Episode 254: M is for Measurement with Dr. Karen Parker Davidson DHA, MSA, M.Ed., MSN, RN

Hi and welcome to episode 254 of the Untethered podcast. Today we have Dr. Karen Parker Davidson joining us. Dr. Davidson is a renowned expert in the field of nasal function, objective nasal measurements, the interpretation of the data for treatment options, the clinical progress, and the instruments used to capture the measurement data. For more than three decades, she's held several positions in the medical device industry, various clinical nursing positions, and specialty certifications in the private sector, as well as time in the U.S. air Force reserves as a flight and critical care nurse. As a respected educator and adject professor at Liberty University and Central Central Michigan University, she has conducted numerous workshops and seminars sharing her insights and techniques with fellow professionals in the dental and healthcare fields. She believes in the power of early intervention and the transformative impact can have on one's quality of life. Her research can be found in medical journals and magazines discussing airway disorders in her new book Breathe through your nose, don't pay through it, the impact the healthcare industry has on nasal function and how we breathe, and is a co author of upcoming releases the Power of the Tongue. In the beginning we were all tongue.

Tied in sleep apnea and pregnancy, the.

Female response to sleep breathing disorders. As a contributing author to Growing into breathing problems to us for collaborative Lifetime solutions and Health Informatics and patient safety in times of crisis. She holds a Doctor of Health Administration degree with focus in Health Policy, three Master degrees in Health Sciences Administration, Nursing and Education, a Bachelor's Degree in Nursing, and is currently pursuing a PhD in business administration with an emphasis on International Business. She's a member of the American College of Healthcare Executives. Through her work, Dr. Davidson continues to inspire and empower individuals to achieve optimal nasal function and overall wellness. She calls the Annapolis, Maryland area home where she resides with her son and two dogs.

Quick Disclaimer all information, content and material.

Of this podcast are the opinions of the speakers and is for the informational.

Purpose only and not intended to serve.

As a substitute for the consultation, diagnosis and or medical treatment of a qualified health care provider.

Welcome to the Untethered Podcast. I am your host Holly Balkan.

I'm a certified myofunctional therapist, feeding specialist, podcaster, business owner and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, airway tether, dural tissue and pediatric feeding therapy space. If you're new here, I challenge you to keep an open mind and join my mission to spread this message far and wide. If you've been around since June 2019. Thanks for being a loyal listener. As we jump into today's episode, remember to listen with correct oral rest. Posture, tongue up, lips closed, teeth apart, breathe through your nose.

Let's get started. Doctor Karen, welcome to the podcast.

Thank you for having me. Good morning.

Good morning.

I am excited to have you join us and I know you've got a whole presentation for us too. So, you know, obviously listeners, you can listen, but if someone wants to see the presentation, you can hop onto YouTube and see it there. I see right now our opening slide says M is for measurement. So I'm going to turn it over to you, Dr. Karen, and let you tell us all about M is for measurement. You know, take it away.

Thank you. So I titled this M is for measurement for a couple of reasons. Everything we do in the medical field has a numeric, quantifiable number. We measure everything. Before I give a blood pressure medication or glucose or, or insulin, we always kind of want to see where that person is as far as their blood sugars. One thing that's really impactful as far as sleep and breathing is the, the C reactive protein and that looks at, again, inflammation. So again, we're quantifying everything but the missing point and the missing puzzle piece to the airway puzzle is airway function. We talk so often about, you know, the anatomy and obstructions, but what's really key to understand is that one area of obstruction in the airway that's going to affect the whole orofacial myology, the craniofacial growth and development. 1 Obstruction does not equate to totality of function. So we kind of have to flip the script and we're getting there. This is all brand new. In fact, our first myofunctional therapist, who's a speech language pathologist, didn't take on rhino manometry. She's the first in the world. She didn't take it on until January of this year. That really emphasizes the amount of education we have to do, the connections and the interactions like we're having today. So there's a valuable point there in what we're doing. But I do want to make a disclosure statement, as I always do, as far as my financial disclosures. I am the VP of GM Instruments by contract because they're in the uk, they do sell the only global rhinomanometer. Also the CEO and founder of Fact Healthcare Consulting Group, which is my education arm for all the interpretations for rhinomonometry. And within that, I created a proprietary platform and algorithm called the DAPHNE scoring system that also has a patient portal that walks you through what all these numbers mean when you do rhinomanometry. And I also do some consulting for various dental and medical companies as well. And non financially. I am an editorial board member of Dental Sleep Practice magazine, as well as serving a four year term as a review committee member for the Commission on Dental Accreditation, also known as coda. Just want to put that out there real quick. This is my, my only thought when I work with my functional therapist, and believe you me, I love y' all because I got to work with you a lot in patients with strokes, the dysphagia, and learning how to learn, you know, retrain and swallowing. And this always kind of piqued my interest that if the tongue is the strongest muscle and the only muscle that's not connected to a bone end to end, then the nose must be the dumbbell to kind of work out that tongue. Now, it sounds kind of odd, a little crazy, but if you think of the anatomy and how close everything is, the tongue and the nose, they're. They're their kin. Their kin. But we also have to understand, how did we get here? Why are we just now talking about the nose, specifically in oral myofunctional therapy? And again, I'm guilty. I've worked with y' all back in home care days with a lot of our stroke patients, and we never looked at this. And I have a secret. I didn't even know about rhinomanometry until 2017. So I've been in the ENT world since 2002 as a vendor rep, selling all these different instrumentation and surgical trays or ENT cases, sleep medicine cases and whatnot. And I didn't know about rhino manometry until GM found me and said, hey, bring this product over to the US where it's very popular in Europe and the Asian markets. So here I am, 25 years into clinical practice and like, wow, this thing's pretty cool. What we found is that it's not so much the anatomical problems that we're having, but the functional problems. And even if you move, remove or adjust any tissue as much or as little as 1.5 millimeters, you will impact the aerodynamics of airflow and the physics of how that patient is breathing. So that's how sensitive this is when we're working anything above the shoulders. So we have that knowledge about the anatomy, we know the dynamics, we know the role of the cilia, how the nose works. But again, we're kind of missing that message as Far as resistance and nasal breathing properly, even if we have an empty nose syndrome now, this is because nasal resistance is 50% higher than oral resistance. Oxygen uptake can be about 10 to 20% higher until we reach too much resistance and then we become a mouth breather. But most importantly, we are a negative pressure circuit when we breathe and that equates to higher activation of the diaphragm for better stabilization of the of the spine. So now we get into the collaboration with our chiropractors and our physical therapists. But we also know that nasal breathing is 22% more efficient than mouth breathing. And here's what's key is that during sleep upper air resistance naturally increases, but during mouth breathing it's two and a half times higher than nasal breathing. So when we look at sleep and what we're doing during the day, especially in myofunctional therapy and with to other tissues, that person, once they go to sleep, a whole lot of things happen. When I talk about this specific like in frenectomies, it seems to be the buzz procedure, the buzz word and the buzz procedure nowadays. So my clinical nurse brain thinks okay, if you clip the frenulum, which we have throughout our body already to keep the organs in place, but if you clip that and the interior portion, what happens to that tongue? And I'll show you because it's really fascinating, it really is. Within this world of myofunctional therapy, speech, language, pathology, nasal function is going to play a crucial role not only in respiratory health and overall well being, but also with oral health, because there is an influence in our breathing, airflow and swallowing. So there is that interconnectedness between the nasal and oral cavity, not only the proximity, the close proximity of both of them, but how the changes in nasal function and transnasal pressure changes can impact oral health and vice versa. So we get into the wheelhouse of orofacial myology that efficient nasal breathing contributes to the optimal oxygen exchange which is essential for our tissue health and so on and so forth. So if we're trying to manipulate tissue and to muscle through the therapy, it only makes sense to have enough oxygenation to make those tissues work. And so here's where we also look at the nasal impact as well as our sleep and breathing patterns. Because these disruptions in nasal function obviously will affect our sleep quality, we have a nasal flow limitation that causes higher resistance in the nose that then in turn it will affect the pressures in the pharyngeal area that will in turn cause a slight drop in our oxygenation or oxygen saturation that create hypoxia, that cause an arousal, and then we wake up. So we have this vicious cycle. But for myology considerations, we also have to look at the contraction of the genioglossus muscle that's going to stabilize as well as enlarge a portion of that airway that's going to be very vulnerable when the tissue collapses during depressurization to some degree. Again, I'll show you the slide. What's really fascinating, but we have to get into that comprehensive patient care collaboration, working with our pts, working with nurse practitioners. Ironically, I just saw a paper today. 71% of us advanced practice nurses practice independently. We don't practice under a physician. So 71% of us are a great referral base for y'. All.

