1
00:00:00,000 --> 00:00:01,000
Maze of the Year.

2
00:00:01,000 --> 00:00:02,000
I hope you enjoyed this video.

3
00:00:02,000 --> 00:00:03,000
I'll see you in the next one.

4
00:00:03,000 --> 00:00:04,000
Bye!

5
00:00:04,000 --> 00:00:05,000
Bye!

6
00:00:05,000 --> 00:00:06,000
Bye!

7
00:00:06,000 --> 00:00:07,000
Bye!

8
00:00:07,000 --> 00:00:08,000
Bye!

9
00:00:08,000 --> 00:00:09,000
Bye!

10
00:00:09,000 --> 00:00:10,000
Bye!

11
00:00:10,000 --> 00:00:11,000
Bye!

12
00:00:11,000 --> 00:00:12,000
Bye!

13
00:00:12,000 --> 00:00:13,000
Bye!

14
00:00:13,000 --> 00:00:14,000
Bye!

15
00:00:14,000 --> 00:00:15,000
Bye!

16
00:00:15,000 --> 00:00:16,000
Bye!

17
00:00:16,000 --> 00:00:17,000
Bye!

18
00:00:17,000 --> 00:00:18,000
Bye!

19
00:00:18,000 --> 00:00:19,000
Bye!

20
00:00:19,000 --> 00:00:20,000
Bye!

21
00:00:20,000 --> 00:00:21,000
Bye!

22
00:00:21,000 --> 00:00:22,000
Bye!

23
00:00:22,000 --> 00:00:23,000
Bye!

24
00:00:23,000 --> 00:00:24,000
Bye!

25
00:00:24,000 --> 00:00:25,000
Bye!

26
00:00:25,000 --> 00:00:26,000
Bye!

27
00:00:26,000 --> 00:00:27,000
Bye!

28
00:00:27,000 --> 00:00:28,000
Bye!

29
00:00:28,000 --> 00:00:29,000
Bye!

30
00:00:29,000 --> 00:00:33,080
Bye everyone, and welcome back to Airway First, the podcast from the Children's Airway

31
00:00:33,080 --> 00:00:34,080
First Foundation.

32
00:00:34,080 --> 00:00:38,360
I'm your host, Rebecca St. James.

33
00:00:38,360 --> 00:00:43,160
My guest today is Jayton Tecknenjane, or JT as we call him.

34
00:00:43,160 --> 00:00:49,200
JT is the Vice President of the Texas Society of Sleep Professionals, and is focused on

35
00:00:49,200 --> 00:00:53,480
the diagnosis and treatment of sleep and neurological disorders.

36
00:00:53,480 --> 00:01:03,480
JT will be kicking off our four-part series on sleep, sleep testing, and sleep diagnosis.

37
00:01:03,480 --> 00:01:10,120
Later on in our series, you'll also be hearing from Dmitri Spector, Jordan Rusk, and Dr.

38
00:01:10,120 --> 00:01:11,880
Gerald Simmons.

39
00:01:11,880 --> 00:01:15,960
So let's go ahead and kick this series off with my interview with JT.

40
00:01:15,960 --> 00:01:18,240
All right.

41
00:01:18,240 --> 00:01:20,440
Thank you so much for joining us this evening, Jayton.

42
00:01:20,440 --> 00:01:22,440
I appreciate it.

43
00:01:22,440 --> 00:01:24,280
Thank you, Rebecca.

44
00:01:24,280 --> 00:01:25,880
So I also go by JT.

45
00:01:25,880 --> 00:01:28,480
Would you see my initials there, Jordan Tecknenjane?

46
00:01:28,480 --> 00:01:31,320
Obviously, CAFF is spelled out here.

47
00:01:31,320 --> 00:01:36,280
So in addition to this being a lecture, I think of it more of like a conversation.

48
00:01:36,280 --> 00:01:38,000
So I'm going to ask you some questions.

49
00:01:38,000 --> 00:01:43,040
So after my name, I also have a lot of additional letters.

50
00:01:43,040 --> 00:01:45,560
What are your guesses on what any of those would be?

51
00:01:45,560 --> 00:01:56,400
Well, I know the RPSGT1 has to do with you reading and deciphering these sleep studies.

52
00:01:56,400 --> 00:01:59,200
You know, that one goes with that one.

53
00:01:59,200 --> 00:02:00,200
Yeah, that's correct.

54
00:02:00,200 --> 00:02:03,880
So RPSGT is registered polysomnographic technologies.

55
00:02:03,880 --> 00:02:05,440
So you see R's and you see T's.

56
00:02:05,440 --> 00:02:07,600
A lot of times, T stands for therapists.

57
00:02:07,600 --> 00:02:08,960
You see RRT.

58
00:02:08,960 --> 00:02:11,640
But in this context, T is for technologists.

59
00:02:11,640 --> 00:02:12,840
So you might be a trainee.

60
00:02:12,840 --> 00:02:13,840
You might be a technician.

61
00:02:13,840 --> 00:02:14,840
You might be a technologist.

62
00:02:14,840 --> 00:02:17,920
A technician pushes the button.

63
00:02:17,920 --> 00:02:21,000
The technologist knows what button to press and when.

64
00:02:21,000 --> 00:02:23,680
So RPSGT is that one for sure.

65
00:02:23,680 --> 00:02:24,680
Registered polysomnographic technologies.

66
00:02:24,680 --> 00:02:25,680
What about the rest?

67
00:02:25,680 --> 00:02:26,680
Any ideas?

68
00:02:26,680 --> 00:02:32,000
I know the VP Texas Sleep Society professional, something like that.

69
00:02:32,000 --> 00:02:33,160
I know the bottom one.

70
00:02:33,160 --> 00:02:34,400
Okay, that's right.

71
00:02:34,400 --> 00:02:37,760
Texas Society of Sleep Professionals recently, I was elected the vice president and we have

72
00:02:37,760 --> 00:02:39,600
an event happening in September.

73
00:02:39,600 --> 00:02:40,600
So that's that one.

74
00:02:40,600 --> 00:02:41,920
What about the rest?

75
00:02:41,920 --> 00:02:46,240
And sadly, you think I would remember the EEG, but you are a registered EEG and I don't

76
00:02:46,240 --> 00:02:47,240
remember what that one is.

77
00:02:47,240 --> 00:02:48,240
There you go.

78
00:02:48,240 --> 00:02:49,240
Yeah, you got it right.

79
00:02:49,240 --> 00:02:53,720
So registered EEG technologies, so in addition to recording sleep studies, I have a recorded

80
00:02:53,720 --> 00:02:57,520
EEG studies which are there for detection of seizure disorders.

81
00:02:57,520 --> 00:02:59,920
So you got them all almost all done.

82
00:02:59,920 --> 00:03:00,920
What's the last one?

83
00:03:00,920 --> 00:03:03,120
Oh man, you're killing me.

84
00:03:03,120 --> 00:03:07,080
A master's and bio something or other.

85
00:03:07,080 --> 00:03:08,080
No idea.

86
00:03:08,080 --> 00:03:09,080
Right.

87
00:03:09,080 --> 00:03:10,080
So engineering, biomedical engineering.

88
00:03:10,080 --> 00:03:11,080
Yes.

89
00:03:11,080 --> 00:03:12,080
There you go.

90
00:03:12,080 --> 00:03:13,080
You got it.

91
00:03:13,080 --> 00:03:14,080
See, I told you you would get it right.

92
00:03:14,080 --> 00:03:15,080
That's more fun when you get it.

93
00:03:15,080 --> 00:03:16,080
You see how much fun you're having?

94
00:03:16,080 --> 00:03:17,080
I'm having a blast.

95
00:03:17,080 --> 00:03:21,400
Yes, it's more fun when you guess and you actually guess wrong, but you got it right.

96
00:03:21,400 --> 00:03:22,400
So let's proceed.

97
00:03:22,400 --> 00:03:23,400
All right.

98
00:03:23,400 --> 00:03:25,920
So what I do, I mean, what are all these letters mean?

99
00:03:25,920 --> 00:03:31,160
So what I do as an engineer, as a technologist is I acquire and analyze and report on data

100
00:03:31,160 --> 00:03:34,160
because that's where we use to make decisions.

101
00:03:34,160 --> 00:03:38,880
So people always think about artificial intelligence and business intelligence and the actual word

102
00:03:38,880 --> 00:03:42,680
intelligence actually means the use of information to make a decision.

103
00:03:42,680 --> 00:03:47,080
And the way you want to think about it is like the CIA, like central intelligence agency,

104
00:03:47,080 --> 00:03:48,080
right?

105
00:03:48,080 --> 00:03:51,720
They go out and they have spies and satellites and whatever else to collect the data that

106
00:03:51,720 --> 00:03:56,880
then military action or some other kind of action could be done based on data.

107
00:03:56,880 --> 00:03:57,880
We're doing the same thing, right?

108
00:03:57,880 --> 00:04:02,480
We're going out and collecting data from clinical sensors and then reporting it to either the

109
00:04:02,480 --> 00:04:05,120
MDs or PhDs or then to make some decisions.

110
00:04:05,120 --> 00:04:07,960
So the way I like to think of it is an intelligence cycle.

111
00:04:07,960 --> 00:04:13,400
And I think of them as three steps and they all start with the letter A. So now it's back

112
00:04:13,400 --> 00:04:14,800
to being a quiz again.

113
00:04:14,800 --> 00:04:19,400
Rebecca, what is the first A in the intelligence cycle?

114
00:04:19,400 --> 00:04:20,400
Automatically.

115
00:04:20,400 --> 00:04:21,400
Airway.

116
00:04:21,400 --> 00:04:22,400
Airway.

117
00:04:22,400 --> 00:04:23,400
Airway has to.

118
00:04:23,400 --> 00:04:25,400
Because airway first, right?

119
00:04:25,400 --> 00:04:27,400
Yes, airway first.

120
00:04:27,400 --> 00:04:29,000
Yes, but it's wrong.

121
00:04:29,000 --> 00:04:34,800
The data intelligence cycle, what do you think has to happen first, right?

122
00:04:34,800 --> 00:04:38,720
Let's work this out.

123
00:04:38,720 --> 00:04:39,720
For the data.

124
00:04:39,720 --> 00:04:43,320
Yeah, if you got to analyze it.

125
00:04:43,320 --> 00:04:45,000
Before you can analyze it, what do you have to do?

126
00:04:45,000 --> 00:04:47,200
I can't analyze data unless I have it with me, right?

127
00:04:47,200 --> 00:04:49,040
So what do I got to do before I can analyze it?

128
00:04:49,040 --> 00:04:50,920
Do you have to accept it?

129
00:04:50,920 --> 00:04:53,600
Yes, accept it or acquire it.

130
00:04:53,600 --> 00:04:56,120
There we go.

131
00:04:56,120 --> 00:05:00,480
So the first step in the data intelligence cycle in the first of the three As is acquire

132
00:05:00,480 --> 00:05:01,480
the data.

133
00:05:01,480 --> 00:05:05,600
So in the sleep study example, we're going to use sensors and observations to acquire

134
00:05:05,600 --> 00:05:06,600
some data.

135
00:05:06,600 --> 00:05:09,320
Now, you already mentioned the second step, mentioned analyze.

136
00:05:09,320 --> 00:05:11,080
So analyze is the second step.

137
00:05:11,080 --> 00:05:15,120
Then you take this data and then we call it scoring and reporting.

138
00:05:15,120 --> 00:05:17,240
We take the data, we generate the statistic.

139
00:05:17,240 --> 00:05:19,400
The most important one of them all is the AHI.

140
00:05:19,400 --> 00:05:20,960
We'll talk about that in detail.

141
00:05:20,960 --> 00:05:22,480
And then some other numbers as well.

142
00:05:22,480 --> 00:05:24,120
That's the step of analyze.

143
00:05:24,120 --> 00:05:28,600
So now that I've done analyzing the data, what would the next step be?

144
00:05:28,600 --> 00:05:29,600
And obviously it has to start with an A.

145
00:05:29,600 --> 00:05:32,040
Because this is the A3 data intelligence cycle.

146
00:05:32,040 --> 00:05:34,960
Yeah, I'm going with something about answering.

147
00:05:34,960 --> 00:05:35,960
I'm not sure.

148
00:05:35,960 --> 00:05:36,960
Answering?

149
00:05:36,960 --> 00:05:37,960
I think that's pretty close.

150
00:05:37,960 --> 00:05:39,200
I'll give you credit for that one.

151
00:05:39,200 --> 00:05:40,760
You get full points.

152
00:05:40,760 --> 00:05:41,760
All right?

153
00:05:41,760 --> 00:05:43,320
The third step is to act.

154
00:05:43,320 --> 00:05:46,640
Because what's the point of having all this data and having all this analysis unless you

155
00:05:46,640 --> 00:05:47,720
do something about it?

156
00:05:47,720 --> 00:05:51,240
So if the analysis report says you have sleep apnea, you should treat it.

157
00:05:51,240 --> 00:05:52,240
Then you should treat it.

158
00:05:52,240 --> 00:05:56,600
Or if the analysis says you should go get some insomnia therapy or behavioral therapy,

159
00:05:56,600 --> 00:05:57,600
you should do it, right?

160
00:05:57,600 --> 00:06:00,080
That's what the analysis shows that you should do next.

161
00:06:00,080 --> 00:06:04,320
So without acting on the data, all the previous steps are pretty pointless, right?

162
00:06:04,320 --> 00:06:08,440
So you must act on the decisions that were based on the intelligence acquired.

163
00:06:08,440 --> 00:06:09,600
So what's the next step after this?

164
00:06:09,600 --> 00:06:10,600
Because it's a cycle.

165
00:06:10,600 --> 00:06:13,600
What do you do next?

166
00:06:13,600 --> 00:06:15,720
I don't know.

167
00:06:15,720 --> 00:06:21,560
I guess you have to do whatever it is that you're supposed to do when you're acting on

168
00:06:21,560 --> 00:06:22,560
it, right?

169
00:06:22,560 --> 00:06:23,560
So what is that?

170
00:06:23,560 --> 00:06:24,560
Yes, after you.

171
00:06:24,560 --> 00:06:25,960
The path is changing lifestyle.

172
00:06:25,960 --> 00:06:26,960
Right?

173
00:06:26,960 --> 00:06:28,440
Okay, so that's all the act, right?

174
00:06:28,440 --> 00:06:32,440
So once you do all your actions, what would the next logical thing be to do, right?

175
00:06:32,440 --> 00:06:33,440
So you did the action.

176
00:06:33,440 --> 00:06:34,440
Oh, to check the question.

177
00:06:34,440 --> 00:06:35,440
See if there's a progress.

178
00:06:35,440 --> 00:06:36,440
See if there's a change.

179
00:06:36,440 --> 00:06:37,440
Yes.

180
00:06:37,440 --> 00:06:39,640
You start over again.

181
00:06:39,640 --> 00:06:40,640
You acquire data again.

182
00:06:40,640 --> 00:06:45,960
There's no point in just acting on it and not following up with saying, did what I thought

183
00:06:45,960 --> 00:06:48,480
I should do improve the situation?

184
00:06:48,480 --> 00:06:52,920
So if the example is always going to be sleep apnea, if I have an AHI and it says to go

185
00:06:52,920 --> 00:06:56,280
do some therapy and I do the therapy, whatever it is, did it work?

186
00:06:56,280 --> 00:06:57,280
I don't know, right?

187
00:06:57,280 --> 00:06:58,280
You have to repeat it.

188
00:06:58,280 --> 00:06:59,280
You have to start over again.

189
00:06:59,280 --> 00:07:02,760
You have to get back into the lab, get the data acquired, get it analyzed, and then work

190
00:07:02,760 --> 00:07:04,400
on whatever recommendation comes out of it.

191
00:07:04,400 --> 00:07:05,400
This is a cycle, right?

192
00:07:05,400 --> 00:07:06,400
This never ends.

193
00:07:06,400 --> 00:07:08,640
Like we do this nightly for some patients, right?

194
00:07:08,640 --> 00:07:12,440
We constantly measure their signals and report back what they should be doing next.

195
00:07:12,440 --> 00:07:15,520
So the data intelligence cycle.

196
00:07:15,520 --> 00:07:18,280
Now we start with the acquiring stage.

197
00:07:18,280 --> 00:07:21,120
And this is the way that we acquire data in the sleep lab.

198
00:07:21,120 --> 00:07:23,560
We have a series of sensors.

199
00:07:23,560 --> 00:07:24,840
We start with the head.

200
00:07:24,840 --> 00:07:25,840
And that's the EEG.

201
00:07:25,840 --> 00:07:26,840
EEG is electroencephalography.

202
00:07:26,840 --> 00:07:30,200
This means brain waves.

203
00:07:30,200 --> 00:07:32,640
From there, we can tell if you're awake or if you're asleep.

204
00:07:32,640 --> 00:07:36,240
And then we look at the EOG, electrooculography, the movement of the eyes.

205
00:07:36,240 --> 00:07:40,640
Once you're asleep, we can say if you're in REM or non-REM sleep.

206
00:07:40,640 --> 00:07:42,640
And then we look at nasal airflow.

207
00:07:42,640 --> 00:07:45,560
We can tell if you're breathing or if you're not breathing.

208
00:07:45,560 --> 00:07:50,800
And if you're having struggling breathing, then you'll see some impact on the microphone.

209
00:07:50,800 --> 00:07:52,760
That's the sound of snoring.

210
00:07:52,760 --> 00:07:57,360
And if there was a pause in breathing, we call that an apnea.

211
00:07:57,360 --> 00:07:58,480
PNEA is breath.

212
00:07:58,480 --> 00:07:59,880
A means without.

213
00:07:59,880 --> 00:08:03,000
And then the next question is what kind of apnea is it?

214
00:08:03,000 --> 00:08:04,920
Because there's multiple kinds.

215
00:08:04,920 --> 00:08:08,240
There's obstructive apnea, which means you're trying to breathe.

216
00:08:08,240 --> 00:08:10,120
And there's central apnea, which means you're not trying to breathe.

217
00:08:10,120 --> 00:08:12,480
How can I tell if your apnea is central obstructive?

218
00:08:12,480 --> 00:08:14,320
Because I have to look at these belts.

219
00:08:14,320 --> 00:08:17,280
That's what these respiratory effort bands are for.

220
00:08:17,280 --> 00:08:19,280
So I'm going to turn on the laser.

221
00:08:19,280 --> 00:08:25,000
So I got these respiratory effort bands, which are used for the declassification of the apnea.

222
00:08:25,000 --> 00:08:29,560
I got the EOG for the declassification of the stage of sleep.

223
00:08:29,560 --> 00:08:34,080
And we have the nasal airflow for the detection of either apneas or hypopneas.

224
00:08:34,080 --> 00:08:35,600
Microphones for snoring.

225
00:08:35,600 --> 00:08:38,880
And then the other thing I mentioned just now was a hypopneas.

226
00:08:38,880 --> 00:08:41,080
So a hypopneas is not a complete obstruction.

227
00:08:41,080 --> 00:08:42,800
It's a partial obstruction.

228
00:08:42,800 --> 00:08:49,600
But it only counts if you have a drop in oxygen or a shift in the EEG.

229
00:08:49,600 --> 00:08:52,080
So you can't just have a reduction in airflow and call it a hypopneas.

230
00:08:52,080 --> 00:08:54,080
You have to have something else.

231
00:08:54,080 --> 00:09:00,560
And then we also observe that a lot of times our patients are going to have not only airway related issues.

232
00:09:00,560 --> 00:09:02,160
They might be grinding their teeth.

233
00:09:02,160 --> 00:09:03,400
That could be airway related, actually.

234
00:09:03,400 --> 00:09:05,720
So that's called Bruxism, measure of the chin.

235
00:09:05,720 --> 00:09:10,840
And we're also measuring leg EMGs, electromygraphy, these are both muscle groups.

236
00:09:10,840 --> 00:09:14,360
Because patients have sometimes leg movements that disrupt them to sleep.

237
00:09:14,360 --> 00:09:16,360
Now, these are all the symptoms.

238
00:09:16,360 --> 00:09:17,360
Is that what you're talking about?

239
00:09:17,360 --> 00:09:21,120
Restless legs is a condition that you would not measure with a PSG overnight.

240
00:09:21,120 --> 00:09:23,200
Because PSGs are recorded during sleep.

241
00:09:23,200 --> 00:09:26,480
Restless legs is a condition that you would measure while the patient is awake.

242
00:09:26,480 --> 00:09:28,280
And it would keep them awake.

243
00:09:28,280 --> 00:09:31,120
PLMs is a condition you would measure during sleep.

244
00:09:31,120 --> 00:09:34,360
So this is just like when kids kick and that kind of thing.

245
00:09:34,360 --> 00:09:35,880
Is that what you're talking about?

246
00:09:35,880 --> 00:09:36,400
Yes.

247
00:09:36,400 --> 00:09:40,320
So you would see that and you would see if it was happening during sleep and if it was disrupting sleep.

248
00:09:40,320 --> 00:09:43,960
So that's where you would use the leg EMG as a part of the PSG.

249
00:09:43,960 --> 00:09:48,960
In addition to all of these sensors which are applied to the patient, you'll see a photo of it soon.

