Exploring Sleep Issues & Solutions

Speaker 1 0:41

Welcome everybody to Airway Answers , expanding your breadth of knowledge and it is Sunday right now and I had to bother Dr Simmons to get him back on because he is the busiest guy ever treating all these airway cases all around the world . Basically , and I said , we did a podcast a couple months ago and Dr Simmons educated us so much on what might be normal in terms of sleep and what might be abnormal and I only got through about half my questions and so I want to finish up here because I have more questions and there's so much information that you know that I feel like is very important for us as dentists , myofunctional therapists , orthodontists , different airway practitioners to know and understand about sleep . So we're going to go through some more details and questions about sleep and we're also going to talk about the fantastic Sleep Education Consortium Conference that's coming up , which is extremely important , and I want everybody to register for this . Dr Simmons will go through talking about what that is and the date of this sleep education consortium that is coming up very soon and you will learn a lot more about sleep , what's normal , what's abnormal , and he will go through all of that when you attend the conference . But I want to talk a little bit about some other questions about sleep . Just to remind everybody , if you don't know Dr Simmons , he is triple board certified in sleep medicine , neurology and epilepsy and he really treats patients all around the world . I refer to Dr Simmons a bunch and he probably sees me almost weekly because I join the telemedicine appointments with my patients and my family members who seek him for their treatment .

Speaker 1 2:24

So last time we talked all about different stages of sleep . We talked about sleep debt Is that recoverable ? We talked a lot about parasomnias like sleep talking , sleepwalking when that's normal , when we should be concerned , even enuresis or nocturesis , and when that might be a problem . We talked about bruxism when that might occur , when that's a problem , what it means when someone bruxes . So I want everybody to go back and watch that podcast , listen to that podcast or watch that visual podcast if you didn't yet , because that's a lot of important information , including information on ferritin and restless leg syndrome , periodic limb movement disorder . We talked about REM sleep and is it ever possible that some people might not get enough REM or not get any REM sleep . We also discussed about central apneas and that's kind of where we left off last time , talking about is central apnea ever normal and what that's about . So watch that podcast to learn about that .

Speaker 1 3:27

But now what I want to talk about is my next set of questions sleep position . That was my next question I was getting to from our last meeting and I wanted to know if someone is diagnosed with positional sleep apnea and I'm putting that in quotes because to me that's a very interesting term Does that deserve any treatment besides positional therapy ? So I do hear a lot of patients get a sleep study and they have sleep apnea in the supine position , but in other positions it's very mild or not even existent , and so they just say it's positional , fix your position . Can you talk about that ?

Speaker 2 4:06

so they just say it's positional , fix your position . Can you talk about that ? Yes , so great questions . Also , it's impressive how many topics we covered last time I didn't really hear a reflection of it with all the different touch points that we had .

Speaker 1 4:20

I want to watch it again . Dr Simmons , you might learn something from yourself .

Speaker 2 4:24

Well , I clearly will bring up a lot of different points while I'm talking , and the question is you know how much time is there to elaborate on each and every one of those ? But and also , the other thing I just want to reflect on in your introduction was about the kinds of health care professionals that may want to be watching this Really physicians and nurse practitioners , medical professionals they are so under educated on sleep . It's unfortunate because , as a result , a lot of people will suffer from these conditions and they're getting diagnosed with other kinds of conditions that are really rooted in their sleep disturbance or they're made their other conditions made much worse because of the sleep disturbance , and the sleep disturbance gets overlooked , not recognized and not treated . So , health physicians , you can't expect your medical doctor to automatically know this stuff , and when you go to see the doctor , the doctor doesn't bring it up , doesn't mean , oh well , then it must not be important , because if it was really that much of a problem , my medical doctor would have known and would have asked me and would have done something about it . That's so far from reality , okay .

Speaker 2 5:39

So going back to your question , positional sleep apnea . Clearly , gravity plays a role . Gravity pulls things down right , and that's also true with the tissue of the upper airway and the mandible , the tongue . So when you're on your back , gravity plays a bigger role , and so obstructive breathing in most individuals is going to be worse when a person is on their back . Now , it's an exception to where on the side there's no obstructive breathing . It's common that it's going to be dramatically better , but to say it's not going to exist , it's only a rare case . Will that occur Now , when someone's making that determination of this ?

Speaker 2 6:25

is positional they're using . Usually they're going to use one night of an assessment and then the question is how much time and what stages of sleep was the individual in when they were on their lateral position versus on their back ? So it might have been that you know they were not in REM when they were lateral or they were only in lateral . Maybe , you know , in towards the latter part of the night , maybe , or you know , for maybe 45 minutes , but the remaining , you know , three hours of recorded sleep time might have been while they're on their back . Sleep time might have been while they're on their back . So if someone's just looking at a number and saying this is your index in this position and they don't take a few minutes to go back to see what data was used to come up with that parameter , they may be misled and they may not be comparing apples with apples . They may be comparing apples with oranges . So I say all this because I've seen where people have been told they have positional apnea and that they're still having problems , they're trying to sleep on their side and they're still having issues with daytime sleepiness and they were just misguided . Clearly their apnea is better . But then you also have to look at what tool was used to make the assessment , such as a home sleep test . Home sleep studies are not as sensitive as getting a study done in the lab using the 1A scoring criteria as opposed to the 1B scoring criteria . All these make a difference . So if you're using 1A scoring criteria , you're in the lab . Maybe you even have a study done with the nasal esophageal pressure catheter . You're going to see how bad is someone when they're on their side . Now , if on their side they're really not pulling , there's not much negative pressure . They're on their side the majority of the night and really all their apnea is occurring when they're on their back , then fine , I think that we can comfortably say the person has positional apnea . But let's say someone has a home study , all right , and there's one night of assessment and you really don't even know what stages of sleep they're in . The device may tell you , but it's frequently not accurate because most home studies are only looking at respiratory type parameters or body position parameters , where they're not looking at brain waves , they're not looking at eye movements , they're not looking at muscle tone . They don't have the channels for that .

Speaker 2 9:01

So with a home study , if it comes back saying positional apnea , if the person doesn't have bad cardiac disease and they're not in any real critical situation , there's no problem in intervening with positional therapy by wearing , let's say , a device that goes around the torso that has like a big bulk material in between the shoulder blades , let's say , or the middle of the back . So whenever they get on the back they're not comfortable and they'll turn to their side again . So let's say they're now on their side and they feel better . Let's say they had symptoms of daytime sleepiness and they had an Epworth sleepiness scale that , let's say , was 12 . Now they've been on positional therapy for about two months . Come in for a follow-up and they say you know , I feel so much better . Great , do the home study now on their side , because now they're on the side the whole night and you'll get the results back and it will say , yep , there's really no apnea , they feel better . End of story , treat with positional therapy . But let's say they come back and they say my wife tells me I don't snore that much , but I'm still feeling tired during the day .

Speaker 2 10:16

Well , at that point you know you could do another home study . But you know they're having apnea . You know that even if they're on their side and their device is working , just because their snoring is better , their symptoms are not resolved . And it's all about symptoms , it's about you know , what is the clinical significance of the airway obstruction . So it would be worthwhile to go forward with a more aggressive therapy than just positional therapy . And do they need to come into the lab ? At that point , it all depends . There's so many variables . So you know , rather than going down all the different paths , it's important to go into the lab . At that point it all depends . There's so many variables , so you know , rather than going down all the different , but you know . But there it's clear that the positional intervention alone was not sufficient to resolve symptoms . It's not just about resolving starring , it's about resolving symptoms .

Speaker 1 11:03

Ah , funny , because all those patients that I've heard that have had positional sleep apnea that was the diagnosis was like mild positional sleep apnea and the doctor didn't do anything . Left done , end of story . But look how detailed your response was of what needs to be followed up when we see there's apnea in supine position . So it's interesting because I don't think many physicians or people running the sleep studies really follow up with those details Right .

Speaker 2 11:33

Yeah , I mean you need to . I mean you know you're leaving the situation unresolved . Yeah , and it's why did the person have a study you go back to , why did they have a study in the first place ? And if the person , if the response was just oh , it's just positional and the person has given no guidance to address the main chief complaint .

