Maze of the Year.
I hope you enjoyed this video.
I'll see you in the next one.
Bye!
Bye everyone, and welcome back to Airway First, the podcast from the Children's Airway
First Foundation.
I'm your host, Rebecca St. James.
My guest today is Jayton Tecknenjane, or JT as we call him.
JT is the Vice President of the Texas Society of Sleep Professionals, and is focused on
the diagnosis and treatment of sleep and neurological disorders.
JT will be kicking off our four-part series on sleep, sleep testing, and sleep diagnosis.
Later on in our series, you'll also be hearing from Dmitri Spector, Jordan Rusk, and Dr.
Gerald Simmons.
So let's go ahead and kick this series off with my interview with JT.
All right.
Thank you so much for joining us this evening, Jayton.
I appreciate it.
Thank you, Rebecca.
So I also go by JT.
Would you see my initials there, Jordan Tecknenjane?
Obviously, CAFF is spelled out here.
So in addition to this being a lecture, I think of it more of like a conversation.
So I'm going to ask you some questions.
So after my name, I also have a lot of additional letters.
What are your guesses on what any of those would be?
Well, I know the RPSGT1 has to do with you reading and deciphering these sleep studies.
You know, that one goes with that one.
Yeah, that's correct.
So RPSGT is registered polysomnographic technologies.
So you see R's and you see T's.
A lot of times, T stands for therapists.
You see RRT.
But in this context, T is for technologists.
So you might be a trainee.
You might be a technician.
You might be a technologist.
A technician pushes the button.
The technologist knows what button to press and when.
So RPSGT is that one for sure.
Registered polysomnographic technologies.
What about the rest?
Any ideas?
I know the VP Texas Sleep Society professional, something like that.
I know the bottom one.
Okay, that's right.
Texas Society of Sleep Professionals recently, I was elected the vice president and we have
an event happening in September.
So that's that one.
What about the rest?
And sadly, you think I would remember the EEG, but you are a registered EEG and I don't
remember what that one is.
There you go.
Yeah, you got it right.
So registered EEG technologies, so in addition to recording sleep studies, I have a recorded
EEG studies which are there for detection of seizure disorders.
So you got them all almost all done.
What's the last one?
Oh man, you're killing me.
A master's and bio something or other.
No idea.
Right.
So engineering, biomedical engineering.
Yes.
There you go.
You got it.
See, I told you you would get it right.
That's more fun when you get it.
You see how much fun you're having?
I'm having a blast.
Yes, it's more fun when you guess and you actually guess wrong, but you got it right.
So let's proceed.
All right.
So what I do, I mean, what are all these letters mean?
So what I do as an engineer, as a technologist is I acquire and analyze and report on data
because that's where we use to make decisions.
So people always think about artificial intelligence and business intelligence and the actual word
intelligence actually means the use of information to make a decision.
And the way you want to think about it is like the CIA, like central intelligence agency,
right?
They go out and they have spies and satellites and whatever else to collect the data that
then military action or some other kind of action could be done based on data.
We're doing the same thing, right?
We're going out and collecting data from clinical sensors and then reporting it to either the
MDs or PhDs or then to make some decisions.
So the way I like to think of it is an intelligence cycle.
And I think of them as three steps and they all start with the letter A. So now it's back
to being a quiz again.
Rebecca, what is the first A in the intelligence cycle?
Automatically.
Airway.
Airway has to.
Because airway first, right?
Yes, airway first.
Yes, but it's wrong.
The data intelligence cycle, what do you think has to happen first, right?
Let's work this out.
For the data.
Yeah, if you got to analyze it.
Before you can analyze it, what do you have to do?
I can't analyze data unless I have it with me, right?
So what do I got to do before I can analyze it?
Do you have to accept it?
Yes, accept it or acquire it.
There we go.
So the first step in the data intelligence cycle in the first of the three As is acquire
the data.
So in the sleep study example, we're going to use sensors and observations to acquire
some data.
Now, you already mentioned the second step, mentioned analyze.
So analyze is the second step.
Then you take this data and then we call it scoring and reporting.
We take the data, we generate the statistic.
The most important one of them all is the AHI.
We'll talk about that in detail.
And then some other numbers as well.
That's the step of analyze.
So now that I've done analyzing the data, what would the next step be?
And obviously it has to start with an A.
Because this is the A3 data intelligence cycle.
Yeah, I'm going with something about answering.
I'm not sure.
Answering?
I think that's pretty close.
I'll give you credit for that one.
You get full points.
All right?
The third step is to act.
Because what's the point of having all this data and having all this analysis unless you
do something about it?
So if the analysis report says you have sleep apnea, you should treat it.
Then you should treat it.
Or if the analysis says you should go get some insomnia therapy or behavioral therapy,
you should do it, right?
That's what the analysis shows that you should do next.
So without acting on the data, all the previous steps are pretty pointless, right?
So you must act on the decisions that were based on the intelligence acquired.
So what's the next step after this?
Because it's a cycle.
What do you do next?
I don't know.
I guess you have to do whatever it is that you're supposed to do when you're acting on
it, right?
So what is that?
Yes, after you.
The path is changing lifestyle.
Right?
Okay, so that's all the act, right?
So once you do all your actions, what would the next logical thing be to do, right?
So you did the action.
Oh, to check the question.
See if there's a progress.
See if there's a change.
Yes.
You start over again.
You acquire data again.
There's no point in just acting on it and not following up with saying, did what I thought
I should do improve the situation?
So if the example is always going to be sleep apnea, if I have an AHI and it says to go
do some therapy and I do the therapy, whatever it is, did it work?
I don't know, right?
You have to repeat it.
You have to start over again.
You have to get back into the lab, get the data acquired, get it analyzed, and then work
on whatever recommendation comes out of it.
This is a cycle, right?
This never ends.
Like we do this nightly for some patients, right?
We constantly measure their signals and report back what they should be doing next.
So the data intelligence cycle.
Now we start with the acquiring stage.
And this is the way that we acquire data in the sleep lab.
We have a series of sensors.
We start with the head.
And that's the EEG.
EEG is electroencephalography.
This means brain waves.
From there, we can tell if you're awake or if you're asleep.
And then we look at the EOG, electrooculography, the movement of the eyes.
Once you're asleep, we can say if you're in REM or non-REM sleep.
And then we look at nasal airflow.
We can tell if you're breathing or if you're not breathing.
And if you're having struggling breathing, then you'll see some impact on the microphone.
That's the sound of snoring.
And if there was a pause in breathing, we call that an apnea.
PNEA is breath.
A means without.
And then the next question is what kind of apnea is it?
Because there's multiple kinds.
There's obstructive apnea, which means you're trying to breathe.
And there's central apnea, which means you're not trying to breathe.
How can I tell if your apnea is central obstructive?
Because I have to look at these belts.
That's what these respiratory effort bands are for.
So I'm going to turn on the laser.
So I got these respiratory effort bands, which are used for the declassification of the apnea.
I got the EOG for the declassification of the stage of sleep.
And we have the nasal airflow for the detection of either apneas or hypopneas.
Microphones for snoring.
And then the other thing I mentioned just now was a hypopneas.
So a hypopneas is not a complete obstruction.
It's a partial obstruction.
But it only counts if you have a drop in oxygen or a shift in the EEG.
So you can't just have a reduction in airflow and call it a hypopneas.
You have to have something else.
And then we also observe that a lot of times our patients are going to have not only airway related issues.
They might be grinding their teeth.
That could be airway related, actually.
So that's called Bruxism, measure of the chin.
And we're also measuring leg EMGs, electromygraphy, these are both muscle groups.
Because patients have sometimes leg movements that disrupt them to sleep.
Now, these are all the symptoms.
Is that what you're talking about?
Restless legs is a condition that you would not measure with a PSG overnight.
Because PSGs are recorded during sleep.
Restless legs is a condition that you would measure while the patient is awake.
And it would keep them awake.
PLMs is a condition you would measure during sleep.
So this is just like when kids kick and that kind of thing.
Is that what you're talking about?
Yes.
So you would see that and you would see if it was happening during sleep and if it was disrupting sleep.
So that's where you would use the leg EMG as a part of the PSG.
In addition to all of these sensors which are applied to the patient, you'll see a photo of it soon.
