1
00:00:00,000 --> 00:00:21,200
Hi everyone and welcome back to Airway First, the podcast from the Children's Airway First

2
00:00:21,200 --> 00:00:22,200
Foundation.

3
00:00:22,200 --> 00:00:26,000
I'm your host, Rebecca St. James.

4
00:00:26,000 --> 00:00:29,280
My guest today is Dr. David McCarty.

5
00:00:29,280 --> 00:00:34,240
Dr. McCarty is a board certified specialist in sleep medicine and a pioneer in the practice

6
00:00:34,240 --> 00:00:38,880
of patient-centered care for those who suffer from sleep disorders.

7
00:00:38,880 --> 00:00:43,880
An award-winning educator, he is passionate about empowering individuals with knowledge

8
00:00:43,880 --> 00:00:49,240
that restores confidence and personal agency as each patient navigates the landscape of

9
00:00:49,240 --> 00:00:54,800
disease and wellness within an increasingly fragmented healthcare system.

10
00:00:54,800 --> 00:01:01,280
He is also the co-creator of Empowered Sleep apnea, an innovative cross-platform educational

11
00:01:01,280 --> 00:01:06,920
project combining storytelling, cartooning, scientific rigor, and quite a bit of fun,

12
00:01:06,920 --> 00:01:11,920
all in the name of helping individuals navigate the fascinating but complex disorder known

13
00:01:11,920 --> 00:01:14,200
as sleep apnea.

14
00:01:14,200 --> 00:01:21,560
Launched in 2023, the project comprises a website, a book, a blog, and a podcast.

15
00:01:21,560 --> 00:01:26,720
The Children's Airway First Foundation is proud to partner with Dr. McCarty and Empowered

16
00:01:26,720 --> 00:01:32,280
Sleep apnea in an effort to help create more information, education, and understanding

17
00:01:32,280 --> 00:01:35,920
around the subject of airway and sleep apnea.

18
00:01:35,920 --> 00:01:41,680
You can find out more about Dr. McCarty at EmpoweredSleepApnea.com.

19
00:01:41,680 --> 00:01:48,040
And now, let's dig into the first part of our two-part series with Dr. Dave McCarty.

20
00:01:48,040 --> 00:01:52,640
All right, good morning and welcome to the podcast, Dave.

21
00:01:52,640 --> 00:01:53,640
Good morning.

22
00:01:53,640 --> 00:01:56,320
Thank you for letting me come on here.

23
00:01:56,320 --> 00:01:57,320
It's a pleasure.

24
00:01:57,320 --> 00:01:58,320
Absolutely.

25
00:01:58,320 --> 00:02:03,280
And before we get started, I'm just going to let people know, because I think it happens

26
00:02:03,280 --> 00:02:09,120
sometimes, I'm kind of gushy on this particular podcast because I started reading the book

27
00:02:09,120 --> 00:02:14,360
about a week and a half ago, maybe, about a week ago.

28
00:02:14,360 --> 00:02:21,160
And I cannot recommend it enough, and even with all the books that I've read so far,

29
00:02:21,160 --> 00:02:22,680
it's very different.

30
00:02:22,680 --> 00:02:27,200
You take a very different approach, which I think is part of its uniqueness, chopful

31
00:02:27,200 --> 00:02:28,760
of so much information.

32
00:02:28,760 --> 00:02:34,400
And as we were talking about a little bit before, it's caused me to look at my airway journey

33
00:02:34,400 --> 00:02:37,840
differently and my daughters differently.

34
00:02:37,840 --> 00:02:42,440
So it really is a very unique experience.

35
00:02:42,440 --> 00:02:43,440
Yeah.

36
00:02:43,440 --> 00:02:44,880
That makes me so happy.

37
00:02:44,880 --> 00:02:46,720
That was totally the intent.

38
00:02:46,720 --> 00:02:47,720
Good.

39
00:02:47,720 --> 00:02:53,840
I love it when the lights come on and suddenly these connections are made and you're like,

40
00:02:53,840 --> 00:02:56,920
oh, I'm thinking about it in this new way.

41
00:02:56,920 --> 00:03:02,680
I'm able to deconstruct this in a way that makes sense and allowing people to see that

42
00:03:02,680 --> 00:03:05,680
complexity in a way that's not scary.

43
00:03:05,680 --> 00:03:07,880
That's what this whole project is about.

44
00:03:07,880 --> 00:03:08,880
Yeah.

45
00:03:08,880 --> 00:03:09,880
Yeah.

46
00:03:09,880 --> 00:03:12,720
And to that point, I mean, just to kind of show people a little show and camera roll.

47
00:03:12,720 --> 00:03:14,600
See, I mean, it's not scary.

48
00:03:14,600 --> 00:03:16,800
Even the book is inviting.

49
00:03:16,800 --> 00:03:22,000
And I will warn somebody before they get their ticket and get on the boat and start through

50
00:03:22,000 --> 00:03:25,520
this journey is not a fast read.

51
00:03:25,520 --> 00:03:26,520
Don't expect that.

52
00:03:26,520 --> 00:03:28,720
It's not supposed to be.

53
00:03:28,720 --> 00:03:32,480
You take points along the way and there's reflection and there's activities.

54
00:03:32,480 --> 00:03:35,040
So it is a journey.

55
00:03:35,040 --> 00:03:36,040
Yes.

56
00:03:36,040 --> 00:03:38,760
It's meant to be an adventure.

57
00:03:38,760 --> 00:03:45,640
The whole style of this project came about due to my partnership with my co-author, Dr.

58
00:03:45,640 --> 00:03:47,160
Ellen Stofford.

59
00:03:47,160 --> 00:03:53,960
We started this project as an audio project because the backstory is that I had developed

60
00:03:53,960 --> 00:03:57,480
a curriculum with my patients, which I taught to all my patients.

61
00:03:57,480 --> 00:04:01,000
I sort of refer to it as the empowerment curriculum.

62
00:04:01,000 --> 00:04:03,960
And essentially it's what amounts to part one of the book.

63
00:04:03,960 --> 00:04:07,920
The first section of the book is all the stuff I would teach people on day one.

64
00:04:07,920 --> 00:04:13,120
And individually, I would vary the curriculum a little bit person by person depending on

65
00:04:13,120 --> 00:04:14,520
what they needed.

66
00:04:14,520 --> 00:04:17,040
But it would usually take about an hour.

67
00:04:17,040 --> 00:04:18,720
That's a lot of instruction.

68
00:04:18,720 --> 00:04:23,240
But if we got that curriculum across and the patient got their feet on the ground and felt

69
00:04:23,240 --> 00:04:25,160
like, I got this.

70
00:04:25,160 --> 00:04:29,000
I can navigate this complex terrain because I understand the jargon.

71
00:04:29,000 --> 00:04:30,440
It's not scary.

72
00:04:30,440 --> 00:04:32,760
Then magic happens.

73
00:04:32,760 --> 00:04:37,560
That's when the magic happens because the patient is fully engaged and they understand

74
00:04:37,560 --> 00:04:41,960
what the stakes are and they understand what their decisions mean.

75
00:04:41,960 --> 00:04:45,040
No one in my clinic ever felt coerced into a treatment.

76
00:04:45,040 --> 00:04:47,360
That's just not the way it worked.

77
00:04:47,360 --> 00:04:48,960
Here's what we are looking at.

78
00:04:48,960 --> 00:04:50,480
Here are the possible options.

79
00:04:50,480 --> 00:04:54,040
And there's actually lots of different things that one can try for a problem like sleep

80
00:04:54,040 --> 00:04:55,040
at night.

81
00:04:55,040 --> 00:04:57,120
And then here's where you are.

82
00:04:57,120 --> 00:05:00,920
And let's talk about where you are and why you might need treatment.

83
00:05:00,920 --> 00:05:06,720
So boiling that down and deconstructing that complexity in a way that doesn't scare people.

84
00:05:06,720 --> 00:05:08,400
That's what the project is about.

85
00:05:08,400 --> 00:05:13,920
But I realized that when I first started to try to put this into a textbook, the magic

86
00:05:13,920 --> 00:05:17,080
was lost somehow because it wasn't engaging.

87
00:05:17,080 --> 00:05:19,520
Like a textbook is kind of scary.

88
00:05:19,520 --> 00:05:24,920
It's got charts and it's got tables and it's got jargon that you have to learn and memorize.

89
00:05:24,920 --> 00:05:29,360
And it's coming at you all one way.

90
00:05:29,360 --> 00:05:35,000
So the recoil response to that education is just human nature.

91
00:05:35,000 --> 00:05:40,120
I spent about six months trying to write this textbook and I got frustrated and every time

92
00:05:40,120 --> 00:05:42,440
I read it back to myself, it was just terrible.

93
00:05:42,440 --> 00:05:48,760
I tried putting humor in and I likened it to standing with a knife while smiling.

94
00:05:48,760 --> 00:05:51,040
It was so scary.

95
00:05:51,040 --> 00:05:53,320
The humor just made it creepy.

96
00:05:53,320 --> 00:05:58,160
So this is when I called Ellen and I said, maybe it's something about the conversation.

97
00:05:58,160 --> 00:06:00,680
Maybe this has to be captured in slight.

98
00:06:00,680 --> 00:06:03,240
Maybe we'll talk about that curriculum somehow.

99
00:06:03,240 --> 00:06:08,320
So she said, graciously, she came along for the ride and said, sure, I'll participate

100
00:06:08,320 --> 00:06:09,400
in that.

101
00:06:09,400 --> 00:06:14,440
And it turns out that what we discovered is in order to make this accessible, we had to

102
00:06:14,440 --> 00:06:17,080
really embrace the adventure.

103
00:06:17,080 --> 00:06:21,520
And as soon as we discovered that, I thought to myself after one of our conversations that

104
00:06:21,520 --> 00:06:26,720
didn't end up making the final cut, we tried several iterations of the recording process

105
00:06:26,720 --> 00:06:28,920
before we came up with something that worked.

106
00:06:28,920 --> 00:06:33,200
And the thing that gelled it all together was I went home that day and I said, you know,

107
00:06:33,200 --> 00:06:36,160
what's the thing that makes me want to go on an adventure?

108
00:06:36,160 --> 00:06:40,280
You know, and I remember back when I was a kid, I had an illustrated version of Peter

109
00:06:40,280 --> 00:06:47,480
Pan and the frontispiece was an illustration of Never Neverland, you know, the island.

110
00:06:47,480 --> 00:06:53,400
And it had the Pirates Cove and it had like skulls on it and little exes and stuff.

111
00:06:53,400 --> 00:06:55,600
And all I wanted to do was look at that.

112
00:06:55,600 --> 00:06:58,320
When I was reading, I'd go back and look at it and imagine that I was there.

113
00:06:58,320 --> 00:06:59,320
Where am I on there?

114
00:06:59,320 --> 00:07:00,320
Yep.

115
00:07:00,320 --> 00:07:01,320
Yeah.

116
00:07:01,320 --> 00:07:02,320
Yeah.

117
00:07:02,320 --> 00:07:05,880
And I was like, well, if that's what engaged my adventure, then maybe we should have a

118
00:07:05,880 --> 00:07:08,080
map to this journey.

119
00:07:08,080 --> 00:07:12,320
And that's when I went home and I drew that isle of sleep apnea map, which I sort of giggle

120
00:07:12,320 --> 00:07:14,440
at because I love dad jokes.

121
00:07:14,440 --> 00:07:15,680
And even that's a dad joke.

122
00:07:15,680 --> 00:07:18,360
I love sleep apnea.

123
00:07:18,360 --> 00:07:21,000
It sort of engages you in a different lens, you know.

124
00:07:21,000 --> 00:07:26,520
And as soon as I drew out the geography of how this decision making should happen, you

125
00:07:26,520 --> 00:07:30,360
know, that you have to talk about certain things up front before you can go here, before

126
00:07:30,360 --> 00:07:34,720
you can even talk about treatments, then it all sort of made sense.

127
00:07:34,720 --> 00:07:38,680
And then suddenly we've got a whole new creation on our hands.

128
00:07:38,680 --> 00:07:44,880
If we can embrace the zany, then, you know, this, this sort of guilty habit that I have

129
00:07:44,880 --> 00:07:51,280
of cartooning, this is sort of my answer to my own ADHD tendencies is during lectures

130
00:07:51,280 --> 00:07:55,000
to pay attention, I'll just draw pictures, you know, and sometimes I'll capture something

131
00:07:55,000 --> 00:07:56,000
in the lecture.