250
00:09:48,960 --> 00:09:51,080
We also have a video camera.

251
00:09:51,080 --> 00:09:55,360
Because there are sleep disorders that aren't going to appear very well on these signals,

252
00:09:55,360 --> 00:09:57,520
but do appear very well on the video camera.

253
00:09:57,520 --> 00:10:02,560
Like parasomias, night terrors, like REM behavior disorder patients acting out of dreams.

254
00:10:02,560 --> 00:10:06,280
That's in combination with the sensors as well as the camera recording the behavior.

255
00:10:06,280 --> 00:10:09,760
So we have the camera as another input to our acquisition.

256
00:10:09,760 --> 00:10:16,640
And one of the most important features of an overnight PSG is the tech mission.

257
00:10:16,640 --> 00:10:19,600
Or we refer to them as the technologists or just tech.

258
00:10:19,600 --> 00:10:23,120
They're making sure all of these sensors are working.

259
00:10:23,120 --> 00:10:26,040
They're making sure like all the patient's comfortable.

260
00:10:26,040 --> 00:10:30,080
If the patient has a parent with them that they're comfortable, that all the instructions are clear.

261
00:10:30,080 --> 00:10:33,800
Everybody's doing great and that the study does go to success.

262
00:10:33,800 --> 00:10:37,400
So that's what we have in terms of an overnight PSG.

263
00:10:37,400 --> 00:10:39,080
And that's what it looks like.

264
00:10:39,080 --> 00:10:45,760
So here's an example of an overnight PSG at the very first stage of the wires being applied.

265
00:10:45,760 --> 00:10:50,000
So what you're observing is an interaction between a technologist,

266
00:10:50,000 --> 00:10:51,720
bringing the scrubs and the patient.

267
00:10:51,720 --> 00:10:59,680
Now this interaction is quite intensive because you're going to spend maybe 12 hours at this facility.

268
00:10:59,680 --> 00:11:01,880
You know, maybe about seven hours in the bed.

269
00:11:01,880 --> 00:11:06,560
You're going to spend about 40 minutes in this process here.

270
00:11:06,560 --> 00:11:12,280
Where the technician is wearing gloves, measuring the head, applying the sensors.

271
00:11:12,280 --> 00:11:14,000
And it's not a quiet situation.

272
00:11:14,000 --> 00:11:16,760
You know, we're chatting with our patient.

273
00:11:16,760 --> 00:11:21,480
And then this interaction that we're having is usually more time than even they spent with their physician.

274
00:11:21,480 --> 00:11:25,400
Their physician sometimes is limited to 50 minutes in a single issue.

275
00:11:25,400 --> 00:11:28,520
So a lot of times we're talking to the patient as each sensor is applied,

276
00:11:28,520 --> 00:11:31,680
we're saying this sensor is applied because of the detection of central apnea.

277
00:11:31,680 --> 00:11:32,840
It's all putting a belt on.

278
00:11:32,840 --> 00:11:34,000
We're putting a wire in your chin.

279
00:11:34,000 --> 00:11:35,280
That's for proxism.

280
00:11:35,280 --> 00:11:36,960
And the patient is free to ask questions.

281
00:11:36,960 --> 00:11:37,760
We can talk to them.

282
00:11:37,760 --> 00:11:42,560
And by the end of this process, the patient finally understands why they're even there.

283
00:11:42,560 --> 00:11:47,280
Because sometimes they show up to these sleep studies and they don't even know what they're there and what's going on.

284
00:11:47,280 --> 00:11:51,680
And then it's the job of the technologist to kind of get them comfortable with the whole process

285
00:11:51,680 --> 00:11:56,520
and explain to them why they're here, why they may come back, why they may not come back.

286
00:11:56,520 --> 00:12:00,520
And then just make sure that the patient also understands the importance of all sensors

287
00:12:00,520 --> 00:12:03,160
and how to interpret them once they do get the report.

288
00:12:03,160 --> 00:12:06,160
So that's what's happening for any time you're able to get to the report.

289
00:12:06,160 --> 00:12:07,360
And this is the same for kids too, right?

290
00:12:07,360 --> 00:12:12,160
When children come in, is it the same or how much does it vary for them?

291
00:12:12,160 --> 00:12:12,960
It's the same.

292
00:12:12,960 --> 00:12:13,320
Yeah.

293
00:12:13,320 --> 00:12:13,440
OK.

294
00:12:13,440 --> 00:12:16,600
So we'll have some upcoming episodes with people that are focused on this application,

295
00:12:16,600 --> 00:12:19,560
like Jordan and they can ask their question better.

296
00:12:19,560 --> 00:12:21,080
But it is the same.

297
00:12:21,080 --> 00:12:26,480
Like when I apply these sensors, this example is actually a pediatric example.

298
00:12:26,480 --> 00:12:27,480
There is no difference, right?

299
00:12:27,480 --> 00:12:31,360
All the sensors I apply to the adults, I apply to the pediatric.

300
00:12:31,360 --> 00:12:35,400
The only difference is maybe the ETCO2, the antityl carbon dioxide,

301
00:12:35,400 --> 00:12:38,080
that's optional for the adults.

302
00:12:38,080 --> 00:12:39,880
It's required for pediatrics.

303
00:12:39,880 --> 00:12:42,600
And the sensors may be of a different size.

304
00:12:42,600 --> 00:12:46,440
If the belts will be smaller, the sensor in the finger might be a different shape

305
00:12:46,440 --> 00:12:48,320
just so that it fits the pediatric population.

306
00:12:48,320 --> 00:12:50,720
Otherwise, the overall workflow is the same.

307
00:12:50,720 --> 00:12:52,560
You have the night tech there.

308
00:12:52,560 --> 00:12:53,960
You have a patient there.

309
00:12:53,960 --> 00:12:57,920
Usually for pediatrics, there might be just one patient as opposed to two,

310
00:12:57,920 --> 00:13:02,280
so that they are more labor-intensive, so you might have to have a higher ratio

311
00:13:02,280 --> 00:13:05,800
of technicians to service the pediatric population.

312
00:13:05,800 --> 00:13:08,720
So that's what we're seeing in the lab, and that's the goal standard.

313
00:13:08,720 --> 00:13:12,280
Like if you're going to do any kind of at-home testing or a device that's

314
00:13:12,280 --> 00:13:15,440
considered portable, you're going to have to validate it against this,

315
00:13:15,440 --> 00:13:21,200
which is considered the in-lab PSG, which is still what I recommend to get.

316
00:13:21,200 --> 00:13:22,920
And parents are there too, right?

317
00:13:22,920 --> 00:13:25,800
While they're hooking them up, a parent would stay with them.

318
00:13:25,800 --> 00:13:26,400
OK.

319
00:13:26,400 --> 00:13:30,720
Yes, the parent has to stay with the pediatric patient in the same room

320
00:13:30,720 --> 00:13:34,600
or maybe the next room over, but they are in the facility the entire time.

321
00:13:34,600 --> 00:13:39,400
We are not a quadrated without the parents being there.

322
00:13:39,400 --> 00:13:43,080
And then this is the head box for all the wires plugged in.

323
00:13:43,080 --> 00:13:48,920
Now, what we just observed was a type one study where PSG is performed

324
00:13:48,920 --> 00:13:51,720
in a sleep laboratory fully attended.

325
00:13:51,720 --> 00:13:54,840
If you take out the sleep tech and you send the wires home with a patient

326
00:13:54,840 --> 00:13:57,720
that's called the type two study, you might see that,

327
00:13:57,720 --> 00:14:00,160
unlike you'll see that in pediatrics.

328
00:14:00,160 --> 00:14:03,480
Wait, so you would hook them up and send them home?

329
00:14:03,480 --> 00:14:04,960
Yes, you would hook them up to the home,

330
00:14:04,960 --> 00:14:09,000
or you would have the patient hook up himself.

331
00:14:09,000 --> 00:14:09,880
That's type two.

332
00:14:09,880 --> 00:14:14,080
So type two is the same thing just in the home environment, no tech.

333
00:14:14,080 --> 00:14:15,480
So same as type one unattended.

334
00:14:15,480 --> 00:14:16,920
So you might hear these terms.

335
00:14:16,920 --> 00:14:19,000
That's why it's important to kind of spell them out.

336
00:14:19,000 --> 00:14:22,880
Like, you might see in a report also, like this study was a type three study.

337
00:14:22,880 --> 00:14:24,000
They might say that.

338
00:14:24,000 --> 00:14:25,960
So this is what it means.

339
00:14:25,960 --> 00:14:28,600
So a type three study is becoming very popular now.

340
00:14:28,600 --> 00:14:33,640
It's pretty much all the channels, but you'll notice it's missing a few.

341
00:14:33,640 --> 00:14:36,320
You're usually missing the leg EMGs.

342
00:14:36,320 --> 00:14:38,720
Most of them don't include actual ECG.

343
00:14:38,720 --> 00:14:43,400
They might just record the pulse, so you won't get arrhythmias.

344
00:14:43,400 --> 00:14:45,800
But you'll get respiratory effort.

345
00:14:45,800 --> 00:14:49,120
And the way I like to think about anything outside of a type one or two study

346
00:14:49,120 --> 00:14:50,600
is that it's not really a sleep study.

347
00:14:50,600 --> 00:14:55,680
It's really a sleep apnea study, because if you're not really measuring seizures,

348
00:14:55,680 --> 00:14:59,080
not measuring parisomnia, it's not a not condition there to measure movement

349
00:14:59,080 --> 00:14:59,960
disorders.

350
00:14:59,960 --> 00:15:02,960
Really, the only outcome is going to be sleep apnea.

351
00:15:02,960 --> 00:15:05,320
So 100% sleep apnea.

352
00:15:05,320 --> 00:15:08,800
Yeah, that's always really useful for anything outside of sleep apnea.

353
00:15:08,800 --> 00:15:10,760
Definitely want to bring them in for the in-lab study.

354
00:15:10,760 --> 00:15:12,720
There are some benefits of taking it home.

355
00:15:12,720 --> 00:15:14,840
I mean, one thing is that it's cost effective.

356
00:15:14,840 --> 00:15:17,600
It's going to be less expensive for you and the insurance.

357
00:15:17,600 --> 00:15:19,880
It's also going to be able to be repeated.

358
00:15:19,880 --> 00:15:22,280
So you can do like four or five of these studies in a row.

359
00:15:22,280 --> 00:15:23,640
You can't do that in the lab.

360
00:15:23,640 --> 00:15:25,880
And you might just have easier access to it.

361
00:15:25,880 --> 00:15:30,520
If there is a situation where it takes like six months to a year to get into your sleep lab,

362
00:15:30,520 --> 00:15:33,720
and you have the option of doing like a type three study tonight,

363
00:15:33,720 --> 00:15:35,880
then let's do the type three study and see what happens.

364
00:15:35,880 --> 00:15:37,080
We might make some progress.

365
00:15:37,080 --> 00:15:39,720
It's not as sensitive, but it is still useful.

366
00:15:39,720 --> 00:15:43,280
So it's a decision to have between you and your doctor about which way to go.

367
00:15:43,280 --> 00:15:45,800
And it's also a decision between you and your insurance sometimes.

368
00:15:45,800 --> 00:15:47,200
And I think, yeah, right.

369
00:15:47,200 --> 00:15:50,800
And I think, I don't remember if it was you and James and I that discussed this,

370
00:15:50,800 --> 00:15:57,680
or if it was just us, but the benefit of being able to do it for five nights in a row

371
00:15:57,680 --> 00:16:00,640
is because if you go into a lab, you may just have an off night.

372
00:16:00,640 --> 00:16:05,680
Either you don't sleep much or perhaps that was like one in a billion

373
00:16:05,680 --> 00:16:07,560
when you had a great night, right?

374
00:16:07,560 --> 00:16:11,200
And the benefit of being able to do multiple because you can see a pattern.

375
00:16:11,200 --> 00:16:15,200
You can actually more likely to pick things up.

376
00:16:15,200 --> 00:16:15,960
I agree with that.

377
00:16:15,960 --> 00:16:19,840
So I do believe like the benefit of sensors like this, I'll show you one,

378
00:16:19,840 --> 00:16:23,760
is that you can repeat the study multiple times, pretty much like forever.

379
00:16:23,760 --> 00:16:25,200
You can do this every night if you really wanted to.

380
00:16:25,200 --> 00:16:28,880
And that'll give you a pattern that you wouldn't see otherwise from a single night.

381
00:16:28,880 --> 00:16:30,680
You know, the first night effect is what you're referring to.

382
00:16:30,680 --> 00:16:32,480
Like you come to the lab, you don't only sleep as well

383
00:16:32,480 --> 00:16:33,920
because you're in a strange environment.

384
00:16:33,920 --> 00:16:37,680
There's also like night to night variability where maybe on Friday nights,

385
00:16:37,680 --> 00:16:40,480
you have worse apnea than on Saturday mornings or Saturday evenings

386
00:16:40,480 --> 00:16:43,760
because of work schedule and school schedule and things like that.

387
00:16:43,760 --> 00:16:47,920
And it could be diet related. Some people like have fast on Friday, things like that.

388
00:16:47,920 --> 00:16:52,520
So having like a couple of days in a row to see what difference it is

389
00:16:52,520 --> 00:16:54,920
is likely going to produce something useful.

390
00:16:54,920 --> 00:16:57,600
So when people ask like, which one's better?

391
00:16:57,600 --> 00:17:00,720
Really, there's a benefit of having multiple night home study.

392
00:17:00,720 --> 00:17:02,840
There's also a benefit of having in-lab study.

393
00:17:02,840 --> 00:17:05,760
So just like when I go shopping, they pick you want a blue one or orange one.

394
00:17:05,760 --> 00:17:08,320
I'm like, just pack them both, right?

395
00:17:08,320 --> 00:17:09,320
Just do them both, right?

396
00:17:09,320 --> 00:17:10,400
Just get the home studies.

397
00:17:10,400 --> 00:17:12,360
Let's do it for a couple of nights and then come in for in-lab study.

398
00:17:12,360 --> 00:17:15,040
Let's do that also because the more information you get,

399
00:17:15,040 --> 00:17:18,240
the better because you won't get the leg movements on a home study.

400
00:17:18,240 --> 00:17:19,800
You won't get arrhythmia as on a home study.

401
00:17:19,800 --> 00:17:21,280
You will get on an in-lab study,

402
00:17:21,280 --> 00:17:23,840
but you won't get the night to night variability on an in-lab study.

403
00:17:23,840 --> 00:17:25,480
So let's just do it both, right?

404
00:17:25,480 --> 00:17:26,680
Let's just get back to back.

405
00:17:26,680 --> 00:17:29,480
So that's what I think is probably the best option.

406
00:17:29,480 --> 00:17:31,080
Now, this one's interesting, right?

407
00:17:31,080 --> 00:17:35,600
I just showed you all of those sensors from the head, literally to the toes.

408
00:17:35,600 --> 00:17:41,720
And now they're saying that you can get the same report off of a single sensor.

409
00:17:41,720 --> 00:17:43,040
Is this a pulse oximeter?

410
00:17:43,040 --> 00:17:44,440
Is that what this is?

411
00:17:44,440 --> 00:17:44,960
It is.

412
00:17:44,960 --> 00:17:46,960
I mean, that's all it is, is a pulse oximeter.

413
00:17:46,960 --> 00:17:48,440
It only has one channel.

414
00:17:48,440 --> 00:17:51,080
And that's based off of this concept,

415
00:17:51,080 --> 00:17:54,520
is that whenever you have a heme on your blood,

416
00:17:54,520 --> 00:17:56,480
it could be deoxygenated or oxygenated.

417
00:17:56,480 --> 00:18:00,080
And the difference is not the shape of it,

418
00:18:00,080 --> 00:18:03,040
but the difference is the way it responds to light.

419
00:18:03,040 --> 00:18:06,640
So light can be either absorbed or reflected.

420
00:18:06,640 --> 00:18:10,200
And there's a certain type of reflection

421
00:18:10,200 --> 00:18:14,560
based on the type of light as well as the amount of oxygen in the blood.

422
00:18:14,560 --> 00:18:18,320
So if you take these concepts, what you can do is you can shine the light,

423
00:18:18,320 --> 00:18:20,760
calculate how much was reflected and absorbed,

424
00:18:20,760 --> 00:18:24,360
and then you come up with this kind of modulation ratio.

425
00:18:24,360 --> 00:18:28,280
And from here, you can tell exactly how much oxygen is in the blood.

426
00:18:28,280 --> 00:18:31,400
You can also tell where we are in the pulse wave.

427
00:18:31,400 --> 00:18:33,320
So you can see that there's pulse.

428
00:18:33,320 --> 00:18:38,440
And then from there, you can pull out like the heart variability.

429
00:18:38,440 --> 00:18:41,400
And then from heart availability, you can pull out respiration.

430
00:18:41,400 --> 00:18:44,240
And then from these two things, you can do like coherence.

431
00:18:44,240 --> 00:18:45,800
And then you can pull out really everything,

432
00:18:45,800 --> 00:18:49,280
including sleep staging arousals and apnea.

433
00:18:49,280 --> 00:18:50,400
So that's like the new thing,

434
00:18:50,400 --> 00:18:51,960
is that you can actually pull out a lot of information.

435
00:18:51,960 --> 00:18:55,120
This technology was recently indicated for pediatric use.

436
00:18:55,120 --> 00:19:00,440
So potentially, you can just do this finger sensor or ring sensor

437
00:19:00,440 --> 00:19:04,360
and really see a complete sleep study at home.

438
00:19:04,360 --> 00:19:05,640
And you can just own that thing, right?

439
00:19:05,640 --> 00:19:09,560
So it is come a long way,

440
00:19:09,560 --> 00:19:11,160
but it's important to understand the limitations.

441
00:19:11,160 --> 00:19:11,600
And we'll talk about that.

442
00:19:11,600 --> 00:19:16,200
And then make those tiny ones for tiny people's fingers?

443
00:19:16,200 --> 00:19:16,480
Yes.

444
00:19:16,480 --> 00:19:19,760
I mean, that device was indicated for H2 and up.

445
00:19:19,760 --> 00:19:20,680
So you can get one.

446
00:19:20,680 --> 00:19:21,640
Two and up.

447
00:19:21,640 --> 00:19:22,800
Holy smokes.

448
00:19:22,800 --> 00:19:23,560
Wow.

449
00:19:23,560 --> 00:19:24,000
OK.

450
00:19:24,000 --> 00:19:24,840
Yeah.

451
00:19:24,840 --> 00:19:26,480
Nice.

452
00:19:26,480 --> 00:19:28,720
And you can even get some of these over the counter.

453
00:19:28,720 --> 00:19:30,600
Like there's like watches and rings

454
00:19:30,600 --> 00:19:32,880
that you can get that actually plot this signal,

455
00:19:32,880 --> 00:19:36,640
like the SPO2, the saturation of oxygen, as well as the pulse.

456
00:19:36,640 --> 00:19:39,080
And we'll look and see how you can interpret those things.

457
00:19:39,080 --> 00:19:40,760
But that's something you can do every night, right?

458
00:19:40,760 --> 00:19:41,560
I mean, you could do this every night.

459
00:19:41,560 --> 00:19:43,000
You can't do a PSG every night.

460
00:19:43,000 --> 00:19:44,760
So that's the advantage.

461
00:19:44,760 --> 00:19:49,320
So I mean, the way that it works is you look at the amount

462
00:19:49,320 --> 00:19:50,840
of red light versus infrared light,

463
00:19:50,840 --> 00:19:52,400
and you plot it on this graph.

464
00:19:52,400 --> 00:19:53,800
And what you'll observe is that I

465
00:19:53,800 --> 00:19:56,240
need these calibration readings we see.

466
00:19:56,240 --> 00:19:57,760
They normally stop at 70.

467
00:19:57,760 --> 00:20:01,000
Even a lot of the oxymetra trends, they stop at 70.

468
00:20:01,000 --> 00:20:02,760
And then if you have a sleep study report,

469
00:20:02,760 --> 00:20:04,640
there's sometimes a phrase on it.

470
00:20:04,640 --> 00:20:09,080
And it says, any value below 70 may not be accurate.

471
00:20:09,080 --> 00:20:13,120
You might get a value of the 70 or 68 or 57.

472
00:20:13,120 --> 00:20:14,120
But you can't really trust it.

473
00:20:14,120 --> 00:20:16,920
Now, we're back to being a quiz again.

474
00:20:16,920 --> 00:20:19,080
Rebecca, why is that?

475
00:20:19,080 --> 00:20:22,720
Why do I have to cut off all my plots at 70?

476
00:20:22,720 --> 00:20:24,800
And why do I have to add that phrase to my sleep studies

477
00:20:24,800 --> 00:20:26,640
and let people know that a value below 70

478
00:20:26,640 --> 00:20:27,920
can't be trusted?

479
00:20:27,920 --> 00:20:29,920
I'm guessing it's some kind of a benchmark.

480
00:20:29,920 --> 00:20:33,720
Like anything below that is just not consistent.

481
00:20:33,720 --> 00:20:35,320
I don't know.

482
00:20:35,320 --> 00:20:36,000
That is right.

