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Episode 119 - Dr. Sahil Chopra - 'Empower Sleep' - Changing Sleep Medicine for Patients

1:06

Hey there, it's Emma Cooksey here, and I'm your host.

1:09

So last week I was telling you guys that I was going to the Carolina Sleep Society conference.

And so I just got back from that at the weekend and it was really great.

I loved it so much and I was so grateful to be given the opportunity to speak and among like a host of really great other people.

1:33

So there was Doctor Afalabi Brown, who you might remember, talked about pediatric sleep apnea here on the podcast.

And so she was presenting and Doctor William Noah, who I've also had on the podcast, was there too.

So yeah, just really great company.

1:51

And I was really grateful to be there.

So when when I'm speaking at these professional conferences, it's never lost on me that, you know, it's really important to have a patient voice represented because I think sometimes that gets lost right when we're talking about like facts and figures and you know, compliance rates and all these things.

2:16

I think that having somebody speak to the patient experience and some of the reasons behind those numbers is really important.

So I'm always really grateful when people see the value in that and invite me to speak.

And the other thing that was so great was when I was on my flight home and I was sitting beside an ex Marine who who started kind of telling me a little bit about his story.

2:42

And he, you know, was asking me what, you know, what I've been doing in Myrtle Beach.

And I told him, you know, I just kind of said I'm a sleep apnea podcaster.

And I was speaking about patient experiences and with sleep apnea.

3:00

And he said, oh, I got a diagnosis with that about eight months ago.

And I got put on CPAP and I'm really struggling.

And I was able to gift him a copy of my workbook I just wrote for new and struggling CPAP users.

And and he was so grateful.

3:18

That just made my day.

I mean, I think it made his day, but it really made my day because I was really able to help somebody like in the world, which is great.

So I've got to give you a little bit of background about today's gas.

So today I'm talking to Doctor Sahil Chopra and of Empire Sleep.

3:36

So you might remember that I did do an interview with one of his patients called Heather who raved about how much she loved working with Doctor Chopra.

And it kind of planted the seed that would want to talk to him at some point on the podcast.

3:51

So before we sat down for our conversation and he was keen for me to just experience their platform, they have an app and they use sleep image rings to kind of monitor people's like get a bunch of data about your sleep over multiple nights.

4:12

And so, you know, he said, can I send you this ring and maybe we can talk a little bit about your sleep before we do the interview.

So there's no way to tell this story without me coming off, like, not sounding great.

4:29

But I was a little bit like, OK, that's fine, I can try out your, your platform.

But because I've been dealing with, you know, residual daytime sleepiness for so long, and I've talked to every doctor possible, I'm just a little bit like, what else can he possibly tell me that I don't already know?

4:50

So the Empire Sleep team sent me this sleep image ring, which we talked about on the podcast before.

But it's not just a sleep tracker.

It's actually a diagnostic tool that's FDA approved as a sleep study, right.

5:07

So it's essentially like giving yourself a sleep study every night, but it's just a little ring you wear on your finger.

So when Sahil looked at my data, we then like, you know, met and had had a chat all about it.

And what he was telling me really matched super well with what I was experiencing.

5:28

So he was saying your sleep apnea seems very well controlled, like in terms of the number of events I was having and my oxygenation was good and all of that.

So again, I've talked about a ton before, but the moment I'm using an oral appliance and a CPAP together and for my severe sleep apnea, that seems to be working really well.

5:53

So he said, yeah, this is working really well, but your sleep quality isn't great.

So and he kind of dug into like and I was like, I know I just have, you know, residual sleepiness from, you know, sleep apnea that we don't really know why.

6:10

And he was like, well, I mean that's that can be right that we don't necessarily solve every single thing.

But he's like, I think you should have an inlab sleep study to rule out like periodic limb movements and which can happen like as part of restless legs syndrome.

6:29

And and essentially, you know, you don't stay in deep sleep because your limbs are moving and you're not aware because you're still asleep.

So this is the bit where I don't sound great.

I'm just thinking to myself, he doesn't know what he's talking about.

6:46

I don't have, like, I wouldn't know if I had, you know, periodic limb movements or restless legs or whatever.

