074: Dr. Michael P. Murphy, Physician of Sleep Medicine and ENT surgeon, Talks to Us About Snoring. Is it a Quality of Life Issue or a Health Issue?

Welcome to the sleep is a skilled podcast. My name is Molly McLaughlin, and I own a company that optimizes sleep through technology, accountability, and behavioral change. Each week I'll be interviewing world class experts ranging from doctors, innovators, and thought leaders to give actionable tips and strategies that you can implement to become a more skillful sleeper.

Let's jump into your dose of practical sleep training.

Welcome to the sleep is a skilled podcast. My guest today is Michael Murphy MD. He's trained as a physician of sleep medicine and as an ear nose and throw E N T surgeon. He is one of only 275 physicians in the United States who is double board certified in these two fields. This dual certification enables him to treat, sleep apnea, snoring, and other sleep related conditions, providing a full range of treatment options.

He's able to perform the inspire surgery for patients with sleep apnea who have not tolerated other treatments. Dr. Murphy's practice is part of the Stanford healthcare system located in a community in the San Francisco bay area, where he has practiced since 2002. His medical practice encompasses a full range of care for patients of all ages.

From young children to adults and seniors. He is a dedicated physician and his success is reflected in service to more than 6,000 patients. Over the past three years alone, his commitment to quality patient care is reflected. 220 grateful testimonies and almost 900 up votes on the Stanford healthcare website.

Now Dr. Murphy obtained his medical degree with distinction in research from St. Louis university medical school was top of his class and was elected to the alpha omega alpha medical honor society. He did his residency at the university of Washington, and Seattle spent two additional years as a NIH research fellow earned a competitive research grant and completed a master's degree in public health.

I think you're gonna really enjoy this conversation that we had today on all things, sleep apnea and more. If you of course have any questions, please don't hesitate to ask and head right on over to this sleep is a skill website and in the lower right hand corner, we have a little sleep bot. So you can ask any questions that you might have around.

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And welcome to the sleep is a skilled podcast. I am really eager to get into this conversation before even hitting record my guest and I were going back and forth, back and forth with lots of different topics that we are excited to share with you all. And I know we're gonna make a profound difference in your journey to improve your sleep.

So without further due, thank you so much for taking the time to be here. And thanks so much for having me. It's really an honor to be on your show. I listen to your podcast and it's always informative. Always lots of helpful, real practical stuff. Oh, good. Well, I'm so glad to hear that it was certainly our intention to make sure that anyone listening, walks away with things that they can begin to implement or research or take, you know, steps to the next level.

So, and I know we're gonna get into that today, and this is so needed because we've only really had, uh, one real dedicated episode on the topic of sleep apnea. And I know you are beyond well versed in this after decades and decades. So I'm gonna put the spotlight onto you to share a bit about how it was that you got into this field and how this relates to how this can help support others looking to improve their sleep.

Yeah, sure. Thanks a lot. I appreciate that. So, uh, I grew up in the east bay in the San Francisco bay area and, uh, went back to the Midwest for med school, uh, and was anxious to get back to the west coast. So I did my otolaryngology head and neck surgery, residency. Most people referred to that as ear nose and throat doctors.

Yes. As a surgical residency. And I did that at the university of Washington. I was very fortunate cuz I finished up in 2000. And I was able to come back and kind of join my hometown ear, nose and throat practice as a general ear, nose and throat doctor. So I've been doing procedures for snoring in fifth avenue, my whole career, although I do other stuff too.

I'm a general ear, nose and throat doctor. So I joke around and I say, you know, when we're, when you're building ear nose and throat practice, what happens is the kids come in and they need ear tubes. Then the mom has allergies and the dad's snores and the grandparents can't hear and need hearing aids. So, you know, that's kind of how you build your practice over time.

It just gets busy and I've been doing that my whole career, but, you know, I really, again, to be more and more aware of just the importance of quality sleep and my patient's lives. And so, you know, over time I got more and more interested and ultimately decided to study four and pass the sleep medicine board.

In 2009 mm-hmm . And so I'm one of 275 physicians in the United States that are board certified as both ear nose and throat surgeons and sleep medicine doctors. And, uh, you know, I tell my patients a lot of the nons sleep apnea type category, uh, type issues like insomnia and ship work disorder. I have a lot of book knowledge and I'm learning as I go, but really the area where I see patients, you know, day in and day out, relates more to snoring and sleep apnea.

So what that's allowed me to do over time is, uh, you know, it doesn't make me better. It just makes me different. I think it's allowed me to have kind of a big picture approach to patients who have snoring and sleep apnea. And, you know, that's really my motivation to reach out to you. And I really appreciate you having me on today, cuz I wanna, you know, get the word out about this and kind of share how I like to approach these issues and you know, hopefully help help a lot of people in the process.

Oh, absolutely. Well, if anyone missed that, when they're listening, this is most likely one of the most well versed people on this topic that many of us will have the privilege to hear from and going deeper on sleep apnea. So we're so grateful for you to be here and to share your knowledge, because I think certainly in what I've experienced from, you know, many of the people that I've worked with around improving their sleep, the topic of sleep apnea has been so confusing for so many and how to approach it or a sense that it's a big, arduous task to navigate through, or, or what's even gonna have an, even if I have that, I don't want the mask, or I don't wanna deal with this.

So then just seemingly a lot of noise or stories. So could you help us kind of break down what this looks like and make it a little less scary? Absolutely. I'd love to, if you don't mind. I think what we'll do is we'll go kind of from 30,000 feet and we'll just please work our way down and then we we'll finish up talking about some real specific stuff.

Um, one thing that I wanted to mention as well is terms of my background, um, is that in addition to getting board certified in sleep medicine in, I think it was about 2018, there's a company name inspired, and they have a surgical option for patients who can't tolerate C pap or other treatments for sleep apnea.

And they approached me to be one of the surgeons in the bay. Be trained to offer the surgery to patients. So, you know, I tell my patients, of course, you know, that they approached me right before COVID hit. So we got slowed down a little bit there, but we're getting up to speed. And, um, and so we'll, we'll talk about that a little bit towards the end too, when we get into more specifics.

So I guess the big thing I would start by saying is that all sleep and all, you know this well, but all sleep problems are just put into categories. There's about six major categories. So one category would be insomnia. Another category would be the circadian sleep prism disorder. So that would be things like shift work and jet lag, things like that.

So snoring sleep apnea come under the category of sleep related breathing disorders. And there by far the most dominant two conditions in that category. And it just so happens that they're incredibly common. So for all you do is you're listening. I tell people I snore too, so I'm not just the president, I'm a client.

So yes, that's nice. Appreciate that vulnerability. You mystify that these, these, uh, conditions are incredibly common. And so, you know, we start with snoring and it's really hard to know a little bit about how common snoring is cuz people define it really in different ways. But the general consensus is that if you, you know, define snoring as, as noisy breathings and stuff at night.

