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OK, so let's look at implementing multimodal evidence-based OSA treatments. So going back to polling question 3, in a patient with RSA on PAP therapy who had persistent symptoms and worsening metabolic risk, what do you prioritize first? Do you review uh pet use and side effects? Do you intensify BP, diabetes management as relevant, such structured weight loss management, consider anti-obesity pharmacotherapy, or coordinate a multi-disciplinary care plan. So I'll give you time to answer this. And I'll give you my take on this question. Thank you very much for answering this. I think there's no right or wrong answer, in fact most of these um options could be correct in your patience, so I don't think there's any wrong answer here. I think these answers are appropriate. So, let's look at patient case number 2 to illustrate the point. A 58-year-old man with severe OSA, obesity, type 2 diabetes, hypertension, dyslipidemia, he's got severe obstructive sleep apnea, his AHI was greater than 30, his oxygen is 79%, and he started CPAP six months ago. He still has persistent sleepiness and fatigue. His score was 14, so anything over 10 is associated with sleepiness. So why is that? He's on CPAP, it shouldn't be the case. Well, if you look at the CPAP download and interrogate the CPAP, you can see that the average use was 3.1 hours a night. There's mask leak, there's dry mouth, and there's residual AHI as well. The BMI's 38, he's hypertensive despite being on two anti-hypertensive. He's got a high hemoglobin A1C consistent with his diabetes and dyslipidemia. And the PAC support is focused on device supply with no weight loss or cardio metabolic clear pain. So lots of things to talk about here. So, options for first line OSA therapy vary according to severity, history and comorbidities. And I think this is one of the take home points. When we're assessing patients with sleep apnea, think about symptoms. Why do they come and see you? How symptomatic are they in terms of their daytime sleepiness, their snoring, their apneas, their unrefreshing sleep, their cognitive issues. What's their severity based on what the sleep study shows? What's their AHI? What's their minimum oxygen saturation? How fragmented is their sleep? And what are their comorbidities? Because we're dealing with the whole patient, not just the sleep study, not just the AHI. And a lot of my colleagues, including my sleep physician colleagues, have become so focused on AHI they haven't stepped back and looked at the big picture, which is looking at the whole patient. So selection of optional therapy is based on those three things. And I guess you could think about this. If mild sleep apnea with minimal desaturation, not symptomatic, do they need treatment? Well, if they've got some cardio metabolic complications and obesity, then obviously we'll target that. If they've got mild to moderate sleep apnea, minimal symptoms, um, but they are symptomatic, then maybe we'll look at what's reversible. Do they need weight loss? Do they need positional therapy if they've only got sleep apnea on their back? Will they use a mouth guard? Will they try a CPAP machine? If they've got moderate sleep apnea, And significant nocturnal oxygen desaturation but not symptomatic, then what's their risk factors? Do we treat their obesity? What's the role of CPAP in not symptomatic patients? Well, they've got sleep apnea and symptoms or moderate sleep apnea and symptoms, but desaturation and comorbidities. What are the treatment options? So I think it's important to note that it's not just one treatment. I think you have to do a nuanced treatment depending on symptoms, severity of disease, and comorbidities. And I think when you're talking to patients, you've got to give them those options. So in patients who have moderate severe sleep apnea and who are symptomatic, then I think CPAP's still first line treatment. But if they've got obesity and metabolic factors, then you should consider weight loss as part of that treatment as well. Or you've got patients with moderate to severe sleep apnea who are not symptomatic. And have got significant cardio metabolic complications, then maybe weight loss should be first line, because we know in patients who are not symptomatic from their sleep apnea, then treatments such as CPAP and splints maybe more difficult to use because patients don't feel any benefit from it. And I think if you treat obesity with weight loss therapy, not only treating sleep apnea, but you're also treating the cardio metabolic symptoms, cardio metabolic disease as well as symptoms as well. So let's talk about CPAP. We know CPAP is the gold standard treatment, it's fundamental, but adherence influences its actual benefit. So let's go back to basics, CPAP is still continuous positive airway pressure. It's a bedside pump that uses air pressure to splint open the airway to collapsing down at nighttime. And it's connected to a face mask or a full face mask or nasal mask or nasal prongs. So it still has the same kind of gear that's been around since 1981 when the first papers of CPAP that came out. As you know, it was invented in Australia and RPA in Sydney was the first hospital to use it. The problem with CPAP is adherence, and we also know that it's dose dependent. So to get the benefits, you've gotta use it all night, and it kinda makes sense. Think about a patient who sleeps 7 to 8 hours a night. If you're using it 2 hours a night, then you've got 6 hours where there's no treatment. That's where the apnea comes back. And we know that the second part of the night, you have more REM sleep, and we know that REM sleep is associated with more severe sleep apnea. So not only are they not using CPAP at nighttime for 6 hours, but they're not usually using it REM sleep. And that's why patients don't feel better. So the more they use it, the more likely their symptoms improve. If you are a good user of CPAP, we know it improves AHI and normalizes the sleep architecture, gets rid of the hypoxia, reduces daytime sleepiness, improves quality of life, reduces, Motor vehicle accident risk weight, it may reduce BP, 2 millimeters if you look at meta-analysis, and it may reduce AF recurrence. But it's not consistent in terms of cardiovascular mortality and other cardiovascular morbidities such as ischemic heart disease, heart failure, or strokes. And the goal of treatment is to improve symptoms and daytime quality of life and daytime sleepiness. That's the goal of treatment. But as I mentioned, CPAP adherence is a major barrier to long-term outcomes, and that's why it hasn't really been shown to improve survival. And we know that 60% of patients with cardiovascular disease and moderate to severe sleep apnea do not use CPAP more than 4 hours a night at 12 months. So we know that non-adherence is associated with lots of social issues, so social economic disadvantaged patients are less likely to be adherent, lower education background, comorbid insomnia, mental health diagnosis and low symptom burden associated with poor compliance. So evidence-based intervention may improve CPAC use such as education, motivational interviewing, even cognitive behavioral therapy. There are common side effects with CPAP use such as dry eyes, dry mouth, claustrophobia, nasal drip, and noisy mask, and these side effects can be remedied by improving mask cleaning, improving the seal, and seeing CPAP therapists on a regular basis, having good. And also feedback with apps, etc. So you can, I guess, troubleshoot these common side effects to improve CPAP use. But overall we know that 50% of patients after 3 years don't use CPAP, and that's in a real life setting. So let's talk about weight loss. So weight loss is important for sleep apnea management. It's a disease modifying treatment. So what I mean by that is CPAP is great when you use it, but when you stop CPAP, the apnea comes back again. But if you're able to achieve weight loss, you can actually reduce the sleep apnea severity, and it's a consistent thing throughout the night. So regardless of how weight loss is achieved, it's consistently associated with improvements in OSA, even resolution of OSA depending on the degree of weight loss achieved, improves and prevents diabetes, it reduces BP, improves quality of life, reduces daytime sleepiness and reduces snoring. And if you look at ASA guidelines, managing OSA in primary care recommends weight loss for patients. Obstructive sleep apnea. So what is the evidence for that? So this is a study that I think is quite good. This is a nice Spanish study. We're looking at men with moderate to severe sleep apnea, and they were randomized to CPAP, usual care, or weight loss over 8 weeks with lifestyle intervention plus CPAP. And the bottom line, it's quite a confusing slide, but the bottom line is 60% of patients who are randomized. To lifestyle intervention plus CPAP, 60% of them actually had OSA remission and actually came off their CPAP machine. So it's doable in a clinical trial program.