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So let's move on now to our second objective, implementing multimodal evidence-based obstructive sleep apnea treatment. So we have now our pulling question 3. In a patient with obstructive sleep apnea on positive airway pressure, who has persistent symptoms and worsening metabolic risk, what do you usually prioritize first? A. Review positive airway pressure use and side effects. B, intensify BP diabetes management as relevant. C. Start structured weight management. Consider anti-obesity pharmacotherapy. Or E, coordinate a multidisciplinary care plan. So leave some time to answer. So patient case 2. It's a 50 8 year old male with severe obstructive sleep apnea, obesity, type 2 diabetes, hypertension, dyslipidemia. So he has already undergone a sleep study that has shown a severe degree of sleep apnea based on an apnea hypopnea index of 38 events per hour, nadir oxygen saturation is 79%. So accordingly, treatment for sleep apnea was initiated, so he started continuous positive airway pressure six months ago. Uh, and has persistent sleepiness and fatigue despite starting CPAP. So his upper sleepiness scale score is 14. His download of his CPAP device shows that his average usage is approximately 3 hours per night. He is struggling with some mask leak and dry mouth, and a residual apnea hypopnea index of 9 events per hour. His body mass index is 38, identical to his AHI. Uh, his BP is elevated despite antihypertensive therapy with an angiotensin receptor blockade agent and a calcium channel blocker. And his hemoglobin A1C remains elevated at 8. His LDL is 124. So positive airway pressure support is focused on um device supply and and there's no weight loss or cardio metabolic care plan. So let's delve into therapy for obstructive sleep apnea a little bit more. So what are the options for first line therapy for sleep apnea according to severity, history, and comorbidities. So as we think about treatment for sleep apnea, it should be approached as a chronic disease. Management requiring long-term multidisciplinary management. And most patients with symptomatic moderate to severe sleep apnea will require treatment with continuous positive airway pressure. Selection of the ideal therapy is really based upon the interpretation of the diagnostic sleep study results in terms of the severity of sleep apnea, as well as the degree of oxygen desaturation. Um, also taking into consideration the symptoms that the patient is presenting with, for example, sleepiness, motor motor vehicle accidents, uh, risk, and the presence of comorbid sleep diagnosis, for example, insomnia, comorbid, um, insomnia with sleep apnea, um, and, uh, insufficient sleep, restless leg syndrome, for example, and also the presence of related Uh, relevant medical comorbidities, for example, cardiovascular disease, respiratory diseases such as, uh, COPD, pulmonary hypertension. So the approach to first line, uh, treatment really involves taking all of this into consideration, and lifestyle modification and advice really should be part of what we are discussing with our patients overall. Um, and then getting into more of the details as far as, again, continuous positive airway pressure has long been considered the um the treatment for uh sleep apnea. Now we are Having more options in our armamentarium to treat sleep apnea, positional therapy, uh, mandibular advancement devices, obesity pharmacotherapy. Uh, but for the most part, again, CPAP is considered first line. Uh, with symptomatic moderate to severe sleep apnea or mild sleep apnea with significant hypoxemia or symptoms such as daytime sleepiness. In anti-obesity therapy, uh, with incret therapy such as trazepatide can also mitigate cardio metabolic risk in those with moderate to severe sleep apnea and obesity, per the surmount OSA trial results. And CPAP therapy, while it is foundational, adherence must be something that we pay attention to as we have patients follow up, uh, after starting their CPAP therapy, and this really, um, is incredibly important. Um, so what is positive airway pressure? It is basically, um, a bedside, a pump. A device that uses a positive airway pressure to serve as a pneumatic splint for the upper airway to prevent the repetitive upper airway collapse inherent to obstructive sleep apnea. This device is connected to a hose, which is connected to a mask, and uh there are a variety of masks that are available, and that mask fitting at the upfront is very important. In terms of size and comfort. And ideally, um, you know, in terms of the goals of optimal therapy, we want people to feel better after using CPAP, so tracking their symptoms such as sleepiness and, you know, considering targeting an upward sleepiness skill score of less than 10, for example, can be helpful. Um, there's no consistent benefit for hard cardiovascular outcomes. Improvement for BP, yes, in systemic hypertension, resistant hypertension, but Trials such as SAVE have not really shown consistent benefit in mitigating cardiovascular outcomes, although there's associations, uh, and biologic possibility for a relationship and association of sleep apnea and cardiovascular outcomes. So, um, and the benefits can be somewhat dose dependent in terms of the usage of CPAP. So the more it is used, the more likely you are to derive benefits, including, um, cardiovascular outcomes. So it can improve the degree of sleep apnea defined by the apnea hypothia index can improve. Sleepiness symptoms, quality of life measures, um, mood in terms of anxiety, depression. Uh, there are data to support improvement in atrial fibrillation recurrence after ablation or cardioversion. And again, BP control has consistently been shown in many randomized control trials. Sleep apnea adherence we do recognize is a major barrier to long term um sleep apnea outcomes and and those beneficial outcomes, achieving those beneficial outcomes. And approximately 60% of those with cardiovascular disease and moderate to severe sleep apnea do do not maintain usage for more than 4. per night at 12 months as you can see in the graph on your right. Um, and the risk for non-adherence can be associated with those who have, um, more socioeconomic disadvantage and perhaps more limited access to care, low educational background, comorbid insomnia, um, uh. Again, mood disorders, uh, and those who have less in the way of symptoms, and evidence-based interventions that improve CPAP that we can really use to help us, um, augment PAP adherence include providing education, motivational enhancement or interview. in cognitive behavioral therapy. So this is really important for us to be aware of because I don't know that many um primary care physicians or even sub-specialists are aware that these are strategies that can really um help improve path optimization. Now common side effects of positive airway pressure also include escape of the pressure resulting in dry eyes, dry mouth, uh, those who have claustrophobia can have difficulty tolerating CPAP, uh, nasal congestion, uh, noise from the device. So paying attention to the specific issues that the patient is bringing forward, uh, in terms of these.