Dr Dave McCarty: Empowered Sleep Apnoea Introduction
Well, this week we explore sleep again, and together we breathe, sleep and breathe are foundational pillars. And as I have said, every time I speak to someone on the subject, be it sleep, breathe, nourish, move, think or any other thing. There’s always another aspect to it, a different perspective that is worth exploring.
Well, my guest today is worth exploring with. My guest is Dr Dave McCarty. Dave attended medical school at Duke University and completed his internship and residency in Internal Medicine in Boston at Massachusetts General Hospital. Dave began his career practising primary health care, but after a handful of years in practise, he followed in his own words, “My own white rabbit into a whole new world called sleep medicine.”.
Now, there really is a magical quality about the way Dave approaches this incredibly challenging and complex field of sleep medicine. And when you meet Dave and visit his website and look at his approach to what is really a very challenging field and look at it because it’s such a feast for the eyes. And that includes not only his website but his newly released book, Empowered Sleep Apnoea. You’ll understand exactly what I’m talking about.
Dave is unique, and he’s very special, apart from being an incredibly passionate practitioner, totally devoted to a patient-centred approach. He’s also a terrific cartoonist. Yes, cartoonist. When you visit his website and read his book, you will understand why I say that. In 2015, he joined the Colorado Sleep Institute as its first medical director the Institute was founded as an innovative clinical model, developed to bring a comprehensive philosophy to the practise of sleep medicine, placing clinical care diagnostics and treatment options, including CPAP therapy and oral appliance therapy all under the same roof. I hope you enjoyed this conversation I have with Dr Dave McCarty.
Dr Ron Ehrlich: [00:00:00] I’d like to acknowledge the traditional custodians of the land on which I am recording this podcast, The Gadigal People of the Eora Nation and pay my respects to their Elders – past, present and emerging.
Hello and welcome to Unstress. My name is Dr Ron Ehrlich. Well, this week we explore sleep again, and together we breathe, sleep and breathe are foundational pillars. And as I have said, every time I speak to someone on the subject, be it sleep, breathe, nourish, move, think or any other thing. There’s always another aspect to it, a different perspective that is worth exploring.
Dr Ron Ehrlich: [00:00:42] Well, my guest today is worth exploring with, my guest is Dr Dave McCarty. Dave attended medical school at Duke University and completed his internship and residency in Internal Medicine in Boston at Massachusetts General Hospital. Dave began his career practising primary health care, but after a handful of years in practise, he followed in his own words, “My own white rabbit into a whole new world called sleep medicine.”.
Dr Ron Ehrlich: [00:01:14] Now, there really is a magical quality about the way Dave approaches this incredibly challenging and complex field of sleep medicine. And when you meet Dave and visit his website and look at his approach to what is really a very challenging field and look at it because it’s such a feast for the eyes. And that includes not only his website but his newly released book, Empowered Sleep Apnoea. You’ll understand exactly what I’m talking about.
Dave is unique and he’s very special, apart from being an incredibly passionate practitioner, totally devoted to a patient-centred approach. He’s also a terrific cartoonist. Yes, cartoonist. When you visit his website and read his book, you will understand why I say that.
In 2015, he joined the Colorado Sleep Institute as its first medical director, and the Institute was founded as an innovative clinical model, developed to bring a comprehensive philosophy to the practise of sleep medicine, placing clinical care diagnostics and treatment options, including CPAP therapy and oral appliance therapy all under the same roof. I hope you enjoyed this conversation I have with Dr Dave McCarty. Welcome to the show, David.
Dr Dave McCarty: [00:02:32] Thank you so much. It’s a pleasure to be here.
Dr Ron Ehrlich: [00:02:34] Dave, ever since I was introduced to you and I had the pleasure of going on to your website and it’s a beautiful website, I have to say. There’s a real artistic flair there, and you definitely take your people on a journey. But tell us give us a little bit of background about your own journey.
Dr Dave McCarty: [00:02:53] You know, this all began because I learnt so much in my journey as a patient-centred sleep medicine specialist, and let me sort of flesh out what that means to me. As I probably don’t have to tell you or any of your listeners, sleep apnoea is a Lovecraftian nightmare of a disorder. It is so nuanced and so complicated and so fraught with co-morbidities and competing diagnoses that it’s very hard to get your hands wrapped around it.
And in my journey as a sleep medicine provider, I sort of insisted on something that’s rather unusual. I kept one-hour appointments for every one of my patients every day. I followed my patients from the moment they came in the door. I read their sleep study and I followed them up and I checked their data and I kind of got deep into the weeds with them.
Dr Dave McCarty: [00:03:45] And what I learnt on this journey is there’s a lot of suffering that goes on for reasons that are completely unrelated to the disease. I call it the suffering of ignorance. People just don’t they don’t understand where they’re going and they don’t understand why they’re there. And this suffering is very real, and it makes people make profound decisions that have real repercussions down the road.
So I kind of learnt along the way we were talking before the show about how you learn your pattern with your patients based on what they need and based on what they’re suffering guide you to. So your patients kind of teach you what they need. And I learnt basically the material, the information that they needed to know to get them prepared for this journey. Okay.
Dr Dave McCarty: [00:04:28] And I’ll tell you an interesting story. Early on in my career at Colorado Sleep Institute, I got backlogged in cases, and I thought, I know what I’m supposed to tell them, so I’m going to just write him a letter. I’ll write each of these patients a letter because I was getting so backlogged with my study review visits. They were looking at months, like two months in advance by this point.
And I had to find a way to get my sleep study stacked down and get these people educated. So I thought, “Oh, I’m a writer. You know, I’m a pretty good writer, so I’ll write this stuff down, and I’ll send everybody their own version of what would later become the narrative and the coffee hut discussion on that.”
Dr Ron Ehrlich: [00:05:03] We’re going to go into that.
Dr Dave McCarty: [00:05:05] And we’ll get into that. And here’s where I learnt something kind of powerful. That month when I did that, my follow-up rate dropped to less than 50%, whereas prior to that, when I’d been doing this education in person, it was closer to 95%.
So people, even though it was me, and even though I was explaining it, people just couldn’t get it. They couldn’t get their heads wrapped around it. I think the letter came down like a third, and I learnt something that the information is not the same as education that allows agency.
So with that in mind that fail, I consider that an epic fail because I didn’t do so well in the follow-up. I sort of forgot about that experience when I finished my clinical career, and I wanted to write this book of all these lessons that I learnt. I kind of forgot that for a moment, and I started to write a handbook, a textbook, and I must have worked on that sucker for six months.
And every single time I wrote what I had written, it was like that letter-writing campaign. It was going to come down like a thud, and it was going to scare people. And I thought to myself, Gosh, it’s crazy. The information is the cure. I know what suffering is. I know what the cure is. The question is, how do I get this information into people in a way that feels good and in a way that makes them feel like they are wanting to explore it? And I didn’t know the answer at the time.
Dr Dave McCarty: [00:06:28] This is when I recruited my partner, Dr Ellen Stothard, who is a sleep neuroscientist and someone I met at Colorado Sleep Institute. She’s the Director of Research there. And she’s also just a whipped-crack smart and really, really fun to talk to. And she loves Sleep, and she loves patient advocacy.
So I thought, you know, if there’s one way we’re going to figure this out, it’s by talking about it. And so I figured that we would start a podcast, and we would have conversations about these subjects in real-time. And it was during that process of producing this podcast that we realised that above all, above all, the headspace had to be fun, and it had to be sort of it had to get people excited.
And then one day, we both sorts of said, Wouldn’t it be cool to have a map of this adventure? And that’s when everything sort of fell into place. The map. I went home that night. I drew that map that’s on the website.
And we started to sort of think about it as if it’s sort of like a journey that you could do for real. And that’s when everything kind of fell into place. And I’m really sort of happy the book actually went out to the publisher today.
Dr Ron Ehrlich: [00:07:32] So fantastic. Very cathartic experiences.
Dr Dave McCarty: [00:07:36] Oh, my goodness. Yes. It’s a bit like, of course, I don’t know anything about this, but it feels painful in some ways. I feel like I’ve given birth to something, you know? Does that ring a bell?
Dr Ron Ehrlich: [00:07:45] Well, I had said that you don’t ever finish a book like that. You just abandoned it at some point because you can keep on, you know like that’s why I do these podcasts. Really. Because after I wrote my book, that was a full stop and a printing. But of course, as soon as it went out, there was something I wish I’d added to it, or I wished I’d asked about it. And so this is what this is all about. I get to ask people like you questions, you know more than I do, and you answer them, and I learn. It’s fantastic.