483
00:20:36,000 --> 00:20:38,440
Or is an exaggeration right?

484
00:20:38,440 --> 00:20:40,240
It is an exaggeration right?

485
00:20:40,240 --> 00:20:40,840
It is.

486
00:20:40,840 --> 00:20:42,600
OK, so you got the right idea.

487
00:20:42,600 --> 00:20:46,800
So the reason why is that we have a calibrated value

488
00:20:46,800 --> 00:20:49,960
for everything on this line.

489
00:20:49,960 --> 00:20:53,680
There was a person who was guaranteed to be at 70%

490
00:20:53,680 --> 00:20:57,640
based off of blood gas, and at 80, and at 90, and at 100,

491
00:20:57,640 --> 00:21:00,400
that we also measured their finger, red light,

492
00:21:00,400 --> 00:21:01,560
nymph red light.

493
00:21:01,560 --> 00:21:06,080
The problem is that for me to get 69, 68, anything below,

494
00:21:06,080 --> 00:21:10,320
I would have to induce or allow a real person

495
00:21:10,320 --> 00:21:13,440
to be at that level of hypoxemia, like lower than 70%

496
00:21:13,440 --> 00:21:15,960
oxygen, just to get our readings from my sensor.

497
00:21:15,960 --> 00:21:18,160
That would be considered unethical, right?

498
00:21:18,160 --> 00:21:19,920
You would literally kill somebody just

499
00:21:19,920 --> 00:21:21,400
to get a calibrated value.

500
00:21:21,400 --> 00:21:22,720
And we're not going to do that.

501
00:21:22,720 --> 00:21:24,600
So we're just going to say, you know what?

502
00:21:24,600 --> 00:21:25,960
We got 70.

503
00:21:25,960 --> 00:21:27,080
That's good enough.

504
00:21:27,080 --> 00:21:28,600
We're just going to put this disclaimer

505
00:21:28,600 --> 00:21:31,360
on all our calibrations that we can't get anything below it

506
00:21:31,360 --> 00:21:33,920
because we're not willing to do what it takes to get it.

507
00:21:33,920 --> 00:21:34,880
And we shouldn't, right?

508
00:21:34,880 --> 00:21:37,880
Anything 70 is already pretty bad, right?

509
00:21:37,880 --> 00:21:38,800
You need to get treated.

510
00:21:38,800 --> 00:21:41,560
There's no situation like, oh, 68 is OK,

511
00:21:41,560 --> 00:21:43,200
and 67 is not OK.

512
00:21:43,200 --> 00:21:44,520
That's not going to happen, right?

513
00:21:44,520 --> 00:21:45,920
That's fine.

514
00:21:45,920 --> 00:21:48,000
But it's important to understand why that is, right?

515
00:21:48,000 --> 00:21:51,120
And that's not really well understood how that happened.

516
00:21:51,120 --> 00:21:53,000
So that's part of the quiz.

517
00:21:53,000 --> 00:21:54,800
Second part of this quiz on the same plot

518
00:21:54,800 --> 00:21:56,720
is going to be this cardiac cycle.

519
00:21:56,720 --> 00:21:59,520
So this is the call the PPG, the photo plus mography.

520
00:21:59,520 --> 00:22:02,040
It's just a measure of the blood at the finger

521
00:22:02,040 --> 00:22:04,200
using the red light.

522
00:22:04,200 --> 00:22:05,440
But this one is not.

523
00:22:05,440 --> 00:22:07,960
What is the term for this signal right here?

524
00:22:07,960 --> 00:22:09,160
And I also covered it earlier.

525
00:22:09,160 --> 00:22:10,720
I want to see what you say now.

526
00:22:10,720 --> 00:22:11,160
I don't know.

527
00:22:11,160 --> 00:22:12,080
Keeping you awake.

528
00:22:12,080 --> 00:22:13,440
I know your pulse.

529
00:22:13,440 --> 00:22:15,320
Does that what I have to do with that?

530
00:22:15,320 --> 00:22:16,400
Cardiac cycle.

531
00:22:16,400 --> 00:22:19,080
If you saw this plot, you know, you see this thing going on.

532
00:22:19,080 --> 00:22:19,880
That's I'm looking at.

533
00:22:19,880 --> 00:22:22,360
I think that's your love, but your heartbeat.

534
00:22:22,360 --> 00:22:23,080
So it's your heartbeat.

535
00:22:23,080 --> 00:22:23,560
Yeah.

536
00:22:23,560 --> 00:22:26,560
Yeah, the love, love, love, love.

537
00:22:26,560 --> 00:22:31,840
OK, so a lot of people would call that the EKG.

538
00:22:31,840 --> 00:22:32,760
OK.

539
00:22:32,760 --> 00:22:33,400
Would you agree?

540
00:22:33,400 --> 00:22:34,200
Right?

541
00:22:34,200 --> 00:22:35,240
Yes.

542
00:22:35,240 --> 00:22:36,560
OK, so EKG.

543
00:22:36,560 --> 00:22:39,040
What do you think that stands for?

544
00:22:39,040 --> 00:22:41,560
I go cardiogram.

545
00:22:41,560 --> 00:22:46,680
OK, so if it was a cardiogram, how do you spell that?

546
00:22:46,680 --> 00:22:49,800
So the story goes like this, right?

547
00:22:49,800 --> 00:22:53,080
You know, people stay out loud EKG.

548
00:22:53,080 --> 00:22:57,120
You have to spell it, they're going to say C-A-R-D-I-O, right?

549
00:22:57,120 --> 00:23:01,960
Because cardiac, cardiac, it's electrocardiography, right?

550
00:23:01,960 --> 00:23:02,960
EKG.

551
00:23:02,960 --> 00:23:06,160
Now, it's spelled with the C, but we pronounce it with the K.

552
00:23:06,160 --> 00:23:08,720
The reason why is that we're not using the English abbreviation.

553
00:23:08,720 --> 00:23:13,520
We're using the German abbreviation of electrocardiogram.

554
00:23:13,520 --> 00:23:15,760
So we always pronounce EKG.

555
00:23:15,760 --> 00:23:17,960
We write down ECG.

556
00:23:17,960 --> 00:23:21,040
And the reason why is because it sounds too similar

557
00:23:21,040 --> 00:23:23,080
to the other one called EEG.

558
00:23:23,080 --> 00:23:26,640
If I say, Rebecca, I really need an ECG right now.

559
00:23:26,640 --> 00:23:27,760
Can you start one up?

560
00:23:27,760 --> 00:23:30,760
You're going to go out and do an EEG because you misinterpreted me.

561
00:23:30,760 --> 00:23:32,760
And EEGs are just so much more fun to do.

562
00:23:32,760 --> 00:23:34,640
Now, I'm like, why didn't you do an ECG?

563
00:23:34,640 --> 00:23:36,600
Oh, you should have said EKG.

564
00:23:36,600 --> 00:23:40,040
And that's why we always say out loud EKG.

565
00:23:40,040 --> 00:23:43,160
But write down ECG because we are still speaking English.

566
00:23:43,160 --> 00:23:44,360
So now you know.

567
00:23:44,360 --> 00:23:45,360
Now I know.

568
00:23:45,360 --> 00:23:47,040
That's interesting.

569
00:23:47,040 --> 00:23:52,080
So from those signals, like from the pulse and the EKG

570
00:23:52,080 --> 00:23:55,440
and from the brain activity, we can tell whether or not

571
00:23:55,440 --> 00:23:59,520
you are in one of two states called the parasympathetic, which

572
00:23:59,520 --> 00:24:03,120
is like the relaxing, the rest and digest,

573
00:24:03,120 --> 00:24:07,440
or the sympathetic, which is your fight or flight.

574
00:24:07,440 --> 00:24:11,600
You definitely want more of this and less of this.

575
00:24:11,600 --> 00:24:13,200
That's kind of the whole point.

576
00:24:13,200 --> 00:24:15,520
The reason why we have all of these discussions

577
00:24:15,520 --> 00:24:18,960
on how airway is related to mental health

578
00:24:18,960 --> 00:24:23,520
is because we have too much sympathetic nervous activity.

579
00:24:23,520 --> 00:24:26,760
There's something waking you up and that is likely the sleep apnea.

580
00:24:26,760 --> 00:24:30,520
And we're going to see what that looks like now on an actual PSG.

581
00:24:30,520 --> 00:24:33,360
So this is what's called effective sleep.

582
00:24:33,360 --> 00:24:35,360
And the most important sensor we're going to focus

583
00:24:35,360 --> 00:24:37,160
on is going to be the SAO2.

584
00:24:37,160 --> 00:24:39,400
You see how stable that is, right?

585
00:24:39,400 --> 00:24:41,640
This is 97 all the way across.

586
00:24:41,640 --> 00:24:43,760
The brain waves are really stable.

587
00:24:43,760 --> 00:24:45,960
The chin is quiet and still.

588
00:24:45,960 --> 00:24:50,360
And most importantly, the breathing is even.

589
00:24:50,360 --> 00:24:51,720
Now, this is with therapy.

590
00:24:51,720 --> 00:24:53,840
This is the same patient before therapy.

591
00:24:53,840 --> 00:24:57,280
What is the, that looks like, I know it's not thoracic,

592
00:24:57,280 --> 00:24:58,920
but what is the one that looks like thoracic?

593
00:24:58,920 --> 00:25:00,320
Where is that?

594
00:25:00,320 --> 00:25:00,960
Where is that?

595
00:25:00,960 --> 00:25:02,080
So let's talk about this, right?

596
00:25:02,080 --> 00:25:09,160
So we have FC and O. That's frontal, central, and occipital EEG.

597
00:25:09,160 --> 00:25:11,440
So it's frontal, central occipital, right?

598
00:25:11,440 --> 00:25:13,440
This is how you can tell what stages you're in.

599
00:25:13,440 --> 00:25:15,040
I wanted to.

600
00:25:15,040 --> 00:25:15,280
Yep.

601
00:25:15,280 --> 00:25:17,040
You have left eye and right eye.

602
00:25:17,040 --> 00:25:18,360
You have the chin.

603
00:25:18,360 --> 00:25:20,560
You have the left and right leg.

604
00:25:20,560 --> 00:25:23,160
We saw that in the previous slide.

605
00:25:23,160 --> 00:25:26,880
Then you have PTAF, it's pressure transducer air flow.

606
00:25:26,880 --> 00:25:28,520
This is a therapeutic study.

607
00:25:28,520 --> 00:25:31,280
So CPAP is continuous pause or area pressure.

608
00:25:31,280 --> 00:25:33,360
Thoracic is that belt we saw.

609
00:25:33,360 --> 00:25:34,920
And abdominal is the other belt.

610
00:25:34,920 --> 00:25:35,800
So you have two belts.

611
00:25:35,800 --> 00:25:38,160
And the two belts you can, right, with the two belts,

612
00:25:38,160 --> 00:25:39,960
you can tell if the patient's paradoxing

613
00:25:39,960 --> 00:25:41,480
or if having central apneas.

614
00:25:41,480 --> 00:25:42,960
And then EKG, we just covered it.

615
00:25:42,960 --> 00:25:45,760
And then SAO2 is the oxygen saturation

616
00:25:45,760 --> 00:25:47,360
as a percentage of over 100.

617
00:25:47,360 --> 00:25:50,200
And then pulse is going to be, is not on this plot.

618
00:25:50,200 --> 00:25:53,520
And then we have, I think, TCO2, like the carbon dioxide level.

619
00:25:53,520 --> 00:25:54,320
OK.

620
00:25:54,320 --> 00:25:54,760
Got it.

621
00:25:54,760 --> 00:25:58,400
Now, in this example, this was the same patient just

622
00:25:58,400 --> 00:26:02,120
earlier in the night where they were effectively treated.

623
00:26:02,120 --> 00:26:05,160
This is a five minute record, and there's seven apneas.

624
00:26:05,160 --> 00:26:08,400
So that's more than 60 events an hour.

625
00:26:08,400 --> 00:26:13,080
So there's maybe 30 to 40 seconds of them trying to breathe.

626
00:26:13,080 --> 00:26:14,400
Oxen levels drop.

627
00:26:14,400 --> 00:26:18,240
In this case, dropping down to 74%.

628
00:26:18,240 --> 00:26:20,240
Pretty much near that cutoff of where you can't even

629
00:26:20,240 --> 00:26:21,680
report accurately.

630
00:26:21,680 --> 00:26:23,320
Then they wake up to breathe.

631
00:26:23,320 --> 00:26:24,600
And then when they wake up to breathe,

632
00:26:24,600 --> 00:26:27,640
their airway opens up, their heart rate rapidly increases.

633
00:26:27,640 --> 00:26:32,400
They fall back asleep, and it happens again and again and again.

634
00:26:32,400 --> 00:26:35,000
Now, are they grinding their teeth?

635
00:26:35,000 --> 00:26:35,920
Is that what's on the chin?

636
00:26:35,920 --> 00:26:37,600
Or is that the moving to wake up?

637
00:26:37,600 --> 00:26:38,240
What is that little?

638
00:26:38,240 --> 00:26:39,160
That's both.

639
00:26:39,160 --> 00:26:40,640
So that could be bruxism.

640
00:26:40,640 --> 00:26:42,840
Sometimes in response to the abstract airway

641
00:26:42,840 --> 00:26:44,960
and the desaturation, the patient will grind their teeth

642
00:26:44,960 --> 00:26:46,960
forward to get their airway open.

643
00:26:46,960 --> 00:26:48,880
It could just be part of the arousal response

644
00:26:48,880 --> 00:26:52,640
where they're waking up, and they have a chin burst as well.

645
00:26:52,640 --> 00:26:54,240
This one likely is a combination of both,

646
00:26:54,240 --> 00:26:56,320
because you also see it in the frontal electrodes.

647
00:26:56,320 --> 00:26:57,760
You see that muscle artifact.

648
00:26:57,760 --> 00:27:00,920
You see the muscle activity in the EEG leads.

649
00:27:00,920 --> 00:27:03,520
But there's two things that are important.

650
00:27:03,520 --> 00:27:04,720
It's like the frequency.

651
00:27:04,720 --> 00:27:06,520
This is happening every minute.

652
00:27:06,520 --> 00:27:07,720
The patient is asleep.

653
00:27:07,720 --> 00:27:09,680
And the magnitude.

654
00:27:09,680 --> 00:27:12,160
These are very long events.

655
00:27:12,160 --> 00:27:13,960
These are like 30-second long events,

656
00:27:13,960 --> 00:27:17,880
and they're calling the oxygen to go from 89 to 74.

657
00:27:17,880 --> 00:27:19,480
So that's the true dramatic reduction.

658
00:27:19,480 --> 00:27:20,440
Are those red lines 60 seconds?

659
00:27:20,440 --> 00:27:24,000
Every time you see one of those red lines, is that a minute?

660
00:27:24,000 --> 00:27:25,440
Is that 60 seconds?

661
00:27:25,440 --> 00:27:27,520
It should be 30 seconds.

662
00:27:27,520 --> 00:27:28,800
So that's one minute.

663
00:27:28,800 --> 00:27:30,320
Two minutes, three minutes.

664
00:27:30,320 --> 00:27:32,200
Wow.

665
00:27:32,200 --> 00:27:34,480
So in sleep medicine, everything

666
00:27:34,480 --> 00:27:35,800
is broken apart into epics.

667
00:27:35,800 --> 00:27:38,960
And these epics are in 30-second segments.

668
00:27:38,960 --> 00:27:41,600
So we could say this is sleep, and this is awake.

669
00:27:41,600 --> 00:27:42,120
This is sleep.

670
00:27:42,120 --> 00:27:43,040
This is awake.

671
00:27:43,040 --> 00:27:46,000
So you measure it in 30 seconds based on that 30-second epic.

672
00:27:46,000 --> 00:27:49,240
We'll actually look at a live example pretty soon.

673
00:27:49,240 --> 00:27:51,000
Now, in this example, you can't really

674
00:27:51,000 --> 00:27:52,960
see the detail of the EKG.

675
00:27:52,960 --> 00:27:54,520
So I got another example here.

676
00:27:54,520 --> 00:27:59,520
In this example, not only did the patient stop breathing,

677
00:27:59,520 --> 00:28:01,840
they also stopped attempting to breathe.

678
00:28:01,840 --> 00:28:03,480
So there's no effort in the chest.

679
00:28:03,480 --> 00:28:10,520
At the same time, their heart literally stopped beating.

680
00:28:10,520 --> 00:28:14,560
So is that common for that to happen?

681
00:28:14,560 --> 00:28:17,800
I mean, this is why I say your apnea is breaking my heart,

682
00:28:17,800 --> 00:28:21,120
because this can happen.

683
00:28:21,120 --> 00:28:24,200
If left untreated, it can lead to arrhythmias.

684
00:28:24,200 --> 00:28:26,800
It can lead to what this is, like a sinus pause or assistory,

685
00:28:26,800 --> 00:28:28,280
depending on your definition.

686
00:28:28,280 --> 00:28:30,920
You also see it in the pulse channel.

687
00:28:30,920 --> 00:28:32,440
The pulse is literally gone.

688
00:28:32,440 --> 00:28:35,360
Like you are dead.

689
00:28:35,360 --> 00:28:37,240
This apnea has killed you, right?

690
00:28:37,240 --> 00:28:39,240
And then you come back to life, hopefully, right?

691
00:28:39,240 --> 00:28:40,840
And that doesn't always happen.

692
00:28:40,840 --> 00:28:44,680
A lot of times, this patient, luckily restored,

693
00:28:44,680 --> 00:28:47,200
took a breath and came back to life pulse response.

694
00:28:47,200 --> 00:28:48,720
That doesn't always happen.

695
00:28:48,720 --> 00:28:51,280
It's important to note that with the right amount of medication

696
00:28:51,280 --> 00:28:53,280
or alcohol or some kind of combination,

697
00:28:53,280 --> 00:28:56,120
this arousal response doesn't happen quick enough.

698
00:28:56,120 --> 00:28:59,400
And your apnea, which you normally wake up from,

699
00:28:59,400 --> 00:29:00,080
you may not.

700
00:29:00,080 --> 00:29:01,480
And that's called a terminal apnea.

701
00:29:01,480 --> 00:29:04,440
This thing is potentially lethal.

702
00:29:04,440 --> 00:29:07,720
Like you can easily die from this in the wrong conditions.

703
00:29:07,720 --> 00:29:12,920
And patients who have just the wrong situation may not wake up.

704
00:29:12,920 --> 00:29:14,680
So luckily, this patient did.

705
00:29:14,680 --> 00:29:17,000
They're fine over here, but they're definitely not fine over here.

706
00:29:17,000 --> 00:29:17,360
So that's good.

707
00:29:17,360 --> 00:29:18,880
It's so logical, right?

708
00:29:18,880 --> 00:29:21,920
It's so logical, because we all learned it in biology.

709
00:29:21,920 --> 00:29:25,800
But to actually see it, I mean, it's not

710
00:29:25,800 --> 00:29:26,680
to be overly dramatic.

711
00:29:26,680 --> 00:29:28,440
That's kind of terrifying.

712
00:29:28,440 --> 00:29:30,640
And then to think that little kids are doing this.

713
00:29:30,640 --> 00:29:32,440
That's terrifying.

714
00:29:32,440 --> 00:29:32,800
It is.

715
00:29:32,800 --> 00:29:34,800
I mean, this is most of my examples

716
00:29:34,800 --> 00:29:36,000
are going to be adult patients.

717
00:29:36,000 --> 00:29:39,240
But everything that I show here, I'm sure James Cardell

718
00:29:39,240 --> 00:29:41,240
or other friends of pediatric labs

719
00:29:41,240 --> 00:29:44,160
can give you examples or even scarier examples of this.

720
00:29:44,160 --> 00:29:46,760
Because the pediatrics, their arousal response

721
00:29:46,760 --> 00:29:48,120
isn't as strong as this.

722
00:29:48,120 --> 00:29:49,600
They might even have worse apnea.

723
00:29:49,600 --> 00:29:51,960
So I'll let them have the glory for that one.

724
00:29:51,960 --> 00:29:53,880
But it is important to note, like this is,

725
00:29:53,880 --> 00:29:54,960
it could get worse, right?

726
00:29:54,960 --> 00:29:56,800
In this example, at least the patient is trying to breathe.

727
00:29:56,800 --> 00:29:58,640
You see the thoracic abdominal effort.

728
00:29:58,640 --> 00:30:00,040
They're trying really hard to breathe.

729
00:30:00,040 --> 00:30:02,160
And this is just an obstructed airway.

730
00:30:02,160 --> 00:30:04,280
In this case, this is called a central apnea,

731
00:30:04,280 --> 00:30:06,160
where their effort is not even there.

732
00:30:06,160 --> 00:30:08,000
And they're not even beating their hearts.

733
00:30:08,000 --> 00:30:10,720
So it can get to be this bad.

734
00:30:10,720 --> 00:30:12,560
Probably the worst example of the evening.

735
00:30:12,560 --> 00:30:13,400
And why?

736
00:30:13,400 --> 00:30:17,720
I mean, I'm going to put it in very lame in terms.

737
00:30:17,720 --> 00:30:22,360
But why isn't their brain trying to wake them up at this point?

