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Episode 124 - Dr. Shane Pahlavan - An ENT Surgeon on Hypoglossal Nerve Stimulator Surgery for OSA Patients

Updated: Jan 10

Emma Cooksey: [00:00:00] So thank you so much for joining me.

Shane Pahlavan: Oh, well, thank you, Emma, and I'm happy to be here. Thanks for the opportunity, and I've, I've actually been a fan of your podcast, and I've listened to some of the patient stories, so, so thank you for what you do for the sleep apnea patients. So, I feel like it's really beneficial and educational, and it's good for the, it's good for also the providers to see the, the, patient side of things to be able to empathize

Emma Cooksey: I think that's something that I didn't really realize when I started out doing my podcast. I really did it more for patients, but now that I'm three years in, there's a lot of dentists and doctors that listen, which I really like. So why don't you start by giving us a little bit of background just about you and you know, like what you do, maybe like a little bit about your medical journey and how you ended up here.

Shane Pahlavan: Sure, yeah, thank you. So I'm born and raised in Houston Texas and I went to Baylor University in Waco for my undergraduate education and I was pre med there. [00:01:00] I was able to attend University of Texas Medical Branch in Galveston for my medical school and then moved back to Houston, back to my hometown for my ENT surgical training.

So I trained at Baylor College of Medicine. and the Texas Medical Assist Center, which was five busiest years of my life, but provided great training because they have some of the most, you know, world renowned hospitals there, including MD Anderson, Ben Taub, Trauma, you know, Texas Children's Hospital the, the biggest VA hospital in the nation is there.

So we're able to train at these, these facilities, which is, you know, given me quite a foundation for my experience from a surgical standpoint and just for patient care. And So what

Emma Cooksey: drew, what drew you initially to the ENT

Shane Pahlavan: space? I, I grew up playing sports my whole life, so I kind of assumed I would do orthopedics.

And so I did a rotation during medical school thinking, okay, this is, this is going to be it. And like most things in [00:02:00] life, it wasn't what I thought it was going to be when I got in there. And so I really didn't like it as much. And so, I, I knew I wanted to do something surgical, and so I rotated through all the different surgical fields, urology, ophthalmology, and then finally settled on ENT because two main things.

One is, I can treat patients from all ages. I tell people I treat people from newborn to 100. Which keeps it interesting for me. I, I love treating all ages. You know, the kids are great. I love even the older patients. You know, the stories I get from them are wonderful too. And then the other fact is I like ENT is the variety of the different procedures and surgeries that we do.

On any given day I can do a sleep apnea surgery, a sinus surgery, a tonsillectomy. And I also do vagal nerve implants for epilepsy patients and it's and ear tubes for a kid you know, a nine month old that has recurrent ear infections. So even within any given day, it keeps it interesting for me.

There's a lot of variety. The anatomy is very intricate, which I enjoy that aspect of it. It's just it's just cool [00:03:00] anatomy. I feel like in our gross anatomy

Emma Cooksey: class.

I can't relate . Yeah. I'm so glad people let you do your job, but I'm just like, oh my goodness. Nothing

Shane Pahlavan: about that. Yeah. They're like, why ENT? Why boogers, mucus, and wax, right. . I say, well, I like to stay above the collarbone. That's what I tell people.

Emma Cooksey: so before this Inspire thing came about, because it's still relatively new.

Yes. Were you? Were you treating some sleep apnea patients with other procedures, like were you working on people's noses and doing tonsillectomies and that kind of thing?

Shane Pahlavan: For sure. So that, you know, sleep apnea surgery has been on a continuum over, over years, right? So when I was in residency, the theory at that point was to do multi level surgery or we called it bi level surgery, right?

So you need to do something to open up the nose and you need to do something to open up the throat. Whether, and that combination could be a multitude of things, right? So it could be a septoplasty and a turbinate reduction in the nose and then a UPPP in the back of the throat or a, or a, [00:04:00] hyoid suspension or, you know, whatever the case may be.

