Dr. Matthew Robertson
First in the region to offer Inspire Sleep Therapy
Hello, my name is Dr. Matthew Robertson, a board-certified otolaryngologist with Alpine Ear, Nose, and Throat in Fort Collins, CO. I am proud to introduce the first implant center for Inspire Sleep Therapy in the Rocky Mountain Western Region. Our program is founded upon decades of surgical and medical experiences that uniquely qualifies us to provide this novel treatment option for CPAP-intolerant OSA patients.
History of Inspire
How did Inspire technology arrive in Colorado and the Rocky Mountain Western Region?
My journey with Inspire started over 3 years ago. I vividly remember being on a family vacation in Moab, UT. I was watching Johnny Manziel walk across the NFL draft stage during my first call to Inspire. At that time, Inspire was a small, East Coast company with a tiny footprint in the Western US. In fact, the closest implant centers for Inspire were Stanford (CA) or Baylor (TX). A courtship and vetting process ensued, and I worked to assemble a team. Fortunately, Inspire has worked out much better for us than Johnny Manziel did in football!
For the previous 10+ years, I have been performing a very similar surgery for epilepsy called Vagus Nerve Stimulators (VNS). There are twelve cranial nerves that leave the brain and direct traffic between itself and the rest of the body. The vagus nerve is the 10th cranial nerve and is a very important and complex nerve. It travels from the brain to the abdomen. In the neck, it lives between the carotid artery and the jugular vein. The vagus nerve controls many things such as the voice box, the heart, and the gut. It can make you faint (or not). The left side has different functions than the right. Decades ago, it was realized that electrical impulses to this nerve can reduce the seizure burden in patients with epilepsy.
Prior to Inspire, VNS therapy was the only FDA-approved cranial nerve stimulator surgery. VNS therapy is a niche surgery market, and my surgical volumes have consistently grown over the past decade. To date, I have performed well over 300 VNS surgeries with zero major complications. I can proudly claim that these volumes are significantly more than any practicing surgeon in the Rocky Mountain Western Region. It is this familiarity with cranial nerve stimulator surgery which initially sparked my interest in Inspire Sleep Therapy.
When I first read about Inspire 3+ years ago, the concept intrigued me. As a “throat cancer surgeon”, I am very familiar with cranial nerves and I routinely encounter many of them during surgery. However, I know cranial nerve stimulators even better. At that time, I was also experiencing less than satisfactory success rates after surgery for my own OSA patients. This is one of the most humbling feelings a surgeon can endure. I was removing tonsils, uvulas, and palates. I was opening the nose and sinuses. I was breaking the jaw and pulling it forward in hopes the tongue would “advance” out of the airway. I would stick implants in the palate, inject alcohol into the uvula, or cauterize the tongue in hopes to “stiffen” it. In life-threatening cases, I was even placing tracheostomy tubes in the neck, knowing that this ultimately bypassed the site of obstruction.
With my VNS experience, I knew that I was uniquely qualified to implant a “hypoglossal nerve stimulator”. The Hypoglossal nerve is the 12th cranial nerve and “lives just 2 houses away” from the Vagus (10th cranial) nerve. But did Inspire really work? I knew that the surgery could be performed on many patients, but which ones should get this surgery? As time passed, I researched the studies and spoke to colleagues from the West Coast to the East Coast. There was a growing consensus that this “thing” really worked! Could it be possible we were “missing the boat” all along? After all, we have been aware of similar technology for decades. We have pacemakers, deep brain stimulators, vagus nerve stimulators, and spinal cord stimulators. Was the solution to simply deliver gentle stimulation to the upper airway muscles via the hypoglossal nerve to keep the airway open while sleeping? And this technology has been under our fingertips all along?
As time passed, this idea made more sense to me. It seemed like this could finally get to the root cause of the problem—the tongue and the upper airway muscles. I liked the idea that a sleep endoscopy could be performed before surgery to confirm this root cause. The more sleep endoscopies we performed, the more we realized that the tongue and upper airway muscles were causative in the majority of cases. Unfortunately, a small percentage of patients are not good candidates for Inspire based upon their anatomy during sleep endoscopy. But it is surely nice that we can identify those patients prior to surgery. Until now, sleep apnea surgery was like buying a car before getting to test drive it. Sleep endoscopy changed that for Inspire. This was different and I felt good about that.