But Dave, you said so many things there already. I mean, I love the patient-centred approach. And the question that a lot of people ask is, what’s the alternative to a patient-centred approach? And sadly, there are many other alternatives out there.
Dr Dave McCarty: [00:08:34] Yeah, well, you know, first of all, what is patient-centred care anyway? That term gets thrown around as if everybody knows what it is. But to me, patient-centred care means that whatever disorder you’re working on, you have to sort of get yourself aligned with the patient and look at the world as much as you can through their eyes, with their value system, you know, and what they think is important, because that makes all that it makes all the difference with something like a sleep disorder, where the or the symptoms are so non-specific, and the treatments can be sometimes abusive, you know, so you really have to get arm in arm with the patient.
Dr Dave McCarty: [00:08:36] In the podcast, I kind of I call it patient-centred care. The best example I can think of is the Vulcan mind meld, you know, where it just gets up, and he puts his fingers across the face, and he says, “Let our minds do what.” You know? And he can actually feel what you’re feeling, you know. And as a doctor, you know, I can’t do that, but I can stop, and I can listen. Okay.
And it’s really the starting with the, “Are you satisfied with your sleep?” That’s the starting point of this whole process because it grounds in the patient’s experience. And that’s why I really believe that a patient-centred model for sleep is really the only model that makes sense because it always self-corrects back to the patient, you know? And that’s the only opinion that matters.
Dr Ron Ehrlich: [00:09:54] Yeah. Well, I mean, I got into this area through chronic musculoskeletal pain, the treatment of headaches, neck aches, and jaw pain. And I had a mentor over 30 years ago, a woman by the name of Dr Janet Travell, who said to me, and she was 92 at the time. And she said to me, “If you ask your patients the right questions, then often they’ll not only tell you what’s wrong with them, but they’ll sometimes even tell you how to fix it. If you’re listening carefully enough.”
Dr Dave McCarty: [00:10:24] That’s the secret. And that’s the crazy secret is that if you teach your patient sort of how the job is done, they’ll do it for you, and they’ll do it better than you can because they’re thinking about it more than you are.
Dr Ron Ehrlich: [00:10:36] But this journey that you take people on, I thought we could go on it together. You start with what’s called the Bay of Narrative, which leads us to the Coffee Hut. Please explain that.
Dr Dave McCarty: [00:10:48] Bay of Narrative is kind of like an educational loading zone. Okay. So basically, the whole point of this educational campaign is to educate listeners, people and providers that there are five reasons to treat sleep apnoea. Okay. Those five reasons are risk, snoring, sleep, wake, and co-morbidities.
Okay, now I’m going to go through those. But of all of those, the most difficult one to talk about for patients and providers both is the phone is the first one. I won’t get it confused with the five-finger approach. So it’s column number one.
Dr Dave McCarty: [00:11:26] The first reason to treat is risk. And talking about risk with sleep apnoea is incredibly complicated. So in order to do it properly, the patient’s going to need some education. You know, there are lots of terms, and there are lots of different types of events that can be stored in a study. And on top of that, there are different definitions for how a given event might be scored.
Like a hypopnoea has two different working definitions right now. And so even the metric that we used to describe sleep apnoea, which is the AHI, the Apnoea Hypopnoea Index, which a lot of people sort of treat like it’s a blood pressure reading like this is the way we measure severity, but it’s a lot more complicated than that. Okay. And even how the AHI is defined can make a difference in how you interpret risk.
Dr Ron Ehrlich: [00:12:10] So Dave let’s just remind our listener about what apnoea and hypopnoea are. Just, just going back to a basic.
Dr Dave McCarty: [00:12:17] Great, great, very basic. The word apnoea means not breathing. So apnoea – not breathing. Pnoea comes from the same root of the word that produces pneumonia. Okay, so apnoea means not breathing. So that’s any event where there is no air going in and out of you. Okay.
And that can happen either because the airway is blocked or because the person has stopped trying to breathe for a moment. And that’s called a central apnoea. So we’ve already gotten into some complexity, two different flavours of sleep apnoea that might be in the same person at the same time. Obstructive sleep apnoea is caused by a blockage of the airway, and central sleep apnoea caused by a pause.
Dr Dave McCarty: [00:12:56] The word hypopnoea means under breathing. So that’s an event where for several seconds, at least 10 seconds, the airflow going in and out of the person is limited. Okay. And as a result of that limitation, something happens. Maybe it’s an arousal from sleep, maybe it’s a drop in oxygen, and that’s where the definitions diverge.
The American Academy of Sleep Medicine definition captures more nuanced events, and so arousal from sleep with a 30% airflow reduction is what allows a hypotenuse to be scored. But for all of the studies that looked at long-term risk, it was the events that caused a 4% desaturation that was caused by the hypotenuse.
Dr Dave McCarty: [00:13:44] So large-scale population-based observational cohort studies like the Sleep Heart Health Study and the Wisconsin Sleep Cohort. These are magnificent studies that actually demonstrate mortality risk with sleep apnoea. These studies were done with the 4% criteria. So already, we get some complexity with: How do I interpret my own score, doc? What does this score mean to me? Boy.
Dr Ron Ehrlich: [00:14:05] And when you are talking about percentages, you’re talking about oxygen saturation in the blood?
Dr Dave McCarty: [00:14:13] Percentage dropped. Yes. Desaturations mean how much oxygen drops in the bloodstream. And it’s usually measured in percentages. “Normal” is considered to be above 90%. And it’s the degree of the dropage that there’s some divergence about where to call that a hypopnoea, you know. So right at the very definition of the disorder, we start to get some blurriness as to what these terms mean.
Dr Ron Ehrlich: [00:14:38] But that the oxygen saturation is one worth just pausing on for a moment because I know sometimes in our practise we might have a pulse oximeter on the finger to measuring a patient’s oxygen saturation. And we know that if it drops below 92%, we stop. You know, we just pause for a moment and just think. So you’re talking about an ideal level of oxygen saturation being what you’re saying would be what would be acceptable.
Dr Dave McCarty: [00:15:13] So this is a very, very interesting question when you start to dig. So what’s normal, and when does the number start to cause problems? Okay, how long does it need to be in order to start causing problems? And when you actually start trying to answer that question with evidence, it gets really, really tricky.
So, you know, I happen to live at a mile high. I live at 5400 feet above sea level. And there are a lot of people that just through attrition of age, their lungs just don’t exchange gases anymore when they’re seven years old, and they may be deciding into the high eighties when they’re sleeping with no evidence of obstructive sleep apnoea.
Dr Dave McCarty: [00:15:51] So the question becomes: Is that a health risk? And the answer is, “Well, I don’t know, is it?” Okay, this person with health problems, you know, does this person have any organ disease that would be threatened by hypopnoea? But if the answer is no, just having those low numbers chronically may actually be adaptive. Right. And may actually help adapt to that higher mountain atmosphere.
So we actually have some population data that says that the risk of cardiovascular death is lower in the mountain-dwelling populations than it is in people at age-matched sea level. And that’s just weird, right? Because I’ve seen these studies come in, and we can get low numbers. And you have to ask yourself, what does this mean to the patient?
Dr Ron Ehrlich: [00:16:33] So yeah, so back to the apnoea and hypopnoea, the AHI index because we’ve kind of redefined that, we’ve defined that for our listener. But it’s a measure AHI Index.
Dr Dave McCarty: [00:16:45] It’s a measure of severity, and it’s often held up as this is you have sleep apnoea because your AHI is this, and typically when numbers get above five per hour, you start getting labelled with the diagnosis of sleep apnoea. But not all AHIs are the same in terms of risk. It depends on the types of events that were scored, so even higher numbers may not contain the same amount of risk in all cases. So this is why the AHI is such a difficult number to decode.
Dr Dave McCarty: [00:17:13] So Bay of Narrative is where we started with this in order to get the patient squared away and comfortable with the discussion about all this nuance, we have to go through a little bit of that vocabulary first. So usually, in the Bay of Narrative Discussion, we would have our talk about sleep satisfaction. Are you satisfied with your sleep? Yes or no? It draws it back to the patient. If the answer is no, then the task is to rate it on a scale of 1 to 10. Okay. And ten out of ten is that it’s perfect. There’s no problem at all. I never have any issues.
One out of ten is that this is about as bad as you can get. Okay? This allows the patient to have a sense of agency, and my vote matters. And I’ll tell you from experience when people are not suffering that bad. They’ll usually give themselves a seven or higher.
You know, they’ll give themselves a passing grade like 70% to see, you know, when they start getting lower than that, there’s some suffering, and they’re not happy, and there’s something bad happening for them. And so, the next task at hand is to help them explain why they gave themselves a bad score. And this is where the magic happens because getting them to put it into words. You might find that they’ve got tons of complaints about their sleep experience, but really no complaints about their daytime experience.
