Vcom: Easy Fix For Common CPAP Challenges

William Noah, MD

Thanks for having me, Audrey.

Audrey Wells, MD

I want to jump right into this device that you named the V-com. That’s V.C.O.M. and it’s causing a little bit of change in the way that sleep medicine doctors think about PAP pressure. That’s positive airway pressure. Can you give us some background on why you started questioning that dogma in our field and how you came to develop the V-com?

William Noah, MD

Well, thank you. Yes. CPAP came out in the eighties, and about 30% of patients who went on CPAP in surveys back then complained of difficulty breathing out and exhaling during expiration. Because of that, the bilevel PAP was used to CPAP continuous or constant pressure, and then bilevel PAP, where there are two levels and ends the degree of pressure and an extra degree of pressure. Since the early nineties, most machines have become where you have a higher inspiratory pressure and expiratory pressure. Now, in the nineties, you had to order what’s called a bilevel, but in the early 2000s, CPAP machines began to get higher inspiratory and lower expiratory. Now, what’s unique about all that is the literature in the 1990s clearly shows that it’s the expiratory pressure that’s therapy. When you drop expiratory pressure, you decrease therapy. We were giving higher inspiratory pressure to compensate, but inspiratory pressure can open the airway. It’s because so many lung specialists, like myself, came into the field when these machines did. We’re used to ventilating people in an ICU where you have to have a higher inspiratory capacity than expiratory. But when you’re trying to stabilize the airway from snoring or sleep apnea, you just need to stabilize it in the expiratory phase. What I found out is that it’s more comfortable to have lower inspiratory pressure. Yes, it’s hard to tell the field. It’s embarrassing for someone like me, a pulmonologist who’s been treating people for 30 years this way, that in some ways we had it backward.

Audrey Wells, MD

That makes so much sense to me. I don’t worry at all about the feeling of embarrassment, because it’s admirable that you went back and questioned the fundamentals, and only by doing that can we have growth. When a person is breathing during expiration, when you exhale your air passively, that is the period when the airway becomes vulnerable to collapse. That makes sense because what you’re saying is that the pressure from the PAP machine is supporting the airway at that point. Now, can you explain this device here? This is your product, the V-Com, and it’s meant to fit in between the mask and the tubing. It’s a little connector piece there. What’s it doing?

William Noah, MD

Well, before I say that, let me add to your excellent explanation that you have to stabilize the airway after you finish exhaling. You have to do it a little bit earlier than that. But you have to stabilize it during exhalation. If you’re on positive airway pressure, it’s different. If you’re breathing spontaneously on room air but on positive airway pressure, you have to stabilize it there. If you do, then you’re not going to have any problems when you breathe in. The problem with the last 30 years, in our understanding, is that we’re lowering expiratory pressure and destabilizing the airway, and then we’re giving all this positive pressure, trying to compensate. But we’re given higher pressure, and higher pressure is going to lead to a lot of problems. The theory behind the V-com was that I needed a way to lower inspiratory pressure. The machines on the market, none of them can lower the inspiratory pressure below expiratory, everything is above. So there was no way to test my theory. No one had ever tested it before. There’s nothing in the literature. No one had purposely ever dropped the inspiratory pressure. I had to create a way to do it. I took advantage of the technical nature of the parabolic nature of turbulence, but when you have a resistor or resistance in a system, the more flow over it, the more the pressure drops. 

When there’s no flow, there’s no pressure drop. breathing in a PAP circuit, in a positive airway circuit on CPAP, there’s all this flow going across the vehicle. There is the inspiratory flow, your breath coming into your lungs, and there’s exhaust flow coming out of the wall and holes in the mask. All that flow creates a pressure drop. Now, when you breathe out, there’s no flow going across. Well, very little flow is going across the V-com because you’re not breathing and the machine’s not giving you air. You’re exhaling. You’re providing flow in the other direction. Most of the flow coming out of the little hose is from your exhaust. Getting rid of your CO2, air, and water vapor. With low flow, there’s no pressure drop. I figured out a way to drop inspiratory pressure and maintain expiratory pressure without building a new type of machine. Yes. so the V-com is released. We weren’t aggressive with the pressure drop. It’s a couple of centimeters. Depending on the higher the pressure, the more you drop because there’s more flow across it. The bigger you are, the more air you’re going to breathe in and the faster you’re going to breathe it. I’m six feet four. My inspiratory flow rate is going to be higher than yours, so therefore I’ll have a higher pressure drop than you likely would. That’s how it works. 