Once I was convinced that I could be technically proficient at the surgery AND that it worked, I had to build a team. One independent, small-town, private practice physician simply isn’t enough for that. Once upon a time, bringing a new technology to the forefront was straight-forward. But today it is a “committee maze”. One committee ensures safety. The next committee assesses whether or not it works. Then there is a committee to evaluate whether or not it works in randomized trials. Finally, there are committees who make suggestions to the other committees. At that time, I knew that I was uniquely qualified to perform the surgery and I was trusting in the technology—all I wanted to do was to start getting them implanted! While this “committee maze” did frustrate me, it serves a valuable purpose in the end. It is a type of “checks and balances” process to protect you, the patient.
I knew that a strong relationship with sleep apnea physicians was paramount for an Inspire implant program to succeed. One thing I have realized about my VNS program is that I have the easy job. At times, it can seem like I am simply the “technician”. I will often joke with VNS patients about being the “cable TV installer”. I don’t determine if the “customer” gets HBO or Showtime. The neurologist determines if a patient is appropriate for VNS and I simply do the surgery and shepherd the patient through the recovery process. But Inspire was different and new. I was in uncharted waters. I knew that I really needed to be invested and involved in all policies and procedures leading up to and after the surgery. I needed to build relationships with providers who understood everything from sleep medicine to sleep labs. Throughout that journey, I have met some of the most committed, passionate people and true patient champions. I was able to see what patients were enduring and it was humbling.
So there you have it! That’s how Inspire came to the Rocky Mountain Western Region. It wasn’t easy, but it would have been much more difficult without my VNS experience. I saw the striking similarities between VNS and Inspire. Inspire treats a different nerve (hypoglossal) for a different reason (OSA). But the technology and surgical techniques are quite similar. I am grateful for my VNS experience and firmly believe it has uniquely qualified me to build a successful Inspire program.
The Inspire Process
What does the implant process entail?
First, speak to your doctor about Inspire. We have engaged physicians up and down the Front Range, including Wyoming. This has typically been in the form of lunch-hour presentations or lectures to explain the technology and discuss the implant process. There is a good chance your doctor has been contacted by myself or one of our team members.
You are also welcome to contact one of our intake specialists to learn more. We would be glad to start collecting data and give you an “aerial-view” of the entire process. We will gather medical records and sleep studies that describe your specific condition. We will often request an updated sleep study to ensure that certain parameters are measured which can affect your candidacy for Inspire. Your local doctor can order this or we would be glad to do it for you. These can be in the form of a home sleep study instead of an in-lab study. However, certain parameters must be measured, such as the degree of central apneas present during your sleep. If your local doctor does repeat the study, please ask him or her to contact us so we can ensure the correct type of study is performed. Early on, you will also be asked to start writing down your opinions about why you think you are CPAP-intolerant (more on this later, i.e. “essay”).
Once we ensure that you meet preliminary inclusion criteria, we will offer you a consultation with Dr. Mark Neagle, a pulmonologist who exclusively treats sleep problems. He works closely with 2 physician assistants whose practices are also limited to sleep medicine. This consultation is called an “Inspire/DISE consultation”. At that visit, your history will be reviewed and the cause of your CPAP-intolerance will be determined. If appropriate, you will be offered a date for a DISE, or Drug-Induced Sleep Endoscopy. For patients traveling from out-of-town, we can try to schedule the office visit and the endoscopy on the same day to minimize travel burdens. The DISE procedure is a critical part in the candidacy workup and is almost always approved by insurance. This involves administering intravenous anesthetic to induce deep sleep and its associated apneic episodes. While you are asleep (and snoring), Dr. Neagle will place a flexible scope in your nose and a brief, 10-15 minute video is recorded. He wants to ensure that the tongue base is truly causing your apnea and that there are no other sites of airway collapse that would contradict proceeding with Inspire. Most patients (~85%) who meet preliminary inclusion criteria are good endoscopic candidates for Inspire after their DISE procedure . However, if you are noted to have any endoscopic findings that suggest you may not be a good Inspire candidate, we will ask for a 2nd opinion from another implant center. We can easily share endoscopic video with other centers in a HIPPA-compliant fashion for their opinion and vise-versa.