We also have a video camera.
Because there are sleep disorders that aren't going to appear very well on these signals,
but do appear very well on the video camera.
Like parasomias, night terrors, like REM behavior disorder patients acting out of dreams.
That's in combination with the sensors as well as the camera recording the behavior.
So we have the camera as another input to our acquisition.
And one of the most important features of an overnight PSG is the tech mission.
Or we refer to them as the technologists or just tech.
They're making sure all of these sensors are working.
They're making sure like all the patient's comfortable.
If the patient has a parent with them that they're comfortable, that all the instructions are clear.
Everybody's doing great and that the study does go to success.
So that's what we have in terms of an overnight PSG.
And that's what it looks like.
So here's an example of an overnight PSG at the very first stage of the wires being applied.
So what you're observing is an interaction between a technologist,
bringing the scrubs and the patient.
Now this interaction is quite intensive because you're going to spend maybe 12 hours at this facility.
You know, maybe about seven hours in the bed.
You're going to spend about 40 minutes in this process here.
Where the technician is wearing gloves, measuring the head, applying the sensors.
And it's not a quiet situation.
You know, we're chatting with our patient.
And then this interaction that we're having is usually more time than even they spent with their physician.
Their physician sometimes is limited to 50 minutes in a single issue.
So a lot of times we're talking to the patient as each sensor is applied,
we're saying this sensor is applied because of the detection of central apnea.
It's all putting a belt on.
We're putting a wire in your chin.
That's for proxism.
And the patient is free to ask questions.
We can talk to them.
And by the end of this process, the patient finally understands why they're even there.
Because sometimes they show up to these sleep studies and they don't even know what they're there and what's going on.
And then it's the job of the technologist to kind of get them comfortable with the whole process
and explain to them why they're here, why they may come back, why they may not come back.
And then just make sure that the patient also understands the importance of all sensors
and how to interpret them once they do get the report.
So that's what's happening for any time you're able to get to the report.
And this is the same for kids too, right?
When children come in, is it the same or how much does it vary for them?
It's the same.
Yeah.
OK.
So we'll have some upcoming episodes with people that are focused on this application,
like Jordan and they can ask their question better.
But it is the same.
Like when I apply these sensors, this example is actually a pediatric example.
There is no difference, right?
All the sensors I apply to the adults, I apply to the pediatric.
The only difference is maybe the ETCO2, the antityl carbon dioxide,
that's optional for the adults.
It's required for pediatrics.
And the sensors may be of a different size.
If the belts will be smaller, the sensor in the finger might be a different shape
just so that it fits the pediatric population.
Otherwise, the overall workflow is the same.
You have the night tech there.
You have a patient there.
Usually for pediatrics, there might be just one patient as opposed to two,
so that they are more labor-intensive, so you might have to have a higher ratio
of technicians to service the pediatric population.
So that's what we're seeing in the lab, and that's the goal standard.
Like if you're going to do any kind of at-home testing or a device that's
considered portable, you're going to have to validate it against this,
which is considered the in-lab PSG, which is still what I recommend to get.
And parents are there too, right?
While they're hooking them up, a parent would stay with them.
OK.
Yes, the parent has to stay with the pediatric patient in the same room
or maybe the next room over, but they are in the facility the entire time.
We are not a quadrated without the parents being there.
And then this is the head box for all the wires plugged in.
Now, what we just observed was a type one study where PSG is performed
in a sleep laboratory fully attended.
If you take out the sleep tech and you send the wires home with a patient
that's called the type two study, you might see that,
unlike you'll see that in pediatrics.
Wait, so you would hook them up and send them home?
Yes, you would hook them up to the home,
or you would have the patient hook up himself.
That's type two.
So type two is the same thing just in the home environment, no tech.
So same as type one unattended.
So you might hear these terms.
That's why it's important to kind of spell them out.
Like, you might see in a report also, like this study was a type three study.
They might say that.
So this is what it means.
So a type three study is becoming very popular now.
It's pretty much all the channels, but you'll notice it's missing a few.
You're usually missing the leg EMGs.
Most of them don't include actual ECG.
They might just record the pulse, so you won't get arrhythmias.
But you'll get respiratory effort.
And the way I like to think about anything outside of a type one or two study
is that it's not really a sleep study.
It's really a sleep apnea study, because if you're not really measuring seizures,
not measuring parisomnia, it's not a not condition there to measure movement
disorders.
Really, the only outcome is going to be sleep apnea.
So 100% sleep apnea.
Yeah, that's always really useful for anything outside of sleep apnea.
Definitely want to bring them in for the in-lab study.
There are some benefits of taking it home.
I mean, one thing is that it's cost effective.
It's going to be less expensive for you and the insurance.
It's also going to be able to be repeated.
So you can do like four or five of these studies in a row.
You can't do that in the lab.
And you might just have easier access to it.
If there is a situation where it takes like six months to a year to get into your sleep lab,
and you have the option of doing like a type three study tonight,
then let's do the type three study and see what happens.
We might make some progress.
It's not as sensitive, but it is still useful.
So it's a decision to have between you and your doctor about which way to go.
And it's also a decision between you and your insurance sometimes.
And I think, yeah, right.
And I think, I don't remember if it was you and James and I that discussed this,
or if it was just us, but the benefit of being able to do it for five nights in a row
is because if you go into a lab, you may just have an off night.
Either you don't sleep much or perhaps that was like one in a billion
when you had a great night, right?
And the benefit of being able to do multiple because you can see a pattern.
You can actually more likely to pick things up.
I agree with that.
So I do believe like the benefit of sensors like this, I'll show you one,
is that you can repeat the study multiple times, pretty much like forever.
You can do this every night if you really wanted to.
And that'll give you a pattern that you wouldn't see otherwise from a single night.
You know, the first night effect is what you're referring to.
Like you come to the lab, you don't only sleep as well
because you're in a strange environment.
There's also like night to night variability where maybe on Friday nights,
you have worse apnea than on Saturday mornings or Saturday evenings
because of work schedule and school schedule and things like that.
And it could be diet related. Some people like have fast on Friday, things like that.
So having like a couple of days in a row to see what difference it is
is likely going to produce something useful.
So when people ask like, which one's better?
Really, there's a benefit of having multiple night home study.
There's also a benefit of having in-lab study.
So just like when I go shopping, they pick you want a blue one or orange one.
I'm like, just pack them both, right?
Just do them both, right?
Just get the home studies.
Let's do it for a couple of nights and then come in for in-lab study.
Let's do that also because the more information you get,
the better because you won't get the leg movements on a home study.
You won't get arrhythmia as on a home study.
You will get on an in-lab study,
but you won't get the night to night variability on an in-lab study.
So let's just do it both, right?
Let's just get back to back.
So that's what I think is probably the best option.
Now, this one's interesting, right?
I just showed you all of those sensors from the head, literally to the toes.
And now they're saying that you can get the same report off of a single sensor.
Is this a pulse oximeter?
Is that what this is?
It is.
I mean, that's all it is, is a pulse oximeter.
It only has one channel.
And that's based off of this concept,
is that whenever you have a heme on your blood,
it could be deoxygenated or oxygenated.
And the difference is not the shape of it,
but the difference is the way it responds to light.
So light can be either absorbed or reflected.
And there's a certain type of reflection
based on the type of light as well as the amount of oxygen in the blood.
So if you take these concepts, what you can do is you can shine the light,
calculate how much was reflected and absorbed,
and then you come up with this kind of modulation ratio.
And from here, you can tell exactly how much oxygen is in the blood.
You can also tell where we are in the pulse wave.
So you can see that there's pulse.
And then from there, you can pull out like the heart variability.
And then from heart availability, you can pull out respiration.
And then from these two things, you can do like coherence.
And then you can pull out really everything,
including sleep staging arousals and apnea.
So that's like the new thing,
is that you can actually pull out a lot of information.
This technology was recently indicated for pediatric use.
So potentially, you can just do this finger sensor or ring sensor
and really see a complete sleep study at home.
And you can just own that thing, right?
So it is come a long way,
but it's important to understand the limitations.
And we'll talk about that.
And then make those tiny ones for tiny people's fingers?
Yes.
I mean, that device was indicated for H2 and up.
So you can get one.