So does that person have insomnia yet? So it helps the provider understand the mindset and what’s categorically important to the patient. Okay, so that process is I call that the Bay of Narrative, and that’s establishing one’s sleep complaints.
Dr Dave McCarty: [00:18:41] After one does that, one goes through the vocabulary that’s involved with discussing risk and then magically, on the island. This is when the island magically allows you to travel to the five reasons to treat monument. Okay. And the reason for the distinction, the monument is meant to be waiting.
You know, it’s always been there. There have always been five reasons to treat. I want people to regard that as an immutable concept because it always brings it back to that discussion. But the problem with modern medical care is that education regarding the subject matter is usually sort of blasted at people on a single visit, and it becomes almost a browbeating ceremony to get people to use the treatment of choice. You know the way our health care system has fragmented. The person usually doing that education is not the person who’s read the sleep study.
And oftentimes, there’s a script element to it. So to the patient, it’s all well and good. The system is trying to be efficient. It’s trying to get people into CPAP machines. But to the patient, that feels like they’re being railroaded, and they don’t feel listened to. So for that reason, I made the discussion about the five reasons it happens in a place where you have all the time in the world.
You know, in the book, I actually describe this place as sort of a luminal space or liminal space, you know, with a place where time stands still, where you’re just comfortable, and you’re relaxed, it’s the right mindset to talk about how this matters to you, you know? And so that’s the reason for the Coffee Hut.
Dr Ron Ehrlich: [00:20:13] Yeah. Well, your allocation of an hour for discussion and a follow-up is just, you know, it’s kind of…
Dr Dave McCarty: [00:20:21] Ridiculous.
Dr Ron Ehrlich: [00:20:22] It’s a very unique approach.
Dr Dave McCarty: [00:20:26] It was a great way for me to learn about this disease.
Dr Ron Ehrlich: [00:20:29] And it’s interesting also to ask patients to score their own sleep quality because many people just accept, this is me, this is normal for me. I’ve never slept any deep, you know? What do you mean? You wake up feeling refreshed? What’s that all about? I didn’t even know sleep was about that. People normalise their own sleep.
Dr Dave McCarty: [00:20:55] They grow blinders to things. For example, you’ve probably experienced this in your practise. It frequently occurs that people decide they’re not going to come to talk to the sleep doctor, even though they snore, even though they’ve got all these problems because they have to get up six times a night to urinate.
And they say, how am I ever going to wear a machine? You know, I have to get up six times to urinate. And no one has ever told them that that symptom is very likely to improve as soon as they get the sleep apnoea effects. You know it just, it breaks my heart that people aren’t, aren’t aware and that those dots have not been connected, you know.
Dr Ron Ehrlich: [00:21:36] Yeah. Yeah. And I mean, that’s an interesting example because I mean, the most extreme example is enuresis with kids bedwetting. But of course, the adult manifestation of that is I get up at night to go to the bathroom, and people just never make that connection between the way they’re breathing as perhaps influencing them getting up at night to go to the bathroom. And yet there’s a very strong connection.
Dr Dave McCarty: [00:22:02] There’s a strong connection.
Dr Ron Ehrlich: [00:22:03] Yeah. So the second element of the reasons to treat is one that is ubiquitous almost for people over the age of 40 or 50. Snoring
Dr Dave McCarty: [00:22:15] Yeah. The second reason to treat is snoring. But even that’s complicated because sometimes people aren’t aware of their own snoring. So they say, “No, I don’t know.”.
Dr Ron Ehrlich: [00:22:22] Mm hmm.
Dr Dave McCarty: [00:22:23] Or if someone were in the room with them, they’d say they would. So, you know, does it matter? And the truth is, snoring does a lot of things that aren’t so hot. You know, the trauma of the vibrational energy back there can be enormous. And there are data that link the development of carotid-specific athrogenesis. I’m talking about building up in here in the carotid where it doesn’t build up elsewhere in the body, sort of as a direct proportion to how much a person snores.
Dr Ron Ehrlich: [00:22:51] Wow. Interesting
Dr Dave McCarty: [00:22:51] So the burden is traumatising of the endothelium in there, and you’re on the right track. But then again, lots of people with sleep apnoea don’t snore, and they can have perfectly legitimate card-carrying, risk-enhancing sleep apnoea and not make a noise. And so they’re walking around. Maybe they’ve been told by a doctor that they don’t have sleep apnoea because they don’t snore.
So snoring can be something that kind of can provides incorrect information sometimes. So we need to think about it. And that’s where the discussion comes in. Do you snore? If so, how much? What position are you in? Is it only when you’re sick, you know? Are you just waking up with the aftermath of snoring like sore throats or a foreign body sensation in the back of the throat, congestion in the nose, that kind of thing?
Dr Ron Ehrlich: [00:23:34] Hmm. And, I mean, I think one of the interesting things about snoring, having been a snorer and having been once since my forties, you know, I used to dismiss it as my wife’s problem, not mine. This was now over 20 years ago, Dave.
Dr Dave McCarty: [00:23:50] You saw the light.
Dr Ron Ehrlich: [00:23:52] Yes, I did. I did. And I kind of dismissed it as, “Oh, come on. It’s not that bad, you know.” And then I was asked to leave the bedroom, and then suddenly her problem became my problem, and I wasn’t going to do that.
And that started this journey that I am still on over 20 years later, which was taking snoring seriously, seeing the difference that it potentially makes to not just myself. But my partner, who I cared dearly about, and I actually ended up staying in the bedroom, which is the programme another we’re doing another programme on that, but we won’t go into that now. But snoring is an interesting one. It’s not just a sociological problem. Sociological problem, is it? It’s not just a social problem.
Dr Dave McCarty: [00:24:36] Well, it is obviously a social problem. And for that reason, some people don’t talk about it and, you know, or they’re embarrassed, or they are they curtail their activities. They won’t go on camping trips or something like that because they’re embarrassed. On the other hand, it might not be that bad, but still, it’s a sign that something more severe could be going on. So I don’t think we can use snoring as a benchmark for whether the disease is present or not. And people sort of need to have their heads wrapped around that, too, you know?
Dr Ron Ehrlich: [00:25:06] Hmm. So the next risk is sleep.
Dr Dave McCarty: [00:25:11] So the sleep experience in sleep apnoea can sometimes be very disrupted, and sometimes it’s not disrupted at all. And I think that for people experiencing this, they need to understand that, you know, just because they sleep fine through the night doesn’t necessarily mean there’s not a problem.
But then again, sometimes people who have sleep apnoea really experience insomnia at night, or they experience multiple awakenings or lots of other different things that happen during sleep, including a sense of just restlessness and an inability to get and stay asleep.
So because the sleep experience can be so highly variable under this one label, getting a person to talk their way through it and understand how it’s impacting them, so they know what they’re kind of watching when they’re going on treatment to see what gets better. That’s what this is all about.
Dr Ron Ehrlich: [00:25:59] Mm-hmm. And then wake. Wake is the next.
Dr Dave McCarty: [00:26:05] So similar to sleep. The Wake experience in a person with sleep apnoea can be highly variable. A person might say that I feel fine and I don’t experience any daytime neurobehavioral impairment symptoms at all. And while other people might be really sort of destroyed by their symptoms, their lives may be very different. And even if their disease is mild. So it doesn’t necessarily, quote-unquote, I don’t really like the use of labels like that because the labels can sometimes carry misinformation.
For example, a person with mild sleep apnoea, a low AHI number might be mild in terms of risk. That person may have really profound symptoms from that problem. And so I dare you to tell that person that their problem is mild. Okay.
So I shy away from using labels, and I prefer to educate people about the five reasons to treat so they can pick them apart. You know, why should I do this? The wake experience can be very different for people. Obviously, the wake experience can be impacted by lots of things other than sleep apnoea. So being able to accurately define it and talk about it so you can set goals of therapy that all happens at the coffee hut.
Dr Ron Ehrlich: [00:27:09] Hmm. Mm-hmm. And the last one of the five risks to treat is co-morbidities, which arguably could be the most important of them all, really, isn’t it?
Dr Dave McCarty: [00:27:19] Well, you know, and you have to break it down this way because sometimes it happens that people ended up in my office referred by a third party having no complaints of their own. You know, I went for a colonoscopy, and my oxygen saturation dropped, or I developed atrial fibrillation, and my cardiologist said I needed a sleep study. How are you sleeping? I sleep fine.
You know, I don’t have any complaints at all. So the question then becomes, do they have a problem that is likely to be making other health problems worse? Is this a reason to treat them? So our comorbid conditions are a reason to treat.
