Sleep Apnea: Testing and Treatment

Foreign. Talk about night lays procedure and sleep apnea. So sleep apnea is a very common condition. It's defined as having periods during the night when you're sleeping where you stop breathing or under breathe for at least 10 seconds and the action count drops by at least 3 or 4%, depending on which criteria we're using. And is scored in how many times this occurs in a given night. It's measured with a sleep test. And we'll talk later about why this is important to measure with a sleep test now that traditionally we'd go to a hospital or a sleep lab. You get hooked up with some equipment, oxygen sensors and brainwaves sensors and sensors moving your chest and position sensors. And you know you're in a, in a foreign environment, not sleep in your own bed. And they would measure how many times a night does your breathing cease. And it's something where somebody's, you know, breathing in deep, they start, they start choking. And you probably heard of this in your, in your life sometime. It could be your significant other somebody when you're camping or something like that. And they give them a measurement the next morning of how many times they had apnea. And the way it's measured is in a score of 0 to up to whatever. There's not actually a ceiling. But typically zero to a hundred and zero means you never had a period where you stopped breathing or under breathed, which is called hypopnea. Stopping breathing apnea for 10 seconds where the action count dropped at least 3 or 4%. And, and we're talking about obstructive sleep apnea, which is caused by the airway collapsing versus something called central apnea, which is something totally different and is related to your brain not stimulating your body to sleep. So obstructive sleep apnea and central sleep apnea are measured by a sleep study. And that traditionally had been in a, in a sleep lab and now it's actually done at home with a device. There's something called the watch pat W a T C H like watch and pat P a T pulse amplitude technology that's FDA approved and commonly covered by insurance to measure your sleep at home. And even your insurance doesn't come cover is not very expensive, just a little over a hundred bucks. And so watch the device goes on your wrist like a watch and there's a sensor goes in your chest and a sensor goes in your fingertips and it gives us pretty much the same measurement. If somebody's relatively healthy, they don't have major obesity or major lung disease or heart failure atrial fibrillation. It works pretty much as good as a sleep lab. So this makes it much easier for doctors to diagnose sleep apnea because now it's not so cumbersome going to an expensive lab and something that a lot of people just don't want to do. So that's sleep apne measurement. Sleep apnea is given a score, and the score less than five would be considered normal. That means five times per hour you stop breathing or stop breathing, which is apnea or under breathing. Hypopnea for at least 10 seconds in action dropped at least 3 or 4%. And the reason I say 3 or 4%, there's two different competing guidelines. There's the American Society of Sleep Medicine that puts at 3%, and there's the federal government that puts at 4%. Long story about why that is, but basically government's trying to save money and not, not treat conditions as broad as American Academy of Sleep Medicine would like them to. If the score is 5 to 15, it's considered mild sleep apnea. And in most people that are generally healthy, it may not have any significant clinical consequences. The score is 15 to 30. Now it's moderate sleep apnea. And even without other medical conditions, the stubs have consequences. And if it's more than 30 means more than 30 times an hour every other minute, that's called severe sleep apnea. This has major health ramifications. I'm going to spend a lot of time talking about that. So mild to none, Mild, moderate or severe. So if your bed partner, significant other is snoring at night, there's a good chance they have sleep apnea. If you're a male over 50, we can just say there's a good chance you have sleep apnea, better than a 50% chance. And if you're a woman over 50, there's probably more like a 30% chance you have sleep apnea. So let's talk about the incidence of sleep apnea. So the first study that was looking at how often does sleep apnea occur and then, so what was done in 1988 started in 1988, the University of Wisconsin, Madison, by the National Institutes of Health, and they set out to determine what's the instance of sleep apnea. And so what is it a condition we need to worry about? Because back then we didn't really have much effective treatment for it. It was just being thought of, treated, and we didn't think much about it. Went to records of employed, employed people that were 30 to 60 years old, and they selected 6,000 ask them to participate in a multi year study to assess the outcomes of sleep apnea. And about half of them agreed. 