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Episode 90 - Dr. Keith Matheny M.D.- ENT Surgeries,NasoClenz & Remote Patient Monitoring for OSA Pat

1:06

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

So before we go on to today's conversation and I just wanted to share with you guys that project sleep have just opened their Rising voices program to Applications.

1:22

So if you're not familiar with Rising voices and it's a program where people living with Sleep Disorders can take a training and the runs for about 6 weeks over the summer and, and you work with and Lauren project sleeps program manager and it helps you to hone your personal experience into a short presentation that you can give in your community in local Healthcare settings.

1:57

Because a lot of doctors don't actually know a lot of information about Sleep Disorders.

So it's trying to put patients in front of people who don't know a lot about sleep, Terrorists and make all of the information really relatable because it's all entwined in the person's story.

2:18

So I did this training and I can't recommend it enough.

So if you're just an ordinary person, living with sleep apnea and you wonder like, what kind of an impact you can make.

Well you can make a really big impact and this is a great way to start along the Journey of becoming a patient advocate.

2:36

So I'm going to put all the information in the show notes.

Oh, and if you have any questions, I've done the program and I help them adapt it from a program just for people with narcolepsy to other Sleep Disorders, including sleep apnea.

2:52

So if you have any questions, feel free to reach out to me directly or there's going to be a link to the rising voices application in the show notes.

So then aside from the normal sponsor, links, I've got a bunch of different links to save money on things in the show.

3:09

So, the first is Co-op, has sent me a cloud pillow, and I never really that into trying new pillows, because I like, the one I already have.

But I have to say, I did really love the pillow.

They sent me.

So, they also are giving my listeners.

3:27

A 20% discount on this pillow called the cloud, and I'm a full face, mask wearer, and I sleep on my side and I thought that it was really comfortable.

But what they do is they send you extra filling for the pillow, so you can make it higher or lower.

3:45

And the idea is that it can suit people, whether they sleep on their back side or front, they'll be details and a link for 20% off in the show notes.

If you're interested in getting a new pillow.

So in my conversation that you're about to listen to, we talk a little bit about this product called nasal cleanse and when they heard there were talking a bit about Product.

4:10

They said, well, do your listeners want, 10% off and free shipping?

And I was like, sure.

So there's also a link in the show notes to the nasal client's is kind of like I described it a little bit in the episode and because Dr.Matheny that I'm going to be talking to has been doing a research study about it with some of his established CPAP patients.

4:32

So they've been using the nasal cleanse kit which is kind of like a wand with some antiseptic gel ow and you twirl it in your nose.

It kind of cleanses your nose before you go to sleep and then they used it in the morning as well.

4:48

And so what they found was and that helped people like they felt more comfortable using CPAP or they thought it was and improve their experience of CPAP.

So if you want to try that, there's a link in the show notes as well.

5:05

So onto today's guest today, I'm joined by Dr. Keith Matheny and the, he's a Vanderbilt trained otolaryngologist in Community Practice, in North Dallas with an emphasis on rhinology and sleep in adults.

5:22

And children, he has a passion for the business aspects of otolaryngology as well as new technology pharmacotherapy and procedures in the NT.

Dr. Matheny holds numerous patents and patents.

Pending on bioabsorbable.

5:40

Local drug delivery implants for use in sinus, and ear surgery, finding to device companies around these Technologies, septum Solutions, and auto logic solutions.

He is also the founder chairman and CEO of u.s.

ENT Partners, as well as the co-founder of sleep, vigil, a company pioneering, the concept of remote patient.

6:03

Current monitoring for sleep, apnea, we're going to talk all about that.

And Dr. Matheny has numerous Journal Publications and is given numerous presentations on his clinical research and on various topics related to the business of medicine over the last few decades.

6:20

So, without further Ado, here is my conversation with Dr.Keith Matheny.

So thank you so much for joining me.

I really appreciate it.

Thanks for having me, I'm excited.

You want to start out just by telling people a little bit about where you are in the Worlds and just introduce yourself a little bit.

6:36

Yeah, sure.

Sure.

Emma.

So, I'm Keith Matheny.

I'm your nose and throat surgeon in Dallas, Texas, USA and within e and t.

And t is a broad specialty.

There are actually seven different subspecialties that you can do within your nose and throat.

6:53

And I do primarily sinus and allergy and of course sleep or I'm going to be here so specifically where the nose is involved in sleep.

Disordered breathing.

So very, very passionate about that.

Take care of both adults and children, and I do a lot of things around my practice to.

7:14

So, I, pretty much right Charlie?

Don't know how you have time to Sweet.

I don't know how you're getting this much out of every day but yeah, give us a quick overview of all the other things you're doing.

Yeah.

Well now I feel like I'm receiving that much out of each day.

7:29

I mean, I really am having fun at this point in my career.

It's See.

Yes, but I love each aspect of it and how it's unfolded.

So I'm here where I pretty much where I grew up.

I'm originally from Miami, so not too far from you in moved around a lot when I was younger.

7:46

But settled here by late Elementary School and did my education, mostly in Texas until I was fortunate to do my surgery, training at Vanderbilt in Nashville Tennessee, which was just a fantastic place to learn and be exposed to so much.

8:03

CH and then came back here about 20 years ago, the the probably the best explanation of me and all the crazy things I do around.

My practice starts with describing the practice that I joined.

I joined two fantastic.

8:19

Physicians one is still practicing with me.

The other one has retired.

Now, both the entities, both ents exactly and we were in a community setting.

So we're out in a large suburb.

Called plane over next to Frisco.

8:36

So these these cities on their own or several hundred thousand people, but technically they're suburbs of Dallas proper.

And so, we have at that time, we're very, very busy.

The first week of my practice, I had dozens and dozens of new patients and was already doing surgery by my second week of practice by joining good people.

8:56

That was busy, and that was just their overflow.

But from the business side of things that that had been neglected and And that's the rule and really one of the passions I have now is helping Physicians run better businesses you know we go to school.