So it turns out that about 40% of us males are habitual snorers, mainly snore nightly, or almost every night. And about 20%, uh, women, adult women snore on a habitual basis. So it's shocking, but that wounds up being about 50 million men and about 20 million women. So there's about 70 million people in the United States are adults that snore on almost a nightly basis, which is pretty incredible.

Then, you know, we talk about sleep apnea and the numbers change a little bit, but they're fairly similar. Depending on how you define it. About 34% of us adult males have, uh, you know, have sleep apnea and about 17% of women's. So, and the numbers start to boggle your mind, but it turns out to be about 25 million men.

And about 15 million women have sleep apnea, not just snoring, but sleep apnea. So, you know, these, these things are very, very common. And, um, it's something that, you know, I think most of us either have a spouse or a family member, and we can talk about the pediatric population as well, but even kids that snore and we worry about that and the children as well.

So there's probably not too many families that don't have someone who's snoring or have these concerns. So it's incredibly common. Absolutely. And this can even extend to people that are not necessarily overtly or to an extreme degree, snoring, you know, so you can correct me if I'm wrong on this. My fiance was just recently diagnosed with REM dependent, sleep apnea after so many times that I've been trying to urge him to get tested and sleep image had sent us a ring for him to test.

He had been very, oh, I'm fine. I'm fine. And we tested and saw that he had REM dependent sleep apnea. And wasn't necessarily not someone that I would, you know, complain of being a snorer per se. I wonder if you can also speak to this topic where it might kind of go under the radar a bit more, it might not have those kind of clear indications of oh, that person's likely as sleep apnea.

Yeah. Yeah. That's actually a, that's a great linen. What I wanted to talk to you next one thing, just to circle back on and that, that is, um, and it turns out, you know, it turns out how common scoring and sleep AP Inne. Yes. The thing that we know really clearly too, is that there's a real clear relationship between weight gain and obesity yes.

And scoring and sleep apnea. And we'll talk about some of the anatomy and why that happens later. But you know, in 20 20, 40 3% of us adults were obese. And the crazy thing is that was up from 33% in just 2015. Wow. So only just in the last five or six years, the percentage of Americans that are obese have gone up 10% and that's a whole nother discussion, but yes, the point is not only are sleep apnea and snoring, incredibly common, but they're getting more and more common all the time.

So, uh, but to get back to what you were asking about Molly, so the way that I like to explain it to my patients, and this is one of the key concepts I share with every patient that comes to see me is I like to explain to 'em that your airway at night, when you're sleeping is just a spectrum in terms of air flow.

Mm. So on one end of the spectrum is streamline air flow and the symptoms. Nice, quiet breathing. You're happy, everyone arounds you happy. Then at some point that streamline airflow becomes turbulent. The symptoms become snoring, and then further down the spectrum. At some point that turbulent airflow becomes obstructed and you slip over into sleep apnea.

And even those conditions are just a spectrum, right? We think of snoring in terms of how loud it is. So you can have a minor snoring that's very light, or you can have super loud snoring where your partner's leaving the room. They're headed off to another room or you're getting nudged and kicked all night long.

Yeah,  sure. Yeah, exactly. And then, you know, sleep apnea itself ranges from mild to severe. So really every night when we're all breathing in terms of our airway, it's just one long giant spectrum. As you related to your fiance, it's not black and white. And if you have CIPA, you don't have it all night, every night, you know, it can be related to different stages of sleep and other things like that as well.

So, but, you know, I used to tell my patients all the time. In terms of where you are on the spectrum. It's important to tell the difference, cuz if you're snoring, that's a quality of life issue. And if you have sleep apnea is a health issue and it turns out, you know, I was kind of wrong about that in the sense that, you know, if you have loud snoring, you're probably very close to having sleep apnea or you may even have mild sleep apnea.

So if turns out that snoring is not, not great for our health either, and we can talk about some of the mechanisms about why that. Sure. But you know, one of the things that we're able to do now is we have these large databases where we can access to lots of health information on people in large healthcare systems.

And so increasingly the researchers are able to look up codes for diagnoses and look into these databases. And studies are showing that people that are loud or habitual snorers have about a 30% increased risk of getting hypertension in and of itself. So it turns out that snoring is just not a quality of life issue.

It can be a health issue as well. And then, you know, as it relates to just some of the effects that negative effects on our body, you know, when we have these episodes, there's a couple main pathways that it happens. But as it relates again to your fiance, You know, one of the things that happens in REM sleep is that's where our body tends to relax, you know, in REM sleep.

And that can lead to obstructions that maybe occur in that stage and not other stages as well. Wow. Really interesting. And how about U R S uh, wondering if you can kind of break that down a bit for us? Yeah, absolutely. So what happens is there's two main events that have happened when we talk about the negative effects that are going on in our body when we're having these, when we having these episodes of snoring and sleep apnea, and that leads to the cascaded problem.

So really you can think of an, almost like, you know, a fork in the road. So when someone's having either snoring or sleep apnea, the first path we think about is something called a respiratory arousal. And what that is is your airway, the airflow through your airway, isn't actually blocking off, but it's so turbulent, it actually causes you to ascend to a lighter stage of sleep.

So when you go in the lab and you do a sleep study and they're measuring your air flow and all these other various parameters, you basically have electrodes in your head and they're measuring your stages of sleep. And they'll score something called a respiratory arousal where the air flow's so tributed, you literally go to a lighter stage of sleep.

And so what it will happen in this situation is, you know, you'll score those events. And the other events we score during, uh, a sleep study have to do with actual blockage of airflow. So two major events just to hit 'em real quickly, cuz it'll tie everything together. Yes would be in apnea in an apnea is where you make an effort to breathe and somewhere in your airway, we'll talk about it a little bit later.

There's a 90% or more blockage of airflow for at least 10 seconds. So you can think of it as almost a complete or total blockage of airflow in your airway for at least 10 seconds. Mm. And we turn that, we turn that in apnea event and then a HIPA event is a 30% or more blockage of airflow for at least 10 seconds.

With a little drop in your oxygen level. So I tell my patients all the time, it's a respiratory event. It's not as bad as an apnea, but it's still an event. So what's happening during your sleep study is, and you do this in the lab. We also do this at home studies like your fiance did as well. Sure. So we're totaling up these events.

Okay. And so when you measure up the apnea on HIPA and you total those up, you come up with the apnea hip HOPA index, and that's the basic measure we use to determine if someone has sleep apnea and if they do how bad it is, as it relates to upper airway resistance syndrome, there's something called the respiratory disturbance index.

And what that is is they add in those respiratory arousals with the apnea and the hypopnea events. Mm. And so what that happens is when you get that diagnosis of upper airway resistance, it's a great question, Molly. Cause I usually tell people. That actually kind of fits right in the middle of the scale, the spectrum between S snoring and sleep apnea.

