Published date: August 6, 2025
Professor Winfried Randerath is active at the Bethanien Hospital in Solingen, Germany and has for years been one of the leading experts within the European sleep world. He is frequently engaged as a speaker and is appreciated for his ability to structure, clarify and tie topics together. He has long held a leading role in the guideline work for the European Respiratory Society and the Baveno classification, the work discussed in this interview and one of his initiatives aimed at structuring and improving sleep care.
Prof. Randerath: We have 20 European centers that want to participate in our prospective study, which is now starting, spread across countries from Sweden to Greece, from Spain to Lithuania, so we hope we will be able to implement projects in the countries where they are carried out. There are of course very different rules according to the regional regulations. For example, many countries, and many health insurance companies, adhere to the AHI. The aim here is to try to bring such a scheme into national guidelines and, in this way, into medical practice.
And of course, it is our mission to say whenever we can, “Please don't just concentrate on AHI, it's just a number that doesn't say very much. Concentrate on what a good doctor does, namely looking at the patient. What symptoms do they have? What risk situation are they in? Don't just stick to a number.”
With this scheme, we are actually recommending something that is intrinsically medical art. And we hope that this will convince our colleagues. The problem is that the AHI is so catchy. It's a number, everyone loves this number. The patient wants to know, “How many events have I had?” The doctor wants to explain something easily, and they do that quickly with a single value.
Health insurance companies also want to stick to a number for definite “yes” or “no” decision—we pay for the therapy or not. A single figure like this not only makes the decision but also the process easier. However, it does not reflect the reality of the patient.
I believe the way forward must be via communication at congresses and via guidelines, but also via discussions with the respective authorities who determine when a therapy is reimbursable.
Prof. Randerath: The traffic light approach should simplify decisions, especially in clinical practice. Medical students who are in specialist training after they have completed their six years don't always see very much on the subject of sleep—we are talking about a few hours during their entire training, which is minimal. The best you can do is raise awareness about what sleep disorders exist, what obstructive and central sleep apnea are, and what accompanying or resulting illnesses physicians should know and think about.
This can really only succeed if we manage to show that we are working at different levels. For example, we have a European Respiratory Society (ERS) task force investigating the impact of PAP therapy. If we get that published and it becomes clear that PAP therapy makes sense, then hopefully we will succeed in convincing even more colleagues it is not just wellness. The fact is that PAP therapy has prognostic significance for patients, primarily in the cardiovascular area, and hopefully that will enable us to convince cardiologists, who have unfortunately become somewhat more cautious in recent years. There is a long way to go. But sleep is so important that we have to go down this path. For me, sleep is one of the most important factors for general health. We need to exercise. We shouldn't smoke and we shouldn't drink a lot of alcohol. We should eat as healthily as possible, but the other key factor is sleep.
And if we succeed in establishing healthy sleep as an essential building block into our consciousness alongside physical activity, avoiding harmful substances and eating a healthy diet from an early age, then we will be able to achieve a healthy lifestyle. We will eventually get to the point where we can say that we have to do everything we can to ensure good sleep. But we’re not there yet.
For example, today we have very important political events and politicians come out of the room at 3:00 a.m. and everyone is thrilled that they have made important decisions at this ridiculous hour, sacrificing a night of sleep. That's terrible. You really should tell them that either they finish at 10:00 p.m. and meet again at 9:00 a.m. the next morning, or you have to say that everything you've decided at night needs to be reconsidered, think about it again and then revisit it. It should not be something for you to be proud of—having worked through the night. It’s something that has damaged your body, that makes your decisions not well-founded. For us, giving up sleep is still something heroic.
Prof.Randerath: Well, of course we still must look at the long-term course to see whether the prospective study confirms what we see in the retrospective analyses. We have already talked about the fact that adoption and widespread implementation can be an issue due to the current insurance and reimbursement realities. Additionally, it could be uncomfortable for a practitioner to look beyond a single number and evaluate more criteria—the challenge here will be to ensure this holistic approach and behavior is understood as something already part of our medical training.
Prof. Randerath: They are of great importance! While these physicians are also sensitized to the topic of sleep apnea, they commonly only have the typical symptoms in mind, such as being overweight, male, having a large neck, sleepy. The other less typical symptoms—and therefore patients—often fall through the cracks, making a scheme like this very helpful.
Patients routinely talk with their doctors about nutrition, exercise and harmful substances, openly acknowledging the value of these things in their overall health. If PCPs/GPs begin routinely including sleep in these conversations, then the topic will come up more often. Patients will voluntarily say, “Yes, I have trouble sleeping.”, “My partner says I always snore.” or “I can fall asleep at any time.”
Armed with these self-reported statements, we as physicians can leverage the scheme to advocate for our patients. In conversations between various players in the pathway—the PCP/GP, the sleep physician, the sleep clinic or lab—the ability to reference the red, yellow or green group designation can help each to prioritize care across providers. If I say to a sleep physician, “I have a patient here who is in the red group.” that will let the sleep physician know that there is a high need for prompt treatment, for example.
Prof. Randerath: These are not yet included in the current study design but will be in the future. We'll have data from polysomnography that will allow us to look at oxygen saturation in the analyses, regardless of the number of disturbances. This is a very, very exciting field and, in my view, an important field.
Other factors such as heart rate variability or pulse wave amplitude probably also play a role. However, I believe they are already an expression of existing diseases. If heart rate variability decreases, it shows that something has already happened to the heart, and if the pulse wave amplitude changes, the vessels have already become stiff. That means with desaturation, I could be at a point where I'm not yet at risk. I consider this desaturation—hypoxic burden (HB) or whatever parameter you use—to be more interesting for the long-term prognosis, while the other parameters represent an established risk, such as stiff blood vessels or other existing cardiac issues.
While I am convinced that we should move away from AHI, it is important that we do not become more complicated because of it. We should not replace one single parameter—AHI—with another single parameter—HB for example. We must include clinical symptoms into the overall picture of risk because we do not want only hypoxic burden, even if the oxygen saturation, to be the prognostically decisive factor that perhaps subsumes everything. It still doesn't tell me whether the patient is symptomatic, and then I'm still only dealing with a prognostic indication. But that can still cause problems, for example, when it comes to adherence. So, in that respect, I'm convinced we need an overall view or holistic perspective, in which hypoxic burden will play a major role.
Prof. Randerath: It is a primary goal of the work to treat the patients who not only need therapy but also those who are most likely to be successful on that therapy so that our work has true purpose and benefit.
If I think about actual practice, I will have many patients who are truly persuaded to improve their health. They may say, "Okay, I hear my risk is high. I have a family history of high cholesterol, so I’ll do what I need to lower my risk” or “If you tell me to go on therapy, I will.”
Conversely, I will have patients who are not so convinced, who might look at me questioningly or hesitantly and I can’t force them to go on therapy. About all I can say is “Keep it in mind, pay attention to your symptoms and let me know if you think the time is right because we do have something for you.”
By taking this approach, I have fewer patients drop off therapy. I can focus on those who are adherent and have greater success. I can also work with those I don’t force therapy on from the beginning but who may come back to me later saying they are ready to try something. All in all, it enables greater impact with patients.
This article is one in a set from our conversation with Professor Randerath. To continue, read “A look at the modified Baveno criteria”.
Privacy|Terms of use |©2025 Resmed|All rights reserved