In this episode of Talking Sleep, host Dr. Seema Khosla welcomes three patient advocates who are reshaping how sleep medicine is practiced and funded. Matt Horsnell, living with two sleep disorders and active as an author and panelist; Emma Cooksey, a patient-advocate and host of the Sleep Apnea Stories podcast; and Julie Flygare, a lawyer, author, and founder of Project Sleep, share their transformative advocacy work.

While clinicians often think of advocacy as writing letters or making donations, these three demonstrate that patient advocacy encompasses far more complexity and impact. They explain the multiple dimensions of advocacy work: legislative advocacy that influences policy and funding, educational advocacy that raises awareness and understanding, and research advocacy that shapes the scientific agenda.

The conversation begins with personal stories—what brought each advocate to this work and how living with sleep disorders motivated their commitment to systemic change. Matt shares insights as someone navigating two sleep conditions, while Emma and Julie discuss how legal training informed their approaches to advocacy and systems change.

Legislative advocacy receives detailed exploration. The guests explain how patient voices influence congressional action, regulatory decisions, and funding priorities. They discuss educational advocacy—raising public awareness, changing misconceptions, and helping people recognize sleep disorders they might otherwise dismiss or normalize.

Project Sleep, Julie's organization, serves as a centerpiece for discussion. While Project Sleep doesn't fund research directly, the conversation addresses which organizations do fund sleep medicine research and how clinicians and patients can access federal funding mechanisms. The guests provide insights into how disease-specific organizations like Wake-up Narcolepsy secure funding and the lessons applicable to sleep medicine more broadly.

Project Sleep's helpline receives attention—what it offers, who it serves, and the critical challenge of sustainability when grant funding ends. The guests discuss Rising Voices, an initiative amplifying patient narratives and lived experience in policy and clinical discussions.

A particularly valuable discussion addresses how clinicians can meaningfully engage with patient advocacy. Is this space exclusively for people living with sleep disorders, or can healthcare providers contribute? The conversation explores collaboration opportunities without appropriating patient voices or experiences.

The guests address practical questions: How do you sustain advocacy work without becoming discouraged? What does advocacy look like at local versus federal levels? What's on the wish list for sleep medicine advocacy? A recurring theme emerges: sustained funding remains elusive despite growing recognition of sleep disorders' impact on public health.

The episode acknowledges that patients bring irreplaceable perspectives to clinical practice, research prioritization, and policy development. Their lived experience of navigating diagnoses, treatments, and healthcare systems provides insights clinicians cannot access through clinical practice alone.

Whether you're interested in supporting patient-led advocacy, seeking to collaborate with patient organizations, curious about how to engage in legislative efforts, or simply wanting to understand the power of patient voices in healthcare transformation, this episode provides essential perspectives and practical guidance.

Join us for this important conversation with patient advocates who are leading meaningful change in sleep medicine.

Episode Correction: During the audio recording, federal funding for circadian research was misspoken as $60 Million. The correct amount is $600 Million.

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In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Sahil Chopra to discuss research challenging a fundamental assumption: that residual AHI measurements from PAP device downloads accurately reflect whether patients' sleep apnea is adequately treated.

Sleep medicine clinicians routinely rely on residual AHI from PAP downloads to determine treatment success, typically targeting an AHI under 5. But what if this metric significantly underestimates untreated sleep apnea? Dr. Chopra's study comparing PAP-determined residual AHIs to cardiopulmonary coupling (CPC)-derived AHIs reveals striking discrepancies: mean residual AHI was 2.4 via PAP download versus 12.1 via objective testing. Even more concerning, 85% of nights showing residual AHI under 5 on PAP downloads had elevated AHI based on objective CPC measurement.

Dr. Chopra explains why he chose cardiopulmonary coupling as the comparator metric, using a PPG-based wearable ring worn for 7-10 nights. He clarifies why PAP devices may systematically underestimate residual disease through mask leak, unstable breathing, and periodic breathing patterns.

A particularly concerning finding involves residual hypoxia. Dr. Chopra discovered significant hypoxic burden in many patients considered "well-treated" by PAP standards—important since hypoxic burden, not just AHI, drives cardiovascular risk.

Dr. Chopra's conclusion isn't that PAP-derived AHI is "bad"—rather, that it shouldn't be the sole metric for assessing treatment efficacy. Even patients with good symptoms may have significant residual respiratory events and hypoxia that PAP downloads fail to detect.

Clinical applications are discussed, including when to pursue objective testing and what interventions to consider when objective testing reveals inadequate control despite acceptable AHI.

