Symposium 36: Novel behavioral medicine assessments / interventions for successful treatment of obstructive sleep apnea (OSA) with comorbid insomnia (COMISA)

Symposium Title: Novel behavioral medicine assessments / interventions for successful treatment of obstructive sleep apnea (OSA) with comorbid insomnia (COMISA)

Obstructive sleep apnea (OSA) is a chronic condition characterized by repeated interruptions in breathing during sleep that cause significant sleep fragmentation and related impairment in daytime functioning and performance (e.g., excessive daytime sleepiness and fatigue, difficulties with concentration and memory, higher rates of depression and anxiety). With up to half or more of patients presenting with insomnia having occult OSA, the co-occurrence of these disorders is increasingly described by the term “COMISA.” Approximately 12-26% of the United States’ population is estimated to have OSA, although these estimates likely under-represent the true burden of this disorder. When untreated, OSA is associated with an increased risk of adverse health outcomes (including cardiovascular disease, metabolic disorders, cognitive impairment, morbidity/mortality, and poorer quality of life), resulting in an estimated economic cost of 149.6 billion dollars due to lost work productivity, motor vehicle and workplace accidents, and increased health care utilization.

While there exist highly effective treatments for OSA – most notably positive airway pressure (PAP) therapy and, more recently, hypoglossal nerve stimulator (HGNS) therapy – adjustment difficulties and insufficient adherence to these treatments remain major impediments to therapeutic benefit. Behavioral interventions aimed at facilitating successful OSA treatment remain a relatively under-addressed area of behavioral sleep medicine and behavioral medicine more broadly, despite the intersection of this disorder with many other domains of health. In this symposium, specialists representing varied disciplines within sleep medicine will discuss individual- and systemic-level barriers to successful OSA treatment. Data from behavioral medicine initiatives within Stanford Sleep Medicine will be presented to highlight these barriers and offer alternative and novel interventions aimed at promoting more optimal, patient-centered OSA treatment.

In the first presentation, clinical sleep psychologists Drs. Molzof and Tingey will describe the development, feasibility testing, and piloting of a multidisciplinary, group-based PAP education and behavioral skills program designed to systematically address commonly encountered treatment challenges faced by patients with comorbid OSA and insomnia (COMISA). They will discuss key behavioral interventions of the “RISE UP - Ready to Improve Sleep and Energy Using PAP” program and share quantitative data illustrating the positive impact of this intervention on PAP treatment adherence. The second presentation by Michael Sepulveda, a registered polysomnographic technologist, will further delve into the behavioral and technical barriers to PAP therapy experienced by patients with COMISA. Qualitative patient feedback from the RISE UP program will also be presented to illustrate the central importance of multidisciplinary support for enhancing patients’ self-efficacy in successful PAP therapy engagement.

For the third presentation, Dr. Barwick, a clinical sleep psychologist, and Dr. Capasso, an otolaryngologist specializing in sleep surgery, will present a case series focused on their joint development of a pre-surgical psychological evaluation (PPE) for patients pursuing hypoglossal nerve stimulator (HGNS) surgery. This PPE for HGNS is among the first of its kind and aims to identify factors associated with optimal versus suboptimal surgical outcomes. Development of a PPE protocol would not only allow customized pre- and post-surgical treatment planning to optimize outcomes but would help to reduce costs and establish standards for future clinical practice.

Taken together, these presentations aim to increase awareness of the behavioral medicine opportunities that exist within the areas of OSA / COMISA treatment by highlighting current novel interventions with the additional hope to inspire further efforts in this area.



Presentation 1

Title: “RISE UP - Ready to Improve Sleep and Energy Using Positive Airway Pressure”: Psychologist insights and patient outcomes from a pilot trial of a multidisciplinary PAP education and behavioral skills group program – Part 1

Presenter(s): Hylton Molzof, PhD, DBSM; Jamie Tingey, PhD

Introduction: Positive airway pressure (PAP) devices, considered the gold-standard treatment, are the most common and effective intervention for patients with OSA. Consistent nightly use of PAP therapy has been shown to improve nighttime sleep and daytime functioning, as well as reduce cardiometabolic morbidity / mortality. However, adjustment difficulties and inadequate use of these devices remain major impediments to therapeutic benefit. The average estimated rates of non-adherence range from 29-83% and have remained persistently low over the past twenty years. Limited knowledge, technical challenges, lack of motivation / confidence, and pre-existing sleep difficulties are among the most commonly cited barriers to successful engagement with PAP therapy. Educational, behavioral, and problem-solving strategies have been found to improve PAP adherence in adults with OSA, resulting in these components being recommended as a clinical practice guideline by the American Academy of Sleep Medicine. To date, however, there have been limited efforts to combine these techniques into a comprehensive treatment package that can be efficiently and effectively disseminated to patients.