And and so, but I'm kind of curious as well, right.

So I said, well, I already looked into having in lab sleep study and it was going to cost me $3000 because my insurance has a really high deductible.

7:06

And so Doctor Chauffeur's just Supercam and he's like, yeah, you could actually look into calling that sleep clinic and saying that you want to pay the cash rate Or, you know, he said, like, there's probably a much lower rate if you're not using insurance.

7:22

So I was really skeptical about that.

But I called them and sure enough, they said if they didn't put it through my insurance, it would only be $850 out of pocket.

So I kind of was like, well, okay, I guess, like, that's worth doing to figure this out.

7:38

So I sign up and I go and I'll probably do another episode all about the in lab sleep study I did and all that.

But essentially, Dr. Chopra was right and the the test showed a bunch of periodic limb movement, which you know, might be part of why I'm not staying in deep sleep as long.

8:03

So I think The upshot is Doctor Chopra really cares about his patients and is trying to dig into the complexity that often is there with sleep apnea, right?

Often times it's not just a case of, you know, solving the sleep apnea part in terms of getting the events under control.

8:25

It's also like is the person actually sleeping well and feeling well rested?

And I feel like he's one of the few doctors actually taking that on, which can be a real challenge.

So a little about Doctor Shopper before our conversation.

So he started off going to medical school in India, and then he had an opportunity to do a residency in a UCLA community program in Kern County, California.

8:52

He worked as a hospitalist and associate program director for three years at Loma Linda University.

He's always loved dissecting complex problems and he went on to do a fellowship in PCC.

9:10

M at Loma Linda University and became deeply interested in sleep and took part in Harvard's program at Beth Israel Deaconess Medical Center.

He describes himself as inspired by all the sleep giants around him and he's aspiring to create a dent in the sleep Care World.

9:33

And that's why he started Empire Sleep.

So without further ado, here's my conversation with Doctor Sahil Chopra.

So thanks for joining me, Dr. Chopra.

Absolutely.

Emma, it's been a it's been a pleasure.

It's been a pleasure to connect with you.

9:49

I'm so impressed with the community that you've put together, so impressed with all the information that you're getting out there.

Now your book is out.

That's super exciting too.

I know, right?

I feel as though, like it's been honestly almost a year in the making, so to finally actually get a copy of it and be done with it feels amazing.

10:15

And all of these months I've just like had a bunch of time, you know, on my calendar that I had to work on it.

And so now it feels really good that, you know, I can take that off.

So it it's good.

I hope it'll help a lot of people.

And so this is not our first time chatting and but it is your first time with me in the closet.

10:34

And so welcome to that.

I don't think I've ever really asked you anything.

I know that you went to Harvard, but I never really asked you anything about your background.

Do you want to tell people a little bit about where you're from and how you got into this whole sleep thing in the first place?

10:51

Yeah, absolutely.

I have pretty humble beginnings.

I went to Med school in India.

Came here, did residency at UCLA in California and internal medicine, and afterwards I worked as a hospitalist.

11:07

Hospitalist is like inpatient internal medicine doctors.

I did that for about three years and it was fun, you know, but I wanted to do something a little bit more exciting and also in California.

California, yeah.

11:23

Yeah.

And.

A specialty that I had always gravitated towards was the, it's called pulmonary medicine and critical care medicine working.

Yeah, in ICU.

And I've always been kind of an adrenaline junkie in the sense of like being very hands on in in patient care, doing procedures.

11:45

I I'd love taking care of like the most complicated patients.

Because typically whoever's in the ICU is usually one of the more complicated people in the hospital.

Yeah.

And.

It it was almost like internal medicine on steroids is how like most people will describe it.

12:02

And I always liked that field.

I I I always gravitated towards it.

I liked being in the unit, I liked the Physiology, and I decided to do a Pulmonary critical Care fellowship.

Luckily I matched at Loma Linda.

Loma Linda's also in California and it was an awesome experience.

12:19

I I learned so much, was surrounded by very interesting people.

And it wasn't until then where I became interested in sleep.

Many things happened, but I think like the most impactful was our fellowship was so busy.

12:39

This is precovid, but our fellowship, we were bouncing between days and nights.

