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132 - Dr. Steven Park - "Sleep Interrupted"

Dr. Steven Park

[00:00:00] 

Emma Cooksey: So Dr. Park, thank you so much for joining me.

Dr. Steven Park: It's a pleasure.

Emma Cooksey: I'm really, really delighted because I'm a big fan. So I've already read your books and listened to your podcast and all the things, but for anybody listening who hasn't heard about your work or doesn't know what you do, can you maybe just give us a bit of a sort of background,

Dr. Steven Park: Well I'm an ENT surgeon also birth certified in sleep medicine. And I started off as a general ENT in private practice in Manhattan for about, I guess, about 13 years. And during my ENT practice years, I discovered that Most of the people who came in for general ENT problems, like sinus, ear problems, throat problems, nose problems, they all had sleep problems.

And on top of the sleep problems, they had acid reflux, and acid reflux can also lead to sinus problems, and then I found out that sleep apnea and acid reflux are related. Or as they say, ASV, sleep apnea, everything is all [00:01:00] connected. And that's what I, that's why I ended up writing my book called Sleep Interrupted, I guess about 12 or 13 years ago.

And I present my sleep breathing paradigm, how everything is all connected. And then it was just a journey for myself and my wife. Both of us have sleep problems. My wife has a long list of chronic health issues. I mean, it's much better now because of what we've done. So this is a personal journey as well as something that I found that's really helpful for my patients as well.

Emma Cooksey: Yeah. I know that you talked a little bit in the Sleep Interrupted book about your wife being pregnant and you noticing some of those issues with her. So did you want to tell us a little bit more about your own experience with sleep disorder breathing?

Dr. Steven Park: Sure. So when I was younger in school, I always fell asleep during classes, even in medical school. So luckily I

Emma Cooksey: I would have thought especially in medical school because it's so many hours.

Dr. Steven Park: right. But [00:02:00] luckily I went into a field where I had to run around all the time. I'm on my feet as a surgeon. And so luckily I went to a profession where I'm constantly

If I had a desk job, I'd be miserable, but it's funny for example, in New York City, I saw a lot of police officers and firemen who, when they're young, they're very energetic, very enthusiastic, and they're very good at what they do. But once they get very good at what they do with their jobs, they get promoted to a desk job and then everything goes downhill.

Emma Cooksey: Oh, that's super

Dr. Steven Park: Because they started to gain weight and then they started to have all the sleep breathing problems. So I see this pattern happening over and over again. Going back to my wife, I wrote in my book that after her first pregnancy, she gained about 50 pounds. And she was miserable during the pregnancy and then afterwards, she was even more miserable because she couldn't lose that weight.

She had severe postpartum depression. It was a really rough year for us. [00:03:00] Eventually, she got better, and then for her second pregnancy she didn't gain that much weight, but then after delivering, she was very dizzy, lightheaded, extremely tired, just, just a mess. And we realized, I wrote this in my book, we realized that she only got better after her first pregnancy, after losing all the weight, and around that time, I had also diagnosed her father with sleep apnea, and she looks like her father,

Emma Cooksey: Like, facially, her, her bone structure. Yeah.

Dr. Steven Park: And so everything kind of came together and that's what gave me the idea to, the inspiration to, to write my book. I got this, you can see this light bulb shining up on my head.

 And so, you know, it's funny. I had all these revelations throughout my life and my journey with my wife, but it's funny that the more you look into this, the more you see how everything's all connected.

It's not just about breathing and sleep, it's about total health, mental illnesses, psychiatric problems, hormonal imbalances, [00:04:00] all stages of life,it's been a really a blessing for me to be able to be privileged to do this information to go beyond the boundaries of Western medicine and to be able to just incorporate this, not only for my health and my family's health, but also to be able to share this information with everyone else.

Emma Cooksey: I got my diagnosis with sleep apnea 15 years ago. And so I've been to many a sleep specialist and I feel like right now the intake or your initial talk with a sleep specialistthey're not looking in your nose, they're not talking about your nose, they're not asking how you're breathing, like, they might look in your throat at your tonsils.

But can you, for people that aren't really familiar, could you explainwhat does your nose have to do with sleep apnea in the first place? And, and why is it bad that we're overlooking it so much?

Dr. Steven Park: Well let me just. Let's go over one misconception about nasal breathing and sleep apnea. So unfortunately, if you [00:05:00] address your nasal congestion, and people think that snoring comes from the nose, so they address the nose first, and a lot of people are very disappointed. And so, yes, it's important to breathe through your nose, but for other reasons I'm going to get into a little bit later what they've shown is that if you do nasal surgery, for example, which is a very aggressive form of treatment for the nose, for nasal congestion, it doesn't really cure sleep apnea.

