King's College London

Prof Joerg Steier's research at King's is focused on sleep-disordered breathing and respiratory muscle physiology.

We caught up with him following the announcement of a £1.48 million grant from the National Institute for Health and Care Research (NIHR) to fund multi-centre clinical trials of spin-out company Zeus Sleep Ltd's anti-snoring device led by King’s College London and Guy’s and St Thomas’ NHS Foundation Trust.

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Hi Joerg, given that sleep is something we all share and occupies such a large part of our lifespans we were fascinated to learn more about your work and its translational journey from lab to commercial spin-out and now clinical trials. How did you start?

I am a respiratory consultant in the NHS working at Guy's and St. Thomas Hospital. When I am on call then I am in the Lane Fox unit, this is a centre for home mechanical ventilation and weaning. And when I am not on call, then I am in the sleep disorder centre at Guy's Hospital, which is the UK's largest centre for complex sleep disorders.

Before this I was at the Royal Brompton and Harefield Hospital in the lung failure team, and prior at King's College Hospital as a PhD student, working with the London Respiratory Physiology Group. This is also where my initial interest in muscle physiology, sleep and therapy came from.

One of the most common sleep disorders, snoring and sleep apnoea, is a niche of respiratory medicine that pairs with my interest in physiology, how the muscles function and relax at nighttime, and how this can affect the physical well-being of a patient while asleep. Sleep medicine also covers the physical aspects of sleep fragmentation when awake and how this can cause sleepiness, wakefulness, memory, cognition, and so forth, but my research is centred around the physical aspects of sleep disorders and sleep therapy.

As is often the case with innovation in the healthcare sector you’ve built on many previous studies combined with your own research and parallel developments in the fields of electronics to create this new technological solution. A synthesis in other words that applies new thinking to ongoing research to update it and translate it commercially to a product that can benefit patients at scale.

Yes, exactly. My early training took place in a large lung centre in Germany, where I had a mentor, Helmut Teschler, who was very much into the development of Autoset positive airway pressure algorithms (continuous positive airway pressure treatment, CPAP) for sleep disordered breathing.

He really lit my interest to engage with sleep medicine, and in 2005 I came to work with the London Respiratory Physiology Group to learn certain physiological methods that they only used here, for example how to measure the diaphragm activity, neural respiratory drive, using transoesophageal electrodes and so on.

That work led me to my PhD with John Moxham at King's College London, and I was reviewing a lot of papers at the time, as you do when you write a PhD, and looking into all these ancient papers from times before the Internet, and so on, with hand-sketched muscles. An early sparking idea came to me after a day in the physiology lab when I’d volunteered my leg as a test subject to assist with someone else’s experiments using a device called a TENS machine (transcutaneous electrical neurostimulation).

The experiment was about the use of electrical stimulation to support training scenarios for athletes, but I realised, well, if you can do this on the leg, maybe you can do this on the upper airway muscles, and this was how the idea was born.

And of course, as I went back through all those papers from the 1970s and 1980s there were many others who had had similar ideas and actually people had tried to use electrical stimulation to keep the muscles of the upper airway active whilst asleep in the treatment of sleep apnoea. Those early papers basically said, yes, this works, only then to be rebutted a year later or so by other groups who said, yes, it works, in theory, but when you zap the patient with high electrical current, in practice, you wake them up, and so the field of sleep research at the time moved on to different areas.

Fast forward several decades, however, and the technology has moved forward rapidly in many areas of healthcare, for example with implantable devices like pacemakers, and we’re now able to apply a lower, longer-lasting, electrical current aligned with a patient’s respiratory rhythm that can activate and keep the upper airway muscles activated and in shape at night, and the airway open without a patient getting that zap!

Which brings us to today with the Zeus Sleeps wearable device, which is smaller, slimmer, has a better battery life, better user interfaces, and an equally interesting journey to market as it’s already commercially available as a treatment for snoring but you’re now exploring clinical uses for sleep apnoea with the potential for the device to be a prescribed treatment, is that right?

Yes, we have recently been awarded an NIHR grant in the i4i scheme as a product development award to run from 2026 using this technology. Our interest was always to treat patients with obstructive sleep apnoea. The observation that when you stimulate the genioglossus muscle, the strongest dilator of the upper airway, opens the upper airway and the patients continues to breathe through the wider airway, that you possibly can treat obstructive sleep apnoea, and, on the other hand, also by having a more stable upper airway have less of a snoring effect, that went hand in hand really.

And it was then in the discussions with King's and Guy’s & St. Thomas' and the development of the product with Morgan IAT that we realised, well, this can be spun out to treat snoring and so we followed that commercial pathway while seeking funding to provide sufficient data to establish clinical guidance for electrical stimulation in patients with sleep apnoea, for which we (rightly) need to provide more evidence before the treatment can be adopted in NHS healthcare.

We’re now working on a UK multi-centre randomised controlled trial to provide the required evidence that this product works not only for snoring, but can also be adapted as an approach for patients with obstructive sleep apnoea; especially those who would not necessarily cope with treatments such as CPAP -which delivers a flow of pressurised air through a mask while the patient is sleeping- but that some patients find discomforting and inconvenient when used long term.

And that issue with the long-term efficacy of current treatments for some patients is compounded by an overall rise in sleep apnoea cases across multiple global populations? 

Our scientific understanding of sleep is still a fairly young entity if you compare it to, for example, surgical or other medical practices that have been going on for thousands of years, whereas sleep was thought to be rather ‘mythical’. REM sleep was only described in the 20th century, for example, and it’s only with an evidence-based and research-supported approach to therapies in the 1980s onwards that clinical sleep laboratories really started to effectively exist in hospitals.

Cases of patients with obstructive sleep apnoea are increasing primarily due to the worldwide development of the obesity pandemic and an aging population. Obstructive sleep apnoea was first described in the 1970s and 1980s, although it was called differently at that time, and it was estimated with the data from the Wisconsin Sleep Cohort, published in 1992 in the New England Journal of Medicine, that about 4% of middle-aged men and 2% of middle-aged women suffered with symptomatic obstructive sleep apnoea.

Two decades on, the prevalence in the same population-based cohort studied with the same methods, had increased, so in about 2012 we saw that about 10% of middle-aged men and 3% of middle-aged women had the condition. And the main factor that had changed was the prevalence of obesity in this cohort of patients.

So, obesity makes a huge difference, and, unfortunately, in the UK, just like in the US and in many other parts of the world, we now see rising levels of obesity. For example, a recent paper in the Lancet extrapolated that obesity levels increase from currently around 1 billion people on this planet to 3.4 billion people by 2050.

And sleep apnoea can impact on other factors as well, from cardiovascular risks and hypertension associated with stroke through to areas beyond healthcare such as the thought that about 20% of the road traffic accidents in the UK are due to sleepiness, not infrequently caused by untreated obstructive sleep apnoea.

Sleep is an overarching theme that affects everyone on this planet. Every one of us needs to sleep, we are all ‘professionals’, and we have only started to understand some of the aspects ‘why’. We haven't got a good answer yet to all aspects of sleep at all, for example, as to the ‘why’ we need to sleep at all, but I hope that by the end of my working career we may be close to answer this question. Some other research groups have some very interesting studies ongoing...

The time for sleep medicine to make a different to our lives is just about to start!