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Episode 84 - Dr. William Noah - Improving PAP Comfort with V-Com

1:51

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

So there's another storm coming to Florida.

You guys, I feel like I'm constantly giving you updates on the weather and my kids are going to be off another day this week because there's another storm coming.

2:07

So I'm kind of fed up with storms.

We've been super, you know, fortunate, and so many people have been so much more affected than us, but I just could do with hurricane season.

Being over at this point.

I organize my podcast in two seasons of 10 episodes just to kind of help me plan out what I'm doing.

2:29

And so I'm going to be taking a break for about four weeks and after this episode today and then I'll be back with 10 more new episodes and I'm already working on those.

So there's some really good topics and a lot of good stories that I think you guys are going to really like.

2:47

So one of the things I've been looking into To is, I'm doing an episode all about different options for and telemedicine and home testing home, sleep apnea testing.

And so we're going to kind of dig into that and look at some different companies and what they're offering and I'm hoping that's going to help you guys out there because that's something that you guys asked me about a lot.

3:12

There's that there's also a lot of you been asking about an update on my own Journey with sleep apnea and I was doing You know, pal expansion, in myofunctional therapy and all the stuff.

And so I do have a really big update on that and the highs and the lows and and where I'm at right now and with everything.

3:34

So that's coming and towards the end of the year.

And but I am so people that have asked, there is an update on that coming.

So today's guest is kind of funny and because I always break all my own rules and but what I saw Did the podcast.

3:52

I had a pretty strict rule that I didn't want to interview, you know, reps from companies about their products, like I wanted it more to be like patient stories and it's fine if people are speaking to their own experience with products, but I didn't really want to, you know, like just give was a company's a platform to sell their staff.

4:15

But having said all that today's guest is Talking about a product you developed, but his name is dr. William Noah.

And I saw him do a webinar about this device, on Enzo data, like they have some webinars and I washed it really intently, because he was talking about this device that made Pap therapy, much more comfortable for people and reduce that feeling of claustrophobia and too much air pressure, right?

4:50

So That was just like way too interesting to pass up.

So I was like I've gotta have that guy on the podcast and so since I had them on and I they sent me one to try and this little device and really makes a big difference to the feel of the air pressure that's coming through your mouth.

5:16

So we really I feel like get into the my new shy of You know, pressures and what exactly is happening with with Pap therapy.

I hope you'll stick with it and really listen to everything that he's saying.

5:32

I try to keep relating it back to you know, anybody like try and not let it get too technical but I think what he's done and developing this product is just really going to help a lot of people.

5:48

So that's why I really wanted to have Doctrine.

Noah on on to today's guest.

So today I'm joined by dr.

William Noah, he grew up in Tennessee and that's where he completed his medical training.

And then he did his pulmonary fellowship at the University of Utah in 1992, he returned to Tennessee to start a pulmonary and sleep medicine practice.

6:12

The Sleep Center is of Middle Tennessee, which has grown into one of the largest Sleep Centers in the United States.

Dr. Noah pioneered remote patient monitoring for sleep by requiring modems on all Pat patients.

6:27

Beginning in 2006 in 2020 dr. Noah received the Visionary award from the Tennessee Public Health Association for developing a way to diagnose and treat patients with Osa across Tennessee.

And six neighboring seats during covid when other programs had shot down.

6:46

So today, we're going to be talking to doctor know about his New company sleep prayers and their revolutionary new device to improve Pap adherence called the v-cam.

So without further Ado, here is my conversation with dr.

7:04

William Noah.

So listen dr.

Noah thank you so much for joining me my pleasure in.

So start off by telling everybody a little bit about your background so you're asleep specialist, you want to explain where you are in the country?

7:22

What your kind of work background up to this point has been.

So I'm a pulmonary critical care and sleep specialist who did all three for about 20 years.

But the last 10 years, Years, I've only done sleep medicine.

7:39

And I am based in the Nashville area.

I, we have three offices around Nashville.

One about 30 miles, Southeast of downtown a town called Murfreesboro Tennessee.

Our main building is there.

We have an office south of Nashville in an area called Franklin Tennessee.

8:00

Well-known City and then we have one North West in a city called Clarksville All larger cities but they're part of the Metropolitan Nashville area.

Okay, I'm on auditing time.

I'm originally from Scotland.

So my geography is just rubbish but I know where Nashville is so that's it.

8:20

We'll just we just say Nashville, we say country music and everyone kind of know, right?

And so primarily in that job, you're treating people with sleep apnea it day in day out all the time.

Right?

Yeah.

We probably put between 50 and 70 thousand people on.

8:36

On CPAP in our practice over the years quite a bit.

Yeah, it's all 300 new referrals a week.