Speaker 1 11:56

Or stay on your back and elevate . You know your upper body right and you'll be fine . That's usually . I don't think most doctors follow up . You know the standard of care these days is not following your patients after you know studies are done and seeing what happens next . So that's really interesting . If we're talking about sleep position , do you have a position you recommend your patients or what is the best sleep position to be in ?

Speaker 2 12:22

The one that you're most comfortable in . Uh-huh Okay in the one that you're most comfortable in . Okay , seriously , because let's say you have an obstructive airway , you know you have sleep apnea . In that , let's say , you're most comfortable on your back .

Speaker 1 12:35

Yeah .

Speaker 2 12:36

Well then , we need to intervene with therapies that you can use while you're on your back and we need to advance the therapy until we're able to adequately treat your breathing while you're on your back .

Remote Patient Monitoring in Sleep Therapy

Speaker 2 12:51

Now there are instances with some patients that have very severe apnea and we put them on positive pressure therapy . We may even have them on bi-level therapy , and we're just having a hard time coming up with the best settings . There clearly are instances where , when we bring them in for the titration study and usually at this point now we're on our second titration study , because the person is still posing to be difficult maybe even a third , and we may come up with a final conclusion . That position is going to be an added component of the therapy . I mean , I just had a patient a couple days ago . That was the conclusion that you know . They were on really high pressures and there were still obstructive respiratory events , but they were only occurring when the patient was on their back and when they were on their side . So much better . So in that case we're going to say use bi-level therapy , bi-level PAP . Some people they call BiPAP Wear that with a full face mask , and the person also had a bruxing splint . Another way of treating them is to get a mandibular advancing appliance , but just put it in neutral position just to keep the jaw from retracting , but anyway , with a full face mask and on their side . And then there's one of those devices that I mentioned going around the torso that they're going to use , and so in that case we're actually going to follow up with a home study .

Speaker 2 14:18

Once the person's doing that and actually we're probably in that case we might even put the person on remote patient monitoring where we monitor their sleep every single night . They wear a ring , transmits the data to the cloud , we get the data . There's an analysis done , called cardiopulmonary coupling , which has been FDA cleared to provide equivalent type of parameters to the apnea-hapodendrox parameters , to the apnea-apopnea index , and so and we're tracking we have over 100 patients that we're tracking every single night wearing such a device , you know , wearing the ring , and we use that to guide therapy . So this would be an instance where it would be best . You know , we can't tell from that ring , though , what position the person is in , but we can still see how adequately we're treating their apnea every single night , and sometimes what we find is patients doing really great and then all of a sudden they're not and it comes up on our dashboard that this person's not doing well .

Speaker 2 15:20

And we call them up and they're like oh , I'm on vacation up in Colorado , there are 7,000 feet and all of a sudden boom . Those settings that we had at sea level don't seem to be adequate at high elevations . Now the machines are supposed to be responding to those elevation changes , but there's so many other changes in airway dynamics that also occur at the higher elevations that the machines sometimes have to be modified . The settings have to be modified um when they're at the elevation , so okay , that's interesting .

Speaker 1 15:54

Yeah , that's important to have that nightly monitoring , versus , oh , you just come in , do a sleep study or do a home sleep study and then see you again in a year or whatever this is the way of the future .

Speaker 2 16:05

There is no doubt in my mind whatsoever that eventually , the field of sleep medicine is going to be monitoring sleep every single night in patients for months at a time , maybe a year , a couple of years at a time . No question in my mind . The thing is , when will that get implemented , and based on what billing criteria and what receptiveness will the insurance companies have , you know , and how receptive will the medical practices be to implement the technology that's involved ? All those little things need to be worked out . We're already doing it . We've developed a method for doing this . We're doing it already . We're way ahead of the game . You know , I'm not trying to think outside the box , maybe I'm just trying to create it , but it's , you know . Clear , though , that there's a treacherous road ahead , with the insurance companies who don't like to necessarily approve everything . Medicare clearly recognizes the importance of remote patient monitoring , but in all the different disease states it hasn't all been all worked out . But there's no question at all in my mind that eventually this is going to be the way to go .

Speaker 1 17:16

And that makes sense , because one night of a sleep study , we know , is not super accurate , right ? The first night effect . And then what did they say ? You should do three or four nights of monitoring .

Speaker 2 17:27

So let's say you're a patient and I'm going to give you a device to say okay , I want you to get your study done . You know we're going to do two nights or three nights , and you know you're getting that study done . So you're going to modify your behaviors . Maybe you're not going to have a glass of wine or two at dinner like you normally do , or you're going to change certain aspects of your routine . So you may not be getting a true representation of what occurs .

Speaker 2 17:51

So when you're monitoring nightly , you get a clear representation .

Speaker 1 17:55

Right and back to sleep position . You said there's , I know there's like a back pack or certain things patients can wear . Is there a certain brand or name of a back splint type thing ?

Speaker 2 18:07

that no , you know , um , no , but if I were to go to um amazon real quick , okay , not that I want it , because , um , and let me see here , um , or let me just go to the , let me see .

Speaker 1 18:27

I've heard of people taking a backpack and shoving like a pillow in the back . It's not really a backpack . Or a wedge . I guess you could use one of those body pillows and put it behind your back .

Speaker 2 18:39

Yeah , let me see here . If I go here and I go images yeah , let's see here .

Optimal Sleep Positions and Airway Health

Speaker 1 18:54

While you're looking that up , one of the things that I find very beneficial is elevating the head of the bed where the your head is in line with your thorax . I tell all my patients to elevate about 20 degrees to a position that's comfortable . You don't want to be sliding down on your bed degrees to a position that's comfortable . You don't want to be sliding down on your bed . But I have the sleep number bed and I find that is really helpful to elevate the head of the bed with a sleep number bed or just , you know , lift the mattress and put a pillow underneath there .

Speaker 1 19:23

But I have a lot of patients who can't sleep on their back . So it's not like , oh , the position most comfortable is on the back . They can't because they feel like they can't breathe when they're flat on their back , but when they tip the head of the bed up , that's really comfortable . So I don't think it should be a flat out recommendation Like don't sleep on your back . I think it's good to sleep on the back with the upper body elevated . Do you have thoughts on that ? Like back sleeping with your upper body elevated is actually a potentially good position .

Speaker 2 19:50

Well , again , again , it goes back to the gravity aspect of things um , that when you're uh , um , if the head of the bed is elevated , then you're going to breathe better , uh , but then again , how is that going to work for your um , your back and um in terms of um , your back and in terms of I'm just going to grab a couple of pictures here , if you know how's it going to be when you're going to be sitting up .

Speaker 2 20:24

And then what about your legs ? Will your legs have a tendency to be more ? Swollen because you're going to have more , if fluid ? May you know , swollen because you're going to have more fluid , may you know , draining and stuff . So there's , in most instances it would be best to sleep completely , you know , flat , but that's not always going to , you know , occur , and so you have to deal with things accordingly . But it goes back to what you know . If you're not comfortable , then you're um , then you're not going to be able to work ?

Speaker 2 21:04

yeah , I could tell you this is the best position . But if you find it to be uncomfortable , what good is it right ? And there's reasons why it to be uncomfortable . What good is it Right ?

Speaker 1 21:11

And there's reasons why it might be uncomfortable whether a person has back issues , other issues , vertigo , or whether it's uncomfortable because they can't breathe in a certain position . What about stomach sleeping ? Now , we don't recommend that because that puts undue pressure on the jaw . But I've also heard sleeping on the stomach does not allow the lungs to expand to their full potential , because your whole body weight is on the stomach , does not allow the lungs to expand to their full potential because your whole body weight is on that stomach . Do you have ?

Speaker 2 21:38

But in most instances that's not . I mean your body weight . That shouldn't be a real issue . The first question is why would that be the most comfortable position for a particular individual individual ? And that frequently is a result of someone who might have more of an airway compromise , and they're tending to want to be on their abdomen because gravity now brings things forward , and but yet they are not even aware of it . Consciously , they just know they're not relaxed when they're on their back .