You will be informed of your DISE findings immediately after waking up. If you are a good endoscopic candidate, then the candidacy workup is complete and you will be offered a formal surgical consultation with myself. During that visit, I will review your case in its entirety and we will discuss the surgery, risks, and recovery. I will also query you about why you are CPAP-intolerant. After our meeting, you will have all the requisite information necessary to make an educated decision about whether or not Inspire is right for you. At that point, I will be glad to start the insurance approval process should you desire.
What does the insurance approval process entail for Inspire? Why is it so difficult to get approved? Are there cash-pay options?
Inspire is an FDA-approved treatment option for CPAP-intolerant OSA patients who meet certain criteria. It is not experimental. Period. It is, however, relatively new. As with most new medications, treatments, or surgeries, insurance carriers are usually slow adopters. Very slow adopters.
If you desire proceeding, my office will work closely with Inspire to submit a request on your behalf for a “pre-determination of benefits”. This is a formal letter that summarizes scientific data, DISE findings, previous failed surgical or medical treatments, sleep studies, and excerpts from your “essay” (see below). This initial request is usually denied, but we will promptly appeal this decision with even more data. Unfortunately, this appeal is also often denied. The insurance company’s reviewing physician will oftentimes have little working knowledge about OSA. For example, a gynecologist or orthopedic doctor may be reviewing your case. But after the second denial, we can usually request a final appeal that is called an external medical review. This typically means that an independent panel of specialty-specific physicians review the case. These are physicians who are much more likely to have a a working fund of knowledge about OSA. At this point, we typically win and approval is granted. However, this process can take 3-6 months. And this does not even include the time spent navigating the candidacy process and having DISE performed. The bottom line is that this process will test your patience. But in the end, this may be a good thing because it gives you plenty of time to make sure Inspire is right for you.
I often wonder if insurance companies try to make this process tedious in hopes that we (or you) “go away” after the first or second denial. But our program is pesky, persuasive, and persistent. Rest assured, we will not give up; we will communicate with you during all phases of this process. And remember this—with each denial, we are getting one step closer to approval!
I have had several patients inquire about a cash pay price. I am currently working with the hospital to establish this. Once this is decided, I will be glad to share details with those who inquire.
What should I expect on my surgery day (and beyond)?
The Inspire implant procedure takes approximately 90 minutes. I have performed over 300 cranial nerve stimulator surgeries, and I will admit this one was humbling. My first Inspire surgery took almost 4 hours! But as with all new surgical techniques, there is a learning curve. Our OR team has been particularly successful in streamlining the surgical workflow from arrival to discharge. We have an experienced track-record with VNS surgery, and I am fortunate to have the the same team members, nurses, and surgical principles for Inspire.
I will personally visit with you and your family prior to surgery. This is the time to ask any last minute questions about the surgery, recovery, or post-op process. But given the extensive pre-op work-up with Inspire, this is typically light-hearted. All patients are well-informed by this point and most are at peace with the surgery. I am always happy to pray with those who ask. I may use a marker to highlight incision lines, bra-strap lines, or previous scars. A nurse will give you a bottle of nasal decongestant that will allow easier passage of your breathing tube while asleep. The surgery is usually performed on the right in the event you someday need a pacemaker. However, I have performed the surgery on the left if your situation warrants that.
Once we are in the operating room, you will scoot from a hospital bed to the operating table. It is a skinny table and a “seat belt” will be placed across your hips. The OR is chilly because of all the layers of sterile gowns we wear. But soon after entering the OR, you will be wrapped in pre-warmed blankets. I am usually in the OR holding your hand while drifting off to sleep. The anesthesia doctor will ask you to breath pure oxygen from a mask that smells like a beach-ball. He or she will ask you to take deep breaths to maximize your oxygen levels. The anesthesia doctor will give medication through your IV that will make you sleepy. Once you are asleep, he or she will place a tube in your nose. This is called intubation and the tube remains in place throughout the surgery so that your lungs receive the oxygen they need.
