What’s better than CPAP?

Show Intro and Guest Introductions 0:00

All right, it's another show and that means it is time for Precals. Wait a second, what's going on? We're missing somebody. We are like a little tricycle without a wheel. Yeah, turning into a bicycle now. It's kind of odd, right? Definitely is. Robert is unable to join us today. That's unfortunate. He's definitely going to be missed. He definitely will be. But I mean, apart from Robert not being here, what else is going on today, Emerson? Well, we actually have two guests on the day, Jerry, which is really unusual for our show.

We usually keep it down to one superstar. Now we have to we've got Dr. David P. White from Brigham Women's and Children in Boston, Massachusetts, who's going to be joining us. we know David White, from our time at Phillips Respironics. But he is a professor of medicine at Harvard Medical School and the senior vice president of medical affairs for ApnaMed. He was the director of the clinical sleep disorders program at Brigham and Women's Hospital for quite some time, and now he's a part-time professor there.

Um, he has a past president, of The American Academy of Sleep Medicine, And the former editor-in-chief of, The Journal of Clinical Sleep medicine. He has over 250 peer-reviewed publications focusing on the pathophysiology of sleep disorder and breathing and innovative treatments for OSA. He was the chief medical officer for years at Respironics and later Phillips Respionics, where he led clinical research strategies in sleep and respiratory markets. So it's exciting to have him on board with us today.

And we also have Dr. Peter C. Gay. Dr Gay is with the Mayo Clinic where he is a professor of medicine consultant in the Division of Pulmonary and Critical Care Medicine with a Department of Internal Medicine. His expertise is the management of chronic respiratory failure, particularly through noninvasive ventilation. His research aims to enhance the delivery of non-invasive ventilation to patients with conditions such as chronic obstructive pulmonary disease, neuromuscular and restrictive lung diseases, central sleep apnea, hyperventilation syndrome, and cases where CPAP therapy for OSA is unsuccessful.

He's actively involved in initiatives to improve Medicare policies to ensure appropriate access to NIV for eligible patients. Um, he's held numerous leadership roles in professional organizations. he served as president of the National Association for Medical Direction of Respiratory Care and the Society of Anesthesia and Sleep Medicine. Additionally, he's been a board member with the American Academy of Sleep Medicine and the America College of Chest Physicians, contributing to committees focused on home care, sleep medicine, and health policies.

For both of these guys, we could go on and on. He also has quite a few peer review publications at 130, so between the two of them, We've got 380 peer-reviewed publications that we could have drawn

Bi-Level Origins and Ventilation vs Oxygenation 3:08

off today. So quite an interesting talk in front of us. We're gonna hear a little bit about maybe the fallacy of IPAP. Hard to know what to think about that. You and I've trained a lot of sleep techs and sleep physicians on, you know, EPAP is for apnea and IPA is is everything else. Kind of interested to see where this is gonna go. It's going to be interesting. And we've had Dr. White on our show before, so it's gonna be fun to have him back on and also to hear the interaction between two of them regarding this fallacy of the bi-level itself.

Yeah. Absolutely. Well, let's go to the show and see what they have to say. All right. On to show folks. Lights off. 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. Folks, we have an amazing, amazing episode today. It's a two-for-one special.

But before we get started, I just want to say a huge, huge thanks to our sponsors. Be sure to check them out. And also our clinical sponsor, Sleep Review Magazine. And thank you, folks, for all that you're doing to continue to help us grow. We can't thank enough for the likes, all the subscriptions, and most of all, the shares. Continue to share with all of the people out there that are in the sleep industry, especially the Sleep Curious. we're getting bigger and bigger, it's all thanks to you. With that, Emerson, what's going on today?

Well, Jerry, we have a really exciting episode today. We've got two great friends, Dr. David White from Brigham in the big city of Boston, Massachusetts. And we've Got Peter Gay, a Dr Peter gave from the Mayo Clinic in The Monstrous Town of Rochester, Minnesota. So we're super glad to have them on today as we talk about the fallacy of IPAP. You know, you and I have been working in sleep a long time. We've done a lot of teaching and you know we used to say EPEP for apnea, IPEP for everything else.