3,000 people of that half of them had the sleep study and the other half conservative controls. So 1500 people were measured for sleep apnea. And they discovered that about 1 out of 4 men and 1 out of 10 women at that time, 1988, had sleep apnea with a score at least 5 or higher. So fast forward 20 years later, they, they did the study, they gave the people their answer. They didn't recommend treatment or anything, said hey, this is, you know, this is a score you have. And they went back 20 years later and they basically looked at the death records. They would track everybody down in the study for the most part. And what they found were people that had a score over 30 that is severe sleep apnea compared to people that did not have sleep apnea, they were three times as likely to have died. Now again, they started at age 30 to 60, so they're fairly young. Now they're 50 to 80 and they were three times more likely to die even when you, they adjusted for other comorbidities. In other words, they've matched smokers to smokers and obesity to obesity and hypertension. Hypertension all cause mortality was up by 3.3x. And the most common, the most significant increase in mortality was from cardiovascular disease. In fact, they looked at people that had the sleep apnea that was severe and they didn't treat it, which is another subgroup. They were five times more likely to die of a heart attack or stroke in that intervening 20 years when they were, you know, would have been at the age 50 to 80. So huge significance. Now the people that had mild to moderate sleep apnea were more likely to be dead, in fact about 50% more likely. But the study was not large enough to make that statistically significant. So we cannot infer from the study that if you have mild to moderate sleep apnea that you'll more likely be dead, particularly if you don't treat it in the next 20 years. But the study would suggest that, and logic would suggest that, but it just wasn't powered for that. They probably would need twice as big of a study to determine that. That's where we're okay. So 25% of men, roughly 10% of women had sleep apnea in 1988. Well, some things have changed since then. Since 1988, our rate of obesity has gone up significantly. So it's gone up significantly. Additionally, they studied people 30 to 60, but studied people 60 to 70, so we look at larger studies. There's one called the Hip Laos study and the Ship trend study. Both of these are done in Europe, Germany, in Switzerland and they did a bigger age range of people, roughly 27 years old. They find that. And again these are the more more recent studies. They more more reflect our current size of people. Now we're finding that roughly 60 to 80% of men and 25 to 35% of women have sleep apnea. So men majority do have sleep apnea and women less than majority have sleep apnea. It's still common. So this is a very common condition and I'm talking about it in the realm of a procedure we do called night lays, which is a laser service that we offer at Allure where we can reverse sleep apnea or at least substantially reduce the score. But let's go over the implications of not treating sleep apnea, conventional treatments for sleep apnea and some of the more modern treatments for sleep apnea. So cardiovascular disease undoubtedly rate of cardiovascular events goes up. In sleep apnea. Study done Mayo Clinic where they looked at Medicare database, they found that people with comorbidity of both sleep apnea and cardio cardiovascular disease, if they treated the sleep apnea, the annual cost of the cardiovascular disease declined and the number of hospitalizations and events declined. There's numerous studies showing that there's a positive effect of treating sleep apnea. I know there's not a good study to say that if you treat your sleep apnea you have the same outcome as somebody doesn't have sleep apnea in the first place. The studies would suggest that, but that's not a foregone conclusion. So there's be some people that would dispute treating sleep apnea at all. But this is generally regarded as a standard care. If you have sleep apnea, you should treat it or you suffer ill consequences, particularly more cardiovascular mortality. What about weight? So that's a big concern, right? Today in the days of using these GLP1 agonists and GIP drugs such as semaglutide, we're seeing that this can effectively reduce weight. Well, does sleep apnea cause weight gain or weight loss? Okay, let's look at the study. So is bi directional. If you have obesity, you're more likely to have sleep apnea. And if you lose weight, if you have sleep apnea, it's likely to get better, but it typically won't go away. However, studies have shown people that have sleep apnea and obesity, their diet effects diet, their efforts to lose weight generally are ineffective until they treat the Sleep apnea. So let's restate that. People with sleep apnea, they're trying to lose weight, have a very difficult time losing the weight until they treat the sleep apnea. Now, that's not to say that treating sleep apnea, the weight just falls off. That does not happen. You still have to make efforts, but the efforts are much more rewarded if we treat the sleep apnea. And going back to the incidents, we said that men are more likely to have sleep apnea, women