It's kind of right between the two. Sure. Yeah, but it's more than just storing people are having arousals, but they don't technically fit into the criteria of sleep apnea. Yes, but they're still having all this interrupted seat because of all those respiratory arousals that are going on in their body.

And they're not spending enough time in the restful stages of sleep at night. Got it. Yeah. That's defined when someone has what's called a respiratory disturbance index that's, you know, over five or elevated. But they don't meet the criteria for sleep apnea and they kind of fall in that gray zone between snoring and sleep apnea.

All right. So I would love to kind of dive into two kind of a two part expose on these topics. So one being testing for this, so people might be listening and speculating. All right. Maybe I need to go deeper on this and actually get this tested if you could one walk us through that process. And then on the second side of that, some of the solutions, depending on where they fall on that spectrum, but for the first part we're questioning, all right, maybe I have this, maybe that's part of unlocking this key of why I just feel so, uh, tired or having those, you know, particular symptoms that seem to relate to the possibility of sleep apnea.

What are my options? Both in the lab and then at home. Great. Great question. So I like to kind of think of it as a steered kind of a stepped up approach in terms of how we think about it. So, you know, the first thing, you know, that helps you get a sense of where you are on that spectrum is, you know, how you feel, but also, you know, what your partner says about you.

Yes. So for instance, you know, one of the things I've asked, you know, usually a guy will come in and he's snoring and his, you know, his fiance or his wife or his partner's there with him, you know, and he'll be talking about his snoring. And one of the first things I'll ask the persons that's with him. Are you worried about their breathing?

I know they're snoring. Sure. But are you worried about their breathing? Because studies have shown that if you're bed partner whoever's around you not only says that you're snoring really loud, but they're witnessing these APNIC events or they're worried about your breathing or some people say, yeah, I actually have to shake my partner every once in a while.

Cause I don't hear breathing. You know, studies show that that's if you correlate that, that doesn't mean you have sleep AP me, but it's, it's pretty predictive. Yeah. And then of course, if you've got the daytime symptoms where you're waking up with headaches, Having trouble with memory concentration, a lot of daytime sleepy.

We'll talk about a practical tool for that in a minute. Great. You know, so the first thing is just your nightly quality of your sleep and your story. And whether people are worried about you, that that's a start, then there's a couple practical questionnaires that people can use that I use in my practice that are great.

So the first one that everybody's list is listening can write down and we can include it. Form is something called the stop bang questionnaire and it's S T O P dash B a N G. It's a questionnaire. You can Google it. And that's based on eight basic questions. That are asked of patients. And what happens is with each question you actually just score.

If the answer is yes, it's a one. If the answer's no, it's a zero and you work your way through this questionnaire and by totaling up the total of that questionnaire, it gives you a pretty good idea of the risk about whether or not you may or may not have sleep at. So I don't know. Well, if you want me to walk you through that or if we just leave that for there and go.

Sure. Well, that could be great to kind of hear, since you said it, I just pulled it up and there's just a couple questions, so that's fantastic. And I'll make sure to include that in the show notes, but yeah. Yeah. Any big call up there so that people listening might say, oh, uh, that sounds like me. Yeah. So you know that, and the first question on the stop bang is whether your partner sees you stop breathing or not at night.

Yes. So it fits right in, and it asks you a little bit about whether you have some elevated blood pressure. And so those are real, that's one practical thing you can do. There's also something called the F worth E P w O R T H sleepiness scale. Yep. And that was a sleepy scale that was used all throughout the country and around the world as a quantitative measure in general, how sleepy you are, and you can look that up.

But basically what it does is it has some different events during the day situations you may be in and it asks you to grade what the likelihood are, is that you would fall asleep or do in those various situations. And again, it's a quantitative thing you can score, and it gives you a general idea of your sleepiness.

And it's helpful to know off about what your baseline sleepiness is. And it's also can be helpful, you know, as we treat people to see if they're responding. In terms of the daytime symptoms. So those are two practical kind of questionnaires and tools that people can use to kind of get an idea of where they may fall along the spectrum.

Fantastic. Yeah. I mean, I think that's so helpful because we might just chalk this up to a swirl of, oh, I know I gotta put the phone away. I gotta go to bed earlier. I gotta do this and that and chalk up our kind of maladaptive behaviors to, and the results with, with those too. That's why we're not, we're not totally rejuvenated.

And yet you're pointing to something very distinct and different. And so, but even just through a couple questions, so we'll include both of those in the show notes so that people can check those out and see, does it look like you are a candidate to get tested for this? Yeah, exactly. So then, you know, we talk about, so you know, what your partners are telling about you.

There's some questionnaires you can use to help out a little bit, and then, you know, there's all kinds of. Tons of consumer, you know, options out there that people can use to kind of check the quality of their sleep. Sure. So you could have the Fitbit or your apple watch, or there's a company called Withings that has a watch and all these, I call 'em consumer devices.

I break them into two categories. You know, one is what I call wearables and those things you actually wear on your body, whether it's a watch or whatever it might be. And then they have something called nearables and you've probably heard about those. That's the way you get the sleep, you know, the sleep comfort bed.

And it's got the mattress thing in there that tells you about all it's gathering information. Yeah. And those things really can really help us in terms of getting us a basic idea about the quality of our sleep. But most of them aren't really FDA approved and keep your eye out. Cause these companies, there's lots of them out there and companies you do and great job of evolving technology and they're becoming more and more sophisticated, but most of those consumer devices aren't really gonna help you determine whether or not you actually have.

Sleep AP, ina or not sure. And so, you know what I would say to everybody out there is that, you know, if it really looks like, and this is I guess, where the rubber meets the road, you know, if you're snoring really loudly or you do the questionnaires and you feel like you may have sleep apnea, it's really important that you seek out a provider so that you can be, you know, seen and evaluated.

And you alluded to it with your fiance, because really at the end of the day, when we're trying to determine where you are on the spectrum, you may, you know, you may need some more formal testing. So yes. For instance, you, you referred to the, um, sleep image device. Yes. That's a really cool device, but you know this well, but basically what you do, you have to be a licensed provider to provide this for your patients.

Yes. But what you do is your provider will get set you up with this sleep image device and you basically wear a ring on your finger. And that ring gathers three pieces of information while you're sleeping at night. So, number one, it does essentially an ECG where it measures your, how your heart's behaving electrically.

It measures the oxygen levels in your blood, and then it also measures the activity of your blood vessels. And so you download an app and this ring sends information to the app, which then goes to your provider. And this is able to do some amazing things in terms of the information it gives you for the, for your sleep.

So it tells you about your sleep quality and efficiency. What percentage of the night you're in bed you're actually asleep. It'll tell you how long it takes you to go to sleep. When you get into bed and how long you're actually asleep, you can measure sleep apnea events because it's, you know, measuring the, the blood vessel activity in your finger.