Two and up.
Holy smokes.
Wow.
OK.
Yeah.
Nice.
And you can even get some of these over the counter.
Like there's like watches and rings
that you can get that actually plot this signal,
like the SPO2, the saturation of oxygen, as well as the pulse.
And we'll look and see how you can interpret those things.
But that's something you can do every night, right?
I mean, you could do this every night.
You can't do a PSG every night.
So that's the advantage.
So I mean, the way that it works is you look at the amount
of red light versus infrared light,
and you plot it on this graph.
And what you'll observe is that I
need these calibration readings we see.
They normally stop at 70.
Even a lot of the oxymetra trends, they stop at 70.
And then if you have a sleep study report,
there's sometimes a phrase on it.
And it says, any value below 70 may not be accurate.
You might get a value of the 70 or 68 or 57.
But you can't really trust it.
Now, we're back to being a quiz again.
Rebecca, why is that?
Why do I have to cut off all my plots at 70?
And why do I have to add that phrase to my sleep studies
and let people know that a value below 70
can't be trusted?
I'm guessing it's some kind of a benchmark.
Like anything below that is just not consistent.
I don't know.
That is right.
Or is an exaggeration right?
It is an exaggeration right?
It is.
OK, so you got the right idea.
So the reason why is that we have a calibrated value
for everything on this line.
There was a person who was guaranteed to be at 70%
based off of blood gas, and at 80, and at 90, and at 100,
that we also measured their finger, red light,
nymph red light.
The problem is that for me to get 69, 68, anything below,
I would have to induce or allow a real person
to be at that level of hypoxemia, like lower than 70%
oxygen, just to get our readings from my sensor.
That would be considered unethical, right?
You would literally kill somebody just
to get a calibrated value.
And we're not going to do that.
So we're just going to say, you know what?
We got 70.
That's good enough.
We're just going to put this disclaimer
on all our calibrations that we can't get anything below it
because we're not willing to do what it takes to get it.
And we shouldn't, right?
Anything 70 is already pretty bad, right?
You need to get treated.
There's no situation like, oh, 68 is OK,
and 67 is not OK.
That's not going to happen, right?
That's fine.
But it's important to understand why that is, right?
And that's not really well understood how that happened.
So that's part of the quiz.
Second part of this quiz on the same plot
is going to be this cardiac cycle.
So this is the call the PPG, the photo plus mography.
It's just a measure of the blood at the finger
using the red light.
But this one is not.
What is the term for this signal right here?
And I also covered it earlier.
I want to see what you say now.
I don't know.
Keeping you awake.
I know your pulse.
Does that what I have to do with that?
Cardiac cycle.
If you saw this plot, you know, you see this thing going on.
That's I'm looking at.
I think that's your love, but your heartbeat.
So it's your heartbeat.
Yeah.
Yeah, the love, love, love, love.
OK, so a lot of people would call that the EKG.
OK.
Would you agree?
Right?
Yes.
OK, so EKG.
What do you think that stands for?
I go cardiogram.
OK, so if it was a cardiogram, how do you spell that?
So the story goes like this, right?
You know, people stay out loud EKG.
You have to spell it, they're going to say C-A-R-D-I-O, right?
Because cardiac, cardiac, it's electrocardiography, right?
EKG.
Now, it's spelled with the C, but we pronounce it with the K.
The reason why is that we're not using the English abbreviation.
We're using the German abbreviation of electrocardiogram.
So we always pronounce EKG.
We write down ECG.
And the reason why is because it sounds too similar
to the other one called EEG.
If I say, Rebecca, I really need an ECG right now.
Can you start one up?
You're going to go out and do an EEG because you misinterpreted me.
And EEGs are just so much more fun to do.
Now, I'm like, why didn't you do an ECG?
Oh, you should have said EKG.
And that's why we always say out loud EKG.
But write down ECG because we are still speaking English.
So now you know.
Now I know.
That's interesting.
So from those signals, like from the pulse and the EKG
and from the brain activity, we can tell whether or not
you are in one of two states called the parasympathetic, which
is like the relaxing, the rest and digest,
or the sympathetic, which is your fight or flight.
You definitely want more of this and less of this.
That's kind of the whole point.
The reason why we have all of these discussions
on how airway is related to mental health
is because we have too much sympathetic nervous activity.
There's something waking you up and that is likely the sleep apnea.
And we're going to see what that looks like now on an actual PSG.
So this is what's called effective sleep.
And the most important sensor we're going to focus
on is going to be the SAO2.
You see how stable that is, right?
This is 97 all the way across.
The brain waves are really stable.
The chin is quiet and still.
And most importantly, the breathing is even.
Now, this is with therapy.
This is the same patient before therapy.
What is the, that looks like, I know it's not thoracic,
but what is the one that looks like thoracic?
Where is that?
So let's talk about this, right?
So we have FC and O. That's frontal, central, and occipital EEG.
So it's frontal, central occipital, right?
This is how you can tell what stages you're in.
I wanted to.
Yep.
You have left eye and right eye.
You have the chin.
You have the left and right leg.
We saw that in the previous slide.
Then you have PTAF, it's pressure transducer air flow.
This is a therapeutic study.
So CPAP is continuous pause or area pressure.
Thoracic is that belt we saw.
And abdominal is the other belt.
So you have two belts.
And the two belts you can, right, with the two belts,
you can tell if the patient's paradoxing
or if having central apneas.
And then EKG, we just covered it.
And then SAO2 is the oxygen saturation
as a percentage of over 100.
And then pulse is going to be, is not on this plot.
And then we have, I think, TCO2, like the carbon dioxide level.
OK.
Got it.
Now, in this example, this was the same patient just
earlier in the night where they were effectively treated.
This is a five minute record, and there's seven apneas.
So that's more than 60 events an hour.
So there's maybe 30 to 40 seconds of them trying to breathe.
Oxen levels drop.
In this case, dropping down to 74%.
Pretty much near that cutoff of where you can't even
report accurately.
Then they wake up to breathe.
And then when they wake up to breathe,
their airway opens up, their heart rate rapidly increases.
They fall back asleep, and it happens again and again and again.
Now, are they grinding their teeth?
Is that what's on the chin?
Or is that the moving to wake up?
What is that little?
That's both.
So that could be bruxism.
Sometimes in response to the abstract airway
and the desaturation, the patient will grind their teeth
forward to get their airway open.
It could just be part of the arousal response
where they're waking up, and they have a chin burst as well.
This one likely is a combination of both,
because you also see it in the frontal electrodes.
You see that muscle artifact.
You see the muscle activity in the EEG leads.
But there's two things that are important.
It's like the frequency.
This is happening every minute.
The patient is asleep.
And the magnitude.
These are very long events.
These are like 30-second long events,
and they're calling the oxygen to go from 89 to 74.
So that's the true dramatic reduction.
Are those red lines 60 seconds?
Every time you see one of those red lines, is that a minute?
Is that 60 seconds?
It should be 30 seconds.
So that's one minute.
Two minutes, three minutes.
Wow.
So in sleep medicine, everything
is broken apart into epics.
And these epics are in 30-second segments.
So we could say this is sleep, and this is awake.
This is sleep.
This is awake.
So you measure it in 30 seconds based on that 30-second epic.
We'll actually look at a live example pretty soon.
Now, in this example, you can't really
see the detail of the EKG.
So I got another example here.
In this example, not only did the patient stop breathing,
they also stopped attempting to breathe.
So there's no effort in the chest.
At the same time, their heart literally stopped beating.
So is that common for that to happen?
I mean, this is why I say your apnea is breaking my heart,
because this can happen.
If left untreated, it can lead to arrhythmias.
It can lead to what this is, like a sinus pause or assistory,
depending on your definition.
You also see it in the pulse channel.
The pulse is literally gone.
Like you are dead.
This apnea has killed you, right?
And then you come back to life, hopefully, right?
And that doesn't always happen.
A lot of times, this patient, luckily restored,
took a breath and came back to life pulse response.
That doesn't always happen.
It's important to note that with the right amount of medication
or alcohol or some kind of combination,
this arousal response doesn't happen quick enough.
And your apnea, which you normally wake up from,
you may not.
And that's called a terminal apnea.
This thing is potentially lethal.