Then, you know the list of you know this better than anybody, I think because sleep apnoea is such a non-specific stressor, because it causes stress by virtue of sleep restriction and sleep fragmentation, and it also causes oxidative stress by virtue of the repetitive oxygen desaturations and the straining the upper airway.
Dr Dave McCarty: [00:28:17] So all of these physiologic stressors writ large over the long term, and these can make lots of other health problems worse. Things like hypertension and diabetes control gets worse; asthma gets worse. The repetitive hypoxic stress can make gout worse, you know, on and on and on and on and on. And so people can collect these other health problems, and they’re seeing their specialists.
And as your listeners are aware, with a specialist drive system, you know, everybody’s kind of managing their own little diagnosis, but nobody is really putting it together as to how all these things relate to each other, you know, and the sleep apnoea. It can be a fulcrum point for a lot of these other health problems.
Dr Ron Ehrlich: [00:28:54] Mm hmm. And the stereotypical person who falls into these high-risk areas is someone who’s overweight and has a thick neck. But it’s not always like that, is it?
Dr Dave McCarty: [00:29:09] Oh, no, no, no. In fact, it’s sort of the dentists that have taught us a little bit more about the emerging phenotype of sleep apnoea. So this is something I get into a little bit in the book because I feel like for people to have mastery over something, they have to kind of understand the history of it. So I have a fun time explaining some of these historical details, but we started all this with a phenotype called Pickwickian syndrome.
Dr Dave McCarty: [00:29:34] Okay. Now, for the listeners interested in literary history, this is based on Charles Dickens’ first novel, The Posthumous Papers of the Pickwick Club, and there was a character in this novel that was named Only Fat Joe. And Poor Fat Joe was a young man who snored even when he was awake, and he was always falling asleep.
And it was kind of just light comedy in the book. You know, right around the mid-twentieth century, people started to write things down in the literature referring to Pickwickian Syndrome because that heavy person snoring, falling asleep in the daytime phenotype was associated with medical disease, pulmonary hypertension and heart failure.
Dr Dave McCarty: [00:30:14] And so it started to make sense to notice when people had this Pickwickian phenotype, you know, right around the 1960s is when people started doing sleep studies. And in 1966, a guy called Henry Gaster did the first poly sonogram on a series of people with Pickwickian Syndrome.
And that’s where we found out that that phenotype was associated with a condition called apnoea during sleep, and it was mostly obstructive at some central apnoea tapping back now.
So now we have a phenotype causing disease. We’ve got a sleep study that shows these events, and now we have a disease called sleep apnoea. So now we flash forward to these studies that I was talking about, and we prove that this disease can cause early death based only on the number known as the AHR.
We’ve got a new mindset, okay? Now it’s a disease that’s defined by a number. And what we’re finding as we move forward in time, forward in industrialisation, we’re finding, and this is coming from the dental and the anthropological literature.
Dr Dave McCarty: [00:31:22] So this is all stuff your listeners should be familiar with. But our skulls have changed shape in the last hundred years because the primary moulding force for our upper jaw is that tongue as one is breastfeeding. That tongue is kind of sculpting out the upper jaw and making this big giant sort of. I don’t know.
It’s like the Superdome. Okay, if you’ve got a tongue that’s really mashing it up, they’re like that. When you’re dribbling food in with gravity out of a bottle and really not working that term up there, the upper jaw ends up shaped like this, and that tends to collapse the nasal airspace like this, like an umbrella.
And that leads to a condition that a lot of dental sleep medicine providers are familiar with called chronic mouth breathing and nasal disuse syndrome. And chronic mouth breathing during development leads to an underdeveloped jaw.
Dr Dave McCarty: [00:32:18] So now we’re in 2022, and we’ve been feeding our kids with bottles like this for a generation. We’ve got a whole group of adults with sleep apnoea based on their AHI. That’s a completely different phenotype than Pickwickian Syndrome.
And so we’re having to get our minds wrapped around that this isn’t all the same thing, you know, and we have to understand that on a granular level to the patient that words sleep apnoea really don’t mean anything at all. We have to help them figure out what those words mean, and that’s what the patient-centred approach is all about.
Dr Ron Ehrlich: [00:32:53] I mean, to put a number on that underdevelopment, in my clinical experience of over 40 years, the number of patients that have enough room for all 32 of their teeth that we’ve evolved to have, just as we’ve evolved to have five fingers on each hand, five toes on each foot, you know, two eyes, and two ears we’ve got all these body parts that have a certain number that we’ve evolved with, and we’ve evolved with 32 teeth.
I would say less than 5% of the population has enough room for all 32 teeth, which means there’s a narrower airway out there than perhaps ideally it should be.
Dr Dave McCarty: [00:33:32] Does that gybe with when you ask those people with the fully developed, you know, 19th-century airways where those people usually breastfed?
Dr Ron Ehrlich: [00:33:42] hey were. It’s interesting because I would also add to that the pre-conception nutrition of both mother and father. I would add to that the nutrition of the mother during pregnancy are that is the food nutrient dense.
That’s really key because this is the work of Weston A Price, who was a dentist in the 1930s looking for tooth decay and found physical degeneration of which narrow jaws were part. And then you come into the breastfeeding, the bottle, you know, the chewing of food and the nutrient density. But the point being that small jaws narrowed teeth, crowded teeth, and smaller craniums, in fact, are ubiquitous.
Dr Dave McCarty: [00:34:30] Reminds me of a band I used to listen to called Devo.
Dr Ron Ehrlich: [00:34:33] Oh, yes. Yes. Like. Well, didn’t they?
Dr Dave McCarty: [00:34:36] Yes. That’s going in the wrong direction, folks. You got to do another round. Yeah, fascinating stuff. So I’m very interested in the concept that sleep apnoea as a label doesn’t mean anything that we as providers. It’s incumbent on us to help people decode what it means to them because it can be very damaging.
You know, psychologically, you get labelled with this, with this diagnosis, and suddenly you’re afraid, and people are telling you, you got to use this machine, or it’s going to give you a stroke. Well, that, I would argue, is unethical if the risk kind of on that person’s scale is low. You know, I don’t think you should browbeat people into using a device that, you know, isn’t really indicated if their disease isn’t that bad.
You know, so I think at some point, the only way we can stitch together this fragmented system is to teach people the information so that they can advocate for themselves in their own narrative because they’re the only common part in all of this adventure, you know, for them.
Dr Ron Ehrlich: [00:35:37] Well, I very often say that your health is just too important to leave to anybody else. You’ve got to take control of it. No. Well, I believe that. And with our help, with guided help. But, you know, I think it is important. I mean, I think if you’re the sort of individual who doesn’t want to know about things, you’ve got a whole industry waiting to greet you with open arms. Right.
And it’s why the pharmaceutical industry generates $1.2 trillion a year. It’s why the medical industry is, you know. But taking control of your own health. But coming back to the sleep study. You mentioned sleep study. And I wondered, could you just give us a brief overview, not too technical, of what a sleep study is?
Dr Dave McCarty: [00:36:25] Oh, wow. Yeah. So most sleep studies these days are done at home. And that’s out of necessity because doing a study in the lab is really intense and labour intensive and expensive. So most insurance payers really want you to do it at home. And they’re really looking for any reason they can to keep you out of the sleep lab.
So I’m going to describe the home sleep apnoea test. Okay. Most standard home sleep apnoea tests these days that conform with the American Academy of Sleep Medicine guidelines are going to have a few different elements on them that are just going to measure the things we care about. Okay.
Dr Dave McCarty: [00:36:57] So the first thing is going to be something that goes under the nose. It looks like an oxygen cannula. So I think that things that you see people wearing in the E.R., but it’s not giving you oxygen. It’s just measuring air going in and out of you. Okay. They’ll usually be a finger probe oximeter measuring oxygen saturations in real-time so that you can see patterns when they’re going up and down. That’s important because it’s not static. It goes up and down.
And how much and how many times per hour that happens is important. There are usually two stretchy bands, one that goes around the chest and one that goes around the belly. Okay. These are going to measure airway or breathing effort. So when those are moving, that’s when you’re trying to move, and you can actually get patterns out of the way. Those are moving, too.
Dr Dave McCarty: [00:37:39] So when there’s relative upper airway obstruction and think you’re trying to suck air in your airway sucking closed, those abdominal and thoracic bands will get out of sync, and they’ll start to seesaw with each other. When there’s no obstruction, they move nice and even together. But when there’s an obstruction, they start to do this. So there are little patterns that you can see when you start to see relative signs of upper airway obstruction.