Mm. So, and this information is all transmitted to the provider and then they can of course, make a diagnosis. And as with your fiance. The information also keeps track of sleep stages so they can actually determine as they did with your fiance. If the sleep apnea is present throughout all the stages at night, or if it's just in certain stages.

Absolutely. So can you, um, cause there certainly are becoming a lot of different options for people. If, if say they do choose to do the at home or in the lab kind of approach to get tested. Are there certain things that you would have people think about if they are choosing some of those providers or certain tests?

So say for the, at home, are there ones that you feel like are more, have more validity or anything to kind of guide through on that topic? And are there times when it makes sense to be in a lab specif. That's a great question. So, you know, it's actually ironic because in my practice we've been doing home sleep studies in my practice for, I would say it probably the last seven or eight years.

Okay, great. I've done a number. I've done a number of systems. There's a company called ResMed res M E D, and they had a system Phillips. Um, Respironics has a system called the Alice system. That's a home sleep study system. That's widely used in the last, uh, in the last few years, I've moved on to something called watch pack, w a T C H P a T.

And I'm having great, great luck with that. And ironically, Molly, it's the exact, almost the exact same setup that the sleep image system uses. So, you know, I tell my patients, you know, it's based on this adrenaline idea. So one of the things that happens, you know, pathologically in our body is when you either have one of these respiratory arousals.

What happens is our, you know, our, a sympathetic nervous system gets activated. So we have this automatic nervous system in our body, right. There's two sides to it. There's this sympathetic system, which I call that the fight or flight side of the equation. I call it the gas pedal. Okay. Yes. And then we have our parasympathetic nervous system, which slows us down.

I call that the breaks. So the idea is that when we're sleeping, we wanna get into these deep restful stages of sleep. Because when that happens, you know, the parasympathetic nervous system takes over. So it allows our body to slow down and recover. Our heart rate goes down, our blood pressure goes down.

The brain, uh, glucose metabolism feeds up to clear our brain of all the effects of the day's activity and our body, uh, growth hormone comes out. So our body heals itself. So the problem with these respiratory arousal is when that happens, we never get into that restful stages of sleep. We don't spend enough time in those restful stages of sleep.

And instead our body gets stressed and we go into the fight or flights response. And then what I tell my patients is it's all gas pedal and no breaks. Your body never gets a chance to slow down. So with respect to these systems that are diagnosing it, whether it's the sleep image system or the watch patch system, when that system gets activated, because we have sleep fragmentation or the other side of the equation is if you have an apnea or a pop event, your oxygen levels are actually gonna drop down.

We call that hypoxia and that does the exact same thing that kicks in the fight or flight response. So you can get to that fight response, two different ways. You can do it through fragmented sleep and respiratory arousal. Or you can do it when the oxygen levels go down when the airway blocks off. But once that happens, when that body goes into fight or flight mode, you know, our hurry and our blood pressure goes up.

But one of the things our body does is it constricts the blood vessels in our hands and our feet, cuz it's shutting blood to the core of our body. It's the basic fight or flight response. And that's how the sleep image and the watch pad system works. So for instance, with the watch pad, it's very similar.

Patients wear a thing on their wrist and it measures their sleep stages and their body position in bed. And there's a thing on their finger, just like the ring for the sleep image system and it measures constriction of blood vessels. So it can identify these events. So that's the basic way that these, these things are keeping track of these events and correlating these events and helping us figure out what's going on.

So, you know, these home sleep study systems help. There's lots of different ones and they work different ways. But in, in essence, that's what they're doing now. Traditionally for many, many years, people would go sleep in a lab, but for practical reason, For insurance reasons. And for a lot of other reasons, you know, going to sleep in a lab is becoming less and less common.

Wow. Okay. Well, I mean, just for the ease of use, I think there's certainly some wins there and thanks for breaking down how they're able to detect some of those apnea events. And then real quick, wondering if you can share, I know you mentioned the insurance piece and I'm sure that's a big topic, but just to demystify this a bit for people, if they might think that, oh, this is gonna be thousands, thousands of dollars, this is gonna be a big hassle.

Can you share how this could go? And hopefully the ease with which people could get this tested? Yeah. One of the things let's step back just for a minute, there's a couple different ways that people can connect with providers. Cuz we had talked about the importance if, if they feel like they may have sleep apnea too, you know, see a provider.

And so yes, one of the things you can do just for starters is start with your primary care doctor, primary care doctors. Increasingly this is happening in our Stanford system and in systems throughout the country. Primary care. Doctors are increasingly being able to provide access to these home sleep study systems or refer you to someone who can other options would be, you know, if you go to the American academy of otolaryngology website, that's the national EENT website, there's a link for find a provider and you can just put in your zip code and they'll tell you the ENT doctors that are in the area.

And it's the same thing for the American academy of sleep medicine that can get you access to either, you know, board certified sleep doctors or ENT doctors. In addition, if you don't just start with your primary care provider, but you know, ultimately the way it's working Molly is that increasingly insurance companies as sleep apnea, snoring become more prevalent as we can.

We become more aware of the serious health effects. If we're not treating these, you know, I'm not running into any problems with these, you know, home sleep studies, especially. Being covered for my patients by their insurance companies. And then in fact, the insurance companies are encouraging these as opposed to in lab studies.

Wow. That is very good to hear. So, uh, couple different steps for people to take that are very accessible from the sounds of it, becoming more, uh, something that they can take, steps where with ease, they'll be able to have some answers for these often, uh, years and years of questions of do I have that?

Could that be? And now we can actually have some answers, so that's fantastic. Now from that place, uh, real quick. I know you mentioned the wearables and how certainly those cannot be diagnostic. I do hear a lot of people speculating around two pieces of kind of bio, uh, metric feedback and wondering, could this be a sign for sleep apnea?

The two pieces being their respiratory rate scores and their blood oxygen scores throughout the course of the night. Now, naturally those cannot be diagnostic, but have you seen this be enough of a flag on wearables that it's had people take steps? Is that, is there any validity to that? No, I do think there's validity to that.

I think that, um, probably the most important one of the two you mentioned have to do with our blood oxygen levels. Sure. Okay. So the apnea hypo index for years has been the basic measure that we use to grade sleep apnea and how bad it is and determine that people have that. And there's a lot of debate going on nationally, internationally about that being a measure and people have some criticism or not, the bottom line is right now, it's the best measure we have.

Sure. But as these devices and we have these wearables and all these other things are, uh, able to track our oxygen levels. It turns out that one of the more significant predictors of if someone has sleep apnea, if they're gonna go on and develop diabetes, and some of these other problems is actually their oxygen levels throughout the night and the extent to which they drop.

