Why I started Advanced Respiratory and Sleep Medicine: I favor the math

Most patients wait a long time for a hospital sleep study, then get handed to an outside equipment company that rarely reports back to the physician who made the diagnosis. I started Advanced Respiratory and Sleep Medicine, PLLC (ARSM) to close that gap. We diagnose straightforward obstructive sleep apnea in adults with a home sleep test, using an FDA-cleared wire-free smart ring worn in your own bed, and we treat it with auto-titrating CPAP, because that is what the evidence and the physiology support. Children are studied in person in our lab. Your first consultation happens within 1 to 2 weeks of reaching us, and testing follows from there. We see patients in Huntersville and Hickory, North Carolina, and by telemedicine, and we fit and monitor the equipment ourselves.

I have been told for years that I needed to publish content to promote my brand. Neither brands nor content existed when I graduated medical school. In the 1990s the only widely read medical writing was printed in peer reviewed journals.

I call today the age of misinformation, because the most widely read medical writing is no longer peer reviewed or published in a traditional journal. That change is both good and bad. In my opinion the quality of information published in traditional medical journals has deteriorated. The journals are exposing themselves as a media to promote advertising rather than to promote good medical information. Clicks are valued more than quality.

My intent is to provide quality. Quality information as well as quality care.

I decided to become a pulmonologist because I met Dr. Gerald Supinski during my internal medicine and pediatrics residency, on my first intensive care unit rotation. It only took a few weeks of working under him to realize that being a good physician required an intimate understanding of physiology and pathophysiology. The first step in caring for any patient is understanding the pathophysiology of the problem. To recognize pathophysiology you have to understand normal physiology. He saved countless people others thought would not live. I wanted to be like him.

That is the lens I bring to sleep apnea. Obstructive sleep apnea is not tiredness. Breathing stops or shallows repeatedly through the night, oxygen falls, and the cardiovascular system takes the strain every time it happens. Untreated, it raises the risk of high blood pressure, heart disease, stroke, and diabetes.

A wait of several months for a diagnosis is not a scheduling problem. It is several more months of a process we already know how to stop.

Dr. Randy Cebul was another mentor who changed my approach to medicine. He introduced me to the science of medical decision making. I put science in quotes because it is a horribly misused term, and medical decision making is really communicated in math. Math is the common language of a lot of professions. If you understand math you can make good medical decisions.

One of my first encounters with Dr. Cebul was in my general medicine clinic. A patient was there for an annual check up. I ordered a chest X-ray because that is what I had watched other physicians do for annual visits. He asked me why I was doing it. I told him it was because everyone else did. That was the wrong answer. He asked me about the clinical data on using a chest X-ray for screening at a well visit. I had no idea. He did. I have not ordered a screening chest X-ray for a well visit since.

I was fortunate enough to encounter two absolute legends in pulmonary and critical care medicine. Dr. E.R. McFadden Jr. was one of the world's experts in asthma and airways disease. Dr. Al Connors is one of the world's experts in critical care. They both had one thing in common. They challenged traditional medical decision making. Dr. McFadden demonstrated that severe asthmatics were more likely to die if they were put on ventilators. Dr. Connors demonstrated that the use of Swan-Ganz catheters in the ICU actually led to an increased risk of death. Neither of them thought doing things to increase a patient's chance of death was a good idea. Not everyone agreed with them. The math backed them both.

Some people think opinion is a better guide for treatment than math. I favor the math.

During my sleep fellowship I was lucky enough to spend time learning from Dr. Kingman Strohl, who was head of sleep medicine at the VA in Cleveland. When you work at the VA you have limited resources. Dr. Strohl would not let that stop him from providing care for his veterans. He had 2 sleep beds for a busy VA. If he had waited for every VA patient to go to the sleep lab, the wait time would have been years.

Back in 2003 and 2004 home sleep testing was not covered by insurance, even though home sleep testing had been shown to have a very high correlation with in-lab testing for diagnosing sleep apnea in the correct population. That is the math. It did not stop Dr. Strohl from using home sleep testing on his patients. He was able to treat his veterans in a timely manner without sacrificing quality.

