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Testosterone Replacement, Low T, HCG, & Beyond
Testosterone Side Effect Management
Obstructive Sleep Apnea and TRT
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<blockquote data-quote="Nelson Vergel" data-source="post: 226065" data-attributes="member: 3"><p>The sleep apnea episode that won’t put you to sleep. Become a sleep apnea guru with incredible insights from Barbara Phillips MD, MSPH, FCCP an expert in pulmonary medicine, critical care and sleep medicine who is also a past president of CHEST! We discuss high-yield topics in the world of obstructive sleep apnea including: home sleep studies vs in-lab polysomnography, the importance of oxygen saturation (the T90 and ODI) when interpreting sleep study results, tricks to improve CPAP adherence, and alternatives therapies for obstructive sleep apnea.</p><p></p><p></p><p></p><p>Time Stamps</p><p>00:00 Disclaimer, intro, guest bio</p><p>03:00 Guest one liner, book recommendation, advice for trainees</p><p>08:10 Clinical case of sleep apnea, some basic stats, and key predictors of sleep apnea</p><p>12:38 Barriers to diagnosis and treatment of OSA</p><p>15:23 Discussion of T90, hypoxemia and sleep fragmentation</p><p>17:05 How to read a sleep study report</p><p>21:55 Home sleep apnea testing</p><p>24:15 What are the consequences of sleep apnea</p><p>28:30 What is the efficacy of cpap for lowering blood pressure and mortality</p><p>31:45 Counseling a patient who is new to cpap</p><p>33:45 Choice of mask</p><p>40:10 Do alternatives to cpap work? e.g. surgery, mandibular advancement devices</p><p>44:17 Modafinil and z-drugs</p><p>47:15 Driver’s license issues in sleep apnea</p><p>48:35 Future of sleep medicine and take home points</p><p>51:15 Outro</p><p></p><p>[URL unfurl="true"]https://thecurbsiders.com/podcast/123-sleep-apnea-pearls-and-pitfalls[/URL]</p><p></p><p></p><p></p><p>Clinical Pearls</p><p></p><p>Metabolic syndrome and obstructive sleep apnea (OSA) are dangerous bedfellows: Estimates suggest at least 60% of folks with the metabolic syndrome have OSA, although, Dr. Phillips suggests the association could be as high as 80+%! (Parish et al. Journal of Clinical Sleep Medicine, 2007 & Drager et al. PLoS One, 2010)</p><p></p><p>STOP ordering sleep studies on patients who CLEARLY have sleep apnea, if there is anyway to avoid it! In patients with metabolic syndrome who have other signs or symptoms consistent with obstructive sleep apnea (excessive daytime sleepiness, morning headaches, resistant hypertension, large neck diameter) with or without high scores on the STOP-BANG questionnaire or Epworth Sleepiness Scale, the pre-test probability that they have sleep apnea and would benefit from therapy is high enough to obviate the need for time consuming, expensive testing when we have autotitrating CPAP (continuous positive airway pressure). – Dr Phillips</p><p></p><p>The apnea-hypopnea index (AHI) is not the be-all-and-end-all: The ODI (oxygen desaturation index) and the T90 (time spent, during a sleep study, with an oxygen saturation at-or-lower than 90%) have been shown to be very useful adjuncts to the AHI when evaluating a patient for OSA. Data suggests that it is not the number of hypopneas/apneas but rather the time spent hypoxemic that is most strongly related to the sequelae of sleep apnea. (Chung et al. Anesthesia and Analgesia 2012 & Dr. Phillips)</p><p></p><p>The data for Home Sleep Testing (HST) is growing: Dr. Phillips cited studies to suggest the data from HSTs is non-inferior to traditional lab-run polysomnography. There is also data that suggests adherence to therapy and improvement in sleepiness is equivalent (if not superior) for patients diagnosed and treated with HSTs and auto-titrating CPAP. (Chai-Coetzer et al. Annals of Internal Medicine 2017, Chai-Coetzer at al. American Journal of Respiratory & Critical Care Medicine & Berry et al. Journal of Clinical Sleep Medicine 2014)</p><p></p><p>While HST is great, it’s not for everyone: Per the AASM, in lab polysomnography rather than home sleep testing is recommended for patients with “significant cardiorespiratory disease, potential respiratory muscle weakness due to neuromuscular condition, awake hypoventilation or suspicion of sleep related hypoventilation, chronic opioid medication use, history of stroke or severe insomnia.” (Kapur et al. Journal of Clinical Sleep Medicine 2017)</p><p></p><p>Mild OSA may NOT require treatment: Careful reading of the AASM and ATS guidelines on OSA treatment suggests it is reasonable to defer CPAP therapy for patients with mild OSA who DO NOT endorse excessive daytime sleepiness. Asymptomatic patients with mild OSA who are started on CPAP and have bad experiences may be much more difficult to reach in the future should their disease worsen. (Kushida et al. AASM 2006 & Chowdhuri et al. ATS 2016)</p><p></p><p>The cost of OSA on society is tremendous: According to the AASM, undiagnosed (and untreated OSA) cost the United States nearly 150 billion dollars in 2015. Of this, 26.2 billion dollars were spent due to car accidents related to sleepiness in the setting of undiagnosed OSA. Nearly 30% of car accidents in the US are associated with drowsy driving which is well-known to be seen in those with sleep apnea. Fortunately, according to the AASM, there is data to suggest that those treated for their OSA are at lower risk. (Hidden Health Crisis Costing America Billions – AASM & AASM Infographic)</p><p></p><p>OSA is a primary care problem: There are not enough sleep medicine doctors to diagnose, treat and manage all the OSA that is out there. Thus, it is a problem that all primary care doctors need to be comfortable with. After all, OSA is not only a potential cause of morbidity and mortality for the patient, but for those the share highways and roadways with them – especially if they go untreated. – Dr. Phillips</p></blockquote><p></p>