Like you can easily die from this in the wrong conditions.
And patients who have just the wrong situation may not wake up.
So luckily, this patient did.
They're fine over here, but they're definitely not fine over here.
So that's good.
It's so logical, right?
It's so logical, because we all learned it in biology.
But to actually see it, I mean, it's not
to be overly dramatic.
That's kind of terrifying.
And then to think that little kids are doing this.
That's terrifying.
It is.
I mean, this is most of my examples
are going to be adult patients.
But everything that I show here, I'm sure James Cardell
or other friends of pediatric labs
can give you examples or even scarier examples of this.
Because the pediatrics, their arousal response
isn't as strong as this.
They might even have worse apnea.
So I'll let them have the glory for that one.
But it is important to note, like this is,
it could get worse, right?
In this example, at least the patient is trying to breathe.
You see the thoracic abdominal effort.
They're trying really hard to breathe.
And this is just an obstructed airway.
In this case, this is called a central apnea,
where their effort is not even there.
And they're not even beating their hearts.
So it can get to be this bad.
Probably the worst example of the evening.
And why?
I mean, I'm going to put it in very lame in terms.
But why isn't their brain trying to wake them up at this point?
Why is it just, it's tired?
We do this every night.
I'm tired.
Or does it not pick it up?
Or?
OK.
So that's a good question, right?
So what happens is, like, the drive to breathe
is based on the amount of carbon dioxide.
Your carbon dioxide builds up, builds up, builds up,
and then you have a desire to breathe.
Now, the reason why this person is not breathing
is related to the same thing we're seeing as heart not beating.
It's because of a cardiac dysfunction.
Because for the sensor, it's called a chemoreceptor,
that drives the breathing.
It has, it depends on the right amount of blood flow.
So if the heart doesn't pump correctly,
that sensor doesn't know, hey, I should
trigger the next breath.
It thinks everything's fine.
It thinks the level of the oxygen carbon dioxide is, like, OK.
And then because the cardiac function is so impaired,
it gets that signal kind of late.
And it's like, oh, man, yeah, we've got a problem.
I need to just think about it.
And then they start breathing again.
So normally, that doesn't take so long.
But in these patients who have their sleep apnea
left untreated for a long period of time,
it gets to be this point where it's like,
every night they start with this obstructive apnea.
It turns into central apnea.
It turns into mixed apnea.
It turns into assistalese.
And then if that's untreated, they
won't even last another couple of years.
So it's important to note, it starts like this,
ends like this.
There is no mild apnea.
It's just not severe yet.
It will get to this point if that's untreated.
You can find out more about the Children's Airway First
Foundation and our mission to fix before six
on our website at childrensairwayfirst.org.
The CAF website offers tons of great resources
for both parents and medical professionals.
Visit our parents' portal, clinicians' corner, resource
center, and video library to see for yourself.
We also encourage parents to join the Airway Huddle, our Facebook
support group, which was created for parents of children
with airway and sleep-related issues.
You can access the Airway Huddle support group
at facebook.com backslashgroups backslashairwayhuddle.
As a reminder, this podcast and the opinions expressed here
are not a medical diagnosis.
If you suspect your child might have an airway issue,
contact your pediatric airway dentist or pediatrician.
And now, let's jump back into today's episode.
So let's look at the same example, a little bit more
cartoonish.
So we have here the same signals I've been looking up before.
This is like the brain wave.
This is the EMG from the chin.
This is your nasal airflow measured at the nose.
And this is the effort.
So just a single event.
So the patient's breathing in, breathing in, breathing in,
and then their airway collapses.
And we have a lot of episodes about airway.
So we'll focus on what the end result is.
It's the airway is collapsed, and the patient
is still trying to breathe.
But now, this effort is not pushing out air.
It's pushing out the stomach.
So we can see that with two belts.
And that's called a paradoxical abdominal movement
with apnea.
Now, this is bad.
We're going to see how bad this is, mainly because
of the pressures forcing internally.
All that negative pressure that's not generating air flow
is going to be applied to the internal organs
and cause all kinds of damage.
Now, during this time, the occipital lobes are dropping
and dropping and dropping and dropping
until it gets to the point here.
At this point, it triggers the arousal response.
Like somebody says, hey, something is off.
Sound the alarms.
The patient wakes up.
You see that massive increase in the chin activity.
They take a hypernormal breath.
They take a massive breath.
And then their heart rate increases.
Occinol lobes are stores.
And then we saw what happens.
It happens again and again and again.
So this is the.
Back on the one we were looking at, I just, again,
you know, trying to help all of us that don't look at these
and really understand them.
Yes.
When they start moving and they take a deep breath,
is that that sound?
Yes.
Yes, that's exactly it.
You can visualize this.
Like these straight up obstructive apneas,
you don't even need a home study.
You can just look at somebody.
That person, is that person breathing?
No, it's obvious, right?
So like when we talk about the type one, two, three, four,
like you can just tell apnea from just looking at somebody.
The difficulty is the other side, the hypopneas.
Like even the home studies may not pick them up.
You might need in-lab studies for those
because it's the arousal, or it's the 3%,
and they may not be picked up
unless you have like those sensors applied.
But for the case we're talking about today,
which is full blown obstructive sleep apnea,
it's pretty obvious.
And what you described is this period here.
The patient wakes up, you see them gasp,
you see them snore, you see them move,
and you see them do this again and again and again,
all night long.
And this is what's happening, right?
They fall asleep and they have this decreased muscle activity.
They start to relax.
When they relax, their airway collapses.
And then that develops into apnea,
a pause and breathe that was up before.
That results in hypoxia,
hypopoxia like the lower oxygen and hypercapnia,
increase in carbon dioxide.
This is what triggers that increased ventilator effort,
that arousal response.
So they increase the effort that wakes you up,
and now that awakening is there to increase that muscle activity.
So it's the opposite of here.
And then once the airway is open, great.
Hypoxia is done, hypercapnia is done,
you're back to normal, so you fall asleep.
And what happens when you fall asleep?
Your muscle activity drops again.
Right?
And this happens you-
And this blockage could be,
your tonsils falling back or your tongue is falling back
or there's something that's blocking the airway,
there's something that's avoiding it.
Yes, exactly.
There's something that's obstructing the airway.
This is obstructive sleep apnea.
Now our job as a nighttime technician is to,
we don't care what's obstructing it, right?
It could be tonsils, we add noise, it could be uvulas.
We don't care, right?
All we do is we report how often
and how bad does this happen?
We report what's called the AHI,
the apnea, hypopnea index,
which is how many times we run into the circle per hour.
So this is one event.
If I have five of these events an hour,
you have an AHI of five.
And that's diagnostic for an adult.
If I have one of these events per hour
and you're considered pediatric,
you're diagnosed with apnea.
So just one per hour is all you need for a diagnosis.
And that's a 10 second event
with at least a three or 4% desaturation.
And then you get a diagnosis of apnea
with recommendation for treatment.
So this is the pattern we see very often.
Now, what I mentioned before was this pressure applied
to the heart.
That's what is really literally breaking your heart.
That you see like this hyperplasia,
you see this right heart dysfunction,
pulmonary hypertension,
it's literally causing a bunch of damage to your heart.
And the other thing that's important to measure as well
is that this movement, you could see it, right?
They're trying, trying to hard to breathe.
They also stretch the heart.
Like the pressure is actually pulling and pushing,
stretching and squeezing the heart to the point
where actually literally over time it fails.
At the same time, it's releasing this peptide called A&P,
which then causes nitam urination,
as well as as pressure is being applied to the bladder.
So excessive stress on the bladder
also causing it to wake up to peace.
A lot of people are waking up saying,
I have to go to like the urologist or something
and get my bladder checked.
It's not the bladder, it's the airway.
You fix the airway that you won't have to wake up to pee.
The reason why are you waking up?
It's because of this constant pressure building up
internally.
Now this pressure, we see that applied to these
internal organs is also applied to the stomach.
That's also the responsible for acid reflux.
I wake up with acid reflux.
Now I need like some kind of antacid
and I also need this bladder control.
And all these things is just religious airway.
Get your airway fixed, you'll be all right.
So just imagine how much pressure you're applying
and how many times you're just beating yourself up.
So this is a zoomed up view of the oxygen saturation plot.