So I'm looking forward to our conversation today. All right. And well, it definitely sounds exciting and the fantasy of bi-level. Didn't we talked about this a little while back? We did. We had Dr. White on, so we talked a little bit about K-PAP. But we're going to dive right in and ask a couple of questions. Dr., welcome to the show. You're new to Sleep Tech Talk, but not new us. It's good to see you today. One of the things that both Jerry and I, because of our history with Respironics, would have talked about you a in our clinical education, whether it was about Biflex or adaptive servo ventilation, or even some of the other bi-level type stuff.

So you've got quite a history with bi level for a lot of sleep technologists and sleep physicians that have ever followed you. Can you tell us a little bit about your journey from where you have been with Bi-Level to where we are now? To be honest, I've always been a device guy. I didn't have enough sense to get into pharmaceuticals and be a rich man. But from the very start, i got enchanted with non-invasive ventilation when it was first brought over really by the French that had been having success with this.

And I was an intensivist. i was planning to do critical care medicine when we started putting masks on people and there you were treating respiratory failure. You were really the people who needed ventilation and where I most was aware, fashioning our own masks in around 1987, 88 of the patients with neuromuscular disease. And boy, did they need IPAP like nobody's business because they were hypercapnic. When they came in with a CO2, the same as their PaO2 and you gave them oxygen, they could quickly get a Co2 that would be double their PAO 2. And that

Why EPAP and Pressure Support Missed the Mark 7:56

really made us aware of the difference between ventilating and oxygenation. And what's kind of cool there is that we only discovered CO2 as a real issue in this century. It was just an afterthought. You looked at the bicarbonate and that told you something about the disease, but we weren't even aware the need to ventilate people. Was all about oxygenating. So it's been a neat journey to understand ventilation through the years. Hey, Dr. Gay, really quickly, if you could just for those folks that don't understand the difference between the two, oxygenation and ventilation, I really appreciate that.

Ventilation is all about moving CO2 and oxygenations is about oxygen to put it as simple as you can. And when you're Ventilating, it's tidal volume and MV. When you're oxygenating it, so about your PAO2 and oxygen delivery. That's interesting. So when you transition over to sleep and you look at sort of Mark Sanders work in the early nineties with bi-level and what we were looking at with just sleep disordered breathing, what do you feel like, you know, was the belief system of that time that really made us embrace that concept that, Dr.

Sanders and the team had stumbled upon during that era. Well, I think that's a misappreciation of the great Mark Sanders, who didn't stumble on anything. He had a keen eyesight on the fact that the people that he was having the most trouble with were the more most corpulent. And as such, he is the first one to really stare at the flow signal when these people had their airway open. but still had evidence of flow limitation. And the marvelous article, I'm trying to remember, it's like from 1980 where he had that front, David, you gotta remember this, where you had first page where it just showed that flow signaling, showed flow limitations and they showed the addition of IPAP and then removing that in these obese ventilators, obviously the area under that curve was much better for those patients who were being assisted in ventilation, but this was really for obesity ventilation.

And of course they had sleep disorder breathing, and we were talking about OSA and obesity, ventilation in the same regard, But we didn't know how to separate the airway from the need to ventilate lungs that had to brush their FRC with their obesity and had two problems. So, you know, as we kind of look forward, Dr. White, the question is, how did we get this backwards? I mean, we're really doing treatment backwards from what we've been thinking about for the last 30 plus years. I think it's an obvious mistake, and I I think everybody thought, well, the IPAP helps ventilation reduce the work of breathing.

So that ought to be good. And this expiratory pressure is uncomfortable. It's where you have to do all this extra work trying to expire. Therefore, that's what we need to fix. They became all the various permutations. Mark Sanders did it first by lowering EPAP. I remember being at an international symposium on sleep and respiration, like 1988, and they brought this BIPAP machine in the restaurant for people and put us on it in one thing and another. thought it was great, but it made a lot of sense if you didn't go back and really look at the carefully at physiology that came out during the 90s that showed that basically lowering EPAP It affects the upper airway patency, and it does it in a whole variety of ways, including it affects lung volume, it effects the force in the air way.

It does a lot of things, but when you turn the EPAP down, you're going to lose patancy. And you can force air across a stenotic airways with just increasing levels of IPAP. That can be done. But it doesn't accomplish much because it's just making it more and more uncomfortable as you crank that IPAP up to try to deal with the problem that you have created by lowering the EPAP. So all that information was there and it took Bill Noah sort of looking at all of that stuff for a couple of years and thinking, this doesn' make perfect sense to me.