Every patient was different. So we actually had to, we would take them in residency and do a sleep endoscopy, a sleep endoscopy before Inspire was even on the radar We would take them and say, all right, where, where are the levels we need to address? And even with that thought process, and we really thought we were doing our best at the time with the technology that we had.

I mean, honestly, and I'll tell patients this all the time, I'm very open and honest about it, is that half those patients we did surgery on and put them through misery for two plus weeks. Half of them, it was a failure. I mean, we didn't cure, in my estimation, if we're not curing them of their sleep apnea, that, in my estimation, is not a successful surgery.

Emma Cooksey: Oh my gosh. We can be best friends. So that'll be a whole thing we'll talk about at some point. from a patient's point of view, surgical success would be, I have an AHI under 5, no further treatment necessary, I don't have to go home and use my [00:05:00] CPAP, right?

And I think that talking to so many surgeons, a lot of people are still using, like the Sher criteria, where they're saying, well, we had a reduction in AHI. But to me, it's just much more simple to put it in terms that patients understand, right?

Shane Pahlavan: So are

Emma Cooksey: you looking for, you know, like having to do further things or are you like, helped the problem?

Shane Pahlavan: Yeah. And years ago, if we got a 50 percent reduction in AHI during a multilevel surgery, we were, we were patting each other on the back, like, cause that was amazing. Great job. But the patients may have gone from an AHI of, you know, 40 to 15, but. They still need a CPAP. Maybe we lowered their settings on their CPAP, but they're still using a CPAP.

That's my point. And so I was like, we have to, there has to be something better, right? We have to be better.


Emma Cooksey: when did you first, hear about Inspire? tell me about that whole thing. And, like, deciding to kind of get involved [00:06:00] with that.

Shane Pahlavan: So, I learned about Inspire about eight years ago and the rep came and he knew I'd been doing a lot of vagal nerve stimulators, which is a very similar procedure on the other side for epilepsy or seizure patients, seizure disorder patients, and so they thought it would be a natural fit that I could Thank you.

Implant their device. And so I went and I was one of the first surgeons to get trained and doing it. We actually, at that time, Inspire was relatively new to the market. They only had a teaching or educational facility in Atlanta. So my partner and I went out there and got trained on it, did the cadaver dissection, and then he and I started doing them here and we're in the North Dallas area.

And so we were the first to start doing them in the area and certainly the first in the private practice world. They had started doing a few at UT Southwestern, which is a university. Here in Dallas, but from a private practice standpoint, that was kind of uncharted waters which was different because at UT Southwestern, everything's integrated.

You have the sleep medicine doctor here, the ENT here, [00:07:00] you know, the sleep lab is all together. So we've, we can

Emma Cooksey: talk, which is honestly what you want, right? For everybody to collaborate together.

Shane Pahlavan: So we've, done that here in the private practice community setting world where we have a sleep study we work with, we have a specific sleep medicine doctor that we work with quite a bit and then us as the surgeons and we started doing them and

I'll be honest, the, the research trial, the STAR trial that came out from Inspire, I read it and I was a little bit dubious on whether or not I believed some of those numbers because they were dramatic. They were dramatic. And I thought, you know, let's see, you know, sometimes the research doesn't correlate to real world.

Right. And so their research showed that these, these patients were getting drops of AHI's of, 55 to 3. And I talked to inspire, I said, my partner and I are going to do 10 of them and let's graph it and let's see if it matches our first 10. Let's see if it matches.

The STAR trial and then we'll reassess if I'm going to keep doing this or not. And [00:08:00] sure enough, our first 10, almost to a T, matched the STAR trial. And so I said, all right, let's go. And then we just kind of opened it up. And now our practice, you know, between myself and all my partners, we've implanted over 250 Inspire

Emma Cooksey: patients.

Yeah, so tell me about, I know that oftentimes marketing people have to make things super simple so that people like get this one message, but I think it leads to sometimes a bit of confusion among patients, like, so patients just get this ad where they're like, okay, it's. Not CPAP, so I can get rid of my CPAP.