The results are pretty disappointing. Maybe 10 percent of people with very mild sleep apnea, they do get better, but overall, in general, it doesn't help. However, for the other sleep apnea treatments to work, such as CPAP or mouth guards, you have to breathe well through your nose. And even if you don't have sleep apnea, it's really, really important to breathe through your nose.

Because your nose makes a gas called nitric oxide, and this gas, when inhaled into your lungs, it increases oxygen uptake by 10 20%. Plus, nitric oxide kills bacteria, viruses, and funguses. So if you breathe through your [00:06:00] mouth all the time, you're going to have problems in your nose, your sinuses, and your lungs too. so going back to the, the breathing issues for the CPAP treatment there's, for example, what really opened my eyes to this is that there was a study many years ago showing that people who couldn't tolerate CPAP, who also had nasal congestion, they used the CPAP maybe 30 minutes on average, but after nasal surgery, it went up to five and a half hours.

And that just opened my eyes. So that's why I'm, I'm relatively aggressive medically and surgically to offer nasal surgery. Do everything you can to improve breath through your nose but then I got, obviously I got the best results when I was able to do nasal surgery, but it's not just septum and turbinates, but we can talk about this a little bit more, but I also address the nostrils.

Now, the reason why people have deviated septums, it's not from nasal trauma, it's from facial underdevelopment. So, and I talk about this in my book, where modern humans faces are shrinking, and that's why everyone needs their wisdom teeth taken out now, and almost everyone needs [00:07:00] braces now, right, all the kids?

Now, a hundred years ago, people didn't need braces, they still had all their wisdom teeth, so something is happening to our faces that's causing it to shrink, and we could talk another hour about that.

Emma Cooksey: we could talk for several hours. Yeah, so I think that that kind of leads me on a little bit to, I hear from so many patients at different stages in this, right, who I don't really hear from people who go to their doctor, get put on CPAP, and are doing just fine. I hear from people who are trying to address like underlying root causes of this and and see sort of longer term solutions that are going to help improve their breathing at night but also their health, right?

So One of the things I hear a lot from people is about this having underdeveloped jaws and high narrow arch palates and they're interested in looking at whether [00:08:00] palate expansion, whether that's like a surgically assisted palate expansion or now I know it's super controversial, but like there's certain companies looking at removable appliances for that.

But should I do, if I'm thinking about some sort of palate expansion surgery should I do that first to see if that will gain some space in the floor of the nose, or should they do nasal surgery first?

I know it probably Entirely depends on the person, but that's a lot of the things that I get asked a lot that I'm kind of like, I must have an ENT surgeon to talk more about that.

Dr. Steven Park: well I've actually interacted with tons of patients and also providers that do the whole range of these palatal expanders. And honestly there's no easy answer, I don't think I can ever recommend doing one over the other. I would say do what you feel most comfortable doing, what's easiest, the lowest hanging fruit first, and what's most [00:09:00] accessible.

In the ideal world, you should try to do everything,

Emma Cooksey: right,

Dr. Steven Park: right, because you want to breathe through your nose, you want a wider palate and so, don't think of it as either or, think of it as

Emma Cooksey: right. I think that that kind of goes. For all of sleep apnea treatment,

 So for people who have maybe done that surgery, but still are dealing with. You know, some nasal issues where stuffiness and that kind of thing, which is maybe not a clinical thing, but it's just still annoying and means that they can't do well with CPAP, is there a particular daily routine or do you recommend breath work?

Do you recommend, you know, using saline or something to clear out nose and the sinuses?

Dr. Steven Park: Yeah, I have a lot to say about that. So, this is before you consider surgery. So, the first thing is, obviously, allergies are a major factor. A lot of people have allergies, and there's a whole list of things you can [00:10:00] do to prevent allergies. For example I'm sure you've heard about this, getting a HEPA filter for your bedroom, getting rid of rugs or carpeting addressing the pet issue, if you're

Emma Cooksey: I know. How do you address the pet issue? That's a nightmare.

Dr. Steven Park: Well, that's why we ended up getting a hyperallergenic dog from the

Emma Cooksey: Yeah

Dr. Steven Park: but, the problem is that We have all these options that people hear about and you implement, but it works to various degrees.So, yes, you have to go down the list, go down the checklist, and do whatever you can, and that will help a certain number of people, but not everybody.

So then, you can also try nasal saline irrigation, but Obviously, if you add on all these things, it just takes up more time, it's aggravating, you're not going to be able to do it all the time. So, now, one thing that has helped a lot of my patients, and this is the most important tip I give to anyone I see, even my friends and family, is don't eat within three to four hours of bedtime.