I had no idea.

Yeah, we. We are a great, great, great referral base. So. And that's why I do, when I do telehealth visits, I always have somebody on standby. And I'll put you on my list if you like. As I'm doing a zoom call and I see something awkward, crowded teeth, that's a red flag. I call in an orthodontist on the zoom call. Here's a link. Get on here with me and the patient. And that's how we collaborate. And it's a great networking and it's actually a great patient care situation. They love it. But there is a little bit of history there. So we talk about nasal pressure and function. It actually goes back to 1653. How we measure this is based on Pascal's. And this comes after Blaise Pascal, who was a French mathematician and philosopher, who's actually a Catholic writer as well. And he finally presented the law of pressure and explained it in a paper and a book as well back in 1653. So as we go, these transitions and how this is all incorporated, it will make sense. Then we have Henri Patois, who was a French hydraulic engineer, who created this tube to take on Pascal's pressure theory. Guess what? Now we're getting into rhino manometry. And so that led into the refrigerator plate, which you all use a lot of times. That was in 1894. And then we get into passive rhino manometry in 1895. So you can see how the transition is pretty picking up the importance of these pressure changes of what's happening in the nose. Then we jump. We'll jump into 1958, where Dr. Simerak, he finally described nasal patency and the assessment with a device. So in 1966, Dr. Klaus Vaught. He is my mentor. Acute story. He is the father of rhinomanometry. He's a dentist, a formal oral maxillofacial surgeon, and an ent. He got completely frustrated with what the patients were telling him after sinus surgery. Oh, yes, Doc, I can breathe. I can breathe. But he just felt like this sixth sense, like something was wrong. So he created the first digital rhinomanometer and started measuring his patients to find what they were saying and what he was measuring were two different things. Hence, we need the M for measurement because we also cannot manage what is not measured. Think about that. We have to be able to manage and measure these outcomes so that we know what we're doing is actually working. So a cute story about Dr. Vaught. He trained Dr. Christian Gimino on rhino manometry, and Dr. Gimino was going to do a talk in riga back in 1989, and he told the organization, he said, I will do the talk only if you have Dr. Vaught there and you invite him. Okay? So Dr. Vaught went and he met Dr. Gimino in 1989, and the rest is history. He also taught Dr. Eugene Kern and Dr. Tucker Woodson. Those are other two big names in sleep. So this January, Dr. Vaught reaches out to me and he says, well, you're the VP of GM Instruments and I'm the father of Random Manometry, and we're the only two in the world that really know this product. Do you think we should work together? Sure. Don't ask me twice. So we connect, we have a few conversations on Zoom. He's lovely, he's German, and he's 87 years old now, so he's up there in years. And he said, karen, I'm ready to retire. I need a legacy. I'm going to send you all of my work, and I want you to carry on my message and my work. Wow, that's a huge task and an honor. So I have in my possession now all the works of Dr. Vaught on airway. And I still. We still do work in the EU in the ENT Airway lab. So there's a whole lot of information. We have three papers that are going to be published in the eu, which is really exciting. But, yeah, I have all of the work going back to 1966 with Dr. Vaught, as well as his interactions with Dr. Gimino. So it's really. It's. It's like. I feel like this treasure trove of information is just fascinating. It's really neat. And then in 1968, Dr. Maurice Cottle, Caudal maneuver. He introduced rhino manometry in clinical rhinology. So we're seeing some validation here. And Dr. Cottle was also the first president of the American Rhinology Society. So we go through the transitions, everything is advancing, it's starting to pick up speed and recognition. Rhino manometry finally got approved in 1992 here in the States. Specifically I had not to promote it, but GM then through that, back in the 80s, they had created in the EU a standardization committee on objective airway measurement. So there is a standardization committee and documents to talk about what is standard, what are the measurements, how to use, and so on and so forth. And we updated everything from the old obsolete rhino manometry to the four phase back in 2015 and 16 through 2017 and then 2018 it was introduced to dentistry. 2019, introduced to orthodontics. We're still doing more research and as of this year is finally introduced to myofunctional therapy. So it's a really neat history and I could go on and on and on. Did you have any questions? What do you think so far?

No, I love this. It's funny because I teach on the history of MYO in my MYO course course. And you know, it's, you know, I tell people like, did you know Miles, 117 years old? People go, what? And I'm like, yeah. And so I've gone through like the history and you know, all the big names and when different, you know, concepts were brought to and disproven and then reproven and you know, all the fun things. And so I never realized I was such a history nerd because as you're talking I'm like, I'm like, people probably see my eyes going everywhere if they're watching me because I'm like looking, I'm reading what it's saying and I'm like this, I'm like, you're so, so such cool information on this slide. I love it. I love the history.