The aims of this pilot study were to (1) identify common barriers to successful and comfortable PAP use, (2) develop a multidisciplinary educational, behavioral, and problem-solving skills-based group program co-facilitated by a sleep technologist and a behavioral sleep medicine psychologist to comprehensively address the technical difficulties and psychological / behavioral barriers to PAP use, and (3) examine the impact of this program on patients’ overall PAP adherence / experience.

Methods: Patients included non-adherent PAP users (average usage <4 hours) and adherent users experiencing discomfort and / or dissatisfaction with PAP therapy. Patients completed a 4-session group comprised of technical education and problem solving to optimize PAP equipment and behavioral / psychological skills to facilitate PAP use. Behavioral / psychological techniques included PAP desensitization, sleep pressure strengthening, sleep hygiene, relaxation, mindfulness, and fatigue management. Additionally, a sleep technologist was present for each group session to provide foundational PAP education, answer PAP-related questions, and offer personalized treatment recommendations. The main outcomes of interest for this pilot program were (1) feasibility and acceptability of the format, content, and delivery of the program, and (2) PAP adherence (average hours of nightly PAP usage).

Results: Participants who were non-adherent to PAP therapy at baseline (n = 19) significantly increased their duration of PAP use by 1.7 hour per night across all nights by the end of the 4-session program. Number of nights using PAP increased from 26% to 65%, while nights using the device > 4 hours increased from 16% to 38% over 8 weeks. Among patients using PAP greater than 4 hours per night at baseline (n = 11), duration of nightly PAP usage remained high, averaging 5.2 hours per night across all nights and 6.2 hours per night on nights the device was used.

Conclusion: These preliminary findings confirm the feasibility and effectiveness of an integrated and comprehensive PAP education program for promoting greater treatment adherence and therapeutic benefit by addressing common technical and behavioral / psychological barriers to PAP use.



Presentation 2

Title: “RISE UP - Ready to Improve Sleep and Energy Using Positive Airway Pressure”: Sleep technologist insights and patient feedback on the importance of multidisciplinary care and patient education for promoting self-management of PAP technical difficulties – Part 2

Presenter(s): Michael Sepulveda, RPSGT

Introduction: Positive airway pressure (PAP) devices are the most effective treatment for patients with obstructive sleep apnea (OSA), yet average rates of adherence have remained low over the past 20 years. Behavioral / psychological challenges to PAP therapy – such as lack of knowledge, low motivation, and claustrophobia – are increasingly recognized as important intervention targets for promoting successful PAP treatment. However, technical education and problem-solving around use of PAP to promote more effective patient self-management is an equally important but often overlooked area with respect to successful PAP adoption and utilization. Addressing technical barriers to using PAP equipment is a first step in enhancing the knowledge, comfort, confidence, and motivation of patients attempting to habituate to PAP therapy. As an extension of presentation 1, we will describe insights acquired through the development of the “RISE UP - Ready to Improve Sleep and Energy Using Positive Airway Pressure” - a multidisciplinary educational, behavioral, and problem-solving skills-based group program for improving PAP adherence among patients with OSA – from the perspective of a sleep technologist. Qualitative patient feedback will be shared to further highlight the importance of multidisciplinary care and education for promoting patients’ successful use of PAP therapy.

Methods: Patients included non-adherent PAP users (average usage <4 hours) and adherent users (>4 hours) experiencing discomfort and / or dissatisfaction with PAP therapy. Patients completed a 4-session group comprised of technical education and problem solving to optimize PAP use delivered by a sleep technologist concurrently with behavioral / psychological skills delivered by a sleep psychologist. Technical education topics were designed to be patient-focused, with emphasis on self-management and encompassed the following topics: (1) PAP equipment education, (2) PAP mask optimization, (3) adjustment of comfort settings, (4) pressure range optimization, and (5) utilization of PAP accessories to address common sources of discomfort. Patients provided qualitative feedback on the educational topics / interventions, as well as the program as a whole, including ratings of their perceived confidence / readiness in using PAP therapy pre- and post-intervention.