Yeah.

The work hours were long, 70 plus sometimes 80.

That was very normal and.

Around that same time we decided to have like a family.

12:57

So my family life was really busy and my work life was just was really busy as well and it was almost like burning both ends of the candle.

Yeah.

And around that same time I started seeing patients in pulmonary clinic and then you would see these patients who just have not slept well for.

13:20

So I wasn't sleeping well.

I would see these patients in pulmonary clinic who just had horrible sleep and it would take them months to get a test, months to get treatment and then they would get lost to follow up.

And I was really bothered by like like you know, sleep is so fundamental to life.

13:40

I I'm personally feeling the adverse effects of not having good sleep and would you say that your yours was mainly sleep deprivation from just like not enough sleep because you were like doing all the things?

13:57

Yeah, I know.

Absolutely.

It was purely sleep deprivation and and I knew that my problem was going to get better as soon as like fellowship ended, kids got a little bit older.

But the fact that the system was so broken that really, yeah, I was like, you know what I need to?

14:14

If I want to have a positive impact in this space, like I need to learn more.

That's sort of my, like, pitch to all my fellowship interviews.

And luckily I matched to Harvard.

They they took me and it's been like never looking back ever since.

14:31

You find your thing.

I did.

I did.

I still work in the ICU.

I work, you know, about a week, a month in the unit.

I still, I I love it.

I.

I feel like a a doctor working in the ICU because it's just, it's so it's so humbling, right?

14:48

Because you're you're dealing with life, you're you're you're dealing with death.

Yeah, that on a multiple times per week basis, you get to have these Endoflife conversations and I just find it very grounding and humbling to be able to do that frequently.

15:06

So listeners are going to remember that I talked to Heather who was one of your patients who talked very highly of you.

And and so that was while I was doing a little series on home testing and the different ways to do that.

15:22

And so the way that Heather described her experience, it was really different and totally outside of the traditional system.

So obviously you were the thing that Heather talked about a lot was that you spent a whole hour with her talking all about her sleep concerns and her taking a really full history.

15:42

And she was just astonished because she'd never spent more than, you know, like 10 minutes with the doctor in an office.

So was that one of the things that you saw that you really wanted to change was more time with patients?

The time is definitely one component of it.

16:01

But the other component of it is like how sleep care is being delivered in general.

And you know, so if we, if we take a step back and we think about sleep disorders, whether it's insomnia or sleep apnea, sleep disorders are chronic.

16:17

They're typically a chronic disorder.

Yeah.

And most chronic disorders, whether it's diabetes, hypertension, there is some kind of diagnostic tool that we're using.

To track these people over a course of time, yes.

16:35

And how we take care of them is not, I will give you a beta blocker or an ACE inhibitor, I will right.

Like we don't think like that about hypertension.

It's like, what medication can we combine to help you have the best cardiovascular or like, yeah, it's not.

16:54

They're not just looking for one treatment, they're looking for whatever combination is gonna have the best outcome for that patient.

Exactly.

And the same thing is true for diabetes.

And for some reason it's interesting in sleep.

It's like sleep apnea equals sleep apnea most of the time, and inside was a sedative or hypnotic, and there's no longitudinal tracking that's really happening.

17:17

And you really, there's no tools to compare.

Do I do better with this or do I do better with that?

Or rather, I'd argued that there for for some people who are actually going for checkups, you know, like once a year there the doctor is looking at data, but they're not looking at data from the patient, they're looking at data.

17:37

From the CPAP machine.

Right.

Yeah, 100%.

It doesn't give the full picture of what's actually happening. 100% And so, like I was always really intrigued by like how come we like we look at sleep?

Apnea for example, this way and then that just basically got our wheels turning.

17:56

Like what do we need to do to make this a more of a chronic care model like what we have for diabetes, for hypertension, How do we replicate that to sleep?

And that basically sort of led us down this path of not only getting a very comprehensive history, but really doing longitudinal sleep testing what we get from.

18:20

A CPAP device is just breathing data and usage data and leak data.

Right.

We.

Don't know how well someone is sleeping and but that's what we're trying, that that is also something that we should be trying to fix.