132
00:07:56,000 --> 00:07:59,440
I've been doing that my whole life and my teachers, you know, in grade school and middle

133
00:07:59,440 --> 00:08:02,400
school, they were ripping my homework up for this.

134
00:08:02,400 --> 00:08:07,160
So I've always sort of had this guilty shame of the cartooning habit.

135
00:08:07,160 --> 00:08:12,760
And lo and behold, it's also an extremely disarming art form.

136
00:08:12,760 --> 00:08:17,560
So we can take really complex subjects that might feel threatening to talk about, and

137
00:08:17,560 --> 00:08:23,200
we put them in a cartoon, then all of a sudden get our hands around it and feel like we can

138
00:08:23,200 --> 00:08:24,960
talk about that problem.

139
00:08:24,960 --> 00:08:30,120
And interestingly, our tuning of this that opened up a lot of opportunities to talk about

140
00:08:30,120 --> 00:08:36,560
difficult subjects, both in the management of sleep apnea, but also for the entire specialty,

141
00:08:36,560 --> 00:08:41,080
you know, how we communicate with other professionals, the cartooning has come in handy and talking

142
00:08:41,080 --> 00:08:43,440
about those types of problems too.

143
00:08:43,440 --> 00:08:46,920
And I'll tell you, it helps too, as you're going through the book and you digest it and

144
00:08:46,920 --> 00:08:52,960
you're entering this Bay of Narrative when they see the map, you'll understand that

145
00:08:52,960 --> 00:08:57,840
the book opens with this cartoon and this lead character is going to guide us through

146
00:08:57,840 --> 00:09:01,560
this and he appears and you have these little stopping points throughout the way, which I

147
00:09:01,560 --> 00:09:06,480
encourage parents as you get the book, take a minute, take the stopping point, don't blow

148
00:09:06,480 --> 00:09:09,280
by that cartoon.

149
00:09:09,280 --> 00:09:11,160
Because I will admit the first one I kind of went, oh, that's cute.

150
00:09:11,160 --> 00:09:12,800
And I kept going.

151
00:09:12,800 --> 00:09:19,640
And I was a few pages away and thought, wait, didn't he, and I went back to the cartoon.

152
00:09:19,640 --> 00:09:20,720
There's a reason they're there.

153
00:09:20,720 --> 00:09:22,880
They're not just fillers.

154
00:09:22,880 --> 00:09:24,600
He was introducing it.

155
00:09:24,600 --> 00:09:25,600
It's the segue.

156
00:09:25,600 --> 00:09:29,920
You know, hey, we're about to talk about something kind of difficult and here we are.

157
00:09:29,920 --> 00:09:31,960
So you know, as we're going through.

158
00:09:31,960 --> 00:09:38,240
I'm glad you noticed that, Rebecca, you know, because the cartoons were definitely part

159
00:09:38,240 --> 00:09:43,320
of the journey for me and the way they're placed in the book, they're meant to be a

160
00:09:43,320 --> 00:09:47,400
little mental nap from the reading.

161
00:09:47,400 --> 00:09:52,840
And it's actually, I hide stuff in them, you know, I tend to put little Easter eggs

162
00:09:52,840 --> 00:09:53,840
in there to find.

163
00:09:53,840 --> 00:09:56,880
I was about to say, I started looking at the pictures, not just words.

164
00:09:56,880 --> 00:10:00,360
I'm looking for things now in the designs.

165
00:10:00,360 --> 00:10:05,000
So I'd encourage you if you want to sort of have some fun, get a magnifying glass and

166
00:10:05,000 --> 00:10:06,320
kind of see what's in there.

167
00:10:06,320 --> 00:10:10,920
Because I build things in kind of for fun, but there's layers within layers.

168
00:10:10,920 --> 00:10:14,200
And I think that's part of the point here is that the more you look, the more you might

169
00:10:14,200 --> 00:10:15,200
find.

170
00:10:15,200 --> 00:10:20,840
And so, yes, the cartoons are meant to be lingered over and it gives you more food for

171
00:10:20,840 --> 00:10:23,280
thought as you go through it.

172
00:10:23,280 --> 00:10:24,280
It does.

173
00:10:24,280 --> 00:10:25,280
And I'll encourage parents.

174
00:10:25,280 --> 00:10:29,120
I will put a link in our show notes to the podcast.

175
00:10:29,120 --> 00:10:34,280
So it, and even if you don't do the whole series at once, do that first episode before

176
00:10:34,280 --> 00:10:39,360
you dig in because you really, the two of you, you set it up so beautifully.

177
00:10:39,360 --> 00:10:42,880
And I just, I just, I just really encourage that.

178
00:10:42,880 --> 00:10:43,880
So I will put that there.

179
00:10:43,880 --> 00:10:45,280
I'm going to tell people to do this.

180
00:10:45,280 --> 00:10:52,760
Well, the first five episodes of our podcast, it's the first season, it's only five episodes

181
00:10:52,760 --> 00:10:59,800
long, but it was basically a contrivance to get across what I call that curriculum.

182
00:10:59,800 --> 00:11:04,000
I wanted to teach the curriculum that would help people unpack complexity.

183
00:11:04,000 --> 00:11:09,200
So basically it's a vehicle to teach people about two five point mnemonics.

184
00:11:09,200 --> 00:11:13,800
There are complexity sense making tools within this very complex problem.

185
00:11:13,800 --> 00:11:15,440
And we can probably get to those in this conversation.

186
00:11:15,440 --> 00:11:16,960
Yeah, we're going to touch on those.

187
00:11:16,960 --> 00:11:17,960
Yeah, sure.

188
00:11:17,960 --> 00:11:21,720
But that's what the whole first season is about is if you listen to all five episodes,

189
00:11:21,720 --> 00:11:26,320
it'll give you a working knowledge of what those two complexity tools are.

190
00:11:26,320 --> 00:11:31,160
And it'll help you communicate with your provider no matter what silo of thought they're in.

191
00:11:31,160 --> 00:11:32,360
Right, right.

192
00:11:32,360 --> 00:11:36,960
And you'll also get introduced to Robert, who to me is a great, it's not so much, not

193
00:11:36,960 --> 00:11:43,640
so much as it applies to us for kids, but even as a parent that's going into this thinking,

194
00:11:43,640 --> 00:11:47,600
the dental provider, the pediatrician, the sleep provider, they just want money.

195
00:11:47,600 --> 00:11:48,600
My kids fine.

196
00:11:48,600 --> 00:11:49,600
Yeah.

197
00:11:49,600 --> 00:11:53,120
No, get to know Robert and you'll understand it's a very different perspective.

198
00:11:53,120 --> 00:11:55,600
So it does even apply to parents.

199
00:11:55,600 --> 00:11:57,920
So I really encourage that.

200
00:11:57,920 --> 00:12:05,880
Okay, so we kind of an understanding for how the book came to be, which again, it is it

201
00:12:05,880 --> 00:12:10,640
is absolutely magnificent.

202
00:12:10,640 --> 00:12:14,120
And we'll dig a little bit more into I was just going to ask one, like, you know, how

203
00:12:14,120 --> 00:12:17,720
can it benefit parents, but instead I want to approach that differently because I think

204
00:12:17,720 --> 00:12:20,800
they'll know as we go through this conversation.

205
00:12:20,800 --> 00:12:26,600
So let's just start with what is diagnosis based medicine.

206
00:12:26,600 --> 00:12:32,120
And I think we all kind of know what it is, but what's wrong with this approach?

207
00:12:32,120 --> 00:12:33,200
Yeah.

208
00:12:33,200 --> 00:12:39,160
So this is kind of one of the things that's hard to talk about because it's a pervasive

209
00:12:39,160 --> 00:12:42,520
way of the way our medical culture works.

210
00:12:42,520 --> 00:12:47,840
But what we're dealing with these days is we have a compensation driven system.

211
00:12:47,840 --> 00:12:52,200
So you know, if you have a diagnosis code that allows payment for something, it's going

212
00:12:52,200 --> 00:12:56,200
to speed you along a pathway that will get you towards a treatment that's covered.

213
00:12:56,200 --> 00:12:57,840
That's just the way that works.

214
00:12:57,840 --> 00:13:01,720
You know, you get diagnosed with sleep apnea and you're seeing a medical provider and what's

215
00:13:01,720 --> 00:13:06,480
covered by their insurance is going to be probably either positive airway of pressure

216
00:13:06,480 --> 00:13:12,560
therapy or a standard mandibular advancement type oral appliance device.

217
00:13:12,560 --> 00:13:15,280
That's what the insurance coverage will be for.

218
00:13:15,280 --> 00:13:17,000
And this is all in flux too.

219
00:13:17,000 --> 00:13:21,240
So a lot of this depends on your carrier and there are many rules involved.

220
00:13:21,240 --> 00:13:26,320
But the bottom line is what insurance pays for is probably what you're going to get.

221
00:13:26,320 --> 00:13:31,800
And then what follows from there is usually kind of a label based approach.

222
00:13:31,800 --> 00:13:35,240
You come in specifically to follow up for your sleep apnea and then the questioning is,

223
00:13:35,240 --> 00:13:36,760
are you using your machine?

224
00:13:36,760 --> 00:13:39,280
And it becomes very treatment based.

225
00:13:39,280 --> 00:13:44,320
And it's just human nature, especially with the fact that most of our providers are operating

226
00:13:44,320 --> 00:13:47,800
on a schedule where they're seeing patients every 15 minutes.

227
00:13:47,800 --> 00:13:50,480
And that might be mandated by their employer.

228
00:13:50,480 --> 00:13:55,480
You know, so this is something that it's very hard to get your hands around and discussing

229
00:13:55,480 --> 00:14:00,760
it actually tends to make people feel defensive because they're doing the best they can.

230
00:14:00,760 --> 00:14:05,560
But the system tends to drive people towards this label based approach.

231
00:14:05,560 --> 00:14:12,720
When you have a very simple version of this problem, then it works okay.

232
00:14:12,720 --> 00:14:17,200
But then we turn around and we keep shaking our heads and wondering in the adult population,

233
00:14:17,200 --> 00:14:22,640
why is the long term CPAP adherence rate 50 to 70%?

234
00:14:22,640 --> 00:14:27,280
And the answer is it's hard to answer that question because those people leave.

235
00:14:27,280 --> 00:14:30,480
And then you can't observe them anymore once they've left.

236
00:14:30,480 --> 00:14:36,200
And in my experience, one of the reasons that people leave is that they feel disempowered.

237
00:14:36,200 --> 00:14:38,200
You know, they feel like they have no agency.

238
00:14:38,200 --> 00:14:43,040
They feel like this label based system ignores their humanity.

239
00:14:43,040 --> 00:14:47,560
And this is where we come back around to the empowerment curriculum, something that recognizes

240
00:14:47,560 --> 00:14:53,040
the individual's narrative, their reason for being there and helps them understand, you

241
00:14:53,040 --> 00:14:55,600
know, why we're going to do something about this.

242
00:14:55,600 --> 00:14:57,720
All of this is very standard education.

243
00:14:57,720 --> 00:15:01,480
There's nothing in this textbook or in, I won't even call it a textbook, nothing in

244
00:15:01,480 --> 00:15:07,080
the beautiful blue book that a standard medical provider would disagree with.

245
00:15:07,080 --> 00:15:12,320
You know, this is why it's been so important to me that the blue book has been sort of

246
00:15:12,320 --> 00:15:16,880
looked at and cherished by individuals from different silos of thought.

247
00:15:16,880 --> 00:15:21,800
You know, Western Medical, my former mentor, Dr. Andy Cheson, who is a past president of

248
00:15:21,800 --> 00:15:26,080
the AASM, gave me a favorable review for the book.

249
00:15:26,080 --> 00:15:32,520
Dr. Keith Thornton, who's a pioneer in sort of the airway dentistry world with the mandibular

250
00:15:32,520 --> 00:15:33,720
advancement devices.

251
00:15:33,720 --> 00:15:38,440
He's the inventor of the TAP physicianer, read the book and loved it.

252
00:15:38,440 --> 00:15:44,400
You know, pioneers in the more outlaws, airway-centered dentistry movement, which are outside Western

253
00:15:44,400 --> 00:15:48,360
medical, have read the book and enjoyed it.

254
00:15:48,360 --> 00:15:53,240
So the point is that the language unifies people and patients can sort of feel like

255
00:15:53,240 --> 00:15:55,600
it can unify their environment.

