Main Clinical Interests:
Sleep Disordered Breathing. Chronic Cough. Asthma. Diaphragmatic Disorders.
Main Research and Academic Interests:
Most sleep clinicians are familiar with the Obstructive Sleep Apnea Hypopnea Syndrome (OSAHS), and two syndromes with cyclic non-obstructive breathing patterns, the Central Sleep Apnea-Hypopnea Syndrome and the Cheyne-Stokes Breathing Syndrome (CSBS). A primary interest of my group has been a complex-pattern breathing abnormality that has been noted for many years, but not previously described in terms of clinical behavior and impliciations, cause, and treatment. Patients exhibiting this disorder appear at first to have purely obstructive sleep apnea, but after the application of CPAP, they develop problematic central sleep apnea or Cheyne-Stokes breathing pattern. Little is known about this unclassified group of patients; they lack a common syndromic definition, clinical or pathophysiologic description. For our purposes, we term this type of sleep-disordered breathing "Complex Sleep Apnea Syndrome" (CompSAS).
We have published a description of the clinical characteristics of this group of patients. Ongoing work includes studies to determine the underlying pathophysiology, the long term clinical sequellae, and the study of novel breathing assistance devices such as Adaptive Servo Ventilation that appear to show promise to treat this complex breathing pattern. Since the pattern resembles central sleep apnea syndrome (CSA) once the patient is treated with CPAP, we also have been adapting what we learn about treating CompSAS to our substantial population of patients who have CSA.
As one of the physicians staffing the Cough and Asthma Clinic, I am a participant in research that seeks to understand improved approaches to the diagnosis and therapy for chronic cough. Our group has adapted the use of exhaled nitric oxide to improve our understanding of the cause and therapy for chronic cough and asthma.
In addition to helping develop practice guidelines as the chair of the American Academy of Sleep Medicine's Standards of Practice committee, I am developing a method to acquire, analyze, and categorize the causes for near miss and sentinel events in the practice of hospital medicine. Sentinel events often signal break down of important underlying systems. Analysis of these root causes may lead to system improvements with the capacity to prevent future accidents. However, one of the limitations of sentinel events is that they are rare, and thus provide only limited data. An additional limitation is that they only catch what is wrong with the system, not what is right with the system as well. Near miss evaluation has the potential to generate more data, since there are inherently more near misses than sentinel events. Additionally, the study of what prevented near miss events from progressing to sentinel events provides a way of understanding the strengths of a system. This appealing aspect of "near miss" science will remain unrealized if they are not reported, or having been reported, are not analyzed and subjected to rigorous analysis. We have an ongoing program developing a merge of practice self examination and near miss reporting.
See my publications