Sleep Apnea Is Changing: What Patients Need to Know

Introduction and Guest Preview 0:00

All right. It's time for another podcast, and that means it's Time for Precals. All Right. Emerson, what's going on today? Well, hey, Jerry. First of all, I am really sad to report to our listeners that our partner in crime, Robert Miller, is not with us today. So we will try to figure this out without him. We don't sound as good, but we look great. That's all that matters. So for us today, we have Dr. Chris Govea. He is a board certified otolaryngologist, ear, nose and throat surgeon who specializes in obstructive sleep apnea care.

After completing his ENT residency, he did a year of sleep surgery fellowship at Stanford University and since then has practiced at Kaiser Permanente in Santa Clara, California. He believes strongly in holistic discussions with patients about OSA, reviewing diagnostic metrics, patient goals, and multidisciplinary treatment options. He is very excited about the future of sleep apnea care. He posts about business tech and practice of Sleep Health at sleepdocs.substack.com. So I'm excited to hear what Dr.

Grivea has to say. You know, when you think of his background, I did a little reading on him. he's had a bit of work at Northwestern. There's some NIH in there. So we've got a guy coming on board today with a nice history in sleep medicines and surgical medicine training. It'll be exciting to see what he thinks of where we're going in Sleep Medicine and what has to say about just the treatment options for patients. Because when you and I started doing this, and literally a year ago, it was a handful of options It's going to be fascinating to hear what he thinks of, you know, what are just the surgery options, not to mention other things that patients can look forward to.

I agree. First off, it's, this is going be exciting with talking to somebody with his pedigree. So that's gonna be fun. But on top of that, that patient centric approach where he involves the patient in discussing treatment options. This is definitely going gonna to fun to here what has to say about it. Um, uh, I think, yeah, We have physicians all over in this industry that do the same thing, but to have the opportunity to talk to one like this, one-on-one, I think it's going to be fun. Absolutely.

Well, look forward to seeing where this takes us today. All right. You ready to go? Let's do it. Sleep Tech Talk is brought to you by Fisher & Paykel. Fisher and Paykle Healthcare is a leader in CPAP mass design and innovation for over 20 years. Their unique technologies have benefited millions of OSA patients through their top CPAP masks.

Sleep Apnea Surgery Background 2:51

These advancements continue to further enhance patient experience and outcomes. Now a word from our sponsor, MedBridge Healthcare. Medbridge Healthcare is a leading provider of sleep lab management services and home sleep apnea testing. MedBridge partners with hospitals, healthcare systems, and medical academic institutions to offer comprehensive, fully integrated services for sleep disorders. Lights out. Welcome everyone once again to another episode of Sleep Tech Talk, the sleep podcast with your hosts and friends, Emerson Kerr, Robert Miller, and me, Dr.

Gerald George Monaco. Folks, thank you all so much for joining us. Yeah, as we say each and every episode, we can't do this without you and we do for you. So thank the love and especially the shares. We can't thank you enough for that. And please keep hitting the subscribe button. Please keep sharing. A huge shout out to our sponsors, without whom we can continue doing this. Folks out there, please be sure to check them out. Once again, shout-out to them. With that, let's get started with an amazing guest.

Emerson, who's going on today? Well, Jerry, we are really lucky to have Dr. Govea. Dr GoVEA is an otolaryngologist with Kaiser Permanente and the author behind Night Shift, a subtract read that I think all of our listeners will certainly enjoy. So we've got a great guest with us today and we're looking forward to some great conversation. All right. Fantastic. Well Doc, welcome to the show. Thanks for having me. I really appreciate it. Look forward Yeah, this is going to be exciting. And so as an ear, nose and throat physician, I'm sure you come across a huge share of patients with sleep disorders.

Can you talk to us a little bit about how you got into this space and how did you get into sleep? Yeah, sure. So I think, you know, sleep apnea has been an essential part of otolaryngology or ear, nose, throat training for a long time. But I just think it was not very exciting until 10 plus years ago. Historically, we were doing UPPPs. We were seeing people with nasal obstruction. And we saw people sleep Apnea, but there weren't a lot of options. When I was going through training, it kind of the beginning of inspires getting FDA approved and kind sleep apnea management starting.