9:13

If we go straight through like I did I was 32 when I started and I had never had one semester three credit hours of business and then all of a sudden were Unleashed on these multimillion-dollar medical practices and as you might expect there run poorly.

9:30

We often delegate the Side of things to people that have been around in our practice for a while.

So in there also typically nurses very little business training to it's just they've been around the block and dealt with insurance companies are dealt with this role or something and so businesses are not rendered.

9:52

Well in mine was no exception.

So just by default because my partner is really wanted to spend their time fully in patient care.

I took over business Patience early on even before I was fully a partner and made a lot of mistakes and learn from those hopefully and then made some good guesses.

10:12

But really transformed our practice into a small practice that was busy in spite of the infrastructure into one that was busy because or busier because of how we were organized.

10:27

And so that evolved into Consulting at first other, my colleagues around do Fort Worth and then that evolved into a much larger company called USC and T, one of the companies that that, you know, about him and that is a National Organization, it's a buying group.

10:46

It's a formal group purchasing organization because it's very expensive to practice ENT.

The average ENT doctor spends, hundreds of thousands of dollars a year just on supplies, much of which is in the Sleep space as we'll talk about no doubt.

11:01

And so as you've learned coming, get over here and seeing the American Health Care system, which is still, in my opinion, the best in the world.

But it's it's certainly flawed and could be better, that that totally tease us up for my first question, you are, but it's more of a story.

11:18

And so yesterday, speaking of the American Healthcare System, my husband has his own business.

So we always have fairly horrible health insurance, just because right by ourselves and we just go with and touch Words are fairly healthy.

11:35

And so this year, we know is there was a plan that was so much cheaper and didn't cover any of our doctors.

But we were like, wow, I think it's fine.

We'll just change and it'll be okay.

So I had to go and see my sleep specialist, and I had an appointment with the old guy, but he wasn't covered.

11:57

So, I looked up and there was one guy in my area who was covered.

Under our new insurance?

Yes, And so yesterday I go up to meet him and I don't start with I'm like the sleep apnea podcast lady, because that's just really weird.

12:12

So I just kind of go as, you know, like a normal person, I tell him all my history and everything been asleep at for 14 years all the things.

So he says, okay let's go through like and do a little evaluation so he is I feel like this is pretty typical from a lot of people that I talk to right.

12:32

He's Board certified in I think internal medicine, but pulmonology and sleep medicine.

Yes, very common.

Yes.

So he listens to my chest and he asked me about how I had my tonsils out and I say yes, when I was 19, he looks in my mouth.

12:50

Ouch, ouch.

Yeah, it was 10 and 19, that's Ruffians.

And then he's like, okay, great.

And then we talk a little bit more about, you know, what's going on with me?

And like, you know, That I probably need a new machine and all the different stuff.

13:06

No, quite questions about my nose?

Have I seen an ENT?

Have I had any procedures on my nose?

No, looking up my nose or any sort of evaluation there.

And I think that's extremely common.

13:22

And if I guess, I just want to start by talking a little bit about why your nose is such an important part of sleep apnea, thank you for asking.

Yeah.

Just like and how you like, I mean to me, when I've had other ents on, they have said like pretty much every person should go and have an evaluation whether the ante if they have sleep apnea but what's your take on it?

13:47

Like should people, you know, have a particular problem and then go or you think everybody should go and be evaluated or washer?

Thought, hey, this is, how does your intake differ from?

Now you will you repay the favor?

You could not have teed me up better, and I'm passionate about About this topic, how much the nose affects sleep disorder breathing and I met you and I have so many colleagues that that share the same sentiment, but starting with the Healthcare System, we have to be careful how we document if a patient comes in for nasal obstruction.

14:24

And for snoring, if I'm not very careful in how I document that patients history and physical exam.

In somebody at the third party payer gets wind that they may have sleep apnea.

It's very difficult for any routine nasal procedures, such as straightening, the septum to be approved because when when at the you know, the in the wisdom of the third party payer, they look at their algorithm and they say, oh well, snoring and sleep apnea and this is not caused by the know.

14:58

So we were denying this surgery when the human body is Is we are obligate nose breathers when we first are separated from our mothers and the placenta is no longer giving us oxygen.

We need to breathe through our nose and one of the first things we check in a newborn baby is that the nostrils are open that there are bony plates in the back, blocking the nostrils.

15:23

Just making sure that we can breathe through her nose.

Just think when you have a cold or allergy attack and you're trying to eat how difficult it is to breathe and eat at the same time.

So, of course, when your experiences, for those of us who have super jacked up noses, like just, what your experience day-to-day jacked up.

15:42

Yeah, don't be so technical.

Don't be so technical objectiveness.

So it's very important and of course, it's Central in sleep disorder breathing.

But yes, unless you're comfortable looking in the nose and this is a larger problem at the care of the Sleep.

16:00

Patient is kind of distributed amongst three specialties.

ENT and apology and neurology and more.

Yeah, and so everybody looks looks through their own lenses, but that's where it absolutely needs to be part of the evaluation of a sleep disorder.

16:18

Breathing patient, not just the tonsils, not just the size of the tongue, not listening to the lungs, which obstructive sleep apnea by definition is above the level of the lungs, right?

You if you're going to skip something, don't skip the upper Airway because that's actually where It's happening, not them in the lungs.

16:36

If you're having pulmonary obstruction, that's a totally different disease, right?

That's not obstructive sleep apnea.

So critical from the tip of the nose, the nostrils, the cartilage around the tip, all the way back through the nasal, passages into the throat.

16:55

So, basically everywhere that the air needs to go to go through your upper area with one needs to be examined.

So, When I'm talking to a patient just like you gestured, I know this is not a video recording but I will go up to the Chart.

17:12

The anatomical chart in each exam room and in this is my schpeel, I will say obstruction in the upper air we can happen anywhere from the tip of the nose.