738
00:30:22,360 --> 00:30:23,880
Why is it just, it's tired?

739
00:30:23,880 --> 00:30:24,800
We do this every night.

740
00:30:24,800 --> 00:30:25,440
I'm tired.

741
00:30:25,440 --> 00:30:26,920
Or does it not pick it up?

742
00:30:26,920 --> 00:30:28,120
Or?

743
00:30:28,120 --> 00:30:28,480
OK.

744
00:30:28,480 --> 00:30:29,560
So that's a good question, right?

745
00:30:29,560 --> 00:30:31,600
So what happens is, like, the drive to breathe

746
00:30:31,600 --> 00:30:33,600
is based on the amount of carbon dioxide.

747
00:30:33,600 --> 00:30:35,440
Your carbon dioxide builds up, builds up, builds up,

748
00:30:35,440 --> 00:30:37,360
and then you have a desire to breathe.

749
00:30:37,360 --> 00:30:39,480
Now, the reason why this person is not breathing

750
00:30:39,480 --> 00:30:41,960
is related to the same thing we're seeing as heart not beating.

751
00:30:41,960 --> 00:30:44,920
It's because of a cardiac dysfunction.

752
00:30:44,920 --> 00:30:47,960
Because for the sensor, it's called a chemoreceptor,

753
00:30:47,960 --> 00:30:49,960
that drives the breathing.

754
00:30:49,960 --> 00:30:52,640
It has, it depends on the right amount of blood flow.

755
00:30:52,640 --> 00:30:54,800
So if the heart doesn't pump correctly,

756
00:30:54,800 --> 00:30:56,440
that sensor doesn't know, hey, I should

757
00:30:56,440 --> 00:30:57,720
trigger the next breath.

758
00:30:57,720 --> 00:30:58,560
It thinks everything's fine.

759
00:30:58,560 --> 00:31:01,800
It thinks the level of the oxygen carbon dioxide is, like, OK.

760
00:31:01,800 --> 00:31:04,520
And then because the cardiac function is so impaired,

761
00:31:04,520 --> 00:31:06,200
it gets that signal kind of late.

762
00:31:06,200 --> 00:31:09,240
And it's like, oh, man, yeah, we've got a problem.

763
00:31:09,240 --> 00:31:10,520
I need to just think about it.

764
00:31:10,520 --> 00:31:12,000
And then they start breathing again.

765
00:31:12,000 --> 00:31:14,080
So normally, that doesn't take so long.

766
00:31:14,080 --> 00:31:16,360
But in these patients who have their sleep apnea

767
00:31:16,360 --> 00:31:18,280
left untreated for a long period of time,

768
00:31:18,280 --> 00:31:20,480
it gets to be this point where it's like,

769
00:31:20,480 --> 00:31:22,560
every night they start with this obstructive apnea.

770
00:31:22,560 --> 00:31:23,800
It turns into central apnea.

771
00:31:23,800 --> 00:31:24,760
It turns into mixed apnea.

772
00:31:24,760 --> 00:31:26,120
It turns into assistalese.

773
00:31:26,120 --> 00:31:27,440
And then if that's untreated, they

774
00:31:27,440 --> 00:31:29,200
won't even last another couple of years.

775
00:31:29,200 --> 00:31:32,720
So it's important to note, it starts like this,

776
00:31:32,720 --> 00:31:34,400
ends like this.

777
00:31:34,400 --> 00:31:35,640
There is no mild apnea.

778
00:31:35,640 --> 00:31:37,120
It's just not severe yet.

779
00:31:37,120 --> 00:31:58,600
It will get to this point if that's untreated.

780
00:32:07,120 --> 00:32:17,280
You can find out more about the Children's Airway First

781
00:32:17,280 --> 00:32:20,160
Foundation and our mission to fix before six

782
00:32:20,160 --> 00:32:24,720
on our website at childrensairwayfirst.org.

783
00:32:24,720 --> 00:32:27,240
The CAF website offers tons of great resources

784
00:32:27,240 --> 00:32:30,600
for both parents and medical professionals.

785
00:32:30,600 --> 00:32:33,640
Visit our parents' portal, clinicians' corner, resource

786
00:32:33,640 --> 00:32:37,400
center, and video library to see for yourself.

787
00:32:37,400 --> 00:32:40,560
We also encourage parents to join the Airway Huddle, our Facebook

788
00:32:40,560 --> 00:32:43,680
support group, which was created for parents of children

789
00:32:43,680 --> 00:32:46,920
with airway and sleep-related issues.

790
00:32:46,920 --> 00:32:48,920
You can access the Airway Huddle support group

791
00:32:48,920 --> 00:32:54,520
at facebook.com backslashgroups backslashairwayhuddle.

792
00:32:54,520 --> 00:32:57,800
As a reminder, this podcast and the opinions expressed here

793
00:32:57,800 --> 00:32:59,800
are not a medical diagnosis.

794
00:32:59,800 --> 00:33:02,360
If you suspect your child might have an airway issue,

795
00:33:02,360 --> 00:33:07,040
contact your pediatric airway dentist or pediatrician.

796
00:33:07,040 --> 00:33:36,840
And now, let's jump back into today's episode.

797
00:33:36,840 --> 00:33:39,560
So let's look at the same example, a little bit more

798
00:33:39,560 --> 00:33:40,840
cartoonish.

799
00:33:40,840 --> 00:33:43,640
So we have here the same signals I've been looking up before.

800
00:33:43,640 --> 00:33:45,360
This is like the brain wave.

801
00:33:45,360 --> 00:33:47,600
This is the EMG from the chin.

802
00:33:47,600 --> 00:33:50,000
This is your nasal airflow measured at the nose.

803
00:33:50,000 --> 00:33:51,640
And this is the effort.

804
00:33:51,640 --> 00:33:53,200
So just a single event.

805
00:33:53,200 --> 00:33:56,400
So the patient's breathing in, breathing in, breathing in,

806
00:33:56,400 --> 00:33:58,640
and then their airway collapses.

807
00:33:58,640 --> 00:34:00,600
And we have a lot of episodes about airway.

808
00:34:00,600 --> 00:34:03,040
So we'll focus on what the end result is.

809
00:34:03,040 --> 00:34:05,520
It's the airway is collapsed, and the patient

810
00:34:05,520 --> 00:34:07,280
is still trying to breathe.

811
00:34:07,280 --> 00:34:11,240
But now, this effort is not pushing out air.

812
00:34:11,240 --> 00:34:13,240
It's pushing out the stomach.

813
00:34:13,240 --> 00:34:14,800
So we can see that with two belts.

814
00:34:14,800 --> 00:34:17,320
And that's called a paradoxical abdominal movement

815
00:34:17,320 --> 00:34:18,440
with apnea.

816
00:34:18,440 --> 00:34:22,400
Now, this is bad.

817
00:34:22,400 --> 00:34:26,080
We're going to see how bad this is, mainly because

818
00:34:26,080 --> 00:34:28,600
of the pressures forcing internally.

819
00:34:28,600 --> 00:34:30,880
All that negative pressure that's not generating air flow

820
00:34:30,880 --> 00:34:32,760
is going to be applied to the internal organs

821
00:34:32,760 --> 00:34:34,440
and cause all kinds of damage.

822
00:34:34,440 --> 00:34:36,480
Now, during this time, the occipital lobes are dropping

823
00:34:36,480 --> 00:34:37,920
and dropping and dropping and dropping

824
00:34:37,920 --> 00:34:40,160
until it gets to the point here.

825
00:34:40,160 --> 00:34:42,520
At this point, it triggers the arousal response.

826
00:34:42,520 --> 00:34:45,040
Like somebody says, hey, something is off.

827
00:34:45,040 --> 00:34:46,640
Sound the alarms.

828
00:34:46,640 --> 00:34:49,360
The patient wakes up.

829
00:34:49,360 --> 00:34:51,720
You see that massive increase in the chin activity.

830
00:34:51,720 --> 00:34:53,160
They take a hypernormal breath.

831
00:34:53,160 --> 00:34:55,080
They take a massive breath.

832
00:34:55,080 --> 00:34:57,520
And then their heart rate increases.

833
00:34:57,520 --> 00:34:58,640
Occinol lobes are stores.

834
00:34:58,640 --> 00:34:59,640
And then we saw what happens.

835
00:34:59,640 --> 00:35:01,080
It happens again and again and again.

836
00:35:01,080 --> 00:35:02,600
So this is the.

837
00:35:02,600 --> 00:35:05,640
Back on the one we were looking at, I just, again,

838
00:35:05,640 --> 00:35:07,800
you know, trying to help all of us that don't look at these

839
00:35:07,800 --> 00:35:09,640
and really understand them.

840
00:35:09,640 --> 00:35:10,640
Yes.

841
00:35:10,640 --> 00:35:13,840
When they start moving and they take a deep breath,

842
00:35:13,840 --> 00:35:15,840
is that that sound?

843
00:35:15,840 --> 00:35:16,640
Yes.

844
00:35:16,640 --> 00:35:17,640
Yes, that's exactly it.

845
00:35:17,640 --> 00:35:19,360
You can visualize this.

846
00:35:19,360 --> 00:35:22,720
Like these straight up obstructive apneas,

847
00:35:22,720 --> 00:35:24,760
you don't even need a home study.

848
00:35:24,760 --> 00:35:26,000
You can just look at somebody.

849
00:35:26,000 --> 00:35:27,360
That person, is that person breathing?

850
00:35:27,360 --> 00:35:29,000
No, it's obvious, right?

851
00:35:30,040 --> 00:35:32,400
So like when we talk about the type one, two, three, four,

852
00:35:32,400 --> 00:35:35,800
like you can just tell apnea from just looking at somebody.

853
00:35:35,800 --> 00:35:39,120
The difficulty is the other side, the hypopneas.

854
00:35:39,120 --> 00:35:41,120
Like even the home studies may not pick them up.

855
00:35:41,120 --> 00:35:42,400
You might need in-lab studies for those

856
00:35:42,400 --> 00:35:44,880
because it's the arousal, or it's the 3%,

857
00:35:44,880 --> 00:35:45,920
and they may not be picked up

858
00:35:45,920 --> 00:35:47,800
unless you have like those sensors applied.

859
00:35:47,800 --> 00:35:49,200
But for the case we're talking about today,

860
00:35:49,200 --> 00:35:51,120
which is full blown obstructive sleep apnea,

861
00:35:51,120 --> 00:35:52,800
it's pretty obvious.

862
00:35:52,800 --> 00:35:54,920
And what you described is this period here.

863
00:35:54,920 --> 00:35:57,200
The patient wakes up, you see them gasp,

864
00:35:57,200 --> 00:35:59,040
you see them snore, you see them move,

865
00:35:59,040 --> 00:36:00,720
and you see them do this again and again and again,

866
00:36:00,720 --> 00:36:01,720
all night long.

867
00:36:01,720 --> 00:36:04,120
And this is what's happening, right?

868
00:36:04,120 --> 00:36:08,080
They fall asleep and they have this decreased muscle activity.

869
00:36:08,080 --> 00:36:09,320
They start to relax.

870
00:36:09,320 --> 00:36:12,800
When they relax, their airway collapses.

871
00:36:12,800 --> 00:36:14,600
And then that develops into apnea,

872
00:36:14,600 --> 00:36:16,200
a pause and breathe that was up before.

873
00:36:16,200 --> 00:36:18,560
That results in hypoxia,

874
00:36:18,560 --> 00:36:21,320
hypopoxia like the lower oxygen and hypercapnia,

875
00:36:21,320 --> 00:36:22,800
increase in carbon dioxide.

876
00:36:22,800 --> 00:36:26,360
This is what triggers that increased ventilator effort,

877
00:36:26,360 --> 00:36:27,920
that arousal response.

878
00:36:27,920 --> 00:36:30,640
So they increase the effort that wakes you up,

879
00:36:30,640 --> 00:36:34,040
and now that awakening is there to increase that muscle activity.

880
00:36:34,040 --> 00:36:35,920
So it's the opposite of here.

881
00:36:35,920 --> 00:36:38,640
And then once the airway is open, great.

882
00:36:38,640 --> 00:36:41,000
Hypoxia is done, hypercapnia is done,

883
00:36:41,000 --> 00:36:43,000
you're back to normal, so you fall asleep.

884
00:36:43,000 --> 00:36:44,320
And what happens when you fall asleep?

885
00:36:44,320 --> 00:36:46,560
Your muscle activity drops again.

886
00:36:47,440 --> 00:36:48,280
Right?

887
00:36:48,280 --> 00:36:49,120
And this happens you-

888
00:36:49,120 --> 00:36:49,960
And this blockage could be,

889
00:36:49,960 --> 00:36:54,560
your tonsils falling back or your tongue is falling back

890
00:36:54,560 --> 00:36:57,040
or there's something that's blocking the airway,

891
00:36:57,040 --> 00:36:58,960
there's something that's avoiding it.

892
00:36:58,960 --> 00:36:59,800
Yes, exactly.

893
00:36:59,800 --> 00:37:01,440
There's something that's obstructing the airway.

894
00:37:01,440 --> 00:37:02,720
This is obstructive sleep apnea.

895
00:37:02,720 --> 00:37:04,920
Now our job as a nighttime technician is to,

896
00:37:04,920 --> 00:37:06,080
we don't care what's obstructing it, right?

897
00:37:06,080 --> 00:37:09,080
It could be tonsils, we add noise, it could be uvulas.

898
00:37:09,080 --> 00:37:10,040
We don't care, right?

899
00:37:10,040 --> 00:37:12,840
All we do is we report how often

900
00:37:12,840 --> 00:37:14,680
and how bad does this happen?

901
00:37:14,680 --> 00:37:17,120
We report what's called the AHI,

902
00:37:17,120 --> 00:37:19,320
the apnea, hypopnea index,

903
00:37:19,320 --> 00:37:23,040
which is how many times we run into the circle per hour.

904
00:37:23,040 --> 00:37:24,080
So this is one event.

905
00:37:24,080 --> 00:37:25,920
If I have five of these events an hour,

906
00:37:25,920 --> 00:37:27,280
you have an AHI of five.

907
00:37:27,280 --> 00:37:29,120
And that's diagnostic for an adult.

908
00:37:29,120 --> 00:37:31,840
If I have one of these events per hour

909
00:37:31,840 --> 00:37:33,840
and you're considered pediatric,

910
00:37:33,840 --> 00:37:35,520
you're diagnosed with apnea.

911
00:37:35,520 --> 00:37:39,160
So just one per hour is all you need for a diagnosis.

912
00:37:39,160 --> 00:37:42,600
And that's a 10 second event

913
00:37:42,600 --> 00:37:45,240
with at least a three or 4% desaturation.

914
00:37:46,120 --> 00:37:48,160
And then you get a diagnosis of apnea

915
00:37:48,160 --> 00:37:50,120
with recommendation for treatment.

916
00:37:50,120 --> 00:37:53,240
So this is the pattern we see very often.

917
00:37:53,240 --> 00:37:58,120
Now, what I mentioned before was this pressure applied

918
00:37:58,120 --> 00:37:59,120
to the heart.

919
00:37:59,840 --> 00:38:02,520
That's what is really literally breaking your heart.

920
00:38:02,520 --> 00:38:04,760
That you see like this hyperplasia,

921
00:38:04,760 --> 00:38:07,360
you see this right heart dysfunction,

922
00:38:07,360 --> 00:38:08,320
pulmonary hypertension,

923
00:38:08,320 --> 00:38:11,440
it's literally causing a bunch of damage to your heart.

924
00:38:11,440 --> 00:38:14,480
And the other thing that's important to measure as well

925
00:38:14,480 --> 00:38:17,640
is that this movement, you could see it, right?

926
00:38:17,640 --> 00:38:19,440
They're trying, trying to hard to breathe.

927
00:38:19,440 --> 00:38:21,600
They also stretch the heart.

928
00:38:22,600 --> 00:38:26,080
Like the pressure is actually pulling and pushing,

929
00:38:26,080 --> 00:38:27,840
stretching and squeezing the heart to the point

930
00:38:27,840 --> 00:38:30,160
where actually literally over time it fails.

931
00:38:30,160 --> 00:38:33,240
At the same time, it's releasing this peptide called A&P,

932
00:38:33,240 --> 00:38:36,200
which then causes nitam urination,

933
00:38:36,200 --> 00:38:39,800
as well as as pressure is being applied to the bladder.

934
00:38:39,800 --> 00:38:42,000
So excessive stress on the bladder

935
00:38:42,000 --> 00:38:43,280
also causing it to wake up to peace.

936
00:38:43,280 --> 00:38:44,600
A lot of people are waking up saying,

937
00:38:44,600 --> 00:38:47,000
I have to go to like the urologist or something

938
00:38:47,000 --> 00:38:48,040
and get my bladder checked.

939
00:38:48,040 --> 00:38:51,440
It's not the bladder, it's the airway.

940
00:38:51,440 --> 00:38:53,880
You fix the airway that you won't have to wake up to pee.

941
00:38:53,880 --> 00:38:55,000
The reason why are you waking up?

942
00:38:55,000 --> 00:38:57,720
It's because of this constant pressure building up

943
00:38:57,720 --> 00:38:58,560
internally.

944
00:38:58,560 --> 00:39:02,600
Now this pressure, we see that applied to these

945
00:39:02,600 --> 00:39:04,720
internal organs is also applied to the stomach.

946
00:39:04,720 --> 00:39:07,120
That's also the responsible for acid reflux.

947
00:39:07,120 --> 00:39:08,240
I wake up with acid reflux.

948
00:39:08,240 --> 00:39:09,960
Now I need like some kind of antacid

949
00:39:09,960 --> 00:39:11,320
and I also need this bladder control.

950
00:39:11,320 --> 00:39:14,960
And all these things is just religious airway.

951
00:39:14,960 --> 00:39:17,880
Get your airway fixed, you'll be all right.

952
00:39:17,880 --> 00:39:19,840
So just imagine how much pressure you're applying

953
00:39:19,840 --> 00:39:22,320
and how many times you're just beating yourself up.

954
00:39:22,320 --> 00:39:27,080
So this is a zoomed up view of the oxygen saturation plot.

955
00:39:27,080 --> 00:39:28,960
And then you can see like when the oxygen is stabilized,

956
00:39:28,960 --> 00:39:31,520
the blood pressure reduces.

957
00:39:31,520 --> 00:39:34,920
Also interesting to note is like when there's a spike,

958
00:39:34,920 --> 00:39:37,240
it's related to the position.

959
00:39:37,240 --> 00:39:38,640
You see like how the position changed.

960
00:39:38,640 --> 00:39:42,000
So a lot of times what we observe is that it's the supine

961
00:39:42,000 --> 00:39:43,320
position that makes everything worse.

962
00:39:43,320 --> 00:39:46,280
So in addition to like everything mentioned like CPAP,

963
00:39:46,280 --> 00:39:49,200
oral appliance and orthodontics, all these things,

964
00:39:49,200 --> 00:39:52,080
a very effective form of therapy is just stay after back.

965
00:39:53,240 --> 00:39:54,680
Here's another example of that, right?

966
00:39:54,680 --> 00:39:56,720
Where the patient was on the right side,

967
00:39:56,720 --> 00:39:58,200
things were pretty stable.

968
00:39:58,200 --> 00:39:59,960
They go to their back and then bam,

969
00:39:59,960 --> 00:40:02,760
you see like this very frequent

970
00:40:02,760 --> 00:40:06,200
and also very severe drop in oxygen.

971
00:40:06,200 --> 00:40:07,200
Until they wake up.

972
00:40:07,200 --> 00:40:08,040
Which makes sense though, right?

973
00:40:08,040 --> 00:40:09,360
Because it's falling back in here.

974
00:40:09,360 --> 00:40:11,000
Falling back, yeah.

975
00:40:11,000 --> 00:40:12,880
And as soon as they turn to their side,

976
00:40:12,880 --> 00:40:14,320
everything's fine, right?

977
00:40:14,320 --> 00:40:18,360
So if you do a study, make sure,

978
00:40:18,360 --> 00:40:20,800
make sure you have this plot on body position.

979
00:40:20,800 --> 00:40:22,120
Because that is what I've seen.

980
00:40:22,120 --> 00:40:23,600
You can see it here, it makes a massive difference.

981
00:40:23,600 --> 00:40:26,160
Like if you just stay on your side,

982
00:40:26,160 --> 00:40:27,200
you end up getting the same effect

983
00:40:27,200 --> 00:40:28,240
as your oral appliance, right?

984
00:40:28,240 --> 00:40:30,640
Because that's just pushing your jaw forward.

985
00:40:30,640 --> 00:40:31,920
You can do the same thing with gravity.

986
00:40:31,920 --> 00:40:33,680
So sometimes you don't need a complicated,

987
00:40:33,680 --> 00:40:34,760
you know, a bunch of effort.

988
00:40:34,760 --> 00:40:36,600
All you need to do is just get a pillow or something

989
00:40:36,600 --> 00:40:38,600
and or a ball on your shirt,

990
00:40:38,600 --> 00:40:41,200
just force yourself to sleep on a position that makes sense.