So I was excited about that possibility, pursued fellowship training to learn, inspire, learn jaw surgery, and learn how to take care of sleep-apnea patients in what I feel like is a more holistic way. And since then, I've been in practice since 2018 at Kaiser Permanente, like Emerson had mentioned, taking care kind of the full gamut of Sleep Apnea Patients. It's been great, very rewarding, Um, it's an exciting time as a physician and treater of sleep apnea, cause there's things coming, but there was also kind of a new wave of just thinking about these patients and kind where their sleep Apnea score fits with their quality of life symptoms and kinda fitting it to the various treatment options that we have.

And that number of treatment option is growing. So yeah, no, I, It's been a really fulfilling career and I look forward to where we're going and sleep out day management. Dr. Gervais, you know, when we think about surgery, That's really evolved a lot over the last several years. I know when Jerry and I started an eon ago, the UPP, that's hard to say sometimes even if you abbreviate it, was sort of a standard and then we saw it kind of change. How has just traditional surgery like that on the throat changed over last few years?

Yeah, I mean, one of the duties of ear, nose, throat doctors is communicating to patients and to sleep medicine folks where surgery, where UPPP fits in. I think in the past 20 plus years ago, the idea was that we were trying to cure sleep apnea with surgery and with Uppp. And that's why I, think for a long time, it was really a disservice to our patients, and We weren't quote unquote curing patients and we were kind of taking everyone and dogmatically taking them to UPPP if they failed CPAP and then when they weren t being cured and they were t having a huge improvement because we weren' t risk stratifying them and looking at their anatomic features.

And talking to them about these nuances, they weren't doing well. And as you've probably heard, it's not a fun surgery to go through. It's still not fun to surgery go though. But if you do it for the right selected patient and you really talk to about what you're going to help, that can be a really satisfying surgery, successful surgery for them.

Inspire and Patient Selection 7:54

So I think that's, you know, we're still recovering from that to some degree. We're kind of digging ourselves out of that hole that we built. Inspire has helped that because I think it has, helped a lot of people. It's kind of opened a new gate to be excited about sleep apnea surgery and brought these patients back to our offices to have that conversation. But no, it's still, a, lot, of my practice is talking to patients about where surgery fits in and where it doesn't fit in, quite frankly, and trying to think about, again, sleepapnea not as just an AHA number, but as, you know, combination of risk, health risk.

symptoms and quality of life. And when you put those things together, I think, again, we can have a very satisfying patient population and surgical practice, but it does depend on having those thing done. With that, we clearly have seen that evolution to Inspire. You mentioned that. I'd love for you to take a few minutes, because our listeners are quite diverse from people in the industry to patients. What is it about Inspir that is really useful for the sleep apnea patient? And what would maybe take you and your patient on a journey away from the UPPP to inspire?

What would that journey look like as we kind of understand your treatment pathway? Yeah, I mean, it's not a hyperbole to say that Inspire was truly a game changer operation when it came out and when FDA approved. Until then, our workflow, if you look at Riley and Powell's historical papers 30 years ago, Phase one, so septoplasty, turbinate reduction, UPPP, and then if they did not respond and had ongoing severe sleep apnea, they were getting jaw surgery. And that was essentially the workflow and the paradigm for 30 years.

We got some TORs for the tongue base, we got other hyoid suspension procedures, but those weren't really being done in large numbers. The minute that hypoglossal nerve stimulation and basically INSPIRE change that and came out with a star paper and began to, you know, market to patients and really spread their message to surgeons, it was a transformative time in sleep apnea management. And again, It's not perfect for every patient, but it is very, very good surgery for the right selected patient.