All the way down to the Adam's apple, which is where the vocal cords are and often it's multiple sites, it's usually not a single site.

17:31

So there's a nasal component.

There's a Oral component.

There's a throat component, sometimes the sheer weight of our our neck or oftentimes the sheer weight of the soft tissue in our neck.

As we put on weight, under our Jaws, as we get more mature.

All of that can cause restricted breathing or complete collapse of the airway.

17:50

And so, therefore, all of it is a potential area to intervene to help that patient, right?

So you're a group of ENT surgeons for people coming being directly.

Referred to for sleep apnea.

18:05

Like do you do testing or any of that or they're coming from like or they're coming separately like having already seen a sleep Specialist or well?

It's my chance.

Okay.

Yeah, multiple channels.

There's a number of patients that have already seen my colleagues in pulmonology or whomever, but I think the vast majority come in for snoring they don't even really, you know, they may abstractly know about this sleep apnea word.

18:34

But don't really know what that is and they're coming in usually dragged by their bed, partner by their ear.

It's one of those, the chief complaints were this, the spouse usually comes with the patient as opposed to coming by themselves and so they just kind of drop them on my exam, chair and say, fix them, please.

18:53

I I'm tired of sleeping.

The sleep divorce where we're sleeping in different rooms and or if they're trying to sleep in the same room where the the bed partner is not.

So they come directly Italy is the answer to your question and in on that topic to, you know, if you and I had recorded this podcast even four or five years ago, I probably would have said the same thing that sleep is a big part of my practice but back then it was quite different.

19:20

So you asked if we do testing, yes, absolutely.

Now, but five six years ago, that patient would be drugged and by their ear and I would look at their upper Airway including their nose, but then I would order A sleep test, typically in lab or I guess.

19:36

Five, six years ago, we were starting to do a lot of Home testing to but elsewhere.

Yeah.

So that patient was essentially lost to me in most cases unless they went through the whole evaluation.

They were prescribed CPAP failed.

That I may never see that patient again.

19:53

So what has radically changed is bringing that all back in house?

So the first step was start was starting to do the Go home, sleep testing, so I was introduced to the technology from what's now zold itamar the watch Pat testing and that's just a very, very common and it's wonderfully, reliable.

20:16

It's a great system there.

Now, are some other really amazing home sleep diagnostic tests to just to be fair, but this is what I was exposed to five six years ago and so instead of just sending that patient down the street after I did their physical exam for sleep, Thing and never seeing him again in most cases unless they failed and came back to me for some type of surgery.

20:40

Now, I had the opportunity to do the diagnostic test to talk through it with the patient and then decide with the patient, what was best whether it was CPAP still in.

Most many cases whether an oral Appliance was appropriate.

20:58

We'll talk about that in a little bit or whether they needed some kind of surgery and again I'm not talking so much about the historical surgeries which are trimming of the soft tissues in the throat.

We still do that on occasion.

Certainly we do tonsillectomies.

21:14

But surgery really even as the surgeon is my last resort.

Now the asterisks there is unless they need something nasal and the third party payer allows me to do that.

So, working on their nostril, strengthening the nostrils that may be collapsing or straightening the septum the dividing wall between In the nostrils, removing nasal polyps which are inflammatory gross that can block the airway, those types of things can help.

21:40

But most of my patients are either prescribed CPAP or are prescribed a dental.

Appliance, I don't know.

I think one of the things from patient's point of view, that's really frustrating about sleep apnea, is knowing that there's different options, but not having them laid out for you by one person, right.

22:01

Like so, we're often times exactly Talking to me all the time about.

I go to the one sleep specialist.

They tell me about CPAP and you then have to go and find yourself a dentist, figure out the how your insurance would pay for that.

22:17

It's just really complicated.

So I'm always really excited when I meet people like you that have practices that are actually managing to do that.

That's what you talked about.

That fragmentation is why we are so abysmal like caring for sleep.

22:33

Patients worldwide.

But, but even in the United States, I mean, what are we treating?

We're diagnosing.

Maybe 10% of patients that have sleep apnea, that's just giving them to diagnosis and then we're probably only treating past three months, ten percent of that 10%.

22:49

So 1% with a then this is a fatal disease this is not and I feel like you are getting that.

Like so one of the things I love about working with and there's a nonprofit called project sleep that I'm on the board where the night That I work with that.

And one of the things I love about them, is everybody there gets?

23:08

This is a major crisis, right?

Like it's a fatal illness, right?

Like the people are just leaving untreated because it's just all too hard and we have to do something about it.

We have to, and we're doing a terrible job.

So besides head and neck, cancer sleep.

23:26

Apnea is easily the most dangerous disease.

I take care of and people seeing ads snoring, you know, and Kind of funny.

And yeah, we have to sleep in separate bedrooms, we have to get two hotel rooms on vacation, it's not funny.

I mean, it's very not only is it, fatal sooner than you should naturally die.

23:45

But all along the way, the morbidity is Extreme, we're even seeing more and more data about the effect on dementia development of dementia, which makes sense your your hypoxic, most of the night.

24:00

So a third of your life.

That's To have detrimental effects on your brain and your nervous system just like it does on cardiovascular.

So the answer to your question about the dentist.

You're exactly right.

I mean we wanted to have a One-Stop shop but I'm in the ear nose and throat surgeon.

24:21

I'm not a dentist and dentists go to school almost as long as doctors learning different materials so I would never pretend to be one.

But I have an outstanding dentist that I In hand in hand with in my office.

So after a couple years of Diagnostics then in my market here in Dallas Fort Worth are actually several really outstanding sleep dentist.

24:45

I mean that are nationally and internationally known one of those approached me because some of his medical dental collaborative, some of the Physicians were retiring and he had some availability and he approached me with the concept of coming into my office.

25:03

Office one or two afternoons, a week and fitting appliances.

We had been referring appliances to him in.

That seems like, they'll succeed, right?