991
00:40:41,200 --> 00:40:43,440
But you won't know that unless you get a study

992
00:40:43,440 --> 00:40:45,000
that confirms that yeah,

993
00:40:45,000 --> 00:40:47,680
on a certain position you're doing fine.

994
00:40:47,680 --> 00:40:52,680
So I'm gonna show you a actual study, okay?

995
00:40:52,680 --> 00:40:55,800
So before those are cartoons, those were interesting.

996
00:40:55,800 --> 00:40:58,520
We're gonna look at this person here.

997
00:40:58,520 --> 00:41:00,960
I'm going to change of view.

998
00:41:00,960 --> 00:41:04,960
This is a real PSG that was reported recently in a real lab

999
00:41:04,960 --> 00:41:07,840
as a part by an actual technologist.

1000
00:41:07,840 --> 00:41:10,440
We'll take a second, get everything sorted out here.

1001
00:41:10,440 --> 00:41:12,920
And here we go.

1002
00:41:12,920 --> 00:41:15,840
All right, so we saw those examples

1003
00:41:15,840 --> 00:41:17,640
and we saw a few different kinds of events.

1004
00:41:17,640 --> 00:41:19,840
We'll see that this patient here is having

1005
00:41:19,840 --> 00:41:21,680
a pretty good experience.

1006
00:41:21,680 --> 00:41:24,920
They're having a pretty nice airway,

1007
00:41:24,920 --> 00:41:26,120
but they are having arousals.

1008
00:41:26,120 --> 00:41:27,560
These are called RERA,

1009
00:41:27,560 --> 00:41:29,600
or respiratory effort related arousal.

1010
00:41:29,600 --> 00:41:30,640
They're pretty long,

1011
00:41:30,640 --> 00:41:32,960
but they didn't really cause a significant drop

1012
00:41:32,960 --> 00:41:35,360
in oxygen saturation of 94, 92.

1013
00:41:35,360 --> 00:41:36,560
It counts, but not really.

1014
00:41:36,560 --> 00:41:39,840
This will count towards a different index called the RDI.

1015
00:41:39,840 --> 00:41:42,920
So I mentioned the AHI is the apnea hypop index.

1016
00:41:42,920 --> 00:41:44,920
If you include these events called RERAS,

1017
00:41:44,920 --> 00:41:46,080
it'll increase the RDI.

1018
00:41:46,080 --> 00:41:47,320
We'll see on the report.

1019
00:41:47,320 --> 00:41:48,160
So let's see what happens.

1020
00:41:48,160 --> 00:41:51,200
So just to add a case, if you're having these arousals,

1021
00:41:51,200 --> 00:41:52,920
but they're not waking up,

1022
00:41:52,920 --> 00:41:56,200
they're still impacting your sleep in the long term.

1023
00:41:56,200 --> 00:41:57,880
Yeah, they're milder events.

1024
00:41:57,880 --> 00:41:59,120
So it depends on the doctor

1025
00:41:59,120 --> 00:42:00,880
and whether or not they want to treat them.

1026
00:42:00,880 --> 00:42:04,360
But you'll see a small increase in the pulse.

1027
00:42:04,360 --> 00:42:06,480
You'll see a small increase in the heart rate.

1028
00:42:06,480 --> 00:42:07,640
You'll see a change in the EEG.

1029
00:42:07,640 --> 00:42:10,320
You kind of need the EEG there to measure these things.

1030
00:42:10,320 --> 00:42:11,320
That's why in in-lab studies,

1031
00:42:11,320 --> 00:42:13,640
the only one that's really capable of detecting these things,

1032
00:42:13,640 --> 00:42:15,000
you can't really see.

1033
00:42:15,000 --> 00:42:16,400
If you take away this channel,

1034
00:42:16,400 --> 00:42:20,160
you really won't be able to see it, right?

1035
00:42:21,600 --> 00:42:22,640
It looks fine,

1036
00:42:22,640 --> 00:42:24,800
because the oxygen level is fine, the air flow is fine.

1037
00:42:24,800 --> 00:42:28,160
It's only because you have an in-lab study,

1038
00:42:28,160 --> 00:42:30,400
you can even measure RERAS and RDI.

1039
00:42:30,400 --> 00:42:32,800
So that's important to remember.

1040
00:42:32,800 --> 00:42:33,960
But let's look at this patient,

1041
00:42:33,960 --> 00:42:35,840
like just a few minutes later, right?

1042
00:42:37,040 --> 00:42:39,040
That's an obstructive apnea.

1043
00:42:39,040 --> 00:42:42,360
That's 36 seconds long

1044
00:42:42,360 --> 00:42:45,560
and it's resulting in of not breathing.

1045
00:42:45,560 --> 00:42:49,320
Resulting in a desaturation of 10%.

1046
00:42:49,320 --> 00:42:51,920
So they're going from like 92 to 82

1047
00:42:51,920 --> 00:42:54,240
or 91 to 81 in this exact example.

1048
00:42:54,240 --> 00:42:59,240
So a 10% drop of obstructive apnea duration 36 seconds,

1049
00:42:59,920 --> 00:43:01,600
like a full epic.

1050
00:43:01,600 --> 00:43:02,720
And then what happens at the end,

1051
00:43:02,720 --> 00:43:03,640
they have this arousal.

1052
00:43:03,640 --> 00:43:07,200
You see a massive increase like we saw before in the chin.

1053
00:43:07,200 --> 00:43:09,120
We see it in the EEG.

1054
00:43:09,120 --> 00:43:10,960
Then we see it also in the pulse.

1055
00:43:10,960 --> 00:43:14,080
The pulse goes from 73 to 84.

1056
00:43:14,080 --> 00:43:16,760
So a 10 point, 11 point increase in the pulse

1057
00:43:16,760 --> 00:43:18,320
in a very short amount of time.

1058
00:43:18,320 --> 00:43:20,520
So that rapid increase, rapid increase,

1059
00:43:20,520 --> 00:43:23,080
rapid increase back to back to back, right?

1060
00:43:23,080 --> 00:43:24,800
That's what ends up causing you

1061
00:43:24,800 --> 00:43:27,600
to have constant low grade anxiety.

1062
00:43:27,600 --> 00:43:28,800
Because every time your heart rate increases,

1063
00:43:28,800 --> 00:43:30,720
that's the sympathetic nervous system.

1064
00:43:30,720 --> 00:43:33,840
That's me like sounding the alarm

1065
00:43:33,840 --> 00:43:35,200
from the police behind you.

1066
00:43:35,200 --> 00:43:36,720
That's like a tiger chasing you.

1067
00:43:36,720 --> 00:43:39,200
That's you fighting for your life.

1068
00:43:40,320 --> 00:43:42,400
The number of times we have the AHI.

1069
00:43:42,400 --> 00:43:43,960
So that's like 30 or 40 or 50.

1070
00:43:43,960 --> 00:43:46,920
That's 50 times an hour where you're like,

1071
00:43:46,920 --> 00:43:48,080
I have to stay alive.

1072
00:43:48,080 --> 00:43:48,920
I have to stay alive.

1073
00:43:48,920 --> 00:43:49,760
I have to stay alive.

1074
00:43:49,760 --> 00:43:51,440
And then when you wake up during the day, what happens?

1075
00:43:51,440 --> 00:43:53,480
Your blood pressure is constantly elevated

1076
00:43:53,480 --> 00:43:55,160
because you have this constant state of stress

1077
00:43:55,160 --> 00:43:57,200
and you have used up all your tolerance

1078
00:43:57,200 --> 00:43:58,280
for any kind of stress.

1079
00:43:58,280 --> 00:43:59,560
You already have been stressed out all night long.

1080
00:43:59,560 --> 00:44:01,680
So what happens is you see a red light,

1081
00:44:01,680 --> 00:44:03,800
you see some traffic, you see your child

1082
00:44:03,800 --> 00:44:05,640
or significant other make a small mistake.

1083
00:44:05,640 --> 00:44:07,240
You're very upset.

1084
00:44:07,240 --> 00:44:08,800
You're irritable, right?

1085
00:44:08,800 --> 00:44:09,640
You're irritable.

1086
00:44:09,640 --> 00:44:11,400
I just think about that in tiny people.

1087
00:44:11,400 --> 00:44:16,400
Man, they're just gonna be crazy during the day.

1088
00:44:16,840 --> 00:44:18,240
Of course they're gonna be anxious.

1089
00:44:18,240 --> 00:44:22,760
Of course they're gonna be like ADHD all over the place.

1090
00:44:22,760 --> 00:44:25,120
Right, so ADHD, hyperactivity.

1091
00:44:25,120 --> 00:44:27,760
If you think about why are these patients hyperactive?

1092
00:44:27,760 --> 00:44:30,000
And now this is the really important key part.

1093
00:44:30,000 --> 00:44:32,320
What happens to hyperactivity patients

1094
00:44:32,320 --> 00:44:34,960
is they're prescribed stimulants,

1095
00:44:34,960 --> 00:44:36,240
riddle in, out, or all these things.

1096
00:44:36,240 --> 00:44:37,320
Those are stimulus.

1097
00:44:37,320 --> 00:44:40,160
Why does a stimulant cause our patient

1098
00:44:40,160 --> 00:44:41,960
to become less hyperactive?

1099
00:44:41,960 --> 00:44:43,680
It's because of this condition

1100
00:44:43,680 --> 00:44:46,160
that they're constantly being woken up all night long,

1101
00:44:46,160 --> 00:44:47,400
that they're sleep deprived.

1102
00:44:47,400 --> 00:44:50,440
Anybody sleep deprived is gonna have to stimulate themselves

1103
00:44:50,440 --> 00:44:51,760
just to stay awake.

1104
00:44:51,760 --> 00:44:52,920
And that's what these children are doing.

1105
00:44:52,920 --> 00:44:55,520
They're not hyperactive, they're sleepy.

1106
00:44:55,520 --> 00:44:58,240
And all they gotta do is just get them to get better sleep

1107
00:44:58,240 --> 00:44:59,400
and they'll be able to focus.

1108
00:44:59,400 --> 00:45:02,480
The solution is never more drugs and pills.

1109
00:45:02,480 --> 00:45:04,280
The solution again, we've been saying this

1110
00:45:04,280 --> 00:45:07,040
for every episode so far, is to get the airway.

1111
00:45:07,040 --> 00:45:09,040
You fix the airway, you won't have these problems, right?

1112
00:45:09,040 --> 00:45:10,680
If they're scoring.

1113
00:45:10,680 --> 00:45:11,640
Yeah, and then how do you know

1114
00:45:11,640 --> 00:45:12,480
if you're having air problems?

1115
00:45:12,480 --> 00:45:13,320
You don't.

1116
00:45:13,320 --> 00:45:15,160
You can't really know how bad this is.

1117
00:45:15,160 --> 00:45:17,400
You're not gonna be able to measure this 30 second long app

1118
00:45:17,400 --> 00:45:19,600
in 10% desaturation without a sensor,

1119
00:45:19,600 --> 00:45:20,840
without a sleep study.

1120
00:45:20,840 --> 00:45:22,560
So the most important thing is

1121
00:45:22,560 --> 00:45:24,520
if you have any symptom of any kind,

1122
00:45:24,520 --> 00:45:27,520
whether that's nocturia, like in nighttime having to pee,

1123
00:45:27,520 --> 00:45:30,120
or daytime sleepiness, or anxiety, or anything,

1124
00:45:30,120 --> 00:45:33,160
really everything that you would have symptom wise,

1125
00:45:33,160 --> 00:45:34,320
the solution is gonna be the same.

1126
00:45:34,320 --> 00:45:36,720
Get a sleep study, find out is it the airway

1127
00:45:36,720 --> 00:45:39,280
before you start doing anything else, like with medications

1128
00:45:39,280 --> 00:45:42,400
or other therapies, because this is easy to do, right?

1129
00:45:42,400 --> 00:45:44,080
Oh yeah, you have apnea or you don't, okay, fine.

1130
00:45:44,080 --> 00:45:45,120
Let's move forward.

1131
00:45:45,120 --> 00:45:47,960
But in this example, right, back to back to back, right?

1132
00:45:47,960 --> 00:45:51,000
We got a 9% desat, 7% desat.

1133
00:45:51,000 --> 00:45:54,880
Arousal, arousal, we have an event here 41 seconds long

1134
00:45:54,880 --> 00:45:58,680
with a 16% drop in oxygen.

1135
00:45:58,680 --> 00:46:01,400
We're just like literally a few minutes ago,

1136
00:46:01,400 --> 00:46:03,520
this guy was like kind of okay, right?

1137
00:46:03,520 --> 00:46:04,360
Right.

1138
00:46:04,360 --> 00:46:06,800
Like he's kind of okay having like mild events,

1139
00:46:06,800 --> 00:46:09,680
now he's having like these crazy severe events

1140
00:46:09,680 --> 00:46:13,840
with 16% desaturation and it continues to happen, right?

1141
00:46:13,840 --> 00:46:15,000
It continues to happen.

1142
00:46:15,000 --> 00:46:17,120
And then what happens is now we have somebody

1143
00:46:17,120 --> 00:46:18,440
in the room with them.

1144
00:46:18,440 --> 00:46:21,280
This is where like the goodness comes in.

1145
00:46:21,280 --> 00:46:24,360
The technician observed what had happened

1146
00:46:24,360 --> 00:46:27,320
and they applied CPAP.

1147
00:46:27,320 --> 00:46:29,800
Rebecca, what is CPAP?

1148
00:46:29,800 --> 00:46:30,880
That's your CPAP, right?

1149
00:46:30,880 --> 00:46:33,200
So they turned up the flow, the pressure.

1150
00:46:33,200 --> 00:46:34,800
The CPAP is- The pressure.

1151
00:46:34,800 --> 00:46:35,640
Exactly.

1152
00:46:35,640 --> 00:46:37,000
Yeah.

1153
00:46:37,000 --> 00:46:40,440
P is for pressure, continuous positive airway pressure.

1154
00:46:40,440 --> 00:46:42,440
It just pushes the airway open.

1155
00:46:42,440 --> 00:46:44,200
Now this is not easy.

1156
00:46:45,080 --> 00:46:45,920
This is a challenge.

1157
00:46:45,920 --> 00:46:47,040
This is why nobody wants to do it

1158
00:46:47,040 --> 00:46:48,160
is because it takes effort.

1159
00:46:48,160 --> 00:46:50,600
The things that are worth doing are not usually easy.

1160
00:46:50,600 --> 00:46:51,920
Even in this example, right?

1161
00:46:51,920 --> 00:46:53,120
This patient's really awake.

1162
00:46:53,120 --> 00:46:55,840
They're not acclimating to therapy rapidly.

1163
00:46:55,840 --> 00:46:57,040
They're not falling back asleep.

1164
00:46:57,040 --> 00:46:59,040
This is not a happy camper at this point.

1165
00:46:59,040 --> 00:47:01,960
He's likely yelling at somebody, get this thing off of me.

1166
00:47:01,960 --> 00:47:02,800
And that's fine.

1167
00:47:02,800 --> 00:47:04,880
We're going to allow him to yell.

1168
00:47:04,880 --> 00:47:07,880
But eventually he does relax.

1169
00:47:07,880 --> 00:47:09,880
We see the muscle tone drop.

1170
00:47:09,880 --> 00:47:12,720
We see him eventually gets the point where

1171
00:47:12,720 --> 00:47:14,480
he's still crying and crying and crying.

1172
00:47:14,480 --> 00:47:17,400
But the technician is in the room adjusting the settings,

1173
00:47:17,400 --> 00:47:19,800
adjusting the mask, adjusting the pressure,

1174
00:47:19,800 --> 00:47:23,040
getting him to finally be able to go to sleep.

1175
00:47:23,040 --> 00:47:26,600
And then what happens is they fall asleep.

1176
00:47:26,600 --> 00:47:27,440
This takes a while, right?

1177
00:47:27,440 --> 00:47:28,400
You can see them on effort.

1178
00:47:28,400 --> 00:47:30,080
They're having to do every one of these little spikes,

1179
00:47:30,080 --> 00:47:31,120
every one of these little comments

1180
00:47:31,120 --> 00:47:32,640
is the technician documenting

1181
00:47:32,640 --> 00:47:36,080
what they are trying to do to get the patient to stay on therapy.

1182
00:47:36,080 --> 00:47:38,720
And then while the patient did fall asleep,

1183
00:47:38,720 --> 00:47:41,360
they immediately have these 24-second events,

1184
00:47:41,360 --> 00:47:42,840
again, having these desaturations,

1185
00:47:42,840 --> 00:47:44,160
because they're not done yet, right?

1186
00:47:44,160 --> 00:47:46,080
Just because you apply CPAP doesn't mean it works instantly,

1187
00:47:46,080 --> 00:47:46,240
right?

1188
00:47:46,240 --> 00:47:47,800
You have to still adjust it.

1189
00:47:47,800 --> 00:47:49,560
But this technician continues to try.

1190
00:47:49,560 --> 00:47:50,640
They see the event.

1191
00:47:50,640 --> 00:47:52,120
They document what they're doing.

1192
00:47:52,120 --> 00:47:53,600
They increase the pressure.

1193
00:47:53,600 --> 00:47:54,560
That's them right there, right?

1194
00:47:54,560 --> 00:47:58,520
They say, I'm increasing to 14, 14 is CMH2O for all

1195
00:47:58,520 --> 00:47:59,160
of these reasons.

1196
00:47:59,160 --> 00:48:00,280
I'm also monitoring the leak.

1197
00:48:00,280 --> 00:48:01,280
I'm going to measure the leak.

1198
00:48:01,280 --> 00:48:02,280
I'm going to fix it.

1199
00:48:02,280 --> 00:48:03,360
It still doesn't work.

1200
00:48:03,360 --> 00:48:04,560
So they continue trying it.

1201
00:48:04,560 --> 00:48:05,440
They continue trying it.

1202
00:48:05,440 --> 00:48:12,240
And then sometime around 4 AM, they find a combination of mask,

1203
00:48:12,240 --> 00:48:16,520
of pressure, of humidity, of tubing, of headgear.

1204
00:48:16,520 --> 00:48:18,400
And then this patient has now achieved something

1205
00:48:18,400 --> 00:48:20,920
they have never achieved in a decade or longer

1206
00:48:20,920 --> 00:48:23,080
called REM sleep.

1207
00:48:23,080 --> 00:48:24,920
So they're actually resting.

1208
00:48:24,920 --> 00:48:26,160
They're actually resting.

1209
00:48:26,160 --> 00:48:27,400
The chin is quiet.

1210
00:48:27,400 --> 00:48:28,560
Air flow is stable.

1211
00:48:28,560 --> 00:48:30,560
Oxygen is 96 all the way across.

1212
00:48:30,560 --> 00:48:31,720
Heart rate is stable.

1213
00:48:31,720 --> 00:48:34,800
They are, for the first time in years, actually getting sleep.

1214
00:48:34,800 --> 00:48:35,880
And they're having dreams.

1215
00:48:35,880 --> 00:48:37,400
They're having actual benefit.

1216
00:48:37,400 --> 00:48:39,160
They're going to have muscle recovery.

1217
00:48:39,160 --> 00:48:40,480
They're going to have immune function.

1218
00:48:40,480 --> 00:48:42,360
They're going to have muscle regrowth.

1219
00:48:42,360 --> 00:48:43,280
They're going to have everything.

1220
00:48:43,280 --> 00:48:45,360
And they're going to have this on the same night

1221
00:48:45,360 --> 00:48:48,680
that they walked in having those 40 second long events, just

1222
00:48:48,680 --> 00:48:49,840
a few hours later.

1223
00:48:49,840 --> 00:48:53,120
All because they did it in the lab with a technician that

1224
00:48:53,120 --> 00:48:56,160
had the skill and the patience to put up with all this, right?

1225
00:48:56,160 --> 00:48:58,880
You can imagine this part right here.

1226
00:48:58,880 --> 00:48:59,920
The patient saying it's not working.

1227
00:48:59,920 --> 00:49:00,520
I hate it.

1228
00:49:00,520 --> 00:49:01,920
The technician is also concerned.

1229
00:49:01,920 --> 00:49:02,800
Is this thing ever going to work?

1230
00:49:02,800 --> 00:49:03,080
I don't know.

1231
00:49:03,080 --> 00:49:04,400
I'm already trying so much pressure.

1232
00:49:04,400 --> 00:49:05,240
You increase the pressure.

1233
00:49:05,240 --> 00:49:06,240
It creates a leak.

1234
00:49:06,240 --> 00:49:07,600
You tighten the mass.

1235
00:49:07,600 --> 00:49:09,040
Mass creates discomfort.

1236
00:49:09,040 --> 00:49:11,120
The higher pressure causes a central apnea.

1237
00:49:11,120 --> 00:49:12,880
It is not easy.

1238
00:49:12,880 --> 00:49:14,760
No, it sounds stressful for everyone.

1239
00:49:14,760 --> 00:49:15,280
It is.

1240
00:49:15,280 --> 00:49:16,640
Like it is a challenge.

1241
00:49:16,640 --> 00:49:18,920
And that's why people burn themselves out doing this, right?