about twice as likely. Older people are more likely to have sleep apnea than younger people. And people that are obese are more likely to have sleep apnea than somebody that's young or somebody that's not obese. So a obese older male most certainly has sleep apnea, whereas a young non obese female has a lower probability of having sleep apnea, probably more like 5 or 10%. So we all fall somewhere in that realm. So we talked about the cardiovascular risk of untreated sleep apnea or sleep apnea by itself and let alone untreated sleep apnea. Those studies were done in the 80s on people that were 60 to 80 years old, and that's the most likely thing they'd succumb from. What about cancer? Well, it doesn't appear that there's any strong link between cancer and sleep apnea. What about neurocognitive decline? Well, bingo. That's one we got to worry about. So those people continue to age, we can continue to see what happens. So neurocognitive decline, a classic one we think about might be Alzheimer's disease, where people have these plaques in their brains and these amyloid plaques and tau plaques. How they get there and how do we get them out of there? This is a big, you know, this is where the science is going right now. How do we get these things out of the brain so that people could decline less or maybe can live a normal active life versus being encumbrant by their brain. So the we could talk a lot about sleep and Alzheimer's, but there's some large studies prior to knowing about sleep apnea. One of them was a woman's, women's Nurses health study, the Nurses Health study, where they looked at tens of thousands of women. They've kind of followed them along. We found that there's a clear association between short sleep and neurocognitive decline. There's a clear association between short sleep and obesity. There's a clear association between short sleep and neurocognitive decline. And short sleep is a fairly good Kind of canary coal mine for having sleep apnea because people sleep apnea do have poor sleep since that time. We have actual data on people that have sleep apnea and we see that people that have sleep apnea when it's not treated, they typically get Alzheimer's a decade sooner than those that do not have sleep apnea. They get sleep, they get Alzheimer's at a higher rate, about a 65% higher rate. Sooner onset. And sleep apnea when it's treated, slows the decline in the face of Alzheimer's. Now, we don't know does treating sleep apnea prevent Alzheimer's? Probably reduces it, but there's no evidence to suggest that. And certainly treating the sleep apnea reduces the decline in cognition in those that have both Alzheimer's and sleep apnea. There's a strong correlation between sleep apnea, particularly untreated sleep apnea, and neurocognitive decline. And once somebody really gets in bad shape with sleep apnea, they're not going to comply with wearing the device you wear to treat your sleep apnea. So when one of your. Somebody in your, in your family, or if you're a doctor and you're treating patients and somebody has the earliest signs of neurocognitive decline, was a sleep test done? Chances are not going back to the incidents. The American Academy of Sleep Medicine did a large study looking at the incidence of sleep apnea and whether or not we treated it. What was the economic impact of not bothering to diagnose or treat sleep apnea? Well, it turns out about four out of five people with sleep apnea don't know they have it because your doctors aren't testing for it. The U.S. preventative health care Task Force recommends against routine sleep apnea screening. Now, it sounds absurd, but they're trying to control the purse strings because if we approve screening, which we historically have not allowed screening to occur, if you look at, say, breast cancer screening, colon cancer screening, this only really started to be required to be covered in 2010. So this is a modern concept. The US Preventive Healthcare Task Force recommends against screening for sleep apnea, saying it's just too expensive, it's not worth it. Well, we know that this increases your risk of death by 3x if you miss it. Why would they suggest it again? It's all about dollars and cents. Look where their money's coming from. Getting back to that, the American Academy of Sleep Study commissioned Foster and Swift to do a large study. This is back in 17, and they were basing it on the 1988 incidents study, which much were much higher now, but it's about $150 billion a year back then that we're wasting in healthcare costs and other related costs by not diagnosing and treating sleep ap. Now of course, treating sleep apnea, there's costs with it, but you take all the money we waste by not treating at all, subtract off the cost of diagnosing, treating, we still save $150 billion a year as a society. That's huge. There's a large trucking company that did their own study because they have these, you know, generally men driving that tend to be overweight that are driving these, you know, 20 to 80,000 pound killing machines down the highway. And sleep apnea leads to fatalities because they fall asleep on the road if they're