Finally, there’s usually some sort of a position sensor on the device, so the little thing usually hooks into a Walkman-sized device that you’ll kind of pin to your shirt. And that has the ability to tell whether you’re on your back or on your side or on your stomach. And usually, there is some sort of a microphone that will measure snoring sounds and things like that. Some of these devices are going to have an EKG monitor, too. Some of them just get pulse rate from the pulse oximeter.
Dr Dave McCarty: [00:38:30] Okay. So overall, it’s something on your hand, something under your nose and things around your chest. You can usually get up and walk around, so it’s pretty easy to do. Okay. The weird part about it for people is that they’re doing it at home.
And so, again, if they don’t know why they’re doing it and they don’t know what these things are, if they’re feeling disconnected, they might start to feel manhandled by the whole system pushing them through.
Dr Ron Ehrlich: [00:38:52] Hmm. Cause, you know, the question then becomes: Is this measuring a typical night’s sleep? I mean, I know that if I wear my ring at night, you know, which I normally don’t wear, I just something that doesn’t feel quite right. And that’s only a tiny ring.
And then I have this little Oura Ring here, which I thought is quite interesting because it’s a sleep. It’s the least invasive thing I have, but that’s quite a lot of hardware, relatively speaking, to go to bed with.
Dr Dave McCarty: [00:39:23] I call that the Heisenberg Uncertainty Principle of sleep testing.
Dr Ron Ehrlich: [00:39:26] Okay. Which we just accept. Are we saying that we’re just getting a snapshot?
Dr Dave McCarty: [00:39:33] Yeah, it would be so cool, wouldn’t it? If we just had, like, something that you can clip on your head really easy and it’s totally lightweight and makes this diagnosis, maybe that day is coming, you know, maybe we’re going to find out that the AHI and all that and we’re going to find a better metric, something that combines, you know, EEG waves with pulse ox or something like that.
And we’ll find a way to quantify this that’s better. But right now, the way our system works is you can’t get a CPAP machine paid for unless you have an AHI that’s high enough. So it’s kind of locked into the way the system works. And that doesn’t always make sense because you could have sleep apnoea as defined by the American Academy of Sleep Medicine, but Medicare doesn’t recognise the events that you had scored, so you can’t get a machine.
And that’s very frustrating for a patient, you know, to experience that yourself. You kind of get the feeling that everybody’s swindling you at some point, and that doesn’t feel very good. And it’s that signal that I’ve tuned into from the beginning of my career to kind of I don’t know.
I feel like my job as their physician is I’m the guy standing there in this big cave with a torch, and I’m like, “Look, this is a dangerous pathway here. Let’s walk together because this way is a little scary. So this is what’s up ahead.” You know, that’s my job. So that’s what all this education in the Bay of Narrative and all that stuff is about.
Dr Ron Ehrlich: [00:40:49] What a wonderful metaphor. I love that. I like that vision. Now, we’ve walked from, we’ve been in the Bay of Narratives and had a cup of coffee at the coffee cup, the chat. And we’ve outlined the five risks, five reasons to treat, five reasons to treat. And now we’re coming into the river of decision.
Dr Dave McCarty: [00:41:08] Yes. So once you complete your coffee hut discussion, a little magic happens. You find yourself on the banks of this deep and turbulent river. And there are lots of ways across, and there are new ways being invented all the time. You’ll notice that the river of decision flows out of a lake called the Lake of Innovation.
Okay, so the problem with this river is it’s very difficult. It’s a river that defies physics. So it runs forwards and backwards. And you really never know where you’re going to end up when you get to the other side. Everybody’s hoping for that magic landing at Pleasant Dreams Beach, but oftentimes people end up in the rough.
Dr Dave McCarty: [00:41:49] Okay, so the purpose of part two is to explain the many different approaches to many different ways across the river and to say what we know and what we don’t know yet. Okay. And so we talk about standard therapies like CPAP and pros and cons and different things that can go wrong with that and yadda, yadda, yadda.
We talk about standard mandibular advancement oral appliance therapy, that that does this and this, but these things can go wrong and what to expect from that and what it cost. Those are introduced as the standard therapies only because those are what’s paid for usually by insurance. Okay, it’s like a common law standard.
Okay. Not to say that one is perfect, for one is better, or one is worse, which is what’s paid for. And that’s what most people, their providers, are going to talk to them about.
Dr Ron Ehrlich: [00:42:36] And Dave, just to remind our listeners that the CPAP refers to the mask continuous positive. Yes.
Dr Dave McCarty: [00:42:44] Yeah. Invented by a countryman of yours.
Dr Ron Ehrlich: [00:42:46] Yes, yes. Yes.
Dr Dave McCarty: [00:42:51] So he invented the CPAP machine with basic stuff that he bought it in the hardware store and put it together in his garage. And boy, what an invention, you know, way better than the ostomy, you know?
Dr Ron Ehrlich: [00:43:02] Oh, yeah. Wow. And the mandibular one is a mandibular advancement splint, keeping the lower jaw and the tongue slightly forward, so it doesn’t drop back and block the airway. So they are the two, as you outlined, the two standard ones. But there’s more.
Dr Dave McCarty: [00:43:19] There’s more. Yeah. So, you know, people will hear about surgeries. And so, if you go see a surgeon, you might be offered surgery. So I wanted people to know kind of when surgeries might be appropriate and when to sort of think about that. In general, with some exceptions, surgery is now considered more of an adjunctive role in the management of sleep apnoea, and there are some exceptions to that, but it’s nobody is really saying that you should go get your soft power and your uvula removed for sleep apnoea as a first line measure anymore, although that was happening in the seventies and in the eighties.
So the thought has changed quite a bit. We’re trying to keep people out of the operating room as much as possible, but still, people are going to read these things. And I wanted them to know kind of where the coaching is on this. I also introduced the subject that you’re familiar with, known as Airway Centre Dentistry, to me.
I think this is a fascinating field in the development of sleep medicine. And I think it just demonstrates two different groups of scientists working with kind of a different philosophy. You know, I think of the medical mindset as doing trials and proving a therapy with Randomised Controlled Trials because there are a lot of things out there that can hurt you and a lot of snake oil that we need to sort of prove that it doesn’t work. So that mindset is important.
Dr Dave McCarty: [00:44:38] But the dentists of our world have always been sort of engineers and innovators. And it’s like the medical world said, here you go, here’s an engineering problem. Here’s a room that’s too small. And the dentist went, “Oh, well, how does the airway develop, and what are the tools that we have, and how can we engineer a solution out of this?” And voila, a new discipline arises with relatively no data.
So we’re in an early part of this discipline. I think we’re in a time frame when it’s tempting for the medical world to sort of start chanting humbug the way they do. And I think it’s important that we keep in mind that the patient is in the middle, and any of that sort of, I don’t know, disparaging talk only harms the patient.
Dr Dave McCarty: [00:45:09] So one of my goals with empowered sleep apnoea is it brings the focus back to the person who this is all about patient gives them language to fend for themselves and anybody, no matter who you are, whether you are a dentist or a physical therapist or a physician or primary care doctor.
We can all have fun with that language and share it with them because it is fun to talk about their narrative and the coffee hut and where are you and are you on treated territory yet, and what kind of complications are you having? It normalises it and takes this insanely complicated subject and turns it into something we can get our hands around in it.
And quite honestly, I tapped into every ounce of fun that I could find in my psyche. And I have a lot of fun, and I have a comic book of a brain, and this book actually makes you feel good for reading it, so I can’t wait to get it out there.
Dr Ron Ehrlich: [00:45:49] Yeah, looking forward, I’m looking forward to reading it. I’m looking forward to it.
Dr Dave McCarty: [00:46:28] Get it out there.
Dr Ron Ehrlich: [00:46:29] I mean, another I mean, there are other issues we’ve covered in our podcast many times. Not many times, but we’ve covered myofunctional therapy. We’ve covered we’ve even done some Buteyko Breathing is a very big focus. I think sleep and breathe.
Dr Dave McCarty: [00:46:51] Absolutely a data-free zone. In fact, the American Academy of Sleep Medicine just published a paper about all of this, saying, you know, making sense of the noise and saying there’s no data. And I want to say there is absolutely no data. Okay.
It doesn’t mean that learning to breathe through your nose isn’t a really good idea. And all of the data suggests we shouldn’t be breathing through our mouths, so if there’s a system that you can learn to help you breathe through your nose, that you can do without going to a doctor. Hmm? Yes. Oh, yeah. Right.
Dr Ron Ehrlich: [00:47:22] Yeah. What’s your view of the use of tape on the mouth? I know. I read an article in the 2015 Journal of Otolaryngology-Head and Neck Surgery, which actually legitimised something that I’ve been using for quite some time. What’s your view of that?
