria. Dr. Trotti is a member of the Board of Directors of the American Academy of Sleep Medicine (AASM). Views expressed in this letter are those of the authors and do not necessarily reflect those of the AASM. The other authors report no conflicts of interest.REFERENCES1. Kadakia KT, Ross JS, Rathi VK. The Philips Respironics recall of ventilators and positive airway pressure machines—breakdowns in medical device surveillance. JAMA Intern Med. 2023;183(1):5–8. CrossrefGoogle Scholar2. Morgenthaler TI, Linginfelter EA, Gay PC, et al.. Rapid response to medical device recalls: an organized patient-centered team effort. J Clin Sleep Med. 2022;18(2):663–667. LinkGoogle Scholar3. Owens RL, Wilson KC, Gurubhagavatula I, Mehra R. Philips Respironics recall of positive airway pressure and noninvasive ventilation devices: a brief statement to inform response efforts and identify key steps forward. Am J Respir Crit Care Med. 2021;204(8):887–890. CrossrefGoogle Scholar4. Tondo P, Pronzato C, Risi I, et al.. Switch of nocturnal non-invasive positive pressure ventilation (NPPV) in obstructive sleep apnea (OSA). J Clin Med. 2022;11(11):3157. CrossrefGoogle Scholar Previous article Next article FiguresReferencesRelatedDetails Volume 19 • Issue 8 • August 1, 2023ISSN (print): 1550-9389ISSN (online): 1550-9397Frequency: Monthly Metrics History Submitted for publicationMarch 26, 2023Submitted in final revised formApril 20, 2023Accepted for publicationApril 21, 2023Published onlineAugust 1, 2023 Information© 2023 American Academy of Sleep MedicinePDF download

In the US, few adolescents get adequate school night sleep, largely due to early school start times. In the START study we aimed to test the following hypothesis: That following the implementation of later high school start times students have lesser longitudinal increases in body mass index (BMI) and shift to more healthful weight -related behaviors relative to students attending schools that retain early start times. The study enrolled a cohort of students (n = 2426) in five high schools in the Twin Cities, MN metro. Heights and weights were measured objectively, and surveys were administered annually from 9th through 11th grades (2016-2018). All study schools started early (either 7:30 am or 7:45 am) at baseline (2016). At follow-up 1 (2017) and continuing through follow-up 2 (2018), two schools delayed their start times by 50-65 min, while three comparison schools started at 7:30 am throughout the observation period. Using a difference-in-differences natural experiment design, we estimated differences in changes in BMI and weight-related behaviors over time between policy change and comparison schools. Students' BMIs increased in parallel in both policy change and comparison schools over time. However relative to changes in comparison schools after the start time shift, students in policy change schools had a modestly more healthful profile of weight-related behaviors - for instance they had a relatively greater probability of eating breakfast, having supper with their family, getting more activity, eating fast food less frequently, and eating vegetables daily. Later start times could be a durable, population-wide strategy that promotes healthful weight behaviors.

The clinical benefits of positive airway pressure (PAP) therapy for obstructive sleep apnea are assumed to require adherent PAP usage, defined by the Centers for Medicare Medicaid Services as ≥ 4 hours of use ≥ 70 https://clinicaltrials.gov/ct2/show/NCT00642486 ; Identifier: NCT00642486. Pascoe M, Bena J, Andrews ND, et al. Dose-response relationship between positive airway pressure therapy and excessive daytime sleepiness: the HomePAP study. J Clin Sleep Med. 2022;18(4):1027–1034.