1242
00:49:18,920 --> 00:49:21,520
But if you go to the right lab, if you get the right technician,

1243
00:49:21,520 --> 00:49:24,920
the technician has the right skill, then we can do this.

1244
00:49:24,920 --> 00:49:26,000
Like I did this for many years.

1245
00:49:26,000 --> 00:49:26,800
I don't do it right now.

1246
00:49:26,800 --> 00:49:29,560
But I was able to achieve this on every one of my studies.

1247
00:49:29,560 --> 00:49:30,400
This is called optimal.

1248
00:49:30,400 --> 00:49:33,960
Optimal means you achieve REM supine with the NHL lesson 5.

1249
00:49:33,960 --> 00:49:37,520
That's what you aim for as a night tech, but only if you care, right?

1250
00:49:37,520 --> 00:49:39,120
And not everybody cares.

1251
00:49:39,120 --> 00:49:41,120
Not all labs are in it for the result.

1252
00:49:41,120 --> 00:49:43,400
They're just in there to get whatever reimbursement you get out of it

1253
00:49:43,400 --> 00:49:44,400
and call it a day.

1254
00:49:44,400 --> 00:49:48,160
But this is an example of what is possible.

1255
00:49:48,160 --> 00:49:50,080
Now, this patient, I guarantee you, once they wake up,

1256
00:49:50,080 --> 00:49:51,840
they're going to feel something they haven't felt in years,

1257
00:49:51,840 --> 00:49:53,000
which is like, oh, that's what sleep is.

1258
00:49:53,000 --> 00:49:53,640
Arrested.

1259
00:49:53,640 --> 00:49:54,840
Yeah.

1260
00:49:54,840 --> 00:49:58,240
And then once they get that first taste of actual sleep,

1261
00:49:58,240 --> 00:49:59,280
they wake up without a headache.

1262
00:49:59,280 --> 00:50:01,080
They wake up without having to pee for every hour.

1263
00:50:01,080 --> 00:50:04,800
They wake up feeling like as if they actually got sleep for the first time.

1264
00:50:04,800 --> 00:50:08,400
They will not leave the lab without that mask.

1265
00:50:08,400 --> 00:50:10,000
They will do whatever it takes.

1266
00:50:10,000 --> 00:50:10,920
They will pay cash.

1267
00:50:10,920 --> 00:50:12,160
They will travel.

1268
00:50:12,160 --> 00:50:14,720
They will do anything to not go without it.

1269
00:50:14,720 --> 00:50:16,920
Patients love the machine.

1270
00:50:16,920 --> 00:50:18,920
Everyone says, I hate CPAP, all that crap.

1271
00:50:18,920 --> 00:50:21,880
It's because they just ended it here, right?

1272
00:50:21,880 --> 00:50:25,160
Even this patient who ended it really well also hated CPAP.

1273
00:50:25,160 --> 00:50:25,800
Even that they should hate.

1274
00:50:25,800 --> 00:50:28,600
Everyone hates CPAP until you put in the right amount of effort,

1275
00:50:28,600 --> 00:50:29,320
until you get it right.

1276
00:50:29,320 --> 00:50:30,040
Get the right combination.

1277
00:50:30,040 --> 00:50:35,040
And at the end of this, though, they now know this is where I have to set it.

1278
00:50:35,040 --> 00:50:35,760
This is the setting.

1279
00:50:35,760 --> 00:50:36,760
Exactly.

1280
00:50:36,760 --> 00:50:37,040
Right.

1281
00:50:37,040 --> 00:50:38,600
So that's where I come to the report.

1282
00:50:38,600 --> 00:50:41,040
So I'll talk about the report and then we'll call it a night for today.

1283
00:50:41,040 --> 00:50:41,240
Right.

1284
00:50:41,240 --> 00:50:44,920
So this is what's called a split night study where it starts off diagnostics,

1285
00:50:44,920 --> 00:50:46,280
ends therapeutic.

1286
00:50:46,280 --> 00:50:52,320
This patient had an H.I. of 41 events an hour.

1287
00:50:52,320 --> 00:50:56,280
That's apneus plus apneus divided by the number of hours of sleep.

1288
00:50:56,280 --> 00:50:59,320
Now, if I factor in the RIRAS, that's the RDI.

1289
00:50:59,320 --> 00:51:03,480
It was 58.1 because not all events classified as apneus.

1290
00:51:03,480 --> 00:51:05,600
And these events were worse on the back.

1291
00:51:05,600 --> 00:51:09,880
So again, if the guy was just on his side, he would reduce his index by more than half, right?

1292
00:51:09,880 --> 00:51:11,360
From 41 to 20.

1293
00:51:11,360 --> 00:51:12,200
And quick question.

1294
00:51:12,200 --> 00:51:14,640
I just, I don't know if you know the answer to this or not.

1295
00:51:14,640 --> 00:51:15,400
Sure.

1296
00:51:15,400 --> 00:51:19,280
Long, long time ago, I heard that one side was better to sleep on than the other.

1297
00:51:19,280 --> 00:51:20,720
Is that true or does it matter?

1298
00:51:20,720 --> 00:51:22,880
Just find a side that works for you.

1299
00:51:22,880 --> 00:51:23,120
Right.

1300
00:51:23,120 --> 00:51:25,280
So better or worse depends on what you're talking about, right?

1301
00:51:25,280 --> 00:51:30,440
Some people say left side is better for like brain function because you flush out the toxins.

1302
00:51:30,440 --> 00:51:32,240
Right side is better for digestion.

1303
00:51:32,240 --> 00:51:33,720
There's something about there.

1304
00:51:33,720 --> 00:51:34,720
Like there is also.

1305
00:51:34,720 --> 00:51:38,800
I heard about it for your circulation, your circulation in your heart.

1306
00:51:38,800 --> 00:51:39,160
Right.

1307
00:51:39,160 --> 00:51:43,240
Left was the way you were supposed to go, which.

1308
00:51:43,240 --> 00:51:46,160
I think it's better to, just like I said earlier, right?

1309
00:51:46,160 --> 00:51:47,960
Like home study versus home study, just do both.

1310
00:51:47,960 --> 00:51:50,640
If left side, right side are both good, do both, right?

1311
00:51:50,640 --> 00:51:54,280
You shouldn't like be restricted to a single position.

1312
00:51:54,280 --> 00:51:55,520
I think that's also bad.

1313
00:51:55,520 --> 00:51:57,960
I think there's benefits of having REM sleep, non-REM sleep.

1314
00:51:57,960 --> 00:52:00,200
There's benefits of having supine sleep and non-supine sleep.

1315
00:52:00,200 --> 00:52:01,840
You should have some kind of mixture of everything.

1316
00:52:01,840 --> 00:52:05,840
Everything has a purpose just by going for one, you're going to limit the benefit of something else.

1317
00:52:05,840 --> 00:52:07,920
So mix it up.

1318
00:52:07,920 --> 00:52:11,400
And this is why I'm a strong believer in CPAP therapy, right?

1319
00:52:11,400 --> 00:52:15,200
Because the only way this guy is going to sleep at night on his back is with CPAP.

1320
00:52:15,200 --> 00:52:19,720
Like this level of apnea, unlikely to be treated with anything other than the CPAP.

1321
00:52:19,720 --> 00:52:20,440
The pressure he's at.

1322
00:52:20,440 --> 00:52:22,480
I'll tell you why here in the next page, right?

1323
00:52:22,480 --> 00:52:25,760
So we have here the oxygen saturation.

1324
00:52:25,760 --> 00:52:28,160
So you went out to 77%.

1325
00:52:28,160 --> 00:52:29,720
That's scary.

1326
00:52:29,720 --> 00:52:31,800
That's extremely low.

1327
00:52:31,800 --> 00:52:33,640
His heart rate is going up to 173.

1328
00:52:33,640 --> 00:52:36,280
We saw that whenever he woke up in his sleep.

1329
00:52:36,280 --> 00:52:38,200
He's going to 94 beats a minute.

1330
00:52:38,200 --> 00:52:40,680
You're not supposed to be really above 60 or so.

1331
00:52:40,680 --> 00:52:43,040
So his sleep is very stressful.

1332
00:52:43,040 --> 00:52:50,160
He is literally stressing out and fighting to stay alive whenever he is in bed.

1333
00:52:50,160 --> 00:52:52,720
Now we start with the CPAP portion of it.

1334
00:52:52,720 --> 00:52:56,720
We see his overall index is actually about the same.

1335
00:52:56,720 --> 00:52:59,160
So 41 events an hour wise on CPAP.

1336
00:52:59,160 --> 00:53:00,320
That's not the point.

1337
00:53:00,320 --> 00:53:03,160
The point is what we see in this next table.

1338
00:53:03,160 --> 00:53:04,920
This is called a titration table.

1339
00:53:04,920 --> 00:53:09,880
So titration means I add a little bit of pressure, add a little bit of pressure until I get an open airway.

1340
00:53:09,880 --> 00:53:13,200
This is what you can get when you do an in-lab study.

1341
00:53:13,200 --> 00:53:16,200
5, 6, 7, 8, 9, 10, those are CMH2O.

1342
00:53:16,200 --> 00:53:17,520
So there's a water pressure.

1343
00:53:17,520 --> 00:53:22,840
5, 6, 8, 9, you can see the events are very high, mostly because the durations are very low.

1344
00:53:22,840 --> 00:53:25,400
This is when the patient was just crying, I can't breathe.

1345
00:53:25,400 --> 00:53:26,400
I can't handle this.

1346
00:53:26,400 --> 00:53:31,040
You know, the technician is doing whatever they can do to just get them to an adequate pressure.

1347
00:53:31,040 --> 00:53:33,360
So then they get to the pressure of 10.

1348
00:53:33,360 --> 00:53:36,080
They're able to get some consistent sleep, only five minutes.

1349
00:53:36,080 --> 00:53:36,680
That's fine.

1350
00:53:36,680 --> 00:53:38,240
H.I. is still too high.

1351
00:53:38,240 --> 00:53:39,040
They go to 12.

1352
00:53:39,040 --> 00:53:41,160
They skip 11 because we don't have time.

1353
00:53:41,160 --> 00:53:43,160
It's still very high.

1354
00:53:43,160 --> 00:53:44,720
And then they skip 13.

1355
00:53:44,720 --> 00:53:45,640
They go straight to 14.

1356
00:53:45,640 --> 00:53:47,480
At 14, they have 41 minutes.

1357
00:53:47,480 --> 00:53:53,440
H.I. is still pretty high, but that's the dramatic improvement over where we came from.

1358
00:53:53,440 --> 00:53:55,000
We came with an index of 40 something, right?

1359
00:53:55,000 --> 00:53:59,000
And then they say, I'm not done yet, just because this is a pretty good reduction.

1360
00:53:59,000 --> 00:54:01,000
But this is where people normally call it.

1361
00:54:01,000 --> 00:54:04,640
If you get an inspire, they say 50% reduction is successful.

1362
00:54:04,640 --> 00:54:06,720
I say, that's crap.

1363
00:54:06,720 --> 00:54:08,640
50% reduction doesn't mean anything.

1364
00:54:08,640 --> 00:54:12,640
If this guy had an H.I. 50 and got on a 25, is that success?

1365
00:54:12,640 --> 00:54:13,640
It's not, right?

1366
00:54:13,640 --> 00:54:16,400
You need to eliminate.

1367
00:54:16,400 --> 00:54:19,280
So that's what happens, right?

1368
00:54:19,280 --> 00:54:21,320
They go to 15, they go to 16.

1369
00:54:21,320 --> 00:54:23,040
At 15, they achieve REM.

1370
00:54:23,040 --> 00:54:24,520
We saw that.

1371
00:54:24,520 --> 00:54:29,000
And at 16, they have completely resolved.

1372
00:54:29,000 --> 00:54:32,240
Oxygen doesn't drop at any point below 95.

1373
00:54:32,240 --> 00:54:33,720
That is super healthy sleep.

1374
00:54:33,720 --> 00:54:35,720
Like that is as good as you can get.

1375
00:54:35,720 --> 00:54:37,040
You can't get better than zero.

1376
00:54:37,040 --> 00:54:38,960
And 95% for someone like that, right?

1377
00:54:38,960 --> 00:54:41,560
And they get a pretty good sample too, 29 minutes.

1378
00:54:41,560 --> 00:54:45,920
And that pressure of 16, that's a lot.

1379
00:54:45,920 --> 00:54:49,080
That's on the border of what you would even prescribe on CPAP.

1380
00:54:49,080 --> 00:54:50,120
If they had to go one higher, they

1381
00:54:50,120 --> 00:54:52,720
would have to go to BiPAP, like BiLol pressure.

1382
00:54:52,720 --> 00:54:55,120
But luckily, they didn't have to go that route.

1383
00:54:55,120 --> 00:54:56,320
They would have been fine if they did,

1384
00:54:56,320 --> 00:54:58,000
but it's better to stay on CPAP.

1385
00:54:58,000 --> 00:55:00,440
And the patient was able to tolerate it.

1386
00:55:00,440 --> 00:55:06,600
You can see the arousal index is also extremely low, 2.1.

1387
00:55:06,600 --> 00:55:07,360
That's nothing, right?

1388
00:55:07,360 --> 00:55:08,480
Less than five.

1389
00:55:08,480 --> 00:55:09,680
And we can see the plot.

1390
00:55:09,680 --> 00:55:11,760
So you'll see here at the beginning of the night,

1391
00:55:11,760 --> 00:55:14,680
the pressure was applied right exactly in the center of it.

1392
00:55:14,680 --> 00:55:18,720
So they have these back to back to back arousals.

1393
00:55:18,720 --> 00:55:19,840
They have these leg movements.

1394
00:55:19,840 --> 00:55:23,160
They have these CNAs are central apneas.

1395
00:55:23,160 --> 00:55:25,160
They have the obstructive apneas at the reras.

1396
00:55:25,160 --> 00:55:26,360
You see all these events.

1397
00:55:26,360 --> 00:55:28,280
The duration is how tall it is.

1398
00:55:28,280 --> 00:55:30,760
It's just constantly having events.

1399
00:55:30,760 --> 00:55:33,200
And then you see at the end, the last hour on CPAP,

1400
00:55:33,200 --> 00:55:35,880
when the pressure is at the 15, 16,

1401
00:55:35,880 --> 00:55:38,880
there's hardly anything the arousals have mostly resolved.

1402
00:55:38,880 --> 00:55:40,920
And most importantly, this oxygen plot, right?

1403
00:55:40,920 --> 00:55:42,440
You see these little dips, like we saw earlier

1404
00:55:42,440 --> 00:55:43,640
in the other examples.

1405
00:55:43,640 --> 00:55:45,280
Like this back to back to back to back to back.

1406
00:55:45,280 --> 00:55:49,880
And then at the end, it's like this little flat line at 15, 16.

1407
00:55:49,880 --> 00:55:52,880
That flat line is what we said was consistent sleep,

1408
00:55:52,880 --> 00:55:54,080
effective sleep.

1409
00:55:54,080 --> 00:55:57,520
And that was because of the CPAP.

1410
00:55:57,520 --> 00:56:01,960
And that's the last point is that don't discount CPAP.

1411
00:56:01,960 --> 00:56:07,120
We have CPAPs, like we see here, this giraffe-colored thing.

1412
00:56:07,120 --> 00:56:08,360
Pediatrics like it.

1413
00:56:08,360 --> 00:56:09,520
We do it all the time.

1414
00:56:09,520 --> 00:56:10,400
You can talk to Jordan.

1415
00:56:10,400 --> 00:56:12,280
You can talk to Dimitri and James.

1416
00:56:12,280 --> 00:56:16,840
They do super good at these titrations.

1417
00:56:16,840 --> 00:56:19,080
It's more challenging when it's a pediatric person.

1418
00:56:19,080 --> 00:56:20,320
But don't give up on CPAP.

1419
00:56:20,320 --> 00:56:22,160
CPAP does work.

1420
00:56:22,160 --> 00:56:23,120
It's not easy.

1421
00:56:23,120 --> 00:56:24,000
It's not easy for the patient.

1422
00:56:24,000 --> 00:56:25,000
It's not easy for the technician.

1423
00:56:25,000 --> 00:56:25,960
It's not easy for anybody.

1424
00:56:25,960 --> 00:56:27,680
That's why some people are easy just to give up on it.

1425
00:56:27,680 --> 00:56:28,560
Oh, that's too much work.

1426
00:56:28,560 --> 00:56:29,920
I don't want to deal with it.

1427
00:56:29,920 --> 00:56:32,840
But we saw just now, and we see it every night in the sleep lab,

1428
00:56:32,840 --> 00:56:35,960
that when you do it right, it works.

1429
00:56:35,960 --> 00:56:37,440
So definitely go for it.

1430
00:56:37,440 --> 00:56:38,520
I mean, there are some side effects.

1431
00:56:38,520 --> 00:56:40,600
You can, especially pediatrics, skull growth.

1432
00:56:40,600 --> 00:56:42,760
I'll let the other speakers talk more about that.

1433
00:56:42,760 --> 00:56:45,560
But I just want to let you know that, yeah, CPAP is an option.

1434
00:56:45,560 --> 00:56:48,520
It is a very effective option.

1435
00:56:48,520 --> 00:56:49,920
But it does take effort.

1436
00:56:49,920 --> 00:56:54,520
But they can, if we start with when they're hypothetically,

1437
00:56:54,520 --> 00:56:59,160
we've got a four or five-year-old, and they come in.

1438
00:56:59,160 --> 00:57:01,760
And they've been diagnosed with ADHD.

1439
00:57:01,760 --> 00:57:05,000
They've got anxiety that's off the charts.

1440
00:57:05,000 --> 00:57:08,760
Trying to get them in to meet with an airway,

1441
00:57:08,760 --> 00:57:10,920
dentistry, and ADHD or somebody.

1442
00:57:10,920 --> 00:57:13,520
And you get ahold of them.

1443
00:57:13,520 --> 00:57:15,120
We get them on CPAP, and now they're

1444
00:57:15,120 --> 00:57:16,680
going to start to sleep right now.

1445
00:57:16,680 --> 00:57:18,480
You start to get the mental functions back,

1446
00:57:18,480 --> 00:57:21,640
getting your child back.

1447
00:57:21,640 --> 00:57:24,560
For a child, in this particular scenario,

1448
00:57:24,560 --> 00:57:26,480
is this something they could grow out of?

1449
00:57:26,480 --> 00:57:30,640
If, let's say, the jaw moves in place, the airway opens up,

1450
00:57:30,640 --> 00:57:31,680
they could potentially.

1451
00:57:31,680 --> 00:57:34,000
I mean, this is just therapy until they get to where they need

1452
00:57:34,000 --> 00:57:36,200
to be, correct?

1453
00:57:36,200 --> 00:57:37,800
Yeah, I think I agree with that.

1454
00:57:37,800 --> 00:57:42,400
So CPAP may be used temporarily until the airway is opened up.

1455
00:57:42,400 --> 00:57:44,680
And that might be a solution.

1456
00:57:44,680 --> 00:57:45,880
I mean, the only thing you would do

1457
00:57:45,880 --> 00:57:48,000
is you go back to the very first slide, right?

1458
00:57:48,000 --> 00:57:49,200
Where it's like, you know what?

1459
00:57:49,200 --> 00:57:50,280
How would you know?

1460
00:57:50,280 --> 00:57:52,600
If they need it or not, you would have to repeat the study.

1461
00:57:52,600 --> 00:57:54,480
So you would just go in this little circle.

1462
00:57:54,480 --> 00:57:58,520
So I mean, this circle is actually more useful and more

1463
00:57:58,520 --> 00:58:00,520
important for pediatrics.

1464
00:58:00,520 --> 00:58:02,200
Because the way they sleep this week

1465
00:58:02,200 --> 00:58:06,040
is going to be different than how they sleep next week.

1466
00:58:06,040 --> 00:58:08,520
Also, they change and grow, right?

1467
00:58:08,520 --> 00:58:11,560
We can do this study pretty often, maybe once a year.

1468
00:58:11,560 --> 00:58:13,960
But you can do a study like this every day.

1469
00:58:13,960 --> 00:58:16,680
So I mean, it's important to do this once in a while

1470
00:58:16,680 --> 00:58:18,720
and do this as often as you can.

1471
00:58:18,720 --> 00:58:21,400
You can just buy this thing and you can track it yourself.

1472
00:58:21,400 --> 00:58:23,080
O2 ring or sleep image ring, there's

1473
00:58:23,080 --> 00:58:24,800
like six of them, you know, different software

1474
00:58:24,800 --> 00:58:25,800
is like an important.

1475
00:58:25,800 --> 00:58:27,360
But now that you have a little bit of skill

1476
00:58:27,360 --> 00:58:29,520
from looking at these plots, you can

1477
00:58:29,520 --> 00:58:33,480
tell if your child or patient is doing well or not.

1478
00:58:33,480 --> 00:58:35,600
And then you can tell if the CPAP is effective or not,

1479
00:58:35,600 --> 00:58:37,920
which is based off that oxymetrient.

1480
00:58:37,920 --> 00:58:39,960
I mean, obviously, it's better to get the whole thing.

1481
00:58:39,960 --> 00:58:41,080
And we can do that also.