Okay. So I guess a practical answer to your question is, you know, the fact that these wearables and some of these things are able to follow our oxygen levels of night, I think that's incredibly helpful information and right. Really, if it raises a flag at all, that's just one more piece in the puzzle, right?

Yes. In terms of determining, if you have to seek out answers and then of course, we go through the process of testing and then that, that move, you know, that moves us on to the whole issue of treatment. Yes. And to that point, so now people have tested, they get back the information of where they're falling on that spectrum that we spoke to.

What are the possible solutions for people and what are some that might be kind of newer that they most likely have not even heard of. Yeah. Great. So I wanna start with a couple big, so, you know, treatment for sleep apnea is a whole, you know, you can really get into a lot of specifics. I'm gonna start with a couple big picture points.

Okay. And then we can touch on a couple things that I think will be interesting for people. The bottom line is in terms of, of treatment, is that if you think you have sleep apnea and I'm glad we had a chance to cover this, you know, you need to get to a provider and, you know, get yourself tested and see, I think having a have a physical exam by someone is really important.

I'll give you a couple of practical exams of why that's important in a few minutes, but what I would say more than anything is that the most important thing you wanna try to do is you wanna determine, you wanna try to determine what the cause of your snoring your sleep apnea is? Mm. Because once you know, though what the cause is, we can really start to talk about solutions.

And what I really want people to try to avoid doing is what I see in my office sometimes. And I feel bad. It's frustrating for them is if you don't know what the cause is, you can spend lots and lots of time looking into solutions that may not even be relevant for you. Yes. And so that's where, you know, we, we, you know, go down the rabbit hole on the internet and spend hours and hours and hours researching things that, you know, may or may not even be, you know, relevant to our particular situ.

That would be the first big picture thing. And then the second thing I would say is, you know, treatment in a lot of situations is gonna wind up being a collaborative effort. So it's very rare for me to have someone who has sleep apnea and I'm the only person that helps 'em. And I'm the only person that treats 'em, you know, there's different levels involved in terms of where we could be having problems with snoring, for our sleep apnea.

So for instance, could be a problem with our nose, you know, and our nose itself. You know, I tell my patients, there's kind of, it's kind of like a map problem with two variables, you got the structure, your nose, and you got the line, your nose, those are the two issues. So obviously if there's a deviated septum on exam or you have some polyps in your nose or something obstructing your nose, you know, that's where, you know, I come in as a, your nose and throat surgeon.

Yes. But a lot of people have trouble with the lining of their nose. We call that rhinitis and they've got allergies or other things. So we got an allergist involved to, you know, help treat them. So a lot of times treatment winds up being a collaborative process as well. Really important. Okay. So seems that there are some facilities that are online that they'll send, you know, an at home sleep test.

And then you have like a, a virtual consultation with the doctor to go over your results for you in your experience. Would you highly suggest then that people take the steps to then make, uh, alternative appointments to then ensure that they are getting this addressed in a holistic manner versus just a one and done?

Yeah. You know, it's interesting with the iPad at telemedicine, it's a great thing, cuz it's allowing a lot of people that normally wouldn't have access to a provider or maybe you live in the rural part of the country and it's a long drive for you to get to see a provider. And maybe there isn't a sleep specialist and an E and T right in your area.

So, you know, I think the idea of having telemedicine and allowing people to have a virtual visit with someone and get the history, get the ball rolling. You know, get a test done, determine if you have a sleep apnea, that's all incredibly positive stuff. I do think at some point it's really important that patients, you know, see a provider and get examined.

And the reason why is at some point, someone needs to take a look in your nose and throat and, and see if there's any issues going on there. I'll give you an example. So I had a 75 year old guy who came to see me last week and he came to see me for the inspired device, cuz he was having trouble with C P a P that's one of the criteria.

And uh, he was super frustrated cuz he tried like 10 different masks and he was feeling like a compete failure cuz things weren't working out and it wasn't anyone's fault really. But he had been diagnosed with sleep apnea and been on C P a P for four or five years, probably in part because of the pandemic had been hard to see providers, but no one had ever really looked in his nose and he had tried a bunch of nasal masks and it turns out he had a severely deviated nasal septum.

And that was the reason why he was struggling for so long. You know, that's, that's a pretty quick fix, you know, take him to the operating room and straighten his septum and hopefully that addresses it. So all these things are incredibly positive, you know, and something's better than nothing, you know, but getting exams at some point, I think are important.

Great. Okay. So we wanna evaluate where the problem is coming from the root cause. And then from that place, what are some of the different types of things that people might treat this with? Yeah. Yeah. And so then the next concept would be in terms of treatment, the general trend is we start, we like to start with the least invasive things and move to the more invasive things.

You know, I tell people all the time, even though I'm a surgeon, we don't go barreling ahead with surgery. We usually try yes. Nonsurgical things first. And, uh, and that goes for all my patients. So I'll just, let's just give you one example. Sure. We can talk it through. Cause it relates to the excite device.

In the inspired device. Great. So, you know, some people will have a trouble with obstruction at the level of their tongue. Yes. And so, you know, the main muscle that allows our tongue to stay forward at night's called the genus muscle. It attach, it starts in the inside of our jaw and attaches to our tongue.

So when it contracts, it pulls our tongue forward. So it, so turns out that when we sleep at night, the tone in that muscle goes down, which makes our airway more collapsible. In addition to that, as we get older, unfortunately like the other muscles in our body, it loses some of its strength. Yes. So it's more prone to be weak and collapsed.

And then studies have shown that for people with sleep apnea, that muscle tires out more quickly, which again, makes them more prone to have obstruction. So when it comes to, you know, treatment, let's just talk about the tongue for a minute. If people have just mild sleep apnea, the two standard treatments for sleep apnea that are nonsurgical or oral appliances.

And C P a P. And you alluded to the show you had with the oral appliance provider. Yes. And those are, those are great options. And, and to be very, very clear, you know, if people have, you know, mild to moderate sleep apnea, significant sleep apnea, those still are two. The main, the two main standard, well accepted treatments that are nonsurgical of patients are having trouble at the level of their tongue.

Sure. Now that said, there are things called myofunctional exercises where you can actually work with a myofunctional therapist, there's ways to get connected with those people. And you do exercises to strengthen, not to just, just the Geno glasses, but the other muscles in your throat. Wow. So that's one option now in a, a relatively new option that's coming out is something called excite.

And you had mentioned to that. Sure. Yeah. And really what that is, is that excites a tongue stimulator where you're doing electrical stimulation to the tongue muscle to strengthen it. And there's some studies that have come out. There's a large multicenter trial that's coming out. But right now the studies have been done just for people with mild to moderate snoring and mild sleep apnea.

So it's not really with people with moderate or severe sleep apnea, but for those patients, the idea is that you have this stimulator device and for a 20 minutes a day for about six weeks, what you do is you just spent, you put this device and it stimulates your tongue with the electrical stimulation to strengthen the muscles of the tongue.