And then you can see like when the oxygen is stabilized,
the blood pressure reduces.
Also interesting to note is like when there's a spike,
it's related to the position.
You see like how the position changed.
So a lot of times what we observe is that it's the supine
position that makes everything worse.
So in addition to like everything mentioned like CPAP,
oral appliance and orthodontics, all these things,
a very effective form of therapy is just stay after back.
Here's another example of that, right?
Where the patient was on the right side,
things were pretty stable.
They go to their back and then bam,
you see like this very frequent
and also very severe drop in oxygen.
Until they wake up.
Which makes sense though, right?
Because it's falling back in here.
Falling back, yeah.
And as soon as they turn to their side,
everything's fine, right?
So if you do a study, make sure,
make sure you have this plot on body position.
Because that is what I've seen.
You can see it here, it makes a massive difference.
Like if you just stay on your side,
you end up getting the same effect
as your oral appliance, right?
Because that's just pushing your jaw forward.
You can do the same thing with gravity.
So sometimes you don't need a complicated,
you know, a bunch of effort.
All you need to do is just get a pillow or something
and or a ball on your shirt,
just force yourself to sleep on a position that makes sense.
But you won't know that unless you get a study
that confirms that yeah,
on a certain position you're doing fine.
So I'm gonna show you a actual study, okay?
So before those are cartoons, those were interesting.
We're gonna look at this person here.
I'm going to change of view.
This is a real PSG that was reported recently in a real lab
as a part by an actual technologist.
We'll take a second, get everything sorted out here.
And here we go.
All right, so we saw those examples
and we saw a few different kinds of events.
We'll see that this patient here is having
a pretty good experience.
They're having a pretty nice airway,
but they are having arousals.
These are called RERA,
or respiratory effort related arousal.
They're pretty long,
but they didn't really cause a significant drop
in oxygen saturation of 94, 92.
It counts, but not really.
This will count towards a different index called the RDI.
So I mentioned the AHI is the apnea hypop index.
If you include these events called RERAS,
it'll increase the RDI.
We'll see on the report.
So let's see what happens.
So just to add a case, if you're having these arousals,
but they're not waking up,
they're still impacting your sleep in the long term.
Yeah, they're milder events.
So it depends on the doctor
and whether or not they want to treat them.
But you'll see a small increase in the pulse.
You'll see a small increase in the heart rate.
You'll see a change in the EEG.
You kind of need the EEG there to measure these things.
That's why in in-lab studies,
the only one that's really capable of detecting these things,
you can't really see.
If you take away this channel,
you really won't be able to see it, right?
It looks fine,
because the oxygen level is fine, the air flow is fine.
It's only because you have an in-lab study,
you can even measure RERAS and RDI.
So that's important to remember.
But let's look at this patient,
like just a few minutes later, right?
That's an obstructive apnea.
That's 36 seconds long
and it's resulting in of not breathing.
Resulting in a desaturation of 10%.
So they're going from like 92 to 82
or 91 to 81 in this exact example.
So a 10% drop of obstructive apnea duration 36 seconds,
like a full epic.
And then what happens at the end,
they have this arousal.
You see a massive increase like we saw before in the chin.
We see it in the EEG.
Then we see it also in the pulse.
The pulse goes from 73 to 84.
So a 10 point, 11 point increase in the pulse
in a very short amount of time.
So that rapid increase, rapid increase,
rapid increase back to back to back, right?
That's what ends up causing you
to have constant low grade anxiety.
Because every time your heart rate increases,
that's the sympathetic nervous system.
That's me like sounding the alarm
from the police behind you.
That's like a tiger chasing you.
That's you fighting for your life.
The number of times we have the AHI.
So that's like 30 or 40 or 50.
That's 50 times an hour where you're like,
I have to stay alive.
And then when you wake up during the day, what happens?
Your blood pressure is constantly elevated
because you have this constant state of stress
and you have used up all your tolerance
for any kind of stress.
You already have been stressed out all night long.
So what happens is you see a red light,
you see some traffic, you see your child
or significant other make a small mistake.
You're very upset.
You're irritable, right?
You're irritable.
I just think about that in tiny people.
Man, they're just gonna be crazy during the day.
Of course they're gonna be anxious.
Of course they're gonna be like ADHD all over the place.
Right, so ADHD, hyperactivity.
If you think about why are these patients hyperactive?
And now this is the really important key part.
What happens to hyperactivity patients
is they're prescribed stimulants,
riddle in, out, or all these things.
Those are stimulus.
Why does a stimulant cause our patient
to become less hyperactive?
It's because of this condition
that they're constantly being woken up all night long,
that they're sleep deprived.
Anybody sleep deprived is gonna have to stimulate themselves
just to stay awake.
And that's what these children are doing.
They're not hyperactive, they're sleepy.
And all they gotta do is just get them to get better sleep
and they'll be able to focus.
The solution is never more drugs and pills.
The solution again, we've been saying this
for every episode so far, is to get the airway.
You fix the airway, you won't have these problems, right?
If they're scoring.
Yeah, and then how do you know
if you're having air problems?
You don't.
You can't really know how bad this is.
You're not gonna be able to measure this 30 second long app
in 10% desaturation without a sensor,
without a sleep study.
So the most important thing is
if you have any symptom of any kind,
whether that's nocturia, like in nighttime having to pee,
or daytime sleepiness, or anxiety, or anything,
really everything that you would have symptom wise,
the solution is gonna be the same.
Get a sleep study, find out is it the airway
before you start doing anything else, like with medications
or other therapies, because this is easy to do, right?
Oh yeah, you have apnea or you don't, okay, fine.
Let's move forward.
But in this example, right, back to back to back, right?
We got a 9% desat, 7% desat.
Arousal, arousal, we have an event here 41 seconds long
with a 16% drop in oxygen.
We're just like literally a few minutes ago,
this guy was like kind of okay, right?
Right.
Like he's kind of okay having like mild events,
now he's having like these crazy severe events
with 16% desaturation and it continues to happen, right?
It continues to happen.
And then what happens is now we have somebody
in the room with them.
This is where like the goodness comes in.
The technician observed what had happened
and they applied CPAP.
Rebecca, what is CPAP?
That's your CPAP, right?
So they turned up the flow, the pressure.
The CPAP is- The pressure.
Exactly.
Yeah.
P is for pressure, continuous positive airway pressure.
It just pushes the airway open.
Now this is not easy.
This is a challenge.
This is why nobody wants to do it
is because it takes effort.
The things that are worth doing are not usually easy.
Even in this example, right?
This patient's really awake.
They're not acclimating to therapy rapidly.
They're not falling back asleep.
This is not a happy camper at this point.
He's likely yelling at somebody, get this thing off of me.
And that's fine.
We're going to allow him to yell.
But eventually he does relax.
We see the muscle tone drop.
We see him eventually gets the point where
he's still crying and crying and crying.
But the technician is in the room adjusting the settings,
adjusting the mask, adjusting the pressure,
getting him to finally be able to go to sleep.
And then what happens is they fall asleep.
This takes a while, right?
You can see them on effort.
They're having to do every one of these little spikes,
every one of these little comments
is the technician documenting
what they are trying to do to get the patient to stay on therapy.
And then while the patient did fall asleep,
they immediately have these 24-second events,
again, having these desaturations,
because they're not done yet, right?
Just because you apply CPAP doesn't mean it works instantly,
right?
You have to still adjust it.
But this technician continues to try.
They see the event.
They document what they're doing.
They increase the pressure.
That's them right there, right?
They say, I'm increasing to 14, 14 is CMH2O for all
of these reasons.
I'm also monitoring the leak.
I'm going to measure the leak.
I'm going to fix it.
It still doesn't work.
So they continue trying it.
They continue trying it.
And then sometime around 4 AM, they find a combination of mask,
of pressure, of humidity, of tubing, of headgear.
And then this patient has now achieved something
they have never achieved in a decade or longer
called REM sleep.
So they're actually resting.
They're actually resting.
The chin is quiet.
Air flow is stable.
Oxygen is 96 all the way across.
Heart rate is stable.
They are, for the first time in years, actually getting sleep.
And they're having dreams.
They're having actual benefit.
They're going to have muscle recovery.
They're going to have immune function.