When it came to treating sleep apnea, Dr. Strohl would start most of his patients on auto-titrating CPAP machines. An APAP machine is a smart CPAP that monitors the patient's airway resistance on every breath and adjusts the pressure to keep it in range. In a multicenter randomized equivalence trial that followed patients for 2 years, auto-titrating CPAP and fixed CPAP produced equivalent improvements in sleepiness at similar cost (Bloch et al., Thorax, 2018). That is the math again.

Airway resistance is also a dynamic value. It depends on the position a person is sleeping in, the stage of sleep they are in, how congested their nose is, whether they are on sedating medications. I love it when physiology supports the math.

APAP is also more cost effective than bringing patients into the sleep lab for a manual titration (McArdle et al., Thorax, 2010). Patients prefer avoiding the sleep lab if they can. In my opinion that is a win-win. It should be the default approach to treating straightforward sleep apnea. It is not. Why?

The break and extended wait in the top track are the parts patients feel. Once an outside vendor takes over the equipment, nobody is checking whether the therapy is working.

For referring providers. ARSM follows the American Academy of Sleep Medicine clinical practice guideline for diagnostic testing in adult obstructive sleep apnea (Kapur, Auckley, et al., 2017). Home sleep apnea testing with a technically adequate device is used for uncomplicated adult patients whose signs and symptoms indicate an increased risk of moderate to severe OSA. In-lab polysomnography is used for patients with significant cardiorespiratory disease, potential respiratory muscle weakness from a neuromuscular condition, awake hypoventilation or suspected sleep related hypoventilation, chronic opioid use, history of stroke, or severe insomnia. If a home sleep apnea test comes back negative, inconclusive, or technically inadequate, we bring the patient in for polysomnography rather than stopping there.

Bronchoprovocation testing, the methacholine challenge, was for a long time ordered routinely to diagnose asthma. I still see people using it in 2026.

There is one problem with it. Airway responsiveness to methacholine is common in people who do not have asthma, so a positive result means much less than most people assume. The value of the test is in a negative result. If the patient does not respond, asthma is very unlikely.

When a patient presents with a respiratory complaint, it is my job to tell them what is causing it. I do not find it helpful to tell them what they do not have.

A child who will not fall asleep or stay asleep is a different problem from a child who snores, gasps, breathes through the mouth, sweats heavily during sleep, or is worn out during the day despite enough hours in bed. Those are signs of upper airway obstruction, and they need a pediatric sleep evaluation rather than a change to the daytime routine.

Dr. Carol Rosen brought my attention back to the world of pediatrics after I had spent most of my fellowship in adult medicine. I spent more time with her during my sleep fellowship than I did with the adult sleep medicine faculty. Being exposed to the neurophysiologic and cardiopulmonary changes that occur in the first months of life changed my overall understanding of sleep. She also introduced me to narcolepsy. The way she led a pediatric sleep lab was an education by itself, and I still apply her methods in my lab today.

Pediatric sleep diagnostics are scarce in North Carolina. I am board certified in Pediatrics and in Sleep Medicine, so a family does not have to change practices as a child grows into an adult. We handle pediatric sleep disordered breathing, narcolepsy, behavioral sleep problems, insomnia, restless legs syndrome, and adult obstructive and central sleep apnea.

Children are studied in person, in our lab in Huntersville or Hickory. Home testing is for patients 18 and older. A child's sleep is not a smaller version of an adult's, and the things I learned from Dr. Rosen about what changes in the first months of life are the reason I want eyes on a pediatric study.

At most health systems, once a patient has a diagnosis they are handed to an outside durable medical equipment vendor. Those vendors rarely send compliance data or clinical problems back to the physician who made the diagnosis. When a mask leaks or a pressure setting is uncomfortable, the patient stops using the machine. That absence of follow-up is a major reason CPAP use drops off in the first year.

ARSM holds its own DME license.