[QUOTE="Nelson Vergel, post: 226065, member: 3"] The sleep apnea episode that won’t put you to sleep. Become a sleep apnea guru with incredible insights from Barbara Phillips MD, MSPH, FCCP an expert in pulmonary medicine, critical care and sleep medicine who is also a past president of CHEST! We discuss high-yield topics in the world of obstructive sleep apnea including: home sleep studies vs in-lab polysomnography, the importance of oxygen saturation (the T90 and ODI) when interpreting sleep study results, tricks to improve CPAP adherence, and alternatives therapies for obstructive sleep apnea. Time Stamps 00:00 Disclaimer, intro, guest bio 03:00 Guest one liner, book recommendation, advice for trainees 08:10 Clinical case of sleep apnea, some basic stats, and key predictors of sleep apnea 12:38 Barriers to diagnosis and treatment of OSA 15:23 Discussion of T90, hypoxemia and sleep fragmentation 17:05 How to read a sleep study report 21:55 Home sleep apnea testing 24:15 What are the consequences of sleep apnea 28:30 What is the efficacy of cpap for lowering blood pressure and mortality 31:45 Counseling a patient who is new to cpap 33:45 Choice of mask 40:10 Do alternatives to cpap work? e.g. surgery, mandibular advancement devices 44:17 Modafinil and z-drugs 47:15 Driver’s license issues in sleep apnea 48:35 Future of sleep medicine and take home points 51:15 Outro [URL unfurl="true"]https://thecurbsiders.com/podcast/123-sleep-apnea-pearls-and-pitfalls[/URL] Clinical Pearls Metabolic syndrome and obstructive sleep apnea (OSA) are dangerous bedfellows: Estimates suggest at least 60% of folks with the metabolic syndrome have OSA, although, Dr. Phillips suggests the association could be as high as 80+%! (Parish et al. Journal of Clinical Sleep Medicine, 2007 & Drager et al. PLoS One, 2010) STOP ordering sleep studies on patients who CLEARLY have sleep apnea, if there is anyway to avoid it! In patients with metabolic syndrome who have other signs or symptoms consistent with obstructive sleep apnea (excessive daytime sleepiness, morning headaches, resistant hypertension, large neck diameter) with or without high scores on the STOP-BANG questionnaire or Epworth Sleepiness Scale, the pre-test probability that they have sleep apnea and would benefit from therapy is high enough to obviate the need for time consuming, expensive testing when we have autotitrating CPAP (continuous positive airway pressure). – Dr Phillips The apnea-hypopnea index (AHI) is not the be-all-and-end-all: The ODI (oxygen desaturation index) and the T90 (time spent, during a sleep study, with an oxygen saturation at-or-lower than 90%) have been shown to be very useful adjuncts to the AHI when evaluating a patient for OSA. Data suggests that it is not the number of hypopneas/apneas but rather the time spent hypoxemic that is most strongly related to the sequelae of sleep apnea. (Chung et al. Anesthesia and Analgesia 2012 & Dr. Phillips) The data for Home Sleep Testing (HST) is growing: Dr. Phillips cited studies to suggest the data from HSTs is non-inferior to traditional lab-run polysomnography. There is also data that suggests adherence to therapy and improvement in sleepiness is equivalent (if not superior) for patients diagnosed and treated with HSTs and auto-titrating CPAP. (Chai-Coetzer et al. Annals of Internal Medicine 2017, Chai-Coetzer at al. American Journal of Respiratory & Critical Care Medicine & Berry et al. Journal of Clinical Sleep Medicine 2014) While HST is great, it’s not for everyone: Per the AASM, in lab polysomnography rather than home sleep testing is recommended for patients with “significant cardiorespiratory disease, potential respiratory muscle weakness due to neuromuscular condition, awake hypoventilation or suspicion of sleep related hypoventilation, chronic opioid medication use, history of stroke or severe insomnia.” (Kapur et al. Journal of Clinical Sleep Medicine 2017) Mild OSA may NOT require treatment: Careful reading of the AASM and ATS guidelines on OSA treatment suggests it is reasonable to defer CPAP therapy for patients with mild OSA who DO NOT endorse excessive daytime sleepiness. Asymptomatic patients with mild OSA who are started on CPAP and have bad experiences may be much more difficult to reach in the future should their disease worsen. (Kushida et al. AASM 2006 & Chowdhuri et al. ATS 2016) The cost of OSA on society is tremendous: According to the AASM, undiagnosed (and untreated OSA) cost the United States nearly 150 billion dollars in 2015. Of this, 26.2 billion dollars were spent due to car accidents related to sleepiness in the setting of undiagnosed OSA. Nearly 30% of car accidents in the US are associated with drowsy driving which is well-known to be seen in those with sleep apnea. Fortunately, according to the AASM, there is data to suggest that those treated for their OSA are at lower risk. (Hidden Health Crisis Costing America Billions – AASM & AASM Infographic) OSA is a primary care problem: There are not enough sleep medicine doctors to diagnose, treat and manage all the OSA that is out there. Thus, it is a problem that all primary care doctors need to be comfortable with. After all, OSA is not only a potential cause of morbidity and mortality for the patient, but for those the share highways and roadways with them – especially if they go untreated. – Dr. Phillips [/QUOTE]
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Testosterone Replacement, Low T, HCG, & Beyond
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Obstructive Sleep Apnea and TRT
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