Dr Dave McCarty: [00:47:38] I used to recommend that quite a bit, particularly for people who were having problems with oral air venting with their CPAP mask. You know, for the listeners, part of the problem with using a CPAP machine is you really want people to breathe through their noses because it’s healthier overall. But oftentimes, people come to the table with a really congested nose.
And so, right out of the gate, they say to themselves, “I’m a mouth breather.” And so they go to their medical equipment company, and they say, “I’m a mouth breather,” and they say, “Okay, let’s give you a big giant mask and put it on your face.” And as soon as you strap that guy on, it’s going to push the mandible backwards, and it’s going to encourage you to keep your mouth open.
That raises the pressure that’s needed for the device to work. Right. And it encourages you to continue with this unhealthful breathing habit of breathing through your mouth. And the problem with that is part of the issue with the nasal congestion is that the more you don’t use your nose, the more your nose gets congested. And that’s called Nasal Disuse Syndrome. A lot of people don’t know that.
Dr Ron Ehrlich: [00:48:39] Say that again, Dave. I missed that.
Dr Dave McCarty: [00:48:41] I’m sorry. Nasal Disuse Syndrome.
Dr Ron Ehrlich: [00:48:44] Nasal disuse. Because I’ve often thought there’s a paradox, isn’t there? In that the less people, the more they breathe through their mouth, and the more likely their nose is to be blocked.
Dr Dave McCarty: [00:48:55] That’s right.
Dr Ron Ehrlich: [00:48:56] That’s a Nasal Disuse Syndrome. I hadn’t heard.
Dr Dave McCarty: [00:48:59] That. It has to do with the fact that breathing through your nose, pulling air through your nose, helps your nose elaborate good things that help keep it open, like nitric oxide is one of them. Nitric oxide does lots of things in the body, but down in the lungs, it helps with gas exchange.
So it makes the breathing you’re doing more effective. And in the nose, nitric oxide kills microbes. Okay, so this guy is supposed to be, you know, the front blockers for your jaw, everything you’re breathing through your nose. If you’re breathing through your mouth all the time, you’re sending everything to your tonsils and challenging those tonsils every day with all these things they shouldn’t be dealing with.
And so they get big, and you continue to breathe through your mouth because your nose is stuck.
Dr Dave McCarty: [00:49:41] So going back to my CPAP patients and the taping, normally if I put somebody on who’s got a stuffy nose on a CPAP machine and I’m gentle enough with the pressures, and I’m not forcing air out the mouth, I can get them on a nasal CPAP and Nasal Disuse Syndrome gets better. They stop snoring on their nose.
The tissues aren’t rattling around all the time. So everything gets better. But sometimes, no matter what I do, they must have floppy soft tissues in the back of the throat. The nasal CPAP pushes air out. So in that setting, a little tape across the mouth can resolve it. And it works well.
Dr Dave McCarty: [00:50:17] For what you’re talking about, which is teaching people how to breathe through their noses again and become better. I usually gave them coaching to go read Patrick McKeown’s book, Close Your Mouth book, for people that were interested, especially when I saw that they were kind of sitting there with their mouths open, you know, and they’re taking these big gulping breaths between sentences.
You know, I got the sense that they were really kind of overdoing it with their mouths. You know, the phenotype I’m talking about. Usually, these are skinnier people with a smaller face and a skinny nose. Those people would really benefit from doing some Buteyko exercises, I think. I always just sort of felt compelled that I’m like, I’m a Western-trained doctor, you know, I trained at Mass General.
So we were all about evidence-based medicine. So I always felt compelled to say, “I’ve got no data to back this up, but breathing through your nose is better for you. If you can learn how to do it this way, I think it’s better.”
Dr Ron Ehrlich: [00:51:09] You’ll be pleased to know. I interviewed Patrick this morning, and his episode will be coming out very close to yours too.
Dr Dave McCarty: [00:51:16] That’s awesome. Way to go, Patrick. I recommended your book to plenty of people.
Dr Ron Ehrlich: [00:51:20] Well, he’s terrific. And I reconnected with him after a couple of years there. We talk about… I mean, the river of decision is something that people work through with all the different alternatives. And there are more than we’ve even talked about there. But then we’re into the treated territory. And one of the issues is insomnia. And I wondered how big a problem is insomnia and how do we define it.
Dr Dave McCarty: [00:51:50] Well, so that depends on whom you talk to. Okay. So I once had a patient whose final diagnosis was narcolepsy, who came to the clinic complaining of insomnia. So all it means is that the night-time experience is dysfunctional, disquieting or unsettling to a patient. So they’ll come in with that word on their lips. Okay.
When you start looking into people studying insomnia, then there are all these definitions. They are having difficulty more times, more often than not, you know, for at least three months. And it’s causing significant difficulties. So the people are trying to be able to create a silo, so this can be studied.
Dr Dave McCarty: [00:52:28] And in my experience, the word insomnia is so nebulous that it can become almost meaningless. Which gets us back to the bay of narrative and sleep-wake complaints. Okay. So that’s why that’s foundational. But to your point, having continued difficulties with sleep or awake on treatment is the rule. Okay.
So I describe this in the book with something I call baseball talk. This is a little fun. It’s just kind of a side throw-off chapter. But I think people need to know that not everybody is a home run. You know, not everybody puts that pot machine on and is like, “Woo, this is the best thing ever.” You know, home runs like that. They’re annoying.
You know, I mean, because they talk about it all the time, and then you can’t get their CPAP machine out of their hand, you know, and their doctors love them because it’s just easier to see. But, you know, great idea. You know, but that’s the in my clinic home runs were about 30-35% means that you know, 65-70% of people are home runs. So what are they?
Dr Dave McCarty: [00:53:27] Well, you got your base hit. You know, somebody who gets some complaints get better, but not all of them. I have something called the slow ball. Okay. This is somebody who comes in with all kinds of sleep-wake complaints. You put them on treatment, and it doesn’t get better until they’ve been using their treatment for a while.
You know, as their autonomic nervous system settles down, then they start sleeping better at night, a year into treatment. Okay. And the problem is, you never know who’s going to be your delayed responder. So this is why coaching is. Because think about it if a person comes in, “I can’t sleep, and I’m tired.” You send a moment of a CPAP machine, and after a week, they’re like, “I can’t sleep, and I’m tired, and I’ve got a mask on my face.”
Well, that person is not going to keep using that machine unless they’ve got somebody there to coach them. And that’s what these complications and competing diagnoses are about.
Dr Dave McCarty: [00:54:20] So basically, in my experience, I came up with a few, and they are Willis-Ekbom Disease, which is restless leg syndrome that often overlaps with sleep apnoea because of the periodic disturbances of sleep that come from the restless legs component of this, the moving of the legs at night, that can be a trigger for central apnoea and central apnoea physiology.
And so this can be wrapped up like a birthday present inside the diagnosis of sleep apnoea. And if you don’t fix it, the person getting the sleep apnoea treated doesn’t get any better. So how do we deal with that? So I talk a little bit about that. I talk a lot about issues that are going to help people understand concepts known as cognitive behavioural therapy for insomnia.
Dr Dave McCarty: [00:55:04] This is all the rage. People are inventing AI apps right and left. They teach you CBTI. I think that’s great. And for the listeners, cognitive behavioural therapy for insomnia is understanding this disorder so that you can choose behaviours and thought processes that won’t be maladaptive. That will help you get out of this morass.
I found in my clinic anyway that if you tell people to do CBTI and you don’t tell them why you don’t explain it to them. They don’t do it because it’s hard. And so I like to teach them the science because the science is cool anyway, like understanding how sleep and wake work is really awesome. I mean, seriously.
Dr Ron Ehrlich: [00:55:41] Like a true sleep position.
Dr Dave McCarty: [00:55:43] And then right once you sort of understand how it all works, it’s like it’s true.
Dr Ron Ehrlich: [00:55:48] It’s true.
Dr Dave McCarty: [00:55:49] And I found that if I could teach people that, I could see the light bulbs come on in their eyes.
Dr Ron Ehrlich: [00:55:56] Mm hmm.
Dr Dave McCarty: [00:55:56] Then they’re ready for CBTI, and then they do it, and then they’d be successful, you know? So we go through some of the skills of CBTI. I talk a lot about circadian misalignment because in clinic delayed. Circadian sleep phase was everywhere. And this is just a disorder of living in civilisation.
Our melatonin onsets are just delayed, and so everything about our signalling for sleep is messed up, and it has to do with lights and what we’re doing at night and all this activity that we have. So I teach people about that.
The thing I do that’s different in the book to teach about all these things, because of course, in clinic, I only got into it when people had the problem, and then I would sort of looking them in the face, and we’d have a moment, and we’d walk through it.