Yeah, it's really quite fascinating. So then we get into the structure and the physiology and the anatomy. And again, our physiology of the nose is dependent on the physical structure. And if you look at it, it's broken down in 2/3 and 80% of our airflow goes to the lungs. A lot of people know that over 50% of upper airway resistance occurs in the nose. And of that 50% 2/3 occurs in the nasal vegetable area. So it's this first one inch area. And that is so, so critical because that's where Bernelli's principle takes effect. And that inspiratory flow is so crucial. Like I said, that's about oxygenation. So these individual aspects of the nose really affect the total function, and that's why you have to break it down. So when we look at nasal function at the chair side, again, it's going to play a crucial role in respiratory health or oral health, digestive health. So there's a whole lot of things that are happening here, from the nasal passages from the nostrils to the nasal pharynx into the oral cavity. It's this whole closed, you know, circuit. But in essence, we do have shared pathways. We also have a shared responsibility. So we have myofunctional therapy. And I'm not really keen on silos. I mean, Even in the 90s, I would try to get all of my doctors to collaborate with my patients because I would literally walk. This is when I was doing home care, home infusion, when I was a certified registered nurse infusionist. And I would walk into the homes and I see this doctor, this literally five different doctors in a bag of pills. Because I would tell my patients, gather up all your pills and put them in a freezer bag for me. And I'll go through them one by one by one. And I'm looking at. At my right hand, I'm looking at my left hand. I'm like, does Dr. Smith talk to Dr. Jones? Probably not, because these two medications are interacting with each other. So in the airway in the nose and the oral cavity, there's a shared pathway between ent, dentist, myofunctional therapist, and we all have to get along and we all have to play nice in the same sandbox because we all bring something, we all have a value that we bring to the table for all these patients. And everything we do is just as important as the person next to us. And I'm going to show you this. Show you why. So this is an actual scan of a patient 15 years old when they did the CBCT anatomical view, static view. It looked good. It was like green to blue, a little bit of yellow. But when they look at the skeletal formation, this is what happens when myofunctional therapy fails. And I don't say fail on the account of the practitioner. I'm talking about compliance with the patient. Because I've tried it. I have to say, if I'm going to talk about it, I have to try it. And I did. It takes dedication and it takes time and it takes a willingness to learn. But I can tell you this just in a matter of two weeks. When I did myofunctional therapy, I noticed a change in my voice and my tone and my articulation. There's value to this. There really is value to this. But when they can't breathe, the medical world, we're built on this reactive model. You have a symptom, we react. In nurse practitioner school, I learned to be proactive and I tell the story. And it was in the fall of 1995, my very first semester. We had this professor, she said, nurse practitioners, we do things a little bit different. Remember this? Prevention, prevention, early intervention. So we juggle, we have this balancing act between prevention and cure. But the medical model has us in reactive mode all the time. And this is what happens when the airway becomes compromised and oral myofunctional therapy is not pulled in to look at the hypotonia on the side of the face that has the highest resistance. We get these skeletal changes and we have a mess, as you can see here. So now we have to go backwards in our reactive mode and fix what we could have probably prevented. And to that end, you can see the periorbital area, how it's different from the left, is different from the right, and vice versa. And you can see the teeth. Look what happens to the teeth. That's from nasal obstruction. And here is how it looks on rhinomanometry. You can see on the right side this big beautiful S, kind of a lazy S. And that's normal. Even his data points are normal. But the left side, he's suffocating. So now he is now in that mode of trying to compensate. Oh, hello, physical therapy. It's this vicious cycle we just can't seem to get out of. And there's this thought that nasal function can be scored on a questionnaire based on what the patients tell us. Well, no, it can't be scored and it can't be seen because it's pressure. We can't see pressure changes like flying an airplane. You can't see the pressure changes in the cabin, but you know they're there because you're an altitude from the ground. Right.

I want to share something with you real quick if I can. So I actually had my. I had nasal surgery April 2022. And when I had. And I've already. I've had adult expansion, I've had tongue tie release. I've been to the pts that are PRI trained. I mean, I've done everything right. I live it, I breathe that, I teach it, I'VE done it. I'm the mother of two kids through it. I'm the wife of the husband who's gone through it. We've done it all. So what was interesting to me was being in this space and not realizing how severely the back of my septum was deviated, that I really could not breathe very well, if at all, through the left side of my nose until I saw the scan. And, hi, I'm That. I'm the specialist in the space. So just to kind of prove your point, right? I was sitting there, and when I saw my. My cbct, and this had gotten worse over time because I'd had cbt, you know, CT scans in the past, I was like, holy cow. No wonder I don't go into REM sleep. My body is, like, jumping me awake. I don't register as somebody who has sleep apnea. Right? I'm not that. You know, I'm one of those cases. But it really did not register to me. So if someone said to me, can you breathe out of both sides of your nose? I go, yeah, I can breathe out of both sides of my nose.

Right.

But I know, actually, according to the scan and actually how I felt after my surgery and after a lot of the inflammation from the surgery went down, down. You know, I could not. I had swollen nasal swell. My. My nasal swab bodies were swollen. My turbinates were enlarged. I had a deviated septum back to the left, completely blocking almost all airflow. And so, you know, when people. When you're saying this to me, I'm going, yeah, yeah, hi, specialist. Thought I could breathe. Nope, couldn't.

Well, and that's what's so fascinating, and that's why I kind of coined that phrase, that nasal resistance is the tornado that's wrecking the airway, slowly affecting our sleep. Because this whole thing. Here's what's fascinating, is I was working in September in a clinic with veterans with ptsd, and I have a little secret, because I can. I can manipulate. With a. With an oral splint, I can manipulate the amount of resistance to help them breathe better. So I'm writing a paper about this to get published. But there is a way we can manipulate so we can decrease the night tears, improve the sleep, and, oh, by the way, if you do it right, we can reduce the nasal resistance. But you're right, it's cumulative, because the one guy in particular, I sat him down. I'm like, ooh, I'm seeing a sympathetic response. He was a little panicky. And I said, you've got some moderate osa, and that's where the DAPHNE score, because you can enter the inspiratory average resistance into DAPHNE that I wrote, and then that will tell you, is it normal, abnormal, severe, and it emulates a sleep study. And I looked at him and said, moderate OSA based on daphne. Based on your rhinomanometry tracings, you have moderate osa? Nope. Excuse me? He said, no, ma', am, I don't. And I said, have you had a sleep study? Yes, ma'. Am. How long ago? Three months ago. And I read an article that, you know, because I was curious. When did you get to that point of ahi? How long does it take? And on average, it's about five years. So you can go about five years of undetected issues that become cumulative, and boom, you have an ahi. Now, my critical care nurse background, during the time when I worked with a HST company, we were doing an in service on sleep studies and what they meant. And I looked at this, and of course, I'm thinking and I'm thinking, and I raised my hand and I said, ahi. And they said, yes, everything is dependent on the ahi. I said, this AHI thing is stupid. And everybody in the room took a gasp. Like, what did you just say? I said, okay, please explain to me the rationale why we wait until someone can't breathe. To help them breathe. Yeah. Who thought of this?

Well, even. And isn't Kristin and Christian Guillemino even say, like, in creating some of the scales, the intention was never for it to be a diagnostic criteria for, like, getting intervention. It was sort of just a scale. And it was now used by, you know, our insurance companies here to determine who qualifies for care and who doesn't.

Yes. And in January 2019, he said that the AHI was his biggest mistake. Yeah. Yeah. So I'm trying to, you know, get awareness out there and say, hello, we have a new metric. We can go in, you know, sooner, quicker, faster, and identify these problems and then collaborate and do something to help them. Because, you know, I have patients in the ICU that were on ventilators. As soon as they buck that ET tube and bite on it, what happens? The flow. The flow through the ET tube to the lungs drops. What happens? The pressure sensors go off and everything starts beeping. And then that's our cue to say, hey, they need more paralytics to relax them so they stop biting on the tube. And then I could look at my monitor and I'm like, okay, there goes the Bells. Now the saturation is dropping into the low 90s. And if I don't do anything, they become hypoxic and become more aroused. It all kind of makes sense because of the gaseous exchange and so on and so forth and how our brain is working even more on a ventilator. And I just find it really fascinating that we just stop and we don't do anything. You know, you look at the statistics when they say 20% of the people have sleep apnea and 80% don't know that they have it. Well, hello. I bet if you measured them with rhinomanometry, you could identify that 80%, probably 60% that need intervention sooner, quicker, faster.

Yeah, well, and I have a question. I have a question for you. So, like, I have a colleague, Ken Hooks, I don't know if you're familiar with him, but he does.

I love him. He's amazing. Okay.

That's who did my home sleep test before my procedure just so we'd have a baseline. And he's taught in my membership. And he's brilliant. Right. So he talks a lot about that, that SpO2, and he's looking at the raw data. And, you know, and this is in my. In my mind, I'm like, I mean, I know why, kind of, but it's like, why are not all sleep tests going through the same diagnostic criteria, the same analysis, in order to determine, you know, what's happening? Because, you know, and so I guess my question to you, that's not really the question. The question is then, does this testing that you're. That you're sharing with us, does this basically get at those same results? Because you kind of said, I tell pretty quickly the same that I would tell from a sleep study.