So that seems like six of one, half a dozen.

The other absolutely not.

So the address the physical address matters.

25:22

All right, so the fact that he comes into my office and he is a there's some legalities to it, of course in every state is different, but in Texas, he is a contractor.

A person that I delegate the fitting of dental appliances to, under my supervision under, my medical supervision and that allows the patient to run the dental Appliance through their health insurance.

25:47

So you alluded to it a second ago when we would send, I would send these patients to the exact same individual.

But by going to his other office, then he was out of network or there was no coverage at all.

It was Cash pay.

And what do we think?

And I think one out Of 10 patients maybe back then would get oral appliances.

26:06

And now it's closer to eight or nine out of ten do because the dentist is in my office, so it's One.

Stop Shop number one, number two, they can run it through their health insurance and which is huge.

It's huge, like, like, sometimes I talk to people and I feel like, you know, saying like, we're not all millionaires, like, you know, for a lot of ordinary people, if things are not covered under health insurance, They're not doable, you know, she after covid.

26:36

Right with, with what's going on, macroeconomic Lee everybody has been so affected.

You don't have the cash flow for what's perceived as quality of life.

You know, we've seen a downturn in our sinus surgery, which we have magnificent technology and unbelievable outcomes.

26:55

The patients are putting up with it, simply because they just don't have the money to meet their deductibles for quality of life for something that's not life or death or they're spending that money instead on their children.

How much more if you think snoring is just kind of funny and kind of a nuisance, you think I well I'm not going to spend X number of dollars on top of mind is not your priority at all.

27:19

Yeah, I totally get that.

That's how it happened.

I have the dentist to thank from hurting me and since then I feel like we really have a good seamless.

Treatment algorithm.

We're still a lot of patience.

I prescribed If I don't, I don't personally do the DME, I send them to some of, my great colleagues.

27:38

In my market, we do the oral appliances, but That's just how, you know, that's just day one.

So, then, I see these patients, my PA will probably see the patient in about three months, the dentist will see him once a year, whatever.

27:53

And I'll see the patient once a year.

But that, that appointment typically looks like.

Okay, mr.

Smith Miss Jones, how are you sleeping with your oral Appliance house this week, three months in.

Three or even 12 months later in and they'll say, oh doc, you know, I'm not getting punched in the arm as much or we're back in the same bed.

28:14

So and I feel like I'm sleeping fine, I'm like, oh, that's great to hear and then we'll ask me about, you know, something else.

And then say, all right, we'll we'll see you next year.

Well, are they sleeping well or not?

I don't really know.

And I understand you get all kinds of data from your CPAP machines.

28:31

But what about our oral, Appliance Visions?

What about your family?

That's my next question.

Yeah.

So so the next level that we're just implementing in our practice, in many of the practices within us e&t around the country is remote, patient monitoring and remote therapeutic monitoring or oral.

28:51

Absolutely, for oral appliances for CPAP, to be honest for things, like Inspire therapy for patients that.

I might have done a nasal procedure on because we're guessing right now, we're literally Asking a patient who is asleep, if they're sleeping better.

29:09

How in the world?

Do we know the answer that question?

Is that objective data?

And so doing using various methods, which it's a whole Topic in and of itself.

But using various methods to measure true, vital signs, you know, respiratory rate, oxygen level, those types of things, we can actually more or less, do a informal sleep study every night.

29:35

So let's not Our.

So I was thinking you were doing a study just to buy oral appliances.

Well, I am doing a research project right now.

Okay.

So okay, so for all your patients are you currently offering that that you're tracking people's vital just started to an amazing.

29:58

Well, it is.

It's amazing in the sense of what we're finding.

Okay.

So going back to, we're only Hang Ten Percent of people who have the time not going to be good news.

No, right.

This is not good news, but it's an opportunity to improve right.

30:16

Yes.

So then we're only treating 10% of that 10% more than 90 days, because most of them have the CPAP in the closet or whatever by that, okay?

Of the 1% that we actually are treating Then we start monitoring them on a nightly basis.

30:34

And we realize how much hypoxia they're still having or how many respiratory events, they're still having, and that's what's scary because those are theoretically the good ones, right?

The other 99% are not good.

This is people using some sort of therapy either some sort of therapy or oral Appliance or something.

30:54

And those people, you're picking this up on, sometimes.

Yeah.

So we that, we just completed a Pilot study and in a cohort of our oral Appliance patients and I'm pleased to say the vast majority of them were very well-controlled there.

31:11

They had.

No see no significant hypoxic events Etc.

We want we monitor them for quite a while and I night for hours, I mean the entire night.

Yeah there certainly were a few that demonstrated significant hypoxia down at least in the 70% range knowing that we had to act clinically but that allowed us to advance their Appliance a little bit further and fix it.

31:36

So that patient though?

I mean I admit and I'm their doctor right last year the year before that we probably had that is it where we chit-chatted?

And they said they're better and their spouses their snoring laughs and they feel better and we talked about golf or their business or whatever and I said, I'll see you in a year and they had a year where they had hypothesis significant Yeah, most nights and that's not.

32:04

Okay, right?

So that's what that's the value of RPM and RTM in the sense of ongoing ability to monitor these patients.

And thankfully, the third party payers now recognize that it's good for them.

32:20

Even selfishly and they recognize the clinical benefit of course to.

I don't want to write to cut.

Also is good.

It's good for them because fewer health, Cern's related to sleep apnea.

If the treatment is actually working, whatever it is CPAP and I could just be his.

32:39

It could like you're saying about the oral Appliance, it's not necessarily that, well, that you have to abandon that treatment.

It's more like, maybe the, the CPAP pressure needs adjustment or so Supply.

Its needs some adjustment.

It might not even be a big change.

Probably not.

32:55

It's probably slowly, probably subtle.

But before we had no idea, Yeah.

So now that is the true Medical Dental collaborative right?