In the book, I had to present these things as if there are different adventures. So I tell stories, and I give little vignettes of people, and they’re all made up. Of course, they’re fictional stories. I’m not giving anybody’s personal information away, but they helped to illustrate some of the
Dr Ron Ehrlich: [00:57:26] Mm-hmm. And, I mean, when we talk about circadian rhythm, boy, that’s opening up a whole huge view of the modern world because every one of our devices, every computer, every TV, every phone, every laptop, every, you know, the reader has the potential to disrupt our circadian rhythm.
Dr Dave McCarty: [00:57:19] Yeah. And all the nanotech things that are going to mess with our rhythms. So getting anxious and reading and taking in world news and getting yourself all hyped up. That’s all working against us. It’s all very complicated. But helping people re-establish the healthful productive, and adapted sleep routine, helping them dig their way out of a morass like a delayed sleep phase, can be very difficult.
Dr Dave McCarty: [00:57:37] One of the fun things we did for the book is I invented a tool in the clinic much less fun to look at than winning the book is. But it was a wheel, so it would help to illustrate the circadian rhythm. Okay. And because it turns out that depending on where you are exposed to light and melatonin, it can move your circadian rhythm forwards or backwards.
And so it makes a big difference, you know, as to when these stimulations are happening. And that especially gets confusing to teach when people are crossing time zones and trying to, like, give a talk in Europe, and you want to help them get prepared and know when to put the dark glasses on and when to take the melatonin.
Dr Dave McCarty: [00:58:20] So I created a gizmo, I call it like a biological decoder ring called the circadian rhythm wheel. And it’s something fun. It’s like a crackerjack toy. You can pull it out of the book and put it together. But you can actually learn something from it, and you can figure out your own circadian rhythm. So people who are interested in you can actually buy one of these separate from the book on the website.
I’m selling them just because I think they’re nifty and they’re really fun. And anybody who crosses time zones, I think it’d be a fun gadget to have. So it’s called the Circadian Rhythm Wheel, and it’s just a fun part of the book is a fun part of that gee-whiz adventure that I was trying to create.
Dr Ron Ehrlich: [00:58:56] And you mentioned melatonin and people, you know, melatonin comes as supplementation, and people sometimes take it when they travel. How should we or could we be using melatonin, and how cautious should we be about its use?
Dr Dave McCarty: [00:59:14] Well, you know, I’ll preface this by saying that melatonin, because it’s not regulated by the FDA in the United States anyway, I don’t know how to handle it in Australia, but over here it’s considered a supplement, which means that you really don’t even if it says, you know, five milligrams on the bottle and this was published, I can’t remember the year now.
I think it was close to ten years ago. Someone did an assay of different leading brands, and it was just all over the map. You know, the variance was maybe as much as 500% was on the label. So with that being said, you don’t really know what you’re getting, and so you have to really pay attention to how it affects you before you sort of just make a blanket statement. We don’t get any signal that melatonin is addictive. You don’t get any signal that it’s going to cause physical habituation.
So as far as an agent to help you sleep, you know, there are worse things. It has the ability to move your circadian rhythm around, though. So I think that’s important because if melatonin is experienced by the brain on the second half of the night, you know, close to morning, if that’s when the melatonin is being observed by cells, by the receptors in the brain, it’s going to actually try to delay your circadian sleep days. Okay.
So if you’re taking melatonin at bedtime, you’re taking an extended-release formulation at bedtime, maybe you go to bed, and you can’t get to sleep, and it’s one in the morning. You’re like, “Man, I’ve got a delayed sleep, so I’m going to take my melatonin at bedtime.” Most of that is going to be experienced on the second half of the night, and it may be contributing to the problem. Okay.
Dr Dave McCarty: [01:00:45] So I think we need to be careful when we kind of choose the formulation. Is it an immediate release or an extended release? Is there any evidence that we’re dealing with a circadian misalignment rather than something else? And, you know, once we’ve thought about all those things, I think it’s an agent that I don’t really, I’m not afraid of for my patients because I’ve really never seen it go wrong.
When it goes wrong, to the point that people don’t like it is that they say, I felt really smoky in the morning, and I didn’t like it, but I really never clinically encountered anything worse than that.
Dr Ron Ehrlich: [01:01:16] And is the idea of an immediate release. If, say, you were taking immediate release, would you take that an hour or so or two before bed or at the time of bed? What would be the timing ideally?
Dr Dave McCarty: [01:01:27] It depends on what you’re trying to do. So if you’re trying to use melatonin as a chrono tropic agent, meaning to try to like, let’s say you’re trying to adjust to a new time zone and you’re trying to use all the technology at your disposal, light and melatonin, because both of these elements can move your circadian rhythm. Then you’re going to want to pay attention to when you’re taking it and try and try and target it.
And that’s where the wheel comes in. So you can actually turn the wheel around, figure out where your circadian sleep phase is, and then you can see on the clock where the best effect to either advance or delay your sleep phase would be. So for that kind of targeted use, I would use low-dose melatonin. You know, we’re talking physiologic doses are less than 0.5 milligrams. That’s what your brain does. Mm hmm.
Dr Dave McCarty: [01:02:11] So taking boxes of, like, five milligrams are super therapeutic. They’re super physiologic. So if you’re taking it to move your circadian rhythm, you’re using a low dose, and you’re actually kind of if you’re trying to advance your sleep phase, you’re taking it like 4 hours before you’re going to bed. You know, so you’re kind of strategizing a little bit if you’re using it as a sleeping pill.
So then you’re using doses of 3 to 5 milligrams, usually that range, and sometimes it’s advisable to take an extended release. If you’re not worried about the circadian misalignment aspect, that’s going to last a little longer and have those soporific effects of sleep-inducing effects lasting closer to the morning.
Dr Ron Ehrlich: [01:02:48] Hmm. And then we come into an area you refer to as the Five Fingered Approach Mountain.
Dr Dave McCarty: [01:02:54] Yes. Yeah.
Dr Ron Ehrlich: [01:02:56] Tell us about that.
Dr Dave McCarty: [01:02:57] So there’s a story behind this. I mentioned the fact that there was a patient that had narcolepsy as her final diagnosis who presented with a diagnosis and insomnia. So this patient actually I described this on the website. I didn’t tell all the details, but I gave her the name Daria for the blog, although that wasn’t her name.
The bottom line is this patient came in with some sleep-wake complaints, got a diagnosis of sleep apnoea, was placed on treatment and then got kind of put on the follow-up trial. And this patient wasn’t educated, didn’t talk that much, and just sort of came to clinic. How are you doing on that? Yeah, I’m using it, you know. So it was a limited exchange. So part of the problem here was cultural communication and all the rest. Okay.
But I came into this patient’s care five years into her care. And it turns out her sleep apnoea wasn’t really the problem. She actually had narcolepsy, you know. And that broke my heart that this woman was using this machine. Going to all the trouble of coming to visit. Being told that she has to do this because she was going to have a stroke if she doesn’t. And she really didn’t need it. And I felt that there was something ethically wrong there.
Dr Dave McCarty: [01:04:07] So, I wanted to create a system whereby whatever’s going on with the patient could always be cross-checked with a checklist. You know, I was fascinated with checklists. That whole Checklist Manifesto book came out. I was at the time, I was teaching physical exam class at the medical school, so I was using the Harvey Robotic Heart Sound Simulator.
The great Dr Harvey was a legend in medical education, and he came up with a five-finger approach for the cardiovascular exam. So I was kind of thinking along the lines of, how are we not going to forget again? And that’s where I came up with this idea that anytime somebody comes in with a sleep-wake complaint. There’s a pretty good likelihood we’re going to find more than one thing wrong.
So we shouldn’t stop with the first label we have a treatment for. That’s what happened with poor Daria. And she got labelled, and then everybody stopped thinking about her for some reason. So that’s called diagnosis-based medicine in my book.
Dr Dave McCarty: [01:05:01] I practise patient-centred medicine. So that’s where the five-finger approach came up, and it was really designed around giving us a checklist so we wouldn’t make that mistake ever again. And the five fingers are thumb is circadian misalignment actually should go this way. That way. Right. Circadian misalignment, the index finger is a pharmacologic influence.
And I put that on their second because I was training physicians at the time for many different walks of life to get into a sleep medicine fellowship. I was the Associate Programme Director and then the Programme Director of the Sleep Medicine Fellowship at LSU Health Sciences Centre in Shreveport, Louisiana.
And we accepted candidates from multiple walks of life psychiatrists. Family practise, paediatricians like you can come in from many angles. I found that depending on your background. You might be radioactively allergic to reviewing the med list with a patient. The psychiatrist wouldn’t even look at the cardiac meds. Okay. To their mind, that was managed by them, you know.