256
00:15:55,600 --> 00:16:00,400
One of the hardest things I've learned to talk about is that when people fall outside

257
00:16:00,400 --> 00:16:06,840
the silo, let's think about maybe that 30 to 50% of people that just fall out of CPAP.

258
00:16:06,840 --> 00:16:11,440
You know, when they fall out of that Western medical silo, maybe it's because they felt

259
00:16:11,440 --> 00:16:13,560
it was pushed at them inappropriately.

260
00:16:13,560 --> 00:16:18,680
Maybe they had an experience like my character Robert, who they were distrustful.

261
00:16:18,680 --> 00:16:20,800
So now they're outside the silo.

262
00:16:20,800 --> 00:16:22,880
How do they know what to do?

263
00:16:22,880 --> 00:16:25,160
How do they know who to ask?

264
00:16:25,160 --> 00:16:30,520
You know, and so this book is designed as a guidebook to help people deconstruct this

265
00:16:30,520 --> 00:16:36,920
in a way that their providers can understand and embrace no matter what silo their provider

266
00:16:36,920 --> 00:16:37,920
happens to be in.

267
00:16:37,920 --> 00:16:43,240
You know, it organizes the thinking and the deconstruction of these very complex problems.

268
00:16:43,240 --> 00:16:44,240
Right.

269
00:16:44,240 --> 00:16:49,480
And gives them the tools, by the way, especially as parents, to where you're not in a silo

270
00:16:49,480 --> 00:16:50,480
anymore.

271
00:16:50,480 --> 00:16:52,760
That's the other thing I'm starting to figure out.

272
00:16:52,760 --> 00:16:59,160
When you have, when you're empowered to, when you're empowered with the words and the tools

273
00:16:59,160 --> 00:17:04,160
to have these conversations with your provider, you're empowered to help with your journey.

274
00:17:04,160 --> 00:17:06,480
So you're going to work through this map together.

275
00:17:06,480 --> 00:17:13,880
So you get to bring in and have a more holistic opportunity for treatment for your child.

276
00:17:13,880 --> 00:17:16,160
So it's, you're not totally siloed.

277
00:17:16,160 --> 00:17:19,840
And I think that's a very important thing to bring up.

278
00:17:19,840 --> 00:17:24,240
So another thing you talk about, and I believe you talk about it in the podcast as well as

279
00:17:24,240 --> 00:17:29,680
a sleep awake complaint, which is interesting.

280
00:17:29,680 --> 00:17:32,400
That was one of those things that really resonated to me and I had to go back and look cartoon

281
00:17:32,400 --> 00:17:33,440
a little bit too.

282
00:17:33,440 --> 00:17:39,160
So because they didn't really understand it at first.

283
00:17:39,160 --> 00:17:41,480
And you actually do talk about it at the podcast.

284
00:17:41,480 --> 00:17:42,640
I remember now.

285
00:17:42,640 --> 00:17:46,480
So well, first of all, what is this?

286
00:17:46,480 --> 00:17:49,480
Because the term, it wasn't what I thought it was actually going to be.

287
00:17:49,480 --> 00:17:52,920
And as a physician, what should you be listening for?

288
00:17:52,920 --> 00:17:54,360
What do you listen for?

289
00:17:54,360 --> 00:17:55,360
Yeah.

290
00:17:55,360 --> 00:18:00,560
So this is an attempt to bring it all back and help the patient capture and characterize

291
00:18:00,560 --> 00:18:05,080
their own narrative with respect to the sleep wake experience.

292
00:18:05,080 --> 00:18:07,200
So let's just sort of break it down.

293
00:18:07,200 --> 00:18:12,360
You know, when people come to the doctor, maybe let's say you show up in a sleep doctor's

294
00:18:12,360 --> 00:18:16,640
office, a provider who is adjacent to sleep.

295
00:18:16,640 --> 00:18:19,080
How do you talk about why you're there?

296
00:18:19,080 --> 00:18:21,880
You know, and the answer is there's multiple dimensions.

297
00:18:21,880 --> 00:18:24,360
And so we as providers can help people break it down.

298
00:18:24,360 --> 00:18:28,720
I usually like to start with a very blanket question to get people oriented.

299
00:18:28,720 --> 00:18:32,680
So I'll say, you know, let's think about your sleep and let's think about how you feel during

300
00:18:32,680 --> 00:18:35,040
the day relative to your sleep.

301
00:18:35,040 --> 00:18:40,560
And let's think about how satisfying that is, you know, and just I'll ask you a blank

302
00:18:40,560 --> 00:18:41,560
question.

303
00:18:41,560 --> 00:18:44,360
Are you satisfied with your sleep wake experience?

304
00:18:44,360 --> 00:18:47,960
I mean, you know, if people say, well, yeah.

305
00:18:47,960 --> 00:18:51,320
You know, sometimes they say, yeah, defensively upfront, because, you know, they're thinking

306
00:18:51,320 --> 00:18:53,280
you're trying to sell them something.

307
00:18:53,280 --> 00:18:57,800
And this is what happened with the character who had fired Robert.

308
00:18:57,800 --> 00:19:00,480
You know, this man was defensive.

309
00:19:00,480 --> 00:19:02,680
And he says, you know, there's nothing wrong with my sleep.

310
00:19:02,680 --> 00:19:07,760
Because from his perspective, the chain of events went from unrelated complaints.

311
00:19:07,760 --> 00:19:14,440
You know, so he came in and it was a standard screening type of primary care visit that

312
00:19:14,440 --> 00:19:19,240
disclosed an irregular heartbeat and frequent trips to the bathroom during sleep.

313
00:19:19,240 --> 00:19:23,480
So he gets sent to two different specialists, a urologist and a cardiologist.

314
00:19:23,480 --> 00:19:25,160
Okay, fair enough.

315
00:19:25,160 --> 00:19:29,240
But both of them know that there's a relationship between the complaint that they're seeing

316
00:19:29,240 --> 00:19:30,240
the patient for.

317
00:19:30,240 --> 00:19:31,920
Cardiologist was a fib.

318
00:19:31,920 --> 00:19:34,840
The urologist was frequent nighttime urination.

319
00:19:34,840 --> 00:19:38,400
Both of them know there's a connection between those problems and sleep apnea.

320
00:19:38,400 --> 00:19:42,400
You know, so they're like just checking the boxes and sending them to the sleep doc.

321
00:19:42,400 --> 00:19:47,520
And meanwhile, he's never complained about his sleep or his breathing once to a provider.

322
00:19:47,520 --> 00:19:48,520
So he didn't understand.

323
00:19:48,520 --> 00:19:49,520
Yeah.

324
00:19:49,520 --> 00:19:52,920
So he's feeling manhandled and he's feeling roughed up and he's feeling pushed into this

325
00:19:52,920 --> 00:19:55,320
machine that's going to take money out of his pocket.

326
00:19:55,320 --> 00:19:58,800
So by the time he gets to the sleep doc, he's defensive.

327
00:19:58,800 --> 00:20:02,040
And he's he's like, there's nothing wrong with my sleep.

328
00:20:02,040 --> 00:20:06,480
And the question that sort of broke it open for the man who inspired Robert was, I said,

329
00:20:06,480 --> 00:20:10,640
okay, so that means that you fall asleep easily at bedtime.

330
00:20:10,640 --> 00:20:15,280
You sleep well through the night and deeply and you wake up feeling refreshed and restored

331
00:20:15,280 --> 00:20:18,120
and you're not tired or sleepy during the daytime.

332
00:20:18,120 --> 00:20:21,560
And he goes, well, no, that's not true at all.

333
00:20:21,560 --> 00:20:25,440
And then both of us kind of shared a laugh, you know, it's like, okay, so I said, so maybe

334
00:20:25,440 --> 00:20:27,280
it's not quite as satisfying as you like.

335
00:20:27,280 --> 00:20:28,280
He says, well, that's true.

336
00:20:28,280 --> 00:20:31,560
Those things are but and then I said, okay, let's talk about those things.

337
00:20:31,560 --> 00:20:34,360
Let's characterize, you know, what this is.

338
00:20:34,360 --> 00:20:38,680
So if you can rate your satisfaction on a scale of one to 10, let's say 10 out of 10

339
00:20:38,680 --> 00:20:39,760
is perfect.

340
00:20:39,760 --> 00:20:44,040
It would be everything that sleep should be deep restorative, you know, I feel great and

341
00:20:44,040 --> 00:20:49,040
energetic during the daytime versus one out of 10 would be, I can't imagine this could

342
00:20:49,040 --> 00:20:53,640
be worse, like this is as bad as it could be in this or any other universe, get them

343
00:20:53,640 --> 00:20:55,520
to put a number to it.

344
00:20:55,520 --> 00:20:59,760
And then all of a sudden, you start to get people engaging because they're like, oh,

345
00:20:59,760 --> 00:21:01,240
okay, all these things might matter.

346
00:21:01,240 --> 00:21:05,320
Okay, well, I guess on a scale of one to 10, I put it at about a six.

347
00:21:05,320 --> 00:21:07,400
You know, that's a failing grade.

348
00:21:07,400 --> 00:21:09,960
This is somebody who's like feeling something at this point.

349
00:21:09,960 --> 00:21:12,240
So now my ears are pricked up.

350
00:21:12,240 --> 00:21:16,520
You know, if somebody says, well, you know, it's fine.

351
00:21:16,520 --> 00:21:20,400
When they kind of stammer that usually it's something under their control.

352
00:21:20,400 --> 00:21:22,800
You know, it's like they know they drank too much caffeine.

353
00:21:22,800 --> 00:21:25,800
They know they're having too much alcohol or something.

354
00:21:25,800 --> 00:21:29,040
But when people are kind of serious about it, they're like, okay, someone's listening.

355
00:21:29,040 --> 00:21:30,720
I'll give myself a five.

356
00:21:30,720 --> 00:21:31,720
Like that's a failing grade.

357
00:21:31,720 --> 00:21:33,960
So now we got to explore that five.

358
00:21:33,960 --> 00:21:34,960
Okay.

359
00:21:34,960 --> 00:21:40,600
So what were you thinking of specifically when you deducted 50% of your total grade?

360
00:21:40,600 --> 00:21:43,360
You gave yourself an F, you know?

361
00:21:43,360 --> 00:21:48,160
And so then they'll say, well, you know, it's hard often to get to sleep.

362
00:21:48,160 --> 00:21:52,560
Well, my partner doesn't like it because I make noise and I snore.

363
00:21:52,560 --> 00:21:57,880
So he often leaves, you know, and I wake up a lot and probably three or four times I wake

364
00:21:57,880 --> 00:22:00,440
up and I'm like wondering if I'm going to get back to sleep.

365
00:22:00,440 --> 00:22:04,800
And then during the day, I'm kind of scatterbrained and I fall asleep at my noon time meeting.

366
00:22:04,800 --> 00:22:05,800
Okay.

367
00:22:05,800 --> 00:22:06,800
Yeah.

368
00:22:06,800 --> 00:22:08,800
Now we've got some narrative.

369
00:22:08,800 --> 00:22:09,800
Yeah.

370
00:22:09,800 --> 00:22:10,800
Now we've got some narrative.

371
00:22:10,800 --> 00:22:11,800
Okay.

372
00:22:11,800 --> 00:22:13,840
So now I understand what's going on.

373
00:22:13,840 --> 00:22:18,140
And you know, this person has five out of 10 sleep satisfaction due to frequent inability

374
00:22:18,140 --> 00:22:20,800
getting to sleep on the front end.

375
00:22:20,800 --> 00:22:25,960
The sensation of light stage, poor quality sleep, easily awakened, prolonged, nocturnal

376
00:22:25,960 --> 00:22:30,480
awakenings, you know, how many trips to the bathroom for Robert, it was two to three, you

377
00:22:30,480 --> 00:22:31,480
know?

378
00:22:31,480 --> 00:22:34,520
And then we get some sense of daytime neurocognitive impairment.

379
00:22:34,520 --> 00:22:39,000
You know, falling asleep at the noon meeting, we can characterize that, you know, losing

380
00:22:39,000 --> 00:22:43,560
my keys, not paying attention, feeling depressed and kind of irritable.

381
00:22:43,560 --> 00:22:45,720
All of these are part of this spectrum.

382
00:22:45,720 --> 00:22:47,880
So now we've got some meat on this.

383
00:22:47,880 --> 00:22:48,880
Okay.

384
00:22:48,880 --> 00:22:51,680
Now we've got a set of sleep weight complaints.

385
00:22:51,680 --> 00:22:57,120
This can now guide us to go and when we're going to have our discussion for our first

386
00:22:57,120 --> 00:23:01,560
deconstruction tool, which I call the five reasons to treat sleep apnea.