We did it at a level where it didn’t interfere with the algorithms on the machine or the analysis of events. We were just focused on a way to introduce this whole concept into the whole field because it’s so forward. If I just released a machine first, there would be an attack on that machine. The V-com could work on any machine. We tested it on the current ones being sold here in the U.S., and it’s not affecting their algorithms. It was a way to do that. Now, what we found was that it’s more comfortable. That was the key behind it—that it’s more comfortable. People under high pressure can start with two V-coms back to back in there, or even three for a night or two, to help them get used and take one out, then take another out. When you put two or three in, you’re going to drop your expiratory pressure a little bit. You’ve got to get down to one. But we found comfort. Well, then we also found that it reduced leaks. In 88% of the patients, it reduced leakage, and it was statistically significant. 2.0001. Of course, we found that it reduced residual events. In other words, the respiratory events you’re having will go down according to the data we collected. We also found that I was surprised that people who are long-term users and doing well on it had increased usage time. That was surprising. These aren’t new patients. These are patients who’ve been on CPAP for a long time and are doing well. They had increased usage over time.

Audrey Wells, MD

Seasoned CPAP users.

William Noah, MD

Yes. Seasoned. Yes. It’s a great word. I wasn’t expecting that. The thing I wanted to find out was that some of your listeners may think, “Oh, I don’t want to hear about this,” but there is a problem we have in the field when you treat people for obstructive sleep apnea with CPAP, some of them can develop central sleep. I had a theory that that was caused by having a higher inspiratory pressure, and so I thought V-com would resolve that. Sure enough, in the trial, we’re getting ready to release the paper now, after 1700 consecutive lab studies, it resolved every one of them. We had eight occurrences of this central sleep apnea. It got rid of everyone. It made perfect sense. The other thing that my sleep techs figured out right away is that it prevents mouth opening. Now, not all. Not all, but it prevented about 70% of mouth openings. In other words, we’re able to use 70% less chinstrap and other other means, like some tape. There’s a new product on the market Somnosil that looks very promising. So decreased sleep, and decreased mouth opening. We’ve had numerous reports, although there is no data on decreased swallowing errors. We’ve also had a lot of reports of decreased noise, but we’ve done no testing. But across the board, 98% are experiencing increased comfort. A new patient started it. That’s the bottom line, and that’s incredible.

Audrey Wells, MD

When we’re talking about CPAP, I just want to say that, as you’ve probably experienced, I know you’ve experienced the resistance that people have to CPAP just internally starting something like this. That comfort is the number one obstacle, and it may be the mask or the pressure, but you’re talking about a 98% improvement in patient-reported comfort with the pressure when using a V-com device. Do I have that?

William Noah, MD

Well, what we found in our initials was that it was a DME up in that number was done in a large regional DME in the Midwest. They were saying that there were new patients, and 46 out of 47 of their initial data showed that they preferred having the V-com in there. That’s where that data is coming from. It’s certainly over 90% of new patients. To be honest, it would be higher. But sometimes people first go on CPAP; they take big breaths because they’re anxious, and then they can blow down and encounter the resistance of the V-com, where if you’re breathing easily like you’re trying to fall asleep, you wouldn’t do that. The experience is probably higher than that if you don’t coach patients on how to breathe with it initially. But yes, they perceive it now. Is it going to fix it here? No, it’s not going to; it’s going to improve it. We already have some evidence that the same DME had about a 12% increase in their adherence over three months; it’s going to increase. But there’s other stuff to hear. You still have to put the machine on. You still got it. I still have to add water to it. You have to carry it with you when you travel. There are other things that people don’t want to do with it. But if we can overcome this pressure tolerance and make it more accessible as far as the comfort part, that will help. It’s like when you give chemotherapy, most everyone gets acetaminophen and some anti-nausea medicine. Are they all going to have a fever or get nausea? No, but you give that just what? Why do you want them to have to suffer with a difficult therapy? Like, starting CPAP could be considered difficult. Is it not? Same. realm is what I just said, but is there anything we can do to make it a little more comfortable? Why not do it? As long as we’re not interfering with therapy and we’re also decreasing adverse effects, we have data.

Audrey Wells, MD

Yes. There are a lot of points that I want to review, but before we go forward, I want to just highlight the fact that you’ve determined that using the V-com in the PAP circuit is not impeding the therapy and that the patient is getting to correct their sleep apnea.