So again I can go through the workflow that I follow the starpaper criteria. But again. I don't want to I cant reemphasize that enough. I mean, when I came out of training in 2012, that was why I pursued sleep apnea surgery as a fellowship is because I knew a new wave of treatments was coming and we were gonna be able to do more for our patients. And that's kind of played itself out over the last 10 plus years. What has been your experience in regards to INSPIRE? I mean, you hear all sorts of things, like you said, for you were saying about the right people, but how does a patient get onto that in order to be a good candidate for it?

And what's your experienced like in getting patients qualified to that? Yeah, I mean, there's definitely a large number of patients that are hungry for an alternative to CPAP. Again, CPap is great for the right selected patient that can tolerate it and use it. I tell them it's the best treatment that we have. It's essentially curative for their sleep apnea, but tolerance and adherence is a difficulty for many patients. So there is definitely an appetite to talk about alternatives.I talk to them about all the non-surgical and the surgical alternatives, again, Inspire has done a lot of marketing and Beyond that, they've done over 100,000 cases of just word of mouth is beginning to spread the message for patients to come in and talk about sleep apnea surgeries with us.

So I tell patients, again, the start trial data, that kind of best selected patient is a non obese BMI less than 32. with moderate to severe sleep apnea that does not have complete concentric collapse on a drug-induced sleep endoscopy. So that's basically bought patients a workup. It's bought them an in-lab sleep study, it's brought them trials of non-surgical therapy with CPAP, maybe an oral appliance, may be even phase one surgeries with me. But if they still have ongoing moderate-to-severe sleep Apnea, they're a candidate.

And the question then becomes, are they the right candidate? How agreeable are they to an implantable procedure that stays in their body for the rest of their life, requires a couple incisions, and requires ongoing follow-up and care? That's really the conversation that I'm having with patients is to kind of break through the noise and say, you know, it's not the most invasive surgery, but it is a real surgery. It is real procedure. That stays with them for rest their lives. There is not a simple flick of the switch and they're done with their CPAP, it requires a little bit of ongoing work.

But again, for the right patient that gets this implant, again it can be very, very successful and can life changing for some people just like CPAT can. Where do you find opportunities to maybe have, you know, dual therapy, to treat someone, whether it's Inspire and something else, where do usually find those in your practice where you really have to combine two things to really treat the patient in the best possible way? Yeah, it's a great question. I mean, I think I get kind of worked up and excited because we've really made a transition in sleep medicine and sleep surgery from such dogmatic prescriptive one therapy to, hey, what can we do to lessen the burden of this chronic disease?

It's not a cancer that we're curing. It is a chronic that were managing and that means bringing those numbers down as low as possible, helping the patients symptoms as much as What is the right therapy for this patient to use long term?

Combination Therapy and GLP-1s 13:18

CPAP is amazing, but if a patient is not going to used it consistently, it's not working for them. So what can we do to get as close to CPAT numbers that the patient's actually going use that tonight? So yeah, I think it is every patient, if they're willing and wanting to, more than willing to do dual plus therapy. I tell every patient that I see, whether it's mild, moderate or severe sleep apnea, we have this full gamut of options. CPAP, non-surgical therapy. So that means weight loss, positional therapy, oral appliance, even nasal strips to help their nose.

Then we go into surgery, nasal surgery. UPPP tongue-based procedures that we want to do, possible INSPIRE slash hypoglossal nerve stimulation. So, no, I think, you know, and that's only increasing, we're getting GLPs now, apno meds around the corner. I this is going to continue to increase. It's a really, that what makes it such an exciting time as a physician, a treater of sleep apnea and someone that is excited about where our treatment options are going. And then when it comes to apnomed, there's lot left to learn.

When you do think about the GOP ones and of course the ones that are coming after the one's we know about now, how do you see that working with what you as an ENT surgeon? How does pharmaceutical marry surgery? Yeah. I mean, I think GLPs are probably the biggest, you know, as much as I said, Inspire was transformative for sleep apnea is niche. GLP is the big thing that's happened to collective medicine since I've been practicing. It's bringing patients from out of the woodwork to talk about a treatment that they're very, very excited about.