• Fitting. CPAP, APAP, and bilevel devices are configured and fitted by our own clinical team.

• Monitoring. We track compliance and leak rates from the device data, under my supervision.

• Adjustments. Pressure changes and mask refittings are handled by the same team that has your diagnostic history.

I hold board certification in Sleep Medicine, Pulmonary Disease, Critical Care Medicine, Internal Medicine, and Pediatrics. That is 5 specialties and 6 board examinations. After I passed the American Board of Sleep Medicine exam, which is a lifetime certification, sleep medicine certification moved to the American Board of Internal Medicine. I was worried I might be excluded from some plans without the newer board, so I sat for sleep medicine twice.

I also hold a Master of Science in Clinical Research from Case Western Reserve University and have been principal investigator on more than 100 FDA clinical trials in sleep and respiratory medicine. ARSM was the only participating site in Mecklenburg County for a clinical trial of an investigational oral therapy for obstructive sleep apnea.

Two of the people I trained under went on to write the standards I practice by. Dr. Dennis Auckley co-authored the American Academy of Sleep Medicine clinical practice guideline on diagnostic testing for adult obstructive sleep apnea (Kapur et al., 2017). Dr. Carol Rosen co-authored the AASM position statement on arousal-based scoring in polysomnography (Malhotra et al., 2018). When I say our protocols follow the guidelines, those are the guidelines, and those are the people who wrote them.

Yes, I passed 6 board exams, even more board recertifications, and earned a master's degree, but lots of people can read books and pass tests. I would not know quality if I had only read books and passed tests. The application of the knowledge is the most important part of the training, and for that you need great teachers. I was lucky to have them. I left a lot of people out of this but I will probably mention them in future blogs.

Print or screenshot this for your referral coordinator.

Adults. You test at home, in your own bed, with an FDA-cleared wire-free smart ring. No wires, no lab, no overnight stay. Kits ship to you or can be picked up in Huntersville or Hickory.

Children. Pediatric studies are done in person at our Huntersville or Hickory office. Home testing is for patients 18 and older, so a child gets evaluated in the lab where we can watch everything that matters at that age.

Either way:

• In-person visits at either office, or a virtual consultation if getting to an office is the hard part

• CPAP fitted and monitored by the same practice that diagnosed you

• The same team from the first appointment through long-term follow-up

What to expect:

We schedule your first consultation within 1 to 2 weeks. Testing happens on your schedule from there. Adults test in their own bed, and children are studied in person in Huntersville or Hickory.

Kapur VK, Auckley DH, Chowdhuri S, Kuhlmann DC, Mehra R, Ramar K, Harrod CG. Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017;13(3):479-504. https://doi.org/10.5664/jcsm.6506 

Malhotra RK, Kirsch DB, Kristo DA, Olson EJ, Aurora RN, Carden KA, Chervin RD, Martin JL, Ramar K, Rosen CL, Rowley JA, Rosen IM. Polysomnography for Obstructive Sleep Apnea Should Include Arousal-Based Scoring: An American Academy of Sleep Medicine Position Statement. J Clin Sleep Med. 2018;14(7):1245-1247. https://doi.org/10.5664/jcsm.7234 

Bloch KE, Huber F, Furian M, Latshang TD, Lo Cascio CM, Nussbaumer-Ochsner Y, Senn O, Russi EW, Kohler M, Schoch OD, Turk A, Imhof E, Laube I, Matthews F, Thurnheer R. Autoadjusted versus fixed CPAP for obstructive sleep apnoea: a multicentre, randomised equivalence trial. Thorax. 2018;73(2):174-184. https://doi.org/10.1136/thoraxjnl-2016-209699 

McArdle N, Singh B, Murphy M, Gain KR, Maguire C, Mutch S, Hillman DR. Continuous positive airway pressure titration for obstructive sleep apnoea: automatic versus manual titration. Thorax. 2010;65(7):606-611. https://doi.org/10.1136/thx.2009.116756 

Citations retrieved from PubMed.