Yes.

Yeah, but it seems more accurate. And is it quicker data?

Yeah, I mean, you can look at the nasal resistance and know where they are at a baseline, do your intervention and then measure, you know, at some type of point at your intervention or treatment, whatever you're doing, and then measure at the end of treatment to look at your outcomes, to see, is there a change in this transnasal pressure? Because again, everything we do starts with the nose. That's why I say the nose knows. It knows too much. And sometimes they can get us in trouble, you know, from medical perspective. But Dr. Hoel, it's H O E L. Dr. Hoel, in 2022. 2020. Excuse me, 2020, he did a study looking at apneas and hypopneas. And it's a known fact, and I have the pictures as well, and I'll get into it later. But it is a fact that you will see more hypopneas than you will apneas with high resistance and people that are predisposed to osa. So, for example, if you have a patient that comes in and you measure them with rhinomanometry and you see them in the orange or the red, that's a category four or five nasal flow limitation. And if you don't do anything, then you're going to have an OSA patient. Is that helpful?

Yeah, no, that's. That's very helpful. I mean, I will tell you that Ken is one of the most fascinating people that I've learned from, and this is why I'm like. So, like, okay, wow. This is really cool, too, because I feel like it's really hard for people to get sleep studies that give them actual helpful information. Obviously, there are not enough Kens in the world. But also, this seems like something that should be in every ENT's office. Office. This should be part of every initial consult. This should be, you know, it's, I.

Would say, primary care office. Yes, absolutely. Anyone that's dealing with nasal obstruction, you got. Again, if you're going to manage, you got to measure. It's just. That's just the whole medical philosophy. I'll tell you a quick story. Back in October, I had a director of a sleep center, so to your point about sleep studies, and he said, oh, I want to try out this rhino manometer. Okay? So a Saturday morning, I was training him, like, what the data meant, and he does test on himself. And I went, whoa. I said, that is severe obstruction, severe flow limitations. Your ahi, if you were to do a sleep study, is going to be over 30. And this is exactly what he did. He fell back in his chair, and he sat there, he went, whoa. And I said, what's wrong? He said, if I didn't think you could walk on water, I do now. And I said, what? He said, I just had a sleep study done on Tuesday in anticipation of our time together this Saturday. And he said, let me pull up my results. RDI was higher than an AHI. And guess what? His AHI was 42. 42 said, you called it. Yeah, you called it. And what's really interesting is that as you're doing therapies and I've got. I've got, you know, tests to show this, improve this, that as you're doing these therapies, you'll see, like an RDI. I'll just throw out some numbers an RDI of 23 and HI of 11. What's interesting is that just minor intervention, like with. I like the intake. Not to promote products, but I do like the intake. But if you were to take a nasal, external nasal dilator and nasal spray, xylitol, for example, what's really fascinating on this one case I have is the AHI went from 11 to 9, but the RDI went from 18 to 11. So that shows you that the first thing that's going to change was that RDI that correlates to the hypopneas, that goes back to nasal resistance. So it's all interconnected. Now we have to flip the script in the medical community, in the sleep world, and I say this often, that breathing before sleep is only found in the dictionary. Think about that. Everything we do is sleep apps, sleep testing, sleep, sleep, sleep, sleep, sleep. But excuse me, we have to breathe well before we sleep well. Right? Yeah, yeah, yep.

So I always say it's kind of morbid of it, if you can't breathe, you're dead. So we have like two basic, you know, needs in life. We need to breathe, we need to.

Be able to eat.

If we can't eat or breathe, we have problems.

Exactly.

The feeding therapist and myotherapist in me, you know.

Yeah, yeah, yeah. And so when we look at this early intervention, here I go on my soapbox again, Dr. Kevin Boyd. And he's amazing. He had a saying fixed by six. Like, wait a minute, just a minute. If you can fix by 6, should we be able to see something? Well, the short answer is yes. So that's why I created this new rule for objective airway measurements in this new campaign called We Can See it three, meaning that the best age to start testing for airway problems with four phase rhinomanometry in the studies is three years old. Now imagine nasal resistance drops by 50% in children from the time of birth to the age of five. Now imagine if you screened all these children at three, the amount of dysfunction in breathing you could identify at such an early age and the amount of intervention and collaboration you could do. Because we can see these transnasal pressure changes and nasal function issues that long before, if not during, these facial asymmetry issues, tongue posture issues and sleep issues. So it's really, really important. Now they use endoscopy and they'll use acoustic rhinometry, which not to be confused with rhino manometry because they sound the same. We can look at the anatomical reasons for the obstruction, but again, that nasal flow volume and resistance can only be determined using anterior rhinomonometry. Now, the anterior rhinomonometry is more popular than posterior. So there's two ways to do it. 95% of the time they do it with anterior rhinomonometry, and the other 5%, just because it's more patient, more patient participation. And if you have tongue issues as far as tongue position, that tubing that sits midline of the tongue is not going to do very well during a test. But what's really most important, and again, this was all the research. It's very new research about this age of three. Again, we can see it's three, these changes. And it's the Welkomorski article that was just published in 2022. So that's how new this is. Now we get into the ADHD conversations. I worked in children's mental health, and I can tell you in that wheelhouse, all of my kids, it was under a federal grant back in North Dakota, and all of our kids, adhd, which ADD is no longer a diagnosis, that was taken out of the apa and the DSM transitioned from three to four. So ADD is no longer a diagnosis. They grouped it under adhd, the attention deficit categories, but they're oppositional defiant, obsessive compulsive adhd. And guess what? Zero had their sleep and breathing tested.

Oh, I know.

Now we know. Yeah. So fast forward 20 years from when I was practicing in mental health. Now we know 20 years later that the nasal respiration and how we nasal breathe will entrain the limbic oscillations of the brain waves in the piriform cortex, which is going to modulate cognitive function. So here we go. It's all wrapping around. And this is where the mental health professionals and collaborating with them is so key. In fact, I have a paper that's being published in a prominent psychiatry journal where I looked at children ages 5 to 12 in a monoblock appliance. It was the guide appliance and it was retrospective. But I looked at two things, the sleep disorder breathing portion as well as the reported ADHD behavior. Now, it's defined ADHD behavior because we did not have a diagnosis, so we couldn't say ADHD. So that being said, 69% of the kids at the seven plus month endpoint, which the mean months was 15. But at the seven plus month endpoint, 69% of children had both breathing disorder and ADHD behavior either resolved or drastically reduced. Now, that's powerful. That's a study that's never been done. Dr. Escobar hypothesized that if you use an oral appliance, you could take away ADHD symptoms. But it was never looked at until we did it. So I did that in collaboration with one of my favorite favorite friends that I did Covid research with, Dr. Hamza Paracha. And he's a psychiatrist. He's a year three psychiatry resident and he works a lot with ADHD kids. So he's like, well, wait a minute here now we should be, you know, entertaining that thought of collaborating with dentists with a psychiatrist. So that's another one of my things, like dentist, any healthcare, healthcare provider, if you're seeing these ADHD behaviors, let's see how they're breathing. Because if that resistance is so high they can't breathe and they're mouth breathing, what's going to happen to these brain waves? And now we know. Yeah. And that study that when we looked at the entrain of the limbic oscillations from nasal resistance and nasal breathing, what was really interesting is that the oscillations in the brain waves are pretty active as long as you were nose breathing. But as soon as they opened their mouth, boom, it dropped. The population they looked at were refractory epilepsy patients. So they had EEGs as well that they were looking at. Yeah, it was quite fascinating. But again, it kind of speaks to that point. And so again, now we get into the digestion after the breathing. There's a whole, the microbiome.