We should fix breathing, but we should also fix their sleep.

18:37

And the only way we can understand sleep is if we do a test, a sleep test that looks at their Physiology while they're on.

Some kind of.

Therapeutic modality like this, looking at whether their oxygen is is desaturating, is looking at their heart rate and all of these other things that we're not normally seeing.

18:59

When we're just looking at CPAP data.

Yeah.

We kind of get it when we do like in in lab titration study.

But even then, if you look at most titration reports, they'll just comment on what's the best CPAP pressure.

Not necessarily.

19:16

How well is that individual sleeping?

And I, and I think that there is this huge gap often between, you know, like people having.

I mean, there's a ton of people where actually if you look at remote patient monitoring and whatever way you want to do it, they're actually not as well treated as we think they are.

19:37

Because oftentimes you know, even like if you're only looking at CPAP data, sometimes those people are.

Still not as well treated as we think they are.

But aside from that, like I think there's this sometimes gap between well treated sleep apnea.

19:59

They don't feel well rested and their sleep, they don't feel like they're having good quality sleep.

So do you see that a lot with your patients?

All the time.

Like I'll just share some anecdotal.

First, I just want to get this off my chest RPM, you know, remote patient monitoring.

20:16

I think it has the right intentions.

It's just it's not, I don't think it's been used the right way because monitoring is not management.

It needs to be remote patient management, like remote patient monitoring, just collecting data and not doing anything about it.

20:36

It doesn't serve anybody.

You don't think people are using it to check that people are being treated properly?

Or is my understanding of it not right?

Well, I guess that's what it's supposed to be, right?

That's what it's supposed.

But whether or not that's happening or not, I I don't know.

So I think that a better term for this is remote patient management because you have some monitoring and then you intervene based off of that.

20:59

Yeah.

So that's my understanding of what remote patient monitoring is so interesting.

Yeah, I just.

We'll just leave it.

We'll leave it there.

We'll leave it there.

So I was asking you about the, the gap between, you know, well treated sleep apnea, but then also like people who are still, you know, struggling with getting good quality sleep.

21:25

And I was asking if that that was, you know, something you came across with your patients.

Yeah, I know it happens very frequently because if you do a sleep test on some kind of therapeutic modality, it becomes very obvious that this person's not sleeping well.

21:42

And but if you didn't do that sleep test, you would just assume because breathing is better, they are presumably sleeping well.

And.

But when you do the test and you see that there's like a very wide spectrum of people.

Some people do very well on certain modalities, yeah, different endotype and some people do very well that do do very that do very poorly on certain modalities.

22:03

That's a different endotype.

And once you know that then it becomes really hard to ignore the data.

It becomes really hard to ignore the symptoms that the patient has always been describing to us.

And and then it just sort of requires us to think okay, like now that I know that you're not sleeping well why are you not sleeping well?

22:29

Is it the device?

Is it, is it the treatment?

Is there something else going on?

And now it just sort of requires sort of peeling the layers of the onion of like what are things that I can do or what are, what are, what is information that I can share with this individual that can help them possibly optimize their sleep and how There's like an example of that.

22:49

And then like others where you have information that someone doesn't sleep well.

And now the question becomes, is it plms? periodic limb movements?

Is it restless legs that's driving that poor sleep quality on top of sleep apnea?

23:06

Or is they need?

There's a component of central apneas that are happening that are not detected by the device, but they're detected by a sleep test, and those need to be addressed with either a sedative, A hypnotic or a different kind of a non vented mask, some way to rebreathe carbon dioxide or even medication.

23:28

So.

It's chest, not checkers, right?

It can be really complicated.

Yeah.

No, for sure.

Yeah.

I'm not probably like having data.

I just saw a lady this morning.

She had some residual obstructive apneas on CPAP.

23:45

There was still, there's room for improvement on her sleep quality.

So we said, all right, let's try increasing the pressures and see what happens.

And it got worse.

She had more more sleep apneic events both from like the CPAP device as well as from the diagnostic test.

24:01

So that is like and but but because the patients are commute are texting with the care team, you can see okay like this intervention did not go in the right direction.

Let's do something else that needs to be happening that.