The first 10 minutes of surgery involves patient positioning and sterile prep/scrub. I will place a clear, plastic sterile sheet over your face so that I can later see tongue motion when stimulating each branch of your hypoglossal nerve. A nurse will scrub your chest and neck under sterile conditions. I will inject local anesthetic in each of the 3 incision areas. This minimizes blood loss and allows you to later wake up with very little pain. I will place 2 very small needle electrodes within the tongue muscles at strategic locations. These monitor different types of muscle contractions once the nerve branches are identified. Certain branches of the hypoglossal nerve must be included in the electrode array and other branches must be excluded. Most branches are called protrusors (sticks the tongue out) and those are precisely the ones I must wrap within the electrode. But a few branches are called retrusors (pull the tongue in), and those are the branches I must exclude from it.
The neck incision is the 1st of three incisions, each of which measures ~2”. This starts in the middle, under your chin, and parallels your jawline. I will identify the main trunk of your hypoglossal nerve and will follow it as it enters your tongue muscles and branches into distinct, albeit smaller nerves. At this point, a small probe is used to deliver an electrical stimulus to each of these branches. I will observe tongue motion as well as read the waveforms that result from the nerve monitor electrodes that are in your tongue. Once I am certain that the major protrusor/retrusor branches are identified, I will wrap the lead around the target nerve branches. At this point, there is a lot of suturing so the lead is secure. I must leave a significant amount of slack in the wire so that there is no tethering in the future when you rotate your head.
The second incision is on the upper chest where I will create a “pocket” for the generator to live. When possible, I will tuck this behind breast tissue. Breast implants do not preclude Inspire, but I need to be aware of them during this part. Finally, I will make a third (sensing lead) incision on your side, well below your armpit. I will identify two distinct layers of muscles between the ribs and place the sensing wire between them.
At this point, I will use something called a “tunneling device” to connect the space between all three incisions. These are commonplace in several surgeries where we need to create a “hidden tunnel” between incisions that are separated by distance. Once the two leads are advanced through the tunnels, the connections are secured to the generator with a surgical-grade “torque wrench”.
I will perform a series of diagnostic tests which measure electrical parameters such as impedance and resistance. I will work closely with the anesthesia physician to make sure the sensing lead is accurately monitoring your breathing patterns during inspiration and expiration. Finally, I will administer a few test impulses while both visually inspecting the tongue and watching the waveforms from the electrodes that are in your tongue.
Once I am pleased with these results, I will irrigate the wounds with antibiotic solution and close them with 2-3 layers of sutures, all of which are dissolvable. Nurses will apply sterile dressings and a sling to your arm. In the recovery room, a chest X-Ray will be performed to ensure there is no pneumothorax (leak of air around the lung) from the sensor wire placement. After a couple hours of recovery, you are free to go home.
Some Inspire patients travel from out-of-town. You are welcome to stay in a local hotel if you prefer and we would be glad to make some recommendations. Leave your bandages alone for 2-3 days. At that point, you can remove them and start using Bacitracin ointment three times daily. I like to check the wound after one week. But if you are from out-of-town, we can electronically share “wound-check photos” in a HIPPA-compliant fashion. Your tongue may be swollen for a couple days because of the needle electrodes that were in it. Please wear the arm sling for a few days, preferably for a whole week. You can expect pain that is mild-to-moderate. Some patients only use Tylenol, while others take Vicodin as needed. Regardless, there should be no need for pain medication after 5-7 days.
One month after surgery, your device will be “activated.” This means that it will be turned on at a lower level. You will be given a remote with a range of settings and encouraged to use it all night, every night. This allows you to gradually acclimate to the device and allow it assimilate into your lifestyle. Most patients start noticing immediate improvement at this point. However, after a month of acclimation, you will return to the sleep lab to perform a formal titration study. This is very similar to CPAP titrations; but instead of adjusting pressure, we are adjusting voltage. We will identify the lowest amount of voltage necessary to achieve our treatment goals.
The battery should last 10 years. Since Inspire is so new, I have not had to replace any generators yet. However, it is very similar to a VNS generator change and I typically can do this in less than 15 minutes. During a generator change, only the middle/chest incision would be opened and the recovery is speedy.
Is Inspire right for me?
Yikes, this is a tough one! I am going to start by saying that I will express my personal opinions in this answer, not scientific explanations or sales pitches. This section is me, singularly discussing my opinions and sharing my observations and patient interactions. Finally, I have no financial disclosures with Inspire or any hospital system. I am independent physician, which means I do not work for Inspire or a hospital system. I will say and do what I feel is best for my patients. Period.
There are 3 main preliminary inclusion criteria which must be met to be a candidate for Inspire.