Whether you rely on PAP downloads to assess treatment efficacy, manage patients with residual symptoms, or seek emerging objective metrics, this episode provides essential perspectives on optimizing PAP therapy.

Join us for this important discussion that challenges current assumptions about measuring treatment success in sleep apnea.

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Andrea Matsumura, a sleep physician with specialized certification in menopause medicine and national advisor for Monarch MD, to discuss how sleep clinicians can better support patients struggling with perimenopausal sleep disturbances.

Since the FDA removed the black box warning on hormone replacement therapy, more patients are inquiring about medications to treat perimenopausal sleep symptoms. Dr. Matsumura, who left traditional practice to pursue menopause certification and now works at the intersection of sleep medicine, mental health, and women's midlife health, provides practical guidance on this increasingly important clinical area.

The conversation begins with Dr. Matsumura's career evolution. After training as an internist with a leadership role at Kaiser Permanente and practicing sleep medicine in a group setting, she pursued specialized menopause certification—a credentialing process explained in detail. Dr. Matsumura discusses what menopause certification encompasses, who can pursue it, and her own path into this specialty. She also discusses her work developing specialized supplements for perimenopausal sleep support.

The episode systematically addresses how perimenopause disrupts sleep. Rather than focusing solely on hot flashes, Dr. Matsumura explains the full spectrum of sleep-related changes. She clarifies the timeline of perimenopause—when it starts and ends—and discusses less commonly recognized phenomena like menstrual hypersomnia that clinicians may not immediately associate with menopause.

A critical discussion addresses patient expectations around hormone replacement therapy. Many patients expect sleep clinicians to prescribe HRT, which raises legitimate concerns for providers unfamiliar with menopause management. Dr. Matsumura provides practical guidance on these conversations and clarifies the role of hormone level testing—addressing the debate between treating symptoms versus checking levels before initiating therapy.

The conversation explores the complex relationship between sleep apnea and menopause. Dr. Matsumura explains why and how obstructive sleep apnea may worsen during perimenopause, how to have these conversations with patients, and when referral to OBGYN colleagues is appropriate for collaborative care.

Additional topics include the role of hypnotics in perimenopausal sleep disorders, absolute contraindications to hormone replacement therapy, how to initiate HRT when appropriate, and whether restless leg syndrome worsens with perimenopause.

Dr. Matsumura addresses common misconceptions about menopause and sleep, helping clinicians understand what practitioners and patients frequently get wrong about this life stage. The episode emphasizes that sleep medicine clinicians don't need to become menopause specialists, but understanding these connections enables better patient care and appropriate referrals.

Join us for this important conversation about supporting women's sleep health through midlife transitions.

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Laura Donahue, an assistant professor of sleep medicine at Vanderbilt University with a background in internal medicine and a researcher in sustainable healthcare, to discuss the environmental impact of sleep medicine practice and practical strategies for reducing carbon footprint and medical waste.

Recent environmental challenges—heat waves exacerbating insomnia, wildfires affecting respiratory and sleep health—highlight how climate directly impacts patient wellbeing. But do sleep medicine clinicians have an obligation to reduce their own environmental footprint? Dr. Donahue explores this question, examining the waste generated by sleep testing, PAP therapy, and ongoing supplies.

The conversation begins with foundational concepts: How does climate change impact sleep health? What exactly constitutes medical waste, and how does it differ from carbon footprint? Dr. Donahue explains methods for calculating carbon footprint and how the US healthcare system compares globally. She introduces life cycle analysis—a comprehensive tool for understanding environmental impact across product lifecycles.

Sleep lab waste assessments receive detailed attention. Dr. Donahue walks through how to conduct a waste audit of sleep facilities and why examining both carbon footprint and waste matters, acknowledging that these metrics don't always move directionally. Her research on PAP device waste, conducted with Dr. Morgenthaler, revealed substantial environmental costs associated with standard OSA therapy—findings that prompted examination of alternatives.

Telemedicine emerges as a potential sustainability strategy. Dr. Donahue compares carbon footprints of virtual versus in-person sleep consultations, exploring how practice model choices affect environmental impact. However, the analysis doesn't focus solely on PAP therapy—hypoglossal nerve stimulators and other non-PAP treatment options receive consideration as alternatives with potentially different environmental profiles.

SHAPE, an organization dedicated to helping healthcare providers examine their carbon footprint and waste generation, receives discussion. Dr. Donahue explains SHAPE's mission and practical resources available to sleep medicine programs. She provides concrete guidance on reducing environmental impact: waste audits, supply chain evaluation, and transitioning to circular economy models where possible.

