Female in 60s, Hx of minor stroke, BMI 21, presenting with insomnia + excessive daytime sleepiness, ESS 19. PSG: severe NREM dominant OSA, AHI 37 (NREM 39, REM 5). 1st started CPAP + stimulus control + no napping. Then added gentle sleep restriction + hypnotic medication. #COMISA

Richard Liu, MD, FRCPC, DABPN, CSCN (EEG), MSc How do you add sleep restriction?

Sandeep Kumar I only add sleep restriction after starting CPAP, otherwise, we are just condensing poor-quality sleep. I set alarm at patients' average wake time, and delay their bedtime. In COMISA, I do this 'gently', and do not restrict very aggressively, ie here I only restrict to 7.5 hours

Sandeep Kumar The limitation is also that in my clinic I can't follow patients as frequently as #CBT -I therapists, nor do I have the full training of a psychologist for CBT-I

But I do want to start this sooner, as improving insomnia will also improve ventilatory stability and #CPAP tolerance

Richard Liu, MD, FRCPC, DABPN, CSCN (EEG), MSc Sandeep Kumar Nice way of displaying this success. We just published a lit review and meta-analysis showing that it is effective and safe to deliver CBT prior to PAP therapy in COMISA patients. :) doi.org/10.1111/jsr.13… Alex Sweetman Douglas Wallace