Speaker 2 22:14

So if you're not relaxed when you're on your back , there's a good chance that , as you're falling off to sleep and you may not even be recognizing you're drifting off to sleep , your muscles relax , your jaw falls back and all of a sudden there's a little . And now , all of a sudden , you're awoken . Your cognition now kicks in , the event is over with . Your sympathetic nervous system is now triggered because of that little collapse you had , and you just feel anxious and you just know that you're lying there and you can't fall asleep . You're anxious and you're anxious and you're anxious and you're not falling asleep and you don't recognize these transitions that may be occurring in between . But over time , though , you also get conditioned that this is not a good place to be , so the tendency , then , is to be either on your side or on your abdomen .

Speaker 1 23:01

Would you say maybe most stomach sleepers have an airway issue , and that's probably yeah . And so here's the thing what if the person is a stomach sleeper and they still have pretty bad apnea ? You kind of think like , oh , it's pulling the tongue forward out of the throat , but that's not .

Speaker 2 23:17

That's not an adequate treatment for that person . I mean they could . They evolved into that position over time because maybe at one point it actually provided some degree of improvement , but as their condition got worse then the improvement was minimized and , um , you know , but treating someone usually is not going to be adequate just by , um , uh , sleeping , what we call prone . When you're on your abdomen it's called , you know , sleeping prone . I just grabbed a couple pictures . Can let me see if Can I share my screen ? I don't know if the screen share is on .

Speaker 1 23:55

It might be .

Speaker 2 23:56

I don't see the oh here . It is Okay , great , okay , let me just . I just popped these into Word . You can see these two right here . So these are two devices , that again . This is one where there's three little bag things . I think these might be inflatable . You blow them up . Or this one , this is actually a cushion .

Speaker 1 24:24

On your back .

Speaker 2 24:25

Yeah , basically yeah , it's like a fanny pack on your back and that way we never either . You can't roll on your back , but if you do , it's just very uncomfortable yeah , it looks like .

Speaker 2 24:34

It looks like that would be uncomfortable years ago we used to tell , before these things were being developed , um , we would tell patients and to , um , put a tennis ball and sew it into like a pocket on , or a wolf , a wolf , a ball , you know um onto a shirt , um , to make like a pocket , and it would go in there . It would achieve the same thing . But then people come out with better devices professionally that you just , you know , don't cut it off .

Speaker 1 25:00

Yeah . So this is really important that if patients like if we're asking our patients what's their most comfortable sleep posture and they say , oh , I sleep on my stomach , Like light bulbs should go off , that there's probably an airway .

Speaker 2 25:11

Yeah and maybe not , but you really want to probe , you really want to be asking questions and , like you said , about mouth breathing and drooling , so when they're prone and then it's harder to clear the saliva it's just going to roll out of their mouth . If they're mouth breathing , mouth breathing , and they're sleeping prone , then you know you can ask them how awake are they during the day , you know , and they're sitting relaxed , not bouncing off the walls and being hyperactive .

Speaker 1 25:41

Yeah , so part of our detective work . But that's interesting relationship , kind of knowing if they're sleeping on their stomach . We already have airway concerns . That's probably related to the breathing issue . What about left versus right ? Is there a better position to sleep on the left side versus the right ?

Speaker 2 25:58

well , some people talk about um , the venous system , um , and which is um , but for I mean for the pregnancy , that may be more of an issue In general . No , Okay . I don't want to get too detailed , and there are some things that we'll talk about right versus left but it's not worth going down that road here , okay .

Speaker 1 26:24

Just one quick , interesting tidbit about myself . So I sleep with my bed angled up pretty high . You can say I'm not sleeping upright , but I but I tip the head of my bed up and I use this pillow called the face saver pillow , and they don't make it anymore and it's like this amazing pillow , cause I use a regular pillow . It goes under my neck , it's almost like a Crescent shape , almost like what you'd wear on an airplane , but a lot thinner , and it puts me in this comfortable hyperension , almost like a little CPR posture , and I feel like I sleep so well . I don't move at all , I don't even barely turn over at night . That's my posture , but my airway is somewhat treated by doing my expansion .

Speaker 1 27:04

Before that I could not lay flat on my back because I couldn't breathe well . And you know how , if you go to get a massage , it's like so relaxing . I would get so much anxiety if I ever were to get a massage , and it would be rare that I would even go to get a massage because I would almost have a panic attack laying flat on my back right , you're supposed to like be calm and relaxed and my heart would start pounding because I can't . I couldn't breathe flat on my back , even something relaxing right as getting a massage . So it's just an interesting thing , right ? Some people , their airway is so prone or vulnerable that your body has an instant like adrenaline rush right , an instant sympathetic nervous system rush , just being flat on the back .

Speaker 2 27:46

Okay . So if you weren't the persistent detective that you are , If you ?

Speaker 1 27:53

weren't the persistent detective that you are .

Speaker 2 27:55

I thought you were going to say ridiculous . No , I said persistent detective , that you are to figure out what's going on and pursuing things along your professional networks and stuff .

Speaker 1 28:14

Where would you be right now had you not recognized that you had an airway problem ? Yeah , probably taking medication for anxiety disorder , working with psychologists , this whole thing , um , being in a different realm , right it's . Is that what you were thinking ?

Speaker 2 28:24

yeah , I mean basically . I mean look at what you just said . You couldn't sleep on your back , right you before you , before now , you can't , you're probably . I don't know if I could be flat , but you are clearly with a hyperextended yeah , this is gonna help open up . We open up your airway further . Yeah , um , but could you even have done that , let's say , 10 years ago ?

Speaker 1 28:47

I don't . I don't know , but I definitely know being flat , like you know , massage or things like that um triggers you would trigger that .

Speaker 2 28:55

How about now ?

Speaker 1 28:57

What'd you say ?

Speaker 2 28:58

But not now .

Speaker 1 28:59

No , not as much , unless I start to fall asleep and immediately my heart starts pounding . So I don't know if that's a conditioned response , so I try to keep myself awake .

Speaker 2 29:11

Or are you starting to relax your airway muscles ?

Speaker 1 29:15

Yeah , it could be , but it's definitely something I probably didn't understand before of like , why does everyone like to get massages ? But it makes me anxious , you know , but it's like uh-huh . So that's just interesting about sleep posture . But definitely , tipping up is very helpful for me and a lot of patients I recommend .

Speaker 2 29:32

A lot of patients will do that as a home remedy if they have sleep apnea . Elevate the head of the bed .

Speaker 1 29:38

In fact I recommend that to most of my patients , even my kids . They don't even know , but I put a little wedge or a little pillow underneath their mattress to tip it up slightly . If they knew they'd probably be all upset about it , but just slight angling upwards .

Speaker 2 29:52

Well , by using other treatments let's say someone's going to be at CPAP therapy , as an example , or some dental appliance those therapies should be titrated to resolve the impact of the position .

Speaker 1 30:10

Okay , and if they're going to be optimized , Okay , so it should resolve , even if the person's flat on their back .

Speaker 2 30:16

They should be able to wear their seatbelt flat . Yeah , I've had patients that couldn't get their diagnostic sleep study done unless they were sitting up in a chair . They haven't been supine in years . Yeah , and I said , and I remember saying in a couple instances to these patients one of my goals for you that will let us know that we are successful is that you'll be able to lie flat on your back again . And they look at me like there's just no way . I don't see that ever happening . So , yeah , we make their diagnosis with them sitting up , because we're lying down they wouldn't fall asleep , um , and then when we put them on pap therapy , we do it with them first sitting up and we slowly over time and they , those individuals , usually need more than one sleep study on the machine , but we're actually slowly bringing them down and making adjustments on the machine to go up pressures .

Speaker 1 31:10

Interesting . Okay , I want to move on to another topic , and it's reflux . So can you talk a little bit about the relationship between reflux and sleep disordered breathing , and then I'll have some more questions about that .