But then they don't really know what this procedure is about. So I'm hoping we can kind of share. So the first thing is, it's not for everybody, right? So can you share a little bit about some of the criteria you're looking at for good candidates for this?

Shane Pahlavan: So, good question. So yeah, part of you know, we tout our high success rate.

[00:09:00] And part of that is we've done a lot of them, certainly, and we get, you know, just like with anything, the more you do, the better you get results with it, but it's also patient selection. You know, I you know I say, look, I'm busy enough as it is. If,I'm going to do this surgery and I'm going to make this recommendation.

I say, I'm going to give you a baseball analogy. I said, we're going for a home run here. I'm not going for singles and doubles. We're, we're going for a home run. So if we're going to do this, we're going to go for a home run. And I want to make sure that you're a perfect candidate for it before we move forward.

And that's why I have a 94 percent success rate with these as

Emma Cooksey: far as. So the success rate to just hammer it home, you're talking about people going from whatever their AHI is to begin with to under five.

Shane Pahlavan: And yeah, and no more CPAP.

Emma Cooksey: No more CPAP. No more CPAP. Okay, we can totally agree on the success rate.

That is a really high success rate. Compared to

Shane Pahlavan: what I've read about, yeah. So and in that, I feel like patient selection is key. And so, I actually draw this out for patients on their sleep study. I'll turn it [00:10:00] over on the back and say, look, your AHI is this.

AHI stands for apnea hypopnea index and I go through the definition and what the categories of normal AHI, mild, moderate, and severe sleep apnea and I say okay you're right here and I'll talk to him about what's the criteria for inspire. Number one is that the AHI has to be between 15 and 65. Okay, that's criteria number one.

So if we do that, I'll put a little check box by it. Okay, we're good there. Number two, most insurances are still requiring at least a trial of CPAP. Most for three months, different ones will take, you know, some of them are as detailed as they'll see if you actually fill the DME. Prescription to get the CPAP.

You can't just say, yeah, I tried it and it didn't work. They actually will cross check you on it. That's a good thing for patients to know too. Yeah.

Emma Cooksey: Are they looking at are they looking at the data from the CPAP?

Or they're just looking to check that you had CPAP at all?

Shane Pahlavan: Most of them are just proving that you filled the [00:11:00] prescription. Very few have heard that actually will try to download the data to see if it's actually for it. I wouldn't put it past insurance companies. Right, right. But, from what I've heard from patients, is that if they've actually filled that DME, durable medical equipment, you know prescription for the CPAP BiPAP three months later if they're still not, you know, wanting to proceed with CPAP or BiPAP, then it's, it's clear for us to, to look at Inspire.

Got it. The third is the BMI criteria. And that's been a little bit of a moving target, so I wanted to. So it's changed recently, right? Exactly. So, commercial insurances historically have, have approved BMI of less than or equal to 32 and Medicare less than or equal to 35. Okay. Earlier this year, Inspire got FDA approval to bump that up to BMI of less than or equal to 40 for all carriers.

Now um, that's great. However, insurances have not recognized that yet. So [00:12:00] that's great in theory, but in a real world setting for patients. It hasn't kicked in through insurance companies yet, and usually how this process will work is Medicare will usually adopt it first. And then the commercial ones will follow suit a little bit after.


Emma Cooksey: mean, that's certainly, I think with like the criteria for CPAP, I think that's the way that happened. Like, I think that a lot of the private medical insurance companies, you know, followed what they were doing with, with Medicare.

Shane Pahlavan: once people meet those three criteria, and if they're interested in proceeding, then I talk to them about doing the sleep endoscopy, which is essentially, we're reproducing what's happening in their own beds at their home every night.

We're doing that medically, so we come, they come in, and I, I can't, or my analogy for patients is that it's just an endoscopy, just like you would get like a GI endoscopy without the, the prep, obviously, but we just come in, the anesthesiologist gives a little bit of propofol just to get you [00:13:00] to induce a sleep like state.