So now we know what is the driver and now we can we can intervene appropriately and hopefully two weeks from now she'll be feeling better.

24:23

So let's talk a little bit about, I got to try out your platform, so I kind of know a little bit about it.

But for people listening, can you explain a little bit about, so they have their first meeting with you, but you want to explain a little bit about the platform, like you have an app and ways that you can communicate.

24:42

And also, well this is like a million questions in one, but also we need to touch on the sleep image ring and how like you're getting the data.

That's that's you could speak for an hour on that, but have a go.

Yeah, I know they can definitely talk for a long time.

24:58

But in a nutshell, Empower Sleep is a virtual care platform that allows people to get personalized sleep care in the comfort of their home.

And we do that through this idea of continuous sleep testing.

25:18

Instead of looking at sleep as a snapshot, we look at it.

We look at sleep as, as a trend over the course of time.

So you can, yeah, test on an ongoing continuous fashion to understand these different interventions that we're recommending to you.

Are they actually helping you or not?

25:35

And instead of that testing data going back to the doctor's office, this data comes back to you as the patient.

And the doctor obviously has access to it as well.

So it it it, it allows us to drive way higher engagements.

25:53

It allows us to drive like a very high level of education because patients are understanding what's happening to them over the course of time.

And it just allows the patient to sort of unlock nuances of their sleep and sleep apnea or insomnia that they weren't able to do otherwise.

26:12

Like I would love to demo this for you, but you know patients can understand that hey would just body position, there can be a 50% reduction in apnea indices and almost doubling in the quality of sleep which is reproducible over a course of a week if done consistent and I.

26:33

Think that one of the things that you're doing, there's always been, I think, so much trial and error, like so many people are told by their doctor.

Positional therapy might help you try that.

And you know lose weight that might help you try that and I think oftentimes we're.

26:51

Left.

With very subjective kind of like, you know, do we think we're sleeping better?

We don't really know.

We're not great at judging that, whereas what you're doing is having them change a thing and then seeing what the data actually shows, which I think is pretty exciting.

27:10

Yeah, no, definitely.

It allows us to develop a what we call a sleep stack, a series of interventions that when combined appropriately for that individual, it allows them to unlock way more healthier sleep as compared to just doing things blindly.

27:29

Yeah.

And it allows us to give personalized recommendations like for you.

This specific intervention results in like this much improvement in, yeah, whatever problem we're trying to solve.

And you're open to like when we talked to Heather, she talked about this combination of the oral appliance and the CPAP together seemed to be what really helped her.

27:53

So you're open to people trying multiple interventions to to see what works, right.

Oh yeah, absolutely.

Like we're you know, like my responsibility is to help you get the right tools right, like it and like it needs to be a mix and match of different things.

29:45

And so explain to people about, So I think sometimes there's some confusion around what is like a wearable and what is a diagnostic FDA you know cleared actual sleep home sleep test.

30:02

So can you explain what the sleep image ring does?

Cuz I think sometimes people see that and they think it's a wearable, like an aura ring.

Yeah, no, absolutely.

So if we think about sleep tests in general, sleep can be measured either directly at the cortex by measuring brain waves, or it can be measured through the so this would be the central nervous system.

30:27

The other way to look at sleep would be through the lens of the autonomic nervous system most like watch pads night owl sleep image.

They look at sleep by looking at the autonomic nervous system and the sleep imaging looks something like this.

30:43

It looks like it's it's the hardware is that of a company called Via Tom which you can buy online.

But the data that gets processed, it gets processed through a company called Sleep Image which is a software as a medical device FDA approved in aiding in the diagnosis of sleep apnea.

31:03

And we use FDA approved, you know softwares and products because those are diagnostic to understand what's happening.

Just to give some give an example, the discrepancy between just this ring on its original with its original software as compared to the sleep image software, the delta that the differences are astronomical like the circle ring, it gives you like an ODI, oxygen desaturation index and there will be a lot of discrepancy.

31:40

I mean we've had patients who were using these consumer grade devices and things appeared normal.

But then even when you test with a medical grade device, even using different kinds of tests, there is way more truth to that than there is which is the consumer grade algorithm.