1482
00:58:41,080 --> 00:58:45,400
But you can't know what to do unless you acquire the data

1483
00:58:45,400 --> 00:58:46,360
and you analyze it.

1484
00:58:46,360 --> 00:58:47,520
And then you act on it, right?

1485
00:58:47,520 --> 00:58:48,720
You just do this daily.

1486
00:58:48,720 --> 00:58:52,000
Like, I do this with my patients every day.

1487
00:58:52,000 --> 00:58:53,000
Like, they're on CPAP.

1488
00:58:53,000 --> 00:58:54,720
The CPAP is reporting to the cloud,

1489
00:58:54,720 --> 00:58:56,960
what their residual AHI is, what their usage is.

1490
00:58:56,960 --> 00:58:59,040
I have other devices that they're monitoring.

1491
00:58:59,040 --> 00:59:00,840
And I call them up and I say, hey, you know, last night,

1492
00:59:00,840 --> 00:59:02,080
this and that, do this.

1493
00:59:02,080 --> 00:59:03,600
And then again and again and again, right?

1494
00:59:03,600 --> 00:59:05,120
So though my patients aren't even children,

1495
00:59:05,120 --> 00:59:07,760
they still repeat the cycle because that's what it takes.

1496
00:59:07,760 --> 00:59:09,640
Because just because you meet them once a year,

1497
00:59:09,640 --> 00:59:10,880
like that's not enough, right?

1498
00:59:10,880 --> 00:59:14,400
This is a daily thing that requires constant coaching,

1499
00:59:14,400 --> 00:59:16,760
constant monitoring, constant adjustments.

1500
00:59:16,760 --> 00:59:18,480
Because especially with your patients, right?

1501
00:59:18,480 --> 00:59:20,640
The pediatric ones, they're changing so often.

1502
00:59:20,640 --> 00:59:25,640
And what they're losing is their most valuable resource,

1503
00:59:25,960 --> 00:59:27,160
which is sleep.

1504
00:59:27,160 --> 00:59:30,320
I mean, you think about it, like we're installing

1505
00:59:30,320 --> 00:59:33,760
all these things on their computers to protect our data.

1506
00:59:33,760 --> 00:59:35,440
We're going to the bank and getting FDIC

1507
00:59:35,440 --> 00:59:36,640
to protect our money.

1508
00:59:36,640 --> 00:59:38,120
But those things are fine, right?

1509
00:59:38,120 --> 00:59:39,440
You can get your money back.

1510
00:59:39,440 --> 00:59:41,560
You can get your possessions back,

1511
00:59:41,560 --> 00:59:42,720
but you can't get back your sleep.

1512
00:59:42,720 --> 00:59:44,120
Your sleep is something you'll never get back.

1513
00:59:44,120 --> 00:59:45,680
So you should protect it even more

1514
00:59:45,680 --> 00:59:48,680
than you protect your data or your money, right?

1515
00:59:48,680 --> 00:59:50,640
You should be protected, especially for your children.

1516
00:59:50,640 --> 00:59:53,120
Because their sleep is necessary.

1517
00:59:53,120 --> 00:59:53,960
Necessary to the point where-

1518
00:59:53,960 --> 00:59:56,000
It's impacting their brain, their IQ, right?

1519
00:59:56,000 --> 00:59:56,880
I mean, again, it can impact-

1520
00:59:56,880 --> 00:59:57,720
Yes.

1521
00:59:58,680 --> 01:00:01,880
It's been developed with organs and-

1522
01:00:01,880 --> 01:00:03,480
It's impacting everything, right?

1523
01:00:03,480 --> 01:00:07,640
So their sleep is being constantly stolen from them.

1524
01:00:07,640 --> 01:00:09,840
If it's not from the app, it's from the school,

1525
01:00:09,840 --> 01:00:10,960
or it's from the society,

1526
01:00:10,960 --> 01:00:12,840
or there's school bus coming too early, right?

1527
01:00:12,840 --> 01:00:15,120
That is a form of theft.

1528
01:00:15,120 --> 01:00:15,960
It is what it is, right?

1529
01:00:15,960 --> 01:00:17,640
You got to call it what it is.

1530
01:00:17,640 --> 01:00:18,960
That sleep belongs to them,

1531
01:00:18,960 --> 01:00:22,280
and we are stealing from them their sleep.

1532
01:00:22,280 --> 01:00:23,240
And unless you call it theft,

1533
01:00:23,240 --> 01:00:25,080
people aren't going to take it as seriously as it is, right?

1534
01:00:25,080 --> 01:00:27,920
Where you're going to the government

1535
01:00:27,920 --> 01:00:29,800
trying to push for change.

1536
01:00:29,800 --> 01:00:31,280
One of the changes people are pushing for

1537
01:00:31,280 --> 01:00:34,080
is the time zones, the daylight savings,

1538
01:00:34,080 --> 01:00:36,040
the school timing, all these things.

1539
01:00:36,040 --> 01:00:38,080
They're not in alignment at all

1540
01:00:38,080 --> 01:00:39,680
with the pediatric population, right?

1541
01:00:39,680 --> 01:00:40,840
They need to get more sleep.

1542
01:00:40,840 --> 01:00:44,080
And we are, as a society, robbing them of it.

1543
01:00:44,080 --> 01:00:46,080
Now, if you do that in a state of war,

1544
01:00:46,080 --> 01:00:48,280
like if you're invading a country

1545
01:00:48,280 --> 01:00:49,280
and you have a prison of war,

1546
01:00:49,280 --> 01:00:50,240
and you deprive them of sleep,

1547
01:00:50,240 --> 01:00:52,560
that's considered a form of torture.

1548
01:00:52,560 --> 01:00:54,520
Like you are considering a war crime

1549
01:00:54,520 --> 01:00:55,600
if you deprive someone of sleep.

1550
01:00:55,600 --> 01:00:57,080
But yet, for our own children,

1551
01:00:57,080 --> 01:00:57,920
we're going to torture them

1552
01:00:57,920 --> 01:00:59,560
and call it necessary.

1553
01:00:59,560 --> 01:01:00,480
Like it's a bunch of crap, right?

1554
01:01:00,480 --> 01:01:03,920
Like it's terrible what we're doing to these children.

1555
01:01:03,920 --> 01:01:05,560
I mean, if they can even breathe, right?

1556
01:01:05,560 --> 01:01:06,440
That's one thing.

1557
01:01:06,440 --> 01:01:08,120
And then when they can breathe, we wake them up,

1558
01:01:08,120 --> 01:01:08,960
say, hey, guess what?

1559
01:01:08,960 --> 01:01:09,800
You gotta wake up for some reason.

1560
01:01:09,800 --> 01:01:10,640
No, you don't, right?

1561
01:01:10,640 --> 01:01:11,480
You can get more sleep.

1562
01:01:11,480 --> 01:01:12,640
There's no reason for you to be awake.

1563
01:01:12,640 --> 01:01:14,600
You don't have any like mission critical job.

1564
01:01:14,600 --> 01:01:15,600
Like nothing's gonna melt down

1565
01:01:15,600 --> 01:01:17,360
if you don't wake up at 5 a.m.

1566
01:01:17,360 --> 01:01:19,520
So let the kids sleep.

1567
01:01:19,520 --> 01:01:20,920
You know, don't steal from them

1568
01:01:20,920 --> 01:01:22,400
the one thing that's the most valuable thing,

1569
01:01:22,400 --> 01:01:23,360
which is their time in their sleep.

1570
01:01:23,360 --> 01:01:24,200
And don't torture them.

1571
01:01:24,200 --> 01:01:25,040
That's what you're doing.

1572
01:01:25,040 --> 01:01:25,880
And just call it what it is.

1573
01:01:25,880 --> 01:01:26,880
It is theft, it is torture,

1574
01:01:26,880 --> 01:01:28,560
and you are a criminal if you are.

1575
01:01:28,560 --> 01:01:31,000
And you may not go to jail, but you're still guilty.

1576
01:01:31,000 --> 01:01:32,840
So just know that, right?

1577
01:01:32,840 --> 01:01:33,840
Next time you wake up a kid,

1578
01:01:33,840 --> 01:01:36,520
like what you are doing is you are legit

1579
01:01:36,520 --> 01:01:37,720
committing a crime.

1580
01:01:37,720 --> 01:01:38,560
So-

1581
01:01:38,560 --> 01:01:39,400
You're stealing from them.

1582
01:01:39,400 --> 01:01:40,240
And that's the point.

1583
01:01:40,240 --> 01:01:41,080
You're stealing from them.

1584
01:01:41,080 --> 01:01:44,240
And if, how long can you stay?

1585
01:01:44,240 --> 01:01:45,760
And this is more for an adult,

1586
01:01:45,760 --> 01:01:47,640
but how long can you stay on a CPAP?

1587
01:01:49,000 --> 01:01:49,840
Forever.

1588
01:01:49,840 --> 01:01:52,840
I mean, I've had, my patients get on CPAP

1589
01:01:52,840 --> 01:01:55,200
and they live on CPAP.

1590
01:01:55,200 --> 01:01:57,680
I have patients that have three CPAPs.

1591
01:01:57,680 --> 01:02:00,640
One for their home, one for their carry-on,

1592
01:02:00,640 --> 01:02:04,360
one for their check-in, like one is small, one is big.

1593
01:02:04,360 --> 01:02:05,520
Sometimes they have a second unit

1594
01:02:05,520 --> 01:02:08,000
just left on their side location.

1595
01:02:08,000 --> 01:02:11,320
They have battery backups, multiple battery backups.

1596
01:02:11,320 --> 01:02:15,600
They tell me they will never sleep without us.

1597
01:02:15,600 --> 01:02:16,640
I mean, you saw the example, right?

1598
01:02:16,640 --> 01:02:19,000
That patient in REM, single oxygen.

1599
01:02:19,000 --> 01:02:19,840
You kidding me?

1600
01:02:19,840 --> 01:02:20,680
Yeah.

1601
01:02:20,680 --> 01:02:21,520
Right, you could feel that.

1602
01:02:21,520 --> 01:02:22,520
That's a difference you can feel.

1603
01:02:22,520 --> 01:02:24,000
And those patients, once they feel that,

1604
01:02:24,000 --> 01:02:27,840
they never want to feel like they did before again,

1605
01:02:27,840 --> 01:02:29,800
because they feel literally sick.

1606
01:02:29,800 --> 01:02:33,640
Like they wake up with this congestion,

1607
01:02:33,640 --> 01:02:35,760
with this headache, with this sense

1608
01:02:35,760 --> 01:02:37,600
that they have been fighting to stay alive all night.

1609
01:02:37,600 --> 01:02:38,960
This is exhausted.

1610
01:02:38,960 --> 01:02:40,200
They cannot manage their day.

1611
01:02:40,200 --> 01:02:41,280
They can't do anything.

1612
01:02:41,280 --> 01:02:43,560
But with just a little bit of CPAP,

1613
01:02:43,560 --> 01:02:45,280
this pressure was pretty high, 16.

1614
01:02:45,280 --> 01:02:46,400
Most of the patients can get by

1615
01:02:46,400 --> 01:02:49,560
with less than half of that and it's more tolerable.

1616
01:02:49,560 --> 01:02:51,440
And it's like, yeah,

1617
01:02:51,440 --> 01:02:53,120
everyone would feel like that again, right?

1618
01:02:53,120 --> 01:02:54,200
They don't.

1619
01:02:54,200 --> 01:02:56,040
They have backup machines even.

1620
01:02:56,040 --> 01:02:57,560
They have two machines in their primary residence,

1621
01:02:57,560 --> 01:02:59,840
just because just in case one of them may not

1622
01:02:59,840 --> 01:03:00,920
will work one night or something, right?

1623
01:03:00,920 --> 01:03:04,880
That's how badly these patients love their machines.

1624
01:03:04,880 --> 01:03:07,240
So when somebody says, I hate CPAP, I'm like, yeah,

1625
01:03:07,240 --> 01:03:08,320
of course you hate CPAP.

1626
01:03:08,320 --> 01:03:09,880
If it's not set to your level,

1627
01:03:09,880 --> 01:03:11,000
if it's not set to your mask,

1628
01:03:11,000 --> 01:03:12,000
if the headgear is just one,

1629
01:03:12,000 --> 01:03:13,720
if like one side is tighter than the other,

1630
01:03:13,720 --> 01:03:15,440
the whole thing just blows air into your eye

1631
01:03:15,440 --> 01:03:16,880
and causes you to be hating it.

1632
01:03:16,880 --> 01:03:18,440
Like obviously you hate it,

1633
01:03:18,440 --> 01:03:21,280
but if you hate your CPAP, right?

1634
01:03:21,280 --> 01:03:23,880
I love mine because I got mine set correctly

1635
01:03:23,880 --> 01:03:26,240
because my wife did my study, right?

1636
01:03:26,240 --> 01:03:28,040
So it's like, of course she did the effort

1637
01:03:28,040 --> 01:03:29,200
it took to do it right.

1638
01:03:29,200 --> 01:03:30,440
And that's kind of what it takes.

1639
01:03:30,440 --> 01:03:33,000
It takes somebody with enough skill

1640
01:03:33,000 --> 01:03:37,000
to really apply the therapy in a way that you can tolerate

1641
01:03:37,000 --> 01:03:39,360
and be patient enough to go through all those difficulties

1642
01:03:39,360 --> 01:03:41,040
that we saw in that one patient.

1643
01:03:41,040 --> 01:03:42,120
It's still open, right?

1644
01:03:42,120 --> 01:03:44,720
Like to go through that, like,

1645
01:03:44,720 --> 01:03:47,480
I mean, I can just imagine how I've lived these nights, right?

1646
01:03:47,480 --> 01:03:50,280
Where the CPAP is on and it's not working, right?

1647
01:03:50,280 --> 01:03:52,840
There's a 29 second long app, you know,

1648
01:03:52,840 --> 01:03:54,600
CPAP is obviously not working.

1649
01:03:54,600 --> 01:03:55,920
And then the patient wakes up

1650
01:03:55,920 --> 01:03:57,480
and when they wake up, they're not happy, right?

1651
01:03:57,480 --> 01:03:58,320
They're just...

1652
01:03:58,320 --> 01:03:59,880
Right, they're tired, they're cranky, sure.

1653
01:03:59,880 --> 01:04:01,720
They're tired and cranky, but look what it,

1654
01:04:01,720 --> 01:04:04,160
I mean, just a little bit of effort

1655
01:04:04,160 --> 01:04:05,040
and a little bit of documentation.

1656
01:04:05,040 --> 01:04:07,320
Now we can get them to this level, like happy sleep too.

1657
01:04:07,320 --> 01:04:09,320
Like this, like when I see these,

1658
01:04:09,320 --> 01:04:10,560
these are called rapid eye movements.

1659
01:04:10,560 --> 01:04:13,400
Whenever I saw this on the nighttime spot,

1660
01:04:13,400 --> 01:04:14,240
we work as somebody, I'm like,

1661
01:04:14,240 --> 01:04:16,000
hey partner, guess what?

1662
01:04:16,000 --> 01:04:16,840
They're like, what?

1663
01:04:16,840 --> 01:04:17,800
This is my dream job.

1664
01:04:17,800 --> 01:04:19,320
And they go, ha ha, good one.

1665
01:04:19,320 --> 01:04:21,240
But it's true, right?

1666
01:04:21,240 --> 01:04:22,080
Because nobody thinks it's true.

1667
01:04:22,080 --> 01:04:22,920
Right, because they're doing what

1668
01:04:22,920 --> 01:04:24,640
they're supposed to be doing, yeah.

1669
01:04:24,640 --> 01:04:27,920
Right, they're dreaming, but you know as a night tech

1670
01:04:27,920 --> 01:04:30,040
that this is your work, right?

1671
01:04:30,040 --> 01:04:31,480
You made this happen.

1672
01:04:31,480 --> 01:04:34,680
These little eye blinks would not have been possible

1673
01:04:34,680 --> 01:04:37,120
if it wasn't for this mask, at this pressure,

1674
01:04:37,120 --> 01:04:38,920
with this head, you're at this humidity, right?

1675
01:04:38,920 --> 01:04:40,720
Any other combination would have caused

1676
01:04:40,720 --> 01:04:43,280
what we just saw literally like four minutes earlier, right?

1677
01:04:43,280 --> 01:04:44,120
Yeah, yeah.

1678
01:04:44,120 --> 01:04:44,960
Right?

1679
01:04:44,960 --> 01:04:46,720
So like it takes a lot of skill,

1680
01:04:46,720 --> 01:04:47,560
takes a lot of patience,

1681
01:04:47,560 --> 01:04:50,200
takes just a lot of training for the night techs.

1682
01:04:50,200 --> 01:04:52,400
A lot of night techs, they want to get these results.

1683
01:04:52,400 --> 01:04:54,240
They just can't because they don't know how, right?

1684
01:04:54,240 --> 01:04:55,160
Or they don't have the right equipment,

1685
01:04:55,160 --> 01:04:57,360
or they don't have the right sensors or something, right?

1686
01:04:57,360 --> 01:05:00,240
So we got to empower them with the skills

1687
01:05:00,240 --> 01:05:01,840
and equipment they need to get these results.

1688
01:05:01,840 --> 01:05:04,720
And when they do, then our patients will benefit.

1689
01:05:04,720 --> 01:05:07,000
I mean, this is like, this is the cleanest thing.

1690
01:05:07,000 --> 01:05:07,840
I'm really happy.

1691
01:05:07,840 --> 01:05:08,920
I found this example for us today

1692
01:05:08,920 --> 01:05:10,680
because it really proves all the points, right?

1693
01:05:10,680 --> 01:05:14,440
Like how effective a single night at sleep app can be,

1694
01:05:14,440 --> 01:05:16,000
how effective sleep app can be,

1695
01:05:16,000 --> 01:05:17,880
and the importance of a night technician

1696
01:05:17,880 --> 01:05:19,360
in combination with the patient, right?

1697
01:05:19,360 --> 01:05:21,680
Because easily at this awakening right here,

1698
01:05:21,680 --> 01:05:23,840
when the patient woke up, you can say, I'm done, right?

1699
01:05:23,840 --> 01:05:24,680
I don't want to deal with it anymore.

1700
01:05:24,680 --> 01:05:25,520
I'm gonna go home.

1701
01:05:25,520 --> 01:05:26,360
And that does happen.

1702
01:05:26,360 --> 01:05:28,440
That happens actually more often than I can,

1703
01:05:28,440 --> 01:05:30,080
when I'm in, that happens a lot.

1704
01:05:30,080 --> 01:05:32,720
And it's like, because these patients are super grumpy,

1705
01:05:32,720 --> 01:05:34,240
but luckily they just fall back asleep.

1706
01:05:34,240 --> 01:05:36,000
They don't cry too much and they're able to deal with it.

1707
01:05:36,000 --> 01:05:39,160
And that's also why that initial discussion

1708
01:05:40,760 --> 01:05:43,080
during this procedure here is so important.

1709
01:05:43,080 --> 01:05:48,080
It's like, hey patient, at 2 a.m. what might happen,

1710
01:05:48,600 --> 01:05:49,720
they might just walk in here,

1711
01:05:49,720 --> 01:05:53,000
wake you up, put a mask on you and say, good luck, right?

1712
01:05:53,000 --> 01:05:57,280
It's going to not be as easy for some people.

1713
01:05:57,280 --> 01:05:58,320
And sometimes what we'll do

1714
01:05:58,320 --> 01:06:00,480
is we'll give them a trial of that just in case.

1715
01:06:00,480 --> 01:06:02,200
Like, hey, Rebecca, just in case

1716
01:06:02,200 --> 01:06:03,720
I got put this mask on you at 2 a.m.,

1717
01:06:03,720 --> 01:06:05,200
I want you to get a feel for it right now

1718
01:06:05,200 --> 01:06:06,520
while I'm putting these bars on you.

1719
01:06:06,520 --> 01:06:08,280
Just put on your nose, kind of breathe against it.

1720
01:06:08,280 --> 01:06:09,120
You kind of see how that feels.

1721
01:06:09,120 --> 01:06:10,800
You're like, yeah, I kind of feel it.

1722
01:06:10,800 --> 01:06:11,960
And there's different masks.

1723
01:06:11,960 --> 01:06:13,440
There's something that goes up the nose and the nose

1724
01:06:13,440 --> 01:06:14,880
and on the mouth.

1725
01:06:14,880 --> 01:06:16,080
I like that one better.

1726
01:06:16,080 --> 01:06:17,840
You know, spend the time and effort to that way.

1727
01:06:17,840 --> 01:06:20,320
When it does happen, which it did happen in this case,

1728
01:06:20,320 --> 01:06:21,160
is already ready.

1729
01:06:21,160 --> 01:06:22,000
They're not startling.

1730
01:06:22,000 --> 01:06:23,160
They're not startling, right?

1731
01:06:23,160 --> 01:06:24,840
So that's also the skill of the tech.

1732
01:06:24,840 --> 01:06:26,160
Not all techs will do that.

1733
01:06:26,160 --> 01:06:27,280
Not all labs will do that, right?

1734
01:06:27,280 --> 01:06:28,120
Because that takes time.

1735
01:06:28,120 --> 01:06:29,880
That takes away from the other patient.