They're going to have muscle regrowth.
They're going to have everything.
And they're going to have this on the same night
that they walked in having those 40 second long events, just
a few hours later.
All because they did it in the lab with a technician that
had the skill and the patience to put up with all this, right?
You can imagine this part right here.
The patient saying it's not working.
I hate it.
The technician is also concerned.
Is this thing ever going to work?
I don't know.
I'm already trying so much pressure.
You increase the pressure.
It creates a leak.
You tighten the mass.
Mass creates discomfort.
The higher pressure causes a central apnea.
It is not easy.
No, it sounds stressful for everyone.
It is.
Like it is a challenge.
And that's why people burn themselves out doing this, right?
But if you go to the right lab, if you get the right technician,
the technician has the right skill, then we can do this.
Like I did this for many years.
I don't do it right now.
But I was able to achieve this on every one of my studies.
This is called optimal.
Optimal means you achieve REM supine with the NHL lesson 5.
That's what you aim for as a night tech, but only if you care, right?
And not everybody cares.
Not all labs are in it for the result.
They're just in there to get whatever reimbursement you get out of it
and call it a day.
But this is an example of what is possible.
Now, this patient, I guarantee you, once they wake up,
they're going to feel something they haven't felt in years,
which is like, oh, that's what sleep is.
Arrested.
Yeah.
And then once they get that first taste of actual sleep,
they wake up without a headache.
They wake up without having to pee for every hour.
They wake up feeling like as if they actually got sleep for the first time.
They will not leave the lab without that mask.
They will do whatever it takes.
They will pay cash.
They will travel.
They will do anything to not go without it.
Patients love the machine.
Everyone says, I hate CPAP, all that crap.
It's because they just ended it here, right?
Even this patient who ended it really well also hated CPAP.
Even that they should hate.
Everyone hates CPAP until you put in the right amount of effort,
until you get it right.
Get the right combination.
And at the end of this, though, they now know this is where I have to set it.
This is the setting.
Exactly.
Right.
So that's where I come to the report.
So I'll talk about the report and then we'll call it a night for today.
Right.
So this is what's called a split night study where it starts off diagnostics,
ends therapeutic.
This patient had an H.I. of 41 events an hour.
That's apneus plus apneus divided by the number of hours of sleep.
Now, if I factor in the RIRAS, that's the RDI.
It was 58.1 because not all events classified as apneus.
And these events were worse on the back.
So again, if the guy was just on his side, he would reduce his index by more than half, right?
From 41 to 20.
And quick question.
I just, I don't know if you know the answer to this or not.
Sure.
Long, long time ago, I heard that one side was better to sleep on than the other.
Is that true or does it matter?
Just find a side that works for you.
Right.
So better or worse depends on what you're talking about, right?
Some people say left side is better for like brain function because you flush out the toxins.
Right side is better for digestion.
There's something about there.
Like there is also.
I heard about it for your circulation, your circulation in your heart.
Right.
Left was the way you were supposed to go, which.
I think it's better to, just like I said earlier, right?
Like home study versus home study, just do both.
If left side, right side are both good, do both, right?
You shouldn't like be restricted to a single position.
I think that's also bad.
I think there's benefits of having REM sleep, non-REM sleep.
There's benefits of having supine sleep and non-supine sleep.
You should have some kind of mixture of everything.
Everything has a purpose just by going for one, you're going to limit the benefit of something else.
So mix it up.
And this is why I'm a strong believer in CPAP therapy, right?
Because the only way this guy is going to sleep at night on his back is with CPAP.
Like this level of apnea, unlikely to be treated with anything other than the CPAP.
The pressure he's at.
I'll tell you why here in the next page, right?
So we have here the oxygen saturation.
So you went out to 77%.
That's scary.
That's extremely low.
His heart rate is going up to 173.
We saw that whenever he woke up in his sleep.
He's going to 94 beats a minute.
You're not supposed to be really above 60 or so.
So his sleep is very stressful.
He is literally stressing out and fighting to stay alive whenever he is in bed.
Now we start with the CPAP portion of it.
We see his overall index is actually about the same.
So 41 events an hour wise on CPAP.
That's not the point.
The point is what we see in this next table.
This is called a titration table.
So titration means I add a little bit of pressure, add a little bit of pressure until I get an open airway.
This is what you can get when you do an in-lab study.
5, 6, 7, 8, 9, 10, those are CMH2O.
So there's a water pressure.
5, 6, 8, 9, you can see the events are very high, mostly because the durations are very low.
This is when the patient was just crying, I can't breathe.
I can't handle this.
You know, the technician is doing whatever they can do to just get them to an adequate pressure.
So then they get to the pressure of 10.
They're able to get some consistent sleep, only five minutes.
That's fine.
H.I. is still too high.
They go to 12.
They skip 11 because we don't have time.
It's still very high.
And then they skip 13.
They go straight to 14.
At 14, they have 41 minutes.
H.I. is still pretty high, but that's the dramatic improvement over where we came from.
We came with an index of 40 something, right?
And then they say, I'm not done yet, just because this is a pretty good reduction.
But this is where people normally call it.
If you get an inspire, they say 50% reduction is successful.
I say, that's crap.
50% reduction doesn't mean anything.
If this guy had an H.I. 50 and got on a 25, is that success?
It's not, right?
You need to eliminate.
So that's what happens, right?
They go to 15, they go to 16.
At 15, they achieve REM.
We saw that.
And at 16, they have completely resolved.
Oxygen doesn't drop at any point below 95.
That is super healthy sleep.
Like that is as good as you can get.
You can't get better than zero.
And 95% for someone like that, right?
And they get a pretty good sample too, 29 minutes.
And that pressure of 16, that's a lot.
That's on the border of what you would even prescribe on CPAP.
If they had to go one higher, they
would have to go to BiPAP, like BiLol pressure.
But luckily, they didn't have to go that route.
They would have been fine if they did,
but it's better to stay on CPAP.
And the patient was able to tolerate it.
You can see the arousal index is also extremely low, 2.1.
That's nothing, right?
Less than five.
And we can see the plot.
So you'll see here at the beginning of the night,
the pressure was applied right exactly in the center of it.
So they have these back to back to back arousals.
They have these leg movements.
They have these CNAs are central apneas.
They have the obstructive apneas at the reras.
You see all these events.
The duration is how tall it is.
It's just constantly having events.
And then you see at the end, the last hour on CPAP,
when the pressure is at the 15, 16,
there's hardly anything the arousals have mostly resolved.
And most importantly, this oxygen plot, right?
You see these little dips, like we saw earlier
in the other examples.
Like this back to back to back to back to back.
And then at the end, it's like this little flat line at 15, 16.
That flat line is what we said was consistent sleep,
effective sleep.
And that was because of the CPAP.
And that's the last point is that don't discount CPAP.
We have CPAPs, like we see here, this giraffe-colored thing.
Pediatrics like it.
We do it all the time.
You can talk to Jordan.
You can talk to Dimitri and James.
They do super good at these titrations.
It's more challenging when it's a pediatric person.
But don't give up on CPAP.
CPAP does work.
It's not easy.
It's not easy for the patient.
It's not easy for the technician.
It's not easy for anybody.
That's why some people are easy just to give up on it.
Oh, that's too much work.
I don't want to deal with it.
But we saw just now, and we see it every night in the sleep lab,
that when you do it right, it works.
So definitely go for it.
I mean, there are some side effects.
You can, especially pediatrics, skull growth.
I'll let the other speakers talk more about that.
But I just want to let you know that, yeah, CPAP is an option.
It is a very effective option.
But it does take effort.
But they can, if we start with when they're hypothetically,
we've got a four or five-year-old, and they come in.
And they've been diagnosed with ADHD.
They've got anxiety that's off the charts.
Trying to get them in to meet with an airway,
dentistry, and ADHD or somebody.
And you get ahold of them.
We get them on CPAP, and now they're
going to start to sleep right now.
You start to get the mental functions back,
getting your child back.
For a child, in this particular scenario,
is this something they could grow out of?
If, let's say, the jaw moves in place, the airway opens up,
they could potentially.
I mean, this is just therapy until they get to where they need
to be, correct?
Yeah, I think I agree with that.
So CPAP may be used temporarily until the airway is opened up.