What, you know, why, so therefore we probably shouldn't be reducing the Epap because that's not getting us what we want. But I think it was a bigger jump, in my mind at least, to think, why don't we lower the IPAP? And maybe that will be more comfortable. Because lowering the iPad does not deal with the upper area obstruction better. It doesn't deal it worse either, but it doesn' help the upward obstruction. it just turns out that it's a lot more comfortably. And if you think about it, it makes a lotta sense.

We all are completely used to doing all our own breathing and how rapidly we inflate the chest, how fast the air moves in, where we stop an inspiration and whatnot. We do it, you know, 15 times a minute, 24 hours a day. And if you don't need ventilation, like Peter was talking about, then having air blasted into you changes all the normal dynamics of inspiration, which makes it awkward. I'm not saying you can't get used to it, but it is fundamentally awkward. Lowering the IPAP makes that whole inspiratory effort more uncomfortable.

And so that's what we think we're going to buy with K-PAP is a lot greater comfort. equal efficacy and therefore, hopefully, better adherence. But I think the biggest jump was saying we can lower IPAP and it's not going to cost us anything and is going help us in terms of comfort.

K-PAP Comfort, Interfaces, and CO2 Rebreathing 13:40

Of course, that was unheard of. Go ahead. The concept that, look, it is like an aqualung. It's like you take a breath and you get this instant relief. You're getting the air that wouldn't have come to you otherwise. It was really the marketing that got us. I got to speak for my, I should say I that goddess got me enchanted with the idea that you had to do this to get that snap of relief. We were talking about selling awake phenomena, sir. You're going to feel this wonderful rush of air. Would you ask for it?

We'll deliver it. And as far as that expiratory, that's the crap. That's. The whiner saying it's too much air that bad. What's opening your airway, Sir. So once you said, well, we won't give you that bad thing that makes you uncomfortable. We'll give it to you when you want it. That's IPAP. So the marketing sold this thing and we were totally sucked into this. That makes sense because part of what we did next is we brought the C-Flexes and EPR and that sort of thing to market to take away and provide pressure relief on exhalation.

So where did we go wrong there, Dr. White, when we think about what all we accomplished with that type of pressure release, where do you think we missed it in that journey of positive airway pressure? I'll just say a number of things. We missed it because what I said before, it compromises the airway. You lower the EPAP no matter what it's going to compromise the area. That's step number one. Step number two is that when C-Flex came out, what you're doing when you lower EPAPP is obviously you are adding a little pressure support.

I mean, that's what Peter is talking about. IPAP is greater than EPIP, you getting pressure supporting. Now, whether you said the EPR is at one, two, or three, all of them are given to you. In addition to, you know, compromising the airway that pressure support has some downside to it if you don't need it and the downside it to. It is one increases leak to if can make the mask. the, you know, makes the mask less stable. And number two, it probably contributed to the development of Texas. Texas really developed after C-Flex came out.

I mean, people started seeing a lot more of it. Nobody ever really raised it, Robert Thomas started going crazy with his, complex sleep apnea. you know, within a year or two after C-Flex came out and we made an observation that basically go back and look at titrations done on CPAP plus as titration is done C Flex or EPR, you don't see the text up when you basically titrate on C PAP and you do see it much more often than when you have some pressure support. And that fits perfectly what we know about ventilatory control.

If you the potential for unstable ventilator control, what call high loop gain, meaning you're close to having really just a fundamental central sleep apnea situation, but you are not quite there, you stable as it is. You throw some pressure support on that and it makes your breath bigger, which then pushes you over the top. Your loop gain goes over what we call one, and you're cycling. And so getting rid of that will get rid a lot of the texas. I think if EPR went away, we would see very little texa.

If you lower IPAP, it's even more the same. you know, not augmenting ventilation, but just making the person do it themselves, and so you end up with a lot more stable ventilation. So I think we made a number of errors that were probably preventable if anybody had really sat down and thought about the physiology. And I'm happy to take some of that blame. I was working at Respironics and Phillips Respirons as a a of this stuff was evolving. I'm much more interested in getting past CPAP completely.

I was interested trying to find alternative methods of treating sleep. Because I didn't believe that anybody had come up with something that made CPap fundamentally better than just straight up average CPapp. And I got interested because I think now we do have something to make it better. Are you with 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 Career with MidBridge Healthcare.