William Noah, MD

The only way it could impede therapy is if the patient wasn’t set correctly to begin with. In other words, if they gave you too low of E-PAP, you had to have that higher I-PAP to help increase the flow over the obstruction that they cause when they decrease yours. Oh, sorry, said E-PAP. expiratory pressure for your audience. But yes, if you’ve not been set adequately, then knocking the inspiratory pressure down a little bit could cause you to have some events if you’re on auto-pap. Okay, that is where it’s self-adjusting, which most everybody has today is an auto PAP. Yes, well, then it couldn’t hurt because, say, it did drop your expiratory pressure a half a centimeter. It would just correct it and go right up for that. If you’ve been set on the right CPAP without an expiratory pressure release like C-flex, then you’re not going to bother your therapy. But if you’re on BiPAP or you have your expiratory pressure release on three, well, then you have a higher I-PAP or lower E-PAP if you don’t have enough E-PAP. Dropping the IPAP could cause you a few events, but as long as you understand that, it’s fine. The way to fix that is to turn the expiratory pressure relief off because they should have never been added to machines anyway. It was our backward understanding that did that.

Audrey Wells, MD

You’re exactly right. This is something I’ve seen in practice. people who are part of the medical practice that I was practicing sleep medicine in when the C Flex and EPR were introduced, everybody was engaging that as a default with new patient setups for CPAP. The report that I was getting was that people had decreased adherence, and I’m sure there is a connection there. Furthermore, nowadays, the machines are programmed. The mask type is programmed into it. You’re supposed to match the mask that you’re wearing with what the machine is programmed to compensate for, but I found that moving all machines to a full-face mask setting, regardless of what your mask looks like, is helpful.

William Noah, MD

Well, you are the first to ever tell me that. That’s quite remarkable on your part that you figured it out clinically. You figure out that patients prefer that. I figured it out from the physics and then found out from the patients. In other words, for your listeners, there’s different resistance in all the different types of mass, but amazing pillow mass has these little cushions. Okay? Because that narrow little hole has high resistance. So what happens is that you’re going to feel the pressure drop across that when you breathe in, just like the pressure drop. Well, not quite as much as that, but the resistance in these cushions is pretty much the same anyway. You go to have a pressure drop. Well, the field engineers are all thinking, “Oh, oh, we have to maintain inspiratory pressure; that’s the therapy.” We can drop expiratory pressure for comfort, but inspiratory is the therapy. 

This is backward. Inspiratory is not the therapy, it’s expiratory. So dropping that inspiratory pressure was added comfort. But then an engineer was started, Phillips will say. then look, Phillips. Phillips introduces most of the stuff. Even if I disagree with it, the others all copy it. You can’t blame Phillips. They were the they were the innovator. I would laugh more at the copiers than at the foolishness, and it is foolishness. They said I recommend you maintain this great pressure. They put algorithms on the machine. When you put a nasal pill mask on to jack up the pressure even more on inspiration, what does it do? Well, these little nozzles make it like a nozzle on your hose and shoot the air against those a little more. But now, with these algorithms, they’ve made it a pressure washer, and so they made it where people couldn’t tolerate the mass. It has the highest adherence. They have hurt adherence and probably hurt therapy for the last 12 to 14 years because no one thought through it. Oh, it’s inspiratory pressure. 

Now, this will make you mad. But I’ve been an engineer, and I’ve interviewed both the engineers at Philips who are brilliant guys who did this. Of course, they did what they were told, and they never tested it on patients because, well, it was just engineering. I have to maintain inspiratory pressure; there’s a cushion dropping the pressure. I’ve got to jack it up because that’s the mission I’ve been given to do.  So yes, after I realized this, we did trials in our practice and we tested it on, I don’t know, 50 patients, and we found that 0% wanted the algorithm and wanted the compensation. In other words, everyone wanted a full-face mask setting where you don’t jack up the pressure for this cushion. Just like you figured it out clinically, which I applaud, I figured out the other way that it was backward, tested it, and found what you did. that’s interesting. Of all the people I’ve talked with, you’re the first to tell me that there was an article about that in the Sleep Review magazine in May this year, 23.

Audrey Wells, MD

I saw that.

