Editorial: Novel technologies in the diagnosis and management of sleep-disordered breathing, volume III

advances, the clinical pathways of sleep-disordered breathing (SDB) and obstructive sleep apnea (OSA) have remained largely anchored to traditional paradigms even as the sleep community has repeatedly called for reform. (Korkalainen et al., 2024) Change is inherently challenging, yet there comes a tipping point where decisive action is required, much like the paradigm shift executed by the Canadian Cardiovascular Society last month in redefining heart failure classifications. (Virani et al., 2025) The 17 articles featured in Volume III highlight how innovative diagnostics, deeper pathophysiological understanding, therapeutic breakthroughs, and integrated care models are converging to reshape SDB management. Together, they signal a growing momentum toward a more precise, accessible, and patient-centered model of SDB management. This editorial synthesizes these contributions and reflects on how the field can leverage this momentum to advance a new era of personalized sleep medicine. (PTT), specifically the respiratory swing (PTTrs), as a diagnostic tool. PTT refers to the interval required for a pulse wave to travel from the heart to a peripheral site (e.g., finger) and was used for arousal event detection. (Pitson et al., 1994) In a large observational study of children, they found that PTTrs may offer a practical, non-invasive complement to oximetry to improve OSA detection in children, potentially offering a scalable alternative to PSG in resource-limited secondary care settings. By demonstrating a connection between PTTrs and OSA severity, the work supports interest in physiologically grounded metrics that can enhance diagnostic transparency and interpretability, an important contrast to machine-learning-based approaches often criticized as "black box" methods. (Chervin et al., 2000), ensuring that diagnostic tools are accessible across linguistic barriers.Several papers in this collection elucidate the bidirectional relationships between sleep apnea and systemic disease. Lu et al. provide compelling evidence of the link between OSA and diabetic complications, even after accounting for metabolic and lifestyle confounders. In a study of 228 subjects with Type 2 Diabetes (T2D), they found that those with moderate-to-severe OSA had significantly higher odds of developing diabetic peripheral neuropathy (DPN) (adjusted odds ratio 2.2) and showed significant correlations with small fiber damage as measured by corneal confocal microscopy. This underscores the need to view OSA as a metabolic stressor that potentially accelerates neurodegeneration. Conversely, treating metabolic disease may improve sleep. Nationwide Inpatient Sample to evaluate the impact of OSA on COVID-19 outcomes. They confirmed that patients with OSA had higher risks of respiratory failure and heart failure. They also reported a paradoxical finding, reduced inhospital mortality among older male patients with OSA. While the authors suggested possible explanations, including "ischemic preconditioning"(Sanchezde-la-Torre et al., 2018) or protective effects from continuous positive airway pressure (CPAP), the possibility of survival bias inherent in a hospitalized cohort could not be excluded.Messineo, White, and Noah provide a comprehensive reassessment of why decades of technological refinements in positive airway pressure (PAP) therapy have yielded only modest, if any, gains in long-term adherence, highlighting that many long-standing assumptions about airway mechanics may be physiologically misguided. They reframe the physiology of upper-airway collapse under PAP therapy and propose that rather than occurring primarily during inspiration, airway narrowing often initiates at end-expiration, when lung volume and tracheal traction are lowest. (Morrell et al., 1998) This challenges decades of device design focused on increasing inspiratory pressure and relieving expiratory pressure, strategies that have not meaningfully improved long-term adherence and could potentially increase Treatment Emergent Central Sleep Apnea (TECSA). (Johnson & Johnson, 2005) Two companion studies translate this physiological insight into clinical practice.V-Com®, a flow-dependent inline resistor, selectively reduces inspiratory PAP but preserves expiratory PAP, and resolves residual TECSA in a small group of patients. (Noah et al., 2025) Kairos positive airway pressure (KPAP) advances this approach by delivering full therapeutic pressure only near end-expiration. (White et al., 2024) In two randomized studies, KPAP produced treatment effects on the apnea hypopnea index (AHI) comparable to those of CPAP, while reducing leak by nearly 50%. At pressure levels of 9 and 13 cmH₂O, KPAP was preferred by 69% and 84% of patients, respectively. (White et al., 2024) These studies collectively support the notion that timing of exposure to pressure may be the key to comfort and physiologic stability. If validated in broader populations, such approaches may become a novel PAP innovation since the introduction of bilevel positive airway pressure (BiPAP). (Sanders & Kern, 1990) For those who cannot tolerate PAP, pharmacological alternatives are emerging. (Daniil Lisik & Ding Zou, 2025) Larramona Carrera reports three illustrative pediatric cases in which combined atomoxetine and oxybutynin therapy produced substantial reductions in OSA severity when adenotonsillectomy and CPAP had failed, with two patients achieving >50% improvement in AHI after one month of treatment. These early observations suggest a potential role for medication-based therapy in complex pediatric OSA and underscore the need for controlled pediatric trials to define efficacy, safety, and target phenotypes for pharmacologic OSA treatment.The final theme in this topic addresses how the care pathway for SDB is being term evidence from a similar comprehensive care pathway, reporting PAP adherence rates of 82.6% at 1 year, and 74.2% of patients at 2 years, significantly higher than traditional models. These findings may directly translate into reduced burden for the healthcare system (Malhotra et al., 2025) and underscore the need for investments in coordinated, patient-centered infrastructure to enhance the effectiveness of disease management. The answers lie in the continued interdisciplinary collaboration demonstrated in this collection. As we refine these technologies and models, we move closer to a future where sleep apnea is detected earlier, managed easier, and treated not just as a disorder of breathing, but as a cornerstone of holistic health.