Speaker 2 31:24

Well , if you go back to the basic concept of what's going on with obstructive sleep apnea , you remember it's not called desaturation apnea , it's called obstructive apnea . Okay , and so it's not about oxygen desaturation , but it's about airway obstruction . And with airway obstruction , as you have the air going through a narrower pathway in the back of your throat , there's more of a vacuum , more negative pressure that's developed in the space back there from what's called the Bernoulli effect . When you're trying to get the same amount of flow through a smaller space , there's more negative pressure . And that negative pressure is not just in the back of your throat , it communicates with your whole chest cavity . So your whole chest cavity becomes a vacuum chamber when you're having obstructive breathing during sleep . So if you have a little bit of an incompetent lower esophageal sphincter that's at the bottom of your esophagus , right where it goes to the diaphragm , you've got your esophageal sphincter that keeps the esophagus closed . So that way contents from the stomach don't reflux up , unless you have like a hiatal hernia . But if there's a slight breakdown in the competency of that so it's not as effective , then if you have increased negative pressure in your chest , then the gastric juices are more inclined to suck up when you're having the obstruction and you're going to have reflux . And then a lot of times patients may not feel the burning from the acid and they'll have quote-unquote silent reflux . And sometimes the dentist is looking and seeing out all the erosion on their teeth and saying this is you know from , you have silent reflux . Well , if the dentist is making that kind of observation , that reflux is probably not occurring when the person is awake and upright , it's occurring when they're lying down right and it's probably enhanced by airway obstruction or obstructive sleep apnea . So ask one question of the person that has reflux do you snore ? Well , they themselves . They'll say no , I don't know that I snore , but my wife says I do . Okay , so otherwise they've been observed to snoring . They deserve an evaluation for obstructive sleep apnea . So sleep apnea can cause gastric reflux from the sucking of these juices up into the esophagus .

Connection Between Sleep Disorders and GERD

Speaker 2 33:47

When I was at UCLA on faculty there running the Sleep Disorder Center , was at UCLA on faculty there running the sleep disorder center we did a small study where we took patients that had nocturnal GERD gastroesophageal reflux disorder . They had it at night and they were being evaluated . They were diagnosed with sleep apnea and then when we went to treat them and do a CPAP titration study . We did the study with the nasoesophageal pressure catheter , so we were measuring the degree of negative pressure in their chest and then we adjusted the CPAP pressure , not just to get rid of their apnea , because their apnea may stop , but they still have increased negative pressure . We continue to increase the pressure until we normalize the negative pressure in their chest .

Speaker 2 34:33

All of those patients had resolution of the GERD Just by treating the sleep apnea and going one step beyond by treating the negative pressure .

Speaker 1 34:41

So do you think most people with sleep disorder breathing have reflux and are just not aware Because there's a lot of silent reflux ? There was some study I read or saw a summary of that like 2,000 patients or something with sleep apnea . All patients in the study had reflux but none of them had symptoms or felt that they had reflux .

Speaker 2 35:01

I don't know the answer to that question and I also know that to answer that question with the study , you have to look at how they were inclusive of their diagnosis of sleep apnea .

Speaker 2 35:11

You have to look at how they were inclusive of their diagnosis of sleep apnea . So if the lab is not that sensitive in picking up the more subtle forms of sleep apnea , but they're only using the 1B rule , for example , where there has to be a 4% desaturation , they're missing all the mild cases . So if they were to do a statistic like that , I would imagine a lot more of them are going to have the nocturnal GERD . But when you start including more of the milder cases that don't have , they might have the same pattern where there's increased negative pressure in the upper airway but the degree is less , all right , so there's not as much tendency to have the reflux . So I don't know the answer , but I don't know that it would be the majority . I think if you did the reverse and you said , out of those patients that have nocturnal GERD , what percent of those patients had sleep-related breathing disturbances or obstructive sleep apnea , I would say more than my guess would be more than half .

Speaker 1 36:05

Yeah , okay , what about , like , do some people only have reflux during the day , or is it pretty typical ? If you have reflux during the day , it's going to be worse at night , due to position and airway .

Speaker 2 36:16

Well , okay . So if you've got , let's say , hiatal hernia and so your lower esophageal sphincter is just not functioning because of the herniation of the stomach up into the diaphragm , they're going to have it 24-7 . So just by being in the lying down and having gastric contents you're going to get reflux and it's not due to the sleep-related breathing problem . But then when you add the sleep-related breathing problem it's going to make it even worse at night . So when someone tells you that the worst GERD is at night , all right , then you got to , you know . And if they say they don't have really any GERD during the day , they're going to clearly tell you that it's worse when they eat certain foods , of course , because there's more contents to reflux . But again , it's worth evaluating .

Speaker 2 37:07

But then when you start asking other questions , there's other symptoms to suggest obstructive sleep , apnea , daytime sleepiness , you know hypertension , snoring , maybe you observe pauses in breathing . So , but that's . But when you think of all the gastroenterologists that are seeing all these patients , I don't know that they really ask these questions to narrow down that group , really ask these questions to narrow down that group ? It's sort of like the urologists when the patients have nocturnal nocturia , so they're getting up frequently to go to the bathroom at night . Nowadays , some of them are finally catching on to ask about sleep apnea . But sleep apnea , you know , the urologists are recognizing that sleep apnea can increase urine production at night .

Speaker 1 37:54

And cardiologists don't even ask , which is like ridiculous , right ? But okay , so I make a recommendation to most of my patients not to eat three hours before bed , or two to three hours before bed . Do you make recommendations to patients about not eating close to bed ?

Speaker 2 38:10

Well , it depends . I mean , there are patients that you know I don't make it a blanket statement to everyone across the board . I mean , yeah , it's good not to eat when it gets close to bedtime , but there are certain instances where a little bit of food may be beneficial . For example , sometimes I have to treat patients with medications to treat restless leg syndrome and those medications have a side effect sometimes not all , you know about 20 of the time causing nausea . And one of the ways we deal with nausea is to take it with a little bit of food , not a lot .

Speaker 2 38:41

You know you don't want someone to eat their largest meal before going to bed , so but sometimes . But . So I don't go into the . You know clearly , again , it depends on the patient as to what's going on In general . So the issue is this you don't digest foods the same way at night while you're asleep as you would during the day , and even movement , just moving around , helps with digestion , and even movement just moving around helps with digestion . So you know , even aside from all the changes in the autonomic nervous system , I mean , basically when you're asleep you're not going to digest things as well . So you're better off not eating much before going to bed .

Speaker 1 39:25

Yeah , in general , and you talked about restless leg real quick , which is going to be my

Asthma and Sleep Link

Speaker 1 39:29

next topic . But I have one more question about reflux , pulmonary reflux and asthma . Now I've heard and maybe you could describe this better I'm not sure about that . You said pulmonary reflux , so refluxing where it's like going into the lungs and people getting misdiagnosed with asthma .

Speaker 2 39:47

but really aspiration . You're talking about aspiration induced asthma .

Speaker 1 39:52

Yeah . Right Like is really sleep disorder , like from sleep disorder Right .

Speaker 2 39:56

So basically , what you're talking about is the reflux situation that we just described , but as a result , the person does a little aspiration , just a little bit at a time , of the fluid it goes up from their esophagus , now it's in their upper airway and now it gets down through the trachea and it goes down into the bronchioles and it gets into the lungs , right . So you're talking about that kind of reflux and then they get reactive airway disease from aspirating these micro amounts of of gastric fluids .

Speaker 1 40:29

Yes , and that's not really . Is that asthma or it's not really ?

Speaker 2 40:34

It is asthma , but it's what's causing it . So asthma is a phenomena of reactiveness of the airway . Okay , of the , you know the smaller , the small alveoli and the smaller parts of the airway , not the big bronchioles , that's a bronchitis . But asthma is going to be reactivity and they get wheezing and it could be from frequently . It's from an allergic reaction causing it ? This would not be an allergic reaction .

Speaker 1 41:09

Sometimes it's induced in some people , right , but it's important to investigate patients that there's a co-relationship between asthma and sleep disorder breathing . Could you talk a little bit more about that ?

Speaker 2 41:20

Well , okay , so it's been a known phenomena within my circles of sleep medicine . You know I'm a neurologist although I frequently tell people I'm a neuropulmonologist because I deal with the neurologic control of breathing but it's a known phenomenon that people that have asthma it's going to be worse if they have sleep apnea and they're going to more nighttime . So take your typical asthma patient and say you know how often do you have asthmatic attacks ? And they may say , oh , three or four times a year . And Next question would be how many of those are in the middle of the night ? And if they say , oh , at least two or three of them are in the middle of the night . And then you know , sometimes they'll be out the day when they're maybe exposed to a lot of you know , pollen or whatever it may be .