And there's multiple reasons why that works. Number [00:11:00] one, Even if you have sleep apnea, for example, when you stop breathing just once or twice at night, it comes up, the reflux, the juices in your stomach come up into your throat because it forced to get sucked up into your throat. So that causes inflammation in your throat.

And what they've shown is that the juices that come up can then go into your nose, sinuses, ears, and your lungs, causing minor inflammation.

Emma Cooksey: Hmm.

Dr. Steven Park: So, it doesn't happen all the time, but people say that when they stop eating late, not only do they, I'm sorry, yeah, if they stop eating late, not only do they sleep better, but the nasal congestion gets a little better too.

Emma Cooksey: Okay. That's a really

Dr. Steven Park: Yeah. Now, the other thing is that, if you have any kind of nasal congestion, let's say you use BreatheVitrips or nasal saline, so you can breathe below your nose. But what happens is a lot of people, what they do is they open their mouth at night. So now we're going to get into the topic of mouth taping.

I'm sure you've heard of that.

Emma Cooksey: let's do it.

Dr. Steven Park: So I

Emma Cooksey: I think a lot of people think super [00:12:00] controversial, but like I don't really think it's that controversial. So let's have your take on it.

Dr. Steven Park: you know, the medical, the general medical profession, especially ENTs are against it. But they have no basis on which they give their opinions because millions, I'm sure millions of people are using mouth taping for benefit, and as far as I know, there have been no complications as a result. Because worst case scenario, you stop breathing, you take it off, and you wake up. if you have an apnea, you stop breathing, and you wake up anyway, so it's the same thing, right? But in theory, by taping your lips If you do this, you're apneas, and the reason is that when you open your mouth, the tongue gets pushed back, so you stop breathing more often, and when I was doing sleep endoscopy, where we take a look at the airway when you're sleeping, it's pretty dramatic when you open the mouth even a little bit, the tongue goes back and obstructs your breathing That's why it's so important to keep your mouth closed, but if you don't, if you can't breathe through your nose, then you can't keep your mouth closed, right?

And one little caveat about the taping [00:13:00] is that most of the stuff that comes out is to tape your lips together. And I think there's a couple of commercial brands out there but if you just tape your lips together You can still open your jaws,

Emma Cooksey: right.

Dr. Steven Park: that's what caused the tongue to fall back. So what I do personally is just to take that one inch white medical tape from the drugstore, just go vertically down the middle, and go under the chin to give it a little bit more support.

Emma Cooksey: So your jaw isn't dropping down and your lips aren't

Dr. Steven Park: right, and you can breathe, you can breathe at the corners of your mouth if you have to. Now in the other, the older way of doing this is to use a chin strap,

Emma Cooksey: Mm hmm.

Dr. Steven Park: but that doesn't work as well because usually the chin straps are elastic. In the old days, I used to recommend wearing a bandana.

Emma Cooksey: Wow. Yeah, I think a little bit of mouth tape does sound more appealing. Some of the mouthtape thing where it gets super controversial is people talking about symptoms of what sound like sleep [00:14:00] apnea and saying just tape your mouth, whereas to me, like, go and get that That's it.

tested for the doctors, but then when people have CPAP as well, you really want to keep your mouth closed, like especially if you have a nasal pillows mask or a

Dr. Steven Park: Mm hmm. Mm hmm.

Emma Cooksey: like that really affects whether the pressure is actually keeping your airway open or whether it's just going straight out your mouth,

Dr. Steven Park: And also, that's why the chin straps can help people with CPAP, because it keeps the jaw closed.

Emma Cooksey: Another thing I kind of wanted to get into was just this whole idea of sleep apnea diagnosis. I hear from so many people who will go and have a sleep study and the doctor says your AHI was too low for a diagnosis of sleep apnea, too low for treatment with CPAP, and essentially like nothing to see here, even though the person has significant symptoms in their life and also events like they're [00:15:00] having a bunch of events, but they're not meeting the criteria for sleep apnea.

 I want to know like where you, where you would like to see this whole idea of, of diagnosing sleep apnea going, should we be looking much more at the spectrum of sleep disorder breathing and preventing some of this or do we want to be looking at, I don't know, hypoxic burden and RDI and different metrics?

Well, this is the area that I have the most amount of interest in, and that's what essentially my book is about. Yes, I talk about sleep apnea, but what I talk about more is something called Upper Airway Resistance Syndrome. And I found out about this condition from Dr. Guilleminault. Dr. Christian Guilleminault, he's one of the founding fathers of sleep medicine at Stanford.