To examine current evidence of the relationship between sleep and pain from the neonatal period through adolescence. This review serves as a critical review of the literature and of the needs for future research on pediatric sleep and pain. The PubMed online database was queried from January 1, 1960, to March 1, 2020, producing 149 articles applicable to pain and sleep in the pediatric population. Of those, 97 articles were cited in this review with the key articles including over 3800 participants. The pediatric literature supports the relationship between poor sleep (both sleep efficiency and nighttime awakenings) and subsequent risk for pain, especially among children with chronic disease. The reverse effect of pain on sleep is not yet well delineated. The key moderating factors explored in the literature are pharmacologic and nonpharmacologic therapies, psychologic health, and the etiology of pain. There is evidence that both altered sleep and pain early in life impact neurodevelopment, as seen by changes in sleep structure in clinical studies and alterations in brain development in animal models. The complicated relationship between sleep and pain is critically important during pediatric development when alterations to a normal sleep structure can have a lifelong impact. It is becoming clear that sleep deprivation and poor sleep quality exacerbate pain. Further research is needed into the complex alterations of sleep in chronic pain conditions as well as treatments to improve sleep in pediatric care. Morris EE, Howell MJ, Pickup E, Iber C, Wang SG. Pediatric sleep and pain:etiologies, consequences, and clinical considerations.J Clin Sleep Med. 2022;18(9):2281–2289.

Objective: In this study, we examine associations between objectively measured weekend night vs. school night sleep patterns, weight status, and weight-related behaviors among adolescents. Design: Cross-sectional study. Setting: Five Minnesota high schools that started early (7:30 or 7:45 AM) in Spring 2016. Participants: Ninth grade students, ages 14.5-16 years (n = 284). Measurements: Students completed surveys, had body measurements taken, and wore sleep (wrist) actigraphs for 1 week (n = 284). We examined weekend night-school night differences in sleep duration and sleep timing. We then assessed whether these factors were related to weight status and weight-related behaviors (eating behaviors, food consumption, physical activity, beverage consumption) using generalized linear mixed models. Results: On average, students slept 1.5 hours (95% confidence interval 1.3-1.7) more and had a sleep midpoint 1.9 hours (1.8-2.1) later on weekend nights compared to school nights. Female students had larger increases in sleep duration on weekend nights than males but similar timing differences. Sleep duration differences were uncorrelated with sleep timing differences (r = 0.01). Neither duration nor timing differences were associated with overweight, obesity, or any of the eating behaviors we examined. However, sleeping longer on weekend nights than on school nights was associated with lower probability of being active 6-7 days per week (p = .02). Conclusions: Adolescents have substantial sleep duration and sleep timing differences on weekend nights vs. school nights. While these differences may not be associated with weight status or weight-related behaviors, they reflect the reality that most adolescents have schedules that restrict their sleep. (c) 2021 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.

PURPOSE:Few adolescents spend enough time asleep on school nights. This problem could be addressed by delaying high school start times, but does this translate to reduced prevalence of sleep-wake problems like awakening too early or feeling sleepy during the day? METHODS:The START study (n = 2,414) followed a cohort of students from five Minnesota high schools to evaluate impacts of school start time delays. Participants were enrolled in ninth grade (Baseline) when all schools started early (7:30 or 7:45 a.m.). At Follow-Up 1 (10th grade) and Follow-Up 2 (11th grade), two schools had delayed their start times by 50 and 65 minutes while three comparison schools started at 7:30 a.m. Six sleep-wake behaviors were assessed at all three time points via survey. Generalized estimating equation models were used to investigate changes in sleep-wake problems between policy change and comparison schools. RESULTS:The prevalence of sleep-wake problems at Baseline ranged from 11% for being late to class due to oversleeping to 48% for needing to be told to wake multiple times in the morning. Compared to students from comparison schools, students at policy change schools reported smaller increases in the prevalence of feeling sleepy daily and oversleeping and being late to class between 9th and 11th grade. After implementation of the delayed start, awakening too early was more common among students at policy change schools compared to the comparison schools. CONCLUSIONS:This longitudinal study provides evidence that delaying high school start times reduces daytime sleepiness and school tardiness.

