Obstructive Sleep Apnea and Insomnia as Coexisting Entities
In this multidisciplinary roundtable discussion, Jaspal Singh, MD, MHA, MHS, interviews Douglas Kirsch, MD, and Seema Khosla, MD, about the management of patients with obstructive sleep apnea and insomnia, considerations for patients and clinicians, CPAP therapy, and hypoglossal nerve stimulation. This is part three of a three-part series on insomnia.
For more insomnia content, visit the Resource Center.
Watch episode one of this three-part series here.
Watch episode two of this three-part series here.
TRANSCRIPTION:
Jaspal Singh, MD, MHA, MHS:
Hello, everybody. I'm Jaspal Singh. On behalf of Consultant360, I wanted to welcome you to Episode 3 of our Insomnia series. Today with us again are Dr. Seema Khosla and Dr. Doug Kirsch talking to us about Episode 3, which is going to focus on the concomitant obstructive sleep apnea and insomnia as coexisting entities. Seema, want to introduce yourself, please?
Seema Khosla, MD:
Sure. My name is Seema Khosla. I'm a pulmonologist practicing 100% sleep medicine in Fargo, North Dakota.
Jaspal Singh, MD, MHA, MHS:
And Dr. Kirsch?
Douglas Kirsch, MD:
I'm Doug Kirsch. I am the medical director of sleep medicine at Atrium Health in Charlotte, North Carolina.
Jaspal Singh, MD, MHA, MHS:
All right. Seema, we'll start with you. You're a pulmonologist, and so you have a lot of patients with CPAP therapies and then we've all seen the cartoons and the commercials and the idea of people struggling, and people tell us sometimes about... we've almost joked about CPAP therapy for some of our patients. Our patients oftentimes joke about it, and they have a hard time, many of them, sleeping with it or their bed partner has a hard time, have found that you know what? This exacerbates their sleep issues when the spouse has a CPAP device. Talk us through what goes in your mind when the patient comes to you and says, "You know what? I can't sleep with this thing," or, "This is really affecting my overall quality of life."
Seema Khosla, MD:
Yeah, that's a really important point, because our goal at the end of the day is to help people sleep better. So while we are willing to accept maybe short-term inconvenience, if it turns into a longer-term issue, then we absolutely have to address it. I think it's important for patients to understand that it doesn't matter how we treat the sleep apnea as long as we treat it, and what that looks like might be a CPAP like you described. It might be a dental device, it might be an implantable device, it may be weight reduction, it may be surgery.
So we just want to make sure that they recognize that it's not that they necessarily have to put up with a mask and an air compressor, it's that we just want to treat it in some way. I think what you're also getting at is that part of the reason why they have difficulty tolerating it may be that it is causing them to be awake or maybe they had a significant insomnia component in addition to their sleep apnea. So how do we decide what to treat first? Do we treat them both at the same time? How do we navigate that?
Jaspal Singh, MD, MHA, MHS:
Yeah, that's a great way of summarizing it, Seema. Doug, where do you start with this?
Douglas Kirsch, MD:
I think these patients can be complex, but I will say the first thing to recognize is sometimes the reason that somebody has insomnia is that they have sleep apnea. It can be a big hurdle to get somebody over the concept that treating sleep apnea, if you need to use CPAP, for instance, that's actually going to help them sleep better. It is a process of convincing them that this is actually not going to make it worse or make their sleep worse. That's not always true, but I think it's an important step sometimes to say, "Hey, let's see," particularly if somebody is complaining that their sleep is fragmented and they're getting up to go to the bathroom frequently and that's disruptive to their sleep, and let's just say they have moderate sleep apnea, that treating that moderate sleep apnea with CPAP machine would be a reasonable first step.