Dr. Steven Park: He passed away a couple years ago. But he just opened my eyes to the situation where so he published a study in 1993, I think. Young men and women, thin, healthy [00:16:00] looking,

Emma Cooksey: yes,

Dr. Steven Park: chronically tired, couldn't sleep, but they didn't have sleep apnea on a sleep test. Now, let me just go back a little bit with the definition of sleep apnea.

Apnea means you stop breathing for 10 seconds. or longer, completely. Hypopneas are partial obstructive breathing and there's different definitions, 30%, 40 percent with oxygen level dropping but basically it has to be for 10 seconds or longer as well. So the apneas plus hypopneas per hour is your apnea hypopnea index.

Now, officially to have a diagnosis of mild sleep apnea, you need 5 or more. To say you have sleep apnea, but let's say that someone like me or a younger person stops breathing 25 to 30 times an hour for 9 seconds each, then your score is gonna be zero. Now you're not gonna have lack of oxygen, but you have, you stop breathing 25 times an hour.

That's gonna cause, it's gonna wreak havoc on your sleep quality and your quality of life. So [00:17:00] these people don't have the classic sleep apnea symptoms, for example, they don't fall asleep during the day, they don't have heart disease, diabetes, they're not overweight, but these people tend to have just chronic fatigue headaches sinus problems, migraines, digestive issues, anxiety, depression, cold hands, cold feet, low blood pressure.

This is what my wife had

Emma Cooksey: hmm, mm hmm,

Dr. Steven Park: after her second

Emma Cooksey: yeah

Dr. Steven Park: and I have some of this too.

Emma Cooksey: mm hmm,

Dr. Steven Park: And so, this is a major problem. I think it's bigger than sleep apnea, honestly. And sleep apnea is pretty big in this country.

Emma Cooksey: yeah

Dr. Steven Park: unfortunately, like you alluded to, the system is set up to kind of, I don't know if they're intentionally ignoring it, but honestly, even if they listen to our concerns and lower the threshold to give people more diagnosis of upper airway resistance syndrome, or even just lower the threshold for sleep apnea.

The system can't handle it, because the sleep study is what takes, what, weeks or months to get sometimes, depending on where you live.[00:18:00] the system can't handle the burden of all the additional patients coming in. But even then, the quality of the treatment, for example, CPAP, as you alluded to, is not that good.

Because you don't get to spend too much time with the doctor or the technician. The follow up is, I mean, like you said, there are some positive situations, but for the most part, as a system, it's really, really bad. And basically, the system is designed to fail. Now fortunately, because of the internet, all these great websites like what you're doing, also all these CPAP support groups, it's much better, it's much easier.

But people who depend on the traditional healthcare system, they're not gonna, most of the time they're not gonna work. Mm

Emma Cooksey: Yeah, it's pretty depressing. I guess what I'm trying to figure out is how we bridge that gap, and also just the fact that there's so many people undiagnosed with sleep apnea,

Dr. Steven Park: hmm. Mm hmm.

Emma Cooksey: just a ton of people. [00:19:00] So, do you think, like, involving dentists is part of that? Like, having them involved with screening, and

Dr. Steven Park: You know, dentists are definitely a couple of steps ahead of the medical doctors as a profession. even since I wrote the book, they've come a long way. In terms of awareness, many more dentists are kind of jumping on the bandwagon to address these sleep breathing problems.

However, even with a dentist, just like the CPAP situation, it's a device, you need good follow up, and not every dentist is very good at what they do. So ultimately, it's not so much the device itself, but the quality of the practitioner. and experience

Emma Cooksey: sometimes the experience of the practitioner can really make all the difference, I think.

Dr. Steven Park: I can actually argue that an experienced dentist can take a very low tech device and do a better job than an inexperienced dentist using a very high tech device, or the latest and greatest device.

Emma Cooksey: Yeah, I agree with you. do you think that we need to [00:20:00] be looking more at kids with starting right at mouth breathing and trying to do some myofunctional therapy earlier, or how do you see that going?

Dr. Steven Park: Well, let's, let's back up even Beyond delivery, I would say you start the whole process when you're pregnantthey've shown that how well the pregnancy goes determines how well the baby comes out with a fully developed face. So, prematurity is actually a risk factor for sleep apnea, okay? But they've actually shown that even one or two weeks term makes a difference in terms of overall health.

Emma Cooksey: Yeah.

Dr. Steven Park: you want to have, you want to try to have as healthy a pregnancy as possible. And so the basic concepts are obviously a healthy diet, minimize stress, which in this day and age is hard to do.