Results: Qualitative feedback from program participants overwhelmingly emphasized the value and benefit of having PAP equipment education, as well as formal mask fittings and consultation from a sleep technologist, to problem-solve equipment-related issues. Though affected by low response rates, among respondents (n = 10), 100% endorsed moderate-to-high perceived importance of PAP, 100% endorsed a moderate-to-high level of readiness to use PAP, and 60% endorsed feeling confident in their ability to use PAP by the end of group. Additionally, patients expressed gratitude for the knowledge and support provided throughout the program, as communicated via formal and informal feedback.

Conclusions: Qualitative feedback from this multidisciplinary PAP education program underscores the benefit of technical education, equipment optimization, and active problem-solving of equipment-related difficulties with a sleep technologist for enhancing patient confidence and success using PAP therapy.



Presentation 3

Title: Pre-surgical psychological evaluation for hypoglossal nerve stimulator implant: A protocol to ensure successful outcomes for patients undergoing surgical treatment for obstructive sleep apnea

Presenter(s): Fiona Barwick, PhD, DBSM; Robson Capasso, MD

Introduction: Hypoglossal nerve stimulation (HGNS) is an FDA-approved treatment for moderate-severe obstructive sleep apnea (OSA). It is an elective procedure that involves surgical implantation of a device that stimulates the hypoglossal nerve, which controls the tongue muscle. HGNS is typically presented as a second-line therapy for individuals who have not had success with positive airway pressure therapy (PAP). The importance of identifying patient-specific characteristics and biopsychosocial factors that impact surgical outcomes is increasingly recognized when assessing potential candidates for elective surgeries. As a result, pre-surgical psychological evaluations (PPE) that assess relevant risk and protective factors for surgical outcomes have become standard practice in many elective surgeries, including spinal, bariatric and organ transplant surgeries as well as spinal cord and deep brain stimulation. Contrary to this recognized standard, and despite observed variability in patient outcomes and success in managing OSA following HGNS implantation, there is no established PPE designed to assess candidates for HGNS. This clinical gap increases the potential for suboptimal surgical outcomes due to unassessed psychosocial risk factors and comorbidities, including insomnia or depression. The equivocality of these biopsychosocial factors impacting surgical outcomes also leads to missed opportunities for supporting more successful use of less invasive and less expensive treatments such as PAP.

Methods: The Risk Factor Identification and Mitigation method, a systematic and empirical approach for developing PPE with reference to spinal, bariatric, and organ transplant surgeries, was used to create a PPE protocol for HGNS that incorporated patient information from medical chart review, clinical interview, and psychometric testing, which will be used to guide treatment recommendations prior to surgery. The PPE protocol will be trialed prior to HGNS surgery on a sample of candidates as part of routine clinical care. Information on post-surgical outcomes will be collected and compared to recommendations from PPE.

Results: An overview of the development and feasibility of administration of a PPE protocol for HGNS will be provided. A case series of HGNS candidates who completed PPE prior to surgery will be presented, highlighting pre-surgical factors associated with post-surgical outcomes. Recommendations for addressing relevant pre-surgical factors identified by PPE to optimize post-surgical outcomes for HGNS will be offered, for example, evidence-based treatment for co-occurring insomnia.

Conclusion: The development of a PPE protocol for HGNS surgical candidates would help elucidate relevant protective and risk factors associated with surgical outcomes, which could aid in determining individuals’ readiness for surgery and identify areas that may need additional support. This information could inform pre- and post-surgical treatment planning to help avoid costly and intrusive surgery if deemed unnecessary (e.g., inadequate trial of PAP therapy) and further help to improve outcomes and lower costs for those undergoing surgery (e.g., treatment for co-occurring insomnia, faster adjustment to implanted device, better management of OSA, fewer post-surgical hospital visits). Moreover, the development of this PPE would advance clinical practice by representing the first protocol of its kind that has been tailored for HGNS, providing the opportunity for broader dissemination to sleep medicine clinics nationwide.