31:58

So it's very important to use a medical grade device if you are titrating a prescriptive intervention.

And so we use sleep image as one of our diagnostic tools and we use it in a fashion that is different from one or two nights, but rather you can keep it as long as you need to so we can see where what directly.

32:19

Over time, yeah.

Yeah, absolutely.

And so am I like so when I was using this I was struggling with the orthosomnia where.

Like, no matter what it is, whether it's an aura ring, a sleep test and a thing, I feel like as soon as somebody is actually looking at my sleep, my sleep gets horrible because I get really.

32:42

Obsessed with the fact?

That I'm, you know, like being monitored and I wake up and go, Oh my God, like I woke up.

So is that how unusual is that?

Like, are you seeing that more and more, or do most people do OK with it?

You know, most people do just fine, most people, but everyone is different.

33:05

And I just reassure them like, hey, it's just to don't get too caught up in the data.

Like that's I I want you to to have it and be able to view it.

But it's my responsibility, it's our responsibility to help help you improve them.

And I think with like some level of affirmation and reassurance and the fact that it's not like a one night sleep test.

33:28

So there's no anxiety of doing the test.

People like over a course of like a couple of days or a week, they'll be fine.

Like it, like the orthosomnia, it's not, it can happen.

But I think with a little bit of reassurance and TLC things, it sort of goes back on the on the back burner.

33:51

So it sits kind of outside of the insurance model of care, right?

Like, so how do people, are they able to get certain things covered by insurance or how does that work?

Yeah, so typically the way the program works is it's a hybrid model in the sense that the visits get covered by the insurance and the consultations, everything will get consultation treatment, all of that's covered by insurance.

34:17

But the ongoing testing and platform access, that's that's something that the patients would be responsible for.

Insurance only pays for one night testing.

But we've learned over thousands of patients that one night testing, it does not allow us to unlock like magical outcomes and one night testing if if that's something that they're interested in and that's something that that the insurance will pay for.

34:43

But it doesn't allow us as the the care team and providers to help really develop a very personalized care plan for those individuals.

So that'll be an out of pocket cost.

So do you think that that I guess I'm interested in how you see the future and how you see things changing, do you like, I mean my hope is that you know insurance coverage will change so that you know more people can be whether you're calling it remote management or remote monitored you know?

35:14

And so that there is more of this like the doctor actually seeing data from the patient and not just the CPAP.

Yeah, I think it'll happen eventually and as we get to you know economies of scale, we'll be able to drop pricing which has been the the dream and vision ever since the beginning.

35:33

But unfortunately, like right now, just given the cost of running a sleep test is expensive, right?

We we it's still so much cheaper to do it this way than to just go online and buy a three nights of sleep testing, for example.

35:50

And and so tell people are you like?

Which states are you available?

In so our program is available across about 45 states.

I think the big ones that were not licensed in yet are Illinois, Texas and maybe a couple of others, but most states if if someone is looking for a comprehensive sleep care program, we we should be able to help them out.

36:16

The other thing that I think that is very important to get across is 1 can be a poor sleeper and have a sleep disorder and 1 can be a good sleeper and also have a sleep disorder.

36:33

These two individuals are fundamentally biologically very different And it's it's extremely important for us as a society or a community as a, you know, providers and I think patients to be aware of that, that when you have someone who has poor sleep to begin with and they and you stack a sleep disorder on top of that, that person is much more challenging to take care of from a medical standpoint.

37:01

Yeah, is someone who is a good sleeper who also has sleep apnea.

Because in those good sleepers who have sleep apnea and when you fix the sleep apnea, they go back to relatively good sleep.

But when you have someone who has poor sleep to begin with and then sleep apnea is a new problem on top of that and you try to fix sleep apnea, sometimes sleep quality can go up, sometimes it can drop even more.

37:26

But that the that cohort of individuals is a little bit more challenging to take care of from any of what's the right tools for them.

But I think we we do the, we do our level best in taking care of more complicated patients rather than some of the more straightforward straightforward patients.

37:45

And it's it's very important to look at sleep that way because then it allows us to understand what are certain things that we can do.

So I I'd like to share like a little just an example of what this looks like if you're.

Right.