William Noah, MD

Yes, well, you did okay. Yes. Well, I don’t want to come across as being so negative, but it’s just crazy. You would put stuff on and not even test patients. Yes, because of. What’s worse is me. I’m out here. Oh, well, they put this on the machine. I have to turn this on for all my patients, and we were just trusting them. That’s never going to happen again. the.

Audrey Wells, MD

Question everything.

William Noah, MD

Well, it’s like this in the ICU on a ventilator as a pulmonologist. This would never happen. We are all over everything. We were all trained that way. But with CPAP, it’s like, well, you got to give them CPAP and all the manufacturers know what they’re doing. and it’s that everyone had this wrong. I know I did.

Audrey Wells, MD

Yes, everybody did. But, fortunately, we’re pivoting now. I just want to recap these comfort improvements because just hearing them on a list would be compelling for anyone who’s either a seasoned user or a new user. The airflow feels more comfortable. There’s the potential for a reduced leak, particularly a mouth leak, eliminating the need for a chinstrap or mouth taping, and less likelihood of central apnea developing in response to pap treatment. Lower frequency of swallowing air and then having an embarrassing morning. That’s called aerophagia. Some people are reporting that the noise of the therapy machine is lower, which hasn’t been explored yet. But what I’m hearing from you is that you’re getting feedback actively from these patients who are using the V-com device. A question that comes up is: How does the pressure setting make a difference? In other words, it seems like higher pressures would yield more of an effect or a perception of comfort for the person using them. Where is that threshold now?

William Noah, MD

I’m not sure I quite understand. Audrey, ask me that again. 

Audrey Wells, MD

If a person is hanging out at therapeutic pressures on the low end, let’s say six to nine centimeters of water, would they feel that effect less or the same compared to someone who is over? Ten, 11, 12.

William Noah, MD

Excellent question. when it comes to expectations. A couple of the pioneers of our field have commented to me that part of the comfort that we get with V-com is because it’s normal to have lower inspiratory pressure when you breathe. You, I and the listeners are all probably having lower inspiratory pressure as we breathe right now. So the V-com lowers inspiratory pressure; it’s more natural, and it’s more humid with that. There’s also this expectation. I expect how it’s going to feel to breathe well; CPAP changes how it feels, and that’s part of the problem. If you’re just starting a CPAP and say you’re on a low pressure of six or five, well, the V-com, I’m still going to make that more comfortable because that expectation will be more normal. If you have the V-com. Now, if you start at 12 or 16, well, it probably makes even more difference there because it’s even more overwhelming. But still, it’s a new expectation. So,  I’m just telling you, in our studies, we don’t differentiate pressure when they enter their own five or 18 centimeters of water pressure; we get similar results.

Audrey Wells, MD

Yes. That’s worthwhile to know. I like the way that you put it. It’s human to expect a lower resistance because, just getting a little bit philosophical here, anybody who’s prescribed CPAP, which is a medical machine that you’re bringing home with you to live on your bedside table, and you’ve got this tubing and mask, feels,  rightly so, a little less human at first. This is making things more normal. I want to say that for anyone who wants to try this, it’s worthwhile to explore. At the end of our talk, I’ll be asking you how they can find one and purchase it. But you ran one of your experiments on people who struggled with CPAP in a lab setting. For those who were ready to walk out the door, an option was presented to them to put the V-com in the circuit as they were trying CPAP therapy for the first time. Can you talk to us about some of those results?

William Noah, MD

Well, again, that’s these wonderful sleep tests. I’ve had 25 years with people who are just great people, and I don’t think the sleep technologist gets enough credit for their role.

Audrey Wells, MD

Oh, my gosh. I could not agree with you more. Yes.

William Noah, MD

Yes. They’re the ones with the patient all night because, for years, I just said, Hey, whatever, they’re the experts; let them choose the mask. When I introduced this and we started getting safety data for our FDA, requirements, and stuff, they were doing all these studies, and they came up with the mouth link and the chinstrap thing. They figured that out. Well, when we started the trial that went on for nine months, looking at the central apnea and the chinstrap, they asked, Look, can you add a third situation here to where someone just can’t tolerate the CPAP? They’re going to pull the wires off during the sleep study. They’re going to leave. We called to abort the study, and can we bring the V-com in? I’m like, well, I guess they’re leaving anyway. Sure, it might help. Fine. whatever. Well, what we found is that we had 30—it was 43—who wanted to abort, and the V-com was brought in, and all 43 and 41 of the 43 continued their studies, of which I had no idea. I would never have thought of that. Yes, the sleep technologist in our practice figured that out. They figured out the mouth opening. They’ve added so much to all of this.