I feel like you're just describing my entire case right now. I mean.

None of it is a.

Surprise to me being in this space, but I just, I love, like, how you're connecting all the dots. Like, I was that kid in preschool whose parents were told to get her tested for adhd. And I was, I didn't get a formal diagnosis till I was 19. How much worse was my sleep at that point? Right. I mean, it's adulthood and you know, and when I start to look at things through this type of a lens, and it's helped me kind of shape my own thinking and working with patients into, I wonder what else is going on because they have this diagnosis. But there's a reason we got here. And what is that like, you know, so I love how you're very, you're prevention oriented, early intervention. What is the root cause? Working with the team and not in silos. Like, you're preaching everything that we say.

That I stand for now, being in everyone on the same party float.

Now that we're all hanging out together.

Let'S go, yeah, we all hang out together, then we'll have, you know, we'll be on to something.

Yeah. And maybe you're going to go over this, but if we don't, I would love at some point to just know, you know, because my practice is primarily pediatric, but we see adults too. I know a lot of us that go into like preschools. Right. And that, you know, we know that mouth breathing is present at birth in some children. We also know that it can develop later as well.

Right.

But a lot of us are going in and doing preschool screenings. And what I encourage people, whether they're pt, ot, slp, who are in there doing these preschool screenings for just typical developmental skills. I'm encouraging them to look at feeding, oral, sensory, motor feeding, but also without looking at mouth position. Are they nasal breathing? Are they mouth breathing? Is food falling out of their mouth when they're chewing and having a little two minute snack with you during your 15 minute screening? You know, so I'm just, I'm kind of curious to know from your standpoint too, because I can, I can see some of our listeners like listening to this and going, okay, this is great. What kind of red flags, if you will, are you looking for that we should be referring these three year olds for a procedure or, you know, for a test and analysis with, you know, someone like yourself or, and, or where do we even find someone who does this?

Yeah, it's. Well, if you look at mouth breathing alone in children, 11 to 56% of kids have mouth breathing. That is the most common oral habit. So a red flag in my world would be mouth breathing because I know if you think about it, we inhale two seconds, we exhale three seconds. And I use what's called the rule of four because at four seconds, if you have no expiratory route, what happens? Your mouth opens. The air has to go somewhere. So even if you see your child just sitting there watching TV and their mouth is hanging open. And again, if you look at nasal dysfunction and how that leads to mouth breathing that affects the oral health, we have to know how to define it. Now here's the clincher. Mouth breathing is defined as more than 25 to 30% of air passing through the mouth instead of the nose. So if you see your child mouth breathing at least a quarter of the time, that should cue you in. Okay, we need to look at this nasal function and we can even do sprays. If you look at the American Academy of Allergy, Asthma and Immunology, their guidelines say do a baseline Test for obstruction, spray with a decongestion, wait 10 minutes, not five, not 15, like I've seen in studies that made me go bananas. 10 minutes. If you see a 35% change or greater, that's a nasal mucosal problem. If it's less than 35, now we're into a structural problem, and that's where the ENT comes into play.

Okay?

If it's higher than 35%, that's where we now pull in an allergist. Is a food allergy is a mold. Mold is becoming very popular, especially like when I lived in Charleston. That was my first nursing job, was in Charleston, South Carolina. And so I was part of Hurricane Hugo when I was in UNC Chapel Hill in nursing school. And then I moved to the site of the storm a year later. What was I thinking? But you know, what's interesting is that during my time that I lived in Charleston, every January and every September, religiously, I got a sinus infection because those molds and spores that are blown in from these storms. And in other talks, I do equate nasal resistance like a hurricane. As the pressure changes, so does the wind. Same thing. So that's something to look at. But to your question, if you're seeing your child breathe 25 to 30% of the time, mouth breathing, then that's going to be a red flag if you notice their behavior changes. If they're more disruptive, we'll be polite. If they're more disruptive, if the teachers say there's a problem, then that's where I pulled in. What's interesting is my cousin in Virginia, she's a school psychologist for the state of Virginia. They have a program, and this is where I would hope that some form of implementation, because it starts at the state level, we can't really. I try to do something federally, you know, across the state. And the way my cousin explained it, it's state by state, but they have programs where they look at the. The activity and function of children from kindergarten to seventh grade. Now, in our area, D.C. maryland, Virginia area, it's a very transient area because of the military. So a lot of these children get lost in this longitudinal evaluation. But if we think about it, we assess their vision, we assess hearing, but we don't assess breathing. Again, we have to breathe well to sleep well. There's no way you need to sleep.

Well and function well. So, I mean, if you're not breathing, everything else is just, you know, falling. Yeah.

And this is why I love, love, love, love, love, love these screenings for children and breathing. What does that nasal pressure, what is it doing? Again, we can ask them, but if you look at. And we can assume you've heard of Paswell's law, and everyone's like, oh, the radius and the diameter, it shrinks, and so on and so forth, that's old news. I will tell you here today, that's gone. The new concept in looking at airway and nasal function is not the diameter, but it's the diameter and the motion of the air over time and the perception. So now we get into the psychophysics of breathing. And the psychophysics of breathing is discussed under the Weber Feichner law. And that law is looking at the patient's perception, which is their reality and their understanding of disease versus how they're actually responding to the stimuli of breathing. And that's where the M for measurement comes into play. And that's why Dr. Vaught created rhinomanometry, because what the patients were saying and what he was seeing on measurements and the tracings were two different things. To your point, this is accumulation of dysfunction that becomes common and even in people over time. You get into these metabolic disorders, they get the high nasal resistance that turns into this whole compensation. The head goes forward, and then they get into the metabolic disorders. And you can see a patient in their posture and their biometrics. What's interesting, if they look like Fred Flintstone, where their hands are backwards, that's a metabolic problem. So look at the posture of your patients when they're walking in. And that's. It's really. It's fascinating to see this little tiny reactive organ on our face and what can happen downstream because of the upstream effect. And so when we get into orofacial myology, I like to call it the trilogy of the trigeminal. I love that, because the trigeminal nerve is so key in what you do. When you look at the nose. Tongue connection and you look at the nose will dictate the genioglossus muscle and that activity during the jaw closing phases. So we have the ophthalmic nerve, the maxillary nerve, and the mandibular nerve. In all these different areas, there's only two sensory V1 and V2. Ophthalmic and maxillary. The mandibular is the only motor sensory nuclei. That's with the proprioceptive affects that you see with nasal resistance and high obstruction. Makes sense.

Makes sense.