Where we make it convenient for the patient from the new patient appointment through the diagnostic stage, we partner with the patient decide what treatment path they want.

33:18

We Implement that, and we monitor them more, or less on a nightly basis.

I mean, obviously people miss a few nights here and there, but we get a good, a good picture of her doing month by month.

Because this is a lifelong severe disease.

33:35

It's very similar you know our cardiologists colleagues are doing a lot which there's unbelievable amounts of sleep apnea in a typical cardiologist practice to believe.

But yeah, unbelievable amounts but they're monitoring patients with hypertension, high blood pressure and they're seeing the same things.

33:54

The opportunities to tweak all along the way rather than coming in and seeing the cardiologist annually or In the couple times here is not the same as every day.

And so this RPM in RTM is just it's really an amazing phenomenon.

34:09

We're very thankful to have it today.

Any Doctor's practice across the country Implement that, like, it's like so it's still, do you know these codes came out in 2019.

So back when the world was all perfect.

34:25

Right before going.

So it's but they didn't really get popular until Listen and they're not, they're still pretty well, I know.

But yeah, became more popular as we started to do telemedicine during covid.

There's a more able to see people in person.

34:42

Exactly.

So, tell me about what the research project is.

Where your is it to do with chips and oral appliances?

Well, this one is not, but Rumors in the market that those kind of devices are coming out, and those will be really powerful.

35:01

So so what we're talking about is oral appliances that have some capability to monitor utilization perhaps even the actual vital signs.

But what we use today, are consumer wearables, and there's really not.

35:17

So that's what you're doing in the research.

Yes, yes.

We're there really is not currently a clinic economically viable, FDA-approved Wireless it.

So it has to be the data taken from the patient and transpose to The Physician electronically.

35:37

In other words, the patient can't wake up at 2 a.m. and do a pulse ox and write it on a sticky note and drop it off here.

I'm really hoping for is is people who are truck drivers or you know people violence yeah pilots and people that were there having to show their compliance.

36:01

Dance, like and so obviously with CPAP that's possible.

But I know that would be a huge change if we had a reliable way of tracking compliance for all appliances, it would be huge who's huge?

That's there's a huge spider web on that too.

So even from a nasal surgery standpoint as you said, the only thing can really be monitored would be CPAP or perhaps inspired utilization.

36:26

But if I operate on a truck driver or a pilot, And they have to tell, you know, the transportation authorities or the FAA, show their utilization.

Well, sometimes after nasal surgery, for example, you can't use your CPAP for a couple weeks, right?

36:45

So there's also, there's all kinds of offshoots of that what you said, and it's so a patient oral.

Appliance, a patient that has where if the surgeon even takes into account what they use, they're doing nasal surgery and pack the nose or Don't pack the nose.

Yeah, so that that patient can use their CPAP.

37:03

Yes, there's real life, economic implications because I, I love truck drivers.

So like I've had a lot of lengthy chess with not only like I interview somebody on the podcast but also just people always email me and whatever and you get into some real situations where people are like, I can't like be out for two weeks.

37:25

Not ironing like, you know, some commission.

They Yeah, right.

Drive those loads otherwise they don't get paid and so I think that that is really yeah I'm excited for that.

Change like them really hopeful.

37:42

And then another thing that I think is how I originally found you was there's a company called nasal cleanse being and so for people listening that haven't seen, it is kind of like it's almost like how ones like it looks almost like a Q-tip but it's awesome.

37:59

Some ridges on it and you use a special gel and you kind of, like, twirl it in your nose to get rid of any, any stuff that's up there.

And, and so, the study that you're doing though, is looking at whether that improves people's experience with CPAP is that right?

38:18

Yeah, actually.

Exactly.

And it was fascinating.

So you summarized it quite well.

So, this nasal cleanse, it's an antiseptic gel so it has some lubricating effects for sure.

But it also broadly cleans the nose from a bacteria from a virus from even a fungus standpoint even from a pollutant standpoint, so things that that patients might be allergic to or irritated by.

38:45

And so what we did in a cohort of our CPAP patients, we had them, we cultured them first just to see what, what bugs were growing at the beginning, and these were already long term CPAP users, so these were not brand-new New.

Yeah, novel users.

39:02

That were using it successfully again based on current measures, you know, I mean to deal with people that are having challenges because they're just starting and all that exactly like the, you know, we all know it takes these days weeks months to really adapt to CPAP to be human.

So these are chronic users already and we culture them and then we had them use it before they put on whatever CPAP masks.

39:24

They use where there was nasal pillows or full face mask would have you and Also cleanse their nose with the nasal cleanse gel in the morning once they took that off and we just look there's something here.

Yes, twice at either end of the CPAP utilization and so after just a couple weeks, we pulled them and said, all right.

39:50

What was your experience, like?

And then we objectively looked at their utilization.

So everybody pretty much use their CPAP every night, but what we saw was Is an increase in duration.

They wore it for more hours and then we cultured them at the end.

40:06

We saw much cleaner noses, both on what we cultured, but even what we exempt.

And so we feel like that the overall impression was I think it was 80.

Something percent of patients said, this made a dramatically positive impact on their CPAP utilization.

40:25

And so what we attribute that to you as Factorial yes the lubricating effects for sure, but we think having the cleanliness like you alluded to a second again not having that air pressure drive those pathogens but potentially or the irritants further back into the nose, made the whole experience more comfortable for your expanding, the trial and both the number of patients.

40:52

So we can get a broader spectrum of what the typical nasal Flora is in a CPAP patient.

Yeah, interest.

So there's all kinds of bugs that live in that circuit.

Even if patients are diligent about cleaning their CPAP circuit, they have different.

41:07

They have a different colonization than just anyone that walks in.

Okay, so here's my question about it.

So we're supposed to have like we're supposed to have some sort of germs going on right?

41:22

Is there good ones, bad ones or I don't really know anything about you Salud.

Okay it's very much like the GI tract.

There's Good, good bugs and bad ones.