I put a camera in the nose, and I actually record it. And I make sure that the anatomy is sufficient as far as the blockage is actually coming from the back of the tongue. So, you'll actually see the back of the tongue collapse, causing the obstruction. 80 percent of the time, that's the case. 80 to 90%.

However, 10 or 20 percent of the time, there's something else back there. That is resulting in the obstruction and those are the patients I do not want to put the inspire in, right? Got it.

Emma Cooksey: So the ones who are going to do best, you're seeing in your DISE procedure that the tongue is, is the thing blocking their airway, essentially.

So that when you do this procedure and it moves the tongue forward, that's going to solve the problem. Whereas if somebody who has like a sort of collapsing, wet straw. I don't know who it was that that described it like that, but you know like where there are airways actually collapsing in on itself, either because [00:14:00] it's tiny or because of like whatever's going on, that's not going to be a great candidate.

so we make sure with with the DISE procedure that the tongue is the main thing happening. Correct. And then do you explain all about what exactly happens during the procedure to them?

Shane Pahlavan: Yeah. so once we get, so we make the patient up, we submitted everything to insurance, including the DISE operative dictated operative report.

We send kind of everything to the insurance company that says, look, the patient has met all of your criteria. There you go. And then usually... It takes about two or three weeks to get approval from insurance companies these days. Four or five years ago it took, I had some patients take nine months

Emma Cooksey: to get approval.

Yeah, the first person I ever interviewed on the podcast was an Inspire patient, but she did this, I don't know how many years, years ago, three or four maybe, and it took a year. It's crazy.

Shane Pahlavan: But it's changed a lot, right? Some people aren't... Insurance companies have gotten used to the code, because initially, any new code with any [00:15:00] procedure, sleep apnea or any procedure, insurances will automatically reject those and those will go to appeal until they get used to seeing those codes come through.

So now they're used to it. So it's, it's a much more streamlined. So after we get approval, we I'll bring the patient in, we'll do a pre op. And I explained about the surgery. So, you know, it's an outpatient surgery. It takes me about an hour to an hour, 15 minutes for it. The patients are able to, to go home the same day.

They have to have a driver, but the actual procedure itself they're completely asleep under general, anesthesia for it. There's two incisions now. It used to be a three incision technique. I know I've seen that. That was going to be my

Emma Cooksey: next question.

Shane Pahlavan: The three, the three incision technique was initially how we did it for about four years.

And then about two and a half years ago, we switched to the two incision technique, which was which was great because the patients usually complain most about the third incision because it was lower down between the rib cage. [00:16:00] So you can imagine for that first week or so, every time you turn, rolled over in bed, caught knees, that hurt, right?

So now we can do it without that incision. And so some of my patients don't even fill the prescription for the postoperative pain meds I send in. I think that's... I would take it for a few days, I tell people, but some of them don't even take it.

Like I said, the surgery takes hour, hour, hour to hour 15, and then there's two incisions.

You know, previously it was three, five centimeter incisions, one in the right, Submandibular region here right on the jawline one in the upper chest and one between the ribcages now It's two four centimeter incisions. We're actually able to make those a little smaller at the top two here and then here

Emma Cooksey: So what is it that you're inserting in the chest one? So it's like a it looks almost like a pacemaker, right? But it

Shane Pahlavan: does something different. Inspire calls it a generator. It's essentially a battery. And so the battery sits here in the right upper chest. So we have to make an incision, make a pocket and actually just [00:17:00] make a pocket to have that sit down in there.

And we sew it to the pec muscle so it doesn't migrate when patients work out or move or something, you know, moving around. And then there's There's two leads that come out of that generator. One goes up to the, to the neck where we hook up to the hypoglossal nerve, which I'll get into. And the other one loops back around and goes in between the ribs right there, and that's called the sense lead.

So it's

Emma Cooksey: sensing when people breathe in, is what its job is.