Speaker 2 42:06

So if they're having preferentially nighttime asthmatic attacks , the next question is what's triggering it to occur at night when your body's relaxed ? And the first thing you have to think about is obstructive breathing because obstructive sleep apnea . When you have all that increased negative pressure in the upper airway , you know it's been shown that the um reactivity of the airway increases , so it's more likely the lining of of the um lung tissue is going to be more inflamed when there's more negative pressure and it's going to have a higher likelihood of this reactivity .

Speaker 1 42:47

So that's not reflex related though just the obstruction itself .

Speaker 2 42:52

Okay .

Speaker 1 42:52

Okay , okay .

Speaker 2 42:54

And so , if so , in other words , if you're exposed to an allergen , you'd be , your reactivity to that would be worse if you have obstructive breathing at the same time .

Speaker 1 43:03

And vice versa . Right , If you have like . The asthma could cause inflammation and obstructive breathing can cause inflammation of the upper airway .

Speaker 2 43:13

Right . So what's been shown is that by treating patients with something like CPAP , you can improve their asthmatic attack and their asthma condition .

Restless Leg Syndrome and Periodic Movements

Speaker 1 43:23

Now someone a parent posted on the Airway Circle parent group . I think that's where it was . Might've been on another group , I'm trying to remember , but every time the child falls asleep they start choking and coughing and wake up like choking or coughing . That's what we're talking about .

Speaker 2 43:38

Maybe they need a sleep study , yeah .

Speaker 1 43:41

Would that be ? I think the child already had tonsils and adenoids removed , like a bunch of other treatments . But could that be that aspiration or pulmonary type that reflux could be , or it could just be an obstruction .

Speaker 2 43:54

We don't know . It doesn't have to be as complex as aspiration . It could be as simple as just obstruction .

Speaker 1 44:01

And now that makes me think I had a patient or somebody posted this was years ago , I think it was a post online child sleeping on their side , their side bubbles like saliva bubbling out of the mouth . Could that be from reflux ?

Speaker 2 44:15

well , maybe I mean like foaming yeah , but the thing is , is that , is that gastric contents coming out of the mouth , or is it just that they're , uh , having increased salivation and they're breathing through their mouth and they're they're ?

Speaker 1 44:30

salivating .

Speaker 2 44:30

I remember who it was , but it was someone I knew but the bubbling is just that there's air mixed with the fluid . Other words , you know , the lips should be sealed and the fluid should go down their throat and they should be swallowing their own secretions .

Speaker 1 44:44

Yeah , I have to find this picture and show you , cause it looked like foaming , like it looked . It was interesting , but okay , so let's move on to restless leg syndrome . We're jumping all over the place here , but I have so many questions . Okay , plmd , periodic limb movement disorder and restless leg syndrome how , how is PLMD different than RLS ? Or do they co-occur all the time ? All ?

Speaker 2 45:13

right . So RLS is a symptom that you have when you're awake and you know you have it . You can describe it . Maybe you don't know what it is , but you have to experience it . In the awake state it's an uncomfortable sensation in your extremities , usually the legs . It's going to occur when you're immobilized . And then the movement .

Speaker 2 45:34

The most important feature to characterize this is that movement improves the symptoms . Now , if someone has it so extensively , the movement may not make it completely resolved and the amount of movement over time may increase of what's necessary to improve it . So at first it's just fidgeting the legs in bed , but maybe now it's gotten so bad that they have to get out of bed and walk back and forth and pace for a few minutes . All right , but movement is being done to provide improvement . But then , lo and behold , the symptoms are going to come back , whether it be a few seconds later or a few minutes later . But the person's moving to get relief , to get soothing . The movement is soothing to them . All right . That's restless limb syndrome or restless leg syndrome , since it's most frequently in the legs .

Speaker 1 46:21

Is it only confined Okay , I was going to say you said most frequently in the legs . It's not only confined to the legs . Could it be other parts of the body ?

Speaker 2 46:29

Sure , it can be so extensive that it's going to include the upper extremities In some instances . It will be restricted to the upper extremities , to the arms .

Speaker 1 46:37

Every face like the jaw .

Speaker 2 46:41

I've never seen where you're going to have restless limb syndrome when just the jaw and not have it everywhere else .

Speaker 1 46:48

Is it possible you have it other places ? But also that feeling in the jaw .

Speaker 2 46:51

The mechanism that's involved could theoretically take place in somewhere else . If it's going to be just in the upper extremities , it's usually because there's some anatomical factor . So there's different causes for restless limb syndrome . One of them is an iron deficiency , and then it's going to be more systemic but it's going to affect the legs more because those are longer pathways . They're longer nerve pathways . So I've never seen someone with an iron deficiency induced restless limb syndrome that has isolated to the upper extremities and not in the lower extremities . So it could be in the lower extremities but it could be so bad that it's now also in the upper extremities . And theoretically it could be in the lower extremities but it could be so bad that it's now also in the upper extremities .

Speaker 1 47:34

And theoretically it could be towards the whole body , Okay .

Speaker 2 47:36

It could also be due to peripheral nerve problems . Okay , and again the peripheral nerve problems . If they're from metabolic causes like diabetes , then they're going to be usually the bilateral and they're going to affect the longest nerves first . So it's mostly going to be lower extremities . But it could also be from compression on nerves or the nerve roots right , it could be from spinal cord abnormalities or the vertebra may be a problem .

Speaker 2 48:09

So in the foramen where the nerves traverse out from the spine , out to the peripheral , to the periphery , if you've got compression , that can cause an imbalance in the transmission of the nerve activity and cause this restless limb syndrome . And it could be in the back and lower extremities . But it could sometimes , if someone has a problem in their neck , they'll have restless lymph syndrome isolated to their upper extremities . So when you only have it in your upper extremities and you don't have in your lower extremities , I would definitely get an MRI of the cervical spine , no question whatsoever . Now , maybe I wouldn't find anything , but it's totally justified because it doesn't follow the reasoning to have it isolated in the upper extremities and not also involving the lower extremities . But when you have a systemic condition it can be so bad that it's going to be lower and upper .

Speaker 2 49:04

So we're talking about restless limb syndrome . Now , with restless limb syndrome , basically all of those patients are going to have periodic limb movements asleep . Restless limb syndrome basically all of those patients are going to have periodic limb movements to sleep . But there is a night-to-night variability in the phenomena , so in any one given night maybe they didn't have very much of it , but if you measure them over numerous nights , you're going to see basically 100% of these patients . You're going to see periodic limb movements to sleep .

Speaker 1 49:30

Okay , wait a second second . So almost every single person who has restless leg syndrome will have periodic limb movement disorder or basically , yeah , it would be .

Speaker 2 49:39

It would be an outlier to have them , yeah , okay , let me finish off the discussion here . The converse is not true . You can have periodic limb movements , sleep and no symptoms of restless limbs while you're awake , right , and a lot of people have periodic limb movements asleep . So that then the question is , at what point should it be treated ? Okay , so if let's say , you had a sleep study done , and you had the sleep study done because you're participating in some research study and they just need normal controls , right , and you're getting your sleep study done and you have periodic leg movements to sleep , so now you know that you have periodic leg movements to sleep , but you have no symptoms of restless legs , you have no daytime sleepiness , you sleep fine . Do we need to treat the fact that you have periodic leg movements in sleep ? I would say no . Now , it's an exception . If it , you know , maybe you have a mild degree . Let's say it was severe . Let's say you had like 45 episodes per hour .

Speaker 2 50:46

Normally a person with that much leg movement activity is going to have some symptoms and they may be in denial initially . They may be so hyperactive during the day that they don't tell you that they're sleeping . But whenever they sit quietly and relaxed in like a lecture hall or a sermon during a service , they're getting drowsy . Then they get up and do this . They avoid certain behaviors . They always are moving because they don't like sitting . Still , they always are moving because they don't like sitting still right .

Speaker 2 51:11

But if there were clearly no symptoms , I don't think you need to treat period . There's some data to suggest that maybe it causes high blood pressure . It might be associated with cardiac disease . It's not . There are studies that have said that . But I'm not sure that I totally believe that if someone is completely asymptomatic that they shouldn't be treated . But what they do need to be treated for is periodic leg movement disorder . That's when you have these periodic leg movements asleep and there are symptoms associated with or as a result of it , such as daytime sleepiness or poor sleep continuity , so they're waking up in the middle of the night . They don't know what woke them up . They don't have restless legs , but they keep on waking up out of their sleep . They're just not feeling well rested .