387
00:23:01,560 --> 00:23:04,960
Now the patient can have that discussion with knowledge.

388
00:23:04,960 --> 00:23:05,960
Okay.

389
00:23:05,960 --> 00:23:09,120
Because the five reasons to treat, I might as well introduce them.

390
00:23:09,120 --> 00:23:10,120
Everybody wants to do it.

391
00:23:10,120 --> 00:23:17,560
Sleep apnea, that the label at this point encompasses such a spectrum of pathology that

392
00:23:17,560 --> 00:23:23,880
the label sleep apnea is almost meaningless these days, because it can encompass such

393
00:23:23,880 --> 00:23:26,920
a broad spectrum of what this means.

394
00:23:26,920 --> 00:23:33,440
So you know, normally a diagnostic label that has an ICD-10 code, you think, well, there

395
00:23:33,440 --> 00:23:35,600
should be a recommended treatment course.

396
00:23:35,600 --> 00:23:41,840
Like you know, if you have an E. coli UTI, urinary tract infection, there is a standard

397
00:23:41,840 --> 00:23:43,960
set of antibiotics that you should take.

398
00:23:43,960 --> 00:23:46,720
You know, it's like boom, boom, you know what you're supposed to do.

399
00:23:46,720 --> 00:23:47,720
Right.

400
00:23:47,720 --> 00:23:56,520
Sleep apnea, because it's so complex, it involves an overlap between obstructive sleep apnea

401
00:23:56,520 --> 00:24:01,960
and pathology, which is a collapse or a narrowing of the upper airway during attempts to breathe.

402
00:24:01,960 --> 00:24:06,720
And it overlaps with something called central sleep apnea, which is a completely different

403
00:24:06,720 --> 00:24:08,320
problem.

404
00:24:08,320 --> 00:24:13,880
But it's an oscillation of effort to breathe that can be disruptive to the sleep wake experience.

405
00:24:13,880 --> 00:24:17,000
And there's many moving parts with that too.

406
00:24:17,000 --> 00:24:20,840
You know, so the many moving parts of obstructive sleep apnea, we all know about sort of being

407
00:24:20,840 --> 00:24:23,640
heavy and having a collapsible upper airway.

408
00:24:23,640 --> 00:24:27,840
That's the narrative for, you know, the folks that need CPAP, but there's a whole different

409
00:24:27,840 --> 00:24:32,600
phenotype that's emerging that involves kind of deficiencies of what's called the craniophacial

410
00:24:32,600 --> 00:24:37,040
respiratory complex, the bony constituents of the face.

411
00:24:37,040 --> 00:24:40,400
You know, this is where our kids that we're talking about are there in this group.

412
00:24:40,400 --> 00:24:41,400
Yeah.

413
00:24:41,400 --> 00:24:42,400
Yeah.

414
00:24:42,400 --> 00:24:43,400
Yeah.

415
00:24:43,400 --> 00:24:45,640
So the concept of introducing, I call it many moving parts.

416
00:24:45,640 --> 00:24:48,520
I think that's the second episode in our first season.

417
00:24:48,520 --> 00:24:53,800
The concept of introducing there are many moving parts to this problem that is encompassed

418
00:24:53,800 --> 00:24:57,320
under the label sleep apnea, and it's complex.

419
00:24:57,320 --> 00:25:00,440
And there are different moving parts that are relevant for different people in different

420
00:25:00,440 --> 00:25:01,640
combinations.

421
00:25:01,640 --> 00:25:06,600
And so what follows from that logically is once you engage that engineering mindset,

422
00:25:06,600 --> 00:25:11,640
then you can fully appreciate the fact that there is no one size fits all solution.

423
00:25:11,640 --> 00:25:12,640
And there shouldn't be.

424
00:25:12,640 --> 00:25:13,640
Right.

425
00:25:13,640 --> 00:25:14,640
Right.

426
00:25:14,640 --> 00:25:20,280
And that way alienates a substantial portion of the people who have this label or will

427
00:25:20,280 --> 00:25:22,520
end up getting this label.

428
00:25:22,520 --> 00:25:28,200
So the five reasons to treat discussion helps to unpack, you know, should we do something

429
00:25:28,200 --> 00:25:30,080
about this for you and why?

430
00:25:30,080 --> 00:25:31,720
And I'll just enumerate them.

431
00:25:31,720 --> 00:25:37,360
There are five reasons to treat sleep apnea and there always will be five reasons to treat.

432
00:25:37,360 --> 00:25:41,760
Different ones are relevant for different people, but that's why I built the monument.

433
00:25:41,760 --> 00:25:47,800
So on the aisle of sleep apnea, there's this big Roman columned monument with big stairs.

434
00:25:47,800 --> 00:25:49,040
And that's designed to sort of.

435
00:25:49,040 --> 00:25:50,040
Yeah.

436
00:25:50,040 --> 00:25:51,040
I don't know if it's.

437
00:25:51,040 --> 00:25:52,040
It's like it's right there.

438
00:25:52,040 --> 00:25:53,040
Yeah.

439
00:25:53,040 --> 00:25:54,040
Yeah.

440
00:25:54,040 --> 00:25:56,960
Your blur is taking it out of the picture, but it's in the middle of the island.

441
00:25:56,960 --> 00:25:58,200
It's there.

442
00:25:58,200 --> 00:26:02,360
You have to go there before you cross over into treated territory because that's where

443
00:26:02,360 --> 00:26:03,600
you break it down.

444
00:26:03,600 --> 00:26:09,760
And the five reasons to treat are risk, snoring, sleep, wake and comorbidities.

445
00:26:09,760 --> 00:26:16,280
Okay, so let's just go through that risk is the first step to talk about.

446
00:26:16,280 --> 00:26:19,760
And that's, I put it first because it's the hardest one.

447
00:26:19,760 --> 00:26:22,680
It's really a nuanced discussion.

448
00:26:22,680 --> 00:26:30,000
And once again, the cartoons, well, it's nuanced because not all sleep apnea is created equal.

449
00:26:30,000 --> 00:26:31,000
Right.

450
00:26:31,000 --> 00:26:35,480
We've got this idea that there's a metric of severity, right, called the apnea hypopnea

451
00:26:35,480 --> 00:26:36,480
index.

452
00:26:36,480 --> 00:26:37,480
Yeah.

453
00:26:37,480 --> 00:26:45,880
So the AHI is kind of a standard metric that's reported, you know, typically an AHI of five

454
00:26:45,880 --> 00:26:49,600
events per hour or more.

455
00:26:49,600 --> 00:26:51,760
It depicts a diagnosis of sleep apnea.

456
00:26:51,760 --> 00:26:56,600
That's kind of convention and part of the culture, especially on the sort of Western

457
00:26:56,600 --> 00:26:57,600
medical side.

458
00:26:57,600 --> 00:27:00,200
It's like the moderate, the severe.

459
00:27:00,200 --> 00:27:04,440
And these labels come up to based on what that number is, mild, moderate, severe.

460
00:27:04,440 --> 00:27:07,400
And those labels can take on the life of their own too.

461
00:27:07,400 --> 00:27:14,080
Now, the problem here is that everything we know about mortality risk with sleep apnea

462
00:27:14,080 --> 00:27:23,080
was really, we appreciate this knowledge based on very good prospective observational population

463
00:27:23,080 --> 00:27:24,080
based cohorts.

464
00:27:24,080 --> 00:27:25,080
Okay.

465
00:27:25,080 --> 00:27:29,720
Where we take a large population of people, you measure their baseline metrics at the

466
00:27:29,720 --> 00:27:33,720
beginning and then you follow that whole population forward in time.

467
00:27:33,720 --> 00:27:34,720
Okay.

468
00:27:34,720 --> 00:27:40,160
And it's a powerful clinical epidemiology tool to evaluate harm.

469
00:27:40,160 --> 00:27:41,160
Okay.

470
00:27:41,160 --> 00:27:43,120
And that's an important consideration.

471
00:27:43,120 --> 00:27:47,720
So some of the major cohorts in this country have been the Wisconsin Sleep Cohort and the

472
00:27:47,720 --> 00:27:49,320
SleepHeart Health Study.

473
00:27:49,320 --> 00:27:50,320
Okay.

474
00:27:50,320 --> 00:27:58,960
These both found a definite signal for AHI influencing long-term mortality, particularly

475
00:27:58,960 --> 00:28:03,680
AHI when defined by, and I'm going to put this out there.

476
00:28:03,680 --> 00:28:06,600
The way you define the hypopnea matters.

477
00:28:06,600 --> 00:28:12,120
So a hypopnea is an event where the airflow drops for several breaths in a row, presumably

478
00:28:12,120 --> 00:28:15,600
because the airway is constricted and then it recovers.

479
00:28:15,600 --> 00:28:18,720
And because of that event, something physiologic happens.

480
00:28:18,720 --> 00:28:24,560
So the classic definition for a hypopnea is a 4% drop in oxygen saturations as a result

481
00:28:24,560 --> 00:28:26,760
of that flow limitation event.

482
00:28:26,760 --> 00:28:27,760
Okay.

483
00:28:27,760 --> 00:28:33,320
And that's the way SleepHeart Health Study and Wisconsin Sleep Cohort define their hypopneas.

484
00:28:33,320 --> 00:28:38,880
So when we're talking about AHI, it's important to know that the mortality data that we all

485
00:28:38,880 --> 00:28:44,800
think about was based on the AHI that used the 4% desaturation criterion.

486
00:28:44,800 --> 00:28:45,800
Okay.

487
00:28:45,800 --> 00:28:51,680
But what these studies definitively showed was that if the AHI was greater than 30 events

488
00:28:51,680 --> 00:28:57,880
per hour, then there was a definite impact on long-term mortality.

489
00:28:57,880 --> 00:28:59,760
People died younger.

490
00:28:59,760 --> 00:29:06,160
And the signal is that they died younger all cause mortality, but also cardiovascular

491
00:29:06,160 --> 00:29:11,120
mortality, which includes strokes and interestingly cancer mortality.

492
00:29:11,120 --> 00:29:12,120
Okay.

493
00:29:12,120 --> 00:29:19,320
So there's something uniquely stressful about repetitive attempts to breathe against a closed

494
00:29:19,320 --> 00:29:23,680
or a semi-closed airway causing oxygen desaturations.

495
00:29:23,680 --> 00:29:26,880
That is bad news for long-term mortality.

496
00:29:26,880 --> 00:29:27,880
Yeah.

497
00:29:27,880 --> 00:29:28,880
And it happens.

498
00:29:28,880 --> 00:29:32,480
But now let's throw in a little complexity now.

499
00:29:32,480 --> 00:29:33,840
Okay.

500
00:29:33,840 --> 00:29:41,360
Let's throw in some complexity that an AHI greater than five may have some increase in

501
00:29:41,360 --> 00:29:42,360
mortality.

502
00:29:42,360 --> 00:29:44,720
It just didn't reach statistical significance.

503
00:29:44,720 --> 00:29:47,160
It's hard to prove that it's due to one thing.

504
00:29:47,160 --> 00:29:48,160
Okay.

505
00:29:48,160 --> 00:29:49,160
Right.

506
00:29:49,160 --> 00:29:52,200
So we're starting to get signal above an AHI greater than five.

507
00:29:52,200 --> 00:30:00,320
So now when we go back and sort of reverse look at that and say, well, what if the 4%

508
00:30:00,320 --> 00:30:02,160
AHI is less than five?

509
00:30:02,160 --> 00:30:06,280
You'll get a group of people that say, you don't have sleep apnea.

510
00:30:06,280 --> 00:30:07,280
You know?

511
00:30:07,280 --> 00:30:08,280
Right.

512
00:30:08,280 --> 00:30:09,280
Look at the mortality data.

513
00:30:09,280 --> 00:30:11,080
And they're pointing at these wonderful studies.

514
00:30:11,080 --> 00:30:12,080
Sure.

515
00:30:12,080 --> 00:30:15,920
But the problem is this is such a multidimensional disease.

516
00:30:15,920 --> 00:30:21,680
There are obstructive type flow limitation events that don't cause the oxygen to drop.

517
00:30:21,680 --> 00:30:22,680
Okay.

518
00:30:22,680 --> 00:30:26,280
This is more often the phenotype in younger people who have healthy lungs.

519
00:30:26,280 --> 00:30:27,280
You know?

520
00:30:27,280 --> 00:30:31,000
So these types of events, they can be scored.