So talk about making it better. So what's the fundamental difference? I mean, when a lay person sees CPAP or a sleep technologist or physician, sleep physician for that matter, what is the difference from bi-level or CPAPP and now K-PAP on the other side? What is patient feeling and what can the clinician understand from it? You want to take that Peter? No, David, you're an artful expression in this regard. Okay. I mean, they're totally different. Just from the basic point of view, in one case, you've got the IPAP grade and the EPAP.

You're supporting ventilation, but you're lowering the EEPAP that can compromise the airway. In the other way, your basically lowering and keeping the ePAP where it is. And with KPAP, actually you don't keep the expiratory pressure exactly where it was. You're actually keeping it quite a bit down during the early parts of expiration, only bringing it back to the optimal level towards the end of the expiration. And I think that's the fundamental magic of this, is that you only need the optimum pressure, what I'll call the holding pressure at the ends of expiration, maybe three quarters or one second.

If you do that, you get the inflation of lungs, the dilation of airway, that when you start the next breath you can drop the pressure. And if you try it, you're asking what it feels like, it just fundamentally feels more comfortable. I was completely skeptical of all of this when Bill Noah called me up and he flew an engineer out here the next day to Denver. And I, and I expecting to feel absolutely nothing different and send this guy home saying, I'm not interested in this, but they put me on it.

It didn't take five breaths or 10 breaths and you could, he switched you back and forth between CPAP and, and CPAP and it was just, I mean, it night and day as far as I'm concerned. So it's not a subtle difference that is difficult for the patient. I think it just feels much more natural like you're breathing for yourself rather than having a machine do it. Dr. Weber, have you been able to put this on any patients yet to really see the difference and maybe have an objective point of view from a patient standpoint?

I mean, we've done comfort studies just where you take naive patients and put them on it for a few minutes and ask them if it's more comfortable. And that has been overwhelmingly in favor. In terms of putting actual people on for sustained periods of time, all I'll say is this. One, the number of people in the company, in sleeper houses, that wear it every night, and they love it. So they don't count because they're biased. But we're just now starting what I would call a usability study, where we are going to put people on K-PAP for about three months to see how they like it and see if they identify any problems or anything.

And we just started this, and the first person we put on it was actually turned out to be a very famous person. I can't tell you who it is for privacy reasons, but somebody that you would all recognize the name immediately, who was unable to use CPAP more than about an hour a night, was very angry about the whole thing. And we put him on Cape out and he is now sleeping comfortably throughout the night. It was just so this is the first one that I have personally had any experience with somebody wearing Cape app over a sustained period of time.

So it's not FDA approved. And so we can't just start putting large number of people you have to do it on protocol. But I was amazingly impressed because this guy's sort of a hard-nosed character. He was not going to be impressed easily, so it was a very good outcome. Have you noticed much when it comes to interfaces? That's clearly a big challenge with any kind of positive airway pressure. What has been sort of the anecdotal or your observation of patients with the different types of interfaces, particularly the pillows, because that's really jetting that air right up the nears and sometimes it can be extremely comfortable for a patient.

What have you seen in that particular interface with a patients on KPAP? We haven't done enough to be able to answer that question. The expectation is, you know, most of algorithms actually increase the inspiratory pressure to deal with resistance. of the nasal mask, so the IPAP is even higher than it would be otherwise, which again does exactly what you just said, jets the air through and can be quite uncomfortable. So my suspicion is that virtually everybody that use nasal pillows are going to get the biggest benefit in terms of feeling the comfort.

But most of people we've been trying have been on nasal pills when we just exposed them to it for short periods of time.

Future of K-PAP and Closing Remarks 22:58

We haven't just don't have enough experience to give you any hard evidence, you know, meaningful at this particular time as to how a mask versus a nasal mask, versus nasal pill is going to respond to the new technology. Looking at it from the other side, there's a lot of overlooked attention to particularly the full face mask into whether it's more important to baffle it and keep it quiet and to maintain the pressure in it. And very little attention now is being paid to the CO2 retention that goes on with these masks with improper venting and whatnot that really affect what you're trying to do in some cases is improve ventilation that we really need to pay more attention to it.

And Bill Noah in particular has carried the torch for that. In fact, standing in the way of some badly manufactured mask that would cause a lot of CO two rebreathing. So there is that problem to think about as well. We're actually doing a study in my lab in Boston, where we're looking at CO2 rebating, because people have not looked at this very much. And there it is amazingly more than you might think there. Even with the regular P10, I mean, regular venting systems, you can get rebreathing it up to eight or 10 centimeters of water.