Emma Cooksey: But I think the diet and the sleep, and a lot of women, for example, I think my wife during her first [00:21:00] pregnancy, she probably had sleep apnea. During the during the pregnancy and this is not picked up by the OBGYNsso I speak as somebody who had one pregnancy with undiagnosed sleep apnea And all the symptoms and I'd be going to the doctor for 10 years telling them, you know, and then my second pregnancy Still wasn't perfect, but I had a diagnosis and I was on CPAP. So I think that it does make a big difference just You know, knowing ahead of a pregnancy, like, what you're dealing with.

Dr. Steven Park: but also I was being referred a lot of pregnant women in my previous hospital And the system is somewhat clunky It takes a lot long time to get the appointment and by the time you treat them Sometimes by the time the CPAP arrives they've delivered already or they've had major complications and they're in the hospital

Emma Cooksey: to even get the sleep tests and things you really have to advocate for yourself, right? And so women who have kind of gone and proactively [00:22:00] said, I'm having these symptoms, this is how I'm feeling.

one woman particularly I spoke to recently, they essentially told her what you just said, like, it would take too long, you know, we're not going to have you do a sleep study when you're so close to the end of your pregnancy anyway, we'll just wait till after the delivery, you know, which when you think about that what we're talking about is lack of oxygen to your brain and you're growing a baby. It's really urgent.

Dr. Steven Park: well taking that to the next level for example a very common complication that we saw in the hospital setting is something called preeclampsia Especially in the Bronx where I used to work, it was very common, especially with obesity. And I was having a discussion with the OBGYNs sleep apnea you can treat, I basically allude to the fact that preeclampsia, there's an association with sleep apnea, and there's lots of studies from, I think, Australia, about 20, 30 years ago, but it [00:23:00] never got put into practice.

And they've shown that these preeclampsic women on CPAP, their fetal heart rate increased. Now they didn't do all the kinds of outcomes, but all the measures show that it did improve the quality of the pregnancy. And so when I mentioned that to them, they say, well, preeclampsia is an endothelial dysfunction issue, which is a very technical term, meaning that the some problem with the vessels right well and what they don't realize is that sleep apnea causes endothelial dysfunction and when you treat people with CPAP the endothelial dysfunction goes away

Emma Cooksey: So is there no, so we're not currently screening those women for sleep apnea?

Dr. Steven Park: never I think it should be universal

Emma Cooksey: Yeah, I do too.

Dr. Steven Park: but the other problem is that most a lot of pregnant women even though they may have symptoms of sleep apnea they're not going to have official sleep apnea like what you're talking about. They're going to have upper airway resistance syndrome [00:24:00] and they have what's called flow limitation where the breath gets kind of diminished so it causes micro arousals in your brain and so it's very fragmented sleep especially in the third trimester.

Emma Cooksey: Do you think that the more that we're seeing improvements with home testing, we might get to a point where we can pick up some of these lower, smaller flow limitations you're talking about? Do you think, or how far away from

Dr. Steven Park: well I think that's a that's a mixed bag. I think it's great that we have more home testing available and that will pick up more sleep apnea, the traditional sleep apnea, but they use the same scoring criteria as in lab sleep studies for sleep apnea.

Emma Cooksey: Yes.

Dr. Steven Park: And also this home test in general, not all, but in general, they're not as sensitive to the lower mild sleep apnea.

Emma Cooksey: feel like that just purely anecdotally from all the people I talk to, I feel like sort of older overweight men with very high AHIs do great with home tests. And they say, yeah, you've definitely got sleep [00:25:00] apnea. The thing I do worry about is sometimes there's people with significant symptoms who maybe don't have have a sleep apnea.

Dr. Steven Park: As high of an a HI and the home test is, you know, negative for sleep apnea. And so a lot of those people, rather than asking more questions about their symptoms and doing more testing, they're kind of just told you don't have sleep apnea Actually, in these situations, what I've suggested to some women is just use a mouth guard.

Emma Cooksey: Yes, I'm thinking particularly about one of my friends that lives close to me here. She's been through, doing the sleep apnea testing. They told her no, even though she had a lot of arisals, they were like, you don't have enough.

Dr. Steven Park: Actual apneas or hypopneas to, to get a diagnosis and a CPAP. And so that was what she did. She went to a dentist she already knew and got a mandibular advancement device and [00:26:00] now is sleeping better. So I think it is one of these things where, I always think we need a million more diagnostic tests, but then in some ways with sleep apnea, you just need a treatment option that works for you, right? I think a lot of the conservative steps, for example, not eating late, nasal breathing optimization sleep hygiene issues, all that's very important. That will address 10 15%, but as you go up the ladder, you need some kind of more definite intervention, right?