And a lot of these patients are overweight. and should be tested for sleep apnea and are gonna have sleep Apnea. So that's an exciting thing to have a conversation with them. The challenge with GLPs is, you know, almost the equity question. I mean, everybody that is overweight or obese would probably have some benefit weighing the pros and cons. the question is who is the right patient to be on it? And from a sleep APnea standpoint, again, it's usually more modest sleep, apne at the more, modest overweight levels, but a lot of patients are morbidly obese and they really did not have good treatment option for me in my surgical office.

When I discussed weight loss, it was kind of like that patient is never going to come back to see me. We're never gonna have a conversation again. Now it's like, hey, I've got really great data and a lot of anecdotal experience to tell you that you can have trajectory on the GLP. So yeah, I think these pharmaceuticals in GLPs and weight loss are continuing to get better. They're becoming less, even more safe. There are becoming oral therapies instead of shots. Cost is really the inequity or the biggest questions for them.

And then yes, after that, again, opens up an entire area that is still in its infancy. Pharmacotherapy for sleep apnea that I thing a lot of the collective us in sleep medicine and sleep surgery have questions about. But it speaks to the appetite that this is happening, that people are excited about the data and they want to hear more about it. So I'm really excited to see where it goes and to continue to here from these companies about where their next direction is. You can hear the passion in your voice about how much you enjoy this aspect of it.

And it's not just a question of papping some patient or, you know, Roto-Rooter kind of thing. You're going through the different steps and the whole thought process, hearing it come out from you, that's really interesting. including GLP ones, which you would think an ENT surgeon would not even go in that direction, but you're talking about that and what's coming in the future. So that begs the question, what do you see coming into the feature in terms of neuromodulation, pharmacotherapy, or anything else?

Yeah, and I'm passionate about it. My patients are passionate. I mean, when I talk about this, When I post about on a Facebook group about my newsletter for a GLP or for apno med, they get a ton of response as to the neuros, the neurostimulations that patients want to hear about the alternatives and they're excited. But there's a lot of strong passion on both sides. So no, I think that's only going to increase. And that is why I am so excited to talk to thought leaders like yourselves and these companies to here about what's coming.

I think, again, GLPs, they're here and they are going to continue to grow in terms of their use and patient's appetite for them is definitely not at the breaking point yet. We're only at beginning of that. And I would say, you know, I was at our I triple S and AAO, our academy meetings for sleep surgery. And there was a lot of excitement about GLP's because I think there's again a transition in sleep surgery from I want to cure this myself to I wanna help my patients in the greatest way and GLPs are incredibly powerful in that world.

And a lotta these patients are not surgical candidates. A BMI 40 plus patient is not a good surgical candidate. So yes, GLPS, Going to continue, and I think there's a lot of excitement about them. I mean, there is excitement, about pharmacotherapy as a whole. So after that, I, think we really want to see where their studies go. We want, to hear more about kind of what niches and what sub groupings do the best on them and that'll be very interesting. we want. To know what it does to sleep architecture and how these patients tolerate it long term.

That's kind, of, what I'm hearing from my sleep medicine colleagues. And then there's new pharmacotherapies coming kind of in the nasal spray and also like respiratory stabilization that I think we're all very interested in hearing more about because it fits a niche that we see in practice.

Future of Neuromodulation and Pharmacotherapy 18:30

The sleep apnea numbers aren't that bad, but these patients are sleepy and they're having disturbed sleep. So there is definitely something to it that want to see, we want get our hands on it. We want learn more these patient that are doing well on and who doesn't do well. Neurostimulation wise, I think we're at an exciting time. We're kind of at this inflection point. Inspire has had the market for 10 plus years, and now we have NXOA FDA approved and starting to do cases in the U.S., leaving over having good data and their study, a little bit different niche with allowing complete concentric collapse and pretty good as well.

And that's coming to the US probably the next calendar year. So that is a really exciting Yeah, there's the beginnings of a whole new wave of neuro simulation. I've kind of called it like the inspire 2.0 generation, less invasive, more targeted, other nerve sites, like, the answer is sort of the callus. So again, I think, and the other thing that I have been hearing from people is that The hypoglossal nerve stimulation technology is a little bit dated when you compare to kind of like vagal nerves and chronic pain stimulation therapy.