Shane Pahlavan: And so at night, when you turn it on with the remote the, you've seen on all their commercials. I tell patients it looks like a garage door remote, but Right. They hold it over the skin to turn it on, and usually there's a, a latency period.

you can adjust, inspire to your specifications, but the default is it kicks on 30 minutes after you turn it on to give you time to go to sleep. And so when you breathe in, at, at, in the, at night, when you're asleep, it, your lungs expand. It triggers that sense lead, which starts the whole process. So it sends that signal to the generator, which sends [00:18:00] a signal to the hypoglossal nerve because we've dissected the hypoglossal nerve out.

We've dissected all the branches out and I've stimulated all the branches of that hypoglossal nerve. And I figure out with nerve monitoring equipment in the room, which one of the branches push the tongue out, which ones bring the tongue in. And then you wrap around those. Those, branches that push the tongue out only.

Okay. And so when that signal comes up, it stimulates that hypoglossal nerve, which does two things to the tongue. It flattens it out or stiffens it, and it brings it out by about a centimeter or two. It doesn't have to be much. It's not coming out. You're just clearing the airway. Exactly. The tongue rotates forward.

So this is the only sleep apnea surgery that we have available to us that we're not cutting anything out. We're actually putting something in, right, and so, to move the natural anatomy out of the way, which is the tongue in this situation.

Emma Cooksey: so you have to [00:19:00] do some sort of test to make sure you have the right part of the nerve?

Shane Pahlavan: So yeah, so we dissect the branches out. No pressure! I know, there's a nerve probe and I actually stimulate each of the branches individually and you can, we have a nerve monitoring technician in the room and we see the amplitude and if we're simulating the thioblossus or the genioblossus and you can see it on a tracing and you say okay, that's in, that's in, that's out, okay, cuff the ones that are, we want to put in the cuff, right?

the ones that push the tongue out. And so it's, you know, and everyone's anatomy is a little bit different and the hypoglossal nerve has some variability and, you know it's a very technical surgery. I think it's a, it's a fun surgery because of the anatomy is interesting. But it is a very technical surgery because those nerve branches are the size of like, they're tiny.

smaller than angel hair pasta. I use magnification glasses to do the procedure.

Emma Cooksey: So once they've done, this is the initial part, right? So they're done with that procedure, they just go home [00:20:00] and heal up. Exactly. And then when do they come back? Because then, then there's going to be like the separate part where you turn it on,

Shane Pahlavan: right?

 I see them back one week after the surgery, just to check the incisions for healing, and then they come three weeks after that, which is a month post op, for the activation, and we do it here in my office. One of the Inspire representatives will come and bring the, the, the controller, and it connects to the iPad, and we turn it on and test it, and they give the initial settings.

And they do a full education for the patient regarding how to use the remote how to turn it up a little bit. They give you a little bit of a range on there. You can dial it up or down a little bit. And then we have close follow up with them. And then we'll usually wait to do a post op titration study after about two or three months.

Just to fine tune that setting for them, but they start using it right after we turn it on I had a gentleman yesterday come in for his activation and he got to use it for the first time last night. He was really excited.

Emma Cooksey: That's awesome.

how long does it take people to [00:21:00] find that sweet spot where it's working, but it's not too much for the, it's not too uncomfortable or, or whatever?

Shane Pahlavan: You know, everyone's, there's some variability with that with the patients, but I'd say generally it takes about three weeks to get super comfortable with it, you know?

And I think there's some learning from the muscles and the musculature of the tongue as well, to getting used to it as well. Cause I feel like the more people use it up front, the faster they improve. If you use it intermittently, your tongue just doesn't know. How to handle that, right? And so the more they use it, the more your body's like, okay, I, you know, I can get used to this and, and the better results they, wind up having.

Emma Cooksey: you obviously don't have a hundred percent success rate. So when things, happen with the surgery, is it more just that they will still need to use CPAP or that it's not quite bringing their AHI under five or what do you see with that?

Shane Pahlavan: Sure, I've had a few that [00:22:00] the AHI wasn't quite under five and we were able, with the Inspire rep change settings to get them under that number.