And that the general term is called the microbiome.

Right?

And so it's all about balance, just like life, right?

41:41

Is all about balance.

So you want to have enough of the good, good foods to offset the negative effects of the bad ones, anything that tips the balance.

So, think about when you get diarrhea after taking antibiotics, that's because the antibiotic has killed the good one.

41:59

Ones and the bad ones are growing and having a party and making you sick, right?

So this is, this is no different or this is this.

So I guess what I'm asking, is, are you not killing all the good bacteria?

Oh great question, great question.

42:18

Yes, you know, at the tip of the nose, it's not really that important.

The balance and there's not the function, there is like in the GI tract for digestion.

Okay, that's actually a great question.

We don't believe so.

It'll neighs occurrence folks.

42:34

They would, they would say, you know, we wash our hands all the time.

We brush our teeth multiple times per day, but we leave this thing in the center of our face, essentially untouched Inserting.

It's just another hygiene method, especially in the times of what do we have?

42:51

The triple pane dimmick now, right in all three of those viruses, typically come in through the nose.

Yeah, so it's sure makes a lot of common sense to be more hygienic with our nose so high.

So you said you're doing a bigger study.

43:07

We are for a bigger number of patients to see a bigger spectrum of bacteria, viruses, and Center for a longer period.

Period of time to really drill down which factors make it make CPAP more pleasant while useless.

43:23

Rachel, that's great.

I'm glad you're doing that super interesting.

45:00

I feel like things like the you triple p and those kind of like removing a lot of tissue that used to happen a lot more real like that's not happening as much now.

So I wondered if you could maybe like just because I've talked to a lot of people who they've maybe had that done in the past and it helps them for a little while but it doesn't help them at all.

45:24

But some people at house for a while and then it's like they get scared.

Tissue and like and all that kind of stuff.

And so I guess I just wanted you to talk a little bit like was talked about how your patients get access to CPAP, or all appliances.

So now I just wanted to talk a bit about the kind of other, we talked a little bit about nasal surgery.

45:44

Maybe you can speak to some of the different procedures that people with sleep apnea can benefit from sure.

Sure.

A little bit about that.

Yeah, we were over four hours of my that but yeah, yeah, sure will.

We can we can summarize 40 plus years of history of that seemed pretty quickly.

46:03

So so again, sleep apnea or sleep disorder.

Breathing is an upper airway disease, so any obstruction potentially can be surgically fixed to cruise the sleep apnea.

So, you referring to First procedures that were done.

46:22

They're still done some today, but yeah, I agree with you a lot less.

Then in the 1980s and 1990s and the Mainstay of treatment back then was the you triple P which is UV.

Low palette 04 Ringo plasti.

46:38

So try to say that quickly through traffic and that's why that's why we use the acronym.

What it means is, trimming the uvula that little punching bag that hangs down in the back of your throat and trimming, the soft tissue around where the tonsils live, whether the tonsils have been removed or not to to create more space.

46:57

Into honestly have less tissue the flap in the breeze, which is where the snoring is happening.

So you hit the nail on the head that works in most patients for a little while but as the tissue relaxes you know, those of us that are more mature, Noah gravity works and so things tend to get floppier and floppier over time.

47:21

And so what we see in those you triple P patients over time.

The initial benefits really less You mentioned scarring to there are potential problems.

Doing that, if a surgeon is too aggressive at the removal of tissue, the patient can end up having speech and swallowing problems where there's too much air leaking through the back of their nose.

47:47

When they're saying certain vowel sounds for example, or if you're leaning over at a water fountain, sometimes the water can actually regurgitate up your nose, so there's those Kind of Lifestyle issues.

It's sometimes, the throat I've seen a couple patients where there were scar tissue that essentially disconnected the nose from the throat that completely closed off the throat.

48:09

At that level, those are uncommon, but certainly things that have to be factored in over the years.

Historically, there have been a lot of surgeries described to reduce the size of the tongue, the base of the tongue, very dangerous, working back there, you know, even when we have to do that for cancer there, Really painful very painful as was the you, triple P.

48:32

Yeah.

Very, very painful just like a tonsillectomy that you experienced at 19 and so those are those are falling out of favor for the pain and the recovery standpoint, but also the lack of durability of the effects now much more invasive surgery is still done by our oral surgery colleagues where the maxilla in the mandible, the upper and lower Jaws can be broken into initially and moved forward.

49:00

And what that does that drags the soft tissue specifically, the tongue anteriorly.

It pulls it.

Further forward away from the threatened, it's within the right patient.

That can be an extremely effective long-term fix for sleep apnea.

And what has become more more common.

49:18

We're still sticking here with the throat.

In the mouth would be the inspired in yes.

So the Inspire implant?

Yeah, it's really An adaptation of what a patient with chronic back.

Pain might have implanted in their spine.

It's a nerve stimulator and so the surgeon will implant some of the leads into the nerve around the nerve, that moves the tongue.

49:44

It's called the hypoglossal nerve and then the in the implant is put under the right collarbone, not to confuse a paramedic or someone else.

Because let's kind of Like a pacemaker, but the other sockets.

50:02

Yeah, is not confused and then there's another lead that goes down to the diaphragm, so that make sure it's being able to gauge when the person's breathing in.

Right?

Exactly.

Hence, the name inspired in slacks me, right?

50:17

When you inspire it, fires the lead around the nerve to the tongue fires and it gives the tongue muscle tone.

So it's not floppy and Back in blocking here and the data on this implant over a long period of time is absolutely excellent and there's a better insurance coverage all the time.

50:39

And so that is a viable option for many of our patients especially those that fail CPAP which as we know is quite a large number.

Yeah, three months.

And so it's, that is a surgical procedure that certainly should be considered in the algorithm.

50:57

It's Seems to me that inspires a lot to do with getting the right patients, who are going to be great candidates for that, right?

Like so there are certain and yeah, I'm far from the expert on that since I don't do it myself.