If it doesn't work, "Okay, let's figure out what we can do.: But I think in that case it can sometimes be quite reasonable. Now it's a slightly different story if somebody is saying, "Man, I can't fall asleep for hours," and they have very mild sleep apnea, those two things seem more likely unlinked. So now it's a matter of, "Okay, well, is there something else we need to do to try and fix the sleep on one side and the sleep apnea on the other?" Maybe that invasive CPAP feel is maybe not the right way to go and maybe you're going to try that positional therapy first, plus doing whatever you're going to do for the insomnia. I wanted to just highlight, just 'cause I know we're not talking about sleep apnea, but it is part of this is that people joke about the CPAP and they say, "Oh, nobody ever uses their CPAP machine."
I struggle with that concept, which is to say, that given the right support and given the right education, people can be incredibly successful with CPAP. So there was all this research that went on in the eighties that talked about how only 40% of people ever use their CPAP machines enough. What I'll say is in a well-run center, you will get numbers that are closer to 75 or 80%. I think that what's important for this audience to hear is that four out of five of our patients are doing really well on CPAP by 90 days, and that's doable in a well-run situation for them where they're getting the support and getting the education that they need. Now, that's not always easy in some places, but I will say it's recognizing that CPAP can be a very successful treatment for sleep apnea.
Jaspal Singh, MD, MHA, MHS:
That's a great point. Then it's funny you say that 'cause as you're talking, I'm thinking about, I work in the cancer center a lot with a lot of my patients and sometimes my oncology colleagues joke that I'm testing someone for sleep apnea when in fact, actually, many of my cancer patients said, "You know what? That was the best thing someone's done for me in the last few weeks is manage and I can sleep better. I'm more rested," and that despite the perception that they might've had. You can imagine especially for our cancer patients, what a huge amount of stress they might be under. But to hear that time and time again, I think it's important.
I think when insomnia and sleep apnea co-exist, I think oftentimes the natural tendency is to focus on insomnia first, for most clinicians, I would say. Maybe I'm wrong. I think for some clinicians actually, it's easy to go the sleep apnea because you can get a study, it's clean, it's objective, it's data-driven, and so you see this schism in the road there. Whereas actually, I think an adept clinician from what you're telling me, from both you are telling me is that you separate the issues deeper, and they might be completely separate issues, the OSA and the insomnia and then attacking them both perhaps with similar strategies but potentially with different strategies might be a better way to go. Is that about right?
Seema Khosla, MD:
I think there's also, there's sometimes a disconnect where people feel like they are awake, but when we look at their EEG, they are sleeping. It may be fragmented sleep, or it may be light sleep. So when we talk to them about this phenomenon, this paradoxical insomnia, and oftentimes, we don't even need a sleep study, it's the bed partner. The patient's saying, "Gosh, it takes me two hours to fall asleep," and the bed partner says, "No, honey, you are asleep in 10 seconds," and so there's a clear disconnect. When we explain the phenomenon of a potential driver may be that the airway is collapsing and causing your brain to wake up. When we open up the airway, it allows you to progress into deeper sleep, then they see that. I think too, allowing patients to maybe have a little bit more knowledge about this and explain it where it's not just all in their head.
We're not saying we don't believe you. It's a very real phenomenon when you have these microsleeps and your sleep is really, really fragmented, it can make people feel really frustrated or unheard if you're saying, "Well, this is telling us that you are sleeping," and it's like, "No, I swear I'm awake." I'm like, "I understand that. We recognize that." So I think it always, goes back to partnering with your patient and allowing them to have that voice or when they first say, "There is no way I'm going to wear that." "Okay, let's talk about something else, and let's move on from this," instead of making it a really antagonistic relationship, like, "How can we work together to come out on the other side of this?"
Douglas Kirsch, MD:
Although, Seema, I'll challenge you on that a little bit just to say that-
Seema Khosla, MD:
I was waiting for it.
Douglas Kirsch, MD:
Well, 'cause I think a lot of people walk in the door to say, "I'm never going to use a CPAP machine." If I said, "Okay, we're not going to touch that with a 10-foot pole," I think that closes that door rather rapidly. I think there's somewhere in between maybe antagonism and discussion around education and why somebody might use a CPAP and that we're not necessarily committing you to something for the rest of your life, that we're only going to try it to see what outcomes happen.