Let's just start with what were you seeing over the years and mine, your patients of what they were telling you about their experiences with CPAP and problems?

8:54

They were having well, they're all the standard things that are online, but where we may differ back in 05. 06.

When modems were available, now they were wired vote.

If they Go through your telephone line when people actually had phones in their house now.

9:12

Yeah.

And and so we began to put those on everyone who at least had a home line now open that and then we, you know, help pilot the first wireless modem with with Respironics which became Phillips.

9:28

So what you're talking about is to track people's usage and their data of their CPAP machine.

Yeah, we did a small study.

Back in 2002 or so, but we had to actually bring the machine in and look at the recorded time and you know, it's one of those things where people who are doing well, want to come in and show you and the people that aren't doing.

9:50

Well, don't want to come in so many, you know, sleep positions.

You know, have this false idea that all their patients are wearing CPAP or at least most of them and that that's really not true.

And the first time we were really able to really know that is when we put modems on it.

10:06

One and then he really know who's wearing and who's not.

And so and then the ones that you don't get data on you just have to assume they're not wearing.

Yeah definitely.

And so then we started using behavioral therapy and our whole Focus has been on it here.

10:22

So our whole Focus has been seeing, who's not wearing calling trying to intervene answer questions.

Make changes to try to get as many people as we could and hear it.

And then 2012 to 2016, we collected data on 4,000 consecutive patients that we just published in the journal clinical sleep medicine, back in January of twenty one.

10:47

And so, I would say that in the fact that you were following up at all, but especially that you're actively contacting patients and encouraging, their adherence that you're in the minority among sleep specialist.

You would, you agree with that?

11:03

Well, I don't know what everyone else does because we're not do.

That my view, this is the therapy and if we're not able to help them wear it and get them to wear it, there's two parts to that.

There's number one, letting them understand the benefit.

11:21

So education on the front end is you all right?

So we're constantly talking about their comorbidities and we want to know when they wear a CPAP or also treating their diabetes in the right, attention prevent heart attacks and so to get them to understand the need.

11:36

And then to help them with the problems that arise from wearing it.

So there's two parts to that, but that kind of gets us to where we are today.

Because after my article came out in 21, I began to look in another area.

I'd never looked at everything I've done.

11:52

Emma is really been mostly behavioral.

You know I mean it's we we really encourage nasal pillows for the last 20 years.

I'll because the nasal pillow dilates.

The nasal Airway up there and and because days Pillows.

Actually people need they did studies that.

12:09

He rinses is better for people that can tolerate nasal pillows.

Well and that's what we're going to talk about today is, is years ago.

Yes.

But the way the machines have been designed in recent years.

It's made it more difficult and, and we've got to get back to the old way again.

12:28

Yeah.

But, but everything was behavioral, but then starting after January at 21.

You know, I'll be there was a change in Phillips.

And one of their senior, I'll say senior leadership because he was let go after the recall.

Yes, he came into Nashville to me.

12:45

There's been a lot of changes of, yeah.

Yeah.

He came to Nashville to meet with me and, you know, we pretty much always use mostly Phillips machines.

Okay?

So we can keep people and, and one database more than the other, but we have tended to use more ResMed.

13:03

Which is very common.

Yeah, and he was just upset one in our Mass business and I and I kind of told him, I said, look, I let my rest or therapist and sleep text make that decision.

You know, they're the experts, your reps have full access to Market to them if they're choosing ResMed piano over your mask.

13:22

You know, that's really your problem.

And it really woke me up and I began to look into it and interview people and interviewed engineers, and I've gone quite deep as you probably could.

Yeah, and and I'm just embarrassed that for 28 years.

13:39

I didn't look into this, a little later in the ICU, I would know everything about that resistance in the system, the flow rates, not just pressure and and but when they're on CPAP, well let's start at 15 to 20 of Auto Pap and you know, write and and what I've discovered you know the becomes just one.

13:57

And would you say that a lot of that is I feel like a lot of that was coming from.

Some sleep specialist just kind of trusting that all these different manufacturers of CPAP equipment and mass, there were doing what they said they were doing and no problem.

14:16

Let's just go ahead and and, you know, set it and forget it and just put it on on the a Pap setting and be done, but there's kind of problems with that, right?

So out of your closet is come, great, wisdom, great truth.

And yes, and I was so guilty that if I Question about how it worked, I would call the rep, you know.

14:36

So a lot of my questions did get pushed up to, you know, higher level, you know, people engineers and stuff.

But, but I just thought they knew so much more than I did or could ever know that, you know, just follow them.

And when I look behind the veil, I found that no one's minding the shop.

14:56

It's it's really kind of a mess.

This whole, I Pap issue that, you know, bringing to light.

Yeah.

That my field.

Is really grabbing because it's just common sense.

