Episode 261: Diving into Hallie’s Home Sleep Test Results 2 Year Post Op with Ken Hooks

Hi and welcome to episode 261 of the Another Podcast. This is your host, Hallie Balkan and today we have Ken Hooks joining us. Ken is the founder and operator of True Sleep Diagnostics, based in Greenville, South Carolina. He offers home sleep tests for providers and via mail order. He's a registered respiratory therapist with 12 years of experience and a registered polysomnographic technologist for adults and Pediatrics with 11 years of experience. He's the former sleep medicine representative for My On Secure St. Francis in Greenville, South Carolina and the former clinical director and instructor of the polysemnographic Technician course at Greenville Technical College. He co authored the case report Rapid Maxillary Expansion and adenotonsillectomy in 9 year old twins with Pediatric Obstructive Sleep Apnea Syndrome and Interdisciplinary effort. 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 coral rest posture. Tongue up, lips closed, teeth apart. Breathe through your nose. Let's get started. Ken, welcome back to the podcast.

Thank you. Thank you for having me.

So I'm excited to have you. It's kind of a treat for me because I know the last time we recorded we were reviewing my sleep results from a couple years ago. Right. Was that the last time we recorded?

That was. Yeah. Okay, 2022 maybe.

Yeah. So it's been a couple years. It was right before I had my, my nose surgery. So I had a septoplasty, a nasal or I had a turbinate reduction. I had a nasal swell body reduction and then I also had a rhinoplasty because I was like, we're under. Why not? So yay. So now it's been two years. Yeah, I do feel like I can breathe a lot better and I know that my results were not perfect, but that there is improvement. So for anybody listening who's like, I want to see what you're talking about, you're going to probably want to watch this episode on YouTube because we are screen sharing my home sleep test report that Ken sent over. But Ken, I want to turn it over to you so you can kind of like tell everybody, like maybe even just start with. For anybody who hasn't listened to the other episode, like what, what you do with home sleep testing in your business and true sleep diagnostics and like even what you send out to people the, the device.

Yeah.

Why that's maybe different because sometimes people hear home sleep tests and they go, well, that's not that valid. And I know you do it differently than others and it gets really good results. So I want to let you kind of speak to that first.

Okay. So I'm going to try to stay on track because I get upset talking about that. I get, as the young folks say, I'm triggered. So the home sleep test is just a modified or scaled down version of an in lab sleep test. The nasal cannula is the same. Pulse oximetry is the same. Even the effort belt is the same. The things that are different are there's no leg leads, so like periodic limb movements that can't be monitored. There's no eeg, all the leads on your head. So on the sleep studies that I have, the sleep stages is interpolated and it's around 85% correctness. The belt in the lab, you'll have two instead of one. And then you'll have EKG in your nose. You'll have two types of monitors. You'll have the nasal cannula, which is the pressure transducer. That's how we see the airflow dynamics. And then you'll have a thermistor that monitors temperature and that. We use that to pick up apneas. So it's like a backup. So the, there's. Other than that, there's no difference. The same thing that you're using in the lab, using on a home sleep test, as far as for assessing airflow and apnea and hypotenuse. The pressure transducer I really love because you can't see the dynamics. The device I use the Alice Night one by Respironics. Some, some labs do use that and it's. I just like it because I'm used to it. I was, I was used to that software. I've used that software. Out of the three or four that I've used. I've used that one the longest. And so it just was a little bit easier for me to use that. And I have my channels and everything already set up. And what I mean by that is like the SpO2 plus or the plasmography, I do use that to kind of see how if the airflow limitation is important or not. The. The plough waveform, every waveform is actually a heartbeat. And the amount of waveforms you have, in like 30 seconds, we can see the heartbeat, but at the same time, if there's something going on with the cleft, if the amplitude reduces, that's a reduced amount of blood flow going to the periphery. And so typically, when you see some upper airway resistance or airflow limitation just behind that, you'll see the body react, the plethora reacts. And since the volume is reducing, we'll also see the heart rate react. And, you know, I say this sometimes. I always believe that the pulse or the heart is the most important thing on a sleep study, because if your body needs oxygen, the heart's going to pump a thousand times a minute to get it what it needs. In times of trouble, everything is shunted to the things that matter most to the body, the heart and the lungs. Everything else is kind of cut off. And so the body is screaming and starving in the heart. Wells, I can give you as much as you want. I'll just pump a little bit faster. So we don't necessarily see oxygen desaturations on patients with upper airway resistance. And even in the sleep scoring manual for apnea, there doesn't have to be an accompanying desaturation. So with the study, I'm doing everything by hand. I don't automate the home sleep test, and the only thing that's automated is the sleep staging. But as far as tabulating the abnormal hypotenuse and talking about the dynamics of the airflow, those are things that I'm actually looking at on the study. So I'll go through the whole thing and assess it. And the hypnogram, if you don't know me, if you've never heard me say anything before, the hypnogram to me, is the most important thing for patients to be able to see because it's tangible evidence of what's really going on throughout the night. And you can see how your pulse rate is spiking in areas where you may have trouble. And some patients will say, well, I don't see any respiratory events. My pulse is spiking. I'm like, yeah, that is the upper airway resistance area right there that we can't actually put on here. But these are things that I'm talking about and that shows the importance of the actual pulse on a study versus oxygen saturation.