Audrey Wells, MD

Indeed, the sleep techs don’t get enough credit for that, and the field doesn’t acknowledge that these are shift workers staying up all night and dealing with the effects of that. Some are so dedicated and think about things on a deep level. I imagine them doing that as they’re actively watching a patient. It’s just remarkable that you were able to show that this device can salvage those treatment studies and help people acclimate better. Fantastic.

William Noah, MD

Yes. Again, I’ll give all the credit to where I was. I had my head over here thinking about these other issues, and that’s why it’s always great to have a good team.

Audrey Wells, MD

I agree with that. Now, I want to pivot a little bit here because on the minds of many people are weight loss drugs and the effect that obesity has on sleep apnea risk. I know that one of the things that you’ve come to realize is the effect of lung volume on acclimation or success with CPAP therapy. I’d like you to describe a little bit about how a person’s weight and where they carry their weight, whether it’s in the belly or the lower body, affect their success with CPAP or even if CPAP should be recommended.

William Noah, MD

Well, it’s an excellent question. This is something we want the CPAP community to know because it’s not well understood in the field and certainly in those who are aligned with the field. Other specialties that also do sleep, such as lung volume, are very important in the treatment of sleep apnea. When you gain weight, the belly fat pushes up on the diaphragm and makes the lung volume smaller. Now, as the lung volume is smaller, it moves up. Then it allows it to take tension off of the throat. The pharynx is like this tube here. If I push up, see, it’s floppy. But if I pull down, increased lung volume will move down and pull and stretch the various and make it stiffer. gaining weight increases sleep apnea, not just for weight, pushing it around the airway. It’s from lung volume, and it’s more the apple build than the pear build, which may be why men have more sleep apnea than women because men tend to have the apple build instead of the pear. With that, increasing lung volume with CPAP overcomes that problem. It makes the airway stiffer, separate from the air pressure pushing the throat open, and increasing lung volume stiffens the walls, just like I was showing you here. It also decreases the work of breathing. If you take all the air out of your lungs right now, I blow all the air out and then try to breathe down there near your residual volume, and you’ll find it’s hard to breathe. That’s how people breathe during the day, and it’s uncomfortable. What this has to do with is oral appliances, the nerve stimulators, the hyperglobule nerve stimulators you hear advertised all the time, upper airway surgery, where they include your uvula and stuff like that, and the sleep apnea pills that are coming out in the next couple of years.

Audrey Wells, MD

That’s right.

William Noah, MD

Under those increased lung falls, they don’t increase lung volume. If you’re obese, your lung volume starts to reduce even at a BMI of 25. If your BMI is over 30, certainly over 35, you’ve got reduced lung volume, or likely. The odds of one of those other therapies correcting you are very unlikely. I’m pushing that we start doing spirometry to measure at least your vital capacity and get a look at your lung volume before we consider other therapies and CPAP. Because if you’re overweight or if your lung volume is reduced, those patients need to be told, “Hey, we’ve got to figure out a way for you to wear CPAP because these other therapies are unlikely to fix you.” People don’t want to hear that either, but it’s just the truth.

Audrey Wells, MD

Yes, that’s putting the patient first and recommending the treatment that is most likely to benefit them. In the context of these injectable weight loss drugs that are coming out now, I fully expect to see obstructive sleep apnea as an indicator for weight loss medication in the future. There are certainly benefits to be had. Even if sleep apnea doesn’t fully resolve, bringing the weight back down to a healthier level can have an impact on treatment choice.

William Noah, MD

That’s true. That’s probably where the role of the pill will be. I’m pretty certain it’ll have significant side effects, and it may even increase fragmentation of the sleep. But we’ll have to wait and see what the trials show. They’re currently in phase three trials right now, and we should know by the end of next year where that’s going. But it may be, for instance, better to pill the mouthpiece together. People are thinking, well, the two of them together might work well. The problem is neither one increases lung volume nor the pill and nerve stimulator. Well, neither one increased lung volume, so I’m not so sure. My good friend David here at Vanderbilt has developed a new nerve stimulator in partnership with Nick, which stimulates the strap muscles of the neck and is trying to stimulate, or, simulate, pulling down and stiffening the pair. It’s trying to mimic what lung volume and CPAP do. The preliminary data is interesting, and it will be interesting to see how that comes out in the next couple of years as well. The field is getting more interesting. Of course, what I’m introducing to the field of following the V-com is, in my biased opinion, even more interesting, and that is changing the algorithms in the machine, whose preliminary results are just incredible. We’re dropping the inspiratory pressure by six centimeters.