Speaker 1 52:04

So those would be yes the non-airway factor that could be impacting our patients and a home sleep study would not get this . They need to be seen in a lab .

Speaker 2 52:14

Right , that's a good point . But some of the home studies come up with parameters that are not truly respiratory . They come up with parameters that are showing arousals because they're looking at heart rate variability and they're seeing increased bursts of tachycardia . So they're picking up arousals but they don't know that they're respiratory , but yet they're labeling them as being respiratory and they're calling it and they're giving it a respiratory disturbance index , and that shouldn't be done . So the home studies , if they're showing apneas or hypopneas and their AHI is abnormal , that's fine . But in some of these home studies , when the only abnormality is the RDI , it's good that it picked up an abnormality , but don't assume for sure that it's respiratory and don't put that person on some pathway to treat their breathing . I mean , you might get away with it , maybe it is breathing , so maybe there's going to be improvement . But then the next patient , you're advancing the treatment more and more and you're not seeing that improve , that that parameter improve , and you're going to over treat with the problem , even respiratory to start with .

Speaker 1 53:22

Yeah , and this is interesting too , thinking of restless leg syndrome . Do you think a lot of kids get misdiagnosed with ADHD ?

Speaker 2 53:30

Oh , yeah , this is a fact .

Speaker 2 53:34

The rest of it's leg syndrome , just sleep disorders . In general . Adhd is a set of symptoms . It's not a disorder . I mean true idiopathic hyperactivity , attention deficit disorder . It does occur , but it's not the majority of these cases .

Speaker 2 53:58

All right , most of the time these cases are due to other things that are precipitating these symptoms , where someone might have a slight tendency towards those kind of behaviors , but they've got something else that's really driving it , such as sleep pathology , and the two most common sleep disorders would be obstructive breathing during sleep , sleep apnea in the kids , or periodic leg movement to sleep , with or without restless leg syndrome .

Speaker 2 54:18

So these are two things that are common in these kids . I said three things because there's restless legs or periodic leg movement disorder , but then obstructive breathing . These are common things that are getting missed and kids are just being put on stimulants left and right , and when then we talk about you know just how we're over-drugging our kids we're just not properly evaluating the underlying abnormality , and a lot of think of how many kids have malocclusion and need braces right . So that malocclusion , that's an airway problem and it means their tongue doesn't have enough space , which means their airway is more obstructed , which means their sleep is going to be disrupted and then they're going to have daytime behaviors as a result of it . Then they're going to be slapped on the stimulant medication . So any child , before placed on stimulant medication , should have a good sleep history at a minimum . What is a good sleep history ?

Speaker 1 55:13

Well , there was just an article in the newspaper today that said there's a shortage of ADHD medications 2024 . And I was like I had to post that on Facebook . What is it really ? But this is interesting about restless leg syndrome . I assume it's genetic right or they're genetic factors .

Speaker 2 55:29

There's yes , because okay . So then there's the idiopathic form , which I didn't get to when I was talking about that . Yeah , there's peripheral , there's iron , then there's going to be , there's going to be from structural problems , and then there's just pure idiopathic , where it's not due to iron and for some reason the dopamine receptors are just not responding properly within the spinal cord and and the person's going to rest Okay .

Speaker 1 55:54

Can you talk about the iron ferritin thing ? But before you do that , I just want to say one thing , cause it just like a little light bulb went off , cause my son was 11 . Um , I talked to you about this before . Um , he has a hard time sitting in class and he had to start pacing back and forth in the back of the room because he can't sit Right . And I talked to him about this and he told me he has this feeling in his legs and he needs to move in order for the feeling to go away . And I'm like restless leg syndrome . Oh my gosh , and he's had this

Restless Leg Syndrome and Iron Levels

Speaker 1 56:25

before .

Speaker 1 56:26

When he was younger , got diagnosed with restless leg syndrome , did the ferritin testing . His ferritin was really low . We treated , and then I kind of forgot about it and like what this is like ? Six or five years later this is happening again . So I asked him , I said just sit still , just sit still and tell me what's happening . And he's like well , I get this feeling in my legs and I really need to move , mommy . And I said what happens if you don't move ? Just stay still . And he goes , it starts going to my arms . And now I need to move my arms . And he described this feeling . So he's been on .

Speaker 1 56:55

We tested his iron and it was really his ferritin , not the iron . The total iron binding capacity was fine , but his ferritin was really low , which I'm going to have you explain in a second . And I put him on an oral iron supplement that's like a liquid that we put in his drink , and it's been almost three months . And I asked him the other day how that feeling in his legs is and he said , oh my gosh , I totally forgot about it . And he's been also commenting that he's not shouting out in class anymore and it just like a light bulb went off in my head , thinking I wonder if he's sleeping better .

Speaker 2 57:27

So his teachers need to know this .

Speaker 1 57:30

Yeah , his teacher , they know yeah .

Speaker 2 57:32

Because you know the parents , because the teachers are the ones that are pretty much bringing up the issue to the parents , saying your child has behavioral problems and they look like they have ADHD , and then they send them off to the doctor . I would . It would be great for the teacher to say you know , there are instances where maybe the child doesn't need medication and that but you should . It's a fine line because the teachers really shouldn't be getting medical advice . But I told this teacher .

Speaker 1 58:02

It's funny because I I said , oh okay , he has this thing called restless leg syndrome . I explained she's like oh , I know all about it , my husband has that he's . So her husband is all frustrated because . So she knows what that is . So it's funny because it wasn't a rare or random thought for her . So she , this teacher in particular , really understood what that was . But I'm wondering he's clearly multiple times the last couple of weeks says he doesn't call out anymore , he doesn't shout out and he's not sure why . But I almost wonder if that ferritin supplement has reduced the periodic limb movements and maybe he's sleeping better . I don't know . Can you talk about iron and ferritin and what you test when there's restless leg or plmd ?

Speaker 2 58:44

we do an iron panel , which consists of an iron level , serum iron level , and it also consists of something called the iron total iron binding capacity , the tidc and um , and then we look at um uh , we do the uh cbc , also looking at the blood count to see if the person's anemic , and we also get a ferritin level . So the ferritin level is , we also get a percent saturation of iron . So , basically , you've got proteins that are binding with iron and you've got a certain amount of binding capacity within your blood , and then you see how much of that capacity do you have , and then what percentage of it is actually being utilized and what's the total iron in your blood . But the one protein that's used to mobilize iron around your body , moving it from one spot to the next , that's ferritin

The Importance of Ferritin Levels

Speaker 2 59:54

. Ferritin is the best measure of metabolically available iron , and so it's the most sensitive measure of iron deficiency . It will start becoming low before the other parameters become low , start becoming low before the other parameters become low . So you really , if you're looking for iron deficiency , you want to get a ferritin , and the thing that's important , though , is that that protein is also one of what we call acute phase reactants , so when your body goes through inflammation .

Speaker 2 1:00:34

Let's say you have an infection , all right , and you're making certain proteins . You're going to make more ferritin . So the ferritin level can be elevated artificially , not because you've got more metabolically available iron or it's going to be . You're going to get a transient increase as part of an inflammatory response . So if someone has a fever and they're sick in another way , it's not the best time to get . The ferritin may have been low , but now , because you're getting it taken at the time when the person may have another condition going on and it may come back in the normal range . And then you'll think , oh , the ferritin's fine , but in fact it was just artificially elevated . But taking that aside , the ferritin level could be low and it's going to represent a low amount of metabolically available iron .

Speaker 2 1:01:38

Now the laboratory norms that are used say is this a normal value or an abnormal value ? When those were established , they used anemia as the endpoint of determining whether the ferritin was high or low . So how much ferritin do you need before you start having anemia ? Because you need iron to make blood cells and when they did that , the levels were pretty much around between 10 to 15 . Okay , so a ferritin that's greater than , let's say , 15 , most labs are going to say that's normal . But now that we know about restless leg syndrome , we know that the ferritin levels should be at least 50 or higher . Meaning that if your ferritin levels are under 50 and you have symptoms of restless legs , it would be worthwhile to put that person on an iron supplement . Okay , and ? Or if they have periodic leg movements asleep , then it would be worthwhile to put that person on an iron supplement .