The first two of these are objective measures (BMI and AHI). BMI (Body Mass Index) “should” be < 32. Many sleep apnea patients will be excluded based on this criterion alone. However, our center does have a board-certified, independent, obesity medicine physician for patients who are “close.” I define “close” as a BMI of 32-35. Once a patient in that range demonstrates significant progress towards a goal BMI of 32, we can consider formally requesting insurance approval.
The second of these objective measures is an AHI (Apnea-Hypopnea Index) of 15-65 which defines moderate-to-severe OSA. This means that you stop breathing 15-65 times per hour. Your sleep study must also have ruled out significant central apneas. Central apneas occur when your brain is not “telling” your body to breathe. Central apneas must account for less than 25% of your total apneas to be considered a candidate for Inspire. Why can’t Inspire be used for patients with AHI’s of > 65? The short answer is that these criteria were used for clinical (STAR) trials during the FDA-approval process. The long answer is as follows. Let’s assume your AHI is 100. Let’s assume we did perform the surgery and we were able to see an 80% reduction in your AHI. That would result in a post-operative AHI of 20. That degree of residual apnea would still require CPAP and your cardiovascular risk profile would still remain high without it. So the short explanation to the long answer is that Inspire has diminishing returns when AHIs are greater than 65.
The third and final criterion is “CPAP-intolerance.” Of all the candidacy criteria, this is the only subjective measure. However, in my opinion, it is the most important. Why? Before considering CPAP-intolerance, each and every Inspire candidate “looks” the same on paper. They all have BMIs and AHIs that fit within an objective range. It’s almost like saying, “in order to get this surgery, you must have blond hair and blue eyes.” But CPAP-intolerance is what differentiates a great candidate from a poor candidate. CPAP-intolerance is what determines who needs Inspire versus who wants Inspire. Let me explain this by using some real-life patient examples.
J.D. is a 24 year old competitive bodybuilder from Denver who saw me for an Inspire surgical consultation. J.D. had an AHI of 50 and a BMI of 31. Obviously, he was in phenomenal shape and couldn’t possibly be asked to lose any more weight. J.D. was an athlete and was well-versed with the long-term cardiovascular risks associated with OSA. Based on the objective measures alone, J.D. appeared to be a great candidate. But the conversation ended abruptly when I asked him to explain his “CPAP-intolerance.” J.D. told me that when he actually used the machine, he felt better. He pulled out his phone and showed me a photo of his beautiful girlfriend, Sarah. J.D. said, “Doc, I love this girl and she doesn’t like the sound of the machine. And quite frankly, I just don’t think it’s sexy.” The room fell silent. I told him that I was sorry but he could not get Inspire. I compassionately told him, “J.D., I get it. I really do. Nobody wants to wear CPAP. Especially a 24 year-old single guy. But in 2016, we aren’t there yet. Keep your faith and determination, and come back to see me in a few years. By then, things may be different. But I can’t recommend that you have this surgery because you are not genuinely CPAP-intolerant.”
Now I’d like to give you some other real-life examples to help illustrate genuine CPAP-intolerance. Again, I would like to emphasize that these are my opinions based on real patient experiences. Other patients or physicians may disagree, and that’s fine. But as the trailblazers in the Rocky Mountain Western Region, this is how I think Inspire should be incorporated into our toolbox to treat certain sleep apnea patients. I think our approach to this has been genuine, ethical, and sustainable.
Meet G.D., an air-traffic controller who lives in New Mexico. G.D. had 10+ surgeries for his OSA at Stanford, Harvard, and even a few local surgeries. G.D. had so many surgeries that some were done to “revise” surgeries that had previously failed. He had tried CPAP, BiPAP, and mouthpieces. He had his jaw broken surgically and advanced forward. He had his tongue cauterized in hopes it would “stiffen”. He had his tonsils and palate removed. He had lost weight. G.D. tried to use CPAP for years but could only tolerate it when he had sleep and anxiety medication to reduce his claustrophobia and panic. The “hangover” he experienced from these medications seemed worse to him than the sleep apnea itself. As you can imagine, this could cause issues with his occupation and could put lives at risk. Fortunately, G.D. has been implanted and is now doing well without CPAP, sedatives, or sleeping meds.