If it's so funny, I was at the Kentucky sleep Society, you know, last week, you know, giving their keynote lecture, you know what, I threw all this out.

15:13

Everyone kind of looks kind of like, shocking each other.

And they're like, yeah, that's right.

And they all said it makes sense, you know, a lot of her saying, you know, I wondered this over the years, but we never questioned it.

And I want to make sure that we don't lose people listening, who are largely ordinary CPAP users, right?

15:32

So when you're talking about, I've have so, you talked about inspiratory and expiratory different pressures, can you explain a little bit about that?

And what that is.

So CPAP is for continuous positive, airway pressure, and its really never continuous because when you breathe in the pressure drops, right?

15:52

Because you're dropping the pressure in order to creat air flow into your lungs, the pressure has to be lower in the lung that it is in the airway or from the machine for airflow to go.

And if for you to breathe out, you have to raise the pressure to go the other way.

Flow only happens because pressure makes it alright.

16:09

Flow doesn't really exist on its own.

It's the result of pressure and resistance but so the way older see paps were they weren't as sophisticated and so when you breathe in the pressure, really dropped lots of times and that was more comfortable, that was more natural.

16:25

Humans, expect to breathe in and have the pressure drop because that's what you're doing right now in the closet is when you breathe in the pressures dropping, Well, when we invented by tap dr.

Mark Sanders and Nancy Kern at Respironics in 1990.

16:42

They were, you know, doing ventilators.

On one side of the room, sea bass on the other and this whole idea by having either that the inspiratory pressure which we call iPad inspiratory, positive airway pressure and the expiratory pressure CPAP okay, that they could now separate those and they can control it and and by having iPad higher than CPAP, You can actually Force air into the lungs and for people with bad lungs, okay?

17:07

Or poor chest wall compliance or you know, neurologic disease, people who need ventilation, not treating sleep, apnea, people who need to relation having the difference between iPad having epact lower helps, the work of breathing for them and somehow we crossed over to.

17:24

Well that'll help the work of breathing for people with normal on Sue, just have sleep apnea and that's where we really got off track.

There could be a money thing here.

In other words I may not be the first to really bring this to light.

They may have figured it out in the company's but no one said anything because they were making millions not billions, billions, all bypass.

17:42

So what happened is Is it someone was was not adherent to CPAP.

That gave the DME the opportunity now to sell them a three thousand dollar machine divide that by bad and it's never really been shown except in a few cases of patients like with COPD and really more of a morbid obesity.

18:03

It's never been shown to improve adherence.

All right?

And but people can make a lot more money on it.

So you know, I mean, you know, respiratory therapist at different DM.

He's in the past, I knew were given and Sentence to get more people on BiPAP because, you know, they can make so much more income.

18:19

You know, let's take away the, you know, the Draconian idea that I think I just want to make sure we don't lose anybody.

So, CPAP one, I mean, you just said that it's not one pressure because you're breathing.

But essentially, the machine is sending one pressure and right, BiPAP?

18:37

It's a different pressure.

When you breathe in, you breathe out, right?

Okay, just checking.

So why BiPAP While BiPAP is the part of the greatest thing for non-invasive, ventilation for being able to ventilate patients, keep them breathing without having to put a tube down their throat, okay.

18:54

It's not been for Sleep Disorder, breathing rate, constructive sleep, apnea, particularly and yeah and that's what we miss in this whole idea of I Pat higher than CPAP has been hurting.

People hurting adherence causing complications side effects to CPAP that we didn't have before.

19:15

For the machines, were quote, less sophisticated.

So in 2003 Phillips came out with see Flags.

Now see Flex what it does.

It drops the pressure on expiration, does it flow base?

Then a couple years later resident came out with their expiratory pressure relief.

19:32

Epr saying, yes, it's the same thing.

It's the only difference is it's not flow based and they argue back and forth but really that's where we got the train off the ship because off the tracks.

My metaphors because the fact that now all the CPAP is effectively became bypass.

19:52

We're right.

I don't just to kind of bring my experience as a patient into it.

So I've been asleep at user for 14 years and when I got originally I had a very like, basic machine that was just a CPAP then, like a lot of people, you know, I went for, I think I started having some symptoms.

20:15

Again and the doctor said, you know we haven't replaced your CPAP for a long time.

Let's get you a new machine and he was all excited because it was going to be, you know, a res meds and are sensed and I think I got.

And so he's like a saint a Pap so it's also titrating, it's going to be great.

20:34

Well, when I first started with that machine and I'd been using CPAP four years at that point I know is you know, That feeling of waiting much pressure, even though it had been set to very similar, you know, it was a range but it was a similar pressure to what I've been used to but I find like the as I breathe in it was just like, really overwhelming too much, you know, I would like gulp too much air and all that.