Speaker 2 1:02:45

Now the norms that we're using for restless legs are actually changing . Sometimes we say , actually 70 should be the threshold and anything less than 70 , especially in kids . Oh , wow , 70 . But the thing is , if the doctor just so you're hearing this , I'm saying ferritin , you remember ferritin ? Then tell the doctor ferritin , they check it , and the lab comes back saying normal , it may be low , it may be , let's say , 25 , and the lab's going to report it as being normal , and your doctor , who doesn't know about restless legs , is going to say normal , and and the lab's going to report it as being normal and your doctor , who doesn't know about restless legs , is going to do it normal , and you're going to hear normal and you're going to think , oh , okay , I guess I don't have the low iron issue , but I'm going to tell you that if your iron is less than 50 , you have restless legs then yeah , and my son was 24 .

Speaker 1 1:03:25

Yep , I remember it was 24 .

Speaker 2 1:03:28

And his lab reported as normal .

Speaker 1 1:03:33

I think they probably did actually . I don't remember . No , I don't remember actually because for his I think it said it was low really pediatric number was . Um was a little more sensitive and I think mine was that low too , and for mine it reported as normal . I forget something weird , but we both have the issue . And why , during pregnancy , can that be worse ? Is it due to iron ?

Speaker 2 1:03:55

yeah , so it's . You know , a woman's growing is a child , you got a fetus , it's growing and , uh , you know there's a lot of nutritional aspects , um , that are going on and women frequently can have low iron , uh , during pregnancy and they can have restless leg syndrome . And they can have low iron during pregnancy and they can have restless leg syndrome and they can have poor sleep and they can have sleep apnea . So there's a lot to talk about with regards to pregnancy . Actually , you know , this brings up some important things and we've skipped on this a little bit .

Speaker 2 1:04:26

You know , if you find this information interesting , you want to learn more , you need to come to the Sleep Education Consortium Conference . I mean , it's a medical conference , so if you're a clinician of any kind , you really want to go . We're actually going to have a lecture on fetal development and the issues of sleep apnea and the impact on the fetus and the impact on the mother and just other aspects of you know , with pregnancy and sleep , and then also issues of pediatrics and early intervention orthodontics and , you know , and for restless legs , we're going to have a world renowned lecturer giving the talk to Dr William Ando , who's extremely well published , has been doing research on restless legs and movement disorders for 30 years , and so he's going to be lecturing at the conference as well , along with a whole host of other clinicians that are highly regarded in their different areas of expertise . It's coming up in April , right around the corner .

Speaker 1 1:05:33

What are the dates ? April so for physicians .

Speaker 2 1:05:36

It's April 5th and 6th and the webpage is medicalsleepconferencecom and I'll pop that up here , I guess in a few minutes . Medicalsleepconferencecom and actually you know what , I'll pull it up right now . That's for physicians . It's a two-day conference and we cover just a whole host of things here . Let me pull it up . Medicalstudioconferencecom , all right . Let me share my screen , all right . So medicalsleepconferencecom it's the 20th year that we're having this and , um , you know , there's a bunch of different , uh , um , teaching points . I'll bring up the lectures in houston what's that ?

Speaker 1 1:06:38

and it's in Houston .

Speaker 2 1:06:39

In Houston correct .

Speaker 1 1:06:41

And there's all the lecturers this year .

Speaker 2 1:06:44

Yeah , so Dr Vees , who is going to talk about a whole host of different types of dental appliances ? Dr Ron Preen . He was actually the president of the American Academy of Dental Sleep Medicine's board exam . The Academy of Dental Sleep Medicine has their own board exam and he was the president of the board exam .

Speaker 1 1:07:06

And last year at that conference Dr Preen told me he's trying to get some myofunctional therapy questions on the board exam and he had me send him a bunch of research . Oh great , maybe that's happened .

Speaker 2 1:07:17

That's great to research , so great Maybe that that's happened . That's , that's great . Dr Boyd , a pediatric dentist who's been really well known on early intervention orthodontics . And then Dr Althe , who's an oral surgeon who does a lot of work with revolutionizing ways that MMAs maxillary mandibular advancement surgeries are being performed , and so he's talking about surgical aspects of treating sleep apnea . And then Brian Dickerson , he's going to talk about billing for medical billing so that people can get paid for the services that they're providing . But Mariana Evans is going to talk about early intervention orthodontics and Kevin's going to actually talk about pregnancy and he's been . You know he also is real involved in anthropology and just development in general , and so he's going to be . He's been really taking a deep dive personally in his own intellectual pursuits on pregnancy and the things that are changing and at what point does mandibular growth become evident that it's being stunted and stuff . So he's going to be doing the pregnancy .

Speaker 2 1:08:22

But Miriam Evans , she's going to be talking about orthodontics and little kids . And then Christy Gatto is going to talk about myofunctional therapy . Maggie Lavender , one of my nurse practitioners , has been working with me for over 10 years . She's going to talk about narcolepsy and idiopathic hypersomnia and various ways of treating people with those conditions in terms of various medications , some of which are brand new , very new , and just some of the various aspects of hypersomnia and treating them . And Dr Maxwell is going to talk about connective tissue disorder overlapping with autonomic dysfunction , pots disease and mast cell disorder and fungus exposure and how all this overlaps with sleep disturbances . This is a really fascinating cutting-edge . Dave McCarty , he's going to be talking about insomnia and about just how do you deal with both the behavioral management aspects of insomnia along with pharmacologic aspects and what he calls the five-finger approach in dealing with patient care with sleep issues . And then Dr William Ando , I already mentioned , is going to talk about restless leg syndrome and also parasomnias . He's a neurologist like myself , but again , his main area is movement disorder , neurology and so even abnormal movements during sleep , parasomnias and restless leg syndrome . And Sal Rodas has been he's going to be during the day where we have our breakout sessions . He's going to be involved . He's been involved with this organization for many , many years , so he has a lot to contribute , even behind the scenes , but he's going to be helping on the hands-on portion of the course . And then Dr Chang Ron he's going to talk about artificial intelligence and the use of that in our health care system and in sleep disorders in our healthcare system and in sleep disorders and using AI within electronic medical regimen systems and finding issues with patient sleep and how he's utilizing that .

Speaker 2 1:10:29

Dr Shire so he's a periodontist and he has some procedures where he cuts away the gums to enhance bone growth actually . So there's things that are done orthodontically in conjunction with some of the surgical things that he's doing to enhance tooth movement and working in patients that have airway disease . It's sort of a cutting edge . And then Dr Tran is an ENT surgeon who's going to talk about treatments of the nose and also treatment of the tongue and doing frenulum releases and just and talking about aspects of ENT that really are important when dealing with airway and obstructive airway conditions . And then Dr Yusufian , he's an orthodontist that's going to talk about the adult interventions that can be done orthodontically but also in isolation and then also in conjunction with surgical approaches , and he's also developed a really unique oral appliance called the ApnoDent and he has a treatment pathway using the ApnoTX . That is revolutionary . And so both Dr Yosethian and Dr Fees , they're going to talk about how to use aligners in conjunction with oral appliances . So if you've got someone that you're doing Invisalign with , you know on them you can be using mandibular positioning in conjunction with the aligners you're putting those patients into . So you know a combined approach Anyhow . So you know it's a pretty packed faculty and so this is so .

Speaker 2 1:12:11

It's for it's two days for the , for physicians All right . For dentists physicians All right . For dentists , it's dentalsleepconferencecom . And it's a three-day conference because on the 4th , april 4th , it's just for the dental professional or myofunctional therapist but it's not for the physicians . There'll be a lot more discussion about appliances . There'll be some discussion for the physicians on the other two days , but there's a deep dive on the first day and then also going over the exam the other two days , but there's a deep dive on the first day and then also going over the exam , the hands-on session where you can actually learn about how to examine the upper airway . So it's a three-day conference for the dental professional and a two-day conference for the medical professional . And for dentists or dental professionals that are going to go to the three day conference , it's dentalsleepconferencecom , and the two day conference for the medical professional it's going to be medicalsleepconferencecom .

Speaker 1 1:13:10

And I urge everyone to go . That's an amazing lineup of speakers and it's just a conference . You learn so much and people can ask more questions there about all their areas of interest or areas of confusion in terms of sleep airway , and it's really hands-on , especially that first day , so I think it's really great . I hope everybody signs up to attend .