Now meet B.T., an electrical power linesman contractor in Texas and Oklahoma. He works in the oil and gas industry. He works at “extreme heights and voltage potentials, and operates heavy machinery in motion”. B.T. has not been implanted (yet) because his BMI was initially 34. He has since lost weight and is now in the insurance approval process. B.T. suffers from severe claustrophobia and panic attacks with objects touching his face. In B.T.’s “essay”, he discussed how this once affected him during a dental procedure when he was administered nitrous oxide. He states, “When they started the gas flow, I went into full panic/anxiety attack mode and actually felt the effects of shock, paleness, shortness of breath, and lightheadedness.” For him, CPAP triggered the same response. He describes CPAP as “an image of me being in a structure when a tornado or another sort of calamity happens, collapses that structure, and I am being buried alive.” B.T.’s feelings are so strong that he says, “If I were ever in some sort of accident, I hope I would be pronounced dead at the scene rather than someone plugging my nose and blowing into my mouth for resuscitation.” Strong words? Yes. Over-the-top? Maybe. But straight from his heart; and after all, who am I to judge that?
A few months ago, I met D.S., a woman who was struck in the face by a foul-ball at a Rockies game in 2011. She suffered severe facial and orbital fractures. After her injury, she was never able to wear CPAP again. She developed jaw problems and couldn’t wear a mouthpiece. She was not overweight. The mask leaked air, possibly due to her altered skeletal structure. It was painful on her previous fracture lines. She found herself truly “between a rock and a hard spot”. The Rockies were gracious enough to write a letter authenticating her story and I think this helped in the insurance approval process. She has since undergone implantation and is healing while awaiting activation.
I have also seen patients who are nurses. One, in particular, is a pre-op nurse at a large hospital in Denver. She is groggy at work and once actually caught herself before administering the wrong dose of medication. Or the river rafting guide who is “on the water” 100+ days per year. Or the patient who lives off-grid. Or the fishery biologist who backpacks to survey lakes for several days at a time. Or the prosecutor who has an allergic reaction to the plastic in her mask and is trying to put crooks in jail with a red triangle on her nose/face. Or the teacher and coach from Wyoming who is giving his lesson plans out of order and mixing up the baseball roster. Or the truck driver.
Not everyone has a dangerous job, but these examples illustrate patients who are truly suffering from inadequately treated OSA, a “silent killer”. And better yet, these examples demonstrate the types of patients who need Inspire. In 3-5 years, perhaps we will implant more patients who simply want Inspire. But in 2016 we need to clearly document why a patient is “CPAP-intolerant” prior to proceeding with surgical consultation.
To that end, we ask every Inspire candidate to write an “essay” about why he or she is CPAP-intolerant. Several positive things have resulted from this exercise. First, and most importantly, it helps to determine whether a patient is genuinely CPAP-intolerant. It helps to differentiate patients who want versus those who need Inspire. Secondly, it causes patients to become more invested in the their care and involved in the process. Oftentimes, patients will say they really didn’t appreciate how severely OSA has impacted their quality of life… until writing this! Finally, these essays serve as a “triage tool.” We have had hundreds of inquiries for Inspire with only 2-3 intake specialists to triage them all. The essay allows us to allocate our resources in the most efficient manner possible. These essays have been a most powerful tool. We ask that they are always truthful and always ethical. From this exercise alone, I have seen many great Inspire candidates. These patients are committed, entrenched, and very capable and competent at advocating for the type of care they deserve. So please don’t take offense to the notion of writing an “essay”. B.T.’s essay was the most compelling one I have ever read. It was a hand-written, 5-page glimpse of his struggles with CPAP. It doesn’t need to be fancy, just truthful and self-reflective. In the end, this is a tool to protect you, the patient. As exciting as Inspire is, I always want to ensure that we implant the right patient for the right reason, each and every time.
What is unique about our Inspire implant program?
When I started to develop our program, my goal was not to be average. It was (and still is) to be part of something truly extraordinary. I try to be in the “top tenth of one percent” in everything I do. That is the type of attitude and attention to detail I have tried to instill in all our our team members. The “small things” may seem inconsequential to some; but these same “small things” can mean the world to someone in need. For example, one of our patients was struck in the face by a foul-ball at a Rockies game in 2011. She has struggled with wearing her CPAP mask ever since. I wanted to authenticate her story in hopes this would make the insurance process “easier”. I called the Rockies organization and they were gracious enough to write a letter on her behalf. Her surgery was approved and she is healing while awaiting activation. I am not certain if this truly helped her surgery get approved, but it certainly didn’t hurt either. These are the types of “above and beyond” efforts that a center of excellence should do for each and every patient, each and every time.