Emma Cooksey: people in a sort of more severe state where Doing CPAP or whatever, they can still benefit from the losing weight from all these things that you're talking about to hopefully make things better, right?

Dr. Steven Park: Oh, absolutely. You have to sleep better to lose weight if you are overweight. Right. Yeah. Now, the one little caveat, which is a little bit disturbing, is that, and they've done pretty good studies on this and did huge meta analyses [00:27:00] and systematic reviews, that about maybe 5 10 percent of people on CPAP gain weight.

Emma Cooksey: yes, yeah, I hear that from people who are saying, wait, my doctor said perhaps I'll lose weight because I'll be sleeping better. Do we know why that is?

Dr. Steven Park: I've read through all these papers and there's no real satisfying explanation. My feeling is that just like that any other intervention even though the CPAP may be treating the severe apneas is causing more micro arousals because something is on your face. Yeah, mm

Emma Cooksey: Also just from people who still have some residual daytime sleepiness, right? Their, their, their doctor's scratching their head because they're looking at their perfect, compliance and that their AHI looks really low, but that's not the same as sleep quality.

Dr. Steven Park: right,

Emma Cooksey: right and that you're absolutely right. Unfortunately, [00:28:00] not I'm not accusing this of all sleep doctors, but as an industry in general They go by the numbers, right, and if your AHI goes from 35 to 2, you should be sleeping much better, but the chances of that happening is very low. I would say less than 20 30%,

so depressing.

Dr. Steven Park: And the reason is that, first of all, if you're not going to use it, it's not going to work, right? Actually there's a story that I have Dr. Karl Stepnowski, he's a very famous see He's a sleep medicine researcher, and he tells me that if 100 people are given CPAP machines for sleep apnea, 20 percent will reject it from the beginning.

So now you're left with 80 people, right? Of those 80, when they start using CPAP, in one year, only 40 are using it, and of the 40, only 20 are using it properly.

Emma Cooksey: Oh, that's interesting. Yeah. So they think that they're, they're using it, but then [00:29:00] they have like a really high leak rate

Dr. Steven Park: Right. Right.

Emma Cooksey: taking it off halfway through and all of that.

Dr. Steven Park: Right. Or,

Emma Cooksey: we're just not diagnosing enough people. And then we're also because of the way the treatment is, like, a lot of those people are not ending up, well treated at the end of it.

Dr. Steven Park: and you also mentioned before that you can have a perfect score on the CPAP machine. And still feel terrible.

Emma Cooksey: do you think we just need a lot more researchI don't mean to sound really cynical, but one of the things I see is that there's a lot of motivation and funding available for people Studies showing the effectiveness of CPAP and, I just haven't seen a lot of studies where they're really looking into that, like why that is.

Dr. Steven Park: I haven't seen any, you're right, there aren't too many studies looking at that. A lot of theories and conjecture about it. But my personal bias about this is that the CPAP itself, it's basically an airway pump, right? [00:30:00] It's an airway stent, it keeps everything open. But you have to assume that the pathway is open.

But one, let me just mention two interesting things that I found. When I was in practice, there's something called epiglottic laryngomalacia. So not everyone's going to have this, but maybe about five types of people will have it where,

Emma Cooksey: know anything about

Dr. Steven Park: yeah. So the epiglottis is the cartilaginous hood on top of your voice box.

Emma Cooksey: Mm hmm.

Dr. Steven Park: And this can flop in when you breathe in. And this is, this happens more often when you're a newborn, a young child will have this. And it's pretty obvious when you see it, because they go like this when they're awake when they're crying. But what I'm seeing is that I see a lot of adults with this too.

Emma Cooksey: Hmm.

Dr. Steven Park: Because traditionally the ENTs are taught that people outgrow it as they get older, but I saw severe cases of epiglottis laryngomalacia. In young adults as well, and especially in kids too. And so when you can, unfortunately the only way to treat that is surgery. People don't [00:31:00] want to go there often times, but the ones that do get treated, they get some amazing results.

Emma Cooksey: Hmm. Good to

Dr. Steven Park: And, and the only way to know this is going on is to do what's called sleep endoscopy, or drug induced sleep endoscopy. And I don't think enough doctors utilize this test. They think, they put a camera up, down your nose or throat. When you're awake, that's enough, but you have to be sleeping to see what's going on.