getting poor sleep. So sleep apnea, not just you're, they're, they think they're sleeping great because they pass out and they sleep and they wake up in the morning, don't really feel refreshed, but they know they slept eight hours. Well, when you're having these constant interruptions in your sleep, you're not getting good deep sleep. They fall asleep during the day. What they found was that they saved tremendously on preventable accidents, but also their hospitalizations plummeted, healthcare costs plummeted. And in that study they found that 84% of the men, 84% of their truck drivers had sleep apnea. So that's pretty alarming. Now it's routine to screen truckers for sleep apnea. Getting back to the neurocognitive decline. So what's going on? Well, we look at sleep apnea and when somebody has sleep apnea, particular scores higher, they don't get very much deep sleep. And our brain needs to clear itself out at night. So we have these, the system called the glymphatic system, it's kind of like the lymphatic system but with a gym that cleans out our brain at night. And there's got to be a differential in the brain and the blood of these proteins so we can get them out of our brain. These are these amyloid and tau proteins we talked about earlier. And when deep sleep is interrupted, this system is not very effective. The brain is not getting rid of these toxins that accumulate. Eventually they accumulate and we can see them on an mri. And that's how, that's part of how we diagnose Alzheimer's, Alzheimer's diagnosis, mostly clinical diagnosis, but there's changes you can see on MRI and there's Also you can do a spinal tap and find these proteins high in the spinal fluid. There's also a blood test now that seems to be able to detect risk of Alzheimer's disease. I've had it done. So I fortunately have low risk. There's a, there's a genetic factor to Alzheimer's as well. There's, it's called apoe. There's two, three and four. And if you have a two copies of four, you have a very, very high incidence of Alzheimer's, about 25 times higher. If you have two copies of two, you have a lower risk. And if you have copies of three, you have an intermediate risk and then there's mixes in between. I'm a three, so intermediate risk. My mother died of Alzheimer's so I'm concerned about scan my brain to make sure that I'm staying keeping a young brain. So sleep apnea, cardiovascular disease, sleep apnea, obesity, sleep apnea, neurocognitive kind, even sleep apnea, trucking accidents. So sleep apnea is not screened for enough. The government recommends against it. Now you can certainly get a sleep apnea test but your doctor's got to, you know, jump through some hoops to get you approved. If you don't meet the approval, you're going to pay for it yourself. Again, these things are cheap to do on your own. Not a sleep labs, not cheap. That might be a couple thousand dollars. But these watchpad devices are rough. 100 to 200 bucks for something that can, you know, change your life. So I recommend doing it. I recommend everybody just get routinely screened. Even my, I have this aura ring and it, it doesn't give me a score, but it shows those little hashtags. When you do have apnea big events, it can't give you an actual score. Be considered a medical advice. It wouldn't be. I'll sell it. But it does show there's apneic events. I did have sleep apnea and I treated myself with night laser and 15, it's never come back. My score is 1.7 which is totally normal. So the diagnosis we talked about that watch pad, there's something called a night owl which is a little fingertip one. Probably pretty good. They're certainly cheaper. We're not using it. They kind of look cheap. They don't give as much information but they're price efficient. Then of course a sleep lab is a gold standard. Once you do have a diagnosis of sleep apnea, I'm not suggesting what kind of treatment you undergo, but I'm suggesting that you do take it seriously and treat this because neurocognitive sign 10 years earlier much more likely cardiovascular disease 3 3x is often and obesity and just some general health. I mean you should be getting good sleep. The standard is called a CPAP continuous positive airway pressure. And this is a device that goes over the mouth or the nose and mouth or just the nose and helps force air in when you under breathe at night. So it's a little machine that's they used to be really kind of big and noisy. Now they're much more compact. They can be traveled with. I wore one once because I had a spinal surgery and the spinal surgery called air caused airway edema. I hadn't had apnea before because I already treated myself and it was made my mouth dry and my face was kind of sore. And then it went away fortunately because I had the surgery and then my neck healed up. But it was unpleasant so I'd be one of the people that didn't like to wear it. We know that of the 1 out of 4 people that do know they have sleep apnea, only 1 out of 3 of those actually get treated. So the incidence of treating sleep apnea is very low. When it is treated, it's generally with cpap. There was a surgery that was done for years where they