And that might be a solution.
I mean, the only thing you would do
is you go back to the very first slide, right?
Where it's like, you know what?
How would you know?
If they need it or not, you would have to repeat the study.
So you would just go in this little circle.
So I mean, this circle is actually more useful and more
important for pediatrics.
Because the way they sleep this week
is going to be different than how they sleep next week.
Also, they change and grow, right?
We can do this study pretty often, maybe once a year.
But you can do a study like this every day.
So I mean, it's important to do this once in a while
and do this as often as you can.
You can just buy this thing and you can track it yourself.
O2 ring or sleep image ring, there's
like six of them, you know, different software
is like an important.
But now that you have a little bit of skill
from looking at these plots, you can
tell if your child or patient is doing well or not.
And then you can tell if the CPAP is effective or not,
which is based off that oxymetrient.
I mean, obviously, it's better to get the whole thing.
And we can do that also.
But you can't know what to do unless you acquire the data
and you analyze it.
And then you act on it, right?
You just do this daily.
Like, I do this with my patients every day.
Like, they're on CPAP.
The CPAP is reporting to the cloud,
what their residual AHI is, what their usage is.
I have other devices that they're monitoring.
And I call them up and I say, hey, you know, last night,
this and that, do this.
And then again and again and again, right?
So though my patients aren't even children,
they still repeat the cycle because that's what it takes.
Because just because you meet them once a year,
like that's not enough, right?
This is a daily thing that requires constant coaching,
constant monitoring, constant adjustments.
Because especially with your patients, right?
The pediatric ones, they're changing so often.
And what they're losing is their most valuable resource,
which is sleep.
I mean, you think about it, like we're installing
all these things on their computers to protect our data.
We're going to the bank and getting FDIC
to protect our money.
But those things are fine, right?
You can get your money back.
You can get your possessions back,
but you can't get back your sleep.
Your sleep is something you'll never get back.
So you should protect it even more
than you protect your data or your money, right?
You should be protected, especially for your children.
Because their sleep is necessary.
Necessary to the point where-
It's impacting their brain, their IQ, right?
I mean, again, it can impact-
Yes.
It's been developed with organs and-
It's impacting everything, right?
So their sleep is being constantly stolen from them.
If it's not from the app, it's from the school,
or it's from the society,
or there's school bus coming too early, right?
That is a form of theft.
It is what it is, right?
You got to call it what it is.
That sleep belongs to them,
and we are stealing from them their sleep.
And unless you call it theft,
people aren't going to take it as seriously as it is, right?
Where you're going to the government
trying to push for change.
One of the changes people are pushing for
is the time zones, the daylight savings,
the school timing, all these things.
They're not in alignment at all
with the pediatric population, right?
They need to get more sleep.
And we are, as a society, robbing them of it.
Now, if you do that in a state of war,
like if you're invading a country
and you have a prison of war,
and you deprive them of sleep,
that's considered a form of torture.
Like you are considering a war crime
if you deprive someone of sleep.
But yet, for our own children,
we're going to torture them
and call it necessary.
Like it's a bunch of crap, right?
Like it's terrible what we're doing to these children.
I mean, if they can even breathe, right?
That's one thing.
And then when they can breathe, we wake them up,
say, hey, guess what?
You gotta wake up for some reason.
No, you don't, right?
You can get more sleep.
There's no reason for you to be awake.
You don't have any like mission critical job.
Like nothing's gonna melt down
if you don't wake up at 5 a.m.
So let the kids sleep.
You know, don't steal from them
the one thing that's the most valuable thing,
which is their time in their sleep.
And don't torture them.
That's what you're doing.
And just call it what it is.
It is theft, it is torture,
and you are a criminal if you are.
And you may not go to jail, but you're still guilty.
So just know that, right?
Next time you wake up a kid,
like what you are doing is you are legit
committing a crime.
So-
You're stealing from them.
And that's the point.
You're stealing from them.
And if, how long can you stay?
And this is more for an adult,
but how long can you stay on a CPAP?
Forever.
I mean, I've had, my patients get on CPAP
and they live on CPAP.
I have patients that have three CPAPs.
One for their home, one for their carry-on,
one for their check-in, like one is small, one is big.
Sometimes they have a second unit
just left on their side location.
They have battery backups, multiple battery backups.
They tell me they will never sleep without us.
I mean, you saw the example, right?
That patient in REM, single oxygen.
You kidding me?
Yeah.
Right, you could feel that.
That's a difference you can feel.
And those patients, once they feel that,
they never want to feel like they did before again,
because they feel literally sick.
Like they wake up with this congestion,
with this headache, with this sense
that they have been fighting to stay alive all night.
This is exhausted.
They cannot manage their day.
They can't do anything.
But with just a little bit of CPAP,
this pressure was pretty high, 16.
Most of the patients can get by
with less than half of that and it's more tolerable.
And it's like, yeah,
everyone would feel like that again, right?
They don't.
They have backup machines even.
They have two machines in their primary residence,
just because just in case one of them may not
will work one night or something, right?
That's how badly these patients love their machines.
So when somebody says, I hate CPAP, I'm like, yeah,
of course you hate CPAP.
If it's not set to your level,
if it's not set to your mask,
if the headgear is just one,
if like one side is tighter than the other,
the whole thing just blows air into your eye
and causes you to be hating it.
Like obviously you hate it,
but if you hate your CPAP, right?
I love mine because I got mine set correctly
because my wife did my study, right?
So it's like, of course she did the effort
it took to do it right.
And that's kind of what it takes.
It takes somebody with enough skill
to really apply the therapy in a way that you can tolerate
and be patient enough to go through all those difficulties
that we saw in that one patient.
It's still open, right?
Like to go through that, like,
I mean, I can just imagine how I've lived these nights, right?
Where the CPAP is on and it's not working, right?
There's a 29 second long app, you know,
CPAP is obviously not working.
And then the patient wakes up
and when they wake up, they're not happy, right?
They're just...
Right, they're tired, they're cranky, sure.
They're tired and cranky, but look what it,
I mean, just a little bit of effort
and a little bit of documentation.
Now we can get them to this level, like happy sleep too.
Like this, like when I see these,
these are called rapid eye movements.
Whenever I saw this on the nighttime spot,
we work as somebody, I'm like,
hey partner, guess what?
They're like, what?
This is my dream job.
And they go, ha ha, good one.
But it's true, right?
Because nobody thinks it's true.
Right, because they're doing what
they're supposed to be doing, yeah.
Right, they're dreaming, but you know as a night tech
that this is your work, right?
You made this happen.
These little eye blinks would not have been possible
if it wasn't for this mask, at this pressure,
with this head, you're at this humidity, right?
Any other combination would have caused
what we just saw literally like four minutes earlier, right?
Yeah, yeah.
Right?
So like it takes a lot of skill,
takes a lot of patience,
takes just a lot of training for the night techs.
A lot of night techs, they want to get these results.
They just can't because they don't know how, right?
Or they don't have the right equipment,
or they don't have the right sensors or something, right?
So we got to empower them with the skills
and equipment they need to get these results.
And when they do, then our patients will benefit.
I mean, this is like, this is the cleanest thing.
I'm really happy.
I found this example for us today
because it really proves all the points, right?
Like how effective a single night at sleep app can be,
how effective sleep app can be,
and the importance of a night technician
in combination with the patient, right?
Because easily at this awakening right here,
when the patient woke up, you can say, I'm done, right?
I don't want to deal with it anymore.
I'm gonna go home.
And that does happen.
That happens actually more often than I can,
when I'm in, that happens a lot.
And it's like, because these patients are super grumpy,
but luckily they just fall back asleep.
They don't cry too much and they're able to deal with it.
And that's also why that initial discussion
during this procedure here is so important.
It's like, hey patient, at 2 a.m. what might happen,
they might just walk in here,
wake you up, put a mask on you and say, good luck, right?
It's going to not be as easy for some people.
And sometimes what we'll do
is we'll give them a trial of that just in case.
Like, hey, Rebecca, just in case
I got put this mask on you at 2 a.m.,
I want you to get a feel for it right now
while I'm putting these bars on you.
Just put on your nose, kind of breathe against it.
You kind of see how that feels.
You're like, yeah, I kind of feel it.