Seema Khosla, MD:
You're right, I didn't explain that well. You're right. After you have a discussion about, "Well, tell me what it is about it," but I think though we all have those patients that are like, "You know what? I've tried it. It's not my thing," versus the person that is apprehensive about it and just needs to understand it more, maybe just wants to give it a whirl, right?
Douglas Kirsch, MD:
Even people who fail, we have a lot of people come back after five years or 10 years and they're like, "You know what? I really didn't have a good experience." Then you dig into why they didn't have a good experience, and again, I think it often circles back to the absence of support. "I was given a CPAP machine and I didn't see a doctor back ever. They gave me a machine and that was it." That ongoing communication with the patient that follows up that education, is where people become successful. I tell them all the time, "You didn't get the support you needed the first time around. This can go." Now there are certainly people who are like, "I did that once, I am not doing it again." Yeah, you have to be able to move to other options if that's the case.
I think the other thing because we are talking about these joint patients of having sleep apnea and insomnia is sometimes you also need to talk about, "Well, would I use medication and a treatment at the same time for their sleep apnea?" The answer is, in some cases, sure, why wouldn't you? Because there is some data that says using sleeping medication can make people more adherent to CPAP. Makes sense. If you're sleeping better, you're less likely to take it off. You're less likely to have a problem with it. So I think that kind of combination therapy in some cases can be quite effective with a goal, again, of maybe not leaving them on that medication forever but to say, "Okay, we're getting you started. I know we're introducing something different, so let's do this and that, and then we're going to back off on that pill down the road."
Seema Khosla, MD:
Yeah, I love that idea to help them acclimate to CPAP, and I think they, again, feel this relief when they're like, "Okay, I can use a little something to help me get used to this new change." This nightly thing that we are asking them to do, that can be a heavy lift for some people. I think it's also worth discussing some of the very preliminary data that's coming out about this was Andrew Sweetman's work about CBT-I for a patient that has comorbid insomnia and obstructive sleep apnea that the CBT-I itself seemed to make the sleep apnea a little bit better.
Jaspal Singh, MD, MHA, MHS:
No, I think CBT-I makes everything better. It's like a lot of things, CBT-I for how I eat, CBT-I for how I exercise, mindfulness. The idea of mindfulness, getting into the deeper root of the cause, controlling some of even the biological signals of what's happening, so I think the aspects of CBT-I, and that comes back to our last episode a little bit about multimodality nuanced approach in that you can actually have two what seemingly are related issues. I think both of you alluded to patients that assume they're both together or clinicians would assume they're both lumped in together but actually might be dealing with completely different entities. Then to Doug's point is that oftentimes, sleep apnea gets the bad rap. I think in a high-functioning clinic with close follow-up and support, you can actually get a lot of patients with obstructed sleep apnea, at least one pathway can be potentially more elite. Now the second pathway may need to start going down either pharmacotherapy or CBT-I or some other nuanced approach, then hopefully, the two pathways merge to align for better overall sleep health in a challenging patient population. [inaudible 00:12:17]
Seema Khosla, MD:
But I also think it's important to recognize that all the education isn't just from the clinician. In a comprehensive program, you have education at the time of CPAP set up, at the phone call follow up, at the, "Hey, I need to ask my RT about this and hop on a Zoom to get a mask to fit," I think there are so many pieces, so many really important team members that we have that are very well-educated, that all have that unified goal of helping this patient to be successful with whichever treatment.
Like what Doug was talking about where you've had somebody on CPAP five years ago and they put it in the closet and then they come back, a lot of the time it's that they didn't like their mask, something as simple as that. They say, "Oh, I didn't know I could do a nasal mask." It's that conversation to really dig into it. Part of that support then is, "Well, let's get you in for a mask fit. Let's have you talk to the RT. Let's follow up in a month and see how you're doing. Talk to the RT in 15 days, and let's see how things are going for you."