Emma Cooksey: So can you explain really briefly? I always assume a lot of knowledge but anybody listening who hasn't heard of a DICE procedure, can you explain a little bit about

Dr. Steven Park: Oh, sure, sure. So this is it's kind of like a colonoscopy, the same kind of sedation, propofol, or some kind of other agent. And basically they have you fall asleep in the operating suite. And we just put a camera through your nose, into your throat, like what happens in the office with an ENT.

Emma Cooksey: Yeah.

Dr. Steven Park: It takes about 5 10 minutes.

Emma Cooksey: So it kind of reproduces what your airway, like your throat is doing while you're asleep. So

Dr. Steven Park: exactly, right. And obviously it's artificial sleep, but they've shown [00:32:00] that for the most part it's a pretty good accurate measure of what's going on.

Emma Cooksey: Yeah, so how often are you doing that for people? Like if somebody comes to you with sleep apnea, would you do that as a matter of course to try and decide what to do?

Dr. Steven Park: almost routinely for everyone who goes to the operating room, I'll start with the sleep endoscopy. And the reason is that they may do well with the CPAP, but if you're in that 10, 20, 30, 40, 50 percent chance that you're not going to tolerate CPAP, I want to know what's happening, I don't want to have to take you back and do it again,

Emma Cooksey: So here's the thing. A lot of people are going to a sleep specialist. They go to their doctor. They have all of these symptoms. They get referred to a sleep specialist. They go have a sleep study. And find themselves back in the sleep specialist's office, probably starting CPAP.

how often should people go and see an ENT? Should everybody go with a diagnosis of sleep apnea just to see what's happening? Or do they need specific [00:33:00] issues? Why, why would they then go and see an ENT?

Dr. Steven Park: okay. Well, obviously a significant number of people will benefit from the CPAP. there are certain number of people that do benefit from the start, especially like you said, the severe sleep apnea patients. The people with mild to moderate sleep apnea, those are the ones that have more problems. So, for example, if your nose is

Emma Cooksey: seems counterintuitive, right? But it's absolutely, the way around it is, like, I've, I've interviewed, some people with such high HI's, and, but not really that many symptoms. They're just kind of like, I went because my wife told me to, and then I went on CPAP, and I love it, and it's great, and, you know, but I was fine before, whereas, it's the people with the very, Low HIs, but who are constantly being woken up and just feel terrible.

So it's really interesting that it's that way, right? But

Dr. Steven Park: Well, what you see is that if you look at the sleep studies, they may have only a few apneas to give 'em the mild sleep apnea, but you see lots of [00:34:00] micro arousals,

Emma Cooksey: yes.

Dr. Steven Park: and so you see a lot more sleep fragmentation as opposed to the classic sleep apnea patients.

Emma Cooksey: so we talked earlier about the importance of nasal breathing. So anyone who can't breathe well through their nose, should those people

Dr. Steven Park: yes, exactly. most sleep doctors would know to do this. If they can't read the notes, send them to an ENT. But the thing is that ENT, most ENT practices also practice sleep medicine. Or they'll treat for sleep apnea, even if they're not sleep medicine doctors.

So, depending on what pathway you end up going to, you can go to a dentist first, you can go to a sleep doctor first, or ENT.

Emma Cooksey: I think that I wanted somebody to tell me, this is a flow chart, you start here and then you go down in this order, but I think that I've realized

 people are all so different and there's such a broad variety in symptoms and what challenges people have, how well they do with different treatments, that there really isn't one. Is that your experience, just that

Dr. Steven Park: [00:35:00] absolutely, that's a really good observation. I have similar findings to that in this regard as well because it's not every individual is very different in terms of what you're going to like, what you're going to respond to, but also your relationships with your providers, your doctors, where you live, what's available, what's not available and CPAP.

probably is the most available, but more and more dentists are doing these mandibular advancement devices now.

Emma Cooksey: yeah

Dr. Steven Park: and then ENTs. So basically now, ideally, in theory, there should be a one interdisciplinary team.

Emma Cooksey: there are interdisciplinary centers, but not really truly integrated.

Dr. Steven Park: Ideally it should be under one roof. Not individual providers. In the, in the same space because there's, there's still that financial aspect. Also, unfortunately with medicine, you have that aspect

Emma Cooksey: tell everybody about the podcast that you did. Are they finished now?

Dr. Steven Park: We stopped doing that because I was doing that initially. I was doing what's called expert interviews. Interviewing [00:36:00] people like you or other people in various different fields. And then I started doing it with my wife.

Emma Cooksey: Yeah. I listened to them all.

Dr. Steven Park: yeah, yeah.

Emma Cooksey: I was sad that they finished.

Dr. Steven Park: we're thinking about on and off by starting it up again, but, you know, we have busy lives now and and I have some other bigger projects.