would cut out some of the tissues, open up the airway. Kind of mostly shunned against. Now there's a lot of failures and complications with it. There's a surgery called Inspire Inspire that's just got approved recently. It's generally not covered by insurance, most insurance yet. But it's like a pacemaker device. It goes on the right of her chest. Looks like a pacemaker wire goes up the hypoglossal nerve and it stimulates it to open up at night so you can breathe. About $40,000 has some potential major complications like losing your voice and stuff. And then we do what's called the night lays Night like laser Night Lays. It's a FDA approved machine for for this indication. It treat soft palate which is the back of the throat, the UV thing hanging down the back of the tongue which might be fat and thick in the floor of the mouth to bring the tongue forward. And we treat the entire region. It's done with a laser called sub ablative. So there's no tissue removed and takes roughly 45 minutes. You don't have to be knocked out for somebody. We use a little numbing spray. Most people just tolerate it. It's this hot and typically you have to do it about three times, two to three weeks apart. For people that have mild to moderate sleep apnea and people that have severe sleep apnea or they're obese or they have had previous CPAP Mach. We treat them five times about three weeks apart and we typically see about a 65 to 70% reduction and a sleep apnea score which in most cases put you into clinically insignificant range. So the night lays first came out for treating snoring which is a like a sister of sleep apnea. Snoring, the airways kind of collapsing, you're making noise at night. Most people snoring have some degree of sleep apnea and most of sleep apnea have some degree of snoring. Not universal, but that's a good sign. And it was effective for sleep apnea. I'm sorry for snoring. And the first studies they were just kind of treating the back of the throat and it was hit and miss. It worked for most people. Not entirely. Probably last two, three years. And then we started getting more aggressive by treating the entire all the way around. It's referred to as sleep. I referred to as night. LA360 Dr. Down in Florida, shift shipman, he's a dentist, really kind of really popularized this and was trained as a ton of doctors and dentists. I'm not, not a dentist, I'm a medical doctor. But he did treat me or trained me and technique's been really good. We're seeing that we can pull that tongue forward, reduce the airway actually gets bigger. People get more air through, they're not choking as much. Slee sleep apnea score comes down. And how long does it last? Not clear. But if your weight stays about the same, probably last several years. Mine's last at least seven years. And we would probably check this test again in a year or so to see if you've gotten it back to give your weights gone up. And the take home message is that if you have sleep apnea, doesn't matter what you do to treat it, don't ignore it. That's that's the key. So you have cpap, the inspire surgical procedure. There is some dental appliances. While some dentists treat sleep apnea. They have these devices that pull the jaw for those work in a lot of patients. And then the night lays procedure which we do at Allure. There's a lot of doctors throughout the country that do this. This is actually technology invented in Slovenia, in Europe, very popular South America, Europe and the United States. And they're. Do you see these machines all over the country and people are trained to do it. So if you Google night lays, if you're not near the lure office, we have it in Michigan. There's a couple of practices that have it not doing a lot of night lays, however, because it's used for different things. So we're the main ones doing it in Michigan. But states you'll find some doctor that does night laser. You always do the go to the Fotana Foto website and do a physician binder. I've referred a lot of people to different doctors in different states and it tends to be more done by dentists because this is also lasers also use a dentistry, although we use it in medical. I use our laser, the Fotana machine a little different than a dental one, but it does the sleep apnea. Also treats vaginal laxity and vaginal dryness. So night lays for sleep apnea. I think everybody should be screened again. The screening test is inexpensive. You don't need to run it through your insurance if you don't want, you know, you're wanting to go. Go through the hassle of your insurance, you know, denying it. I don't want to say the price right now because these podcasts stick around and prices change, but they're not that expensive. It's done at home, and as soon as you wake, you hook it up to your phone with an app and then it connects to the device. And then in the morning, you, when you go to bed, you start it. When you get up in the morning, you stop it and the report goes right to your doctor's office, in this case our office, and we see it right away and the PA looks at it in the morning and we give the patient a call and go over with them. So thank you very much.