Go for it.

38:05

So this is the the patient interface and they basically through a mobile app, they can see their sleep data every morning, they can see their apnea, indices, Rdis.

And this is like once someone becomes a patient of ours, they know what these numbers mean, they can see their sleep quality, duration, stable sleep, so forth.

38:30

They can journal what are the different things that they're doing and.

They change like from just doing CPAP to adding an oral appliance as well.

They can mark it in here so that you can see what result that had.

Yeah, I have a patient that over the weekend had called me.

38:47

She was.

She had just started using INAP a few.

And yeah, actually this week's episode is by INAP.

OK, cool.

And so there was a big difference between how her sleep was with INAP as compared to being on CPAP.

39:06

So like, patients can really understand what's the best tool for me.

And like as I run a couple of different experiments, how do I combine things to to serve me the most.

So they get this like dashboard, there's educational material in here that we put together.

Yeah.

39:21

So they understand how different things can be influencing their sleep and they can look at like a seven day trend of what's happening to their sleep.

But what I'm really excited about is this sort of longitudinal window and this is a really cool example both visually and from a medical standpoint.

39:42

This is a person that we've been taking care of and you know they had pretty substantial apnea 8 guys in the 40s to.

So H.I is in the red on the left here.

Yeah.

Sleep quality is on the right as a as the the line graph.

39:58

Yeah.

And you can see that.

Without CPAP his H.I's are ranging between 30s to 40s and the second This person started using side sleeping inclined pillow and there's a 50% reduction in that apnea index.

40:17

That's a lot.

That's a lot saddle.

That's a lot and it's very powerful information to know.

So now need more concrete about like like like you know you when you sleep on your side in this body position you your numbers are substantially better and person wanted to use a dental appliance or something else to stack on top of this.

40:40

That might be a solution versus saying okay, you have severe sleep apnea and you need to be on a CPAP and that's and I'll see you in six months.

So having this longitudinal data becomes very insightful for people and they can see how like different things are influencing their sleep.

40:55

So like this is an example of someone we put on CPAP and you can see how CPAP data is integrated into this tube, like their pressures leak and all that stuff.

And you can see that their sleep apnea indices are a little bit better, but sleep quality is worse with CPAP than it is without CPAP, right?

41:16

Like this is he felt better, but but there's clearly a reduction in in sleep quality.

And I and I hear about that anecdotally from people all the time.

Like, I mean don't get me wrong, there's ton of people that go on CPAP think it's the best thing ever, have the best sleep ever and are happy campers.

41:37

But I don't really hang out with those people.

Like if they don't, they're not going to listen to podcasts.

If I sleep happy, they're all done.

But like, I do feel hear from a lot of people that they say, well, Cpap's keeping my age shy low, but I feel like I'm sleeping worse.

Yeah, no for sure.

41:53

And that then like and like when you visually see this information as a provider.

Yeah, it's we need to do something about this.

And so with behavior, they're getting to mark down, like if they're having alcohol or they're eating late and all of these kind of things that really kind of have a big effect on sleep, 100%, 100%.

42:13

And what we figured out for him was he was having some hylucine apnea like a central apnea.

So we we tried it.

We did a medication, we did a trial with a medication called diamox that resulted in improvement in his sleep.

42:29

So that told us okay this is going to help you and then we we added a non vented mask to his system like a non vented.

See, I had literally never heard of a non vented mask until I talked.

To you.

So can you explain to people, so what's to do with CO2?

42:45

And can you explain a little bit about what that is?

Yeah, yeah, absolutely.

And like with this non vented system now now this person has unlocked.

He's gone way down.

Yeah.

Not only are our app he's down, but his sleep quality is like.

Is up.

He's very, like, almost close to Physiology, you know, Physiology.

43:04

Yeah.

So that's that's why like longitudinal testing is so helpful and so useful in.

This guy's success story, Yeah, like many others, you know.

Was he really psyched?

I was really psyched, Yeah.

43:20

Because like, what's going on?

Like what are we doing that is like helping you so much?

And yeah, and then it's like Oh yeah, we just tried the non invented system and like just overnight.

Yeah, So what is the the non inventing mask?

Thing.