21:02

And so once you took to the internet and we're on all the chat sites, everybody was talking about it and saying, oh, there's an epr setting.

If you change the The epr setting.

It's going to be much more comfortable.

21:18

So, honestly, like, most people, I knew in the little, like, it's not very big Community.

The whole sleep apnea thing, especially back in the day.

And so, as soon as those machines came out, so many people were just talking about, like, you know, just just bump up, your EP are saying.

21:34

So can you explain a little bit about what that's actually doing to the pressure.

And, and why we were getting relief from that?

so, The big misconnect that happened is that we got caught up that expiratory pressure was the, was the offending agent and you know, in the surveys back at that time, about 20% of patients, you know, had trouble exhaling but initially, the problem is the inspiratory pressure.

22:05

It's trying to force it in your lungs.

If I was to take in the ICU and I went to sedate you and pharmacologically paralyze, you, okay.

And put you on CM CPAP it would just inflate your lungs all the way full and just hold him.

That's what it would do.

22:22

And and so when you go on CPAP, you have to resist that pressure.

Seems you have to learn to breathe backwards to breathing in is active but actively, you know, pulling the air in by lowering the pressure in the chest when you breathe in on CPAP, it's active as well, but you have to resist the pressure.

22:40

Whether I'm pulling 5, cm / pushing 5 cm exclaiming, whoa.

Work.

But if I'm having to resist, 10 centimeters, that's more work than it is, to pull five.

And that's where we've lost it that the iPad app for patients with normal lung mechanics, all right?

22:58

They don't need iPad, they don't need it above CPAP, and by doing that you're leading the all these other problems.

And and so the other thing to take home that we've missed is a CPAP is the therapy.

And there's tons of as you're breathing out as you're breathing out, if you stabilize the airway during exhalation, it doesn't matter about inhalation.

23:23

You've got to stabilize it at the end of exhalation for, okay, right there at time 0.

But you you if you do that, the iPad app is less important.

In other words, this is the take home messages.

They've been jacking up your iPad for the last 20 years and they've been doing it for no therapeutic reason.

23:42

And Causing I believe more problems of people tolerating it and more people you have to use full face.

If you go in a full face, the odds be wearing it.

Long term have gone way way down and and so what I'm really what I'm introducing into the world, is this whole theory that lowering iPad, glowy Pap would be better, okay?

24:04

That it would be more comfortable.

The problem is no machine in the world.

Does that currently?

Well, I won't say no machine.

I'm in my lab, I'm doing that, but But but I couldn't help it.

25:51

It will be this.

So this is exactly.

So I shared a little video on my Instagram of the v-cam you guys sent me and we'll get on to what that is and all that in a second.

But one of the big things that everybody kept saying to me was, oh, I don't understand what my daughter has to set my pressure and if that, you know, if there's a device that changes your pressure, then that's going to not be an effective treatment.

26:17

So what you're saying is they're completely different The iPad Mini Pap part of it.

Like it's actually the you said the E, Pat part that is deciding whether it's, you know, like enough pressure to hold your airway open basically.

26:35

So it's all backwards.

I mean if those been backwards for 20 years and I was backwards, okay?

And you know, I'm embarrassed about it, you know that I didn't treat like a ventilator oh just give me you know, and I just listened to the manufacturers and boy that was a mistake.

26:51

You know, I know now and CPAP is there.

So if you drop a CPAP like with epr or see Flex with these expiratory reduction, you're dropping therapy, right?

Okay.

I mean for instance, the most common thing happens at a DME is they switch their Master full face.

27:09

I mean it's like it it it's like before the door closes when you walk in order to switch you to a full Pace committee offices, I mean there's respiratory therapist I've interviewed that's all.

They use his full face because it no one called And that's so this is, I could talk about this for four hours.

27:25

Yeah, but this is one of the things that drives me crazy is so I have a largely, not functioning nose, which is a problem, which is like so many people with sleep apnea Ray, but that's not good.

We should be encouraging people to breathe through their nose because that's how they're supposed to Breathe, Right?

27:43

Like, it's not great to just kind of to me.

It should be the other way around and you should start with these will pay Pillows and leave.

The can't do that do a nasal mask and if they can't do that, do a full face mask.

But it seems like a lot of places.

27:59

The DME people are saying just do a little face mask because then if that doesn't work you don't want to come back and no big deal and this will sue anyone however you breathe.

And if you don't really know of your mouth breather, then just take this and that just seems all backwards to me.

28:16

It is backwards and that's what happens.

And that's what I want to change.

And so for instance if you were tied 82 16 cm in the lab and they put you on a nasal pillow and you were having some comp rubble and you show up at a DME office and they go well first we're going to put you on epr so that's going to drop you three centimeters on E pack which is well drop your iPad but eyepatch not therapy.