So I think there's going to be, again, an appetite from the market and these large companies to say, hey, can we invest in some R&D to bring that technology forward? How much better does that do for the patient experience, the surgeon experience? Yeah, we're at an early inflection point. But again, this is why my colleague and I wanted to start this newsletter six plus months ago, because we were having these conversations privately and with colleagues all the time. And we thought that there was an appetite for it.

Originally, I thought the appetite would be on the patient side. There is patients that are very interested in this world. It's more so people like you guys, people on inside that, are kind of having the same conversations. They want to hear from as many people as possible about what are these next wave? What do we think as clinicians that we are seeing these patients every day? So it's an exciting time, Fisherman Peggle Solo is the world's first autofit CPAP mask. It simplifies setup with its revolutionary auto-lock technology.

Simply stretch to fit, touch to adjust. Go to fphcare.com forward slash solo. Are you a sleep tech looking for new opportunities? Well, MedBridge Healthcare is one of the largest employers of sleep technologists and they are growing. If you are a Sleep Technologist interested in a new position, potential paid relocation, or looking for a career advancement, consider a carrier with MidBridge Healthcare. Now back to the show. You're spot on. I mean, all of those things are really what the future is and it's sort of a Moore's law thing.

You know, just as we get settled into one place, something new is coming that's going to surplant everything else. But to kind of take a little bit of step back for our listeners as come toward the end of our show, if someone is fortunate enough to come see Dr. Govea, Kaiser Permanente, What is it that, what journey will you take them on and what can they expect from having the opportunity to be in your care there at your facility? Yeah. I mean, I would say the thing that I pride myself on and my fellowship director, Robson Caposso at Stanford, prided himself on is really just taking a step back when these patients come in the office, hearing about their journey that got them to sleep steady.

What led them into the sleep study? Was it symptoms? Or was it that they have AFib? Wasn't that? They just are very proactive about our health and their Apple Watch was saying that their flagging for sleep apnea because it makes a difference. Then going through the sleep apnea data with them and talking about, you know, what are we treating? Are we treated just the number? are you treating your symptoms? Or are treating the snoring that's bothering your partner, keeping you out of the room? And then talking to them about really, again, the full breadth of options.

It's not a prescriptive CPAP. Like you said, CPAT has an amazing place in the treatment algorithm. And if they can tolerate it, wonderful. But I'm going to talk to you about all their options and the pros and cons, The level of invasiveness for all of them. I tell them that they're happy and satisfied. Their numbers are good. and their quality of life is happy. And I haven't done surgery, like I'm happy, I am good. But if they need a surgeon, happy to kind of take them through that journey and support them on the road.

So no, that's what's been instilled in me. I think that is where otolaryngologists kind fit in the sleep apnea treatment algorithm. Again, taking them though all the options. We have the best ability to give them the full lay of the landscape of pros and cons of everything. Really rely on multidisciplinary care with our sleep medicine providers. dentists. There's a lot of cooks in the kitchen in our world, but I think we have an opportunity to captain the ship in a really unique way. You were talking about this behind the scenes conversations and hence the development of the newsletter.

What message would you want to give out to other ENT surgeons that are out there curious about how do I approach these patients? Any thoughts on what you'd like to tell them? Yeah, I would say it's an incredibly exciting time. There's these new treatment options. there's a gigantic market and a lot of patients that want to see someone to talk about their sleep apnea as a whole, their Sleep Health as whole but also

Patient-Centered ENT Care 23:30

the surgical and the alternative treatment option. So I think that's exciting. But with that comes a responsibility to do right by the patient and not be so dogmatic to inspire to CPAP to any other surgery. It's to treat the patient in the best way possible. What is the treatment option for them, whether it's non-surgical to surgical? I've told patients, sorry, I told ENTs that my fellowship was much less about learning surgery and I learned jaw surgery that was very unique as an ENT. Inspire is a surgery I think any general otolaryngologist can do, It's the responsibility to understand what the sleep test is telling you how to talk to the patient about their treatment options to find who is the best candidate for these surgeries.