Thank you. I know that. I'm so glad that I triggered you because it's always a fun part of episode.

It's almost like the very first podcast. We don't know if you remember this, but I just. It was after talking to a pediatric sleep doctor and it was. I was so mad, but I was on fire.

That's good, right? Because that, that just brings out the best side of you. You're like, educate people here. And I think it's like, it's so, it's so interesting because that's. That that rhetoric is like, oh, well, if it's at home and it's not in a lab, then it's not as, you know, it's not as good of a study or it's not as accurate, it's not as valid. And you know, what I've learned from you and some other others is that actually it is and it really about the interpret interpretation of the data too on the back end. And so I love that, you know, you do a lot of this manually and you're able to kind of pull together a whole picture, which is why I was like, all right, Ken, we're doing this before, we're going to do this after. And you know, it took me a good solid year or so to heal because I had the rhinoplasty and there was swelling and inflammation, everything. And then so finally I was like, oh my gosh, okay. It's been like two years now. Like, let's do this thing. I went for like my two year follow up with the ENT and I was like, ken, we got to record, we got to do another sleep study. And you like sent me the thing and here we are. So. So yeah, I want to dive into. And you tell me where you want me to scroll to on here. Do you want me to start up top?

So yeah, we can start up top. And so I'm actually looking at my other screen over here. I'm looking at your old study too, so we can kind of make comparisons. So there's subtleties to. There are subtleties to sleep and sleep reporting that we don't necessarily take into consideration or look at. And sleep being very, very subjective is something that we really have to take into consideration the whole thing. And I know I talk junk about numbers, but at the same time Numbers can shed light on improvement. And so when we look at, when we look at the numbers up here, the time and duration, you almost minute for minute. The total sleep time on this study, this newest one is 422 minutes. Your previous one was 448 minutes. So we're really close to the same amount of time. Your sleep efficiency on the previous one was 90%. This one is 96.2. Now, this can be a little bit overestimated because we don't have true eeg, so there's no arousals. The previous one, I can tell you that there were a bunch of arousals and fragmentation throughout the whole study. So the increase in sleep efficiency is better. The wake after sleep onset is reduced. The previous one was 24.5. This is 14.5. So we're seeing an increase in sleep consolidation. We'll be able to see that on the Hypnogram, too. The hi, 0.1, I'm going to tell you, I mean, all my patients, and I do, do a lot of kids, the ahis. If I see someone with high or moderate or severe, I mean, it may be like 1%. So the majority of my patients do not have clinical sleep apnea. It's very mild. So for me to see a 0.1, I would say, I mean, I don't necessarily care about that anyway because I need to look at the airflow, I need to look at the dynamics to see how the body is reacting to what's going on. So in comparison, though, the hi on the last one was 0.7. So we still see a reduction in significant events as well. Where the previous study, the total was five significant events and there was one here as we scroll down to the next page. Okay, so, interestingly, one thing that I can't remember if I ever taught this before, but when you increase nasal efficiency, there's a potential to also increase oxygen saturation because the turbinates, excuse me, provide back pressure to keep the alveoli and the lungs open, allowing you to have better oxygenation. So average oxygenation on the last one, 95%. Average on this one, 96%. Is that a huge difference? Is it's bigger than you probably think because the heart is working less to provide this with the vasal flow being better. The lowest on this one is 93%. The lowest on the previous was 91%. So we're still doing everything better on this study. The heart rate on this one, the average picked up by the machine was 55.3. The previous one was 57. The highest heart rate was 84. This one is 73. So we are seeing increases in sleep consolidation and physiological changes as well. More of a. I can't even think of a word, like the body's better, the body's getting better. I'll say it that way. When we look at the sleep stage, and that's interpolated by the machine, you had 14% deep sleep last time, you had 17.7. This time, the ranges, which is kind of controversial for deep