28:38

Okay so now instead of getting 16 you're getting 13 and now I put you on a full face mask that's going to drop you at least two from a nasal pillow Palin size of the nasal pillow cushion.

So now you're rocking out of there is 11 cm and you're not getting treated today and and they think they did a good job.

And and that's the problem.

28:55

There is an e Pap that every Airway needs and they need that, are they need that Eep and they're going to get.

In other words, if you're on auto Pat and you turn on epr, it's just going to titrate the iPad higher because he Pat's got to go back to where it has to be.

And we've got this idea that we, this that, I believe, like gospel, you know, all these years that you titrate the CPAP up to get rid of the apneas and then you use the iPad to get rid.

29:21

The hypopneas in the snoring and it's just not true.

You need a Pap and once you get the righty Pap stabilize the airway during exhalation.

The rest doesn't matter.

So going back to your mass thing.

So what's happened is you see that normal drop in pressure?

29:37

During inspiration the engineers were told, hey, you got to maintain therapy throughout inspiration to well, the pressure is going to drop.

Well, we but the marketing people say hey we want to advertise our machine that only varies in prayer.

Assure you no one point something CM, you know, during the cycle and it's so foolish because you want it to drop during inspiration for Comfort.

30:00

But they've determined.

No, it's not.

One of the reasons nasal pillows were so comfortable years and years ago, will say more than 10 years ago is because the pressure would drop even more with the nasal pillow on inspiration, because the resistance in the cushion, the little holes made the pressure drop, right?

30:18

And therefore, when you breathe out against it, it made the Pressure higher in the ferric so you needed less set pressure on the machine made in the shin.

Quieter dropped.

All the flows is made everything better, right?

So, but they go, oh no, we can't have that pressure drop on inspiration.

30:34

So that's why you have to when you set a nasal pillow setting on your machine or X2 on a Phillips.

You know, all that's going to do is Jack the pressure up even more on inspiration.

So when you Jack that pressure up on inspiration to counteract, the drop in pressure that you're Owing to have across the resistance will, then going through that little bitty hole.

30:55

Guess what the saying, flow?

Now has to increase the velocity.

So it's like, taking an air jet and spraying the inside of the, the nostril.

And that's why people can't tolerate it.

They, they have, that's forcing people to full face masks.

They don't have any resistance in them and they're losing the benefit on exhalation and, and they're having to put all that strap and stuff on when they could tolerate a nasal pillow.

31:19

Yeah, we three over over.

Set of our patients and up on nasal pillow and our practice and hangs on that way for your.

And I think that's why our adherence is higher in the literature.

You know, partly because of that, I'll tell you this.

The number one resupply mass in the Phillips is the Nuance their nasal pillow, okay?

31:38

And they're discontinuing it, which it's just makes no sense.

Because it that mass has great advantages of high pressure and then.

And then, of course, the number one mask is the T10 by ResMed.

So it's interesting.

The two Is that are the most resupplied meaning that the patients using it long-term our nasal pillow mask.

31:56

I mean, that all it.

Tells you right there?

Yeah.

The different.

So, so I think we kind of glossed over it but just for people listening, can you explain like, one of the things I heard you talking on the end?

So data webinar and that's when I was like, I've got to talk to that guy and but you were talking about different masks, different Mass, shapes different.

32:21

Hers can change the pressure.

Absolutely.

Yeah.

Absolutely right back because I think that's kind of a shocker.

So Philips, Mass particular nasal pillow, cushions have more resistance than them at the medium and large side.

Small, they're all about the same, it'll ResMed Mass have have less but ResMed has one setting for like all three nasal pillow cushions so he put on nasal pillow but of course the point is we don't even use that.

32:48

We said every machine on full facts and the reason, We do that.

Even though we're using nasal pillow on everyone because I don't want them, their engineering screwing, he their jet.

We're trying to protect the patient from jacking up.

The pressure on a full face, it's not expecting any resistance.

33:04

So it doesn't Jack.

The pressure up this much.

If you put in nasal pillow, it's going to jack the pressure up more.

She's gonna she's become so sophisticated that they develop these what called Low inertia turbines and they have now motor speed control instead of bow.

So they can it can it can change pressure inside Taney asleep.

33:22

And so when it senses you start to breathe in, it's going to jack that up and that's why people can't handle nasal pillows.

They said that all that blowing in my nose.

Well, if the pressure would normally drop like it should with the resistance and your insta Tory effort, well then it would be so much more comfortable and so what can we do?

33:40

Like so you basically don't have any of your patients to an epr on it that we stopped at a while back.

We used to we we had ever I had everyone on it for ya.

You know 20 years.

Yes, sir, 15.