A particularly relevant discussion addresses plastic waste from CPAP devices and consumable supplies. Dr. Donahue explains how waste audits serve as the first step toward identifying reduction opportunities and discusses strategies for minimizing single-use plastics in sleep medicine practice.

The episode acknowledges that sustainability requires institutional commitment and individual awareness. Dr. Donahue emphasizes that small changes—from supply selection to practice model design—accumulate to meaningful environmental impact.

Whether you're interested in sustainable healthcare, concerned about medical waste, seeking to reduce your sleep practice's carbon footprint, or wanting to better understand climate impacts on sleep health, this episode provides practical guidance and evidence-based approaches.

Join us for this important conversation about environmental responsibility in sleep medicine practice.

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Karin Johnson, Professor of Neurology at UMass Chan School of Medicine–Baystate and expert on circadian rhythm policy, to discuss two competing legislative bills addressing permanent time change in the United States.

Two bills currently before Congress present starkly different solutions: the Sunshine Protection Act for permanent daylight saving time and the Sunshine for Our Kids Act for permanent standard time. Both campaigns use compelling language that makes their position sound obvious, complicating decisions for policymakers and clinicians alike.

Dr. Johnson reviews the AASM's official position on daylight saving time and what research reveals about time change effects—both short-term consequences of bi-annual clock transitions and long-term health impacts of permanent DST, particularly on adolescent mental health and circadian rhythm disruption. She explains what happened during the 1974 experiment with year-round daylight saving time and why that experience remains relevant today.

The conversation details both the Sunshine Protection Act and the Sunshine for Our Kids Act, including their legislative progress and specific provisions. Dr. Johnson clarifies which approach sleep medicine clinicians support and provides practical guidance on advocacy.

An intriguing discussion explores a proposed compromise to move clocks by 30 minutes and leave them there—why didn't this gain traction? Dr. Johnson also reveals how industry influence shapes policy, discussing candy companies' historical support for daylight saving time and other commercial interests that complicate what should be a health-based decision.

Dr. Johnson emphasizes that permanent standard time better aligns with human circadian biology, particularly for adolescents whose naturally delayed circadian rhythms suffer under permanent DST.

Whether you're seeking to understand these competing bills, advocate for science-based policy, or interested in how medical evidence influences legislation, this episode provides clarity on a complex issue with direct health implications.

Join us for this important conversation about how sleep medicine can influence public health policy.

In this special live episode recorded from the SLEEP 2026 annual meeting in Baltimore, host Dr. Seema Khosla welcomes Dr. Sanjay Patel, director of the clinical sleep program at University of Pittsburgh Medical Center, to discuss groundbreaking medications for sleep disorders poised for FDA approval in 2026 and 2027.

The pharmaceutical landscape for sleep medicine is undergoing unprecedented transformation. Dr. Patel surveys the emerging drug pipeline that will fundamentally change how clinicians treat obstructive sleep apnea, narcolepsy, and idiopathic hypersomnia.

For obstructive sleep apnea, Dr. Patel discusses AD-109 (atomoxetine and R-oxybutynin), explaining the mechanistic rationale and practical considerations including use with tirzepatide. The Incannex drug combining dronabinol and acetazolamide receives analysis for different patient populations, and sultiame is discussed as a carbonic anhydrase inhibitor option. A critical framework emerges: Should treatment be symptom-based or airway-focused when PAP-intolerant patients present?

Tirzepatide, the GLP-1 agonist FDA-approved for moderate-to-severe OSA, receives comprehensive coverage including muscle loss concerns, long-term use, and emerging oral GLP-1 options. Retatrutide, the triple-hormone agent combining GLP-1, GIP, and glucagon, is also discussed.

The episode's most exciting segment focuses on orexin agonists for narcolepsy. Three pharmaceutical companies—Alkemeres, Centessa (purchased by Lilly), and Takeda—are developing these mechanistically novel agents. Dr. Patel clarifies how these medications differ, discusses why one medication disrupted nocturnal sleep (suggesting continued roles for oxybates), and addresses how clinicians will choose between similar medications.

Dr. Patel emphasizes a fundamental question: Should the field prioritize symptom management versus airway patency for OSA, and mechanistic approaches versus symptom management for narcolepsy?

Whether you're interested in emerging OSA treatments, narcolepsy innovations, or the future of pharmacological sleep medicine, this live episode provides essential updates on medications that will soon reshape clinical practice.

Join us for this exciting conversation about how sleep medicine will transform in the coming years.

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Abhishek Goyal, Professor and Head of Respiratory Medicine in Dehradoon, India, and Dr. Prakhar Agarwal, a pulmonologist in private practice in Bhopal, India, to discuss their research comparing fixed CPAP versus auto-titrating CPAP (APAP) on blood pressure control and autonomic nervous system response.