521
00:30:31,000 --> 00:30:32,000
Okay.

522
00:30:32,000 --> 00:30:37,080
Those are scored as respiratory effort related arousals in a sleep lab.

523
00:30:37,080 --> 00:30:39,080
And they can be disruptive to sleep.

524
00:30:39,080 --> 00:30:43,000
Turns out that part of the diagnosis of obstructive sleep apnea is that if you're having symptoms

525
00:30:43,000 --> 00:30:46,400
like, you know, let's say you've got a bunch of sleep wake complaints, you've got you're

526
00:30:46,400 --> 00:30:50,280
dissatisfied, you're waking up a lot, you're snoring.

527
00:30:50,280 --> 00:30:57,000
And you've got, you know, 15 respiratory effort related arousals or RIRAs per hour, but no

528
00:30:57,000 --> 00:30:58,960
apneas and no hypopneas.

529
00:30:58,960 --> 00:31:00,120
You know?

530
00:31:00,120 --> 00:31:04,520
According to the American Academy of Sleep Medicine, you would still have a diagnosis

531
00:31:04,520 --> 00:31:10,520
of obstructive sleep apnea in that setting because the obstructive event rate is greater

532
00:31:10,520 --> 00:31:11,520
than five per hour.

533
00:31:11,520 --> 00:31:13,880
They include RIRAs in that definition.

534
00:31:13,880 --> 00:31:16,400
Now here's the problem though.

535
00:31:16,400 --> 00:31:25,480
The way our standards are written, RIRAs are an optional event to score for labs to be accredited.

536
00:31:25,480 --> 00:31:27,240
You don't have to, in other words.

537
00:31:27,240 --> 00:31:29,680
RIRAs are troublesome, you know?

538
00:31:29,680 --> 00:31:35,560
And traditionally, it has been a toss up whether some insurance companies will cover RIRA predominant

539
00:31:35,560 --> 00:31:36,720
obstructive sleep apnea.

540
00:31:36,720 --> 00:31:43,480
So again, we get this sort of treatment pathway that locks the thinking about this problem.

541
00:31:43,480 --> 00:31:46,920
If you can't get treated for it, then it's not really a problem and there's no one to

542
00:31:46,920 --> 00:31:47,920
tell you risk.

543
00:31:47,920 --> 00:31:50,520
So, you know, you're not my problem.

544
00:31:50,520 --> 00:31:52,760
So I've got 15 minutes, you know?

545
00:31:52,760 --> 00:31:55,320
I can't get you on CPAP anyway.

546
00:31:55,320 --> 00:31:59,160
So this is kind of the boots on the ground experience.

547
00:31:59,160 --> 00:32:04,360
And when patients get that signal, they get confused because they're led to believe the

548
00:32:04,360 --> 00:32:06,640
study was normal.

549
00:32:06,640 --> 00:32:08,520
And that's not always the case.

550
00:32:08,520 --> 00:32:11,080
So here we have complexity again.

551
00:32:11,080 --> 00:32:15,800
So going back, let's say this person did get the diagnosis of obstructive sleep apnea because

552
00:32:15,800 --> 00:32:18,560
they have 15 RIRAs per hour.

553
00:32:18,560 --> 00:32:21,480
No apneas, no hypopneas.

554
00:32:21,480 --> 00:32:22,840
What do we say about risk?

555
00:32:22,840 --> 00:32:26,560
Well, this is where we can go back and say, well, yes, you qualify for the label sleep

556
00:32:26,560 --> 00:32:29,120
apnea based on these criteria.

557
00:32:29,120 --> 00:32:33,160
But what we know about this flavor of sleep apnea is that it doesn't seem to have an impact

558
00:32:33,160 --> 00:32:36,520
on long-term mortality based on these population studies.

559
00:32:36,520 --> 00:32:37,520
Okay?

560
00:32:37,520 --> 00:32:45,600
So it's a subtlety that is often lost, especially let's say it's a lab that is being generous

561
00:32:45,600 --> 00:32:47,040
with their scoring.

562
00:32:47,040 --> 00:32:53,440
So the American Academy of Sleep Medicine has changed the definition of hypopnea.

563
00:32:53,440 --> 00:33:02,960
So now a lab can use an arousal from sleep as the physiologic endpoint that allows scoring

564
00:33:02,960 --> 00:33:09,920
of a hypopnea as long as there is that requisite 30% reduction in airflow on the airflow trace.

565
00:33:09,920 --> 00:33:18,040
So now we can see how someone might get an AHI of 15, 20, 30.

566
00:33:18,040 --> 00:33:22,320
When they're 4% AHI would have been registered.

567
00:33:22,320 --> 00:33:23,320
Yeah.

568
00:33:23,320 --> 00:33:24,320
Okay?

569
00:33:24,320 --> 00:33:25,320
Holy smokes.

570
00:33:25,320 --> 00:33:30,520
Now my brain is blown because now we're using the same three letter initials, AHI to mean

571
00:33:30,520 --> 00:33:33,240
very different things about mortality risk.

572
00:33:33,240 --> 00:33:34,240
Okay?

573
00:33:34,240 --> 00:33:37,920
So again, going back to that first step, how do we talk about risk?

574
00:33:37,920 --> 00:33:40,120
How do we present this to our patients?

575
00:33:40,120 --> 00:33:44,960
Do we use a defensive stance and say, well, you have severe sleep apnea because your AHI

576
00:33:44,960 --> 00:33:52,400
is 31 and severe sleep apnea, we have to treat this with CPAP because there's a stroke risk.

577
00:33:52,400 --> 00:33:55,440
And now we can see how the patient might start to feel coerced.

578
00:33:55,440 --> 00:34:00,480
Especially if they find out later that that AHI was generated using the AHI.

579
00:34:00,480 --> 00:34:04,560
Using the arousal criterion instead of the 4% criterion.

580
00:34:04,560 --> 00:34:10,640
So it would have no relationship to the AHI numbers that were reported by those important

581
00:34:10,640 --> 00:34:12,960
population based studies.

582
00:34:12,960 --> 00:34:16,400
So hence labels and numbers can be misleading.

583
00:34:16,400 --> 00:34:19,520
What we need to do is unpack these for people.

584
00:34:19,520 --> 00:34:26,240
And again, the whole project is about the fact that unpacking it requires an understanding

585
00:34:26,240 --> 00:34:28,440
of the jargon.

586
00:34:28,440 --> 00:34:31,520
That can be scary.

587
00:34:31,520 --> 00:34:34,160
Jargon is scary for people, especially if they don't have confidence.

588
00:34:34,160 --> 00:34:36,120
But that's what the Bay of Narrative is for.

589
00:34:36,120 --> 00:34:38,120
That's what the Bay of Narrative is for.

590
00:34:38,120 --> 00:34:39,120
That's what the Bay of Narrative is for.

591
00:34:39,120 --> 00:34:45,040
Yeah, come to the Bay, have a fruit cocktail, I would say.

592
00:34:45,040 --> 00:34:49,520
A nice fruit drink as we walk, drinking out of a coconut with a little umbrella is the

593
00:34:49,520 --> 00:35:19,320
kind of state of mind you should be in.

594
00:35:20,440 --> 00:35:25,800
The CAF website offers tons of great resources for both parents and medical professionals.

595
00:35:25,800 --> 00:35:30,280
In our Parents Portal and Clinician Corner, you can find educational and informational

596
00:35:30,280 --> 00:35:36,600
content including videos, blogs, our recommended reading list, comprehensive medical research,

597
00:35:36,600 --> 00:35:42,560
podcasts, events, parent support, and educational opportunities.

598
00:35:42,560 --> 00:35:46,720
Parents are also encouraged to join the Airway Huddle, our Facebook support group which was

599
00:35:46,720 --> 00:35:51,240
created for parents of children with Airway and sleep-related issues.

600
00:35:51,240 --> 00:35:57,160
You can access the Airway Huddle support group at facebook.com backslashgroups backslash

601
00:35:57,160 --> 00:35:59,240
airwayhuddle.

602
00:35:59,240 --> 00:36:04,080
Are you a medical professional or parent that's interested in being a guest on a show?

603
00:36:04,080 --> 00:36:08,400
Then shoot us a note via the contacts page on our website or send us an email directly

604
00:36:08,400 --> 00:36:12,720
at infoatchildrensairwayfirst.org.

605
00:36:12,720 --> 00:36:17,840
As a reminder, this podcast, The Opinions Express Tier, or Not a Medical Diagnosis,

606
00:36:17,840 --> 00:36:22,600
if you suspect your child might have an airway issue, contact your pediatric airway dentist

607
00:36:22,600 --> 00:36:24,480
or pediatrician.

608
00:36:24,480 --> 00:36:50,480
And now let's jump back into my interview with today's guest, Dr. Dave McCarty.

609
00:36:50,480 --> 00:36:58,680
So, you saw how long I rambled on about that.

610
00:36:58,680 --> 00:37:04,080
There's a lot of jargon about risk and as a result, most providers don't do it and they

611
00:37:04,080 --> 00:37:05,080
can't do it.

612
00:37:05,080 --> 00:37:07,320
I'll introduce another flavor to this.

613
00:37:07,320 --> 00:37:13,120
So we, to risk, before we move on, the discussion about risk again is based on those population

614
00:37:13,120 --> 00:37:14,800
based cohorts, right?

615
00:37:14,800 --> 00:37:20,520
Those were both studies that were done on middle-aged people, younger middle-aged people

616
00:37:20,520 --> 00:37:25,920
to begin with generally, who were free of baseline cardiovascular disease, generally

617
00:37:25,920 --> 00:37:30,160
at baseline, and who lived at sea level.

618
00:37:30,160 --> 00:37:35,820
Three factors that I want to consider when now we're talking about another complexity

619
00:37:35,820 --> 00:37:39,960
of sleep apnea, which is called central sleep apnea.

620
00:37:39,960 --> 00:37:46,080
So central sleep apnea, again, is this oscillation of respiratory effort that happens as a result

621
00:37:46,080 --> 00:37:48,360
of many factors.

622
00:37:48,360 --> 00:37:53,800
And some of the risk factors for the development of more central apnea physiology events on

623
00:37:53,800 --> 00:37:56,640
your study are aging.

624
00:37:56,640 --> 00:38:01,520
So just being older and getting older means that your circulation time and cardiac output

625
00:38:01,520 --> 00:38:06,840
tends to drop as a factor of aging-related cardiac disease.

626
00:38:06,840 --> 00:38:11,360
And circulation time, how long it takes for your blood to get around the whole circuit,

627
00:38:11,360 --> 00:38:16,280
around the block, when that's prolonged, it tends to lead to unstable respiratory control,

628
00:38:16,280 --> 00:38:17,280
okay?

629
00:38:17,280 --> 00:38:22,640
So the older that you get, the more cardiovascular disease you mount up and the higher elevation

630
00:38:22,640 --> 00:38:24,480
you live at.

631
00:38:24,480 --> 00:38:28,880
All of these are factors that influence how much central apnea physiology is going to

632
00:38:28,880 --> 00:38:29,880
emerge.

633
00:38:29,880 --> 00:38:32,920
Now, here's the rub.

634
00:38:32,920 --> 00:38:35,720
Central hypopneas are a thing.

635
00:38:35,720 --> 00:38:39,000
This is where it's not an absolute pause in effort.

636
00:38:39,000 --> 00:38:45,080
It's a reduced amplitude and often a reduced rate of breathing that happens that creates

637
00:38:45,080 --> 00:38:50,920
an airflow limitation that causes oxygen.

638
00:38:50,920 --> 00:38:55,920
It is considered optional because it's hard to tell the difference between- often these

639
00:38:55,920 --> 00:38:57,720
findings are mixed.

640
00:38:57,720 --> 00:39:01,760
So there can be features of obstruction and features of central apnea physiology happening

641
00:39:01,760 --> 00:39:05,160
simultaneously, one superimposed upon the other.

642
00:39:05,160 --> 00:39:11,160
But the basic teaching point is the more risk factors you have for central apnea physiology,

643
00:39:11,160 --> 00:39:17,520
the more likely it is that your AHI number is going to be weighted towards central apnea

644
00:39:17,520 --> 00:39:18,840
physiology events.

645
00:39:18,840 --> 00:39:19,840
Okay?

646
00:39:19,840 --> 00:39:26,760
Now, keep in mind that a true central apnea, you can consider it a pause in breathing that

647
00:39:26,760 --> 00:39:29,520
follows a heavy sigh, okay?