sleep, is 13 to 20%. I kind of like closer to 20%. And the deep sleep is a testament to the body's ability to feel safe. If upper airway resistance or significant events are occurring throughout the night, the body is either not going to go into deep sleep or it's going to go, just not for a long time. In deep sleep, we're completely disengaged from our surroundings. We can't feel and we can't hear. And with us still being animals, as mammals, we do have instincts of trying to, for survival. And if the body's like, well, I mean, we're on edge all the time, we're under a threat all the time, we can't necessarily go to sleep because what if you don't come out? So we do see an increase in deep sleep here, which is really good. Also we see a slight increase in REM sleep. So REM sleep, we'll max out REM sleep at 25%. Usually anything over that will signal some sort of maybe sleep deprivation or increased stress, physiological or mental. The previous study, that was 22.3%. So we also see an increase in REM sleep. The hypnogram below here is like a quick snapshot, but we'll go to the next page for, for a bigger one. So here we can see that during. Oh, let's go through the channel. So this top snore channel here is the machine actually picking up the snoring. On a home sleep test, the snoring is picked up through the nasal cannula. Increased airflow, turbulence. In a lab, there's a vibration monitor we'll put over the vocal cords to pick up the snoring. It's called a microphone, but it's not a microphone. The thing that I like about this coming through the nasal cannula is even if there's no snoring, we can still quantify or look at heavy or harsh breathing where there's increased resistance in that tube. So some of these, and you can't see them here, but they're really, they're small blips. And the bigger the blips, sometimes they're huge. The actually, the louder the snore is for that patient. The next line down is the heart rate or pulse rate. That's the green line. This line, for the most part, should be fairly straight throughout the study. And in comparison from the last one, this one, even this is improved. There was some chaos on the last. The last one even. Just to say this again, Even with an AHI of 0.7, the pulse was still chaotic. And if the pulse is chaotic and the patient has signs and symptoms, then we do have a problem. Apneas and hypotenuse don't tell that story. So on the heart, we have the heart rate. Here is the second channel. The channel below that, the blue channel, is the oxygen saturation. Haley is fit and athletic, so her heart rate's lower. So they're kind of coming together. One thing that we could tell about a patient, too, is potentially how well their heart is operating. If this is very chaotic or we see extreme peaks and valleys, you kind of see where it's, like, fuzzy in areas. Those fuzzy areas are fluctuations. Besides the times where we see really big vaults, usually that's during a body movement, we'll see them that big. But for patients that don't do not necessarily have great heart function, we will see a lot of spikes, and we'll see a lot of fuzzies as the body is trying to keep you alive. The next channel down that snore actually is me going through the study and highlighting all these blips. The machine will do this automatically, but if I see there's areas where there's actually no snoring, then I'll take out the whole chain, and I'll go back through and actually do the snoring to make it more realistic and true to what it is for the patient. The next line down, the respiratory events, these are significant events. Apneas and hypopneas will show up here. Again, this does not necessarily tell the tale for a patient. It would be the pulse that would be the most important thing to look at on the hypnogram. Unless, of course, you have severe sleep apnea and there's just tick marks, like, scattered all throughout there. The next line down is the body position. The body position is important. Sometimes patients will say, well, they told me to do, like, two or three nights. The difference between nights for a patient on a sleep study will be A, heavy drinking, B, narcotics or medicine changes, stressful days, or sleep deprivation. If you think about it and the other thing is to make sure that you got a good study. Some providers will do multiple nights to say, okay, this was the best night is good. There's no difference in if you go to a sleep lab, they're not going to say, yeah, we need you to be here for like three or four nights because. But there's this misconception that you have to do multiple nights on the HST because things may change. So I've done multiple three to five night studies and I mean, honestly and truly, there may be