BACKGROUND Sleep duration, quality, and timing may influence dietary quality. In adults, poor dietary quality is a risk factor for numerous chronic diseases. It is unclear how these various sleep domains influence adolescents' diets because prior population-based studies have not effectively manipulated sleep, did not include objective sleep measures, and had short follow-up times. OBJECTIVES The objectives of this study were to examine 1) how adolescent sleep characteristics relate to dietary quality; and 2) how delay in high school start times (which lengthened sleep duration) affects dietary quality over 2 y. METHODS In the START study, adolescents (grades 9-11, n = 423) attending 5 high schools in the Minneapolis, Minnesota metropolitan area were annually assessed in 3 waves (2016-2018). At Baseline, all schools started "early" (07:30 or 07:45). From Follow-up 1 through Follow-up 2, 2 "policy change schools" shifted to later start times (to 08:20 and 08:50). Three "comparison schools" maintained their early start throughout. Sleep characteristics were measured with actigraphy. Mixed-effect regression models were used to examine cross-sectional and longitudinal associations of sleep characteristics with dietary quality, and school start time policy change with dietary quality change. RESULTS Cross-sectionally, later sleep midpoint and onset were associated with dietary quality scores 1.6-1.7 lower (both P < 0.05). However, no prospective associations were observed between sleep characteristics and dietary quality in longitudinal models. Shifting to later school start time tended to be associated with a 2.4-point increase in dietary quality score (P = 0.09) at Follow-up 1, but was not associated with change in dietary quality scores at Follow-up 2 (P = 0.35). CONCLUSIONS High school students attending delayed-start schools maintained better dietary quality than students in comparison schools; however, differences were not statistically significant. Overall study findings highlight the complexity of the relation between sleep behavior and diet in adolescence.

Sleep apnea is a common sleep disorder that, if left untreated, can have critical complications to the individual. The most common and effective treatment for sleep apnea is the Continuous Positive Airway Pressure (CPAP) therapy. But it has a long-term adherence rate as low as 60% due to discomfort and other factors. Although previous research has attempted to increase CPAP usage, there has been little to no change in its average adherence for the past two decades. This paper attempts to change this scenario using a large longitudinal dataset combined with a Recurrent Neural Network model to generate therapy use recommendations after one month of therapy. We performed a retrospective cohort analysis on 3380 patients during their first six months of therapy and compared our personalized recommendation system with the current generic recommendations made by sleep physicians. We show that recommendations generated by our artificial neural network model are easier to achieve since they are significantly closer to patients' therapy progress while being equally successful in maintaining therapy adherence.