So sometimes there can be some tweaks to the settings on the actual electrodes. The two that I have in my practice that weren't cured one, one patient has severe, severe insomnia. And so, I have him working with the sleep medicine doc to help us with that because we can actually download the data from the Inspire to look at when it's used, how long it's used.

Yeah. And it was all over the place. He's trying to sleep, like, an hour in the afternoon and three hours in the evening and his... Yeah. This, this Inspire implant is, is, works best in a setting where you turn it on and you're going to be in bed for at least six hours plus. Yeah. It's not one that you can, all right, I'm going to take a nap here or catch a cat nap here.

It's, it's not good for that situation. Yeah. My other patient he wound up having a lot of insomnia issues as well, some [00:23:00] PTSD. He's a veteran. Yeah. And so. Yeah,

Emma Cooksey: I feel like, I don't know how often you come across this, but, but one of the things I'm really interested in right now is just this, for some patients, I think it's this whole thing of sleep where people without sleep apnea sometimes have issues with their sleep.

And I think, I think sometimes when people have a diagnosis of sleep apnea, they think all of their sleep issues are, to do with the sleep apnea when they're not necessarily and like sometimes you get into this thing whether it's CPAP or or you know like they've done an oral appliance or whatever it happens to be they'll they'll say well I'm, I'm not sleeping well though.

And the doctor's kind of going, well, I looked at your data and you know, it looks like your, your medical condition of sleep apnea is really well controlled. And so can that be frustrating sometimes when you're, you're kind of like

Shane Pahlavan: looking at the data? Yeah, especially with those two patients, because, you know, like I said, I like to, I'm pretty selective on which patients I do [00:24:00] this to.

And so, you know, I felt like with those two specifically. You know, their sleep apnea was so bad, they was masking some of this other stuff. So now that their sleep apnea, their numbers look better, you know, but I don't count that as a cure because they're still having trouble, right? So. Right. Their sleep apnea was so severe that, yes, it was masking some of these other issues.

And then now that we've got their sleep apnea under control, then we really see, oh, wow, like, You start to

Emma Cooksey: unravel the whole, Yeah,

Shane Pahlavan: yeah, like, the next layer of the onion, you're like, okay, now, now I see what's going on here.

Emma Cooksey: I don't know if you have experience with this, but

the powers that be approved using Inspire and Down syndrome, like kids with Down syndrome. Do you do that in your practice or have you heard of

Shane Pahlavan: anyone who's done that? I'm not opposed to doing it. So yeah, FDA approved Inspire implants for Down syndrome patients for ages 13 to 18.

That's what the FDA approval came through and their AHI from 10 to 50 [00:25:00] range and then that age is 13 to 18 approval. There's only been two done in the Dallas, Fort Worth area, relatively new. I've definitely talked to them about being involved with that. We have a new cook's children's hospital close to us.

And This could be a huge, huge benefit for down patients. You know, one of the issues with down patients is they generally a lot of them have a larger tongue and so, and smaller mouth. And so from an anatomical standpoint, yes, I think it would be extremely beneficial. Well, we have to be careful with down, down syndrome patients is really evaluating that sleep study because a lot of them will also have a central component.

As well, we just need to make sure that they're not over that threshold, which is the same threshold for adults, is that the central component of their sleep apnea has to be less than 25%.

Emma Cooksey: So that's one thing we didn't touch on with the criteria. So if somebody has... A mixture of obstructive events and [00:26:00] central events.

You're going to want to check that they're not over a certain amount.

Shane Pahlavan: That's central. Yeah, exactly. So if they're over 25 percent of their apnea or hypopneas are central, then it just shows that they're not going to do as well because We're only treating the obstructive component with Inspire.

Emma Cooksey: Right on.

So people are listening to this and they're like, I'm all in. Where do I go? What's the best way to find an experienced surgeon who has done a bunch of Inspire like you if they don't live in Texas?

Shane Pahlavan: Sure. It's not feasible to come see myself or my partners who do a lot of these. The Inspire website is actually really good.