We never thought that'd be possible. And the other thing that nobody talks about at all is the fact that anything that's giving you CO2 rebreath is also having you re-breathe a lower fraction of inspired oxygen. Your alveolar oxygen is 14%, okay? And you breathe that out and then re breathe in 14% oxygen and your PO2 is gonna go down. If you do that, if you have circuit re breathing, So we think the rebreathing is a much bigger deal than a lot of people have thought historically. And again, we have an algorithm that's gonna deal with that in a very straightforward way.

Will the patients that are experiencing that, will they be showing signs of morning headaches? What would be some things that could alert a clinician that maybe we don't have the right interface for this patient? I think the main one is that they're going to wake up and pull the mask off their face and tell you they feel extremely short of breath. The problem is it feeds on itself.The more you hyperventilate because your CO2 is going up, the more your re-breathe. Bigger tidal volume, higher respiratory frequency.

You far exceed what the exhaust port can do. It just keeps building and building until the patient just rips the masks off. you know, things that think something has gone around. I can't remember, honey. It's how many patients have told me that over the years, and I did not understand the mechanism that was causing that. Dr. Gabe, from your standpoint, what can we expect in the future or the coming future for K-PAP, both for the patients as well as for clinicians? Well, first of all, we've got to understand where we been coming into the world where auto CPAP was going to rescue us because it's that high pressure, that damn pressure goes so high and gets in the way of life that if we have a smart guy that's going bring it down when we don't need it, That's the holy grail.

Didn't work. In 2003, we thought a little better manipulation of that expiratory pressure was what we wrote about called a novel bi-level pressure system for the treatment of obstructive sleeper. That was really the first flex thing. Uh, you may remember that David, that was Pete Hill's, uh, magic proportional pap. And we thought this was really cool because it had that gradual decline and it was fast. It happened in every breath. So that must be good to eliminate that bad expiratory pressure, but, Uh that only built on itself.

so if you get that good boost with bi-level pap and you flex it on the back end. God, that's got to be the answer to the world. Our 2000 study was even more misleading. So we took patients that did not do well. And then after a period of trying to cozy up to them and make their mass fit well and play the whale music, we sent them home for a couple of weeks and they came back and only about 20% of them kept using their PAP. We put them in the lab and randomized to Biflex. we randomized the CPAP better titration.

Then we brought them back and then we really misled people, because only 28% of them now were wearing their CPAP, uh, compliantly. And now a whole 49% percent of the bi-level PAP people that's significantly different, but not even half of him got better with a biFlex device. But since this was better than that, we could say there's a significant improvement by using biflex. Bang, We got a winner, But somebody didn't take home the real lesson is probably first of all, if you show anybody something different, they're gonna like it better than the sea crap that they gave up in the first place.

So that misled them. But the most important lesson here, and this is where I think K-PAP has a winner, that if lose these people upfront, you're never gonna rescue the majority of people with some kind of expiratory pressure manipulation, dropping the pressure that the need. That if capture them upfront with something that's intrinsically more comfortable. That's where the big win here is. And I think that's what the future is going to be a big benefit with K-PAP. Don't you agree with that, David?

I agree. It's a really hard thing to test because you're talking about testing acceptance at all as opposed to just rejecting it sort of outright and walking away. So it's not easy to design a study to look at that. But I do think if more people accept it, that is a Well, Docs, we sincerely appreciate you being here. We are getting out of time. So just any final words or thoughts, Dr. White, on your side to summarize what people should be seeing in the future? Well, all I can say is this, we have a webinar that's coming up on the 12th and 13th of May that Peter and I and Bill know are going to do.

And we're going go into all the details around the physiology. We're gonna go around in detail what Peter was talking about the history of path and history by level and where it came from and what mistakes were made. And then Bill's going to explain all the physiology of upper airway collapse in the face of inspiratory and expiratory pressure. And I'm going go through all of the data around K-PAP and OPAP less than EPAP, and explain to all that exactly where we stand. So we invite people to come to that, hope they will, we think it will be very educational.