Co-Presenter - Fiona Barwick PhD, DBSM  Student
Stanford Sleep Medicine

Co-Presenter - Jamie Tingey PhD  Student
Stanford Sleep Medicine

Co-Presenter - Michael Sepulveda RPSGT  Student
Stanford Sleep Medicine

Co-Presenter - Robson Capasso MD  Student
Stanford Sleep Surgery

Symposium Title: Novel behavioral medicine assessments / interventions for successful treatment of obstructive sleep apnea (OSA) with comorbid insomnia (COMISA)

Obstructive sleep apnea (OSA) is a chronic condition characterized by repeated interruptions in breathing during sleep that cause significant sleep fragmentation and related impairment in daytime functioning and performance (e.g., excessive daytime sleepiness and fatigue, difficulties with concentration and memory, higher rates of depression and anxiety). With up to half or more of patients presenting with insomnia having occult OSA, the co-occurrence of these disorders is increasingly described by the term “COMISA.” Approximately 12-26% of the United States’ population is estimated to have OSA, although these estimates likely under-represent the true burden of this disorder. When untreated, OSA is associated with an increased risk of adverse health outcomes (including cardiovascular disease, metabolic disorders, cognitive impairment, morbidity/mortality, and poorer quality of life), resulting in an estimated economic cost of 149.6 billion dollars due to lost work productivity, motor vehicle and workplace accidents, and increased health care utilization.

While there exist highly effective treatments for OSA – most notably positive airway pressure (PAP) therapy and, more recently, hypoglossal nerve stimulator (HGNS) therapy – adjustment difficulties and insufficient adherence to these treatments remain major impediments to therapeutic benefit. Behavioral interventions aimed at facilitating successful OSA treatment remain a relatively under-addressed area of behavioral sleep medicine and behavioral medicine more broadly, despite the intersection of this disorder with many other domains of health. In this symposium, specialists representing varied disciplines within sleep medicine will discuss individual- and systemic-level barriers to successful OSA treatment. Data from behavioral medicine initiatives within Stanford Sleep Medicine will be presented to highlight these barriers and offer alternative and novel interventions aimed at promoting more optimal, patient-centered OSA treatment.

In the first presentation, clinical sleep psychologists Drs. Molzof and Tingey will describe the development, feasibility testing, and piloting of a multidisciplinary, group-based PAP education and behavioral skills program designed to systematically address commonly encountered treatment challenges faced by patients with comorbid OSA and insomnia (COMISA). They will discuss key behavioral interventions of the “RISE UP - Ready to Improve Sleep and Energy Using PAP” program and share quantitative data illustrating the positive impact of this intervention on PAP treatment adherence. The second presentation by Michael Sepulveda, a registered polysomnographic technologist, will further delve into the behavioral and technical barriers to PAP therapy experienced by patients with COMISA. Qualitative patient feedback from the RISE UP program will also be presented to illustrate the central importance of multidisciplinary support for enhancing patients’ self-efficacy in successful PAP therapy engagement.

For the third presentation, Dr. Barwick, a clinical sleep psychologist, and Dr. Capasso, an otolaryngologist specializing in sleep surgery, will present a case series focused on their joint development of a pre-surgical psychological evaluation (PPE) for patients pursuing hypoglossal nerve stimulator (HGNS) surgery. This PPE for HGNS is among the first of its kind and aims to identify factors associated with optimal versus suboptimal surgical outcomes. Development of a PPE protocol would not only allow customized pre- and post-surgical treatment planning to optimize outcomes but would help to reduce costs and establish standards for future clinical practice.

Taken together, these presentations aim to increase awareness of the behavioral medicine opportunities that exist within the areas of OSA / COMISA treatment by highlighting current novel interventions with the additional hope to inspire further efforts in this area.



Presentation 1

Title: “RISE UP - Ready to Improve Sleep and Energy Using Positive Airway Pressure”: Psychologist insights and patient outcomes from a pilot trial of a multidisciplinary PAP education and behavioral skills group program – Part 1

Presenter(s): Hylton Molzof, PhD, DBSM; Jamie Tingey, PhD

Introduction: Positive airway pressure (PAP) devices, considered the gold-standard treatment, are the most common and effective intervention for patients with OSA. Consistent nightly use of PAP therapy has been shown to improve nighttime sleep and daytime functioning, as well as reduce cardiometabolic morbidity / mortality. However, adjustment difficulties and inadequate use of these devices remain major impediments to therapeutic benefit. The average estimated rates of non-adherence range from 29-83% and have remained persistently low over the past twenty years. Limited knowledge, technical challenges, lack of motivation / confidence, and pre-existing sleep difficulties are among the most commonly cited barriers to successful engagement with PAP therapy. Educational, behavioral, and problem-solving strategies have been found to improve PAP adherence in adults with OSA, resulting in these components being recommended as a clinical practice guideline by the American Academy of Sleep Medicine. To date, however, there have been limited efforts to combine these techniques into a comprehensive treatment package that can be efficiently and effectively disseminated to patients.