And the original results have been pretty good. People have had a reduction in their AHI. Snoring has been consistently approved and it is, is becoming more available. So that's something that I think is, you know, gonna come down the road and we'll get more and more data as that comes out. And it looks like for people with significant, certainly when people with snoring and also people with have mild sleep apnea, that might be a good option for them.

Interesting. Okay. That's touching on a kind of relatively new device. And how about the pallet expanders? Is that anything you suggest? Yeah, that's that's good. So, um, the way that works is I tell patients the way I kind of explain the pallet expanders is that, um, the roof of your mouth is the floor of your nose.

If you just kind of conceptually think about that. Sure. So, you know, if you kinda put your fingers out in front of you and you think of the roof of your mouth and your nose is a triangle, if you have a nice flat pallet, the bottom of that, triangle's nice and flat, the big airway. If you have a high ACH pallet that narrows the bottom of the base of that triangle.

So the idea is that if you have a high ACH palette, the base of your nose is much smaller and it narrows your airway, right? So by doing pallet expansion, you're basically making that triangle larger. Hmm. And I think, you know, a high ACH palette in the narrow nasal airway. Is something that I think we need to be more aware of.

And I think that people can have, you know, if they have that issue, P expansion is a really good, really good option for those people. Great. So it's interesting. You mention that, cuz whenever we think of trouble breathing through our nose, you saw a patient last week, exact same situation. People always think of problems on the inside of their nose like PS or deviated septum, you know, but the problem might not be in the inside of your nose.

It might be your P in a, you know, that circles back to an exam. And we see that in kids too, and it's very important. And the pediatric population, if the patients are snoring and they have those high arch palates, that it's nice to fix that sooner rather than later. Cause that of course relates to facial growth and all those issues as their, as their face is developing over time.

So it's an, it can be very helpful in adults and especially important in the pediatric population. Oh, so important. I love this concept of, you know, even attacking this early so that we have the ability to make some of these corrections right out of the gate, and then be able to hopefully correct over time and retest and see what's working and what's not working.

So that would be fantastic. Yeah. Yeah. That's right. And I'm glad you had the person on the talk about oral appliances because in my practice, I really think, you know, they're underutilized, so sure. You know, the idea is that the American academy of sleep medicine says that for people of mild to moderate sleep apnea, An oral is an acceptable first line of treatment instead of C P a P for patients.

Okay. And so, especially if patients are having obstruction at the level of their tongue and that usually relates just to their job position and that's how they're kind of created, you know, they may have a job that's maybe a little more posteriorly positioned, or if the man will lower jaws, a little more narrow that sun, you know, your tongue sits a little higher up in your mouth.

And so bringing the lower jaw forward in the tongues unit, it works with the jaw. So if the jaw comes forward, the tongue comes forward. You know, an oral appliance can be a great first line of treatment. The American academy of dental sleep medicine is a website, much like the other ones I referred to sure.

Where, you know, if you, um, if you're a member of that academy, it means you're a dentist. That's done additional special training in dental sleep medicine. And those are specialists that, you know, have expertise in that. So oral appliances are a great option as well. Great. Okay. So then if people are looking to take the oral appliance route, is that something then you would recommend for them to go directly to their dentist?

Or would you say no, you'd wanna kind of still begin with the ENT or their, are there kind of a, a triage that you suggest for people. Yeah, I do think that, uh, practically speaking, I think that starting with the dentist is a good idea, cuz there are experts in inclusion increasingly, you know, it's great. I, you know, I maybe I'm catching up with the dental community.

That's probably what's happening, but you know, I think, I think the dental community is really aware of airway concerns and airway issues. Sure. And with a lot of the, you know, facial scans and stuff, the dentists are able to do, they're actually to measure able to measure the size of the airways. And so, you know, if you have any concerns about that, you know, I think talking to your dentist and seeing if your jaw seems to be normal in position or in width, that's a good place to start.

One thing I will say, and I tell this to my patients with oral appliances is really, it's really important when they make the appliance for you. The upper piece goes into position cuz your upper face doesn't move. And then the lower piece attaches to the upper piece. Right? So as your lower jaw comes forward, your tongue's gonna come forward with it cuz they're attached.

But the key to that is when that appliance is in you can't open your mouth. Mmm. So you can breathe your mouth a little bit, but you can open your mouth. So one of the key things I see in patients all the time in my practice is oral appliances are great, but you gotta be able to breathe through your nose.

So yeah, you know, that's one thing that's important to keep in mind is if, you know, if you have trouble breathing through your nose at night, it doesn't mean you can ultimately use an oral appliance. You probably can, but it gives back to what we've talked about earlier. You need to figure out why you're having trouble breathing through your nose.

Absolutely. And how about the popularity? Uh, that's emerging around mouth tape. Is that something that you think is more layered of a topic or could be concerning or any dangers there or, yeah. Great question. It's so interesting. You mentioned that because I just read a fantastic book called breath by James Mester.

So good. Yeah. Uh, it's so good. It's so good. And, um, he, you know, he did that experiment where they closed off his nose for a couple weeks and within a couple nights he developed sleep apnea. You know, what I would say about that is, and it's a great lead in to what we just talked about with the oral appliance.

But, you know, we are designed to breathe through our nose. That's just how we were made. Yeah. And if we're not breathing well through our nose, there's a whole cascade of problems that, that go along with that. So the idea with mouth taping is, and you know, um, James nester referred to this in his book is that by taping your mouth, you're basically forcing yourself to breathe through your nose.

Mm-hmm . And the idea is that by doing that, your nose is gonna make some adjustments, cuz our body's always adapting. So your nose accommodates and over time is gonna make some adjustments so that you're breathing more effectively through your nose. I'm all for that. What I would say is, I don't think it is a treatment at this point.

You know, if you have mild to moderate sit down and you mouth taping, isn't a treatment. It's not that. Yes. Um, but I think that using that, you know, to improve your nasal airway is interesting. And I think there's a lot of merit to that. And there's even some companies now that are incre, you know, coming out with branded mouth tape and all those other things, which is good too.

So yes, Okay. And then, so we've touched on some of the, the things that people could do to treat this, anything that we left out around the C P a P inspire, or even the laser treatments, anything to share there. Oh, great. Yeah. We're right on the same track. Cause I just wanted to talk about C a P. So yes, please.

One of the things we talked about is getting at the root cause of why you're having snoring sleep apnea and addressing the solution. So one of the most important messages I wanna share with everybody and it has to do with C P a P and that's the, as you know, the gold standard treatment. And the reason why it's the gold standard treatment is because number one, there's no medical complications from C P a P.

It can be super annoying, which we can talk about, but there's no medical complications in C P a P. And the other thing is I say to my patients, it's the quickest, easiest way to know if your sleep apnea is gone. Mm. Cause you're gonna get up in the morning and the machine's gonna tell you if you had any events.