Free AccessLetters to the EditorPracticing sleep medicine amidst a pandemic: a paradigm shift Muna Irfan, MBBS, Wajahat Khalil, MBBS, Conrad Iber, MD Muna Irfan, MBBS Veterans Affairs Health Care System, Minneapolis, Minnesota University of Minnesota Medical School, Minneapolis, Minnesota , Wajahat Khalil, MBBS Veterans Affairs Health Care System, Minneapolis, Minnesota University of Minnesota Medical School, Minneapolis, Minnesota , Conrad Iber, MD University of Minnesota, Fairview, Minneapolis, Minnesota Published Online:August 15, 2020https://doi.org/10.5664/jcsm.8590Cited by:1SectionsAbstractPDF ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutABSTRACTCitation:Irfan M, Khalil W, Iber C. Practicing sleep medicine amidst a pandemic: a paradigm shift. J Clin Sleep Med. 2020;16(8): 1405–1408.INTRODUCTIONThe field of sleep medicine lends itself to innovative practice models but adoption to standardized continuous care models and virtual delivery formats has been suboptimal due to the focus on facility-based centers and on variation in practices driven by diverse structures in health care and reimbursement. The American Academy of Sleep Medicine's long track record in practice standardization and its pivot to continuing care quality metrics and virtual care have set the stage to optimize continuous virtual models. Actual implementation of virtual components has been slow-paced until recently when conventional practice came to a grinding halt in the wake of the COVID-19 pandemic.GENERAL NEEDS ASSESSMENTSeveral factors hinder efficiency, care continuity, and timely care in the traditional facility-based model. Access to diagnostic strategies has been limited by uneven distribution of sleep laboratories and home studies. Chronic disease management has been constrained by incomplete integration of durable medical equipment, as well as the limited allocation of resources to the specialty care continuum of a comprehensive virtual sleep medicine. Conventional sleep practice in facilities has inherent inefficiencies for many medically stable patients, including extensive physical spaces, expenditure of time in travel and rooming of patients, and limited geographic distribution of fixed resources. The realities of the COVID-19 health risk has exerted a force for re-examining the ability of virtual care to meet safety realities and perhaps even solve existing access and cost issues.There are three areas of need to be addressed in the transformation of sleep medicine: (1) a vision of a permanent virtual continuous care model to supplement physical visits, (2) a transformational map for re-entry of patients into diagnostic pathways, and (3) standardization of relaxed telemedicine rules moving forward. We propose transitional strategies with components that can continue the transformation of sleep medicine.TRANSFORMATION OF CARE STRATEGIESIn order to efficiently and safely provide effective care to our patients while containing the risk of COVID-19 spread, the following methodological formats could be incorporated into sleep practice.Synchronous interactionReal-time virtual encounters using video-based technologies such as Zoom, Video Connect, AmWell, or Doximity should be integrated into existing clinic workflows, existing asynchronous patient portals, electronic health records, and internal health record messaging. Telephone visits also can be conducted, especially when patients are identified as having obstacles to video connections. Both visit types can be employed for initial encounter, therapeutic initiation, and interval assessment and monitoring.Asynchronous interactionTemporally separated interaction including (1) E-consult, whereby clinical decision making is based on electronic chart review and structured reporting, (2) online self-assessment tools forwarded through patient portals, and (3) storage and forward interpretation of sleep diagnostics, including polysomnography (PSG), home testing, actigraphy, and oximetry.The current guidance issued by AASM regarding COVID-19 mitigation strategies and reopening of sleep services suggest using a carefully cogitated multiphase approach in accordance with state executive orders, local public health statements, and health care system directives in the context of the magnitude of local spread of the corona virus. We share our implemented approach in 2 major academic sleep centers in Minnesota under different local healthcare systems.The clinical pathways are represented in Figure 1 and Figure 2.Figure 1: Pathway for management of sleep-disordered breathing.Download FigureFigure 2: Pathway for management of other sleep disorders.Download FigureManagement of sleep-disordered breathingConsults are triaged—based on locally established criteria—into either the virtual sleep clinic for complex concerns or into E-consult for the appropriate candidate based on self-assessment tools or screening by referring provider. Two home sleep testing (HST) pathways include:For appropriate candidates, disposable HST equipment is mailed to the patient with instructional brochures, video link, and individual telephone or group teleconference for equipment use instructions. Data is uploaded through blue tooth to the cloud where it is accessed and interpreted by a physician.Alternatively, patients utilize mail-in or pickup/drop-off reusable HST equipment. Preemptive screening for symptoms suggestive of COVID-19 is done, followed by curbside HST equipment pickup and drop-off during designated times. Staff handling of equipment follows local implementation of Centers for Disease Control guidelines for disinfection, with equipment storage for 72 hours before reuse. Proper personal protective equipment for the staff handling the equipment and a disinfection protocol are ensured.Clinical decision making is supplemented by patient self-assessment tools and sleep questionnaires. Auto-titrating positive airway pressure (APAP) equipment is mailed to a patient with OSA. Therapy initiation is facilitated by instructional brochures, video link, and telephone or video-based communication.Virtual cloud-based therapy efficacy and adherence monitoring is performed.Other considerationsIn-home capnography and overnight oximetry to monitor therapy can also be performed. Training of the clinician and laboratory and scheduling staff in the established policies is critical.Management of other sleep disordersPatients who are referred for other sleep concerns such as insomnia, parasomnia, or sleep-related movement disorders are evaluated via virtual encounter and then, depending on local services available, a clinical decision is made to use either a conservative, behavioral, or pharmacological strategy. For insomnia, self-directed cognitive behavioral therapy-I instruments and a virtual cognitive behavioral therapy-I care model are both employed depending on the patient's needs. Other behavioral strategies such desensitization and image rehearsal therapies for nightmares are also provided virtually. A telehealth coordinator and a virtual case manager play essential roles in ensuring that the process works smoothly. Weekly meetings to discuss challenging cases and provide a platform for supervision, discussion, and quality improvement constantly enhance care delivery in the current dynamic medical environment.PROPOSAL FOR MULTIPHASE RESUMPTION OF THE POLYSOMNOGRAPHY LABORATORYTiming of graded opening depends on local healthcare organization policy and state directives.Preemptive screening of patients who need a PSG will be done. Screening will be repeated on the day of the diagnostic testing. COVID-19 testing can be considered if feasible.An increased patient–to–sleep technologist ratio will minimize contact exposure and allow rotation of available staff. Proper personal protective equipment will be provided for the lab staff.Only a diagnostic PSG will be performed initially. Increased virtual monitoring and adjustment of devices will replace most titration studies. For complex patients for whom a titration PSG is required—and after discussion of the risk/benefit balance—a preprocedural screen will include COVID-19 testing before the PSG. If possible, titration PSGs will be conducted in a negative pressure room. Laboratory staff will be screened daily for development of any symptom of concern.Follow-up virtual-care coaching with review of residual disease and remote adjustment of CPAP and respiratory-assist devices will be leveraged to optimize subjective and objective targets, including utilization of repeat home monitoring when appropriate.The PSG laboratory at will resume at full capacity once the risk of COVID-19 transmission is deemed to be minimal to none.Alternative approachEnhanced type II PSG with real-time remote diagnostic and therapeutic monitoring and intervention is a viable option that can potentially expand our clinical management capabilities and ease the bottleneck in therapeutic PSGs currently being performed in laboratories for complex sleep disorders.While the models suggested are approved by the local governing body for launch in a preliminary phase in May, we are prepared to adjust processes with the expectation that modifications or intermittent short-term restrictions may be required in response to any surge in local community transmission.These times call for collective endeavors, as the best interest of the patient is the driving force motivating us to come together as one community.DISCLOSURE STATEMENTAll the authors have seen and approved the manuscript. This work is derived from practice models at Minneapolis Veterans Affairs Health Care System Sleep Services and University of Minnesota-Fairview Sleep Services. Grant funding for patient registry by Inspire Medical. Previous article Next article FiguresReferencesRelatedDetailsCited by Telemedicine in Sleep-Disordered BreathingVerbraecken J Sleep Medicine Clinics, 10.1016/j.jsmc.2021.05.009, Vol. 16, No. 3, (417-445), Online publication date: 1-Sep-2021. Volume 16 • Issue 8 • August 15, 2020ISSN (print): 1550-9389ISSN (online): 1550-9397Frequency: Monthly Metrics History Submitted for publicationMay 5, 2020Submitted in final revised formMay 13, 2020Accepted for publicationMay 14, 2020Published onlineAugust 15, 2020 Information© 2020 American Academy of Sleep MedicinePDF download