And hopefully patients have a lot of my patients have looked at that. Maybe a lot of your listeners will as well. They have Inspire Sleep is the, the website, but they have a great website and you can actually go in there and they have a, a find a doctor option and you take it. Type in your zip code and it will populate the doctors in your area that that perform the procedure.

Now, [00:27:00] there are some of those that may pop up and they may have a little asterisk or a could say like a center of excellence. Those are the physicians or surgeons that do the most of these. We've been lucky enough to partner with the sleep medicine doctor in our area, so our practice and theirs.

is a center of excellence, which there's less than 10 or 12 in the nation. We're the first in Texas and certainly the first. We've been, we've been very blessed with the collegial relationship with, with another sleep medicine practice that we work with. So and we've been able, like I said, to replicate what they do at the university, having everyone kind of on the same page, you know, and that's, that's important for this.

This is not just. A tonsillectomy that I do or put in ear tubes and you know call me

Emma Cooksey: if you need me. So I guess that's one thing from a patient point of view,we would just love it if all of the people with anything to do with sleep apnea would all be talking to each other all the time.

So how have you managed to do that? Is it to do with the fact that you're getting referrals from those sleep [00:28:00] specialists? You know, people that haven't done well with CPAP maybe are being sent to you, or, or did you go and like, knock doors or how, how should people be like making those connections?

Shane Pahlavan: For sure.

For us it was with a local sleep medicine specialist that was familiar with Inspire and we've we met up and we said. Like I said, I have no interest in in, you know, ordering CPAP supplies and I'm not going to steal those patients from you. I just said, those ones that are surgically, give me a chance to show you what we can do to help you.

And we really hit it off. And we're we're able to have that relationship where we're always constantly in communication. Hey, this patient needs follow up. This patient is due for their post op titration study. Or, hey, I need an updated sleep study. Or, hey, this patient needs to get adjusted. So we have that communication.

And, and that's rare in today's... This is a healthcare environment, unfortunately, where doctors are talking to each other a lot, right? And so Why didn't we change

Emma Cooksey: that? I mean, [00:29:00] I'm just like kind of bashing in and just like trying to change it myself, but I feel like maybe there's a larger systemic thing that can happen.

Shane Pahlavan: one issue is that we're all kind of operating on an island sometimes and we need to not be that way. And that's a, that's a physician problem. The other problem is just a systemic problem where everyone is on their own medical systems record. They don't talk to each other.

You go to one facility. I mean, I had privilege at six hospitals and facilities around here. Each of them has a different EMR. Each of them has a different password I need to keep track of

So, you know, I can do something here in my office and they don't know about it at the hospital and vice versa. They can do something at the hospital and then a patient comes and sees me for their pre op for an Inspire and I'm like, anything change from your medical history? Like, yeah, I had you know, I was diagnosed with a, Cardiac blockage.

I had to have a catheterization last week. Oh my God.

Emma Cooksey: Yeah. And every single time. So I'm not going to get into like, so I grew up in Scotland, right? So, and we have [00:30:00] the National Health Service, which definitely has its problems. But here's what I would say about that. At least it's joined up, right? You have one set of medical records and every doctor you go to.

is feeding everything back to your GP and there's never a question of like that whole thing like I feel like like next week I'm having to go in for like a colonoscopy which I'm not looking forward to but like you know it's like I've never been to a doctor before they're just asking me all of this stuff and I'm like seriously like it's all over here on this other system but they don't

Shane Pahlavan: talk to each other you know yeah that's a pain point that People feel like they have to give their entire medical history at each visit because the doctor's communication isn't there, and they're all on different medical record systems.


Emma Cooksey: if you can think of any ways to solve that, let me know. so Is there anything else about the Inspire procedure that we haven't covered? I feel like we talked really well about how you do the initial procedure, but the [00:31:00] actual, like, how it works, like, so there's a remote and they turn it on right before they're going to go to sleep and then that activates this thing where they're breathing in, the sensor you were talking about sends the message that the tongue has to move out of the airway and they hopefully sleep all night.