Right's the app. You're gonna have an app on your phone. It's gonna tell you how many hours you used it for. If you had any acne or a PNE events, it's gonna give you all the information you need. So what I tell to my patients is all the time, if we're trying to get at the underlying cause of what the problem is, sleep apnea.

Doesn't have to be a life sentence. It could be a temporary tool. And so, you know, I think that one of the reasons why I see patients and they come to see me and they've failed C a P, and again, I'm not being critical. I'm just explaining the situation. You know, someone did a sleep study on them. They may not, I have had a physical exam.

Maybe they have maybe they haven't and they get prescribed C P a P and someone hands them a prescription and gives a machine. And then that's. Right. And the patient says to themself, wow, am I gonna have to sleep with this machine? The rest of my life? Right. And so what I say to my patients is, especially as it relates to the weight piece, it turns out when we put on weight and gain weight, we gain weight in our neck, right?

Mm-hmm  that makes it causes collapse below our tongue that relates to your collar size. And we see the people with the big necks in the sleep apnea, but it also turns out that when we gain weight, we actually gain weight and put fat in our tongue mm-hmm . So they've done very interesting studies where they do an MRI scan and they measure the size of someone's tongue.

Then the patient loses weight and they repeat the MRI scan. And the tongue's literally smaller. Very interesting. So in the American academy of sleep, medicine says, if you have sleep apnea, you lose 10% of your body weight. You actually need to be rest studied. You may not even have sleep apnea anymore. Or if you do, it may not be nearly as severe.

Sure. So my patients that have, you know, weight component and, and they have sleep apnea. I actually tell him, you know, C P a, P's your friend. It's not a life sentence. This is a tool you're gonna use to reverse all these negative, you know, effects going on in your body, pursue some weight loss. And we'll look forward to the day when we can have our throwaway, the C a P machine party.

I think how you approach C a P in terms of your mindset has a lot to do with how well we tolerate it and whether or not people stay on it. Now, one interesting thing, Molly is that one of the things that people have a real hard time with, with C P a P has to do with the, with the headgear and all the masks.

So there is actually a new, a company called beep sleep it's beep E E P S L E E P. And what they've done is they've developed a C P a P system that's based on adhesives that doesn't require masks or head. The technology is evolving. And so that's just kind of a cool, cool new thing. That's out there that people can use, cuz really with C and by the way, some people do need C a P for life.

I don't wanna give the wrong impression there. And C a P is incredibly effective. The studies are very clear on C a P and I, I would never wanna give people the wrong impression. Sure. C P a P is a gold standard for a reason. Because it's very effective for the reasons we talked about. Yes. But you know, it's one thing to see it as a life sense.

It's another thing to be sleeping well and using it while you're continuing your journey to try to figure out the under underlyingly reason. Yes. You know, why you're having these conditions. Um, I like that reframe. I think that's really important as people navigate that. So it's, you know, not something that becomes a non-compliance issue and instead it's something along the way of actually making a difference with this profound area.

Fantastic. And how about laser treatments or inspire or anything else that we need to touch on as far as possible treatments? So the treatment falls, you know, the treatment depends on the level, right? So if there's a nasal issue, can do some nasal treatments. There are some laser procedures for the P. And so, you know, if multiples levels are involved, the most important thing to understand is, you know, you, you've gotta, you've got all the treat, the levels.

If you fix your P and your tongue's blocking, you're still blocking. So what I would say is, you know, again, it gets back to understanding the, the level where the problem is, and coming up with the appropriate treatments, laser, you know, procedures on the pallet can be very effective at that level. You know, the inspired device is interesting because we had talked about myofunctional exercises and the site device, we're walking up the ladder right for time obstruction.

And, you know, then we get into the oral appliance. And so, you know, the, the inspire surgery is, uh, a relatively new surgical procedure for patients that have obstructive sleep apnea. That really, it has to be moderate or severe. The ABNE IPO index has to be between 15 and 65. So it can't be mild sleep apnea.

It can't be terribly severe either where people are having itty blockage events a night. But for those people, those are people that are intolerant of C P a P. And by that, I mean, they really have tried and they literally cannot tolerate C a P. Some people are claustrophobic. Some people may have allergic reaction to multiple masks.

Yeah. And so this is a surgery where for the appropriate patient, I've had excellent results and we don't operate on the tongue or the jaw we operate on the nerve that moves the tongue. Mm. So we go to the operating room and we make an incision under the jaw there in the front. And I find the hypoglosal nerve that moves the tongue.

There's branches that move the tongue back. You don't want those cuz that's gonna obstruct your airway. We find the branches that move the tongue forward. And under the microscope we do nerve stimulation and we identify those branches and we put on electrode cuff around those nerve. Mm. And then we go down into the chest, it's on the right side.

Instead of the left, you can almost like think of it like a pacemaker, but it's on the other side. Mm. And on top of the Peck muscle of the chest muscle, we put what's called the pulse generator. It's kind of the brains and barrier to the device. Then finally we go between the second and third ribs through that same incision in your chest.

And we slip a little breathing sensor in between the breathing muscles. So what we do at that point, the last thing I do is I tunnel the little electrode from neck down into the chest and we hook it all up. And the way it works is when you go to breathe at night, the breathing sensor in your chest sends a message to the pulse generator, and then that interns as a message up to the electrode and it moves your tongue forward.

So every time you go to breathe at night, when you're sleeping, your tongue's coming forward to open your airway. So that's the basic idea of how the inspired device works. And it actually is controlled by, it's almost like a TV remote control. It's a little handheld device that sits on the side of your bed.

So you turn on the device and hopefully you're asleep before the device starts working. And as you're sleeping, your tongue's coming forward and move your open your, your airway. So, you know, that's one of the relatively newer options for people that have sleep AP that are not really tolerating at this point, other options of treatment and like anything else, the indications for that type of technology may evolve over time and it may be more widely available, but that's the general concept for it at this point.

Awesome. Okay. Anything we left out in that, the kind of walkthrough of those different treatment options or did we hit on most of the ones available at the moment? I think so. I think we've covered oral appliances and C P a P on a kind of a big picture, uh, you know, thing in some of the newer treatments.

So, uh, yeah. Fantastic. Okay. So then that brings us to the final part of the podcast where people have commented that with, when we have people on the podcast that have such an immense level of information around sleep, they wanna know, well, what are they doing for their sleep? So , um, and I'm sure this is dynamic and I'm sure the ships different points and if you're traveling and lots of things, but let us know.

The first question is what are you doing currently for your nightly sleep routine that we might learn from? Yeah. Okay. Well, one of the things I'm, I'm trying to do is just make sure that I'm going to sleep pretty much at the same time every night. Sure. So that my body's, you know, settling into, uh, a routine and trying to pretty much get up every day at the same time as well.