Abstract Introduction Upper Airway Stimulation (UAS) and Continuous Positive Airway Pressure (CPAP) are trackable therapies for obstructive sleep apnea. We used recent big-data cohorts to compare changes in sleepiness versus usage. Methods ADHERE is an international registry of real-world UAS outcomes from 2016 to date. General UAS criteria are CPAP intolerance, AHI 15-65 (<25% central+mixed), and suggested BMI≤35. Baseline ESS is collected from the medical record, and follow-up ESS and usage is collected 2-4 months after therapy activation. M Health Fairview maintains a database of cross-linked CPAP and EHR data. All new adult sleep patients from 2015 onward were included paralleling ADHERE: BMI≤35, AHI 15-65, and daily CPAP-EHR data starting at least 60 days prior to 2nd ESS measurement. Baseline ESS was collected at consult, and follow-up ESS was collected approximately 6 months later. Device-reported usage hours were compared with the changes in ESS from baseline. Results UAS (n=690) and CPAP (n=514) groups were similar: age 59.7±10.8 versus 59.7±13.6, 78% versus 75% male, and AHI 35.3±14.4 versus 33.8±14.0. UAS group was slightly less obese, BMI 29.3±3.9 versus 30.0±3.4 (p=0.001), with higher baseline ESS, 11.4±5.6 versus 8.6±5.3 (p<0.001). UAS usage was higher at 6.4±2.0 hours/night versus 5.2±2.0 hours/night with CPAP (p<0.001). UAS group average ESS decreased 2.5 points for patients with 0-4 hours of use (n=81), decreasing to 3.8 points with at 4 or more hours of use (n=609). CPAP group average ESS decreased 2.5 points for patients with 0-4 hours of use (n=125), decreasing to 3.3 points with at 4 or more hours of use (n=389). Conclusion Compared to prior works and the UAS cohort, this CPAP cohort was more likely to have normal ESS at baseline. UAS and CPAP both demonstrate a dose-response curve associating increasing hourly usage with larger ESS reductions. Support Kent Lee of Inspire Medical Systems provided background information and access to a de-identified ADHERE data set for analysis.