That's a it's kind of embarrassing because they've got a hat.

33:57

I know, but thank you for being the one person.

Saying there's a problem.

Well if someone's having trouble tolerating the pressure they're going to have to get used to the E Pap one way or another.

I mean there's a certain CPAP they're going to need.

34:13

Yes and they're going to have to get used to the thought was behind all this that e Pap was more offencive and it by Our needs have been given higher iPad.

I can still treat them and that's just not really that true.

I mean they're I mean they're exceptions but in general CPAP is the issue.

34:30

I Pap is the offensive part.

You see when you the more I Pap you're blowing down there long, you're blown it down their esophagus so it's causing their own faiza.

That airs got to go somewhere that goes in there.

Yeah, so that's when people get like that feeling that they swallowed air and they have like, blowing in their stomach and all of that stuff.

34:49

Yeah, I remember remember.

He's having Arrow phaser on CPAP that we would switch to BiPAP because we were Toto.

That would help that then you know, I didn't think food enough.

I mean now I realize how stupid that was.

You know I remember this one particular Doctor Who was a patient and you know and I put them on BiPAP and he really couldn't Delhi difference and you know it's it's just I think there was a disconnect the Physicians weren't giving we as a group weren't giving the right feedback.

35:21

Back to the engineers, the engineers did.

What they were told they didn't do, right?

They just don't know.

I mean, when I asked Engineers about the nasal resistance and because, you know, when you breathe through your nose, you have another resistor and so you drop pressure even more on a nasal mask any time, because you go prostitute, you know, the Nate, depending on your congestion.

35:39

The resistance could be real hot.

And then when you breathe out through your nose, you Bill deep.

And that's why nasal mask need lower pressure than a full face.

But I, it's just kind of embarrassing.

You know that we as a field we go in the ICU and we know everything about the ventilator.

35:56

Yeah.

And we just order CPAP and we've sort of treated and oftentimes not like it seems like this is not happening maybe as much in your clinic but I've never had a titrating study ever and I've been asleep at for 14 years.

36:12

Like it was only a lot later on when I started discovering Oscar and you know people out there that were like, oh maybe your pressure is Not right, and and then with the a Pap I still never had the titrating study.

They just set a range.

36:39

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37:51

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38:07

So the thing I did want to ask you about was so do you want to just explain to everybody where this idea for your Viacom thing came from and maybe try and explain to us what exactly that does.

So so the idea came up once I start investigating all this and you know really focusing on.

38:27

I mean I had to relearn calculus, I had to read learn physics.

I remember when holiday morning, they were looking for me for breakfast and I was down here reading, you know, gas laws.

Cause, you know, you're still know it was, you know, I get, I get onto things, I get a little carried away times.

38:43

So I came up with this idea that if I could reduce iPad, you know, that, that would but I needed to test it so, but there was no machine, you know, that I could do that on.

And so I had to invent a way to drop the iPad and, you know, and keep app up and so the way to do that was add what we call non compensated resistance into the circuit.

39:05

So I made the First, v-cam, it was 3D printed, you know, the first few of them back in July of, I just made a prototype just, you know, a few of them that, you know, I would put on, you know, just volunteers friends, a lot of a lot of Executives and staff from different manufacturers showing then, you know, the and people could feel the difference immediately.

39:26

You know, we say 15 seconds is better than 15 minutes of explanation in.

So I did all that and was trying to figure out what to do.

I and then finally A I realized the only way I'm going to really prove this I'm going to have to manufacture it, get it FDA you know get the FDA requirements done and I can put it on patients and then I can have real data.

39:47

Yeah and then you know because I because what I'm telling you I would I didn't tell anyone publicly that I was thinking this.

I mean I didn't kiss you.

You kind of probably quite rightly thought that everybody be like what?

Well just I was so going against what everybody else is doing right.

40:05

Well I mean I was probably The worst critic.

I mean I didn't believe it myself, you know, I I could feel the difference and I put on all these people and they could all feel the difference but I knew there had to be something I'm missing.

You know this is too weird.

How could the whole field the off like right now?

40:22

Well here's a really funny thing, though.

Listening to you talk about it, it makes me feel a million times better as a patient and as someone that spends all her time, talking to patients because, you know, I think you can start thinking you're Daisy.

Like, I remember, you know, trying to explain to my doctor when I got this new machine.

40:42

Well, it's just feels really different and, you know, and they would just be, like, I don't know what you're talking about it.

Like it's fine, you know where another people would say, the same thing, like I used to be able to do a nasal pillow Mass, but now it's the pressure feels totally different so we're not crazy, it's no good takeaway.

41:01

No you're not.

You know the famous saying medicine.

If you listen long enough the patient will tell you what's wrong.

What they need?

Yeah, but the problem is you have to listen enough, you know, to do that.