very small changes in between them. All the nights are so close together with the only difference being body change, body position change. If you sleep on your left side all night and everything is looking decent and then you sleep on your back one night and just like all hell breaks loose, of course those nights will be different. So for patients it is really. I know this is another thing in sleep where everybody says sleep on your back because that's where you're worst and we want to fix you at your worst. How do you sleep naturally is really what we need to be seeing. Because if you sleep on your left side naturally and you have a partner, a bed partner that says, yeah, they do sleep on this side. That is what we want to assess, we want to assess the problem there because with upper air resistance, facial architecture can play a role. If we have, you know, the tongue pressures are not the same on either side, then sleeping on one side may be better for the other. There may be more nasal congestion on one side than the other based off of the way the palate is shaped because of that. So body position is there. The next line down or the next channel down are the actual sleep stages. The highest line is wake. The next line down that has the salmon colored tops, that's REM sleep. The blue lines are light sleep, which would be one and two stages one and two. And then deep sleep is the green. That would be stage three or three and four. Here we could see a breakdown or tangible evidence of sleep stages. In a perfect world, in the most perfect world of unicorns and ponies, our sleep would roll in 90 minute increments. You go to sleep, you go into deep sleep, you come back up at a light sleep and then you go to REM sleep. REM is a very light stage of sleep. And then you go back down. You start off with a bunch of deep sleep, a little bit of REM sleep. As the night goes on, you get more REM sleep and you get less deep sleep. This is the process the body goes through for a couple of things or for multiple things. But in deep sleep, it almost is the like it's the house cleaner is doing everything is cleaning the body, you're getting oxygen, the muscles and tissues. Inflammation is being reduced. But it also is starting to take these thoughts and memories and ideas and it's spreading them out, it's categorizing them. In deep sleep, we also get rid of protein plaque in the brain through cerebral spinal fluid. If you are having arousals and upper airway resistance or respiratory events, norepinephrine will fill that space. So you can't release, you can't get rid of that protein plaque. 3 Cerebral spinal, it's only one channel. Then when you're going into REM sleep, all these things that are starting to be categorized, it's going to be locked away. So REM sleep is all about cognition. It's also when we depotentiate the amygdala or wash the amygdala away. So the amygdala is part of our fear based system and it's where we kind of hold on to traumas and all the things that shape us into who we are. And when we wash that away, today's troubles are not tomorrow's troubles. They're memories of today or memories of yesterday. But if we don't wash this amygdala, if that process is broken, we can have anxiety and trauma. We become more carnal and aggressive in nature. The synapses, we don't produce or maintain as many synapses. It looks like the brain of a patient that does have some pretty good ptsd. So short term memory loss comes from there. Early morning headaches, anxieties, aggression, or, you know, testiness. When you wake up and you love grits and somebody says you want grits and you're like, I don't give a crap about no grits. That it could be that you did not necessarily sleep that well. You didn't get good REM sleep. And in those two stages, not only can you dream in rem, but you can dream in deep sleep as well. So for kids, the kids that have night terrors will be in deep sleep. You can't get through to them. They can't see you, they can't hear you, because they're still in deep sleep. It's just that deep sleep has been broken. So they're there and they are still in the midst of that dream and then they fall back out and they don't remember anything. So that's a night terror. And then in REM sleep. We have the nightmares where you wake up and you go, that was crazy. That kind of thing. So this would be, this, this hypnogram here would be the place that I would go with the patient and say, okay, so let's look at how your pulse is doing over the whole night. For patients with upper airway resistance, we are going to typically see severe respiratory events in REM sleep. I have been doing research for the last two months on why the upper airway tone just is completely done for.