But yeah, there are certain BMI perimeter area a lot of criteria.

51:16

Yeah, but assuming that has been met, there's broad Insurance, third-party, payer coverage and and it's a it's a nice tool to have because it's in a very very effective.

Treatment for these patients and then we have nasal options.

Okay.

So in these can go hand-in-hand for the nipple yes.

51:36

Hey that may be for you so you can go hand-in-hand with oral Appliance patients.

Yeah.

Or again the third party payers are going to assassinate me for saying this but many times we need to improve the nasal airflow before a patient can successfully use CPAP.

51:53

But to me it's like why are we saying like this or that this or that when you could have like there's people who do really well with an oral Appliance and a CPAP and there's people who do well you know like or diesel surgery in oral Appliance I have many many of those So, we have again, there's been so much Innovation within here, nose and throat.

52:17

It's amazing.

What, we have at our fingertips and the companies have all worked hard to get third party payment.

So we have several options to strengthen the nostril.

So the audience may be familiar with Breathe, Right nasal strips.

Yeah, those are the springs that looks like a piece of tape that you put on the tip of your nose.

52:36

A lot of athletes were these, it seems like in the early 2000s and it just mechanically Your nostrils open.

If you stop and think about it, or even go look in the mirror and breathe in very hard.

Your nostrils might collapse again as we get more mature, our cartilage gets weaker in our nose.

52:55

And so that nostril, collapse is a very common and very prevalent source of nasal obstruction.

And so we have at our disposal, a Zant Physicians, some heat treatments using radio waves, radio frequency.

53:11

There's a remember.

Really nice well-studied implant that can be placed in the soft tissue of the nose, to support the nostrils.

It doesn't change.

None of these treatments change, the Cosmetic appearance of the patient's nose, but it prevents that nostril collapsing.

53:28

So that helps in many, many cases.

Do you say that some in office?

Procedure it is all about those procedures can be done in the office and sometimes in conjunction with procedures that were doing in the operating.

Such as straightening the seventh.

53:46

So a lot of people have heard the term deviated septum.

The septum is, is part cartilage and part bone, but it's a wall between the two nostrils and it's kind of the rule, not the exception, that a patient has a Bend or a jagged edge in their septum just even minor bumps on your nose as a kid or playing sports or who knows what even a baby head-butting you pet him.

54:12

Ed biting.

You can cause a deviated septum.

So it's very, very common but that causes one nostril, or both to be very restricted behind the soft tissue of the moves.

And when we think about CPAP even BiPAP patients, part, or all of the air pressure is being delivered nasally, right?

54:33

So if the patient has nasal obstruction, be right?

Should be.

Yeah, so if the patient is nasal obstruction, how in the heck is that going to work?

It's not Of course, we have to streamline the nose.

I mean, that's simple.

Common Sense, even though it's really tough, you know, in some third party payer situations to get that done.

54:53

But so are the insurance company.

So, what is the problem with the insurance company pay for it?

Is it that they're saying we want to pay for CPAP only because because this patient has just been diagnosed with sleep apnea and septoplasty.

55:09

What have you is not an approved treatment for sleep apnea, right?

Because they're looking at on its own.

Yeah, right.

That's for us.

Yeah.

So we just have to be careful and usually I mean In fairness to the third party payers, we usually can go through an appeals process, which takes a lot of time and time away from our patient care to explain that.

55:30

It's to sip.

Well, it's not two separate issues but it's two separate levels that we as the clinician need to address for this patient.

And so Are some mild sleep apnea patients where it's primarily nasal in origin and and you can fix the sleep disorder Breathing by strengthening their nasal valves and pitching for septum.

55:53

The third thing you can do is reduce the size of the turbinate, the turbinates like the word it comes from like a wind turbine.

Those are natural structures inside the nose that filter and humidify the air.

And also are the First Responders to Allergy and irritants so many times they're swollen.

56:13

When you feel congested during an allergy attack like someone that sews Ting this podcast.

Yeah.

Ordering a cold or whatever your turbinates.

That's what swelling.

And so there are procedures again, primarily centered around heat using radio waves to shrink those down.

56:30

So there I like to describe it as a tripod.

Like you would set a camera on there are three legs to nasal obstruction.

The septum the But also the nasal valve, and nostrils and many times you have to improve all three for a patient to be able to breathe adequately, but if you do, so in a sleep apnea patient, you're going to improve it for sure.

56:57

In a mild sleep apnea patient.

If the nose was the source, you might just cure it very much way back in the day, any sort of surgery, maybe had a lower success rate.

You want to speak to like that, there was this technology.

He's getting better not as successful.

57:14

In mostly it was just tough for patients to recover from.

It was barbaric and my career is interesting, I kind of span both Ira's.

So we have had so much innovation in the ENT space and now starting with bringing the angioplasty balloon catheter out of the heart and out of the Cardiology space into ENT in the early 2000s to do sinus.

57:42

You're in in some patients but then that really spawned a Renaissance of other technologies that improved nasal surgery.

So how we used to do this even as recently as 25 or 30 years ago, he was a very destructive procedure to fix a septal to do sinus surgery.

58:02

For example, a lot of tissue was removed some patients needed.

Even today, I still do it in certain types of chronic sinus patients today, but many patients don't need Need that invasive of a procedure and so that has also allowed us to start packing the nose less.

58:21

You know, the kind of the I mean that this is why I hear some star stories about.

Yeah, it was tough for patients, you know, we caused so much bleeding and bruising that we had to pack the nose with all kinds of gauze.

And so, even removing that gauze was very painful and traumatic for patients in most cases.

58:42

Look, you don't have to do that.

So, we have after septoplasty, and I'm pleased to say that I brought this to the market, but a very comfortable splint, little straw.

That's soft and spongy.

And, and it is easy to flush sailing through these deep breathing through it at the same time.

59:02

Yeah.

What a concept.

You have no surgery.