That really is, again, a responsibility, to anybody doing these cases and being a, quote unquote, sleep otolaryngologist. But with that come gigantic rewards, patient satisfaction, and a giant market that's going to knock down your door and want to see you to talking about your sleep apnea, along with their other ear, nose, or throat problems. So I think that that why there's been willingness from otolarngologists to grow Fantastic. Doc, thank you so much. That was phenomenal. But we are out of time.

If people want to get more information about you and your Substack, where can they find it? Yeah, I really appreciate it. I've really enjoyed the conversation. Thank you. And folks, we'll definitely have that information in our show notes. Doc, once again, thank you so much for joining us. We sincerely appreciate the time. Really appreciate it. It was a pleasure. And folks out there, thank you so much for joining us. Once again, we sincerely appreciate you being there with us, Thank you for all the views, all, the likes, All the shares and all of the subscriptions and a huge shout out once again to our sponsors for helping us make this happen.

Until next time we say lights on. Be sure to check out our clinical sponsor, Sleep Review Magazine. More details in show notes. All right. Another day, another show, and it's time for some post-calls. Wow, okay. We keep bringing in these underachievers on here. Right. They haven't done anything in life. I mean, wow, what a guy. And I love his passion. What did you think about the show? You know, I agree. Dr. Corbella is somebody who brings real passion to his craft. I mean, it's no surprise when you look at his pedigree and his history in sleep medicine, he can't help it.

But it was so refreshing to hear the process he takes patients through to find the right kind of therapy and not being really blinded. He's really kind embracing a multimodality approach even within his own practice. And that's refreshing because You know, as we look at what's happening in sleep apnea treatment, it's so easy to hear stories of doctors who stick with just sort of their simple, straightforward approach and to here how he's able to kind of move through the different stages and different opportunities for the patient.

I know there are a lot of physicians out there just like him, but it was great to have a guest like that to articulate how they do it in their practice. I agree. You're right. There are a lot of physicians out there and surgeons out that think like this. But to be able to hear him say that, I mean, he walked through all different modalities of treatment from, of course, the various surgeries, but also he talked about oral appliance, straight CPAP, and he talk about the future. It was exciting to here that from another physician that Hey that they are considering all these all the therapies and and what's excited about what happening

Closing Thoughts and Takeaways 27:30

in the future and to me that was probably the most fascinating thing to hear from him was how excited he was about where we are. In the field right now that there's so much change going on and it makes his job all the more exciting. And he talks about the passion, not just for him, but also from the patients as well, because now they also have a lot of options. Well, they do. When you think about when you and I started in this, the options, you could count them maybe on one hand. of what a patient had for sleep apnea.

Now it's pharmaceutical, that's neuromodulation, it still CPAP. It's so many different things for the patient and we've never been so fortunate as we are right now. As diagnostic capabilities become more granular, so do the therapy options. And it really puts us in a phenomenal position where maybe, just maybe we can really chip away at that 85% that are undiagnosed and untreated. and actually treat them with the right kind of therapy that'll work for them. I also love the fact that how he talked about involving the patient in the decision-making process, helping them better understand what options are out there and not just saying, hey, I think this is what you need to do.

It's involving them and igniting their passion as well to figure out how they can have a better life. To me, that was really wonderful, the old school approach of involving your patient with therapy. Well, there's so much data that shows that actually is going to produce better outcomes. So, no, I mean, huge shout out to Dr. Grivea for his practice, what he's doing there at Kaiser. And I look forward to reading more of Night Shift and getting educated myself with this sub stack read. I can't say anything today, but I'm looking forward learning more from him and I hope our listeners do too.

Same here. I think that's a good opportunity to close. And I wish Robert was here once again, but unfortunately he couldn't make it this time, we'll see him back on the show soon. Yeah. We don't sound quite as good without him, But we're grateful when he can be. Exactly. All right then until next time folks, everybody out there. Cheers.