Audrey Wells, MD

Is that right? Below the exhalation pressure?

William Noah, MD

Yes. Below. Yes. you, but then we also hide it. I’ll have to; I’ll have to talk about it more in the future, but it’s quite exciting. It’s the most exciting thing I’ve been involved with in my whole career, for sure, by a factor of many times.

Audrey Wells, MD

That’s fantastic news. I like that there’s a new look at CPAP machines and how they deliver. It’s certainly a disruption to our field but in a very positive way. Final question: I’m wondering, who is the V-com not for who should not buy this and try it out?

William Noah, MD

If you’re heavy and you’ve been on CPAP for a long time and you like that flow in there, you may be one of the ten, or 12%, of long-term users who don’t prefer it. If you wear it for a week, you may forget about it because you get used to what we did the last couple of nights. so that there are going to be even up to 15% of long-term users who don’t prefer it. Now that they wear it long enough, they might find they have a little less gas in the morning and things like that. But those are individuals as far as people on ventilators, and currently some work is being done using V-com ventilation, but we’re saying do not because it drops expiratory pressure, and yes, certain pulmonologists who understand all this are investigating some of this, but we’re telling people not to put it on a ventilator because it can decrease the amount of ventilation you’re getting. not in that room if you’re on my BiLevel; if you’re on BiPAP or BiLevel device, you would have to have your E-PAP set therapeutically for you. In other words, it can treat you alone because otherwise, if you need that positive, that higher inspiratory pressure because your expiratory pressure has been set lower, then knocking that down could cause you to have some events. If you’re not on auto-pap, the machine can adjust for you. I would talk to your sleep specialist about that on a BiLevel device. All this is going to just go away in the future. I can just tell you now that V-com was just my way to introduce the concept to the field in a non-threatening way and in a way that wasn’t going to hurt anything or change our mindsets, as it has yours.

Audrey Wells, MD

Since the pandemic, most people with new prescriptions are on auto-pap. It sounds to me like if you have uncomplicated obstructive sleep apnea, prescribed CPAP, or prescribed auto-pap, it would be reasonable to try out the V-com and see if it improves your experience.

William Noah, MD

I would like to make one comment to your audience, and this is very important. We’re talking about these aggressive words like the reverse of treatment, backward, or things like that. I want to make sure everyone understands that your therapy was fine, that you were treated, and that you were treated according to the standard of care. That’s for the 50,000 we’ve treated. You were treated, and it’s a fact that we missed the opportunity to give you a little more comfort on the front. It is what we missed in this, and I don’t think anyone’s, “ treatment was backward.” All right. I just want to say that our view of physiology was a little off.

Audrey Wells, MD

It’s important to point that out like this. This was the standard of care. People are getting the correct prescription. It’s the comfort factor that was not as robust as it could have been as we close up here. I wonder if you can tell people where they can buy the V-com device, and if they want to learn more about you, where would they go?

William Noah, MD

Well, I don’t know who would want to know any more about me. Well, not even my daughters or my wife. I would think my mother just passed away a few weeks ago. That was the only person who wanted to know more about me. But that’s @sleepcenterinfo.com. That is the website for sleep centers in Middle Tennessee that can tell you more about our practice and what we do here in the Middle Tennessee area across the state. To get a V-com on the website, I believe it’s getvcom.com. Okay, so GETVCOM dot C.O.M. getvcom.com. That’s easy to remember and that was when I got one, they’re around $30. That’s where they are.

Audrey Wells, MD

That sounds great. I want to say it’s been a pleasure to speak to you today. You certainly opened up new possibilities for better comfort and better treatment with CPAP therapy. Thank you for the work that you’ve done in this regard. It’s been a pleasure.

William Noah, MD

Well, thank you, Audrey. Thank you for all the work you’re doing, educating the masses out there, and all the stuff you’re doing across the country. This seminar—everything is to increase. There is so much knowledge out there. and it’s great that a sleep physician like yourself has made the effort to do all this. Congratulations.

Audrey Wells, MD

I appreciate that. Thank you so much.