For years, difficult-to-treat hypertension has been recognized as an indication for sleep studies, reflecting the assumption that treating sleep apnea improves blood pressure. But does the method of PAP therapy matter? Beyond achieving a residual AHI under 5, are there treatment nuances that could optimize cardiovascular outcomes? Dr. Goyal and Dr. Agarwal's research addresses these questions, building on landmark work by Dr. Pepin examining fixed versus auto-titrating PAP therapy.

The motivation includes both clinical and economic considerations. A 2021 Portuguese study examined cost implications, and similar economic pressures exist in India where APAP is significantly more expensive than fixed CPAP. The study used a crossover design comparing fixed CPAP to APAP, measuring blood pressure dipping patterns and autonomic response to assess cardiovascular effects.

The results have prompted Dr. Goyal to reconsider his clinical practice regarding pressure selection, raising important questions: If fixed CPAP offers superior blood pressure outcomes, should the standard practice of prescribing APAP devices be reconsidered? This challenges assumptions about adaptive algorithms and raises questions about prioritizing cardiovascular outcomes beyond AHI reduction.

The episode contextualizes these findings within India's unique healthcare landscape, exploring surprising OSA incidence data and examining whether craniofacial anatomy or arousal patterns differ from Western populations. Dr. Agarwal discusses how pressures are typically determined and the practical differences between APAP 4-20 versus narrow-range settings.

Whether you're prescribing PAP therapy for hypertension, optimizing cardiovascular outcomes, or seeking evidence-based approaches to pressure selection, this episode provides important international perspectives.

Join us for this discussion that may prompt reconsideration of how we set PAP pressures and what outcomes we should prioritize.

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Daniel Buysse and Dr. Todd Arnedt, both members of the AASM clinical practice guideline committee, to discuss the newly released guidelines on combination treatment for chronic insomnia disorder in adults.

Unlike previous guidelines, this new guidance specifically addresses what happens in real-world clinical practice: patients often request both cognitive behavioral therapy for insomnia (CBT-I) and pharmacotherapy, or arrive seeking medications while clinicians advocate for behavioral interventions. The guidelines provide evidence-based recommendations for navigating these combination treatment scenarios, incorporating patient preferences in ways previous guidelines did not.

The conversation explores the guideline development process, including how committee members were selected and how diverse professional backgrounds enriched the discussion. Dr. Buysse and Dr. Arnedt explain why patient preference wasn't adequately reflected in original practice guidelines and how this updated version addresses that gap.

The first recommendation receives detailed examination: In adults with chronic insomnia, the AASM suggests combination treatment with CBT-I plus medication over medication alone (conditional recommendation, low certainty of evidence). The experts clarify which medications were examined, including whether dual orexin receptor antagonists (DORAs) were included, and explain why evidence certainty is low despite numerous studies. Pharmaceutical sponsorship creates methodological differences—PSG outcomes, fixed time in bed requirements—that complicate interpretation. The high placebo response in insomnia trials adds another layer of complexity.

Critical implementation questions arise: What does "combination therapy" actually mean? Should both treatments start simultaneously, or should one precede the other? Can patients start medications while awaiting CBT-I appointments given typical access delays?

The second recommendation appears paradoxical: The AASM suggests against combination treatment over CBT-I alone, yet recommends combination over medication alone. Dr. Buysse and Dr. Arnedt explain this nuanced position—CBT-I alone remains superior, but for patients who prioritize rapid total sleep time improvement over daytime symptom reduction, combination therapy may be reasonable.

The conversation addresses whether treatment order matters and whether clinical (not just insurance-driven) logic suggests a medication hierarchy—zolpidem before eszopiclone, the role of trazodone, when to consider ramelteon. A crucial question emerges: What about patients who refuse or cannot access CBT-I? How do these guidelines apply when the preferred behavioral treatment is unavailable or unwanted?

Throughout, the experts emphasize that guidelines inform but don't dictate clinical decisions. Patient preferences, values, and individual circumstances must shape treatment plans. The guidelines provide evidence-based frameworks while acknowledging the complexity of real-world insomnia management.

Whether you're treating chronic insomnia, navigating patient requests for medications, addressing CBT-I access barriers, or seeking evidence-based approaches to combination therapy, this episode provides essential guidance.

Join us for this important conversation about balancing behavioral and pharmacological approaches to chronic insomnia in clinical practice.

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes Dr. Lee Neilson, Assistant Professor of Neurology at the University of Iowa and staff neurologist at the Iowa City VA specializing in movement disorders, to discuss his groundbreaking research examining whether obstructive sleep apnea represents a modifiable risk factor for Parkinson's disease.