Jaspal Singh, MD, MHA, MHS:
For our audience of clinicians of various types, I think what's happened in the sleep world, a lot of the sleep providers have just basically prescribed CPAP and then to Doug's point, not provided that support network. This is like anything else in life. If you want to do weight loss, you don't just give a prescription of weight loss and then just walk away from that patient, you coach them through the process. Smoking cessation is a perfect example in my space. You need to coach them constantly. "You don't just quit once you quit multiple times." The whole program's been much more embedded. I think CPAP hasn't gotten that level of attention in a lot of communities.
So I think that's an important aspect. The insomnia part, I think you mentioned, Seema, the idea that it may not be CPAP that is the treatment for mild to moderate sleep apnea, for example. For severe, probably is worthwhile in certain cases really pushing on that. But in mild to moderate, you mentioned other thoughts, the ideas of oral appliance therapy, of weight loss, aggressive weight loss efforts, and positional therapies. You mentioned other avenues. Sometimes from what I gather you're implying is a conversation and some degree of not compromise, but the degree of negotiation with the patient. Is that about right? Am I hearing you right?
Seema Khosla, MD:
Yeah, and I think it's more in this spirit of showing them their options and listening to them and letting them be equal partners in that shared decision-making instead of that more paternalistic, "Here's a CPAP, you must wear this or you will die." It's this, "This is an option, you may have heard... you may have had..." I usually will ask, "Do you have any experience with CPAP? Do you have friends or family members, and what are their thoughts?" Because often, those opinions and experiences are reflected then in patient expectations. My dad loves his CPAP, he can't sleep without it. I'm on board," versus, "My neighbor gave his away. Everyone I've ever met hates or CPAP, I'm really worried about it." "Well, let's just try it in the evening. Try it for 10 minutes when you're watching TV," and ease into it and acknowledge that this is harder than taking a pill. Acknowledge the effort that they are putting into it so that they feel heard.
Jaspal Singh, MD, MHA, MHS:
That's a great point of putting this together. Along that route we're building this idea of what they've heard, I have to say the manufacturers and marketing team of a certain device company for hypoglossal nerve stimulation have done an incredible job marketing. I'm impressed by the brilliance of their ads. Yet it's created this perception that that might be the holy grail for obstructed sleep apnea, especially in insomnia patients. So Doug, what are your thoughts on that option for these patients with both insomnia versus sleep apnea? I see a lot of my patients asking about this therapy. Give me a brief overview of what it might be and what you, at this stage in the early stage of the conversation with a patient with sleep insomnia. Where are you with that discussion?
Douglas Kirsch, MD:
I think that it's a recognition that one treatment does not fit all. CPAP is not the answer for everybody who has sleep apnea, whether you have insomnia or not. I think that that is an important aspect of it, that it's not CPAP or bust, it's, "Here's a series of options and we are going to continue down a pathway." I think we've expressed that idea a couple of times, and the same is true of sleep apnea. Hypoglossal nerve stimulation, obviously advertising talks a little bit about how it's not a CPAP machine. It is effectively anti-advertising against this idea of a mask in a machine, but it does not advertise really what it is, which it is a stimulator. It is an implant, it is a surgery and they put a device in, and they run wires up into your neck and it stimulates your tongue. I will say I have had some patients who have gone from CPAP to hypoglossal nerve stimulation and have found that they tolerate hypoglossal nerve stimulation better, and their insomnia is somewhat better because they don't have a CPAP machine.
At the same time, I have other people who have gotten a hypoglossal nerve stimulator and have said, "Yeah, I'm finding it difficult to sleep 'cause my tongue keeps moving at nighttime, and it's uncomfortable," and those kinds of things. There is no perfect treatment, and it's important to understand that advertising doesn't lay out all the pros and cons of any given treatment. I think hypoglossal nerve stimulation is going to be an increasingly large treatment for sleep apnea as we go forward with not just one device that's out there, but two new devices coming into the marketplace. In the end, it's about making a good decision with that patient, recognizing the pros and cons of that intervention and saying, "Yeah, in this case, if you can't tolerate this form of therapy, this is maybe a reasonable next step for you. Let's see how it goes. Here are the pros and cons of that, and let's take that next step and see if you're a good candidate for that."