Early-on, I also wanted to have a means to capture patients who were overweight and had a BMI > 32. On paper, these patients may not meet criteria today. But the excitement surrounding Inspire may provide the necessary spark for them to be candidates tomorrow. To that end, I have engaged other local physicians who deal with weight loss on a daily basis. I have collaborated with independent obesity medicine and bariatric surgeons for these patients and I am proud they are part of our team.
Most importantly, our Inspire program is founded upon a wealth of experience with every team member. From a surgical standpoint, I am uniquely qualified by having performed over 300 cranial nerve stimulator surgeries. Our board certified sleep medicine physicians are augmented by physician assistants who also have practices limited to sleep medicine. Our Inspire Program Director has served as the sleep lab lab manager at Poudre Valley Hospital/Medical Center of the Rockies for over 15 years. Together, we have decades of requisite surgical and sleep medicine expertise for improved patient satisfaction and unsurpassed patient outcomes.
What does the future hold?
Of course, I don’t have a crystal ball. But here are some of my thoughts.
First, there are some very exciting developments on the horizon with Inspire and Down Syndrome children (and adults). We currently do not have FDA-approval for Inspire in the pediatric Down Syndrome patient population. However, this is precisely the patient population that I suspect would benefit MOST from Inspire. Sleep apnea and a large tongue are almost always present in these patients. I would like to be an investigator and implanting surgeon for these off-label, multi-center, clinical trials. In my opinion, untreated OSA plays a significant role in the shorter life-expectancy of these individuals. I am currently in discussions with Inspire and our Down Syndrome community to bring this issue to the forefront.
Secondly, we need to better appreciate the relationship between sleep apnea and cardiovascular risk profiles. I believe there could be secondary gains with Inspire in certain patient populations, such as those with Atrial Fibrillation. Some physicians are hypothesizing that the benefits of Inspire could be realized in the realm of cardiology. For example, could Inspire result in fewer cardiac ablations? Could Inspire result in less blood-thinner use? I have fielded calls from cardiologists/electrophysiologists who have Inspire on their radar for their patients. That alone tells me this is gaining traction in those arenas.
Finally, I am always trying to minimize the incision size. I am even trying to figure a way to perform this with 2 incisions, instead of 3. While I am not ready to do this yet, it’s something to strive for. These are they types of things that a center-of-excellence should do. Focused on better outcomes and always forward-thinking. Trying to be versatile and accommodating. And making sure that we are committed to quality, not quantity. Doing the right thing for the right patient—each and every time.
New Sleep Apnea Surgery to Help Denver Woman Struck in Face by Todd Helton Foul Ball
CBS Local Denver 4—Aug 31, 2016
Poudre Valley Implants Colorado’s First Device For Sleep Apnea
The Denver Channel-Mar 10, 2016
New Device Offers Additional Treatment Options For Sleep Apnea
CBS Local-Mar 10, 2016
Solutions unmasked for patients with sleep apnea
Loveland Reporter-Herald-Jan 1, 2016
New sleep-apnea treatment comes to Poudre Valley Hospital
BizWest Media-May 12, 2016
UCHealth unmasks new sleep apnea treatment
The Coloradoan-Feb 8, 2016
UCHealth first in state to offer newest technology for sleep apnea
The Coloradoan-Dec 18, 2015
Poudre Valley Hospital implants state’s first device to treat sleep apnea
The Coloradoan-Mar 11, 2016
Solving the Sleep Cycles: New implant may help those with sleep apnea
Greeley Tribune-Apr 5, 2016
Education & Experience
Alpine Ear, Nose, and Throat, P.C.
Chief, Surgical Subspecialty Service Line
Poudre Valley Hospital/ Medical Center of the Rockies, University of Colorado Health
Chief, Department of Surgery
Poudre Valley Hospital
Vice Chief, Department of Surgery
Poudre Valley Hospital
University of Cincinnati
University of Cincinnati
Doctor of Medicine
University of Cincinnati College of Medicine
Summa Cum Laude