Dr. Neilson's ambitious study analyzed records from 13 million patients within the VA system to investigate whether OSA is associated with higher risk of neurodegenerative disorders and whether treating sleep apnea might help delay the onset of dementia. The conversation traces the research design from initial hypothesis through methodology, explaining how he narrowed this massive dataset and defined both OSA diagnosis and Parkinson's disease progression.

Critical methodological details emerge: How was OSA diagnosed—through sleep testing, and using 4% or 3% hypopnea criteria? How did the study differentiate between mild and severe sleep apnea? How was Parkinson's disease identified—through clinical notes, medication records, or longitudinal follow-up? Dr. Neilson clarifies whether the analysis included only PD or extended to other neurodegenerative disorders like Alzheimer's disease.

The core findings receive extensive examination: Did CPAP therapy have a modifying effect on PD risk? After adjusting for confounding factors including BMI, diabetes, depression, and hypersomnia, which variables mattered most? What was the number needed to treat to prevent one case of Parkinson's disease? Could hypoxic burden be examined as a potential mechanism?

Intriguing tangential discussions explore whether idiopathic RBD can be distinguished from trauma-related RBD and whether these represent separate pathological processes. The conversation takes an unexpected turn into the neuroprotective effects of smoking in Parkinson's disease, with Dr. Neilson explaining proposed mechanisms and drawing parallels to ischemic preconditioning that might occur with OSA.

The episode addresses severity gradients—did OSA severity correlate with PD risk? It also tackles a fundamental question: Does treating sleep apnea delay dementia onset or actually prevent it? Dr. Neilson discusses whether non-PAP therapies were examined and addresses a critical ethical concern in sleep apnea research: Is it irresponsible to withhold treatment from symptomatic patients, and did this study focus on non-sleepy individuals or include all OSA patients regardless of symptoms?

This research has profound implications for how sleep medicine practitioners frame the importance of OSA treatment with patients and families. Beyond addressing immediate symptoms like sleepiness, treating sleep apnea may reduce long-term neurodegenerative risk—a compelling motivation for adherence that extends beyond quality of life to disease prevention.

Whether you're counseling patients about the importance of OSA treatment, interested in the sleep-neurodegeneration connection, or seeking evidence-based approaches to discussing long-term benefits of therapy, this episode provides essential insights.

Join us for this important conversation about how the work sleep medicine practitioners do every day may profoundly impact patients' neurological futures.

In this episode of Talking Sleep, host Dr. Seema Khosla welcomes David Messerschmitt, a retired computer and signal processing engineer, and Stuart Crisp, a retired process control engineer and educator, to discuss patient-facing open-source PAP platforms and how informed users leverage detailed data to optimize their sleep apnea treatment.

This episode represents a departure from the typical clinical expert format. After eight seasons focusing on sleep medicine professionals, these engineer-patients reached out to share how platforms like Sleep HQ and OSCAR have transformed their understanding and management of sleep-disordered breathing. Both are power users who have helped thousands of fellow patients navigate complex PAP data, representing a patient empowerment movement that many clinicians may not fully appreciate.

David and Stuart explain what Sleep HQ and OSCAR are, how these platforms differ from standard clinical downloads, and what data visualization capabilities they offer. The platforms integrate multiple data streams—high-resolution flow rate data from PAP device SD cards, pulse oximetry from wearable rings, and sleep architecture from devices like Apple Watch—creating a comprehensive picture that goes far beyond what's typically reviewed in clinic appointments.

The conversation explores sophisticated analysis techniques these informed patients employ: identifying upper airway resistance syndrome through inspiratory flow limitation and heart rate spikes, distinguishing sleep onset versus wake onset events, detecting REM-related apneas, and recognizing positional apnea patterns. Stuart and David discuss "Somnopose," chin tuck events, and what they call "high-level waveform forensics"—detailed signal analysis that reveals subtle breathing pattern abnormalities.

A crucial discussion addresses whether these patient communities represent antagonism toward the medical establishment or an unmet need that sleep medicine should embrace. The guests emphasize their desire for collaboration, not confrontation, and offer insights into how clinicians can better partner with informed, data-driven patients who arrive with detailed self-analysis.

Whether you're encountering patients who bring detailed PAP data to appointments, curious about what these platforms reveal that standard reports don't, or seeking to better collaborate with informed patient communities, this episode provides essential perspectives from the patient side of sleep medicine.

Join us for this unique conversation that bridges the gap between clinical expertise and patient empowerment in sleep apnea management.