Shane Pahlavan: Yeah, that was a good synopsis for sure. So yeah, it times the protrusion of the tongue with the respiration and that's what it's doing in sync and synchrony with that. And so one of the big things is that I tell patients, and I mentioned it, like this, this is the only sleep apnea surgery that we're, we're not cutting anything out.

We're, we're actually putting something in to move your natural anatomy out of the way. And so some people get hung up, Oh, well, I have to have an implant. And I get that too. It's actually more common to have implants than people realize because a lot of people have pacemakers. Right. And so. So many. And the other question that patients usually always ask is, Dr.

Pahlavan, what [00:32:00] happens when I go through airport security? I say, well they give you a card to show the TSA. And number two... The only time that they actually will see it is in the security, if you go through where you have to put your hands up and it, they'll rotate around security, they'll notice it there.

And they essentially think it's a pacemaker, just a cardiac device.

Emma Cooksey: I feel like when I first started CPAP 16 years ago, people would be like, what in the world? And I'd have to take it out. And now they're just like, oh, it's CPAP and on

Shane Pahlavan: to the next thing, so they'll get the same.

The newer version of the inspire generator or battery, it's approved for most MRIs. That's a question people will give me sometimes if they need it for other issues. So that's, that's a one that a talking point patients will ask me about sometimes.

Emma Cooksey: And then, oh, the other thing is, and then, so at some point they need their battery replaced.

Shane Pahlavan: Yes, good question. So I haven't had anybody implanted 10 years yet. I think my longest is six and a half, right? So I haven't had to change a battery out yet for Inspire. I changed batteries out for vagal [00:33:00] nerve stimulator surgery I've done. You know, over a hundred. And that procedure is actually only the chest incision and you switch out the battery and sew it back up.

It's a 20 to 30 minute outpatient procedure. Okay. Cause we leave the neck, we leave the neck the leads, the cuff, all that's the same.

Emma Cooksey: So, so just really quick. So I guess what I want to know is, Now that you're doing Inspire, what other surgeries are you still involved with to do with sleep apnea?

Shane Pahlavan: I certainly, I still do tonsillectomies and UPPPs.

That volume has decreased now that I have Inspire. Okay. And those, those patients are much fewer and far between now, but I still do it. I have one tomorrow. I have a UPPP tomorrow.

Emma Cooksey: so I often say that I don't ever hear from people who get sleep apnea, figure out something that works great, and then go about their lives, right?

So I'm only hearing from people that are having a terrible time or, you know, have been through a lot But I think with [00:34:00] UPPP... what would make a good candidate for that surgery? Because I feel like a lot of them were done back in the day and a lot of people didn't see great results or they saw great results for a short period and then were dealing with scar tissue and different things and it wasn't really what they'd hoped.

So what kind of people are you doing that procedure on now? So

Shane Pahlavan: those are the patients who maybe have mild sleep apnea, maybe in that 5 to 15 range when I examine them that have either large tonsils and or a low lying palate or enlarged uvula. So if I feel like the oropharynx is the main issue of the obstruction, instead of the tongue, and their AHI is in the 6 to even 16, 17 range, maybe they're at the bottom of the criteria for inspire, then I will give that option to them.

Because with UPPP, I can usually get the AHI down by 50 percent. That's what I tell patients. [00:35:00] Now depending on where they're

Emma Cooksey: starting fairly low, then

Shane Pahlavan: Could potentially prove it Could be. Yeah, exactly. And that's my point is that I would never offer a UPPP to an AHI patient of like 30. 'cause I like, even, even though I, you know you could have a great surgery, a great recovery.

I get you to 15. Where are we at? We haven't really done much for you. But if I'm starting at, if I'm starting at nine, you know, I think that's a good option. And they have the anatomy on examination that is, that warrants that option then. Sure. Let's try it.

Emma Cooksey: Well, listen, thank you so much for joining me. I really appreciate it.

Shane Pahlavan: Okay. Yeah. Thanks for having me.

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