648
00:39:29,520 --> 00:39:34,080
The heavy sigh is what happens during the recovery relative arousal phase.

649
00:39:34,080 --> 00:39:36,520
And then what happens is just pause.

650
00:39:36,520 --> 00:39:40,640
And it's an instability between those heavy sigh and pause type of states.

651
00:39:40,640 --> 00:39:42,600
And that, you know, the pause can be relative.

652
00:39:42,600 --> 00:39:45,160
It can be reduced effort too.

653
00:39:45,160 --> 00:39:51,920
Now that type of an instability is not the same as struggling to breathe against a closed

654
00:39:51,920 --> 00:39:54,240
or semi-closed airway, okay?

655
00:39:54,240 --> 00:39:57,280
It doesn't produce the same type of physiology.

656
00:39:57,280 --> 00:40:04,000
And to date, we don't have any reliable data that shows that pure central sleep apnea represents

657
00:40:04,000 --> 00:40:08,440
a long-term mortality risk the same way obstructive sleeping, okay?

658
00:40:08,440 --> 00:40:09,440
Gotcha.

659
00:40:09,440 --> 00:40:14,480
Now, we've got that, then separated in our minds that, you know, we can think about them

660
00:40:14,480 --> 00:40:16,160
kind of separately.

661
00:40:16,160 --> 00:40:21,400
What happens when, you know, someone has maybe mildish obstructive sleep apnea and then they

662
00:40:21,400 --> 00:40:25,880
start to get more instability with the respiratory effort as they get older.

663
00:40:25,880 --> 00:40:31,120
And now they've got kind of a mixed phenotype and their number is kind of high.

664
00:40:31,120 --> 00:40:37,200
Is this the same problem as Wisconsin sleep cohort, AHI 30 showing mortality rate, you

665
00:40:37,200 --> 00:40:42,480
know, a survival rate of 57% at 18 years.

666
00:40:42,480 --> 00:40:44,200
That's what that study showed.

667
00:40:44,200 --> 00:40:50,000
When the AHI was over 30, as opposed to people with AHI at less than five, who's had basically

668
00:40:50,000 --> 00:40:57,400
a 98% survival rate at 18 years, Wisconsin sleep cohort showed that 57% of that cohort,

669
00:40:57,400 --> 00:41:01,000
AHI greater than 30 was still alive at 18 years.

670
00:41:01,000 --> 00:41:02,720
That's a huge problem.

671
00:41:02,720 --> 00:41:03,720
Okay.

672
00:41:03,720 --> 00:41:11,120
But what if it's an 80 year old woman with atrial fibrillation who lives in the mountains,

673
00:41:11,120 --> 00:41:16,560
who has a primarily central apnea phenotype, central hypopnea phenotype and she's going

674
00:41:16,560 --> 00:41:20,280
to get a number AHI 35.

675
00:41:20,280 --> 00:41:22,320
Is that the same problem anymore?

676
00:41:22,320 --> 00:41:24,480
And your answer is it's not.

677
00:41:24,480 --> 00:41:25,480
No.

678
00:41:25,480 --> 00:41:26,480
Yeah.

679
00:41:26,480 --> 00:41:33,960
The solution to her problem may be why don't you move to C level and see what happens when

680
00:41:33,960 --> 00:41:39,360
you retest and maybe avoid back sleeping and sleep with your mouth closed, you know, to

681
00:41:39,360 --> 00:41:42,040
handle whatever the obstructive component might have been.

682
00:41:42,040 --> 00:41:48,520
So there's the concept of many moving parts is relevant to all of this risk discussion

683
00:41:48,520 --> 00:41:53,920
too, you know, the discussion of a risk requires that we understand the difference between central

684
00:41:53,920 --> 00:42:01,040
apnea physiology and obstructive sleep apnea pathology and those two things can be intermingled

685
00:42:01,040 --> 00:42:03,080
with each other.

686
00:42:03,080 --> 00:42:07,160
So I think I'm done talking about risk.

687
00:42:07,160 --> 00:42:11,280
The second step of the monument is snoring.

688
00:42:11,280 --> 00:42:16,880
By the way, in the little adventure, there's the five reasons monument and then coffee

689
00:42:16,880 --> 00:42:17,880
hut.

690
00:42:17,880 --> 00:42:18,880
Right?

691
00:42:18,880 --> 00:42:21,240
It's five reasons to treat monument and coffee hut.

692
00:42:21,240 --> 00:42:22,240
And I did that on purpose.

693
00:42:22,240 --> 00:42:26,920
It was kind of a spur of the moment decision, but I realized I didn't want it to be a scary,

694
00:42:26,920 --> 00:42:30,880
big monumental place that, you know, you had to regard with dignity.

695
00:42:30,880 --> 00:42:32,440
You had to go and recognize it.

696
00:42:32,440 --> 00:42:37,080
It's a monument, but then the place you need to go is the coffee hut because what you need

697
00:42:37,080 --> 00:42:40,520
is about, you know, as many hours as you need to sit.

698
00:42:40,520 --> 00:42:42,520
It needs to be a digest.

699
00:42:42,520 --> 00:42:43,520
Yeah.

700
00:42:43,520 --> 00:42:46,680
Inpatient place, you know, where you're not rushed.

701
00:42:46,680 --> 00:42:52,040
And so for me, the image that came to my mind was was one of those old converted railroad

702
00:42:52,040 --> 00:42:54,280
cars that's now a diner.

703
00:42:54,280 --> 00:42:55,280
Yeah.

704
00:42:55,280 --> 00:42:56,280
You know, yeah, I know.

705
00:42:56,280 --> 00:42:57,280
All night.

706
00:42:57,280 --> 00:42:59,360
You can stay as long as you want.

707
00:42:59,360 --> 00:43:00,800
Time doesn't exist.

708
00:43:00,800 --> 00:43:04,160
The waitress is real nice and you eat, pie and drink coffee.

709
00:43:04,160 --> 00:43:07,760
So that was the liminal space that I felt was appropriate.

710
00:43:07,760 --> 00:43:13,120
That was the opposite of the usual clinical encounter of, you know, you got 15 minutes.

711
00:43:13,120 --> 00:43:15,480
Here's what sleep apnea is with this trifold handout.

712
00:43:15,480 --> 00:43:17,480
Boop, boop, boop, and out.

713
00:43:17,480 --> 00:43:18,480
Yeah.

714
00:43:18,480 --> 00:43:22,000
You know, and to most people, unless it's very straightforward for them, they think

715
00:43:22,000 --> 00:43:25,600
they find that dissatisfying and they know there's something more to it.

716
00:43:25,600 --> 00:43:30,640
And if their case turns out to be more complex, then they end up looking back on that discussion

717
00:43:30,640 --> 00:43:32,880
with a little bit of distrust.

718
00:43:32,880 --> 00:43:35,720
And I think that's a problem that we should be talking about, you know.

719
00:43:35,720 --> 00:43:40,840
And I think, and I want to, I want to interject here before we move on to snoring too.

720
00:43:40,840 --> 00:43:43,560
That's another thing that you're going to learn throughout this book as you go on this

721
00:43:43,560 --> 00:43:44,680
journey.

722
00:43:44,680 --> 00:43:47,240
And I want parents to really, really hear this message.

723
00:43:47,240 --> 00:43:52,480
We talk about it all the time, advocating for your child is so huge.

724
00:43:52,480 --> 00:43:55,080
That's part of the empowerment project for sure.

725
00:43:55,080 --> 00:43:56,080
Exactly.

726
00:43:56,080 --> 00:43:57,080
I mean, yes.

727
00:43:57,080 --> 00:43:59,320
I mean, okay, y'all went to med school.

728
00:43:59,320 --> 00:44:01,040
Y'all are the experts.

729
00:44:01,040 --> 00:44:02,120
Not denying that.

730
00:44:02,120 --> 00:44:06,040
But to your point where 15 minutes were in and out, you're going to miss things.

731
00:44:06,040 --> 00:44:11,640
So if your gut, if your instinct, if something is wrong, something was messed, something

732
00:44:11,640 --> 00:44:16,120
was not addressed, say it, bring it up.

733
00:44:16,120 --> 00:44:21,920
Go to a second opinion, but you keep advocating until you feel like, okay, I'm comfortable.

734
00:44:21,920 --> 00:44:22,920
We're on the same page.

735
00:44:22,920 --> 00:44:23,920
Let's move forward.

736
00:44:23,920 --> 00:44:24,920
Yeah.

737
00:44:24,920 --> 00:44:25,920
Yeah.

738
00:44:25,920 --> 00:44:26,920
I totally agree.

739
00:44:26,920 --> 00:44:32,840
And the language of the empowered sleep apnea project is designed around self-advocacy, but

740
00:44:32,840 --> 00:44:38,360
it's designed also because this is a, this is a difficult project or a difficult process

741
00:44:38,360 --> 00:44:44,560
for most providers, providers who are feeling time impoverished are feeling the rush of

742
00:44:44,560 --> 00:44:45,560
that.

743
00:44:45,560 --> 00:44:52,360
And a natural tendency towards being very straight and very direct with one's instructions.

744
00:44:52,360 --> 00:44:58,880
And so you can fall into this systematized way that you feel there's no other way to

745
00:44:58,880 --> 00:45:03,000
do it, you know, because you've got to get through this conversation and they have to

746
00:45:03,000 --> 00:45:08,240
be aware of the risks and you can't let that remain unsaid.

747
00:45:08,240 --> 00:45:12,240
You know, so it's a very difficult place for providers to be as well.

748
00:45:12,240 --> 00:45:14,560
And this is the point of the friendliness of the book.

749
00:45:14,560 --> 00:45:18,560
So, you know, so the subtext is the book is called a handbook for patients and the people

750
00:45:18,560 --> 00:45:20,560
who care about them.

751
00:45:20,560 --> 00:45:24,400
Those people who care about them are their providers, you know, so if we can share the

752
00:45:24,400 --> 00:45:30,120
language patients out there, this would be a beautiful gift for your sleep doc or your

753
00:45:30,120 --> 00:45:33,280
primary care provider because it is fun to read.

754
00:45:33,280 --> 00:45:35,200
They can put it in their waiting room.

755
00:45:35,200 --> 00:45:39,680
People like to sort of pick it up and look at it and it helps engage the conversation.

756
00:45:39,680 --> 00:45:43,760
So if you can go in and your provider understands, you know, the whole five reasons to treat

757
00:45:43,760 --> 00:45:49,400
paradigm and you can have that discussion, then things flow a lot more smoothly, you

758
00:45:49,400 --> 00:45:50,400
know.

759
00:45:50,400 --> 00:45:52,040
So, right, right.

760
00:45:52,040 --> 00:45:53,800
I don't want to keep people in suspense.

761
00:45:53,800 --> 00:45:54,800
Second reason to treat.

762
00:45:54,800 --> 00:45:55,800
So, okay.

763
00:45:55,800 --> 00:45:56,800
Yeah.

764
00:45:56,800 --> 00:46:01,760
So I put that as its own distinct reason because it's a spectrum.

765
00:46:01,760 --> 00:46:05,320
Some people are unaware if they snore, but they might still do it.

766
00:46:05,320 --> 00:46:09,080
And there are ways to check on that so that you can use an app to sort of monitor and

767
00:46:09,080 --> 00:46:13,040
play it back and see some people and go listen to your kids at night.

768
00:46:13,040 --> 00:46:14,040
Oh, yeah.

769
00:46:14,040 --> 00:46:15,040
And you can record them too.

770
00:46:15,040 --> 00:46:16,040
Not just once.

771
00:46:16,040 --> 00:46:17,040
Yeah.

772
00:46:17,040 --> 00:46:18,040
Not just once.

773
00:46:18,040 --> 00:46:19,040
Absolutely.

774
00:46:19,040 --> 00:46:20,040
A couple of times.

775
00:46:20,040 --> 00:46:21,680
More data is more better, you know.

776
00:46:21,680 --> 00:46:26,200
There are people who have rip roaring, real life threatening sleep apnea who do not make

777
00:46:26,200 --> 00:46:27,320
a sound.

778
00:46:27,320 --> 00:46:29,920
You know, silent sleep apnea is a thing.

779
00:46:29,920 --> 00:46:33,440
And so for people who say, well, I can't have sleep apnea because they don't snore, that's

780
00:46:33,440 --> 00:46:35,200
an important consideration.

781
00:46:35,200 --> 00:46:41,000
You know, it doesn't represent a reason to treat for you if you don't snore.

782
00:46:41,000 --> 00:46:42,000
But right.