Melatonin Use and Safety Discussion

Speaker 1 1:13:33

Can I ask you one last question ?

Speaker 2 1:13:34

before we go .

Speaker 1 1:13:36

It's a melatonin question and I do have a bunch more . We're going to have to do a part three . But is melatonin um , okay , is that safe to give to a child and what are your thoughts for adults ?

Speaker 2 1:13:46

as well . You know this . The recommendation really is to not be giving your child melatonin . All right , um , when a child needs melatonin to go to sleep , they're better off being evaluated , for why are they having problems going to sleep ? So you don't want to give melatonin to mask some other issue . And then what's the downside of giving the melatonin ? Well , we'll find out more , unfortunately , as years go by because of all the melatonin use that's been done . The story of melatonin is that your brain produces it . Well , it's excreted from your pineal gland and your pineal gland is not from the brain . So when I say the brain , it's not really true . It's produced in the pineal gland and it's released by the pineal gland , is not really , it's not from the brain . So when I say the brain , it's not really true . It's produced in the pineal gland and it's released by the pineal gland , and it's regulated through the sympathetic nervous system , but primarily through exposure to light .

Speaker 2 1:14:51

So when you have light exposure , that's perceived into your brain and then it causes sympathetic activity to go up out to your body and then up to the sympathetic chain up into the pineal . Activity decreases and you then release melatonin . And the release of melatonin is then going to get into the brain and the brain's wakefulness will be decreased by melatonin . So it's not increasing sleepiness , it's decreasing wakefulness . And so that which helps you fall asleep because whether you're awake or asleep depends on the balance between two systems One is your sleep system and the other is your awake system . That's why , when you're more sleep deprived , you have to rev up your wake system to stay awake . So you become hyperactive .

Speaker 2 1:16:00

But when you get sleepy , you're going to get sleepy either by reducing your wake system . If your sleep system , which is governed by GABA , a neurotransmitter , gaba , if that's going to be at a high level , then you'll fall off to sleep . But you could also get sleepy by lowering your wake system . So melatonin is going to lower your wakefulness . So if you're inside all day long , you're never going to suppress your melatonin levels . And then when you're going to have that increase when you're in darkness , it's not going to be as increased . Well , the relative change is minimized , so your brain doesn't react as much to the melatonin increase , whereas if you're in bright light during the day , you're lowering your melatonin and your brain melatonin levels are going to go down , and then the increase you get when you're in darkness is going to have a more robust effect .

Speaker 1 1:16:58

That's why it's like oh , when you get your kids out to the beach or swimming out at the pool , they sleep way , and they fall asleep quicker and easier . Maybe that has something to do with it . The sunlight , very much so .

Speaker 2 1:17:07

Yes , definitely . So the thing to do is to try to work with bright light exposure rather than just give the child melatonin . But then maybe they have restless leg syndrome , maybe they have a breathing problem , maybe these other issues , one of the other things too that we didn't talk about , even with the ADHD , kids are environmental factors . So environmental factors really even are , you know , behavioral as well . So let's say you're , you've got working parents and the child , you know , at night child's home , and now the parents are home and they want to have their quality time with the child . So maybe they're spending the quality time keeping the child up , and the child's now up to about 11 , 1130 . And then goes to sleep , but then has to wake up early to go to school .

Speaker 2 1:17:56

And then , you know , and the child may be getting insufficient total sleep time as a result of behavioral problems . Or maybe they live in a bad area , in a broken home , and there's yelling and screaming going on and all these other reasons why the child is just not falling asleep , because they're upset and they're nervous , or there's gunshots outside , because they're in an inner city environment . All these are going to play a role , and so if the child is getting insufficient total sleep , then there can be symptoms of ADHD . It doesn't have to be from restless legs or obstructive breathing . It can just be sleep deprivation by itself because of other factors . So when it comes to melatonin , though , and trying to get the child to go to sleep , you want to look at other things . You want to look at behavioral factors , you want to look at emotional factors , you want to look at physiologic factors . You don't want to just give the child melatonin .

Speaker 1 1:18:48

Okay , what about adults ? Is there any contraindications for adults taking melatonin ?

Speaker 2 1:18:55

Very little . But again same thing . They say , geez , ambien is really bad for you . Well , ambien , prescribed in the right setting , can be very life-saving in many instances . But you don't treat all sleep problems by giving Ambien . You treat the underlying cause and sometimes so if I have a patient that they have bad sleep apnea and just feeling the mask on their face is irritating to them and they just have a hard time getting acclimated to it because they just got sensitive face or whatever the feeling of it . But if I give them a little bit of Ambien , boom , they're out , they sleep well , they wake up the next day , they feel great . Fine , let them take that low degree of Ambien as long as they don't have to enhance the dosage . The benefits outweigh the harm . But when you start giving Ambien to treat every kind of sleep problem , that's just the problem in and of itself , and then patients will do strange things when they're woken up out of their sleep , from their apnea , but they're under the influence of the drug , they're going to get out of bed and do something totally inappropriate , and it's not that Ambien made them do it , it's Ambien allowed that behavior to happen .

Speaker 2 1:20:07

So , going back to melatonin , if it turns out that someone needs to be on melatonin . What else is going on Now ? There are people that you know we're treating their physiologic factors but they need to be on a sleep aid . Melatonin would be a more benign sleep aid to be on . So if I had to give someone five milligrams of melatonin in order to take care of their insomnia and I've worked on relaxation techniques with them , you know biofeedback and calm down , maybe I've also treated the restless legs , whatever that's not a big deal . If I have to give them a little bit of Ambien sorry , a little bit of melatonin , it's not that big of a deal . But again , you want to do it in the context of overall treatment plan that's based on an understanding of what's causing their insomnia , not blindly saying , oh , all patients with sleep problems should take this pill .

Speaker 1 1:21:03

So get that , get the underlying cause , cause I know a lot of parents seem to give their kids melatonin without knowing that there could be an underlying cause as to why their child's having a hard time falling asleep . So that was- .

Speaker 2 1:21:18

Melatonin is actually for something called REM behavior disorder , where patients are acting out their dreams . Melatonin is actually for something called REM behavior disorder , where patients are acting out their dreams . Melatonin actually is one of the treatments . It's first-line treatment .

Speaker 1 1:21:27

Oh , wow , and that's a very mild type of treatment , right ? Because it's sort of- .

Speaker 2 1:21:31

Well , we'll use a much higher dose than what most people will take . We'll actually go up to 20 milligrams of melatonin .

Speaker 1 1:21:37

Okay , that was so educational and I do have more questions . I'm not going to do it now , I'm just going to have to have you come back again . But also , everyone needs to attend the Sleep Education Consortium . This is a big deal 20th year , which is amazing . Congratulations , that's really amazing . And what a great lineup of speakers . It's one of the best conferences there is . So I hope everybody goes to your website , signs up and is there April 4th through 6th . Bring your teams . It's a great . It's a great conference .

Speaker 2 1:22:08

And if you are going to be coming in from out of town , sign up Now . Get a hotel space before the hotel space is all taken .

Speaker 1 1:22:16

Okay , that's great . Well , thank you so much for talking with me and everybody on this Sunday evening . We appreciate all your expertise helping all of our patients , helping all the professionals understand all these details about sleep . It's so informative . I feel like we know more than so many other practitioners because we've learned all this information from you . So thank you so much .

Speaker 2 1:22:41

Sure , and if you're really , you know , up on getting as much information and education . Also , airway Palooza is another event that you should consider . It's actually coming up in a few weeks . In three weeks it's going to be in New Orleans . Airway Health Solutions is putting that one on . Just if you type in on the internet , airway Palooza , you'll see it , and a lot of great speakers at that . I'll be one of the speakers Dr McCarty and Dr Boyd , we're going to be speaking , but there's a whole big lineup and that's going to be worthwhile to attend as well .

Speaker 1 1:23:20

That's so great , that's wonderful . Thank you so much for all that information and we appreciate all of your time .

Speaker 2 1:23:26

You're welcome . Thank you for having me , yeah of course .

Speaker 1 1:23:29

Thank you so much . We'll see you soon .

Speaker 2 1:23:31

Take care .

Speaker 1 1:23:32

Bye , thank you .