So my body's settling into routine sometimes I'm good at this. Sometimes I'm not. We know that alcohol reduces the tone of the muscles in our tongue and throat. So ideally I'll have my glass of wine a little earlier in the night. Yes. If, uh, if I don't do that then myself, but more importantly, my wife probably pays for that a little bit.

So, you know, the idea of, uh, enjoying a glass of wine, but a little earlier in the evening, uh, promotes good sleep. Alcohol does affect the quality of our sleep in multiple ways. Um, one of the things it does is it cause us to go into our REM sleep. At a different time of the night and that ultimately will lead to early morning awakenings.

So, you know, if you're having a little more alcohol than you should, you may find that you're waking up early in the morning before you'd like to. So that's a basic sleep hygiene thing that we all, you know, probably have days where we're better and worse at. So those are a couple things. Great. Okay.

That's fantastic. And then your morning sleep routine, if that, if you know, might sound like a misnomer, but really we do that intentionally, uh, with the belief that how we set up our days can impact our nights. So any, uh, noteworthy things around your morning routine that are important for managing sleep.

That's good. You know, I'm gonna be real honest with you, dad. I, I probably should look into a little bit better morning sleep routine. Usually I'm hopping outta bed and trying to grab a little exercise before, you know, I get my day going. So you, you might be able to teach me about that one, Molly. Okay.

Well, so fantastic playing into that cortisol pulse a bit, any emphasis on, uh, sunlight or light, uh, therapies in any way, shape or form in the mornings or something that you're evolving with in your relationship to that? I'd say I'm more evolving in my relationship to that. Okay. Got it to, well, certainly I think, uh, many of us are doing that very same thing, so fantastic.

We'll have to circle back with you in the future and see how that's all going. And then the next question would be what might we see on your nightstand? Or it could be your proverbial nightstand if you're traveling. Uh, so apps or gadgets, ambience, et cetera. Oh, traveling or at home or both, you could do either one.

What everyone speaks to you that you think might be noteworthy for people to hear about? Well, in the relaxation mode, um, I might not stand at home. My wife got us a diffuser. So as we're going to bed at night, we try to get a little bit of a. Relaxing spa, like vibe there going, I guess that might relate to my nightly sleep routine a little bit there.

Yeah, a little bit. Nice. I like that. It's very cool. I usually have a good book on my bedstand right now. I'm reading a book called, uh, why we sleep by Matthew Walker. He's a PhD scientist outta Berkeley, and he does an amazing job of being this incredible, you know, hardcore science researcher. But in his book, he explains the science of sleep in a really kind of rubber meets the way a road down to Earthway.

So I'm reading that. And then right now we just got a family picture. We went to, uh, Mexico and helped build a home for. A single mom with a three year old, uh, son a couple months ago. And so that was just a really cool family time. So we gotta picture that on the, uh, next, oh, I, that it you're one of the first people to mention, uh, something like that that can actually just, you know, inspire a, a response of a memory and a feel good response.

So I love that. Very cool. And then the last question would be, what would you say might have been the biggest aha moment around the management of your sleep or even, uh, that's made the biggest change to your sleep game? I think the biggest thing for me is just trying to make sure that when I, you know, head back to go back to sleep.

I just kind of get myself, I joke about the diffuser, but I think it is really important that I just try to get myself kind into relaxed mode because you know, all of us are gone a hundred miles an hour, all day long, and our lives are so busy. And, you know, the inclination is for me to say, you know what?

I gotta check my email one more time before I go to bed, then of course send me, someone sends me an annoying email and then I'm upset and my mind is racing about something. And so probably the biggest thing I've done is I just say, you know, at, around, you know, go around bed around 10 o'clock, you know, at nine o'clock.

I just say to myself, you know what I'm done. Putting all this stuff away. If something urgent, someone's gonna find me, if not, I'll figure it out when I deal with it tomorrow. And just trying to give my body a little time to go from that sympathetic fight or flight gas pedal mode. Yeah. To the break mode and just allow myself to slow down.

It's really not very elegant advice, but, but I do, I do think it's helped. Oh, huge. And the training of. Process can be a lifetime training of how to be a person that can even know themselves to put that break in place when they need to. Well, and it's a process, Molly, you know, some days are better than others.

Some days there's stuff going on, you can't control, you do the best, you can hundred percent. Well, I like that. And also just the acceptance of the human condition that you're not bad or wrong if you're not able to always with perfection, uh, control that response. So that's fantastic as well. Yep. And I'm sure people listening now have had, uh, the experience that there is just a ton of information that you have on, you know, I know we just spoke to sleep apnea largely, uh, but certainly that extends out to many areas of sleep that you are well versed in.

So how can people follow more about what you're doing or, uh, work with you? Let us know all the, all the ways they can do that. That's great. I really appreciate that. You know, um, I'll be honest with you. I'm, I'm just getting started with trying to get the message out, you know, and I, I, I think my aha moment for me, you know, was that in the last couple months I realized that I've kind of come up with this way that I approach things.

And I, like I said, it doesn't make me better. It just maybe a little bit broader perspective on things. Sure. And I'm really finding that, you know, I ask at the end of every visit, I ask my patients, okay, does the plan make sense? Do you understand where we're doing what we're doing? And they, for the most always, or I won't, I keep going until they say, yeah, but they'll say, you know what?

This makes sense. I understand what we're doing. And I just realize with everybody's suffering so much, these tens of millions of people out there and not just them, their spouses suffering with snoring and sleep AP me and all the consequences of that. I'm helping people, but I'm helping people one patient at a time.

So my motivation and I appreciate you having me on is I just, yeah. In my own way, I just wanna start trying to reach out to more people. So, you know, I've got a website, sleep check up MD, and I'm starting to get going on Instagram. Full disclaimer, as y'all go and check out there's there's not much there yet.

there will be working process we're in the process, but I'm committed to what I wanna do in terms of, uh, you know, getting the message out there and really just helping in any way I can. Oh, fantastic. Wow. Well, thank you so much. And I'm so glad that you are committed to that because this is such an important area.

And I know you touched on just the deleterious effects that can happen when these things go unchecked and it is just astronomic. The difference that this can make for people when they do one, uh, take the steps to get this tested two, actually take the steps to understand the treatment options and find the right treatment for them.

And it can be such a rewarding thing. It can, you know, the colors can be brighter. You know, the, the, it can just be such an amazing experience of life that they might not have really ever been privy to in their adult lives. So really important stuff. And I thank you for doing the work you're doing. Thank you so much.

Oh, well, thank you. You've been listening to the sleep is a skill podcast. The number one podcast for people who wanna take their sleep skills to the next level. Every Monday, I send out something that I call Molly's Monday, obsessions containing everything that I'm obsessing over in the world of sleep head on over to sleep is a skill.com to sign up.

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