783
00:46:42,000 --> 00:46:44,360
You may still need to treat this for the other four reasons.

784
00:46:44,360 --> 00:46:45,360
Right.

785
00:46:45,360 --> 00:46:47,680
That's enlightening for people.

786
00:46:47,680 --> 00:46:49,360
Sometimes people don't have a bed partner.

787
00:46:49,360 --> 00:46:54,160
And so they may not know if they snore, but they may have what I call snoring aftermath

788
00:46:54,160 --> 00:46:55,160
symptoms.

789
00:46:55,160 --> 00:46:56,680
I would say you have the signs.

790
00:46:56,680 --> 00:46:57,680
Yeah.

791
00:46:57,680 --> 00:47:02,080
So nasal congestion or irritability in the back of the throat, foreign body sensation,

792
00:47:02,080 --> 00:47:07,040
dry mouth, wake up dry mouth, all this yucky crud back there.

793
00:47:07,040 --> 00:47:09,040
That might be snoring aftermath.

794
00:47:09,040 --> 00:47:11,360
So you know, if you're getting that and you're like, well, I don't know.

795
00:47:11,360 --> 00:47:17,440
Again, we can use technology to try to characterize what this burden of snoring is for you.

796
00:47:17,440 --> 00:47:20,720
When I talk about snoring, I want to know what the social burden is.

797
00:47:20,720 --> 00:47:25,480
I want to know how this impacts people's decisions to go camping or go places with people.

798
00:47:25,480 --> 00:47:29,520
Whether it's impacted sleeping arrangements at home.

799
00:47:29,520 --> 00:47:32,920
You know, so you can get a real sense for what this is doing.

800
00:47:32,920 --> 00:47:38,560
Because the other side of this is that snoring is not necessarily benign.

801
00:47:38,560 --> 00:47:40,480
Snoring is vibrational trauma.

802
00:47:40,480 --> 00:47:41,480
Okay.

803
00:47:41,480 --> 00:47:44,080
Which creates an inflammatory response.

804
00:47:44,080 --> 00:47:49,640
So snoring can be part of the pathogenesis of, you know, sinusitis, for example, it's

805
00:47:49,640 --> 00:47:52,960
a mucosal irritant due to vibrational trauma.

806
00:47:52,960 --> 00:47:58,880
And there are also some lines of data that suggest that the burden of snoring, okay,

807
00:47:58,880 --> 00:48:04,400
meaning the intensity and the duration at night itself can be an independent risk factor

808
00:48:04,400 --> 00:48:07,920
for getting atherosclerotic plaque buildup in the carotids.

809
00:48:07,920 --> 00:48:08,920
Okay.

810
00:48:08,920 --> 00:48:10,640
So it's just due to proximity.

811
00:48:10,640 --> 00:48:11,640
All this, right.

812
00:48:11,640 --> 00:48:12,640
Right.

813
00:48:12,640 --> 00:48:13,640
Yeah.

814
00:48:13,640 --> 00:48:14,840
It can be pretty high intensity stuff.

815
00:48:14,840 --> 00:48:17,160
And it just damages the lining of the arteries.

816
00:48:17,160 --> 00:48:18,160
Okay.

817
00:48:18,160 --> 00:48:24,520
So a frank discussion about the impact of snoring on you, you know, my patient, that's what that

818
00:48:24,520 --> 00:48:25,760
step is all about.

819
00:48:25,760 --> 00:48:28,040
Really getting your hands around how much this matters.

820
00:48:28,040 --> 00:48:29,040
Okay.

821
00:48:29,040 --> 00:48:33,240
So at the end of the day, is snoring a reason to treat or not?

822
00:48:33,240 --> 00:48:35,760
And the patient can say yes or no.

823
00:48:35,760 --> 00:48:38,960
One word reasons to treat is just sleep.

824
00:48:38,960 --> 00:48:43,400
You know, I've made these one word reasons to make it easier to remember, but the sleep

825
00:48:43,400 --> 00:48:44,680
experience.

826
00:48:44,680 --> 00:48:49,160
So this is where we go back and we flesh out again those sleep wake complaints that we

827
00:48:49,160 --> 00:48:50,920
talk to our patients about.

828
00:48:50,920 --> 00:48:52,920
How is the nocturnal experience?

829
00:48:52,920 --> 00:48:54,640
Is it easy to go to sleep?

830
00:48:54,640 --> 00:48:56,520
Is it easy to remain asleep?

831
00:48:56,520 --> 00:48:57,560
Do you toss and turn?

832
00:48:57,560 --> 00:48:59,400
Are you easily awakened?

833
00:48:59,400 --> 00:49:03,320
Do you awaken in the morning with any physical discomforts?

834
00:49:03,320 --> 00:49:07,280
You know, a lot of sleep apnea patients will have headaches in the morning and they're

835
00:49:07,280 --> 00:49:11,360
just like, I'm a headachey person and they don't sort of think about it.

836
00:49:11,360 --> 00:49:19,320
Nocturnal reflux, you know, acid reflux is always a problem with people with sleep apnea.

837
00:49:19,320 --> 00:49:20,880
Not always, but you know what I mean.

838
00:49:20,880 --> 00:49:26,320
When you're trying to suck and you're trying to sort of breathe against a semi-closed airway,

839
00:49:26,320 --> 00:49:30,480
you're creating a suction for the abdominal contents to come up.

840
00:49:30,480 --> 00:49:34,600
So a lot of people will be given the label of heartburn.

841
00:49:34,600 --> 00:49:40,640
They'll be advised to take some sort of antacid medication to relieve the symptoms.

842
00:49:40,640 --> 00:49:45,640
And it's never fully investigated as being related to something that's happening with

843
00:49:45,640 --> 00:49:47,880
their breathing at night.

844
00:49:47,880 --> 00:49:51,720
Same thing is true with frequent trips to the bathroom.

845
00:49:51,720 --> 00:49:53,160
Nocturia is what that's called.

846
00:49:53,160 --> 00:50:00,000
You know, normally the physiology during sleep is we're kind of designed to put a little

847
00:50:00,000 --> 00:50:04,400
minimization of how much urine we're producing while we're sleeping.

848
00:50:04,400 --> 00:50:05,920
That's just normal physiology.

849
00:50:05,920 --> 00:50:08,280
That way we can sleep through the night.

850
00:50:08,280 --> 00:50:14,600
But when people have sleep apnea, it changes the physiology of how fluids are sensed.

851
00:50:14,600 --> 00:50:19,760
And it can actually increase the pressures in the right-sided elevated chambers of the

852
00:50:19,760 --> 00:50:21,440
heart, the right atrium.

853
00:50:21,440 --> 00:50:27,320
As a result of the vassal constriction that happens in the pulmonary bed during these breathing

854
00:50:27,320 --> 00:50:28,320
events.

855
00:50:28,320 --> 00:50:29,320
Okay?

856
00:50:29,320 --> 00:50:34,440
And what that does basically is it tells the heart an erroneous signal of fluid overload

857
00:50:34,440 --> 00:50:38,160
and the heart then sends a signal to the kidneys to make more urine.

858
00:50:38,160 --> 00:50:39,160
Okay?

859
00:50:39,160 --> 00:50:44,760
So a lot of times the frequent bacteria is a sign that the sleep apnea is putting a strain

860
00:50:44,760 --> 00:50:47,880
on the heart and it's just connecting those dots can be hard.

861
00:50:47,880 --> 00:50:53,760
If you went to a more label-based physician and said, I have frequent bacteria, they may

862
00:50:53,760 --> 00:50:55,640
say, oh, well, it's your prostate.

863
00:50:55,640 --> 00:50:57,640
Let's put you on a medicine for that.

864
00:50:57,640 --> 00:51:00,440
And once that label gets a fixed, it's hard to think about it any other way.

865
00:51:00,440 --> 00:51:01,440
That's hard to shake it.

866
00:51:01,440 --> 00:51:04,480
And in children, it's probably going to present differently, correct?

867
00:51:04,480 --> 00:51:05,480
Yeah.

868
00:51:05,480 --> 00:51:06,480
In children, you might...

869
00:51:06,480 --> 00:51:07,480
They're not going to get up.

870
00:51:07,480 --> 00:51:08,480
They're just going to bed wet.

871
00:51:08,480 --> 00:51:09,480
That's right.

872
00:51:09,480 --> 00:51:10,480
Yeah.

873
00:51:10,480 --> 00:51:15,880
Nocturnal aneurysis can be part of this picture for children for the same reasons.

874
00:51:15,880 --> 00:51:21,880
Aneurysis is a complex subject, but it has to do with the sleep disruptive aspects as

875
00:51:21,880 --> 00:51:29,440
well as the physiology of bladder control.

876
00:51:29,440 --> 00:51:31,280
So that's the sleep experience.

877
00:51:31,280 --> 00:51:35,360
Again, worth on line for the patient, worth going back to that original discussion at

878
00:51:35,360 --> 00:51:39,440
the Bay of Narrative, how do you perceive your sleep experience?

879
00:51:39,440 --> 00:51:40,440
What's wrong?

880
00:51:40,440 --> 00:51:42,240
Why isn't it a 10?

881
00:51:42,240 --> 00:51:45,320
Fourth reason to treat, the wake experience.

882
00:51:45,320 --> 00:51:51,640
So this is where we unwind the patient's perception of quality of their daytime neurobehavioral

883
00:51:51,640 --> 00:51:53,800
context in their waking day.

884
00:51:53,800 --> 00:51:57,920
Do they feel like they can stay awake effortlessly?

885
00:51:57,920 --> 00:52:00,240
Or do they have to stand up at meetings?

886
00:52:00,240 --> 00:52:02,120
Do they fall asleep behind the wheel?

887
00:52:02,120 --> 00:52:04,520
These are the more dramatic presentations.

888
00:52:04,520 --> 00:52:11,560
There's a very commonly used Epworth sleepiness scale, which is a numeric score for how likely

889
00:52:11,560 --> 00:52:16,400
you are to doze off during periods of inactivity during wakefulness.

890
00:52:16,400 --> 00:52:17,880
That's helpful.

891
00:52:17,880 --> 00:52:24,720
If it's elevated, anything over 10 and higher is typically considered too much daytime sleepiness

892
00:52:24,720 --> 00:52:25,720
on that scale.

893
00:52:25,720 --> 00:52:30,880
But it shouldn't be used to turn people away from care.

894
00:52:30,880 --> 00:52:35,400
A normal Epworth score certainly doesn't mean you don't have any daytime neurobehavioral

895
00:52:35,400 --> 00:52:36,480
impairment.

896
00:52:36,480 --> 00:52:40,880
It just means you're not metathesting as inappropriate dozing episodes.

897
00:52:40,880 --> 00:52:46,960
So sleep disruption and sleep deprivation, meaning you're not getting enough hours or

898
00:52:46,960 --> 00:52:52,080
the hours that you're getting are so disrupted that you can't get all of that physiologic

899
00:52:52,080 --> 00:52:54,760
sleep pressure out of your head.

900
00:52:54,760 --> 00:53:01,720
That can produce symptoms that are really nonspecific, attention deficit, inability to

901
00:53:01,720 --> 00:53:06,280
control one's emotions in kids is often what we see.

902
00:53:06,280 --> 00:53:12,680
They often become hyperactive rather than dozy.

903
00:53:12,680 --> 00:53:18,120
In adults, it can be a different spectrum altogether due to the chronicity of it.

904
00:53:18,120 --> 00:53:22,120
How this affects people can go different ways.

905
00:53:22,120 --> 00:53:29,200
Sometimes the chronicity of this fight or flight stimulation that happens at night can

906
00:53:29,200 --> 00:53:36,080
lead to sort of a chronic overactivity of all of that fight or flight apparatus.

907
00:53:36,080 --> 00:53:40,040
So people end up feeling anxious, twitchy.

908
00:53:40,040 --> 00:53:44,720
They suffer from insomnia more than excessive daytime sleepiness.

909
00:53:44,720 --> 00:53:52,880
They may present with stress-related syndromes like migraine headaches or TMJ dysfunction,

910
00:53:52,880 --> 00:53:58,400
problems with their jaw joints, grinding can be part of that.

911
00:53:58,400 --> 00:54:03,760
So it can be kind of not on the radar screen for what we usually think sleep apnea, which

912
00:54:03,760 --> 00:54:08,360
is the classic presentation, of course, the pick-wicky syndrome of the heavy person who

913
00:54:08,360 --> 00:54:11,560
snores and is falling asleep at the lunch table.