The aims of this pilot study were to (1) identify common barriers to successful and comfortable PAP use, (2) develop a multidisciplinary educational, behavioral, and problem-solving skills-based group program co-facilitated by a sleep technologist and a behavioral sleep medicine psychologist to comprehensively address the technical difficulties and psychological / behavioral barriers to PAP use, and (3) examine the impact of this program on patients’ overall PAP adherence / experience.

Methods: Patients included non-adherent PAP users (average usage <4 hours) and adherent users experiencing discomfort and / or dissatisfaction with PAP therapy. Patients completed a 4-session group comprised of technical education and problem solving to optimize PAP equipment and behavioral / psychological skills to facilitate PAP use. Behavioral / psychological techniques included PAP desensitization, sleep pressure strengthening, sleep hygiene, relaxation, mindfulness, and fatigue management. Additionally, a sleep technologist was present for each group session to provide foundational PAP education, answer PAP-related questions, and offer personalized treatment recommendations. The main outcomes of interest for this pilot program were (1) feasibility and acceptability of the format, content, and delivery of the program, and (2) PAP adherence (average hours of nightly PAP usage).

Results: Participants who were non-adherent to PAP therapy at baseline (n = 19) significantly increased their duration of PAP use by 1.7 hour per night across all nights by the end of the 4-session program. Number of nights using PAP increased from 26% to 65%, while nights using the device > 4 hours increased from 16% to 38% over 8 weeks. Among patients using PAP greater than 4 hours per night at baseline (n = 11), duration of nightly PAP usage remained high, averaging 5.2 hours per night across all nights and 6.2 hours per night on nights the device was used.

Conclusion: These preliminary findings confirm the feasibility and effectiveness of an integrated and comprehensive PAP education program for promoting greater treatment adherence and therapeutic benefit by addressing common technical and behavioral / psychological barriers to PAP use.



Presentation 2

Title: “RISE UP - Ready to Improve Sleep and Energy Using Positive Airway Pressure”: Sleep technologist insights and patient feedback on the importance of multidisciplinary care and patient education for promoting self-management of PAP technical difficulties – Part 2

Presenter(s): Michael Sepulveda, RPSGT

Introduction: Positive airway pressure (PAP) devices are the most effective treatment for patients with obstructive sleep apnea (OSA), yet average rates of adherence have remained low over the past 20 years. Behavioral / psychological challenges to PAP therapy – such as lack of knowledge, low motivation, and claustrophobia – are increasingly recognized as important intervention targets for promoting successful PAP treatment. However, technical education and problem-solving around use of PAP to promote more effective patient self-management is an equally important but often overlooked area with respect to successful PAP adoption and utilization. Addressing technical barriers to using PAP equipment is a first step in enhancing the knowledge, comfort, confidence, and motivation of patients attempting to habituate to PAP therapy. As an extension of presentation 1, we will describe insights acquired through the development of the “RISE UP - Ready to Improve Sleep and Energy Using Positive Airway Pressure” - a multidisciplinary educational, behavioral, and problem-solving skills-based group program for improving PAP adherence among patients with OSA – from the perspective of a sleep technologist. Qualitative patient feedback will be shared to further highlight the importance of multidisciplinary care and education for promoting patients’ successful use of PAP therapy.

Methods: Patients included non-adherent PAP users (average usage <4 hours) and adherent users (>4 hours) experiencing discomfort and / or dissatisfaction with PAP therapy. Patients completed a 4-session group comprised of technical education and problem solving to optimize PAP use delivered by a sleep technologist concurrently with behavioral / psychological skills delivered by a sleep psychologist. Technical education topics were designed to be patient-focused, with emphasis on self-management and encompassed the following topics: (1) PAP equipment education, (2) PAP mask optimization, (3) adjustment of comfort settings, (4) pressure range optimization, and (5) utilization of PAP accessories to address common sources of discomfort. Patients provided qualitative feedback on the educational topics / interventions, as well as the program as a whole, including ratings of their perceived confidence / readiness in using PAP therapy pre- and post-intervention.