Dr Dave McCarty: [01:06:01] So I had to get people into the mindset of thinking about the drug list critically, because as it turns out, there’s lots of drugs that do terrible things to sleep and wake and nobody is even thinking about it. And so they’re blaming everything on the sleep apnoea. Then when really, what they needed to do is switch from a lipid-solid soluble beta blocker to something that’s less likely to get into the brain.
You know, but if you’re not thinking along the lines of, you know, this could be the drug, you’re not going to go there. So that’s why after circadian misalignment, figuring out where you are, where your circadian cycle is, you look at the drugs.
The third thing to look at as the middle finger is medical problems, medical factors because lots of medical factors can influence sleep and wake for the worse. So the question there is, can we tune out these medical factors any better? You know, are you having chronic pain that’s keeping you awake? Do you have interstitial cystitis that’s getting you up every 4 hours to pee? Maybe we can manage that. Okay.
And if you can’t manage the medical problem any better than not sleeping or feeling fatigued. Those are forms of suffering, and those symptoms have potentially relieving treatment courses.
So sometimes, you need to target the sleep experience. Just because a person can’t sleep because they’re in pain doesn’t mean you can’t find a way to maybe give them a little pharmacologic assistance that say, you know, so you have to think about medical problems very critically.
Dr Dave McCarty: [01:07:18] The fourth domain is kind of broad, and it’s called psychosocial and psychodynamic. This is where you have to consider the patient’s larger mental health situation, their safety at home. I once had a patient who was referred for insomnia because she was being beaten up at home.
That’s why she couldn’t sleep was because she didn’t feel safe. Right. That’s not a job for Ambien anymore. Right. So doing a measured consideration of mental health issues and safety and at physical the physical experience of sleep, too. Is it a place where they’re comfortable, that kind of thing?
Dr Dave McCarty: [01:08:00] I put at the very end because I was training fellows who were always looking for the obvious, what I call primary sleep diagnosis. So that’s when you get to think about once you’ve gone through the first four fingers, then you can start to blame things on sleep apnoea and things that you’re kind of used to. Restless leg syndrome, narcolepsy, idiopathic hypersomnia.
These are kind of standard bread and butter sleep medicine diagnoses that you get labelled with. Those are common things to be labelled with. And I wanted my fellows to think about those things last. Okay. And it’s because if you skip the first four, you’re likely to get to that first. And then off you go to chart legend land. And that person doesn’t get the attention they need.
Dr Ron Ehrlich: [01:08:39] Okay. Well, how do you diagnose narcolepsy?
Dr Dave McCarty: [01:08:45] Narcolepsy? Oh, boy. Fascinating disease. So for what it is, narcolepsy is.
Dr Ron Ehrlich: [01:08:50] Just remind us of what it is so that.
Dr Dave McCarty: [01:08:53] Everybody knows what type one diabetes is, right? That’s where the pancreas has specific cells in there that make insulin, and something happens, and you get an immunologic experience that makes your body destroy those beta islet cells. The cells that make insulin all of sudden know insulin. You’re a diabetic boy in the old days that would kill you if you didn’t get insulin replacement therapy. But that’s an immunologic model of a disease process.
We think narcolepsy is the same way. There is a small set of neurones in the hypothalamus that make a neurotransmitter called hypocretin, and this neurotransmitter’s job is to do lots of things, including regulate the neurotransmitters that keep you awake and it regulates the mechanisms of REM sleep.
And REM sleep is one of the most fascinating rabbit holes in all of sleep medicine. REM sleep is where you have dreams, and REM sleep is where your body is paralysed while you’re dreaming to protect you from running around. Well, it turns out when you screw up hypocretinl and you make it disappear. It becomes very difficult to maintain states. So being awake and maintaining wakefulness becomes very difficult. People just nod off.
They can’t deal with mounting sleep pressure, so they just fall asleep out of nowhere. The elements of REM kind of come springing out of the box out of nowhere. So the paralysis that goes along with REM can sometimes intrude on wake because of strong emotion. Which is weird, right? That sleep paralysis that’s supposed to happen only when you’re dreaming can happen because you’re frightened or because you laugh.
And how about that for weird explaining to friends why you fell down the stairs? Because they told you a joke. So not being able to stay asleep at night because it’s a problem of maintaining states. That’s why my patient came to the sleep doctor complaining of insomnia when her final diagnosis was narcolepsy.
She had a disrupted, nocturnal experience. She felt tired a lot during the daytime was noticing she was falling asleep. The way she interpreted that narrative was, I don’t sleep well at night in it. Weird.
Dr Ron Ehrlich: [01:10:55] Mm-hmm. Wow. And finally, we come to the Pleasant Dreams beach, which is screaming everywhere everyone wants to be.
Dr Dave McCarty: [01:11:04] Yeah. Happy Z’s sheep counting ranch and pillows and pleasant dreams beach. I mean, this is where we all want to go. And I put it as a physical location on the island because that’s our destination. But not everybody gets there. And I didn’t want people who didn’t get there right off, right out of the gate. I didn’t want them to feel like they were failures or feel like there was something wrong with them, or feel like I don’t know that somehow this wasn’t for them or someone was trying to rip them up.
I wanted people to understand that even if you’re not there, there’s a process. And you know, I’ll tell you right now, if you’re not at Pleasant Dreams Beach, it’s a good time to go to Five Finger Approach Mountain and take a look around because it can usually help you figure out some things that you can do to get you there.
Dr Ron Ehrlich: [01:11:44] Wow. I’ve just this has been fantastic. It’s been like I feel like I’ve had a fellowship in sleep medicine. But I wanted to ask you, just finally taking a step back from your role as a physician, because we are all individuals on a health journey ourselves in this modern world. What do you think the biggest challenge is for an individual on that journey?
The Biggest Health Challenge
Dr Dave McCarty: [01:12:07] I can’t speak for anybody but myself. The biggest challenge for me in navigating this journey was trying to find a way to help people through a system that was fragmented. So that was very challenging for me. And as a result, you know, it’s difficult to deal with some of the emotions that come along with that.
When I’m spending a lot of time with my patients, I’m seeing proportionately fewer people, and I’m making less money. And yet, you know, these people are coming to me with problems diagnosed elsewhere that weren’t handled.
So, you know, that’s no one’s fault is what I finally come to. But I had to work through a lot of kind of feelings of anger and resentment about how the system treats people to come to this place where I realised that this happened kind of organically. No one kind of went to the table and said, I’m going to create a system that mistreats people and makes them feel railroaded. But nevertheless, it’s there, and that suffering is very real.
Dr Dave McCarty: [01:13:07] So, I’ll tell you, the challenge that I had in my clinical practise was dealing with that suffering on a daily basis and feeling powerless to do anything about it. So this explains why I made the transition that I did. I felt like all these lessons were vital. I could see with my own eyes when people knew this information and internalised it, and had agency. Their lives were different.
Their management of the disease was different because they were in the game, and they felt comfortable with it. This book captures the essence of what it was like to be my patient, but I don’t have to be in the room anymore. And it overcomes the problem of that information density with the headspace that we talked about at the very beginning of the discussion.
Dr Ron Ehrlich: [01:13:46] Well, Dave, thank you so much for joining us today and sharing your wisdom and knowledge with us. And I’m really looking forward to the book, which I’m sure is coming out soon. We’ll have links to your website, and people can certainly will find it there, I’m sure. So thank you so much for joining us today.
Dr Dave McCarty: [01:14:04] It has been my pleasure. Thank you so much.
Dr Ron Ehrlich: [01:14:08] Well, from the moment I was first introduced to Dave, and I visited his website and actually, he visited mine, we realised there was a great connection there, and it wasn’t a disappointment when I met him. I just love his passion. I love his patient-centred approach. I love the fact that he sets aside time to talk to his patients.
And as I’ve said many times, if you listen to your patients, they’ll often not only tell you what’s wrong with them, but sometimes they’ll tell you how to fix it. Sleep medicine is a little bit more complicated than that, but Dave’s approach of literally taking you on a journey and that journey, which we covered in the podcast in which he covers in his book Empowered Sleep Apnoea, is a truly unique book.
I would strongly recommend that you visit his site to get a clue as to what he is about and check out the book, which has just recently been reviewed. I hope this finds you well. Until next time. This is Dr Ron Ehrlich. Be well.
This podcast provides general information and discussion about medicine, health, and related subjects. The content is not intended and should not be construed as medical advice or as a substitute for care by a qualified medical practitioner. If you or any other person has a medical concern, he or she should consult with an appropriately qualified medical practitioner. Guests who speak in this podcast express their own opinions, experiences, and conclusions.