Reena Mehra, MD, MS

“There are newer treatment modalities over the past few years that are coming to light. Upper airway neurostimulation is a novel treatment for obstructive sleep apnea, specifically for severe sleep apnea and those who have not been able to tolerate positive airway pressure.”

Continuous Positive Airway Pressure (CPAP) has been the standard of care treatment for obstructive sleep apnea (OSA) for the past decade. Although effective, the device is connected to a tube that splints open all aspects of the airway and can be adjusted for pressure based on what the patient needs, which has driven some of the patient criticisms of the device that have, in turn, been linked to its poor adherence rates, probing the need for more treatments.

Reena Mehra, MD, MS, director, Sleep Disorders Research Program, Cleveland Clinic Lerner College of Medicine, told 

 that the number of treatments for OSA are growing, with many of them still in the testing stage. She mentioned upper airway neurostimulation as a relatively new treatment option but noted that so far it has only been available for patients with severe cases of OSA.

In this interview, Mehra gave an overview of the current landscape of sleep apnea treatments, detailed what is in the development pipeline, and discussed what potential impact these new options might have in the near future. 

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The director of the Sleep Disorders Research Program at Cleveland Clinic Lerner College of Medicine detailed the advancements that have been made with OSA treatment devices.

Reena Mehra, MD, MS: Advances in Sleep Apnea Treatment Devices

“The notion is that if obstructive sleep apnea is a very high pretest probability, and you’re pretty certain the patient has it, then the home testing will suffice to realize that diagnosis of sleep apnea.”

The traditional methods of diagnosing obstructive sleep apnea (OSA) have been undertaken in a laboratory setting, typically with the use of polysomnography and and the help of multiple different monitoring techniques such as electroencephalography (EEG) and electromyography. Now, however, sleep apnea can be diagnosed at home with the use of portable wearable devices.

 that although these devices do not capture the same physiological breathing patterns as the laboratory techniques, they can act as a surrogate for clinicians. Typically, these devices do not directly monitor sleep apnea, but they may detect apneas and hypopneas or an abnormal slowing of breathing.

In this interview, Mehra discussed how at-home wearable devices are expanding the treatment and diagnosis of OSA, and what limitations still remain and come along with the use of these new tools. Additionally, she described the major differences between diagnosis in a laboratory setting compared with an at-home device.

The director of the Sleep Disorders Research Program at Cleveland Clinic Lerner College of Medicine discussed new technologies being used to diagnose and treat sleep apnea.

Reena Mehra, MD, MS: Wearable Technologies for Sleep Apnea

“Given the acceleration to the use of telemedicine, I certainly think this will be a large part of how we will be caring for our patients going forward.”

As hospitals, clinics, and private practices continue to limit their person-to-person interaction during the COVID-19 pandemic, the accelerated use and growth of telemedicine has been a beneficial consequence. In some parts of the country, governmental rules and restrictions on travel have forced the need for telemedicine to take a larger role.

Reena Mehra, MD, MS, director, Sleep Disorders Research Program, Cleveland Clinic Lerner College of Medicine, sees the potential of virtual visits and diagnosing patients with sleep apnea through telemedicine. For years, Cleveland Clinic has tried to remain at the forefront of pushing the envelope on accelerating the process of telemedicine, and so Mehra and her colleagues have plenty of experience.

, Mehra detailed specific measures that she has taken to adjust her practice during the COVID-19 pandemic, as well as how this change in how care can be delivered has expedited the utilization of telemedicine in sleep medicine.

The director of the Sleep Disorders Research Program at Cleveland Clinic Lerner College of Medicine offered her insight on how telemedicine is being utilized to help diagnose and treat sleep disorders amidst COVID-19.

Reena Mehra, MD, MS: Expediting Telemedicine During COVID-19

“General adherence is thought to be 50% to 70%. Our estimates here at Cleveland Clinic are a bit higher, at 80%, maybe even 90%. The struggle is, really, to try to identify the root cause of the problem, in terms of why the patient is not able to tolerate the device.”

In the treatment of obstructive sleep apnea (OSA), continuous positive airway pressure (CPAP) is considered the gold standard—and for good reason. It is highly effective in the treatment of OSA. Although, despite this efficacy, patient adherence to the treatment is generally considered a challenge, with some estimates suggesting that even with mask and machine alterations and accompanying behavioral intervention, adherence remains a severe issue in the management of OSA.

Reena Mehra, MD, MS, director, Sleep Disorders Research Program, and professor of medicine, Cleveland Clinic Lerner College of Medicine, told 

 in an interview that the real challenge is getting to the cause of a patients’ lack of tolerability to CPAP. She noted that there are a number of potential reasons, ranging from pressure intolerance and mask issues to nasal congestion and beyond.

At Cleveland Clinic, Mehra and colleagues offer patients unique resources through its group-based CPAP clinic, where patients are offered 1-on-1 meetings with clinicians to help identify and address these issues. Mehra discussed the ways in which adherence issues can be tackled, as well as insight into why it is such a challenge for patients with OSA using CPAP and other medications.

1. Rotenberg BW, Murariu D, Pang KP. Trends in CPAP adherence over twenty years of data collection: a flattened curve. 

. 2016;45:43.doi: 10.1186/s40463-016-0156-0.

The director of the Sleep Disorders Research Program at Cleveland Clinic Lerner College of Medicine offered her perspective on the adherence challenges in treating obstructive sleep apnea with continuous positive airway pressure.

Author | Reena Mehra, MD, MS

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