So anyway made the prototypes and then you know, I kept, it experiments and more experiments and a lot of this I had to kind of learn.

41:18

I mean I just kept learning and learning learning because it's just so foreign to what we do is doctors, you know, basically trying and who I talk to all the time or Engineers?

Yeah you know no Physicians they would look at me like you're crazy, you know.

And so finally I decided to to make it so we you know, started Thing with the manufacturer to mold it and, you know, bake the first mold and and then you know, had to get them out in time and get all the FDA, you know, requirements, you know, to get it registered and I got all that done and the goal was to get it done.

41:49

To release it at APS S at the Sleep means.

Yeah, we did.

We had a booth and we had three hundred doctors or in peace, mostly.

All Doc, sleep doctors actually put on a CPAP mask.

There at the booth and feel the difference of the Viacom and and get to experience.

42:06

With and get the feedback from them.

And I would kind of get to explain to them the physics of it.

Yeah.

And so the other thing for us, we were able to start doing is put it on patients and that's that's what's really given me the confidence.

Now to go forward because I have enough data and, and be honest, all my peers that I've had a chance to share all this with, you know, they all jump like that.

42:28

You know, I was at University of Utah, doing grand rounds, their sleep Department week for last.

And, you know, I mean, one of the senior, Most senior faculty is, you know, it already tried this and put it on patients and have data.

But when I shared all this, I mean the whole departments like you know, they're all excited about doing all these studies with us and partnering with us and dr.

42:52

Christian Sundar, Who's chief of sleep?

There he was here.

We had dinner in Nashville last week and, you know, planning all kind of experiment.

So, the same thing when I was in Kentucky last week and you know, everyone's excited to do this, here's the bottom line.

The machines are uncomfortable.

43:10

They've over-engineered.

Okay, for they jacked up this iPad, really through, no therapeutic reason to make it uncomfortable, causing all these other problems.

Okay, causing mouth opening leak, all this stuff and and the only way to fix it right now is if he come because of ecom's, the only way that's, you know FDA registered device to put in there that will drop iPad and then the so I wanted to carry on but I also just wanted to make sure we don't lose anybody.

43:38

So the B column is join explain like what it looks like.

This is it right here?

It's a resistor.

It goes here between the mass goes.

Here's a nasal pillow Mass.

Yeah is here and the circuit hose goes here and you put it right in between the mask hose and the CPAP.

44:00

So this is this is very important because resistance is flow dependence.

So the pressure drop is Depended.

So an inspiration.

You have lots of flow because you have the tidal volume coming to the patient.

So on inspiration, you have lots of flow.

So you have big pressure.

Drop on exhalation.

44:17

You have very little flow across especially at low pressures.

You have not hard and so therefore it maintains, he Pap, here's the bottom line.

CPR drops CPAP which is therapy.

Okay.

But maintains the iPad.

Yes.

But that's not what we want to do.

44:32

We want to slow or iPad and razy or maintaining power mean.

Clean it.

This maintains bigger be maintained CPAP, it's backwards and that's where we've been.

We've been backwards for these years and that's important.

Now, if you go and you just turn down the approach, I take someone's on 12, they can't handle it, so you turn them down to nine.

44:50

Will you drop ppap an iPad, okay, as though the v-cam drops the iPad without much of that?

Well, and real high pressures, you're still going to have some flow across it, all right, so it can drop a little bit, but if you're on will Auto, it'll just titrate up.

So say, you need another half, centimeter or whatever.

45:06

So that's what it does.

Now here's what's fascinating, we released it.

But the idea of training with, I mean the whole thing's fascinating honestly, but when we released it, as the idea of training wheels for CPAP, yeah, that it was going to be for new patients.

45:22

I thought patients who are already used to the flow already used to that pressure.

Don't need it.

You've already gotten used to it?

They're not know.

We still need it dr.

Noah well, that's what we found in our studies confirming.

That it doesn't Fect therapy, you know, 101, patient 63 ResMed machine, 21 Phillips and 17 react tail.

45:44

So on those 101 patients, 80% or 77 percent who got to try it, you know, in their circuit, you know, for the do this experiment to wear it before nights.

They, these are people who've already been wearing CPAP for a year or two and do it well.

46:00

So, almost 80% wanted to leave it in there circuit.

Hey, can I keep this?

I like the feel of it better.

Hey, my wife.

Likes that the sound is less.

Hey, my mouth's not coming open now, myleik is less than the morning my age.

I is less than the morning, and what we found out in those hundred one, patience is the Viacom did-didn't adversely affect therapy.

46:19

In other words, there P 95 percent he 90% didn't change right, but what we found is it decrease the leak tremendously, the fact that p-value was 0.0001 and it also reduced the residual index.