Fantastic. Dr. K, anything from your side where people can get more information or anything else? I think its important to realize how easily we can be led into the majority thinking is gotta be the right thinking. And when somebody like Bill Noah comes along and says, you know, maybe looking at this wrong, it's so hard to move the compass needle. We're trying to do that with science and studies, but we're gonna need more studies to really prove this. But let's get the message out is what we really wanna do.

Well, gentlemen, thank you so much. We sincerely appreciate it, and we thank so you much for being here and sharing more about K-PAP. we're really excited about changes and alternatives that are not out there right now, that're coming on board. And everybody out is waiting for something, so we think you for sharing that information with us. And folks out there, thank you so much for joining us once again on our show. And we thank all our sponsors. We also want you to remember to check out Sleep Review Magazine and continue to like, continue subscribe, and most importantly, continued to share.

Until next time, we say, lights on. Sleep well. Bye, guys. Cheers. Before we go, We would like to thank our sponsor, MedBridge Healthcare. MedBridge Healthcare is developing innovative inpatient, post-discharge, and population health programs to screen comorbid conditions, diagnose and treat sleep disorders. Learn more about their innovative solutions and career opportunities at MedbridgeHealthcare.com. Once again, you can learn more about their innovative solutions and career opportunities at medbridgehealthcare.com.

All right. It was another show, and that means it's time for some post-calls. And that was quite a show. Way too many big names on one show isn't it? Oh my gosh, you know, to have both Dr. White and Dr Gaon is quite a treat. I mean, these guys have done so much for sleep medicine over the last probably three decades, when you really think about their contribution to what we do. You and I as educators over years have quoted these and presentations we've done about CPAP, about bi-level, pulmonary disease.

So it's fun to have them on the show today and really get to hear their journey from really being in one paradigm where we're thinking about IPAP and its use in sleep disorder breathing to really rethinking it as maybe something that isn't suitable for the sleep apnea patient. It's interesting you said that about three decades, even after three to see their passion for something like this, this new technology that's developing, to just see the passion, see something new. It is absolutely amazing and we need to say that even old school folks that have been doing this forever, who kind of wrote the manual on how things are done, like you say earlier in Precals, nearly 400 papers between the two of them.

the peer reviewed articles, I shouldn't just call them papers, so peer-reviewed articles between the two of them, they're so excited that something new is out there, that there's an alternative for patients, there is something that's going to make things even more comfortable. This is 30 years later. Well, it kind of plays into that whole concept of sunk cost fallacy, you know, here we are as an entire industry, trying to figure out how to make something work that simply wasn't working. And absolute kudos to Dr.

Bill Noah for asking that question. I think the first time he did it was with the VCOM as an adapter that he was able to place in line. Uh, in his office. Yeah. You know, yeah. In the very beginning. And it was, was very kind of super secret idea, but to see how that is, has really come forward from this adapter that could be placed in line to reduce inspiratory pressure. It blew my mind even back then. And really thinking, okay, this is a game changer to where we are now that it could actually be inside of a PAP device and provide that pressure relief on inspiration.

And, you know, we've spent so much time you and I teaching people and training people to say it's expiratory relief and here today we're hearing it. It's exactly not that, right? Right. Yeah, so it flips everything upside down. And really that question we posed to Dr. White in the beginning, have we been doing it backwards? It absolutely seems like it is. I'm looking forward to their ongoing studies to look at adherence. We certainly know that it's efficacious, but I'd love to see the long-term story of their adherents and what this is going to mean for these patients that usually end up quitting and failing CPAP.

And I agree. And for me, that's the exciting part is to see this development and to seeing their passion and see the whole journey of where it's going. I just can't wait to actually see something that is in production and be able to say see patients on it afterwards. Well, I think the webinar that Sleep World magazine is going to be hosting here soon will give everyone a chance to hear the full story. We're looking forward to that. So on that webinar, Dr. White had wrapped it up. It'll be him, Dr.

Gay, and Dr Noah. And boy, what a trifecta to get to hear about this journey with K-PAP, where we've gone wrong with IPAP and what the future looks like. I agree. So with that, let's close and folks out there, be sure to check out the webinar and learn a whole lot more about us. All right. Good show. Until next time, we say cheers. Sleep Tech Talk is sponsored by React Health. Within our Luna PAP device line, each offering is FDA approved, encompassing CPAP, APAP by level and by-level ST models.

Our thoughtfully selected array of PEP interfaces and accessories complement our LUNA PAPP device-line while accommodating diverse patient requirements.