1736
01:06:29,880 --> 01:06:32,040
If you have three patients to do one one night,

1737
01:06:32,040 --> 01:06:33,880
which some labs do, you can't do that, right?

1738
01:06:33,880 --> 01:06:35,360
You got three patients to take care of.

1739
01:06:35,360 --> 01:06:36,880
You can't possibly put the effort it takes

1740
01:06:36,880 --> 01:06:38,280
to acclimate the patient.

1741
01:06:38,280 --> 01:06:40,160
So it's not only the technician.

1742
01:06:40,160 --> 01:06:41,400
The technician is doing whatever they can do.

1743
01:06:41,400 --> 01:06:42,680
It's also the lab protocol.

1744
01:06:42,680 --> 01:06:45,280
Some labs are saying, oh, we got to do two patients.

1745
01:06:45,280 --> 01:06:46,720
You got to do three patients.

1746
01:06:46,720 --> 01:06:48,680
And then some labs will allow us to do one.

1747
01:06:48,680 --> 01:06:51,240
If you just have one, then you just have more ability

1748
01:06:51,240 --> 01:06:53,680
to focus on that one patient and get everything done

1749
01:06:53,680 --> 01:06:54,680
like the way it's supposed to be.

1750
01:06:54,680 --> 01:06:55,520
Right?

1751
01:06:55,520 --> 01:06:56,800
So you can ask these questions.

1752
01:06:56,800 --> 01:06:58,800
You can say, am I the only patient?

1753
01:06:58,800 --> 01:07:00,760
How many patients else are you observing tonight?

1754
01:07:00,760 --> 01:07:01,760
If what's the protocol?

1755
01:07:01,760 --> 01:07:03,080
Like, is this lab accredited?

1756
01:07:03,080 --> 01:07:05,200
You know, like you have the right to choose, right?

1757
01:07:05,200 --> 01:07:06,040
You can refuse.

1758
01:07:06,040 --> 01:07:06,860
You'd be like, you know what?

1759
01:07:06,860 --> 01:07:08,440
I want to go to Rebecca's lab because she does it right.

1760
01:07:08,440 --> 01:07:10,320
And I'm like, go for it, right?

1761
01:07:10,320 --> 01:07:11,680
Don't go to the other guy's lab.

1762
01:07:11,680 --> 01:07:13,120
There's plenty of labs.

1763
01:07:14,440 --> 01:07:15,880
Anybody that we invite on here,

1764
01:07:15,880 --> 01:07:17,040
I will just go to theirs, right?

1765
01:07:17,040 --> 01:07:18,000
I don't have a lab currently.

1766
01:07:18,000 --> 01:07:21,440
So if it's James Cardell from Stanford or from Dmitri

1767
01:07:21,440 --> 01:07:23,400
from the pediatric facility he goes to

1768
01:07:23,400 --> 01:07:26,960
or Jordan from Pets of Children, right?

1769
01:07:26,960 --> 01:07:29,720
Or, I mean, especially we have Dr. Simmons, right?

1770
01:07:29,720 --> 01:07:32,440
He also has labs, CSMA in Houston, Austin and Woodland.

1771
01:07:32,440 --> 01:07:35,320
So anybody who is a member of this society

1772
01:07:35,320 --> 01:07:37,560
or foundation that has a facility,

1773
01:07:37,560 --> 01:07:39,760
and they mostly have this equipment too,

1774
01:07:39,760 --> 01:07:40,760
you know, go with them,

1775
01:07:40,760 --> 01:07:44,080
but don't just go where you're told to go

1776
01:07:44,080 --> 01:07:44,920
because you have a choice.

1777
01:07:44,920 --> 01:07:46,520
We're gonna carry this look, right?

1778
01:07:46,520 --> 01:07:48,480
If a parent gets referred,

1779
01:07:48,480 --> 01:07:53,480
and obviously we listed that small group,

1780
01:07:53,840 --> 01:07:58,640
where can they go to find, I guess, ratings?

1781
01:07:58,640 --> 01:08:00,680
Like, how do they know if it's a good lab?

1782
01:08:00,680 --> 01:08:03,560
Where is a good resource for them to go up?

1783
01:08:03,560 --> 01:08:06,640
So a good resource would be the American Academy

1784
01:08:06,640 --> 01:08:07,580
of Sleep Medicine.

1785
01:08:07,580 --> 01:08:12,580
They have a locator of what's called accredited labs.

1786
01:08:13,640 --> 01:08:17,200
So if a lab meets the criteria to be AASM accredited,

1787
01:08:17,200 --> 01:08:19,560
then they'll shop on some kind of list.

1788
01:08:19,560 --> 01:08:21,960
That's an option, but I would still go with the people

1789
01:08:21,960 --> 01:08:24,000
from this podcast because you have vetted them

1790
01:08:24,000 --> 01:08:25,040
and they're here talking to us

1791
01:08:25,040 --> 01:08:27,160
and they care enough to, you know, talk about it.

1792
01:08:27,160 --> 01:08:28,720
So I would go with that one first

1793
01:08:28,720 --> 01:08:30,920
and then just reach out to people

1794
01:08:30,920 --> 01:08:32,120
that are on the podcast, right?

1795
01:08:32,120 --> 01:08:34,880
So like if, in the example, right?

1796
01:08:34,880 --> 01:08:38,840
So you're in Michigan, right? I would just call Dr. Simmons.

1797
01:08:38,840 --> 01:08:41,000
Hey, Dr. Simmons, do you have a partner in Michigan?

1798
01:08:41,000 --> 01:08:42,840
And ask him, right?

1799
01:08:42,840 --> 01:08:44,840
And then let him say what he said.

1800
01:08:44,840 --> 01:08:45,760
Which is a great idea.

1801
01:08:45,760 --> 01:08:47,520
Because if you haven't worked with the CSMA,

1802
01:08:47,520 --> 01:08:49,400
and you can call them directly,

1803
01:08:49,400 --> 01:08:50,680
all the info is on their website,

1804
01:08:50,680 --> 01:08:52,480
but that staff's gonna help you.

1805
01:08:52,480 --> 01:08:53,920
They will find what you need.

1806
01:08:54,960 --> 01:08:56,480
Right, I mean, they're the ones that brought us together.

1807
01:08:56,480 --> 01:08:58,000
So I wanna give them as much credit as I can.

1808
01:08:58,000 --> 01:09:01,200
So it's, I would just go with, I mean,

1809
01:09:01,200 --> 01:09:03,440
but also important to note is you don't have

1810
01:09:03,440 --> 01:09:05,040
to stay in Michigan.

1811
01:09:05,040 --> 01:09:07,280
I have patients fly in.

1812
01:09:07,280 --> 01:09:10,440
I had patients fly internationally

1813
01:09:10,440 --> 01:09:12,360
when I was at what was called the Houston Methodist

1814
01:09:12,360 --> 01:09:14,200
Neurological Institute.

1815
01:09:14,200 --> 01:09:15,880
Most of my patients weren't moved, actually.

1816
01:09:15,880 --> 01:09:19,160
Most of our patients were actually traveling patients

1817
01:09:19,160 --> 01:09:21,760
who came in from different cities, different states

1818
01:09:21,760 --> 01:09:23,440
because of the doctors.

1819
01:09:23,440 --> 01:09:25,120
And then because of the doctors, you know,

1820
01:09:25,120 --> 01:09:27,560
the lab had to meet their expectations.

1821
01:09:27,560 --> 01:09:30,120
The lab was also a pretty high standard lab

1822
01:09:30,120 --> 01:09:31,780
and it is showed, right?

1823
01:09:31,780 --> 01:09:34,680
So I recently met up with the crew that I worked with

1824
01:09:34,680 --> 01:09:36,720
like 10 years ago at the Houston meeting

1825
01:09:36,720 --> 01:09:39,920
and we still have stories like from the nights there,

1826
01:09:39,920 --> 01:09:41,480
which were pretty incredible.

1827
01:09:41,480 --> 01:09:42,320
That is awesome.

1828
01:09:42,320 --> 01:09:43,960
All right, so you alluded to this.

1829
01:09:43,960 --> 01:09:46,520
So I wanna give parents kind of a heads up.

1830
01:09:46,520 --> 01:09:49,640
This is, it kind of just evolved this way.

1831
01:09:49,640 --> 01:09:52,200
So this is the beginning of a four part series

1832
01:09:52,200 --> 01:09:55,760
that we're gonna be doing specifically around sleep.

1833
01:09:55,760 --> 01:09:57,760
It's like testing.

1834
01:09:57,760 --> 01:10:01,480
And you wanna give us, just give them a little insight

1835
01:10:01,480 --> 01:10:04,560
into we've got Jordan coming and Dmitri and James.

1836
01:10:05,680 --> 01:10:08,080
Yeah, so these people I've all worked with in the past.

1837
01:10:08,080 --> 01:10:10,200
So Jordan is now the head of education

1838
01:10:10,200 --> 01:10:12,700
at the Texas Children's Hospital.

1839
01:10:12,700 --> 01:10:15,900
So she runs exclusively pediatric studies

1840
01:10:15,900 --> 01:10:17,200
and she trains the technicians,

1841
01:10:17,200 --> 01:10:18,460
kind of like how I'm training you

1842
01:10:18,460 --> 01:10:19,800
on the importance of doing one.

1843
01:10:19,800 --> 01:10:20,640
She trains the technicians

1844
01:10:20,640 --> 01:10:22,080
on the importance of doing it correctly.

1845
01:10:22,080 --> 01:10:24,560
So she does the full PSGs.

1846
01:10:24,560 --> 01:10:26,800
She is the person, and she's not the person in this image here,

1847
01:10:26,800 --> 01:10:30,440
but she trains the person that would be in this image

1848
01:10:30,440 --> 01:10:32,680
and then she trains them up to get the point

1849
01:10:32,680 --> 01:10:34,280
where they're able to pass the exam.

1850
01:10:34,280 --> 01:10:36,560
Cause as a, we saw on my first slide, right?

1851
01:10:36,560 --> 01:10:41,000
The RPSGET, that's what she has to get her technicians

1852
01:10:41,000 --> 01:10:42,680
either renewed if they have it

1853
01:10:42,680 --> 01:10:44,820
or they need to get it if they don't have it.

1854
01:10:44,820 --> 01:10:48,400
So that's Jordan, she's talking about technician education

1855
01:10:48,400 --> 01:10:49,840
and whatever else she has talked about.

1856
01:10:49,840 --> 01:10:51,880
We have James Cardell, who I work with.

1857
01:10:51,880 --> 01:10:54,240
He actually purchased this equipment.

1858
01:10:54,240 --> 01:10:57,720
You see on the plot here called Compumetics Profusion.

1859
01:10:57,720 --> 01:11:00,080
And that's the software I also demonstrated later

1860
01:11:00,080 --> 01:11:01,360
in this presentation.

1861
01:11:01,360 --> 01:11:03,000
I work with him as a specialist,

1862
01:11:03,000 --> 01:11:04,440
so a specialist is a person that comes in

1863
01:11:04,440 --> 01:11:06,920
and deals with all the cabling and firewalls and all.

1864
01:11:06,920 --> 01:11:09,320
So I sat in contact with him for the last four years

1865
01:11:09,320 --> 01:11:13,280
and he runs Lucille Packard's Children's Hospitals Sleep

1866
01:11:13,280 --> 01:11:14,120
Center.

1867
01:11:14,120 --> 01:11:15,800
So he works during the day.

1868
01:11:15,800 --> 01:11:18,240
What happens is we saw on the plot,

1869
01:11:19,400 --> 01:11:22,120
you saw here like these little boxes

1870
01:11:22,120 --> 01:11:25,000
where it says Riva and Arousal and it says stage two.

1871
01:11:25,000 --> 01:11:27,640
What he will do is he will go through each 30 seconds

1872
01:11:27,640 --> 01:11:31,520
and use this exact software to stage it,

1873
01:11:31,520 --> 01:11:33,240
score it and then run the reports

1874
01:11:33,240 --> 01:11:35,000
and generate these little tables.

1875
01:11:35,000 --> 01:11:36,640
So he's called a scoring technology.

1876
01:11:36,640 --> 01:11:39,040
So we'll talk about how to classify the event.

1877
01:11:39,040 --> 01:11:41,800
Like why is that a Rira versus why is that a hypopnea

1878
01:11:41,800 --> 01:11:43,320
versus an apnea versus central?

1879
01:11:43,320 --> 01:11:44,720
Like how do you make that distinction

1880
01:11:44,720 --> 01:11:46,200
and how many percent do you saturation

1881
01:11:46,200 --> 01:11:47,840
to point where it counts and arousals?

1882
01:11:47,840 --> 01:11:48,680
When do they start?

1883
01:11:48,680 --> 01:11:50,360
When the end, it's like a whole science behind it.

1884
01:11:50,360 --> 01:11:51,600
And you have to click and drag.

1885
01:11:51,600 --> 01:11:52,840
It's like a whole to do.

1886
01:11:52,840 --> 01:11:56,120
And then we have Dmitri who is also a researcher

1887
01:11:56,120 --> 01:11:58,840
who also does children all the way down to birth.

1888
01:11:58,840 --> 01:12:01,240
So he is gonna talk about his research

1889
01:12:01,240 --> 01:12:04,120
and his other experience working with pediatrics.

1890
01:12:04,120 --> 01:12:06,680
So all three people I'm recommending to you, Rebecca,

1891
01:12:06,680 --> 01:12:10,240
are all pediatric focused RPSGTs.

1892
01:12:10,240 --> 01:12:14,360
So my experience, I left the lab and went into industry

1893
01:12:14,360 --> 01:12:17,560
and became an engineer and I worked more on like the acquisition

1894
01:12:17,560 --> 01:12:19,760
for the publications and for the FDA approvals

1895
01:12:19,760 --> 01:12:21,520
for novel devices.

1896
01:12:21,520 --> 01:12:25,120
But my partners that I'm recommending are still frontline

1897
01:12:25,120 --> 01:12:26,680
dealing with patients, dealing with parents,

1898
01:12:26,680 --> 01:12:29,600
dealing with airways and keeping up with the advancements.

1899
01:12:29,600 --> 01:12:31,200
And they just call me whenever the computer breaks down

1900
01:12:31,200 --> 01:12:33,200
and I help them when they need that help.

1901
01:12:33,200 --> 01:12:34,280
That's awesome.

1902
01:12:34,280 --> 01:12:35,120
I love them.

1903
01:12:35,120 --> 01:12:40,040
So parents, if you're hearing this in a month or two,

1904
01:12:41,080 --> 01:12:44,520
the links in these podcasts we're talking about

1905
01:12:44,520 --> 01:12:45,360
will be included.

1906
01:12:45,360 --> 01:12:48,920
But if not, if you're hearing this, you know,

1907
01:12:48,920 --> 01:12:53,240
July, June, July, then we invite you to just stay tuned

1908
01:12:53,240 --> 01:12:56,960
because these other three episodes are on the horizon.

1909
01:12:58,360 --> 01:13:00,280
Yes, I look forward to hearing them myself, you know.

1910
01:13:00,280 --> 01:13:01,640
They all, we all learn from each other.

1911
01:13:01,640 --> 01:13:02,880
Even though I've been doing this for a long time,

1912
01:13:02,880 --> 01:13:06,880
I'm sure I can learn from all three of the future attendees.

1913
01:13:06,880 --> 01:13:07,720
Which is awesome.

1914
01:13:07,720 --> 01:13:10,920
Well, I cannot thank you enough for this.

1915
01:13:10,920 --> 01:13:13,320
Even though you made me quiz my way through it,

1916
01:13:13,320 --> 01:13:14,480
I still cannot thank you.

1917
01:13:14,480 --> 01:13:15,320
You did great.

1918
01:13:15,320 --> 01:13:16,160
Thank you for it.

1919
01:13:16,160 --> 01:13:17,880
It was a real, I mean, being able to see this

1920
01:13:17,880 --> 01:13:22,080
and have it explained is really, as a parent,

1921
01:13:22,080 --> 01:13:25,280
it's really eye-opening, a little jarring to think.

1922
01:13:25,280 --> 01:13:26,440
Wow, I mean, you see it.

1923
01:13:26,440 --> 01:13:29,040
Boom, your kid is not breathing for 20, 30, 40.

1924
01:13:29,040 --> 01:13:30,320
That's crazy.

1925
01:13:30,320 --> 01:13:32,440
So thank you very much for taking all the time

1926
01:13:32,440 --> 01:13:34,520
to explain all those to us.

1927
01:13:34,520 --> 01:13:36,200
And what I would like to do again,

1928
01:13:36,200 --> 01:13:38,000
whenever you have the chance is to actually,

1929
01:13:38,000 --> 01:13:40,200
if you have a recording or a report,

1930
01:13:40,200 --> 01:13:42,440
you know, we can review it and we can see the details

1931
01:13:42,440 --> 01:13:44,040
of that because it's more impactful.

1932
01:13:44,040 --> 01:13:46,960
Like I gave all these examples from other people,

1933
01:13:46,960 --> 01:13:48,680
unless you're own patient or your own child,

1934
01:13:48,680 --> 01:13:50,680
then I think it'll be even more impactful.

1935
01:13:50,680 --> 01:13:52,160
It's not something we could do in the future.

1936
01:13:52,160 --> 01:13:55,400
Until then, I do have a recording on YouTube.

1937
01:13:55,400 --> 01:13:58,240
It's actually on the TEDx channel, you can look up.

1938
01:13:58,240 --> 01:14:01,000
And we have that event in September.

1939
01:14:01,000 --> 01:14:02,560
But it does compete, Rebecca can't go,

1940
01:14:02,560 --> 01:14:03,920
she has also a competing event.

1941
01:14:03,920 --> 01:14:06,360
So it depends if you want to re-know our Texas,

1942
01:14:06,360 --> 01:14:08,240
my events in Texas, obviously.

1943
01:14:08,240 --> 01:14:10,120
And then I'm also on LinkedIn.

1944
01:14:10,120 --> 01:14:11,800
So I think all those will be in some comments.

1945
01:14:11,800 --> 01:14:12,640
Her show notes are-

1946
01:14:12,640 --> 01:14:14,160
Yep, all that's gonna be in the show notes.

1947
01:14:14,160 --> 01:14:16,360
Yep, and the TED talk is awesome.

1948
01:14:16,360 --> 01:14:17,520
I've heard it and promoted it.

1949
01:14:17,520 --> 01:14:18,880
I was super proud of it.

1950
01:14:18,880 --> 01:14:21,920
So it's on here and it actually is on our YouTube channel.

1951
01:14:21,920 --> 01:14:26,920
Right now, it's underneath the playlist for sleep.

1952
01:14:28,880 --> 01:14:30,400
So check it out if you haven't.

1953
01:14:31,520 --> 01:14:33,160
Check it out if you haven't.

1954
01:14:33,160 --> 01:14:35,000
Yes, Rebecca, this was great.

1955
01:14:35,000 --> 01:14:36,240
This was great, this was a ton of fun.

1956
01:14:36,240 --> 01:14:38,040
And you handled the quiz really well.

1957
01:14:38,040 --> 01:14:41,000
I give you full credit, you pass with an A plus.

1958
01:14:41,000 --> 01:14:41,840
I'll take it.

1959
01:14:41,840 --> 01:14:43,280
There you go.

1960
01:14:43,280 --> 01:14:44,520
Thank you.

1961
01:14:44,520 --> 01:14:46,520
You can stay connected with the Children's Airway

1962
01:14:46,520 --> 01:14:50,280
First Foundation by following us on Instagram, Facebook,

1963
01:14:50,280 --> 01:14:52,600
X, LinkedIn, and YouTube.

1964
01:14:53,600 --> 01:14:56,480
Don't forget to subscribe to the Airway First podcast

1965
01:14:56,480 --> 01:14:58,640
on your favorite podcasting platform

1966
01:14:58,640 --> 01:15:00,560
so you won't miss an upcoming episode.

1967
01:15:02,200 --> 01:15:03,480
If you'd like to be a guest

1968
01:15:03,480 --> 01:15:05,520
or have an idea for an upcoming show,

1969
01:15:05,520 --> 01:15:08,320
shoot us a note via the contacts page on our website

1970
01:15:08,320 --> 01:15:13,320
or send us an email directly at infoatchildrensairwayfirst.org.

1971
01:15:13,320 --> 01:15:15,520
Today's episode was written and directed

1972
01:15:15,520 --> 01:15:16,960
by Rebecca St. James,

1973
01:15:16,960 --> 01:15:19,720
video editing and promotion by Ryan Draughn

1974
01:15:19,720 --> 01:15:22,920
and guest outreach by Kristie Bojikian.

1975
01:15:24,320 --> 01:15:26,320
And finally, thanks to all the parents

1976
01:15:26,320 --> 01:15:28,040
and medical professionals out there

1977
01:15:28,040 --> 01:15:30,320
that are working hard to help make the lives of kids

1978
01:15:30,320 --> 01:15:33,040
around the globe just a little bit better.

1979
01:15:33,040 --> 01:15:44,040
Take care, stay safe, and happy breathing, everyone.

1980
01:16:03,040 --> 01:16:05,040
Thank you.