So now we get this whole mechanical thing. And that's why I call it the trilogy, the trigeminal. Because I can manipulate it with a splint, just by 1.5 millimeter change, you can see a whole drastic view of how someone's breathing all during a random manometry test. And I've got the slides. It's really, really interesting. So as far as the myofunctional therapy, here's kind of that whole sequelae of events that might be helpful for the parents. The nose, nose, the tongue. We have 12 pairs of cranial nerves or the three that I just mentioned. The three of the trigeminal nerve are involved in the highways and the byways of nasal function. But there's also three others that are affected by nasal function. That's the glossopharyngeal nerve, the vagus nerve, as well as the hypoglossal nerve. Now, there's a lot of focus on the vagus nerve, but I'm here to tell you it's a hijacker, it's a hitchhiker. I call it the hitchhiker because it feeds off of the trigeminal nerve. And it's really interesting to see what happens through that influence just in the breathing patterns. And again, when you see that negative pressure increase within the nose and surrounding areas, guess what? You're going to get what I've coined crazy tongue. Now, how does crazy tongue happen and what is your role in this particular scenario? Well, we have nasal congestion or flow limitations. Then we have the increase of nasal resistance. Then we have the increase in the oropharyngeal pressures that result in mouth breathing, that result in altered tongue posture, that affects the, the speech and the swallowing dynamics. And it just repeats. It's on, it's like the news cycle. It's on a 24 hour cycle. It just doesn't stop. Now, if you were to do rhinomanometry and look at the genius glossus muscle, which can be the influencer, right under the mandible, and how it's affecting their swallowing and their speech. Based on the nasal function, you get into the connection to the hyoid bone. So now we're bringing more anatomy into this. I mean, the head is so amazing. There's so much there that's interconnected and how the nasal dysfunction will disrupt the immediate postural responses and the downward movement of the hyoid bone. So you see how this is all coming together and we also have to consider the age. So my biggest thing is what a difference age makes. I think we know that when we hit in our 50s and our 60s. But children are not small adults. Let's just get that out there, they're not small adults.

And I was gonna say, if I can interrupt you real quick, I love this image, and I see that it has your name copywritten to it 20, 23. Because do you know how hard it is to find an image of a pediatric upper airway next to an adult upper airway with the tongue actually up in the roof of the mouth? Most pediatric images have the tongue down or kind of like floating in the center of the mouth. And I have to, like, point that out in presentation. So I love that you have this image here.

Would you like me to share it with you?

Yes, please.

Please do. I am happy to share it with you. You know, this is something I saw when I worked in the pacu, especially because, you know, we go to intubate a child, the tube size we use an adult obviously is not going to be the tube size we use in a child. And that really speaks to the airway differences. But here's. Here's what's really fascinating is that we talked about the transnasal pressure changes dropping by 50% from birth to the age of five. But their nostrils also change from round to triangular shape, which does make a difference in development. The nose also becomes more projectile from the face. We see about 30% of our nose, and the other 70% is in our head in the cavity. So the nose becomes more projectile as well as the nasal height, and the breadth will increase with age as well. But you'll see more changes in men and boys than you will the females. And that's why when we're working with kids, we have to have a pediatric software. So, for example, a lot of people will use acoustic rhinometry. It's a good product. Again, it's showing the area of location and how bad it is. It's that mean cross sectional area. Well, one sound tube that you use in the testing does not equal for all people. So the adult sound tube is a lot longer than a child sound tube because you have to look at the distance of that sound pulse wave, like a sonar. You have to look at the distance of that sonar pulse wave and how it's going to react to the geometry in the cavity of the nose. Make sense? Yeah. So the adult. The adult sound tube, because we have a competitor out there, one sound tube does not fit. All software for kids is different than adults. So there are distinguishable differences when you're looking at measuring the nasal cavity. And that's what's really, really important. You know, one thing I like to emphasize when we look at Oral facial myology, and we call it rhinopathia. That's our new medical term, rhinopathia. That's looking at any type of dysfunction or deformity in the nose. And like sleep apnea, there is phenotyping and there is endotyping. When you look at rhinopathia, phenotyping and endotyping in orofacial myology, you can see how, and this is based on studies, this is how impactful with what you do is impacting nasal breathing. The nasal resistance is significantly higher and greater in class two than in class three children. So even on that visual over the computer screen and you have them smile and you can see that occlusion, that's going to be a key indicator as well. The Class 2 also significantly correlated with inferior tongue posture, another red flag. Now, the nasal resistance in Class 2 is negatively correlated with intermolar width. So the conversation about the intermolar width, we couldn't find nasal resistance correlating to that. But tonsil size in a class three is significantly correlated with forward tongue posture. So you're seeing how this is all coming together.

You wouldn't believe, like how many ents and doctors look at us like we have five heads when we suggest that maybe the tongue is sitting low and forward because the tonsils are really enlarged and like kissing, you know, like, what a concept.

I know, right, right, yeah. And even in the Class 3, they found that there was significant correlation between the tonsil size and the mandibular incisor position. Again, all in a smile on a screen and you can pick up so much. So the relationships of the upper airway factors will differ between class two and class three children. But there's so many red flags. Now, if we look at the phenotypes and endotypes, this is what I was discussing real quickly. You know, the phenotype is the category of those distinguishable characteristics that you'll see those physical attributes. The endotype is a mechanical or the pathobiological mechanisms of that particular disease. And now we even have a genotype. Yes, Our genes, based on what we have and how it acts on the chromosomes, can make up and determine the phenotype or the shape of our nose. And people said what? I said, yes, our genes can determine our nose. Is it a pear shape? Is it a button nose? It's quite fascinating. But when you look at everything that you do and the endotyping, the biomechanics of breathing as it relates to orofacial myology, you have to consider the resistance Nasal flow, the effort in breathing, as well as the partition of airflow. Like you said with your sinus surgery, are they breathing on the right and left? You can look at an X ray or MRI or CT scan and go, I can see the partition 100% on one side and 0 on the other. And it all plays a significant role in your clinical evaluation. This is what I was talking about. And this is where it's key with what you do on the genotype. The development of the nose and the embryo occurs preskeletal and skeletal phases. Now, this is well documented and it has this regulated interaction of multiple signaling cascades through the entire process of development in utero. And when you look at the key factors which control the frontal nasal development, that evidence will suggest the association of various nasal dimensions and the related syndromes with multiple genes. So Trisomy 21 is very, very popular. The bridge of their nose is flatter, they have a smaller cranial morphology, they're more predisposed to osa. Same with your Ms. Patients. Just a neurological impact. They're more prone to nasal resistance and sleep issues as well. So there is another piece of the airway puzzle to consider, is the genetics, is that causing a problem? And when you look at the whole hierarchy and how this comes together, from the least effective portion and identification to the most effective, the geometric distribution doesn't play as big of a role as the logarithmic distribution. And the logarithmic distribution is the amount of airflow and pressure it's taking them to breathe. So you can see that cascade in the hierarchy of importance. Now, again, here we go with the psychophysics. What the patient is saying and what you're seeing can be two different things. And we have to understand that correlation between measurements and their sensation of nasal obstruction, because that sensation of impaired breathing will equal to the sensation of elevated, their elevated power to breathe, if that makes any sense. But again, it comes between, down between the stimulus and their perception. Is their actual stimulus to breathe correlate to their perception of breathing? Now, this is key in empty nose syndrome because when they have all those turbulent surgeries and I, and I don't know why, but when I sold, when I sold the, the sinus drills and blades, a lot of SMRs, submucosal resections, turbinectomies, it seemed like that inferior term. It was so beat up so many times and. But that's a lot where you see a lot of allergic reactions happening as well. So it's kind of right behind that nasal valve area. And that seems to be pretty delicate as well. You know, there's so much involved there. So when we're talking about the assessment portion of it, I would say potato, potato, subjective, objective, because subjectively, and I'd use it in clinical practice. What brings you here today? Tell me about your symptoms. Tell me your history. We're getting their perception again, that's their reality. But we have to understand that there's a missing correlation between the subjective sensing of what's going on versus the actual visual and mechanical portion as far as what's going on. So we really don't have any type of like, physical anatomical considerations when we're talking to the patient subjectively or when they fill out the questionnaires. Right. We don't know physically what's going on until we actually measure. And that's the objective portion comes into play. And that's why it's so important. Again, if you want to manage, you have to measure. You can't have one without the other. That quantifiable numeric data that you have shows you that progress. And so, again, from a clinical perspective, that's so important because when they go to sleep, we're going to run into four problems. And this is where we have rhinopathia, our new word. This came from our research over in Europe at the ENT Airway Lab. So, you know, the problem is in the USA, we're about 40 years behind Europe and Asia. So that's why people say, well, I haven't heard of rhino manometry. You're right, we're so far behind the eight ball. But when we look at our sleep and the therapy that you're doing, we're going to have four problems, the body position and nasal congestion. As soon as you go back 60 degrees, and you can do this in your chair, as soon as you go back 60 degrees, you will feel the transnasal pressure changes all throughout your nose. And even you feel probably a little bit of drainage going back in your throat as well. But also when you are lying down and come up 30 degrees, you'll feel the decrease. So when I see people that say, oh, I can't breathe, I have CPAP. Put your head up 30 degrees. See if that, you know, drops a little bit. Then we have to look at the mandibular protrusion and what's happening now there's a study that's really fascinating. They use the MADS and looking at the mandibular advancement devices. So from baseline to a 50% effective protrusion, which was about 1 to 3 millimeters in the study, they saw the nasal resistance drop by 23%.