Results: Qualitative feedback from program participants overwhelmingly emphasized the value and benefit of having PAP equipment education, as well as formal mask fittings and consultation from a sleep technologist, to problem-solve equipment-related issues. Though affected by low response rates, among respondents (n = 10), 100% endorsed moderate-to-high perceived importance of PAP, 100% endorsed a moderate-to-high level of readiness to use PAP, and 60% endorsed feeling confident in their ability to use PAP by the end of group. Additionally, patients expressed gratitude for the knowledge and support provided throughout the program, as communicated via formal and informal feedback.

Conclusions: Qualitative feedback from this multidisciplinary PAP education program underscores the benefit of technical education, equipment optimization, and active problem-solving of equipment-related difficulties with a sleep technologist for enhancing patient confidence and success using PAP therapy.



Presentation 3

Title: Pre-surgical psychological evaluation for hypoglossal nerve stimulator implant: A protocol to ensure successful outcomes for patients undergoing surgical treatment for obstructive sleep apnea

Presenter(s): Fiona Barwick, PhD, DBSM; Robson Capasso, MD

Introduction: Hypoglossal nerve stimulation (HGNS) is an FDA-approved treatment for moderate-severe obstructive sleep apnea (OSA). It is an elective procedure that involves surgical implantation of a device that stimulates the hypoglossal nerve, which controls the tongue muscle. HGNS is typically presented as a second-line therapy for individuals who have not had success with positive airway pressure therapy (PAP). The importance of identifying patient-specific characteristics and biopsychosocial factors that impact surgical outcomes is increasingly recognized when assessing potential candidates for elective surgeries. As a result, pre-surgical psychological evaluations (PPE) that assess relevant risk and protective factors for surgical outcomes have become standard practice in many elective surgeries, including spinal, bariatric and organ transplant surgeries as well as spinal cord and deep brain stimulation. Contrary to this recognized standard, and despite observed variability in patient outcomes and success in managing OSA following HGNS implantation, there is no established PPE designed to assess candidates for HGNS. This clinical gap increases the potential for suboptimal surgical outcomes due to unassessed psychosocial risk factors and comorbidities, including insomnia or depression. The equivocality of these biopsychosocial factors impacting surgical outcomes also leads to missed opportunities for supporting more successful use of less invasive and less expensive treatments such as PAP.

Methods: The Risk Factor Identification and Mitigation method, a systematic and empirical approach for developing PPE with reference to spinal, bariatric, and organ transplant surgeries, was used to create a PPE protocol for HGNS that incorporated patient information from medical chart review, clinical interview, and psychometric testing, which will be used to guide treatment recommendations prior to surgery. The PPE protocol will be trialed prior to HGNS surgery on a sample of candidates as part of routine clinical care. Information on post-surgical outcomes will be collected and compared to recommendations from PPE.

Results: An overview of the development and feasibility of administration of a PPE protocol for HGNS will be provided. A case series of HGNS candidates who completed PPE prior to surgery will be presented, highlighting pre-surgical factors associated with post-surgical outcomes. Recommendations for addressing relevant pre-surgical factors identified by PPE to optimize post-surgical outcomes for HGNS will be offered, for example, evidence-based treatment for co-occurring insomnia.

Conclusion: The development of a PPE protocol for HGNS surgical candidates would help elucidate relevant protective and risk factors associated with surgical outcomes, which could aid in determining individuals’ readiness for surgery and identify areas that may need additional support. This information could inform pre- and post-surgical treatment planning to help avoid costly and intrusive surgery if deemed unnecessary (e.g., inadequate trial of PAP therapy) and further help to improve outcomes and lower costs for those undergoing surgery (e.g., treatment for co-occurring insomnia, faster adjustment to implanted device, better management of OSA, fewer post-surgical hospital visits). Moreover, the development of this PPE would advance clinical practice by representing the first protocol of its kind that has been tailored for HGNS, providing the opportunity for broader dissemination to sleep medicine clinics nationwide.

Co-Presenter - Fiona Barwick, PhD, DBSM,
Stanford Sleep Medicine

Co-Presenter - Jamie Tingey, PhD,
Stanford Sleep Medicine

Co-Presenter - Michael Sepulveda, RPSGT,
Stanford Sleep Medicine

Co-Presenter - Robson Capasso, MD,
Stanford Sleep Surgery