Seema Khosla, MD:
Do you find that you have to do some recalibration of expectation or a certain level of deprogramming when somebody comes into your office saying, "I want this, I want this hypoglossal nerve stimulator?"
Douglas Kirsch, MD:
I will say many of the patients who walk in will ask me what Inspire is and, "How can I get it?" Without recognizing that it's actually a surgery. Right?
Seema Khosla, MD:
Mm-hmm.
Douglas Kirsch, MD:
So I think that you really have to start at the very basic level of saying, "This is what this thing is. It's not a CPAP machine without a mask. It's a very different kind of thing. There are aspects of this that are really great, which is that it's not a device and it doesn't need to be cleaned. It is easy to travel with in some ways as long as you're not going through airport security. But on the downside, there are these aspects of the device that make things challenging sometimes." I think it can be a real benefit for some number of people.
Some people have done really well with this device, but it's not 100%. I think it's important for people to recognize that there is no perfect treatment. To your point, calibrating expectations about, "Is this going to cure my sleep apnea?" It may not. It may not completely rid you of it in the same way CPAP does. So I know this isn't a discussion necessarily on sleep apnea, but I think it is a relevant discussion to say when you are talking to an insomnia patient who also has sleep apnea that trading one treatment for another may have some benefits and some downsides. It's important to have a conversation about both of those aspects.
Jaspal Singh, MD, MHA, MHS:
No, I think that-
Seema Khosla, MD:
I think you've hinted at something too, that so many times when people go to see their primary care doctor about insomnia, a lot of time it turns out to be sleep apnea. My mom is a family practice doctor, and a lot of people talk to her about their sleep. She has now become more comfortable talking about CPAP ordering a sleep study and talking to them about what this means. So I feel like, again, it brings us back to the first episode where we really want to be thoughtful about how we use these words and help me understand, "I know the medical clinical definition of what we think insomnia is. What does insomnia mean to you?" "Well, gosh, I wake up five times at night to empty my bladder." "Well, do you also snore, or have you considered that it might be something else?" So it's, again, part of that conversation and aligning our language and expectations and then developing a treatment plan.
Jaspal Singh, MD, MHA, MHS:
[inaudible 00:21:05] I'm going to-
Douglas Kirsch, MD:
So I think as you look at the different physicians who may be listening to this, I think asking those questions, "So, okay, you're coming in with insomnia. Tell me about what that is." Then having a couple of extra screening questions to ask about sleep disorders may well help in the basic process of managing your patient. Because if you can understand, "Hey, they snore, they have a body mass of 40 and they're sleepy during the daytime, that may not just be insomnia, it may be insomnia and something else." It's important to know that as you think about what path this person's going to take.
Jaspal Singh, MD, MHA, MHS:
Right. I would take that example and say that they can also still have insomnia and obstructive sleep apnea or something else.
Seema Khosla, MD:
Right.
Jaspal Singh, MD, MHA, MHS:
I think to summarize for our listeners as we wind up, I think the idea of insomnia and obstructive sleep apnea and what's the intersection of both of those disorders, recognizing that they may be completely separate and need attention separately, or they may be interconnected and one may be more masking than the other, and it's just hard to tease out. But with time, with support, with the right resources, the right information, and I love how, Seema, you mapped out the idea of shared decision-making, getting them to understand the options and the nuances, and then taking a nuanced approach. Doug, to your point, is, no, there's not a perfect therapy.
There are therapies for all of these, whether it be insomnia, whether it be for sleep apnea, but going through and marching forward with a plan can really help alleviate not just their symptoms, but their overall health, well-being, their lifestyle, which help them achieve their health goals. Is that pretty accurate? All right. Well, I want to say this is a lot of fun. This whole series was a lot of fun, and I can't thank you both enough for your generosity of your time. Again, I'm Jaspal Singh. On behalf of Consultant360, I wanted to give a special shout-out and thanks to my guests today, which are Dr. Seema Khosla and Dr. Doug Kirsch. Thank you so much for both of you.
Seema Khosla, MD:
Thank you.
Douglas Kirsch, MD:
Appreciate it.