It's huge.

However, when they went from baseline to 75% or the targeted protrusion, the nasal resistance went backwards. It increased by 43%. Interesting. So this is all in relation to the velopharyngeal area. The mean cross sectional area of the pharyngeal area was increased.

Yeah.

But the mandible was manipulated too much again. The trigeminal nerve V3 picked up on that. And what happens? B2 kicks in and maser mucosa and it becomes obstructed. And that's what was happening.

Interesting. That's fascinating.

Yeah. So it's so sensitive, you know, it's just.

And you know, to that point too, because I have colleagues who used to be in. They put veneers on. You know, they hold whole practices where just veneers were what they did. And they would say, patients who come back to me, who, with their, their veneers were cracking, they were having issues with their teeth. Well, hello. I mean, the body's going to win out every time. And he. And what one of my colleagues actually said to me, me was, he said I literally was putting them into a state of distress by moving their jaw to where we thought it should be by putting his veneers on and bringing the jaw forward. Then they go to sleep and their body be like, nope. And so, you know, it's no surprise that we'd have these issues following, you know. So anyways, red flag if you have been.

Yeah, absolutely. Another red flag. Now, here's what's key. We get into problem number three. Back to your. Your question about sleep studies. Now, AHI does not determine nasal resistance. Right. However, the resistance determines the RDI before the ahi. Now, if I get to sleep, world to pick up on that and agree with me, because I have the data, I just can't make this up. You know, I'm not gonna put my reputation on the line and just pull something out of the air and say what Karen says, no, this is the research and it's quite fascinating. But again, it goes back into that nasal endotyping and look at the number of hypopneas that you're going to see versus the apneas that's going to really identify that suspected OSA patient. But they also found that nasal resistance and the BMI were pretty much the two key indicators for sleep disorders and dysfunctional breathing. Here's the other thing too, that's going to really affect. Because we're dealing so much with the muscles in the face. Problem number four, Bernelli's principle and the nasal valve. This is really key and important. 30% of the measurements we have seen with rhinomanometry will show a nasal valve phenomenon. I'll show that looks like. So basically the elasticity of the nasal wall right here will determine the flow and velocity during breathing. So that's, you know, another piece to the jigsaw puzzle. And this is what it looks like. You can see slight modern and heavy. And what happens, those little loops that you see how they see how they get bigger, they're skinny, they get bigger and bigger and bigger. Now that's the nasal dial phenomenon. What was happening during this, I want to say around 2010, Dr. Vaught saw this crazy curve, like what is happening here. And that's where they said, ah, nasal valve. So you can pretty much bet that at least 30% of your patients will have some form, ever so slight, but some form of a nasal valve phenomenon that's going to affect their breathing, that inspiratory phase. It is also important to note that 80% of us have some form of nasal deviation because of birth. When we come through that birth canal, that's our first nasal trauma. You're putting a square peg in a circle and you're squishing this bowling ball through a tiny canal. That's where you're going to see problem as well in your newborns. This is the slide I wanted to share with you that when you look at it, you can see the burgundy tracing here. My PowerPoint will work, but you can see the burgundy tracing right here. That's crazy tongue. So what's happening when you look at the rhinomanometry test? It's a good test because we picked up four respirations. It's a 15 second test that's going to pick up four complete nasal or respiratory cycles. Now you look at the mean flow up here at the top and it shows a category 3 flow is categorized in category. 1, 2, 3, 4, 5. 1 is normal, 5 is red. Complete hypoventilation. You can also see the resistance in the, in the range. They're already above the normal, the normal range. But you can also see if their nasal cycling well, it's above 20%. So yeah. Now this particular person, we did nasal release technique and they had a DNA device. But what was happening here is you had the delayed genoglossus excitatory reflex. So the excitation of the genoglossus reflex and how it responded to the increase in the negative pressure via the hypoglossomotor nucleus was how the tongue getting sucked right back into the throat. This patient was on myofunctional therapy, but wasn't compliant.

It's hard to do Maya with a DNA appliance. I had one.

What's that?

I had this appliance. It's hard to do myo when someone's in a DNA appliance, especially if they're supposed to have the appliance in upper and lower for 16 hours a day, because your tongue is basically being reinforced into the wrong position with the idea that when the appliances are out, your tongue will make its way up to the roof of the mouth. I've seen it work with children. I think it's less successful with some adults.

Interesting.

Yeah, it definitely created more tongue space for me, but I had to train my tongue to go up there.

Yeah, yeah. And when you. When you do rhinomanometry, it's really fascinating. And this is the only case I've seen. You know, I get these interpretations, like, what's happening here? Crazy tongue that you get that increase, you know, that increase of negative pressure that's sucking the tongue, you know, back into the throat. And it's just a force of nature. So I created the 10 commandments of nasal measurements and orofacial myology.

I love it.

So we want to look at the ten commandments. When I quantify the nasal airflow and resistance and see what impact that's going to have during the orofacial activities and measure nasal patency to identify those restrictions. Evaluate the influence of that obstruction is going to have on orofacial coordination and range of motion. Assess the relationship between the nasal measurements and tongue strength, considering the potential impact on speech and swallowing. Also monitor the effect of the nasal measurements on orofacial muscle tone, looking for those correlations between hyper and hypotonic conditions. Because you can look at your patient and see the asymmetry in their face and pretty much call it out. What side is going to be higher in resistance than the other side. We also want to investigate the role that these nasal measurements are going to have and how they're going to influence the overall muscle function during activities such as chewing and swallowing and facial expressions, as well as examine the impact of nasal parameters on the resting posture of the tongue and jaw, considering their role in orofacial myology. And then we're also going to evaluate the potential connection between nasal measurements and development of oral habits that could affect the muscle patterns. Investigate how nasal measurements can correlate with speech articulation and clarity, given the interplay between the nasal and oral structures. And finally, the tenth commandment is to consider the implications of the objective nasal measurements for treatment planning in orofacial myology, aiming to optimize that nasal function and its impact on overall orofacial health. So how do we do this? How do we do this, Haley? We start with this whole. Now, I'm a military girl, so everything to me is an acronym. Love it.