I'm especially writing another follow up book now. And so like different projects, but one thing I'm focusing on now is not just to do more sleep apnea or UARS is I've kind of I've expanded my horizons to include not just sleep apnea and breathing, and obviously that's important, but to include nutrition habits circadian rhythms stress reduction exercise, the whole, the whole shebang, just, the problem is that just treating the sleep apnea, that's just, It's not satisfying,

Emma Cooksey: I know. And you just can't get away from, cause trust me, I've been trying, but you just can't get away from the fact [00:37:00] that nutrition is a huge part of this.

Is there anything else you can share?

Dr. Steven Park: well let me just kind of give you the three to five simple tips to get started with. So number one, no eating, no eating close bad time. Number two, optimize nasal breathing, we talked about that, but you can start with using breathe right strips right away, right, and that'll help and using nasal saline, whatever you can do to open up your nose.

If you have to use allergy medicines for a short period, that's fine too. Then number three no electronic screens before bedtime. That's a big one for everyone these days, even for myself. And the reason is, two reasons. Number one, and people may know this already, that blue light in these new screens lowers your melatonin sleep hormone. And so, now melatonin starts to go up around two hours before your natural sleep time. 10, it's gonna start to go up at eight, but that's when people start to watch TV or use your screens, right? And so delays your [00:38:00] sleep onset time. But one thing that people may not know about is that melatonin, the hormone also lowers stomach acid production, insulin

Emma Cooksey: not know

Dr. Steven Park: Yeah. And also tightens the lower esophageal sphincter.

Emma Cooksey: if people are dealing with this problem that you were talking about of the stomach acid getting sucked up, then that might help.

Dr. Steven Park: Right, so it makes, if you eat, if you eat late and use screens, acid reflux is going to be much worse. And then the other, on the flip side, in the morning, first thing in the morning, you want to shine as much sunlight into your eyes as possible, so reset your circadian rhythm. And also, now this is one other area that's really, really big, which people talk about sometimes, but they don't give enough importance, is how sunlight gives you vitamin D.

And most people in America are very vitamin D deficient. It's shockingly low on average. Especially with COVID, it got much worse.

Emma Cooksey: Mm hmm.

Dr. Steven Park: So now, because of the scare about skin [00:39:00] cancer, you know, people are overly cautious about skin cancer, but what I think, the studies I've read is that, yes, skin cancer may have come down a little bit, But all the other cancers went up because you're not getting vitamin D in sunlight.

Emma Cooksey: So a first thing in the morning walk without being super covered

Dr. Steven Park: Right. Yeah,

Emma Cooksey: your skin exposed, sounds like it would do the bright light and the vitamin D.

Dr. Steven Park: you have to be practical. If it's cold, you have to wear something. But the most important thing is to stick that sunlight into your eyes to reset your circadian clock. And then as much skin exposure as possible, and depending on how quickly you burn. Early morning is not that bad, but even during the day, it's important to get sunlight, because around the middle of the day, that's when you get the vitamin D conversion the most.

But also early morning and late afternoon, that's when you also get near infrared radiation. The red lights, near infrared. Now, I don't know if you've heard about this, this is

Emma Cooksey: I, well, so I [00:40:00] have, but just because of my friend Mollie Eastman, who's a, an influencer on Instagram, and she's always sending me all sorts of things.

Dr. Steven Park: It's pretty interesting. Yeah.

it. I use the red light box every day,

Emma Cooksey: Okay.

What time are you doing the red light?

Dr. Steven Park: well, I do it whenever because I don't, I can't depend on the sun all the time. Sunlight is the best way of getting near and far, early morning and late afternoon. But I do it on a regular basis, but also after I injure myself during sports or I have a sore knee or muscle ache, I use a red light therapy.

And it's, the theory behind it, the reason why it works is that the near infrared light activates the mitochondria to produce melatonin in all of your body, acts as an anti inflammatory antioxidant. Yeah,

Emma Cooksey: takes a while, if you use it on a regular basis, it takes a while to see the results, but I'm a true [00:41:00] believer.

So how long do we have to wait for your new book?

Dr. Steven Park: I'm doing the book proposal right now for the publisher, so maybe,

Emma Cooksey: too long. I

Dr. Steven Park: I'm hoping to launch it in the fall.

Okay, is there anything else that we didn't cover that you want to share with the audience? Well, I think this is a topic that you keep bringing up on your podcast and we mentioned a couple of times. Yes, you have to work with the doctors, but ultimately you have to take total responsibility for your own health, right?

Emma Cooksey: Well, thank you so much for your time. I really appreciate

Dr. Steven Park: my pleasure. I had fun.

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