914
00:54:11,560 --> 00:54:15,840
That's not the way it always is.

915
00:54:15,840 --> 00:54:18,000
So again, many moving parts.

916
00:54:18,000 --> 00:54:22,600
So helping to deconstruct the wake experience for people allows them to explore some of

917
00:54:22,600 --> 00:54:29,960
these things that may have been labeled something else, anxiety disorder or ADHD or something

918
00:54:29,960 --> 00:54:30,960
like that.

919
00:54:30,960 --> 00:54:36,240
The last reason to treat is going to be consideration of comorbidities.

920
00:54:36,240 --> 00:54:45,000
That's a mouthful, but it basically refers to the also-ran diagnoses, these other elements

921
00:54:45,000 --> 00:54:50,960
on your problem list that are vulnerable to untreated sleep apnea.

922
00:54:50,960 --> 00:54:54,920
And this is really meant to be a discussion between provider and patient.

923
00:54:54,920 --> 00:54:55,920
It's a big one.

924
00:54:55,920 --> 00:54:56,920
Yeah.

925
00:54:56,920 --> 00:54:57,920
It's meant to be an inventory.

926
00:54:57,920 --> 00:54:59,760
How are you doing overall?

927
00:54:59,760 --> 00:55:02,480
What are we treating you for?

928
00:55:02,480 --> 00:55:05,640
What are you seeing providers for or therapists for?

929
00:55:05,640 --> 00:55:07,600
Could this be related?

930
00:55:07,600 --> 00:55:12,760
And drawing attention to the fact that the reflux and the migraine headaches and the teeth

931
00:55:12,760 --> 00:55:19,160
grinding and the frequent nocturia all could be part of this syndrome helps people say,

932
00:55:19,160 --> 00:55:22,880
oh, okay, now I see what we're taking aim at.

933
00:55:22,880 --> 00:55:28,040
Because the truth is, for many of these other problems, it's really hard to make them better.

934
00:55:28,040 --> 00:55:32,240
You can manage them, maybe, but it's hard to make them better if you don't address the

935
00:55:32,240 --> 00:55:34,960
underlying sleep disorder breathing.

936
00:55:34,960 --> 00:55:35,960
Because it's that...

937
00:55:35,960 --> 00:55:40,280
And this is where you talk about in one of the first two episodes about the boil the

938
00:55:40,280 --> 00:55:42,280
frog thing.

939
00:55:42,280 --> 00:55:46,360
Because they could be here and we're just going through life.

940
00:55:46,360 --> 00:55:47,360
We've adapted.

941
00:55:47,360 --> 00:55:48,360
We're just moving through it.

942
00:55:48,360 --> 00:55:51,160
But all this damage is being done.

943
00:55:51,160 --> 00:55:53,920
And no one has yet connected the dots.

944
00:55:53,920 --> 00:55:58,720
So this is a real opportunity for providers to help patients connect their dots.

945
00:55:58,720 --> 00:56:03,600
And the five reasons to treat it always helps shed clarity for folks.

946
00:56:03,600 --> 00:56:09,720
So in the fictional character, Robert, in our podcast was based on a real life event

947
00:56:09,720 --> 00:56:13,400
that actually caused me to come up with this discussion.

948
00:56:13,400 --> 00:56:18,600
And it took a very hostile patient who was very distressed over the medical system with

949
00:56:18,600 --> 00:56:24,040
a very significant and complex problem and allowed him to find his way through it.

950
00:56:24,040 --> 00:56:26,920
And he became one of my best patients, best.

951
00:56:26,920 --> 00:56:29,320
But he did well on his therapy.

952
00:56:29,320 --> 00:56:33,000
But it was a complex journey that he never would have undertaken if he didn't understand

953
00:56:33,000 --> 00:56:34,000
it.

954
00:56:34,000 --> 00:56:36,680
And that was the important part of the experiment for his story.

955
00:56:36,680 --> 00:56:41,200
And it turns out that he started the discussion when I said, are you satisfied with your sleep?

956
00:56:41,200 --> 00:56:44,800
And he said, yes, defensively.

957
00:56:44,800 --> 00:56:49,800
And then when we broke it down, we realized that he had elements in all five reasons to

958
00:56:49,800 --> 00:56:52,360
treat that were pretty profound.

959
00:56:52,360 --> 00:56:56,680
And so when he came away from that discussion, he was like, I get it now.

960
00:56:56,680 --> 00:57:00,880
And I get that you're not trying to sell me something that this is this is pervasive.

961
00:57:00,880 --> 00:57:03,720
And I didn't even see it.

962
00:57:03,720 --> 00:57:08,400
And so at the end of the day for Robert, the character who the man who inspired Robert,

963
00:57:08,400 --> 00:57:14,080
his actual solution was a was a complex one because he required management of several

964
00:57:14,080 --> 00:57:19,160
elements that were contributing to his sleep-wake experience, not just his breathing too.

965
00:57:19,160 --> 00:57:21,480
But again, the aisle helps you get there.

966
00:57:21,480 --> 00:57:26,000
That's the other five point mnemonic on right, which is the five finger approach.

967
00:57:26,000 --> 00:57:29,200
So I don't know that we're going to have time to go through this one.

968
00:57:29,200 --> 00:57:33,160
This may be a subject for a different discussion, but the five thing I like is something very

969
00:57:33,160 --> 00:57:34,160
helpful to that.

970
00:57:34,160 --> 00:57:35,160
Yeah.

971
00:57:35,160 --> 00:57:36,160
And I do want to dig into that.

972
00:57:36,160 --> 00:57:40,720
But before we do that, I just kind of want to touch on a little bit more on comorbidities

973
00:57:40,720 --> 00:57:47,320
because as a parent, that is such a scary word.

974
00:57:47,320 --> 00:57:49,760
You know, when you think about your kids, right?

975
00:57:49,760 --> 00:57:54,600
And we're talking about little people and they're, you know, they have decades ahead

976
00:57:54,600 --> 00:57:55,600
of them.

977
00:57:55,600 --> 00:57:58,800
And we think we're doing the right thing.

978
00:57:58,800 --> 00:58:02,200
You know, we brush our teeth twice a day and we floss and we're eating.

979
00:58:02,200 --> 00:58:03,200
Okay.

980
00:58:03,200 --> 00:58:06,960
You have a cookie, but we had all these other things that were healthy and we're active

981
00:58:06,960 --> 00:58:13,000
and we're controlling screen time and we're watching so many things right now.

982
00:58:13,000 --> 00:58:23,600
And now we're, we're faced with this huge bucket of ADHD levels are everywhere and your

983
00:58:23,600 --> 00:58:27,320
child has anxiety and your child has depression and you're looking around going to have this

984
00:58:27,320 --> 00:58:29,000
happy balanced house.

985
00:58:29,000 --> 00:58:31,000
What's going on?

986
00:58:31,000 --> 00:58:36,360
These are all signs and symptoms and these comorbidities that we just don't talk about

987
00:58:36,360 --> 00:58:38,680
with children.

988
00:58:38,680 --> 00:58:44,840
We can be addressing them now and it's going to improve their health.

989
00:58:44,840 --> 00:58:49,720
So this conversation is so critical for us to be having with our providers.

990
00:58:49,720 --> 00:58:50,720
Absolutely.

991
00:58:50,720 --> 00:58:56,360
And fortunately, there's a lot of headway that's being made in the idea of preventive

992
00:58:56,360 --> 00:59:02,760
and functional approaches to malocclusion and orthodontia in children.

993
00:59:02,760 --> 00:59:06,560
Because this is, this is where a lot of this rubber is hitting the road is in the dental

994
00:59:06,560 --> 00:59:07,560
office.

995
00:59:07,560 --> 00:59:12,280
Because in many cases, it's the first professional that's going to look critically at the size

996
00:59:12,280 --> 00:59:16,200
and shape and function of someone's airway.

997
00:59:16,200 --> 00:59:21,440
It's just not on the radar screen of many pediatricians to look at it with that in mind

998
00:59:21,440 --> 00:59:22,440
yet.

999
00:59:22,440 --> 00:59:27,960
You know, I think it will be and the more this signal is getting out there, you know,

1000
00:59:27,960 --> 00:59:29,960
the more we're going to be able to talk about it.

1001
00:59:29,960 --> 00:59:36,440
But for children, especially I want to emphasize to parents that mouth breathing is not normal.

1002
00:59:36,440 --> 00:59:39,280
Kids should breathe through their noses and they should breathe through their noses when

1003
00:59:39,280 --> 00:59:40,280
they're sleeping.

1004
00:59:40,280 --> 00:59:42,080
Snoring is not normal during sleep.

1005
00:59:42,080 --> 00:59:43,080
It's not cute.

1006
00:59:43,080 --> 00:59:46,880
It's not good for them and it should be evaluated.

1007
00:59:46,880 --> 00:59:53,120
And you know, cognitive issues like attention deficit disorder should be looked at critically

1008
00:59:53,120 --> 00:59:58,720
with respect to sleep because sleep is the original and best performance enhancing drug.

1009
00:59:58,720 --> 01:00:03,800
You know, so if we're having problems with performance, it's of course I'm biased because

1010
01:00:03,800 --> 01:00:07,600
I'm a sleep physician, but it is it can be subtle.

1011
01:00:07,600 --> 01:00:13,600
And if there's a question about performance, we want to really look critically at the sleep,

1012
01:00:13,600 --> 01:00:18,640
not just the breathing, but you know, habit surrounding sleep and whether that's conducive

1013
01:00:18,640 --> 01:00:20,440
to getting a good night's sleep.

1014
01:00:20,440 --> 01:00:26,280
So one of the great things about the empowered sleep at me a book, you know, among the wonderful

1015
01:00:26,280 --> 01:00:33,720
things that I think are in there, you can learn about these fundamental sleep wake processes

1016
01:00:33,720 --> 01:00:34,720
from this book.

1017
01:00:34,720 --> 01:00:39,040
It'll it'll teach you things about how to manage your circadian rhythm and about how

1018
01:00:39,040 --> 01:00:43,760
to think about your sleep so that you can make the behavioral choices that are conducive

1019
01:00:43,760 --> 01:00:44,920
to good sleep.

1020
01:00:44,920 --> 01:00:49,560
It gets into that complexity because it matters, you know, understanding that will allow you

1021
01:00:49,560 --> 01:00:54,560
another place to visit in your mind, your problem solving mind if things aren't going

1022
01:00:54,560 --> 01:00:58,480
perfectly on whatever strategy you've got for your airway at present, you know, gives

1023
01:00:58,480 --> 01:01:00,480
you stuff to work on.

1024
01:01:00,480 --> 01:01:01,480
Agreed.

1025
01:01:01,480 --> 01:01:06,360
Thanks again to today's guest, Dr. David McCarty for sharing his medical insight and

1026
01:01:06,360 --> 01:01:09,320
to each of you for listening to today's episode.

1027
01:01:09,320 --> 01:01:14,960
To hear part two of our conversation, check out podcast episode number 48.

1028
01:01:14,960 --> 01:01:17,640
And if you're new to our podcast, please don't forget to subscribe.

1029
01:01:17,640 --> 01:01:22,200
And if you enjoyed what you heard in today's episode, leave us a review or a comment telling

1030
01:01:22,200 --> 01:01:24,800
us about what you enjoyed most.

1031
01:01:24,800 --> 01:01:28,800
You can stay connected with the Children's Airway First Foundation by following us on

1032
01:01:28,800 --> 01:01:34,000
Instagram, Facebook, X, LinkedIn, and YouTube.

1033
01:01:34,000 --> 01:01:38,200
Parents can also join us via our Facebook Parents Support Group, the airway huddle,

1034
01:01:38,200 --> 01:01:43,360
at facebook.com backslash groups backslash airway huddle.

1035
01:01:43,360 --> 01:01:47,760
You can find tons of great content for parents and medical professionals like via the parents

1036
01:01:47,760 --> 01:01:51,920
portal and clinicians corner on our website.

1037
01:01:51,920 --> 01:01:56,120
If you'd like to be a guest or have an idea for an upcoming episode, shoot us a note via

1038
01:01:56,120 --> 01:02:04,240
the contacts page on our website or send us an email directly at info at childrensairwayfirst.org.

1039
01:02:04,240 --> 01:02:08,440
And finally, thanks to all the parents and medical professionals out there that are working

1040
01:02:08,440 --> 01:02:12,600
to help them make the lives of kids around the globe just a little bit better.

1041
01:02:12,600 --> 01:02:40,600
Take care, stay safe, and happy breathing everyone.