And there's different masks.
There's something that goes up the nose and the nose
and on the mouth.
I like that one better.
You know, spend the time and effort to that way.
When it does happen, which it did happen in this case,
is already ready.
They're not startling.
They're not startling, right?
So that's also the skill of the tech.
Not all techs will do that.
Not all labs will do that, right?
Because that takes time.
That takes away from the other patient.
If you have three patients to do one one night,
which some labs do, you can't do that, right?
You got three patients to take care of.
You can't possibly put the effort it takes
to acclimate the patient.
So it's not only the technician.
The technician is doing whatever they can do.
It's also the lab protocol.
Some labs are saying, oh, we got to do two patients.
You got to do three patients.
And then some labs will allow us to do one.
If you just have one, then you just have more ability
to focus on that one patient and get everything done
like the way it's supposed to be.
Right?
So you can ask these questions.
You can say, am I the only patient?
How many patients else are you observing tonight?
If what's the protocol?
Like, is this lab accredited?
You know, like you have the right to choose, right?
You can refuse.
You'd be like, you know what?
I want to go to Rebecca's lab because she does it right.
And I'm like, go for it, right?
Don't go to the other guy's lab.
There's plenty of labs.
Anybody that we invite on here,
I will just go to theirs, right?
I don't have a lab currently.
So if it's James Cardell from Stanford or from Dmitri
from the pediatric facility he goes to
or Jordan from Pets of Children, right?
Or, I mean, especially we have Dr. Simmons, right?
He also has labs, CSMA in Houston, Austin and Woodland.
So anybody who is a member of this society
or foundation that has a facility,
and they mostly have this equipment too,
you know, go with them,
but don't just go where you're told to go
because you have a choice.
We're gonna carry this look, right?
If a parent gets referred,
and obviously we listed that small group,
where can they go to find, I guess, ratings?
Like, how do they know if it's a good lab?
Where is a good resource for them to go up?
So a good resource would be the American Academy
of Sleep Medicine.
They have a locator of what's called accredited labs.
So if a lab meets the criteria to be AASM accredited,
then they'll shop on some kind of list.
That's an option, but I would still go with the people
from this podcast because you have vetted them
and they're here talking to us
and they care enough to, you know, talk about it.
So I would go with that one first
and then just reach out to people
that are on the podcast, right?
So like if, in the example, right?
So you're in Michigan, right? I would just call Dr. Simmons.
Hey, Dr. Simmons, do you have a partner in Michigan?
And ask him, right?
And then let him say what he said.
Which is a great idea.
Because if you haven't worked with the CSMA,
and you can call them directly,
all the info is on their website,
but that staff's gonna help you.
They will find what you need.
Right, I mean, they're the ones that brought us together.
So I wanna give them as much credit as I can.
So it's, I would just go with, I mean,
but also important to note is you don't have
to stay in Michigan.
I have patients fly in.
I had patients fly internationally
when I was at what was called the Houston Methodist
Neurological Institute.
Most of my patients weren't moved, actually.
Most of our patients were actually traveling patients
who came in from different cities, different states
because of the doctors.
And then because of the doctors, you know,
the lab had to meet their expectations.
The lab was also a pretty high standard lab
and it is showed, right?
So I recently met up with the crew that I worked with
like 10 years ago at the Houston meeting
and we still have stories like from the nights there,
which were pretty incredible.
That is awesome.
All right, so you alluded to this.
So I wanna give parents kind of a heads up.
This is, it kind of just evolved this way.
So this is the beginning of a four part series
that we're gonna be doing specifically around sleep.
It's like testing.
And you wanna give us, just give them a little insight
into we've got Jordan coming and Dmitri and James.
Yeah, so these people I've all worked with in the past.
So Jordan is now the head of education
at the Texas Children's Hospital.
So she runs exclusively pediatric studies
and she trains the technicians,
kind of like how I'm training you
on the importance of doing one.
She trains the technicians
on the importance of doing it correctly.
So she does the full PSGs.
She is the person, and she's not the person in this image here,
but she trains the person that would be in this image
and then she trains them up to get the point
where they're able to pass the exam.
Cause as a, we saw on my first slide, right?
The RPSGET, that's what she has to get her technicians
either renewed if they have it
or they need to get it if they don't have it.
So that's Jordan, she's talking about technician education
and whatever else she has talked about.
We have James Cardell, who I work with.
He actually purchased this equipment.
You see on the plot here called Compumetics Profusion.
And that's the software I also demonstrated later
in this presentation.
I work with him as a specialist,
so a specialist is a person that comes in
and deals with all the cabling and firewalls and all.
So I sat in contact with him for the last four years
and he runs Lucille Packard's Children's Hospitals Sleep
Center.
So he works during the day.
What happens is we saw on the plot,
you saw here like these little boxes
where it says Riva and Arousal and it says stage two.
What he will do is he will go through each 30 seconds
and use this exact software to stage it,
score it and then run the reports
and generate these little tables.
So he's called a scoring technology.
So we'll talk about how to classify the event.
Like why is that a Rira versus why is that a hypopnea
versus an apnea versus central?
Like how do you make that distinction
and how many percent do you saturation
to point where it counts and arousals?
When do they start?
When the end, it's like a whole science behind it.
And you have to click and drag.
It's like a whole to do.
And then we have Dmitri who is also a researcher
who also does children all the way down to birth.
So he is gonna talk about his research
and his other experience working with pediatrics.
So all three people I'm recommending to you, Rebecca,
are all pediatric focused RPSGTs.
So my experience, I left the lab and went into industry
and became an engineer and I worked more on like the acquisition
for the publications and for the FDA approvals
for novel devices.
But my partners that I'm recommending are still frontline
dealing with patients, dealing with parents,
dealing with airways and keeping up with the advancements.
And they just call me whenever the computer breaks down
and I help them when they need that help.
That's awesome.
I love them.
So parents, if you're hearing this in a month or two,
the links in these podcasts we're talking about
will be included.
But if not, if you're hearing this, you know,
July, June, July, then we invite you to just stay tuned
because these other three episodes are on the horizon.
Yes, I look forward to hearing them myself, you know.
They all, we all learn from each other.
Even though I've been doing this for a long time,
I'm sure I can learn from all three of the future attendees.
Which is awesome.
Well, I cannot thank you enough for this.
Even though you made me quiz my way through it,
I still cannot thank you.
You did great.
Thank you for it.
It was a real, I mean, being able to see this
and have it explained is really, as a parent,
it's really eye-opening, a little jarring to think.
Wow, I mean, you see it.
Boom, your kid is not breathing for 20, 30, 40.
That's crazy.
So thank you very much for taking all the time
to explain all those to us.
And what I would like to do again,
whenever you have the chance is to actually,
if you have a recording or a report,
you know, we can review it and we can see the details
of that because it's more impactful.
Like I gave all these examples from other people,
unless you're own patient or your own child,
then I think it'll be even more impactful.
It's not something we could do in the future.
Until then, I do have a recording on YouTube.
It's actually on the TEDx channel, you can look up.
And we have that event in September.
But it does compete, Rebecca can't go,
she has also a competing event.
So it depends if you want to re-know our Texas,
my events in Texas, obviously.
And then I'm also on LinkedIn.
So I think all those will be in some comments.
Her show notes are-
Yep, all that's gonna be in the show notes.
Yep, and the TED talk is awesome.
I've heard it and promoted it.
I was super proud of it.
So it's on here and it actually is on our YouTube channel.
Right now, it's underneath the playlist for sleep.
So check it out if you haven't.
Check it out if you haven't.
Yes, Rebecca, this was great.
This was great, this was a ton of fun.
And you handled the quiz really well.
I give you full credit, you pass with an A plus.
I'll take it.
There you go.
Thank you.
You can stay connected with the Children's Airway
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If you'd like to be a guest
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shoot us a note via the contacts page on our website
or send us an email directly at infoatchildrensairwayfirst.org.
Today's episode was written and directed
by Rebecca St. James,
video editing and promotion by Ryan Draughn
and guest outreach by Kristie Bojikian.
And finally, thanks to all the parents
and medical professionals out there
that are working hard to help make the lives of kids
around the globe just a little bit better.
Take care, stay safe, and happy breathing, everyone.
Thank you.