So if we think about what's, if we think about central sleep apnea or hilukin apnea, where, yeah.

43:43

Can you explain what high loop gain is for people that are listening that are not sure about that?

Yeah, so think of it as a, so we have a I'll just use this example of we have a thermostat in our home, right.

44:00

And this thermostat we set when we put it on auto, we give it a range.

So we want our temperature to be between say 68 and 75.

The the the second our home temperature.

44:15

The second the thermostat senses that the temperature is gone to 76, it will turn on the A/C.

The second it senses it's gone to 67, like below 68 it'll turn on the heater, so the the thermostat.

44:32

That's that's a great.

Analogy keep going.

So, so when you have, when you have a thermostat that's that has a wide window, there's a lot of room for fluctuation, yes, Okay.

And similarly, our breathing is controlled in a similar fashion, where breathing is regulated with both carbon dioxide and and oxygen, but carbon dioxide is much more narrowly regulated.

45:02

And whenever our carbon dioxide levels go above a certain threshold, that'll cause us to hyperventilate.

If it goes below a certain threshold, it'll tell us to stop breathing, right?

45:17

Because if I hyperventilate now, if I breathe really fast for say, 30 seconds, I will exhale off all of the carbon dioxide that I have to exhale.

This will allow me to hold my breath longer until my carbon dioxide levels rise, until they go beyond that threshold to say okay I need to start breathing again.

45:42

So loop in refers to this.

It's a it's a term that comes from like physics and engineering that is just regulation that regulates things very narrowly and loop loop our breathing is loop in is control, loop in controls our breathing.

45:59

And people who have a narrow window can very easily hyperventilate or very easily hypoventilate.

They can either breathe very quickly, very easily or they can breathe very slowly, very easily.

So people who have central sleep apnea kind of tendencies, their breathing is also dysregulated and the way to stabilize breathing then becomes heavy is to then stabilize carbon dioxide levels, keep them within that window that we want to keep them within.

46:34

So using then a non vented mask, a mask that like typical CPAP machine mask will have a whole bunch of yeah.

And if you help somebody rebreathe a little bit of carbon dioxide by having some attachments to the mask you can help stabilize breathing and non vented mask.

46:54

There's a lot of literature on this that can be used to address high loop gain central sleep apnea, and we use it frequently in our in our practice because we can see what's happening with someone's breathing and sleep across time.

The other thing that can also be done in these situations is using a medication called acetosolamide or diamox.

47:15

There's also a lot of data on this.

The most of the work on diamox and acetosolamide comes from high altitude mountain sickness.

People like anybody who goes high enough will have central sleep apnea.

This Physiology can't handle it and by giving somebody low doses of dime ox, you can also stabilize breathing and that can be very effective also.

47:42

So we will describe these different things that help or the other way to help stabilize breathing is if you increase the depth of someone's sleep.

That's why sometimes when you give, that's basically referring to increasing the arousal threshold, the threshold that wakes up Giving somebody a sedative or a hypnotic increases arousal threshold and that'll also stabilize breathing.

48:06

So there's a whole bunch of different ways and targets that one can help stabilize sleep and stabilize breathing as a result of that.

So you have ongoing data and you have this relationship with the patient.

It allows us to be very personalized with what we're doing.

48:22

And if something doesn't help, then we've done a weak trial.

If it didn't work, then let's try something else.

Yeah, but scientific in its nature.

Yeah, thank you so much for explaining that.

Cuz yeah, that's interesting.

I'm.

Never.

I need to go and like, now I'm gonna go and, like, read all those papers.

48:43

That's cool.

So yeah.

So I think anything else before we wrap it up.

I can talk to you for like all afternoon but you probably have places to be.

I know if there's anything I can do to support you Emma like I the more of us who sort of join forces in the sense and drive this drive the awareness of sleep problems the importance of sleep and there are lots of solutions available I think better off like society will be.

49:20

So if there's anything that I can do to to support you, please, you know, let us know.

I appreciate it.

Thanks so much for joining me, Dr. Chaupra.

I really appreciate it.

Thank you for having me Emma, and look forward to supporting you guys on your on your journey of supporting as many patients as you can.


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