46:35

And that came Value was .001 so you know it it looks like it may actually improve their by decreasing the leak and people who are already doing.

Well, the other thing we thought is people would just discard it.

You use it till you're used to the pressure and you don't need it.

46:53

Well we're not, you know, we're a month for now I guess.

Yeah.

And what we're finding is is the ones who put it in there circuit, they don't ever take it out, they like the field because it's rounding off the flow curve, makes it smoother and And I wasn't expecting.

47:08

I didn't know in fix mouth open, you know, we've reduced chinstraps by 85% because of this.

I didn't think that I never thought of that.

One of my sleep text discovered intact right off the bat.

The first week we used it and of course the big exciting thing for me.

As I had this Theory last November of what was creating treatment, emergent Central, sleep apnea.

47:28

And, and the only way I could prove, my theory was to release this and we've had 14 cases consecutively in the lab and it's resolved.

All Fourteen cases.

So, so we're pretty excited.

Planes.

People listening about the central.

47:43

So what you just talked about, just explain that a little bit more.

So people develop and Central at Mia's because of the president on because of the pressure.

Yeah, and my theory was so Central.

Sleep apnea is the function usually of CO2 that you have a threshold to where if your CO2 gets below that threshold.

48:06

Yeah.

Are you asleep then?

Your brain will pause and let the CEO to come up before you take another breath and that time period is more intense.

S is called a central apnea, all right?

And so the whole thought of this engineering gang engineering term called Luke gay.

48:22

Yes, that's been the whole thing behind it, but even with Luke gain or a high Loop gain, or in-state, an unstable system, you still gotta have.

Some hyperventilation, you got to have some increased in minute ventilation or in the size of tidal volume.

So in order to blow that CO2 down well my whole theory was that the pap itself because it's trying to expand the lung.

48:44

Alright it's increasing tidal volume on new patients until they get used to where they could control it themselves and that's why this treatment emergent goes away.

You know that when they because people get used to the CPAP and they're able to throw that pressure resisted and then they bring their tidal volumes back down their study back in 1978 before.

49:04

Colin Sullivan ever use CPAP to treat, Treat sleep apnea that these two researchers Barbara Bishop and another lady up at Buffalo, New York University and they show that that CPAP increased tidal volume and increase minute ventilation, and we've known that for years.

49:25

So, so, it's so funny.

See Flex came out in 2003, epr year to later.

Okay, well guess what we for that develops and ResMed respectively.

Yeah, right.

But guess, It's what we discovered in 2005, Robert Thomas at Harvard, discovered Texa or treatment emergent Central sleep apnea, he discovered this entity because we caused it.

49:48

You see when we invented the EP ours and see Flex, We cause sit and this by dropping iPad resolves it.

So I'm really excited about that and it's so funny that we just had our I don't know what's funny or what, but it's I guess it's a little embarrassing.

50:07

But the good news is now we know it.

Now now the v-cam will fix, you know, fits with any machine and we can improve things for visions.

And then I've, you know, I'm really already obsoleting it because, you know, ultimately, I'm, we need to change the algorithms in the machine great, so that they are more comfortable.

50:24

In fact, by altering the algorithm, I can actually do a better job than even the Viacom can but right now this this improves the functioning of all the other machines and still.

Now, all the people listening are going to want one So do they have to go through their DME?

Is there a way to get this just as a consumer?

50:42

Or what's the best way for people to find it?

I guess I should answer that.

Yes it's it'll be up in a few weeks there will be then I consider the information.

50:57

Yeah it's going to be since it doesn't need a prescription.

Yeah.

Well we say that if you have a you have to have a prescription for Sita.

Yes.

Because it's an accessory to CPAP but it doesn't have to have a separate prescription in.

Okay?

It will be available online, different CPAP stores and and we're going to be another company is going to be selling it online to patients to make it available because because you know now there's going to be, you know, 15, I don't know, maybe 20% of long-term users who aren't going to prefer it although their wives are probably going to want it because it's quieter I use with We're just, but probably those people are just used to it, right?

51:40

Like, you know, probably just kind of get some that they're used to whatever they're doing.

Right.

But what I was shocked at is 80% of those who are used to it, still preferred.

I know we just found that out, you know, last month and so now we're going to, we're going to make it available to those people, to get it.

51:57

It's very inexpensive and I think they're going to offer like a money back guarantee.

So if you're one of those who, you know, it didn't improve that, you know, you can get your, get your Me back so.

Well, listen, I can talk to you for five hours but I'm gonna have to let you go.

But I really appreciate your time explaining all this to us.

52:15

Well, thank you Anna, for what you're doing to help, improve the education and knowledge of the community who are CPAP users.

I think it's wonderful.

Your closet has ever had such a cute new plan for it.


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