I love it.

So I was sitting in my office and someone said, how did you come up with this? I was just sitting there going, you know, midline valve. Oh, Maverick. This is Maverick. Maverick is the midline. Is the nose midline, or is there an axial deviation? A. We're going to assess for asymmetry. Eyes, ears, jaw, head. Then we have V in Maverick, which is you will tilt your patient's head backwards and look at the columella and the nostrils to see if they're equal in size or if there's a deviation. Then E. We're going to look at the elasticity of the nasal wall. And that's simple. I created a pinch test. You know how we. We pinch our skin for dehydration and turgor. Pinch your nose, release it, and see if it comes back. You can look at the elasticity and that. That plays a huge role in it as well. And then see. Sorry about that. R is reporting your oral observations. What do you see in the oral cavity that's going to correlate, like we were saying, the class 2, class 3 malocclusions, and so on and so forth. What are you seeing in the oral cavity in all your observations? Write those down. We talk a lot about the palate. Then we look at the inspiratory resistance. That is R. I'm sorry, that's the I is sorry resistance. C is congestion, and K is your kinetics and breathing. So that was the spray test I was talking. I love. Not to be professional, but I love X. Clear. We use it all the time. It is. It is the. The best thing. Now, we can do this in the home with the peak nasal inspection inspiratory flow meter, so we can really personalize their treatment. Because the flow meter is manual, it's compact and portable. It will still give you inspiratory objective measurements, but it does not look at pressure. We use this a lot with our allergy patients. I do have some myofunctional therapists that are now picking that up because we'll get into that in a minute. But the main purpose of this, and it's a, it's a quick test, you do three, you do it three times where you tap it and the little dial comes down. Then you tilt the flow meter so the magnet goes back up into the neck and then you put it horizontal and you sniff real quick like you're sniffing a flower. And you do that three times. You take the average and then I'll tell you if it's normal or abnormal. Now there was, there was some discussion. Everyone said, well, the normal value is 100 liters per minute. No it's not because it's dependent on age and gender. So your little 7 year olds are not going to take in 100 liters a minute. There's no way. They don't have the title volume to do that. And that's why I created. It's also the patient portal is on the Daphne where patients can go in and they can subscribe for a month and just do their measurements for a month and type in their three values. Daphne will average it out for you and tell you if it's normal or abnormal. And then of course we have the rhinomanometer looking at the four phases which will include the, the baseline, the stimulation phase where we're breathing, post stimulation phase where we're inviting the recovery and the adaptation of the nasal passages after breathing and then the recovery phase. So it's pretty comprehensive. You know, you do have your, your challenges with patient cooperation. The clinical interpretation is a lot of numbers. That's where I come into play. And then we get into the scope of practice. Who can do this? It is a billable, it's a, it's a billable procedure under 92512. Now for all of the myofunctional therapists that are speech language pathologists, there is a modifier. There used to be, if you look at the Palemento GBA, they would have the code is 92512. So it's 92512 is a billing code. And speech language pathologists will have their own modifier. So that's a billable code for you. Anyone can really do this. Now when you look at the medical and dental assistance, like the dental hygienist that might be doing myofunctional therapy, this, this is out of their scope of practice, but it depends on the state. But typically I can't teach or sell a rhino manometer to a dental hygienist. I can't. There are some that do the, the pnif, the peak nasal inspiratory flow meter. But again, this is ideal for physical therapists, speech language pathologist. This is so critical for slp, ot, nurse practitioners, dentists. Those are the ones that can use it just independently. And it also helps. What I like is this Eisenhower decision matrix, you know, deciding what's urgent, what's not urgent, what's important, what is not important. How do you decide and delegate or delete what you don't need as far as your information. And to that end, the dentist, the orthodontist, and those are incorporating myofunctional or orofacial myology therapy. You now become the referral source for MDs nurse practitioners. Yeah. And that's all I have. So thank you.

Well, thank you. This has been amazing. I feel like this, you know, should have been like a presentation in our membership. We'll have to have you come and give another presentation for our members, because.

I would love that.

Phenomenal. Thank you. Thank you. And this was incredible. I'm sitting here just going, yes, yes. Okay. And again, I feel like you just described my entire life, life and case as you went through your presentation. Like, where were you when I needed you 15 years ago?

Well, I'm here now.

No, I think it's wonderful and I love that this information will be accessible and available to our listeners because I do feel like, you know, it's kind of next level in the sense that we talk about a lot of these concepts, but we haven't all. You know, I think it's hard for people to sometimes connect, to connect the dots or to even understand, like, what else is out there. And this is, you know, the rhino, Rhino manometry. I'm like, I say that right. I know will be new, a new concept for many. So I'm excited for our listeners to hear all about it and to really understand the benefits because I do feel like it's very beneficial now if somebody wanted to purchase, you know, the appliance or get tested or not appliance, the device. Get tested on. Like, how. Or test, test it. Sorry, get trained on how to use it. Can they. Do they contact you directly? How do they. How do they do that?

Yeah, yeah. So I do all the training. I walk into the interpretations. If they want to. If they want to do the interpretation software on the point of contact, we do use distribution networks, so we have two that we use as well. So a lot of the dentists or who's ever in your audience, dentists, orthodontists that work with bio research, they're another good source. But when we get into the down and dirty details of what this data means, that's where I step in and do all the educational aspects. So if you want to do a group, if you want one on one, and I've sat with some dentists for nine hours just going through case after case after case and walking them through, this is what's happening, this is what is ideal, this is what you should see based on that treatment option. I'm happy to help. And that's why I created fact. The fact Healthcare Consulting Group is the education arm separate from GM because through regulatory efforts, they can't really do that. So that's why I filled in that gap.

Fantastic. Well, we'll make sure that the website is linked for all of our listeners. Where else can they follow you online?

So I'm on LinkedIn under Karen Parker Davidson. I'm the only one in the country.

Love that for you.

I don't know if that's a good thing or a bad thing, but yeah. And also on Instagram, appropriately, it's at underscore the nose knows. So it's T H e n o s e k n o w s. So the knows knows. I'm not on Facebook professionally, just personally. I just, I find I have better luck on Instagram and LinkedIn.

I love it.

Perfect. Well, thank you.

Yeah, I've got my books, books and publications that are all listed on LinkedIn as well. And my new book is coming out.

Oh, well, promote it.

Tell us more. So we're getting through the printer and the editor issues. It's been on, you know, this, this, this idea. Who said, who told me to write a book? But I'm writing three books and I also have a children's book coming out, but the first one is breathe through your nose, don't pay through it. The impact the healthcare industry has on nasal function, how we breathe, it's really, you know, drilling down into each section of the healthcare industry and what role they play and examining that role as far as nasal function and breathing. And then my children's book, it's going through illustration now, but that little book is called my little nose where the air goes. So that should be out hopefully in April. Cute.

I love it.

I love it.

All right, well, keep us posted on all those fronts. And thank you so much for joining me today.

Did you have any other questions, any thoughts? What do you think so far?

I, I loved it all.

I loved it all.

I love, like I said, I love how you connected the dots and I think that a lot of this information, I think it's gonna be very thought provoking for some of our listeners. I think some of our listeners are also. Yeah, I think they're gonna go like, wait, I need. I need more. So I'm glad you have a book that they can. That they can reference and.

Yeah. Well, it's been a pleasure. I've really enjoyed this. We could talk all day over coffee.

We definitely could.

It's wonderful. Thank you.

Thanks for listening to this podcast.

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