We kept in.

You can actually breathe.

Right.

So that's that's good.

And then again.

I want to highlight again the colleagues in this space that have developed these other techniques for the nasal valve and in other ways for us to be less invasive, but the outcomes in general are also better.

59:23

So it's the best of both worlds.

It's way less invasive and in general, more effective than some of these barbaric techniques we used to do.

Yeah.

So nasal surgery, yes, it has a bad rap but when patients give it a fair chance and talk about more modern techniques can really help.

59:42

Many things can be done awake in our ENT offices.

Now, as opposed to in the OR with all kinds of packing and black eyes afterwards and all kinds of bleeding is just not that way in most cases it.

So and then the other thing I'm really interested in is the palatal stiffening.

1:00:02

If you offer that like you want to tell you, I do, I find just candidly, I do it last because I'm such a fan of oral, Appliance therapy.

And my Patient outcomes even proved by my recent clinical trial our overall, so good.

Yeah.

1:00:17

But but let's talk about that because there are patients that are great candidates for that.

And I know many of my colleagues around the world, still do these procedures.

All right, so if you think and there's a Video probably 20 years but it's a great wind tunnel study and it just has this membrane kind of like the Reed and a saxophone or clarinet just blowing in this winter and if you can imagine that as the soft palate, so the soft part of the roof of your mouth, when you tighten up where it's attached to the hard part of the roof of your mouth.

1:00:54

So the hard palate when you stiffen that muscle, the soft part can't flap in the breeze.

This much and that's what's causing snoring and ultimately causes the airway collapse when the soft palate and the tongue, hit the back wall throat.

So interestingly if you think about the palette like a sail on a ship so let's keep that wind tunnel model in mind if you put more rope right around the Mast through the sale, that sale is nice and tight and it can catch the wind really drive that sailboat.

1:01:28

If you for some reason had more weight.

Wait out on the end of the sale, it actually would blow back and forth even worse.

And so, we saw that there was a technology.

Again, I'm trying to avoid using brand names here, but there was a technology where the doctor would put some implants into the soft palate.

1:01:49

Yes.

If they stayed by the bone again, right by the Mast of the sale and that announcement, they worked fine.

But they Finn would migrate foreign bodies in a thin piece of soft tissue.

In our bodies, work hard to reject.

1:02:06

That just any time, you've been in a car accident, you have some glass in your skin, you know, that's ultimately going to come out and that's what would happen with these implants.

So frequently or they would migrate.

I feel like people are not using those as much anymore, right?

1:02:22

It was a really fun out of food.

Yeah.

Those those came out close to 20 years ago, so what we are doing for pallet stiffening, Is again, the radiofrequency the Heat, and we're trying to create a scar.

There were some other things that were injected, I should mention Teflon in particular, but that would really migrate in make, the problem worse, not better.

1:02:44

It would actually cause the snoring to get worse, as it migrated to the end, to the uvula, or to the end of the.

So, now, what we do in these procedures is just stiffen the soft tissue right by the bone using radio frequency, and that's very effective.

It's not covered by Insurance because it's for snoring, right?

1:03:08

Snoring in general is a cash pay business.

Insurance companies, don't cover that unless you think you find it helpful people with sleep apnea.

It contributes.

Yeah, can be helpful because again, as we said at the outset sleep, apnea is often multi-level.

1:03:27

There's some nasal obstruction.

There's some palliative Direction you may sort of your tonsils.

The tongue is often a problem and just the sheer weight of your neck.

So there's four or five levels that contribute to sleep apnea.

Yeah.

So intervening at multiple gives you the best chance at a good clinical outcome far as which patients do well with which of those procedures is it just a case of finding a really expert ENT who is used to doing this to really evaluate what you have going on.

1:04:01

Yeah, but I think, you know, Ian T is especially it's a, it's just a great group of people that attracts really good.

Physicians, you know, top of their medical school classes.

Usually very nice people.

So most ENT Physicians can perform it exquisitely, adequate head, and neck exam.

1:04:23

And that includes in many cases using a flexible scope in the nose and having the Patience nor closing closing the nostrils, closing their mouth and just look at what's happening aerodynamically.

And that tells you so much about the spots where the sleep apnea is happening.

1:04:43

Yeah.

Therefore spots that you can intervene to help it.

Do you do dice procedures to or not as much?

Yes, I, I don't.

I mean, I do it.

Yeah, I do kind of those procedures with the patient awake, so, so it's not, you know, we use the flexible Scopes all the time, but certainly, when a Is going through candidacy for inspire, they have to have that procedure.

1:05:04

Yeah, so yeah.

So my colleagues at do the Inspire they do those all the time.

Is there anything else?

I've missed that you particularly want to talk about?

I don't think so.

I mean this is just been fantastic.

It's a humongous topic, right?

I think we did really well though, you think we did but because we we sounded the alarm that were just not doing and even an okay job at caring for that's very serious disease.

1:05:30

Yeah, despite having a lot of technology that can help.

And so I think it calls for collaboration amongst the entities and pulmonologist and neurologist and primary care.

Physicians, kudos to Industry that continues to invest in develop diagnostic equipment, but certainly therapeutic equipment and kudos, to the third party payers in the example of paying for remote patient monitoring remote therapeutic monitoring Even though it behooves them from a bottom-line standpoint because their patients are healthier.

1:06:06

They also understand the importance in just patient quality.

I really hope that we're moving towards having that be a very normal part of this, but one of the huge parts of it is just this, like, people just falling away like, you know, you know, CPAP therapy or oil pipes or whatever is they try not working for them and then Then they just give up and you know, like there's no, well, how are we going to solve this then?

1:06:36

And I'm trying to problem solve it because they're just like, they're just not going to bother going back.

Exactly.

There are, they feel like they've tried?

And this is as good as it gets and sure.

No, it's sure not.

There's lots of emotion.

Thanks, it's been really fun.

1:06:52

Thank you.


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