Positive airway pressure (PAP) therapy integration is a component of electronic health record (EHR) sleep medicine optimization. EHR optimization facilitates telehealth in continuous care population health. A coordinated care plan can leverage early telehealth interventions.

This cohort study examines how delaying school start time is associated with objectively assessed sleep duration, timing, and quality among adolescents from public high schools in Minnesota. Importance Sleep is a resource that has been associated with health and well-being; however, sleep insufficiency is common among adolescents. Objective To examine how delaying school start time is associated with objectively assessed sleep duration, timing, and quality in a cohort of adolescents. Design, Setting, and Participants This observational cohort study took advantage of district-initiated modifications in the starting times of 5 public high schools in the metropolitan area of Minneapolis and St Paul, Minnesota. A total of 455 students were followed up from grade 9 (May 3 to June 3, 2016) through grade 11 (March 15 to May 21, 2018). Data were analyzed from February 1 to July 24, 2019. Exposures All 5 participating schools started early (7:30amor 7:45am) at baseline (2016). At follow-up 1 (2017) and continuing through follow-up 2 (2018), 2 schools delayed their start times by 50 and 65 minutes, whereas 3 comparison schools started at 7:30amthroughout the observation period. Main Outcomes and Measures Wrist actigraphy was used to derive indices of sleep duration, timing, and quality. With a difference-in-difference design, linear mixed-effects models were used to estimate differences in changes in sleep time between delayed-start and comparison schools. Results A total of 455 students were included in the analysis (among those identifying sex, 225 girls [49.5%] and 219 boys [48.1%]; mean [SD] age at baseline, 15.2 [0.3] years). Relative to the change observed in the comparison schools, students who attended delayed-start schools had an additional mean 41 (95% CI, 25-57) objectively measured minutes of night sleep at follow-up 1 and 43 (95% CI, 25-61) at follow-up 2. Delayed start times were not associated with falling asleep later on school nights at follow-ups, and students attending these schools had a mean difference-in-differences change in weekend night sleep of -24 (95% CI, -51 to 2) minutes from baseline to follow-up 1 and -34 (95% CI, -65 to -3) minutes from baseline to follow-up 2, relative to comparison school participants. Differences in differences for school night sleep onset, weekend sleep onset latency, sleep midpoints, sleep efficiency, and the sleep fragmentation index between the 2 conditions were minimal. Conclusions and Relevance This study found that delaying high school start times could extend adolescent school night sleep duration and lessen their need for catch-up sleep on weekends. These findings suggest that later start times could be a durable strategy for addressing population-wide adolescent sleep deficits. Question How is a delay in high school start time associated with adolescent sleep? Findings In this cohort study of 455 high school students, those attending schools that shifted to later starts after baseline measurements (1) got approximately 43 minutes more objectively measured sleep on school nights, (2) slept less on weekends, and (3) had similar bedtimes 2 years after the start time delay, relative to students attending comparison schools that started early throughout the observation period. Meaning These findings suggest that delayed school start times may be a readily deployable sleep promotion intervention that can effectively allow adolescents greater opportunity for healthy sleep.

Visual hallucinations, illusions, and distortions have been observed in individuals undergoing severe periods of extended wakefulness. However, the incidence of these perceptual phenomena occurring during applied domains such as driving have been underreported. This study investigates effects of a 30-hour period of extended wakefulness during which participants abstained from stimulants and were not allowed to sleep or nap. Participants drove every 4 hours during this period on an uneventful 30-minute driving route in a fullcab high fidelity driving simulator. At the end of the study, participants reported whether they experienced significant visual illusions or distortions, and when the events occurred. Participants reported visual distortions and illusions during drives comprising a time period between 22 and 30 hours awake. Furthermore, self-reported mental workload and extroversion predicted the likelihood of experiencing the visual phenomena. Potential mechanisms for this relationship and possible consequences for safe driving performance during significant sleep deprivation are discussed.